Our work is devoted to helping health professionals learn different types of stigmas, recognize the effects of stigmatization, and guiding the implementation of effective strategies to assess and address those stigmas in a variety of settings. This article outlines the most common forms of mental illness/substance use disorder (MI/SUD) stigma, their negative effects, and the importance of acknowledging and addressing them with an intersectional lens. We will share our strategies for assessing and addressing stigmatization in the 2022 Winter Issue of Behavioral Health News.
We define stigmatization as processes operating on interpersonal, intrapersonal, and structural levels (Knaak et al., 2017) involving labeling of differences, stereotypes, prejudice, and discrimination (Pescosolido & Martin, 2015) causing loss of status and separation from non-stigmatized people (Link and Phelan 2001). But we ultimately ask people to think of stigmatization as the specific actions or inactions that result in lost opportunities for people experiencing MI/SUD (Thornicroft, Rose, Kassam & Sartorious, 2007). Since assessing and addressing these lost opportunities requires a nuanced approach, we also ask people to learn the most common forms of stigma that recipients of service, their families and significant others, their communities, and they themselves may experience.
Public stigma is the general public endorsing stereotypes that lead to discrimination against people with MI/SUD (Corrigan, Roe & Tsang, 2011). Self-stigma happens when a person with MI/SUD internalizes those negative public views, resulting in the limiting of one’s own self-efficacy and goals (Corrigan & Rao, 2012). Perceived stigma is the belief that disclosure of one’s MI/SUD will result in discrimination (Brohan et al., 2011). Label avoidance happens when a person does not seek help or discontinues treatment to avoid being assigned a stigmatizing label (Corrigan, 2016). Stigma by association is when the effects of stigma are extended to someone linked to a person with MI/SUD (Van der Sanden et al., 2013). Health professional stigma happens any time a health professional allows views of MI/SUD to negatively affect the care they provide (Grappone, 2014). Diagnostic overshadowing, a form of health professional stigma, harms individuals when health professionals inaccurately attribute physical symptoms to MI/SUD, resulting in “inadequate or delayed treatment (Shefer et al., 2014).” Finally, structural stigma – the type that fosters and maintains all other forms of stigma – includes laws, institutional policies or other societal structures that result in decreased opportunities for people with MI/SUD (Bos et al., 2013) and happens at all levels of public and private institutions (National Academies of Science, Engineering & Medicine, 2016).
When teaching these stigmas, we acknowledge that most – if not all – the researchers cited are white and many are men, reflecting the funding disparity for researchers of color (Hoppe et al., 2019), women, and non-binary researchers (Safdar et al., 2021), among other systemic and structural forms of racism and gender-based discrimination. So, while all the definitions are important to know, it is also required that we are prepared to effectively use an intersectional lens when assessing and addressing these various forms of discrimination. Crenshaw (2015), who coined the term “intersectionality,” describes it as “an analytic sensibility, a way of thinking about identity and its relationship to power. Originally articulated on behalf of Black women, the term brought to light the invisibility of many constituents within groups that claim them as members, but often fail to represent them.” Intersectional stigmatization takes into account additional marginalized and privileged group membership of individuals with MI/SUD (Fox et al., 2017). It includes but is not limited to: housing status (Petrovich & Cronley, 2015), military service (Tanielian & Jaycox, 2008), homophobia (McLaughlin et al., 2010), structural racism (Lukachko et al., 2014), weight stigma (Puhl & Heuer, 2010), ethnicity (Yang et al., 2014), cultural betrayal trauma (Gómez & Gobin 2020), white fragility (DiAngelo, 2018), carceral involvement (Hansson & Markstrom, 2014), health equity tourism (Lett. Et al., 2022), socio-economic status (Buckmen et al., 2022), religion (Pfaff et al., 2021), ageism (Evans, 2018), accent discrimination (Freynet & Clément, 2019), ableism (Kattari, 2020), know-your-place aggression (Mitchell, 2018), biphobia (DeLucia, R., & Smith, N., 2021), gender-based discrimination (Vigod & Rochon, 2020), insurance disparities (Livingston, 2013), immigration status (Barajas-Gonzalez et al., 2022), and structural violence (Winter & Leighton, 2001).
We start off the “Effects of Stigmatization” section of our curriculum with the quote, “We argue that stigma is in fact a central driver of morbidity and mortality at a population level (Hatzenbuehler, Phelan, & Link, 2013).” In other words: if we do not target stigmatization directly, we, at best, worsen outcomes and, at worst, stand by while clients, community members, and even our own colleagues die because of it. The pre-COVID life expectancy was 10-25 years less for people experiencing MI/SUD than for people without MI/SUD, even though the top five causes of death were the same (Firth et al, 2019; Walker et al., 2015) with people experiencing MI/SUD less likely to receive evidence‐based treatments for heart disease, stroke, asthma, and diabetes (Druss et al., 2010).
Since the pandemic started, there is evidence that people with schizophrenia spectrum disorders have an increased mortality due to COVID compared to those who do not have those disorders (Nemani et a., 2021), and that minoritized individuals are more likely to die of COVID than white individuals. Specifically, Indigenous individuals 3.3 times, Pacific Islanders 2.6 times, Latinx/Hispanic individuals 2.4 times, and Black individuals 2 times more likely (https://www.apmresearchlab.org/covid/deaths-by-race). COVID-related stigma is prevalent, is driven by anti-Chinese discrimination, and is also experienced, to a lesser extent, by people who work in the health professions (Gutierrez et al., 2022). COVID has also coincided with 100,000 overdose deaths in 2021, the largest amount ever in the U.S., with the highest rates among Black and American Indian/Native Alaskan individuals (Ahmad et al., 2021).
The stigmatization of people who use substances is not the sole cause of overdose deaths, but it likely plays a significant role. Stigmatization limits access to life-saving medications for people with opioid use disorder based on “non-medical, non-scientific grounds” (National Academies of Sciences, Engineering, and Medicine, 2019) and overcoming stigma is identified as one of the fundamental components needed to improve access to opioid use disorder treatment (Yang et al., 2019). Substance users are viewed as violent, manipulative, and unmotivated by many health professionals (Boekel et al., 2013) and this can result in perceived and self-stigma, causing people to drop out of SUD treatment (Brener et al., 2010).
Established evidence shows that harm reduction (HR) strategies save lives, lower risk for Hepatitis C Virus & HIV infection, and increases access to both health and social services for individuals who use substances, but the stigmatization of HR strategies stops its use due to negative attitudes about substance users, health professional burnout, and emotional/behavioral distancing from recipients of services (Knaak et al., 2019). People who inject drugs may internalize these negative views and behaviors, causing them to avoid using sterile syringe sources (Rivera et al., 2014).
While people with SUD experience higher levels of stigma than other diagnoses (Pescosolido, 2013), all individuals who experience stigmatization are at risk for negative emotional, social, and vocational outcomes (Shrivastava et al., 2013) and at increased likelihood of suicidality (Mayer et al., 2020). The structural criminalization of MI/SUD, especially toward Black people, results in increased risk for harm – even death – at the hands of law enforcement (Jordan et al., 2021). Individuals who do not have insurance and use emergency rooms to access care for MI/SUD may encounter staff who are at an increased risk of stigmatizing behavior since, by the nature of their work, they see only people when they are in crisis (Thornicroft et al., 2008). Clinicians in community mental health centers who experience stigma by association are more at risk for burnout and decreased job satisfaction (Verhaeghe & Bracke, 2012), highlighting stigma as a workforce development issue that is crucial to address as agencies struggle to hire staff amidst an increasing need for services.
There are countless other studies documenting intersectional stigmatization. If we did not include representation from a specific minoritized identity or study that you would like us to include in our assessment and intervention article in the upcoming Winter 2022 Issue of Behavioral Health News, please reach out to us and let us know. We look forward to presenting what we refer to as the “good news” part of our curriculum and sharing promising practices and our own experiences helping hospitals, community mental health centers, and state agencies target intersectional stigmatization at structural, clinical, and community levels.
Gretchen Grappone (she/her/hers), LICSW, Gretchen Grappone Consulting email@example.com. Positionality: Gretchen is white, gay, cisgendered, and has lived expertise of depression. Jayden Carr (he/him/his), BS, firstname.lastname@example.org. Positionality: Jayden is African-American and lived expertise of anxiety and depression.
Ahmad, F., Rossen, L., & Sutton, P. Provisional drug overdose death counts. National Center for Health Statistics. 2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
Barajas-Gonzalez, R., Torres, H., Urcuyo, A., Salamanca, E. & Kourousias, L. (2022). Racialization, discrimination, and depression: A mixed-method study of the impact of an anti-immigrant climate on Latina immigrant mothers and their children. SSM – Mental Health. 2. 100084. 10.1016/j.ssmmh.2022.100084.
Boekel, L. van, Brouwers, E., Weeghel, J. van, & Garretsen, H. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131, 23-35.
Bos, A., Pryor, J., Reeder, G., & Stutterheim, S. (2013). Stigma: Advances in theory and research. Basic and Applied Social Psychology, 35, 1–9.
Brener, L., von Hippel, W., von Hippel, C., Resnick, I., & Treloar, C. (2010). Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach. Drug Alcohol Rev 29, 491–497.
Brohan, E., Elgie, R., Sartorius, N., & Thornicroft, G., for the GAMIAN-Europe Study Group (2011). Self-stigma, empowerment and perceived discrimination among people with bipolar disorder or depression in 13 European countries: The GAMIAN–Europe study. Journal of Affective Disorders, 129, 56-63.
Buckman J, Saunders R, Stott J, et al. (2022). Socioeconomic Indicators of Treatment Prognosis for Adults With Depression: A Systematic Review and Individual Patient Data Meta-analysis. JAMA Psychiatry, 79, 406–416.
Corrigan, P. (2016). Lessons learned from unintended consequences about erasing the stigma of mental illness. World Psychiatry, 15, 67-73.
Corrigan, P., & Rao, D. (2012). On the self-stigma of mental illness: Stages, disclosure, and strategies for change. The Canadian Journal of Psychiatry, 57, 464-469.
Corrigan, P., Roe, D., & Tsang, H. (2011). Challenging the Stigma of Mental Illness. Lessons for Therapists and Advocates. Chichester, West Sussex: Wiley-Blackwell.
Crenshaw, K. (2015, September 24). Why intersectionality can’t wait. Washington Post. https://www.washingtonpost.com.
DeLucia, R., & Smith, N. (2021). The Impact of Provider Biphobia and Microaffirmations on Bisexual Individuals’ Treatment-Seeking Intentions. Journal of Bisexuality. 21. 1-22.
DiAngelo, R. (2018). White Fragility: Why It’s So Hard for White People to Talk about Racism. Beacon Press.
Druss B., von Esenwein S., Compton M., Rask K., Zhao L, Parker R. (2010). A randomized trial of medical care management for community mental health settings: the primary care access, referral and evaluation (PCARE) study. American Journal of Psychiatry 167, 151–159.
Evans S. (2018). Ageism and Dementia. In: Ayalon L., Tesch-Römer C. (eds) Contemporary Perspectives on Ageism. International Perspectives on Aging, 19. Springer, Cham.
Fox, A., Valerie , A., Earnshaw, V., Taverna, E., & Vogt, D. (2017). Conceptualizing and Measuring Mental Illness Stigma: The Mental Illness Stigma Framework and Critical Review of Measures. Stigma and Health, Advance online publication. http://dx.doi.org/10.1037/sah0000104.
Freynet ,N., & Clément, R. (2019). Perceived Accent Discrimination: Psychosocial Consequences and Perceived Legitimacy. Journal of Language and Social Psychology, 38, 496-513.
Gómez, J., & Gobin, R. (2020). Black Women and Girls & #MeToo: Rape, Cultural Betrayal, & Healing. Sex Roles 82, 1–12 (2020).
Grappone, G. (2014, January 21). Helping Nurses Overcome Stigma. Presented at Dartmouth Hitchcock Medical Center Nursing Grand Rounds, Lebanon, NH.
Gutierrez, A. M., Schneider, S. C., Islam, R., Robinson, J. O., Hsu, R. L., Canfield, I., & Guerrini, C. J. (2022). Experiences of stigma in the United States during the COVID-19 pandemic. Stigma and Health. Advance online publication. https://doi.org/10.1037/sah0000354
Hansson, L., & Markström, U. (2014). The effectiveness of an anti-stigma intervention in a basic police officer training programme: A controlled study. BMC Psychiatry. 14, 55. doi: 10.1186/1471-244X-14-55.
Hatzenbuehler, M. (2014). Structural stigma and the health of lesbian, gay, and bisexual populations. Current Directions in Psychological Science, 23, 127-132.
Hoppe, T. et al. (2019). Topic choice contributes to the lower rate of NIH awards to African-American/Black scientists. Sci Adv, 5: https://www.science.org/doi/10.1126/sciadv.aaw7238.
Jordan, A., Allsop, A., & Collins, P. (2021). Decriminalising being Black with mental illness. The Lancet Psychiatry. 8. 8-9. 10.1016/S2215-0366(20)30519-8.
Kattari S. (2020). Ableist Microaggressions and the Mental Health of Disabled Adults. Community Ment Health J. 2020, 56, 1170-1179. doi: 10.1007/s10597-020-00615-6. Epub 2020 Apr 18. PMID: 32306130.
Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Health Manage Forum. 30, 111-116.
Knaak, S., Romie, C., Mercer, S., & Stuart, H.. (2019). Harm Reduction, Stigma and the Problem of Low Compassion Satisfaction.. Journal of Mental Health and Addiction Nursing, 3, e8-e21. 10.22374/jmhan.v3i1.37.
Lett, E., Adekunle, D., McMurray, P. et al. (2022). Health Equity Tourism: Ravaging the Justice Landscape. J Med Syst 46, 17, https://doi.org/10.1007/s10916-022-01803-5.
Link, B. & Phelan, J. (2001) Conceptualizing stigma. Annual Review of Sociology, 27, 363 -385.
Livingston, J. D. (2013). Mental illness-related structural stigma: The downward spiral of systemic exclusion. Calgary, Alberta: Mental Health Commission of Canada. Retrieved from www.mentalhealthcommission.ca on January 7, 2019.
Lukachko, A., Hatzenbuehler, M., & Keyes, K. (2014). Structural racism and myocardial infarction in the United States. Social Science & Medicine, 103, 42-50.
McLaughlin, K.., Hatzenbuehler, M., & Keyes, K. (2010). Responses to discrimination and psychiatric disorders among Black, Hispanic, female, and lesbian, gay, and bisexual individuals. American Journal of Public Health, 100, 1477-84.
Mayer, L., Rüsch, N., Frey, L., Nadorff, M., Drapeau, C., Sheehan, L. &, Oexle, N. (2020). Anticipated Suicide Stigma, Secrecy, and Suicidality among Suicide Attempt Survivors. Suicide Life Threat Behav. 706-713.
Mitchell, K. (2018). Identifying White Mediocrity and Know-Your-Place Aggression: A Form of Self-Care. African American Review, 51, 253 – 262.
National Academies of Sciences, Engineering, and Medicine. (2016). Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Pres. doi: 10.17226/23442.
National Academies of Sciences, Engineering, and Medicine. (2019). Medications for opioid use disorder save lives. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25310.
Nemani K, Li C, Olfson M, et al. (2021). Association of Psychiatric Disorders With Mortality Among Patients With COVID-19. JAMA Psychiatry. 78, 380–386.
Pescosolido, B.A. (2013) The Public Stigma of Mental Illness: What Do We Think; What Do We Know; What Can We Prove? Journal of Health & Social Behavior, 54, 1-21.
Pescosolido, B., & Martin, J. (2015) The Stigma Complex. Annu Rev Sociol, 41, 87-116.
Petrovich, J., & Cronley, C. (2015). Deep in the heart of Texas: A phenomenological exploration of unsheltered homelessness. American Journal of Orthopsychiatry, 85, 315–323.
Pfaff, S., Crabtree, C., Kern, H., & Holbein, J. (2021), Do Street-Level Bureaucrats Discriminate Based on Religion? A Large-Scale Correspondence Experiment among American Public School Principals. Public Admin Rev, 81: 244-259.
Puhl, R. M., Heuer, C. A., & Brownell, K. D. (2010). Stigma and social consequences of obesity. In P. G. Kopelman, I. D. Caterson, & W. H. Dietz (Eds.), Clinical obesity in adults and children (pp. 25-40): Wiley-Blackwell.
Rivera, A., DeCuir, J. Crawford, N., Amesty, S., & Lewis, C. (2014). Internalized stigma and sterile syringe use among people who inject drugs in New York City, 2010–2012 Drug and Alcohol Dependence, 144, 259-264.
Safdar, B., Naveed, S., Chaudhary, A., et al. (2021) Gender Disparity in Grants and Awards at the National Institute of Health. Cureus , 13: e14644. doi:10.7759/cureus.14644.
Shefer, G., Henderson, C., Howard, L., Murray, J. & Thornicroft, G. (2014). Diagnostic Overshadowing and Other Challenges Involved in the Diagnostic Process of Patients with Mental Illness Who Present in Emergency Departments with Physical Symptoms – A Qualitative Study. PLoS ONE 9(11): e111682. doi:10.1371/ journal.pone.0111682.
Shrivastava, A., Bureau, Y., Rewari, N., & Johnston, M. (2013). Clinical risk of stigma and discrimination of mental illnesses. Indian Journal of Psychiatry, 55, 178-182.
Tanielian, T., & Jaycox, L. (2008). Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, USA: RAND Centre for Military Health Policy Research. Can be accessed online at: http://www.rand.org/content/dam/rand/pubs/monographs/2008/RAND_MG720.pdf.
Thornicroft, G., Brohan, E., Kassam, A., & Lewis-Holmes E. (2008). Reducing stigma and discrimination: candidate interventions. International Journal of Mental Health Systems. 2, 3.
Thornicroft, G., Rose, D., Kassam A., & Sartorius, N. (2007). Stigma: ignorance, prejudice or discrimination? British Journal of Psychiatry, 190, 192-193.
Van der Sanden, R., Bos, A., Stutterheim, S., Pryor, J., & Kok, G. (2013). Experiences of stigma by association among family members of people with mental illness. Rehabilitation Psychology, 58, 73-80.
Verhaeghe, M. & Bracke, P. (2012). Associative stigma among mental health professionals: Implications for professional and service user well-being. Journal of Health and Social Behavior, 53, 17-32.
Vigod, S., & Rochon, P. (2020). The impact of gender discrimination on a Woman’s Mental Health. EClinicalMedicine. 20:1 00311. doi: 10.1016/j.eclinm.2020.100311.
Walker, E., McGee, R. & Druss B. (2015). Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry, 72, 334-341.
Winter, D., & Leighton, D. (2001). Structural violence. In D. J. Christie, R. V. Wagner, & D. D. Winter (Eds.), Peace, conflict, and violence: Peace psychology in the 21st century. New York: Prentice-Hall.
Yang, L., et al. (2014). What matters most: a cultural mechanism moderating structural vulnerability and moral experience of mental illness stigma. Social Science and Medicine, 103, 84-93.
Yang, L., Grivel, M., Anderson, B., Bailey, G., Opler, M., Wong, L. & Stein, M. (2019) A new brief opioid stigma scale to assess perceived public attitudes and internalized stigma: Evidence for construct validity. Journal of Substance Abuse Treatment 99, 44-51.