International Journal of Emergency Mental Health and Human Resilience
Open Access

Stigma, perceived stigma, Enacted stigma, Self-stigma, Substance abuse, Depression.

Merriam Webster dictionary defines stigma as a mark of disgrace and shame (Meriam Webster, 2016). Stigmatization is an interactive social process with attitudes of people affecting a person with a particular trait or habit e.g. a drug abuser. Drug abuse has dire social and moral repercussions, even when the person is undergoing treatment, due to the stigma affiliated with it. Why stigma becomes important is because of the negative effect it has on the drug abuser in ways more than one e.g. difficulties in job employment, interpersonal rejection, devaluing thoughts about oneself, seclusion, or avoidance of intimate contacts due to fear.

Research conducted in New York on the consequences of stigma showed that 6% of participants were denied medical treatment, 16% were denied housing, and 24% were paid lower wages because of a history of drug abuse (Link, et al. 1997). A study done Connecticut showed that 31% were stigmatized by their family and friends, 18.9% by coworkers, 28.4% by health care workers and 21.6% by others (Earnshaw, et al. 2013) A research conducted in Nevada showed that drug abusers experienced unfair treatment (60%) and family rejection (45%) (Link, et al. 2004). In a similar study, Perceived stigma was prevalent in 85%, avoidance and seclusion in 74%, social support by friends and family was 45% (Ahern, et al. 2007). A study done in America on the effect of stigma on alcoholics showed that stigma was highest in men with low socioeconomic status (Keyes, et al. 2010). A study conducted in Puerto Rico showed that 18.7% of the health professionals believed that drug addicts are disagreeable patients (Varas-Díaz, et al. 2010) In research conducted in America in mentally ill patients, participants reported discrimination (74%) and unreliability (69%). (Stigma as a Barrier to Recovery, 2016) A study conducted in Chennai, India showed that 67% of the people felt that they needed to hide their drug use, 70% felt ashamed of using drugs (Latkin, et al. 2010) In a similar study, 30% of participants felt that they had negative social support and 41.4% had fear of treatment (Rapp, et al. 2006). Another research reported that increased exposure to illicit drugs was associated with an increased risk of lifetime use of those drugs between 35% to 49% (Palamar, et al. 2013; Palamer, et al. 2012) A study done in New York proposed that awareness among the masses could lead to better interaction with the stigmatized people (Link, et al. 2001) Another study showed that about 70% of the respondents had feelings of self-stigma and worthlessness (Luoma, et al. 2013). Some studies have been done on the prevalence of drug abuse in Pakistan, it was found out that the most commonly abused drugs included tobacco (Afzal, et al. 2013: Alam, et al. 1998; Ali, et al. 2008; Rozi, et al. 2005), cannabis, cocaine, opium and heroin, 80% of the drug abusers were males while 20% were females. The most common behavior associated with the stigmatized people was the use of Intravenous needles (Altaf, et al. 2007).

The purpose of the present paper was to determine whether there were any enduring effects of stigma even when treatment effectively reduces substance abuse. Our study outlined the factors which play a key role in the stigmatization of drug abusers. This will help shift the approach of treatment providers, health professionals, and family members towards the drug abuser. This will also help spread knowledge and awareness among the masses regarding this social issue. Moreover, many productive studies can be based on the results of this research to ascertain the factors involved in the stigmatization of drug abusers.

A cross-sectional study was conducted to find out the Impact of Stigma on patients receiving Substance Abuse Treatment in Psychiatry Department, Mayo Hospital, and Lahore in a duration of 6 months. A total of 100 subjects were taken using a simple random sampling technique. Inclusion criteria included male drug abusers aged 18 to 70 being treated for substance abuse. Exclusion criteria included females, uncooperative patients, and tobacco and caffeine abusers. Written consent was taken from all the selected subjects. Data was collected by interviews using a pretested questionnaire containing questions representing various variables while keeping all the ethical and social considerations in mind. The variables were defined as: Stigma is the interdependence of 5 attributes i-e labeling, stereotyping, isolation, status loss, and bigotry which a drug abuser is subjected to (Link, et al. 2001) Perceived Stigma is the belief that certain characteristics will always be found in association with a certain group of individuals (Luoma, et al. 2007). Self-Stigma encompasses the negative feelings, the person being stigmatized feels about himself, leading to low self-esteem and lack of confidence, resulting in moral, physical, and mental deterioration (Link, et al. 1989) Enacted Stigma is the kind of stigma which the person receiving it faces in his everyday life like interpersonal rejection, seclusion, and social discrimination(Link, et al. 1989).

100 people were included in the study, males, between 18 to 70 years (n=100). The highest incidence of drug abuse was between 21 to 40 years of age (83%). The most commonly abused was heroin and opiates (55%) followed by white crystal (37%) and Marijuana (8%). The highest incidence of drug abuse duration was 1-5 years (70%). Majority of them reported that they were considered less capable (80%), 71% received bad comments, 52% were not treated nicely, 40% concealed their treatment history, 41% were avoided and 48% were made to feel low when people came to know about their treatment history. 99% reported that people were highly unlikely to befriend, trust or hire a substance abuser as a teacher or caretaker of children. 97% reported that most people think low of a substance abuser. 90% felt that an average individual is preferred over a person treated for substance abuse. 73% felt that most people would not be willing to marry a person treated for substance abuse. 76% hid substance abuse from their family, 94% thought they had destroyed their life and 77% thought most people will not consider them a drug addict if they stop taking drugs. 70% reported being insulted, 67% reported labeling. 57% responded that stress was not the reason for their substance abuse. 72% felt that people refused to give them time or money.79% felt people thought low of their character. 87% felt they were trustworthy. 73% were content, 64% thought they were as important as others. Only 25% felt like a loser and 93% wished they had more faith in themselves. 96% were certain they had good qualities. 76% got family support under all circumstances, 73% got emotional support from family and 66% shared their problems with family. 45% got peer support and only 33% talked about their difficulties with friends. 41% of the participants were not depressed, 41% were mildly depressed and 17% showed moderate depression as shown in Table 1.

Table 1. Demographics.

We set out to determine the impact of stigmatization on substance abusers in our study. Our hypothesis has turned out partially successful as 58% of the participants were reported mild to moderately depress as a result of the stigmatization they experienced. This could also be attributed to the low socioeconomic status (80%) to which the majority of our participants belong, and socioeconomic status could very well be a determining factor in the overall mental health of the participants. A further study where participants are taken from a broader range of socioeconomic groups could be conducted. In another study, the level of stigma perceived by illicit drug users has been shown to persist even when drug use is reduced or ended and remains strongly associated with mental health symptoms.

The participants reported almost similar positive responses to perceived stigma, with substance abuse being a factor in others not befriending them (99%), trusting them (99%), or hiring them for responsibility positions as school teachers and caretakers for children (100%) and even marrying them (73%). While the participants did report experiencing enacted stigma and self-stigma, most of them did not conceal the fact that they had undergone treatment for substance abuse (60%), even though initially hiding their substance abuse from their families before treatment (76%). They also stated that they were not avoided by people when they left treatment (59%), and most were hopeful that this negative perception will disappear once their treatment was completed (77%) Table 2.

Table 2.Enacted Stigma.

There may be some light at the end of the tunnel but enacted stigmatization, perceived stigmatization, and self-stigmatization continue to be the factors in impacting the mental well-being of these substance abusers. The participants reported receiving social support (76%) and emotional support (73%) coming from their families while being shunned by peers in general (55%), and majority reporting good self-esteem, associating good qualities with themselves (96%) and considering themselves trustworthy (87%) despite the contrary perceived opinion. Substance abusers continue to face challenges as illicit drug users are seen as weak, immoral, and as causing a risk to society. Our results are congruent with a previous study conducted on the effect of stigma on substance abusers which showed participants were subjected to enacted stigma (60%), rejection by friends (38%), and rejection by family (45%). As put forward by previous research, experiences of discrimination in drug abusers can range from major exclusions to put-downs and slights (Earnshaw, et al. 2013). Table 3.

Table 3.Perceived Stigma.

In the present study, most participants reported experiencing high levels of self-stigma, however interesting point to note is that only 43% attributed their drug abuse to stress indicating that a high proportion (57%) indulged in this habit for pleasure’s sake or as a consequence of bad company. 52% were subjected to enacted stigma in the form of being treated unfairly. Rejection by friends was 55% and rejection by family only 26% indicating a strong social support system that comes from living together as a family. A large majority (79%) experienced negative and devaluation thoughts about themselves. Another study done in a Methadone treatment site found out that friends and family-related rejection were about 69% (Earnshaw, et al. 2013). The slight difference in the results is due to dissimilarities in the geographical area and cultural and family values.

It was found out that participants were subjected to an alarmingly high level of perceived stigma manifesting as being discriminated in friendships (99%) and in seeking employment (100%) and not being considered trustworthy (99%). A study was done in America to study how stigma influences of mentally ill patients, the values of perceived stigma for the above variables were lower in comparison (66%, 81%, and 69% respectively) (Stigma as a Barrier to Recovery, 2016). This suggests that drug abuse is more negatively stereotyped and seen as a taboo in our country in comparison to mental illness, and for obvious reasons Table 4.

Table 4. Self Stigma.

In our study, 71% of the participants experienced enacted stigma in being labeled as drug addicts and 72% encountered perceived stigma in being refused time and money. In a study conducted in North Eastern United States, similar results were obtained; with 41.9% participants facing stereotyping and 50.5% being refused time and money (Earnshaw, et al. 2013). Table 5.

Table 5. Self Esteem.

In the present research, 40% of the participants felt fear, 76% felt self-stigma and about 45% had social support. In contrast, a study done in 2006 found participants experiencing fear (7.4%), self-stigma (4.5%), and social support (8.3%) (Rapp, et al. 2006) Table 6.

Table 6. Social Support.

Our data shows that 41% of participants felt that most people think low of a substance abuser and a high majority (99%) responded that most employers won’t hire them. Likewise, 73% responded that they will not be ideal candidates for marriage. In the research conducted on stigma and its consequences in America, participants agreed that they will be looked down upon (65%), will not be hired by employers (72%), and will not get married (62%) (Link, et al. 1997). These findings are almost consistent.

Many participants of research conducted in India reported feelings of enacted and self-stigma because of their substance abuse. About 57% of the participants felt that people avoided them and did not want to be around them (Latkin, et al. 2010). This is in line with our results where 41% of the participants felt that most of the people avoided them.

In our study, 41% of the participants reported mild depression while 17% were moderate to severely depressed. However, the majority (42%) was normal and showed minimal signs of depression. This goes on to show that most of the patients recovering from substance abuse were hopeful about their future and contented with themselves. No previous study has been done to measure depression in substance abusers experiencing stigma. Table 7.

Table 7. Depression.

Stigma in its various forms affects the drug abuser undergoing treatment. It results in relatively low self-esteem and varying degrees of depression. However, the stigma associated with drug abuse decreases to some extent after getting treatment. Social support by family and friends is attributed to an overall decreased experience of stigma.

The author declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.