"We Weren't Raised that Way": Using Stigma Management Communication Theory to Understand How Families Manage the Stigma of Substance Abuse

The elephant in the room: Metaphors in women's accounts of life with a family member with problematic substance use

Background: Research has shown that a family member's problematic substance use has significant deleterious mental and physical health impacts on other members of the family. Women are more often affected than men. These negative health effects persist as the person with problematic substance use ages, and they vary according to the relationship status. Aim: The aim of this study was to gain a deeper understanding of how women experience and are affected by their family member's substance use problems. Method: A metaphorical analysis of narrative interviews with 11 daughters and five wives of older adults (>65 years) with problematic substance use. Results: We identified four areas of signification in which metaphors were employed: (1) experiences (chaos and crash and walking on eggshells); (2) strategies (complicity and silencing); (3) dilemmas (deceit or a disease and open or closed dilemmas); and (4) consequences (obtaining or retaining an identity, health and different types of help). Conclusion: Family life with a parent or spouse with a substance use problem was described as chaotic, unsafe, uncertain and with no prospects of change. The study illustrates how metaphors are used to mediate experiences and worldviews pertaining to existential matters founded in deep negative emotions, deceit, shame and stigma. Metaphors make up a crucial material for communicating emotions and themes that are difficult to convey due to shame and stigma.

Narrating the Sociocultural Experience and Management of Stigma Related to Military Caregiving

Despite accelerating the recovery and rehabilitation of wounded veterans and saving the U.S. substantial sums in avoided long-term care costs, military caregivers (MCs) are an underserved community lacking resources and support. On top of managing a variety of emotional, physical, relational, and occupational challenges, MCs experience stigma. Indeed, caregiving can be a stigmatized task, especially for military-affiliated individuals who may be expected to adhere to cultural norms of personal sacrifice and resilience in the face of adversity. The current study uses narrative inquiry to better understand the unique experiences and characteristics of MCs providing care for veterans experiencing posttraumatic stress. Specifically, this study examined MCs' narratives to uncover the sociocultural experience and management of stigma related to military caregiving. Interviews with 15 military caregivers of veterans experiencing PTS demonstrated that military caregivers experienced stigma for 1) staying in the relationship, 2) enabling the veteran, 3) mismanaging the condition, and 4) flaking on plans and relationships. In response to stigma, MCs often challenged stigma through strategies of denial or evasion of responsibility. This study contributes to communication scholarship by introducing co-stigma management and further interrogating processes related to stigma management communication. In addition, the results can inform Veteran Affairs (VA) healthcare, caregiver assistance programs, health practices, and support-seeking behaviors.

Experience of Family Members of Relatives With Substance Use Disorders: An Integrative Literature Review

Background: Substance use disorders (SUDs) present substantial challenges for family members living with or supporting relatives with SUDs. This review explores existing literature on family members' experiences with relatives with SUDs and their support needs. Method: An integrative review was conducted by searching literature in the Cumulative Index of Nursing and Allied Health, PubMed, PsycINFO, ProQuest, and Scopus databases. Results: Five themes were generated based on analysis of 26 empirical studies: (a) family members' and caregivers' experiences of SUDs; (b) impact of SUDs-related aggressive/violent behaviors on families; (c) dilemmas faced by family members; (d) culture and family stigma related to SUDs; and (e) factors contributing to SUDs, challenges, and support needs. The review highlighted barriers to seeking support due to stigma and guilt, underscoring the need for structured support programs. Conclusions: This review sheds light on the challenges faced by family members with relatives suffering from SUDs and emphasizes the crucial need for structured support programs. The findings provide insights for developing initiatives to address the social and trauma-induced needs of family members and to establish support resources for them.

The Associations among Perceived Courtesy Stigma, Health and Social Behaviours in Family Members and Friends of People Who Use Substances: An Ecological Momentary Assessment Study

Background: The stigma and discrimination experienced by individuals with an alcohol/substance use disorder often extends to the family members and friends who provide care, which is known as courtesy stigma. This courtesy stigma can lead to isolation, poor mental health and might impact the quality-of-care these individuals provide. The aim of this study was to examine the frequency of experienced courtesy stigma/discrimination in individuals in a family support service for a loved one's substance use, and to examine any cross-sectional associations with changes in mood, health- and social-related outcomes. Methods: Thirty-six individuals (25 female) with a mean age of 51.91 years took part in an ecological momentary assessment study in which the experience of courtesy stigma/discrimination and measures of mood, health (e.g. alcohol use, nicotine use, healthy eating, sleep, physical activity) and social connections were taken 3 times per day for fourteen days. Results: Across 1029 competed assessments (compliance ∼68%), there were 122 (∼11%) reports of courtesy stigma/discrimination. The most common sources of stigma/discrimination were from family members (∼43% of occurrences) and friends (∼31% of occurrences). Experiencing this stigma/discrimination was associated with increases in alcohol and nicotine use, as well as reductions in healthy eating, physical activity, sleep, social connections, and mood. Conclusions: The experience of courtesy stigma/discrimination was common in a sample of individual's who support a loved one with alcohol or substance use disorder. These experiences are associated with changes in health and social behaviors and may lead to a poorer quality of care.

Black family members' cultural beliefs and experiences regarding substance use and misuse by relatives: A focused ethnography

Research explored substance use in Black communities in Canada, but a gap exists about the experiences of Black family members, caring for relatives with substance misuse within the Canadian context. Black family members are defined as African Canadians, Caribbean Canadian or Caribbean Blacks. This paper explores Black family members' beliefs and experiences regarding their relatives' psychoactive substance use and misuse. A focused ethnography was conducted with 26 Black family members with 17 participants originated from various parts of Africa, and nine participants originated from parts of the Caribbean. Participants comprised of mothers (n = 5), fathers (n = 2), step-fathers (n = 1), husbands (n = 1), wives (n = 2), uncles (n = 5), aunties (n = 2), siblings (n = 5), in-laws (n = 2), and guardians (n = 1). Three themes were generated: cultural beliefs and perceptions regarding substance use and misuse of family relatives; "When he starts drinking, hell breaks loose": Perceived impact of substance misuse on family safety and stability; and, the experiences of stigma and the keeping of secrets. Prioritizing public health approaches, such as public policies and campaigns that dismantle stigma and systemic barriers, and increase awareness about substance use and harm reduction interventions among Black communities.

Stigma Communication Surrounding Nonmedical Opioid Use Among Affected Family Members

A growing body of research demonstrates the role of language in stigma toward nonmedical opioid use (NMOU). Terms like "substance abuser" perpetuate stereotypes and evoke punitive judgments. This study examines how affected family members (AFMs) communicate stigma when discussing their loved one's NMOU. Semi-structured interviews were conducted with 34 adults with a close family member with a history of NMOU. An iterative approach was used to analyze instances when stigmatizing terms or messages were used. AFMs described people engaged in NMOU as underweight, "dirty," or "nodding off," and often labeled these individuals "addicts" or opioid "abusers." Responsibility for the NMOU was attributed to both internal (e.g. choice) and external (e.g. brain disease) factors. People engaged in NMOU were linked to physical danger, resource threats, and threats to the family members' reputation and relationships. While most stigma messages related to the person engaged in NMOU, stigmatizing messages directed toward AFMs also emerged; family members labeled "enablers" were judged, blamed, and described as a threat to the person engaged in NMOU. Although AFMs expressed care and desire to support their loved ones, they often conveyed stigma in their language choices. This language among AFMs may reflect internalized stigma. Increased efforts are needed to help AFMs cope with the challenges of a loved one's NMOU and identify effective ways to support their loved one. One way AFMs can support their loved one is by using more inclusive, person-first language.

School nurses and menstrual communication: Destigmatizing the stigma among adolescents

OBJECTIVE

The purpose of this study is to understand how school nurses, often the first line of defense for menstruating adolescents, use communication to assist adolescents in destigmatizing menstruation.

DESIGN

I conducted semi-structured narrative interviews with nine nurses employed in a large school district in Northeast Indiana.

METHODS

Interviews were coded, categorized, and used a phronetic iterative approach.

RESULTS

Analysis determines that nurses assist menstruating students using steps toward accepting menstruation and suggesting ways to avoid menstrual stigmatization.

CONCLUSION

This study suggests that school nurses use positive language to assist students in handling their menstruation problems, develop allyships with parents and other teachers, and stress menstrual education. This study highlights the need for more funding for menstrual products and additional school nurses.

COVID-19 Courtesy Stigma among Healthcare Providers in India: A Study of Stigma Management Communication and its Impact

In early 2020, the first wave of the COVID-19 pandemic hit India, generating one of the highest rates of infection and death in the world. Meanwhile, healthcare workers experienced stigma and discrimination due to their association with COVID-19 patients. This study analyzed healthcare workers' experience of courtesy stigma in India, the communication strategies they used to manage stigma, and the impact on their mental health. A cross-sectional survey of 150 healthcare workers in India showed that almost 50% experienced discrimination due to their association with COVID-19 patients. Using Confirmatory Factor Analysis and Structural Equation Modeling, this study found that experience of discrimination was associated with perceived courtesy stigma. Two stigma management strategies (reducing offensiveness and passive acceptance) mediated the relationship between perceived courtesy stigma and perceived stress and depression. Participants also reported engaging in stigma management strategies of bonding with other healthcare professionals and passive acceptance of the stigma more than reducing stigma and displaying/disclosing stigma. We conclude that perhaps due to depletion of cognitive and emotional resources, healthcare workers engaged more in social support (bonding) and passive stigma acceptance strategies to alleviate the stress associated with providing COVID-19 patient care. Practical and theoretical implications are further discussed.

Understanding stigma through the lived experiences of people with opioid use disorder

BACKGROUND

Stigma toward substance use disorders reduces treatment seeking and recovery efforts of persons who could most benefit from services. This is particularly true for opioid use disorder (OUD) stigma, which in recent years has likely fueled the overdose epidemic. Understanding the stigma surrounding OUD and stigma reduction efforts that can be implemented are needed to enhance treatment and recovery efforts. This project explores the lived experiences of persons who were in recovery from OUD or a family member of someone with OUD with a focus on stigma.

METHODS

We utilized a qualitative method to examine secondary data of published transcripts where people's (N = 30) experiences with stigma emerged through storytelling.

RESULTS

Thematic analysis found three overarching types of stigma that were described by participants, 1) Social stigma: misconceptions contributing to social stigma, labeling and associative stereotypes, persistence of stigma throughout recovery; 2) Self-stigma: internalized feelings due to stigma, concealing and continuing substance use, inadequacies of navigating recovery; and 3) Structural stigma: treatment and recovery resource barriers, challenges of reintegration.

CONCLUSIONS

The experiences described by participants highlight the multifaceted impact of stigma on the individual as well as society and add to our understanding of the lived experience of stigma. Future recommendations are discussed to improve the experience of individuals with lived experience of OUD; including implementing evidence-based strategies to reduce stigma such as using stigma-free or person first language, dispelling common myths, and supporting comprehensive recovery pathways.

Investigating the Content of #UequalsU on Twitter

Undetectable = Untransmittable (U = U) is the scientific fact that HIV cannot be transmitted when an individual is virally suppressed. This breakthrough discovery has the potential to greatly reduce HIV stigma and its negative effects. However, U = U is not widely known. Given that Twitter has the potential to raise awareness of health issues, the purpose of this study was to analyze the content of the #UequalsU on Twitter. The results showed that mentioning sex and mentioning love were strong predictors that a tweet would be liked and retweeted. This information could help to spread the message of U = U more widely and potentially lessen HIV stigma.

How People in Recovery Manage the Stigma of Being an Alcoholic

Although stigma can jeopardize the recovery efforts of people who formerly misused substances, potentially leading to relapse, how people in recovery for alcoholism manage stigma has not been comprehensively or systematically examined. Using stigma management communication theory (SMC) and in-depth interviews of 22 adults in recovery, this investigation uncovered the six main strategies participants used to negotiate the stigma of being an alcoholic. Consistent with the tenets of SMC, interviewees accepted, evaded responsibility for, reduced offensiveness of, avoided, denied, and/or ignored/displayed the stigma, depending on whether they accepted or challenged that the stigma of being an alcoholic applied to themselves and/or the public's perception. Findings inform practical strategies to help individuals in recovery effectively manage stigma while sustaining their sobriety. The study also suggests ways programs such as Alcoholics Anonymous and treatment centers can use communication to break down recovery barriers.

Family' members experiences of their older relative's alcohol and substance misuse

BACKGROUND

Alcohol consumption in Norway and much of the western world has increased during the past decades, in particular among older adults (> 65 years). Although living with a family member's alcohol misuse has been shown to have a significant deleterious health impact, research on this topic is both lacking and urgently needed to develop targeted health services.

AIM

To generate knowledge of how family members are affected by their older relatives' alcohol and other substance misuse problems.

METHOD

In 2020, 17 individual interviews were carried out with the wives and adult children of older adults with alcohol and other substance misuse problems. Data were analysed using content analysis.

FINDINGS

Analyses revealed two main themes; the impact of living with psychological stress over time, and the impact over time on family relationships and functioning. Both included four subthemes, representing different dimensions of participants' experiences of the impact of their older relative's alcohol and substance misuse.

CONCLUSION

The challenges family members experienced through ongoing exposure to their relatives' alcohol and/or other substance misuse increased over time. These experiences had significant negative consequences for their health and life situation.

Weeding Out the Stigma: Older Veterans in Illinois Share Their Experiences Using Medical Cannabis

Many U.S. Veterans are using cannabis for medical purposes. Modern research findings continue to point to medical cannabis as a potentially effective alternative to prescription medications for treating a range of medical conditions. While research exists on the use levels of cannabis, limited research can be found on the perceived stigma of using cannabis, especially among older Veterans. We surveyed 121 older U.S. Veterans who were enrolled in the Illinois Medical Cannabis Patient Program during Fall 2020. We then used maximum variation sampling to select a subset of 32 Veterans to partake in a phone interview. Two researchers conducted and qualitatively coded 30-minute audiotaped semi-structured interviews. Interview topics included (1) the use of cannabis, opioids, and benzodiazepines; (2) interactions with medical providers; (3) stigma regarding cannabis use; and (4) educational materials. We share findings from stigma. We identified three themes: (1) stereotypes regarding people who use cannabis, (2) media portrayal of cannabis users, and (3) hesitation in disclosing cannabis use. Stigma creates situations in which older Veterans may be hesitant to disclose their use of cannabis with physicians and friends/family, which can be dangerous and socially isolating. Additional research is needed to expand upon our findings with more generalizable methods.

Preferences for Delivering Brief Alcohol Intervention to Risky Drinking Parents in Children's Social Care: A Discrete Choice Experiment

AIMS

Many parents in contact with children's social care services misuse alcohol however do not meet the threshold for specialist alcohol treatment, and typically do not receive appropriate support for their needs. Brief alcohol interventions have been found to be effective in healthcare settings, however, it is unknown whether the brief intervention structure delivered within health settings would transfer well into children's social care. This paper aims to examine the characteristics of brief intervention for alcohol misusing parents which social care practitioners consider to be important and acceptable to implement in this sector.

METHODS

We assessed preferences for, and acceptability of, brief alcohol intervention with parents in contact with children's social care using a discrete choice experiment. We recruited 205 children's social care practitioners from London and the North East of England. Data were analysed using mixed logit which accounted for repeated responses.

FINDINGS

Six attributes showed statistically significant coefficients, suggesting that a brief intervention with these attributes would encourage implementation. These were: level of alcohol-related risk targeted; intervention recipient; timing of intervention; duration of sessions; number of sessions and intervention structure. The attribute of most importance identified based on the attribute with the largest coefficient in the conditional logit model was risk level.

CONCLUSIONS

Brief alcohol interventions delivered to parents in social care should focus on the impact upon children and the wider family, they should be a flexible part of on-going casework and should be more intensive and less structured.

Substance Use Treatment Using Cultural Arts and 12 Steps: Curriculum Training and Community-led Implementation in Zambia

•

Evaluating training in 12 Step group therapy curriculum utilizing Zambian art forms.

•

Zambian-led implementation of curriculum brings addiction treatment into communities.

•

Training professionals changes perspectives on value of treating substance users.

•

This curriculum-based treatment decreases client substance use frequency.

•

This curriculum-based treatment increases client participation and motivation.

Introduction

Substance use in Zambia is stigmatized and treatment access is limited. Over 30,000 people are homeless in Lusaka, where one-quarter of homeless youth report use. Zambia's Ministry of Health recently developed policies targeting alcohol, suggesting Chainama, the only mental health hospital, offer treatment. Together, they endorsed training in the curriculum studied in this paper. We hypothesized training Zambian professionals would improve their perceptions of substance users and treatment. We then explored if treatment using the curriculum, as delivered to clients by training participants, would encourage client motivation to change, participation in groups, and reduce substance use frequency.

Methods

Part 1: One-hundred professionals were trained in a curriculum-based, literacy-free intervention employing cognitive behavioral and rational emotive behavior therapy techniques to explore 12 Steps of addiction recovery through Zambian art forms. Pre/post questionnaires captured perspectives around substance users and treatment. Part 2: Trained organizations delivered the curriculum in their communities. Twenty-five organizations rated feasibility and benefit of the curriculum. Data for 200 clients recorded pre/post motivation to change, open-sharing/participation, and frequency of substance use.

Results

While training significantly modified professionals’ perspectives regarding the value of offering treatment, their views of substance users did not change. Clients endorsed increases in “motivation to change” and “participation/open-sharing.” Frequency of alcohol, marijuana, inhalant, and cigarette use significantly decreased.

Conclusion

Training in the curriculum helped address a public health need, playing a role in increased motivational variables and decreased substance use. Research addressing this study’s limitations is encouraged.

Video abstract

For a video summary of this paper, please visit https://youtu.be/uDZTVxtzF1Y.

"I Grew Up Amidst Alcohol and Drugs:" a Qualitative Study on the Lived Experiences of Parental Substance Use Among Adults Who Developed Substance Use Disorders Themselves

Experiencing parental substance use (PSU) has been associated with a heightened risk of developing substance use disorders (SUDs) in offspring. The primary goal of this study was to explore perspectives of adult children with lived experience of PSU who also developed SUDs themselves through first-hand experience. This study was conducted in Flanders (Belgium). A qualitative exploratory research design was applied. Seventeen semi-structured interviews were conducted with adult children of parents with SUDs (range: 29-48 years) who themselves had developed SUDs. All interviews were audio-taped and transcribed verbatim. Three overarching themes emerged through thematic analysis: 1) loneliness and neglect in childhood; 2) stigma and the self; and 3) the role of social connection in substance use and recovery. The narratives highlighted the central role of feelings of loneliness, isolation and belonging among children of parents with SUDs in childhood and adulthood. Increasing public awareness on the impact of PSU on children and accessible support is needed to overcome stigma and remove barriers to social inclusion for children of parents with SUDs. Findings may prove valuable in informing policy, program and treatment development aimed at breaking maladaptive intergenerational cycles.