By: Alondra Alamillo
Introduction
Lily is a year sober today, but she does not feel it is worth celebrating. Although she is now months into her successful probation, she struggles to accept her past Adderall use. Despite her progress, she has no hope of recovering the stable career and family support she had before her charges. After her second offense, she was kicked out of her parent’s home and left to navigate court-ordered conditions all on her own. However, through all the court-appointed requirements including frequent drug testing, officer visits, treatment plans, and her continued sobriety, she was able to maintain her probation. Still, she can not celebrate. Coworkers and peers view her as untrustworthy and constantly discriminate against her, labeling her as an addict and criminal. To avoid ridicule, Lily often thinks about quitting her job entirely, as she feels she will never be known for anything besides her past mistakes. Blinded by her internalized feelings of shame and judgment, she fails to recognize that her progress has been worth it. She fears that even after successfully completing her probation and paying off her fees, it will not be enough to be considered a valuable member of society. For Lily, and other individuals with Substance Use Disorder, the reality is they cannot celebrate. When the world around them refuses to retire the stereotypes, it can cause them to stop seeking the development they deserve and have worked hard to achieve. When vulnerability is high, the risk of relapse is greater.
Stigma
Individuals living with mental illness have a history of facing discriminatory stigma, and as a result, are less likely to seek treatment and services (Newman et al., 2023). Negative societal attitudes, such as excluding and disapproving of people struggling with mental health challenges, are far more common than for people struggling with physical illnesses (Verona et al., 2023). Self-stigma is the concept of having negative attitudes about oneself and relates to the internalization of negative characteristics and stereotypes associated with a group. Much like labeling theory, where others use stigmatizing labels to describe minorities resulting in internalization and conformity to society's views. Peers and coworkers labeled Lily as untrustworthy and judged her for her charges associated with her past substance use; it contributed to her self-stigma.
Substance Use Disorder
Substance Use Disorder (SUD), in some cases, is characterized by impaired control of use, social impairment, risky use, and tolerance categories(Diagnostic and Statistical Manual of Mental Disorders, 2013.). Classification can be rated as mild, moderate, or severe depending on the number of criteria met. SUD is particularly stigmatized, as it is believed that those who suffer from it are entirely responsible for their disorder; even when people are working to overcome SUD and the setbacks created by the disease, the misuse of substances, addiction, and unlawful activities are viewed as preventable choices (Luoma et al., 2012.) The criminality aspect associated with substance use creates another layer of socially unacceptable qualities (Newman et al., 2023). Such as in Lily’s past Adderall use, her criminal record was an additional challenge that made it difficult for her to return to her prior career position.
Self-Stigma in SUD
Unable to accept substance misuse due to social disapproval, individuals with SUD may go to great lengths to hide their use to avoid judgment and rejection. Social withdrawal as a coping mechanism is formed from believing the stereotypes associated with addiction and criminality. According to a study conducted by Luoma et al. (2012), the Substance Abuse Self Stigma Scale (SASS), a method of measuring self-stigma in individuals with SUD was tested. notably, measuring perceptions of other people’s stigma was highly related to fear of discrimination. Social withdrawal, as an attempt to avoid stigma from others, was suggested to have a high correlation with self-stigma (Luoma et al., 2012.)
Self-forgiveness Model
To test for the effect the model of self-forgiveness has on individuals diagnosed with SUD together with treatment as usual, scores were collected before and after the 6-step self-forgiveness model using the SASS model. In a study conducted by Verona et al. (2023), an additional scale was introduced known as the Self-Forgiveness Dual Process Scale (SFDPS.) The 6-step process according to Verona et al. (2023), can be divided into two main areas. The first three steps focus on helping “individuals accept responsibility for their actions…” while the final three steps are designed to repair “emotional self harm and helping individuals accept themselves as flawed human beings.” This study used self-reporting, and based on the 6-step process, the scales were designed to emphasize responsibility and to reinstate positive self-opinions.
After comparing pre- and post-participant scores, the results suggest that self-forgiveness is a statistically significant predictor. The condition that included the 6-step SASS model along with treatment as usual was more effective in decreasing self-stigma than the condition without the self-forgiveness model. Interestingly, the aspect emphasizing that participants take responsibility for their past actions did not have a main effect as expected. While the intervention highlighting self-forgiveness steps in treatment was significant, participants involved in this study had already held themselves accountable and have accepted their actions. The intervention had been indicated to be a “strong predictor of the extent to which participants replaced self-condemning ones with self reaffirming ones.” (Verona et al., 2023).
Why Empowerment Matters
According to a study by Webb et al. (2024), an important finding was recognizing that stigma can be regarded as the root of internalized stigma. Replacing self-condemning rituals with positive reaffirming ones to help heal self-concept is effective, promoting empowerment in individuals with SUD is vital to stopping self-stigma (Webb et al., 2024.) Additional steps that make a difference include creating an environment where self-stigma cannot happen by supporting peers with SUD and helping to diminish stigma surrounding mental illness to target the root cause (Rusch et al., 2005.). From a clinical standpoint, placing a special emphasis on self-forgiveness specifically, instead of focusing on forgiveness from others or forgiving others, may be a way of returning power to individuals with SUD. Advancement in reform or evaluating the efficacy of SUD treatment for justice-involved individuals could also help diminish the stigma surrounding its criminality.
References
Diagnostic and Statistical Manual of Mental Disorders. (n.d.). DSM Library. https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596
Geralt. (2018, January 19). Download Woman, Bullying, Stress. Royalty-Free Stock Illustration image. Pixabay. https://pixabay.com/illustrations/woman-bullying-stress-finger-3089939/
Luoma, J. B., Nobles, R. H., Drake, C. E., Hayes, S. C., O’Hair, A., Fletcher, L., & Kohlenberg, B. S. (2012). Self-Stigma in substance abuse: Development of a new measure. Journal of Psychopathology and Behavioral Assessment, 35(2), 223–234. https://doi.org/10.1007/s10862-012-9323-4
Newman, B. N., & Crowell, K. A. (2023). The intersectionality of criminality and substance use self-stigmas. Stigma and Health, 8(2), 212–222. https://doi.org/10.1037/sah0000293
Rüsch, N., Angermeyer, M. C., & Corrigan, P. W. (2005). Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma. European Psychiatry, 20(8), 529–539. https://doi.org/10.1016/j.eurpsy.2005.04.004
Verona, Michael & Branthoover, Holly. (2023). The Effect of a Self-Forgiveness Model on Self-Stigma in Individuals Diagnosed with Substance Use Disorders Counseling and Values 67 (2022) 203-224. 67. 203-224. 10.1163/2161007x-67020004.
Webb, J., & Boye, C. (2024). Self-Forgiveness and Self-Condemnation in the context of addictive behavior and suicidal behavior. Substance Abuse and Rehabilitation, Volume 15, 21–30. https://doi.org/10.2147/sar.s396964
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