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McGinty E.E., Goldman H.H., Pescosolido B. et al.
Social Science and Medicine: 2015, 126, p. 73–85.
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More media stories of addiction being successfully treated would reduce stigma and ease social reintegration and recovery, suggests this innovative study. Reading just one such story made a national US sample more willing to work with former dependent users of illicit heroin or prescription painkillers and accept them into their families.
Summary Stigma toward people with mental illness and substance use problems is substantial and widespread. Enduring social stigma is linked to discrimination, under-treatment, and poor health and social outcomes, including difficulty finding and maintaining housing and employment. For example, studies have found that a third of the US public think people suffering from untreated major depression are likely to be violent toward others, as did 60% in respect schizophrenia and 65% and 87% in respect alcohol and cocaine dependence. Expectations that stressing a biological basis for mental illness would defuse stigma have not been realised.
A nationally representative sample of the US public read short vignettes either neutrally portraying a woman, portraying the same woman as drug dependent or mentally ill, or as having had these disorders but now in remission through treatment.
Then they answered questions which assessed different dimensions of stigma to people with these disorders.
Vignettes of untreated, active heroin addiction or mental illness – but not untreated addiction to pain medication – heightened the desire be socially distant from addicted or mentally ill people.
In contrast, portraying the same person as in remission from addiction did not exacerbate any negative attitudes, and on some measures actually led to more positive attitudes than the neutral depiction.
For the researchers these results suggest that portraying people who have successfully been treated for mental illness or drug addiction may be a promising strategy for improving public attitudes toward these groups.
These findings are largely based on reactions to written vignettes portraying an addicted or mentally ill person. However, many for whom effective treatment has led to symptom control and recovery bear little resemblance to the untreated, symptomatic individuals portrayed in the vignettes. Such portrayals in the media may spread and intensify social stigma toward these groups. In contrast, portrayals of successfully treated patients may elicit more positive attitudes. Research on other stigmatised health conditions such as HIV infection suggests increased public recognition of their being treatable has reduced stigma and discrimination.
The featured study was the first to examine whether levels of stigma are influenced by portrayals of untreated, symptomatic sufferers versus those who have successfully recovered through treatment. It did so for schizophrenia, major depression, addiction to prescribed painkillers, and heroin addiction, in each case portraying people whose symptoms met US diagnostic criteria. To eliminate the potentially confounding influences of race, gender, and education, each vignette ( samples) portrayed the same, college-educated, white woman – ‘Mary’. This account focuses on reactions to the addiction vignettes.
Selected from a national US panel, the 3,940 (70% of those asked to join the study) respondents were very similar to the overall US population. In 2013 they were randomly allocated to read either a neutral depiction of Mary, one of the depictions of her as actively suffering one of the untreated conditions, or one of her having recovered from a condition through treatment. Participants who had read about one of the addiction conditions were then asked a series of questions which tapped different dimensions of stigma to a “person with a drug addiction”. Participants who had read the mental illness vignettes were asked corresponding questions about a person with mental illness. Half those who had merely read the neutral depiction of Mary were asked the addiction questions, half the mental illness ones. This methodology made it possible to test the impact on stigma-related beliefs and attitudes of attributing untreated or successfully treated addiction or mental illness to Mary.
Neutral Mary is a white woman who has completed college. She has experienced the usual ups and downs of life, but managed to get through the challenges she has faced. Mary lives with her family and enjoys spending time outdoors and taking part in various activities in her community. She works at a local store.
Untreated heroin addiction Mary is a white woman who has completed college. A year after college, Mary went to a party and used heroin for the first time. After that, she started using heroin more regularly. At first she only used on weekends when she went to parties, but after a few weeks found that she increasingly felt the desire for more. Mary then began using heroin two or three times a week. She spent all of her savings and borrowed money from friends and family in order to buy more heroin. Each time she tried to cut down, she felt anxious and became sweaty and nauseated for hours on end and also could not sleep. These symptoms lasted until she resumed taking heroin. Her friends complained that she had become unreliable – making plans one day, and cancelling them the next. Her family said she had changed and that they could no longer count on her. She has been living this way for six months.
Treated heroin addiction [As above up to “...Her family said she had changed and that they could no longer count on her.”] She had been living this way for six months At that point, Mary’s family encouraged her to see a doctor. With her doctor’s help, she entered a detox program to address her problem. After completing detox, she started talking with a doctor regularly and began taking appropriate medication. After three months of treatment, she felt good enough to start searching for a job. Since then, Mary has received steady treatment and her symptoms have been under control for the past three years. She lives with her family and enjoys spending time outdoors and taking part in various activities in her community. Mary works at a local store.
The questions participants were asked were:
• Desirability of social distance: how willing they would be to have a person with addiction or mental illness marry into their family or start working closely with them;
• Perceptions of treatment effectiveness: whether they saw the treatment options for that condition as being effective, and whether with treatment most can get well and return to productive lives;
• Willingness to discriminate: whether they agreed that discrimination against people with mental illness/drug addiction is a serious problem, that employers should be allowed to deny employment to these people, and landlords deny housing;
• Endorsement of supportive policies: whether for or against requiring insurance companies to offer benefits for treatment equivalent to those for other medical services, and whether they would support increased government spending on treatment, housing subsidies, and on programmes that help these groups find jobs and offer on-the-job support.
Relative to the neutral depiction, vignettes of untreated, active heroin addiction or mental illness heightened the desire to be socially distant from such people, but this was not the case after reading about untreated addiction to pain medication charts. Other stigma dimensions (perceptions of treatment effectiveness; willingness to discriminate; endorsement of supportive policies) generally were not significantly affected. An exception was that respondents who read the untreated heroin addiction vignette were more willing to endorse discrimination against people with drug addiction.
In contrast, portraying Mary as having overcome her problems through treatment did not exacerbate any negative attitudes, and on some measures actually led to more positive attitudes than the neutral depiction. In particular, portrayals of successfully treated addiction to heroin or prescribed painkillers led fewer respondents to reject the prospect of working with someone with addiction or having them marry in to the family. Again relative to the neutral depiction, vignettes of successful treatment made respondents more likely to believe treatment can effectively control symptoms. However, in general these successful-treatment vignettes did not weaken preparedness to endorse discrimination or bolster enthusiasm for supportive policies.
Given these different and sometimes opposing effects relative to the neutral depiction, not surprisingly, the effects of portraying an untreated, active disorder differed from those of portraying the same disorder successfully treated. After reading the depiction of successful treatment, significantly fewer respondents wanted to maintain social distance ( charts), more believed in the effectiveness of treatment, and fewer were willing to endorse discrimination. However, beliefs that with treatment most sufferers can get well and return to productive lives were unaffected, as generally was endorsement of supportive polices. Of the two addictions, differences between reactions to treated and untreated vignettes were more consistent and larger after portrayal of heroin addiction than after portrayal of addiction to prescribed painkillers.
As other studies have found, even after reading a vignette portraying successful treatment, more people were willing to work with someone with addiction or mental illness than to welcome them in to the family, and respondents desired more social distance from people with drug addiction than from those with mental illness. For example, 34% and 42% of respondents who read the treated schizophrenia and depression vignettes were unwilling to work closely with a person with mental illness. In contrast, for the prescription painkiller and heroin vignettes, the corresponding figures were 70% and 64%.
As hypothesised, portrayals of untreated, symptomatic mental illness and drug addiction, characterised by abnormal behaviour including deterioration of personal hygiene and failure to fulfil work and family commitments, heightened desire for social distance from people with mental illness or drug addiction. In contrast, adding a paragraph depicting transition to successful treatment improved some attitudes, even relative to a neutral depiction which did not mention these conditions at all.
These results imply that portraying people who have successfully been treated for mental illness or drug addiction may be a promising strategy for improving public attitudes toward these groups. Exposure to a single, one- or two-paragraph vignette, led to significant movements in public attitudes, suggesting in turn that repeated such depictions presented through the news media, popular media, and other sources, are important influences on public attitudes. The implication is that a shift in emphasis away from portrayals of symptomatic, untreated individuals, and toward portrayals of those who have successfully been treated, could reduce public stigma and discrimination toward people with these conditions.
Rather than seeking directly to influence the media, national stigma-reduction campaigns may be a more feasible route to widespread dissemination of portrayals of successful treatment. In addition, expanding access to effective treatments and encouraging treatment entry is likely be a critical way to reduce public stigma and discrimination. Longstanding social stigma has led current and former sufferers to conceal these conditions; even family members sometimes don’t know that a loved one is an exemplar of successful treatment. Driven by stigma, concealment probably also perpetuates stigma by preventing family members, friends, and acquaintances becoming aware of the possibility of successful treatment.
The findings may help explain why emphasising an inherent biological basis for mental illness and addiction does not reduce stigma. Seeing these conditions as inherent flaws (moral or biological) is not, however, cemented into the public psyche. Portrayals of successful treatment lead to improved public attitudes, suggesting many Americans are receptive to the idea that mental illness and drug addiction are treatable conditions.
Despite other positive changes, the vignettes portraying successful treatment did not increase support for public policies which benefit people with mental illness and drug addiction. Support for increased government spending is in the USA strongly related to political ideology and party identification, affiliations which may have overpowered the influence of portrayals of successful treatment. It is also possible that the vignettes led respondents to believe that supportive policies are not needed.
The results of this study should be interpreted in the context of several limitations. Among these are that exposure to a single, one- or two-paragraph vignette portraying a person with mental illness or drug addiction is not how the public typically experience these conditions, either personally or through the media. Personal experience probably elicits a stronger emotional response, and rather than a single vignette, the news media exposes Americans to multiple, competing portrayals. The effects of the vignettes were assessed immediately after exposure; it is unclear whether these effects persisted. Results may have been different if the portrayed individual had different demographic characteristics.
commentary This groundbreaking study offers support for one of the main planks of the recovery movement in the UK as well as in the USA – that in the words of the UK Recovery Federation, “Making recovery visible” will help destigmatise problem drug users, as well as offering hope and a route for others to follow. Interestingly, the recovery portrayed in both addiction vignettes entailed long-term remission through continuing treatment, which helped keep “her symptoms ... under control”, not the clean break entailing ‘cure’ and treatment exit often envisaged in recovery discourse. Nevertheless, Mary’s successful efforts to keep her addiction at bay and her social reintegration seemed enough to make social reintegration more possible by somewhat diminishing the still major barriers to acceptance into workplace and family.
However, the authors’ caution that this study was divorced from the portrayal of addiction in everyday life must be taken seriously. Conceivably, for example, people who have agreed to join a social survey panel may respond in ways they intuit the researchers would want – in this case, reacting to questions immediately following a portrayal of mental illness or addiction in ways implied by the portrayal. If a real heroin-addicted person came in to their lives to work alongside them or marry their children, it remains an open question whether as many would be prepared to accept them as were anonymously and in theory in the study. Even more open is whether these US findings would be replicated in other cultures with different attitudes to the kind of ‘success’ and ‘redemption’ portrayed in the addict scenarios.
For the moment accepting the findings as indicative of real public reactions, the most powerful finding is that for both addiction vignettes, portraying someone successfully in remission led more people to say they would accept an addicted person into their lives, even though that person was not described as having also overcome their dependence. It could be that reading the successful-treatment vignette just minutes before led study participants to cast the unspecified “person with a drug addiction” in the same light, and react as if they too were an example of successful treatment. More hopefully, perhaps becoming aware of the possibility of their regaining – and though overwhelmed by addiction, retaining the capacity for – a normal, productive and responsible life, led to greater acceptance of actively dependent users of heroin or prescribed painkillers. The former interpretation leaves the divide unbridged between the worthy ex-addict who has done something about their problem, and the unworthy active addict as yet unable to get a grip; the latter interpretation implies that portraying the worthy ex-addict diminishes this divide and leads to greater acceptance of people actively dependent.
That divide has been examined in respect of alcoholism by sociologist Ron Roizen. His argument that recovery places the alcoholic not just back in their pre-alcoholic social estimation, but offers “new social credit”, seems in line with the featured study’s finding that the redeemed heroin addict led to more positive attitudes to addiction than a depiction which did not mention addiction at all. In turn this chance of gaining social credit in some respect over and above that available to someone never addicted at all may motivate recovery because it offers the chance of a life which rather than being persistently tainted by one’s past, can gain some shine because the fact that it is past is seen as a positive virtue.
The divide between acceptance of the ex-addict and rejection of the addict they once were was one of the themes of the major British analysis of stigma in relation to problem drug use. Undertaken for the UK Drug Policy Commission (UKDPC), it included a review of research on the nature, sources and consequences of stigmatisation, later updated and developed by the same author as a journal article.
Like the featured study, it held out “the prospect of change for the better” from a position where “The general public perceives problem drug users to be dangerous, deceitful, unreliable, unpredictable, hard to talk with and to blame for their predicament.” Though the featured study investigated treatment as a route to destigmatisation, the UKDPC review reminded us that for drug users, treatment is also a way they feel the impact of stigma, particularly through having their methadone consumption take place observed and sometimes in public at pharmacies. Patients in methadone maintenance treatment can feel particularly stigmatised, but the very act of seeking treatment of any kind serves to elevate an ‘addict’ or ‘junkie’ identity into what above all the person ‘is’, even though they may also be a mother, father, friend, nature-lover, worker, or artist.
The UKDPC review pinpointed blame as lying at the heart of the stigmatisation of drug users. The perception that they are responsible for bringing about and maintaining their own disorder also excludes problem drug users from the set of ‘unfairly discriminated against’ groups such as people with mental illness and or a disability. It recommended what the featured study sees as the risky and unproductive route of challenging the entrenched and widespread assumption that users are solely culpable for their condition, and highlighting the genetic, environmental and other underlying causes of vulnerability to addiction: “Such a model of addiction leaves little room for simplistic blame: how can an individual be blamed for his/her genetic and early family background?”
However, the review and an associated UKDPC summary and policy paper also endorsed the ‘Making recovery visible’ strategy implied by the featured study, implemented in Britain (among other ways) in the form of public ‘recovery marches’ and recovery cafés, vehicles for recovering drug users to make visible their presence and their commitment to self-improvement.
The review also tackled the controversial issue of whether stigma is on balance a good thing because it stops people taking drugs in the first place, and because shame drives problem users into treatment. It argues not, because scare tactics have not been found to prevent drug use, and the evidence suggests stigma keeps users away from treatment.
This text gained from the responses of US-based sociologist Ron Roizen and Mick McManus, Alcohol Co-ordinator at the London Borough of Barking and Dagenham in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 07 March 2015. First uploaded 26 February 2015
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