An investigation of stigma in individuals receiving
treatment for substance abuse
Jason B. Luomaa,⁎, Michael P. Twohiga, Thomas Waltza, Steven C. Hayesa,
Nancy Rogetb, Michelle Padillab, Gary Fisherb
aUniversity of Nevada, Reno, Department of Psychology/296, Reno, NV 89557, USA
bCenter for Addictions and Substance Abuse Technologies, University of Nevada, Reno, Reno, NV 89557, USA
This study examined the impact of stigma on patients in substance abuse treatment. Patients (N=197) from
fifteen residential and outpatient substance abuse treatment facilities completed a survey focused on their
experiences with stigma as well as other measures of drug use and functioning. Participants reported experiencing
fairly high levels of enacted, perceived, and self-stigma. Data supported the idea that the current treatment system
may actually stigmatize people in recovery in that people with more prior episodes of treatment reported a greater
frequency of stigma-related rejection, even after controlling for current functioning and demographic variables.
Intravenous drug users, compared to non-IV users, reported more perceived stigma as well as more often using
secrecy as a method of coping. Those who were involved with the legal system reported less stigma than those
without legal troubles. Higher levels of secrecy coping were associated with a number of indicators of poor
functioning as well as recent employment problems. Finally, the patterns of findings supported the idea that
perceived stigma, enacted stigma, and self-stigma are conceptually distinct dimensions.
© 2006 Elsevier Ltd. All rights reserved.
Keywords: Stigma; Substance abuse; Substance dependence; Coping
1. The role of stigma in individuals receiving treatment for substance abuse
There can be little doubt that substance abusers in recovery face stigma in its various forms, including
enacted, perceived, and self-stigma (Link, Yang, Phelan, & Collins, 2004). Enacted stigma refers to
Addictive Behaviors 32 (2007) 1331–1346
⁎Corresponding author. Tel.: +1 503 260 8424; fax: +1 503 281 4852.
E-mail address: firstname.lastname@example.org (J.B. Luoma).
0306-4603/$ - see front matter © 2006 Elsevier Ltd. All rights reserved.
directly experienced social discrimination such as difficulty in obtaining employment, reduced access to
housing, poor support for treatment, or interpersonal rejection. Perceived stigma refers to beliefs that
members of a stigmatized group have about the prevalence of stigmatizing attitudes and actions in society
(cf., Link, Cullen, Streuning, Shrout, & Dohrenwend, 1989). Self-stigma refers to negative thoughts and
feelings (e.g., shame, negative self-evaluative thoughts, fear) that emerge from identification with a
stigmatized group and their resulting behavioral impact (e.g., avoidance of treatment, failure to seek
employment, avoidance of intimate contact with others).
In general mental health areas, enacted stigma is associated with multiple negative outcomes such as
unemployment (e.g., Link, 1987; Penn & Martin, 1998), housing problems (Page, 1983, 1993; Penn &
Martin, 1998), and difficulty in social adjustment (e.g., Perlick et al., 2001). Self-stigma in the seriously
mentally ill, many of whom also have substance use disorders, is associated with delays in treatment
seeking (Kushner & Sher, 1991; Scambler, 1998; Starr, Campbell, & Herrick, 2002), diminished self-
esteem/self-efficacy (Corrigan & Watson, 2002; Link, Struening, Neese-Todd, Asmussen, & Phelan,
2001; Wright, Gronfrein, & Owens, 2000), and lower quality of life (Rosenfield, 1997). Samples of
substance abusing individuals self-report fear of stigma as a reason for not seeking treatment
(Cunningham, Sobell, Sobell, Agrawal, & Toneatto, 1993; Hingson, Mangione, Meyers, & Scotch, 1982;
Klingeman, 1991; Sobell, Sobell, & Toneatto, 1992; Tuchfeld, 1981; Tucker, Vuchinich, & Gladsjo,
1994). Because the work on stigma towards mental illness is more advanced (Corrigan, 2004; Link,
Struening, Rahav, Phelan, & Nuttbrock, 1997; Wahl, 1999), we drew on this work as a source of measures
to adapt for use with substance abuse stigma, and as a conceptual guide in researching this area.
The present study isan initial attempt to examine the role of stigma toward substanceabusein people in
recovery from substance use problems. While a number of studies have documented the existence of
various forms of stigma relating to substance use (Fulton, 1999), few studies have examined the relation
between stigma and treatment for substance use (Semple, Grant, & Patterson, 2005), or the relationship
between substance use stigma and other outcomes of interest such as patient functioning or substance use.
Now that stigma is fairly well documented as a phenomenon, it is important that research begin to
examine the relationship between stigma and functional outcomes in substance abuse.
Five questions were examined. The first assessed the degree to which persons in recovery experienced
stigma in its various forms. Second, we examined evidence for stigma as a multidimensional concept in
the substance abuse area (Corrigan, 2004; Link et al., 2004). We assessed whether our conceptually
distinct measures of stigma (self-stigma, perceived stigma, and experienced stigma) are in fact empirically
distinct and associated in predictable ways with each other and with outcomes of interest. The third
question was suggested by Link et al.'s (1989) modified labeling theory of stigmatization, which holds
that the stigma process does not primarily begin to impact an individual until the person has entered the
treatment system and has received a diagnostic label. Thus, we examined whether experienced stigma
would be higher for those with more prior episodes of treatment.
The fourth question examined the impact of secrecy as a method of coping with stigma. Stigma
researchers have made a distinction between concealable stigmas, such as substance abuse, and public
stigmas, such as race or certain diseases (Goffman, 1963; Smart & Wegner, 1999). Little evidence exists
whether it is generally helpful or hurtful to conceal substance abuse as a method of regulating stigma. The
issue was examined empirically in the present study. The fifth area we examined was whether intravenous
(IV) drug use or involvement with the legal system predicted higher levels of stigma. Researchers have
documented that stigma toward substance abuse is usually seen in a benign or even positive light among
those working in the criminal justice system (Fulton, 2001; Room, 2004), raising the possibility that drug
1332J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
use may be even more actively stigmatized in people having contact with the criminal justice system.
Research has also suggested that IV drug users form a distinct subculture that is more heavily stigmatized
by both providers of services and other substance users (Fulton, 1999).
This study included 197 patients (108 men, 89 women), averaging 35 years old (SD=10.3, range 14–
73), at 15 different substance abuse treatment sites, representing 11 different public treatment agencies in
Nevada. All 15 sites provided both alcohol and drug treatment services, seven providing outpatient
services, five providing residential services, and three providing both residential and outpatient services.
Although we were unable to obtain exact census figures, estimates from treatment center staff suggested
that our sample represented a fairly small proportion of those participating in treatment at the time of
assessment, probably 20% or less. The sample was fairly evenly distributed across sites (ranging from 4 to
23 participants, mean=13.1, SD=5.7).
Participants self-identified as 8% American Indian, 3% Asian/Pacific Islander, 10% African American,
68% Caucasian, 7% other, with 6% not responding. When asked about Latino/Hispanic origin, 11%
identified as Mexican, 6% as “other Hispanic”, 34% as “not Hispanic”, with 50% not responding. When
asked about marital status, participants reported: 41% never married, 18% married, 11% separated, 24%
divorced, 2% widowed, with 5% not responding. Participants reported participating in an average of 1.9
previous episodes of treatment (n=195; SD=2.4), On average, participants (n=178) reported a longest
prior period of abstinence of 14.3 months (SD=29.1). Participants reported using a wide range of drugs,
a mean of 13 years (SD=8.8), 68% (n=121) methamphetamines for a mean of 9.7 years (SD=7.5), 55%
(n=97) cocaine for a mean of 6.7 years (SD=7.5), 42% (n=74) hallucinogens for a mean of 6.0 years
(SD=6.9), 29% (n=52) amphetamines for a mean of 9.1 years (SD=8.2), 14% (n=25) heroin for a mean
a mean of 4.3 years (SD=7.4), 14% (n=25) benzodiazepines for a mean of 5.5 years (SD=7.4), 7%
(n=12) methadone for a mean of 5.6 years (SD=10.1), and 22% (n=39) other opioids for a mean of
6.6 years (SD=8.0), and 66% (n=118) other (mostly cigarettes) for a mean of 17 years (SD=10.5).
Participants were recruited, over one summer, through postings at the fifteen substance abuse treatment
facilities described above and through flyers handed out by treatment staff to patients at those facilities.
Experimenters arrived on a predetermined day and assessed all interested participants in a group room at
their treatment agencies. The experimenters gave a brief description of the study and emphasized that
participation was completely voluntary. Experimenters reviewed the consent forms, allowed for
questions, collected the signed consent forms, and gave a copy to each participant. Participants then
completed questionnaire packets, typically taking about one hour. Participants anonymously placed
completed questionnaires in a box and were reimbursed with $10 gift cards to a national department store
chain. Questionnaires in the packet were in the order presented in the Measures section.
1333J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
The first few pages of the questionnaire contained 34 face valid questions regarding personal char-
acteristics, substance use, social functioning, education, and employment. Five yes–no questions asked if
participantshadexperiencedspecificformsofenactedstigma.Theseweretreatedasindividualitems, not as
a separate scale.
2.3.2. Quality of life
The Quality of Life Scale (QOLS; Flanagan, 1978) measures several aspects of functional status,
including tasks of daily living, work, social activity, and family contact. Participants respond to this 16-
item scale on a seven-point Likert scale ranging from terrible (1) to delighted (7). Higher scores reflect
higher quality of life. The coefficient alpha obtained in the present study was .93.
2.3.3. Overall mental health
The General Health Questionnaire-12 (GHQ-12; Vieweg & Hedlund, 1983) available in several forms,
is a widely used self-report questionnaire designed to measure general mental health and stress. The 12-
item version, used in this study, asks participants to respond based on a four-point Likert scale. Higher
scores indicate poorer mental health. The GHQ-12 has been shown to have high internal consistency. The
current study obtained a Cronbach's alpha of .91.
2.3.4. Perceived stigma
The Substance Abuse Perceived Stigma Scale (SAPSS) is a 12 item questionnaire that assesses the
construct of perceived stigma. The SAPSS was adapted for use with participants with reported substance
abuse problems from a measure of perceived stigma in mental health patients (Link, 1987). The term
“mental health patient” was changed to fit individuals with reported substance abuse problems, and items
were scored on seven point Likert-type scale where 1=never and 7=always with agreement indicating
non-stigmatizing behavior or attitudes. The scale was scored by reverse scoring each item, summing the
items, and dividing by 12, thus higher scores indicate more perceived stigma. Example items include,
“Most people would hire someone who has been treated for substance use to take care of their children” or
“Most people do not think less of a person who has been treated for substance use.” The original mental
health measure by Link (1987) showed adequate reliability (alphas=.73–.82), as did substance abuse
version in the current study (obtained coefficient alpha=.89).
2.3.5. Secrecy coping
A four item scale was created based on the scales from Link et al. (1997) that attempted to measure
secrecy as a method of coping with stigma. Item content was modified to focus on substance abuse. An
example item is “Do you think it is a good idea to keep your history of substance use a secret?” Items were
rated as yes or no. Higher scores indicate higher secrecy and total scores ranged from 0 to 4. The present
study obtained a Cronbach alpha of .57.
2.3.6. Stigma-related interpersonal rejection
of enacted interpersonal stigma that was originally developed by Wahl (1999). The term “mental health
1334 J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
consumer” was changed to fit individuals with reported substance abuse problems, and items were scored
The scale includes nine statements asking about experiences such as being treated as less competent,
hearing others say unfavorable things about people with substance abuse problems, and worrying that
others will view one unfavorably. Reliability and validity data are not reported by Wahl (1999); the data
were presented descriptively. A coefficient alpha of .79 was obtained in the current study.
2.3.7. Internalized Shame Scale (ISS)
The ISS is a highly reliable (alpha of .95) 30-item test that asks subjects to report how often they find
themselves experiencing a variety of shame-related thoughts and feelings (Cook, 1987). It has 24
subjects rated each item on a five-point scale ranging from 0 (never) to 4 (almost always). Due to a clerical
error, the present studyused aseven-point scale ranging from 1(never) to 7 (always).Estimates of internal
consistency were excellent (coefficient alpha=.96).
2.3.8. Experiential avoidance and psychological flexibility
The Acceptance and Action Questionnaire (AAQ; Hayes, Bisset et al., 2004; Hayes, Strosahl et al.,
2004) is a nine-item measure of the willingness to accept undesirable thoughts and feelings, while acting
in a way that is congruent with values and goals. Participants respond on a seven-point Likert scale
ranging from never true (1) to always true (7). Lower scores reflect greater experiential willingness and
ability to act in the presence of difficult thoughts and feelings. Hayes, Bisset et al., (2004), Hayes, Strosahl
et al., (2004) found that scores of 42 and 38 represented upper quartile scores on experiential avoidance in
clinical and non-clinical populations. The AAQ has good convergent and discriminant validity (Hayes,
Bisset et al., 2004; Hayes, Strosahl et al., 2004) but its internal consistency is just adequate (.72). A
coefficient alpha of .52 was obtained in the current study.
3.1. To what extent do people with substance problems experience stigma?
Five items from the demographic questionnaire assessed enacted stigma. The most commonly reported
experience was believing they people treated them unfairly because they knew about their substance use
(60%, n=118), 46% (n=90) felt that others were afraid of them when they found out about their
substance use, 45% (n=88) felt some of their family gave up on them after they found out about their
substance use, 38% (n=75) felt that some of their friends rejected them after finding out about their
substance use, and 14% (n=27) felt that employers paid them a lower wage because of knowing about
their substance abuse history. Approximately 39.5% (n=75) reported three or more of these experiences.
The mean number of endorsements was 2.05 (SD=1.43); 17.4% of the sample (n=33) reported
experiencing none of these forms of enacted stigma.
On the SRS, our measure of stigma-related rejection, the mean item score was 3.0 (SD=1.0), which
corresponds to a “seldom” on the scale (Table 1). On average, across each item, 17% of respondents reported
“frequently,” “almost always” or “always” experiencing the various forms of rejection listed in the scale.
Participantswereleast likelytoreportthat theyhadbeenadvisedtolower their expectationsasaresult of their
1335 J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
drug use and that friends who learned of treatment for drug abuse were supportive and understanding (i.e.,
friends were not very supportive). The stigmatizing experience they were most likely to report was hearing
others say unfavorable or offensive things about people who have been in treatment for substance use.
On the SAPSS, our measure of perceived stigma, participants showed a mean item score of 4.21, which
is significantly above a neutral score (4) on the scale, t(194)=3.17, p=.002. Although scores varied
across items, this could be interpreted to mean that the average participant believes that most people with
substance abuse problems are devalued or discriminated against; 59% had a mean score over the midpoint
of the scale, with 44% of individual item responses indicating a perception that most people devalue/
discriminate and 30% indicating disagreement (Table 2). The most strongly endorsed forms of stigma
were that most people would not trust someone who had been in treatment for substance use to teach
young children (59%) or take care of young children (69%). The least strongly endorsed forms of stigma
were evidenced by agreement that most employers will hire someone who has been treated for substance
use if he or she is qualified for the job (49%), most people believe that a person who has been treated for
Frequency of responses to items regarding experiences with stigma-related rejection
Items Never Very
Seldom Sometimes Frequently Almost
Always Mean SD
1. I have worried that others will view me
unfavorably because I have been in treatment
for my substance use. (N=195)
2. I have been in situations where I have heard
others say unfavorable or offensive things
about people who have been in treatment for
their substance use. (N=193)
3. I have seen or read things in the mass media
(e.g., television, movies, books) about people
who have beenintreatment for their substance
use that I find hurtful or offensive. (N=195)
4. I have avoided telling others outside my
immediatefamilythat I have beenintreatment
for my substance use. (N=194)
when they learned I have been in treatment for
my substance use. (N=193)
6. I have been shunned or avoided when it was
revealed that I have been in treatment for my
substance use. (N=192)
7. I have been advised to lower my expectations
in life because I have been in treatment for my
substance use. (N=192)
have been in treatment for my substance use.
9. Friends who learned I have been in treatment
34302666 217 113.4 1.6
242420 68367 14 3.8 1.6
3527 3659 2684 3.31.5
47 31 2047 1816 14 3.31.9
55282952 2063 2.9 1.6
66 3326 451164 2.71.6
10227 2028933 2.21.5
34 423846 134 15 3.2 1.7
724126 35667 2.51.6
Items were numbered 1–7 with 1=“never” and 7=“always”.
1336J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
substance use is just as intelligent as the average person (49%), and most people would willingly accept
someone who has been treated for substance use as a close friend (50%).
3.2. Are measures of stigma conceptually distinct?
Generally, analyses conformed with the predicted pattern of results, suggesting that these measures are
conceptually distinct. Internalized shame was moderately correlated with reports of past stigma-related
rejection (r=.503) and to a lesser level with perceived stigma (r=.248). Perceived stigma was moderately
correlated with experienced stigma-related rejection (r=.423), but less with internalized stigma (.248).
Frequency of responses to items regarding perceived stigma
Item (1) Very
(2) (3) (4) Neutral
(5) (6) (7) Very
1. Most people would willingly accept someone who has
been treated for substance use as a close friend. (n=197)
2. Most people believe that a person who has been treated for
substance use is just as intelligent as the average person.
substance use is just as trustworthy as the average citizen.
4. Most people would accept someone who has been treated
for substance use as a teacher of young children in a public
5. Most people feel that entering treatment for substance use
is NOT a sign of personal failure. (n=197)
6. Most people would hire someone who has been treated for
substance use to take care of their children. (n=197)
7. Most people do NOT think less of a person who has been
in treatment for substance use. (n=197)
8. Most employers will hire someone who has been treated
for substance use if he or she is qualified for the job.
9. Most employers will NOT pass over the application of
another applicant (n=197)
10. Most people in the community would treat someone who
has been treated for substance use just as they would treat
anyone else. (n=195)
11. Most people would NOT be reluctant to date someone
who has been treated for substance use. (n=195)
12. Once they know a person has been treated for substance
use, most people will NOT take his or her opinions less
7 143463 55 8 16 4.21.4
8 11 6427 46 21 20 4.2 1.6
2021 81 2623 16 10 3.51.6
3521 60 5211 117 3.21.5
13 16 453551 20 174.1 1.6
3427 75 411046 3.0 1.4
1817 5944 37 147 3.7 1.5
6 10 32 5273 13 114.3 1.3
15 1264672694 3.6 1.3
1112 7137 49 105 3.81.3
106 54 70 4393 3.8 1.2
41064 584981 3.9 1.1
Items were numbered 1–7 with 1=“Very Strongly Disagree”, 2=“Strongly Disagree”, 3=“Disagree”, 4=“Neutral or don't
know”, 5=“Agree”, 6=“Strongly agree”, and 7=“Very Strongly Agree”. Average scores are not reverse scored, so lower scores
indicate more perceived stigma.
1337J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
Internalized shame was moderately correlated with other variables related to psychological functioning,
namely the AAQ (r=.564), quality of life (r=−.487), and global mental health (r=−.487), with stigma-
related rejection less so (r=.292 with AAQ, r=−.282 with QOL, r=.293 with global mental health) and
perceived stigma the least (r=.119 with AAQ, r=−.290 with QOL, r=.152 with global mental health).
Perceived stigma had about the same level of correlation with quality of life as stigma-related rejection.
Interestingly, perceived stigma was correlated with both years of education (r=.294) and with weeks of
employment in the last year (r=−.224), while the other two scales were not.
3.3. Is reported stigma related to the number of previous episodes of treatment?
In order to examine the possibility that the stigma process does not primarily begin to impact an
1989), we ran a linear regression predicting the number of previous treatment episodes from our three
stigma scales (experienced rejection, perceived stigma, and shame). In order to determine which statistical
controls to use, we examined the matrix of zero-order correlations between the number of previous
episodes of treatment and possible correlates including gender, age, ethnicity, previous education, number
of drugs of use, number of years of use of most typical drug, secrecy coping, quality of life, and overall
mental health (see Table 3). Those variables with a significant zero-order correlation with number of
previous episodes of treatment were included in the final regression model (Table 4).
Preliminary analyses to examine violations of regression assumptions identified two problems. The
first analysis identified two outliers using the rule of thumb of those cases having standardized residuals
greater than 3.3 (corresponding to an alpha of .001). These two cases were excluded from the regression
analysis (the cases had standardized residuals of 3.47 and 4.03). Inspection of the data from these two
subjects showed means well within 2 standard deviations of the mean on all variables except the number
Zero-order correlations between variables used in the linear regression described in Table 4 (n=161)
# of prev. episodes of
Quality of Life (QOL)
Overall Mental Health
Max years, all drugs
# of drugs in lifetime
Note: Number of previous episodes of treatment refers to the correlation between the logeof the number of previous episodes of
treatment and other variables. This table refers does not include the two outliers removed for the purposes of the regression
analysis and was created using listwise exclusion of missing variables. Low scores on the perceived stigma scale indicate greater
stigma; high scores on the internalized shame, and Secrecy scales indicate greater stigma. For the well-being measures; higher
scores on the QOL indicate greater well-being; low scores on the GHQ indicate better well-being.
1338J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
of previous treatments for which they reported values that were approximately 9 and 10.5 SDs above the
mean. The second analysis of assumption violations showed that the number of previous treatment
episodes was positively skewed, so this variable was transformed using the natural log of the number of
previous episodes plus one. Finally, a standard diagnostic check for multicollinearity was performed,
showing an absence of high correlations between variables (all with rb.8) and tolerance values of more
than .4 for all variables, both of which suggest an absence of multicollinearity.
A test of the full model with all predictors, compared to the model with only the control variables was
statistically significant, indicating that the three stigma variables added significantly to the prediction,
above and beyond the controls (Table 4). We then examined the ability of individual variables to predict
episodes of previous treatment by examining the significance of individual regression coefficients. We
found that the level of stigma-related rejection experiences and number of drugs used in life continued to
predict number of previous treatment episodes, even after controlling for all other variables.
3.4. Is secrecy as a coping method associated with different levels of functioning?
Higher levels of secrecy coping were associated with (see Table 5) lower levels of psychological
flexibility, lower quality of life, more experiences of stigma-related rejection in the past, higher
internalized shame, poorerglobal mental health, and most strongly with perceived stigma. Secrecy coping
was not correlated with weeks of employment in the past year or educational level. Those reporting
problems with employment in the past 30 days also reported higher levels of secrecy coping than those
without employment problems, t(182)=2.86, p=.005.
3.5. Do IV drug users experience higher levels of stigma than non-IV users?
We examined the association between IV drug use and stigma by conducting t-tests on the variables
reported below, comparing those participants who reported having ever used IV drugs (n=32) and those
Summary of hierarchical regression analysis for variables predicting number of previous episodes of treatment (N=169)
VariableB SE Bβ
Quality of Life
Overall Mental Health
Max years, all drugs
# of drugs in lifetime
Quality of Life
Overall Mental Health
Max years, all drugs
# of drugs in lifetime
Note: R2=.128 for step 1 (pb.001), ΔR2=.059 for step 2 (p=.01).⁎pb.05, †p=.064.
1339J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
who reported no prior IV drug use (n=165). There were no significant differences on measures of
psychological flexibility, global mental health, quality of life, number of previous treatments, internalized
shame, or age. IV users more often reported using secrecy as a method of coping, t(193)=2.07, p=.04.
They also reported higher levels of perceived stigma, t(193)=2.24, p=.03. The measure of stigma-related
rejection approached significance, t(189)=1.96, p=.051 with IV drug users reporting more rejection.
3.6. Do people with current contact with the legal system report higher levels of stigma?
Our sample was split into two groups, those who were currently uninvolved in the legal system (n=93)
was hypothesized. There were no between-group differences in level of perceived stigma, t(180)=.126,
p=.90, secrecy as a coping method, t(179)=.206, p=.84, quality of life, t(177)=.171, p=.86, general
mental health, t(181)=1.79, p=.076, or number of prior episodes of treatment, t(144)=.29, p=.77. Those
with current legal problems actually reported less internalized shame, t(178)=3.28, p=.001, less stigma-
related rejection, t(176)=2.21, p=.028, and higher psychological flexibility, t(180)=3.55, pb.001.
Correlations between major outcome measures
Acceptance and Action (AAQ)
Quality of Life (QOL)
Global mental health
Weeks employed in last year
Years of education
No. of days of employment
problems in last 30
Enacted stigma item:
rejection by friends
Enacted stigma item:
family gave up
Enacted stigma item:
people were afraid
Enacted stigma item:
people treated him/her unfairly
Enacted stigma item:
employers paid lower wages
Note: numbers above are Pearson Correlations (with pairwise exclusion of missing data) subjected to two-tailed tests. For the
stigma scales: low scores on the Perceived stigma scale indicate greater stigma; high scores on the internalized shame, and
Secrecy scales indicate greater stigma. For the well-being measures: low scores on the AAQ-9 indicate higher psychological
flexibility; higher scores on the QOL indicate greater well-being; low scores on the GHQ indicate better well-being.
1340J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
4.1. Presence of stigma
Participants reported fairly frequent contact with various forms of enacted stigma and interpersonal
rejection related to their substance abuse. Participants believed that stigmatizing attitudes and behaviors
towards people with substance abuse were fairly common. Overall, about 60% of participants scored
above the midpoint on our scale measuring perceived stigma. Averaging across individual items, about a
third of the time participants agreed that most people held individual stigmatizing attitudes or behaviors.
Overall, these levels of endorsement were somewhat lower than Ritsher and Phelan (2004) found in their
sample of seriously mentally ill and Link et al. (1997) found in their sample of the dually diagnosed. One
interpretation of these results is that our sample of substance abusing participants perceive less stigma
than the seriously mentally ill participants in her sample. This interpretation is weakened by the
differences in response options between our scales and theirs, with our scale including a “neutral” option
and the other author's scale not including this option, potentially reducing the rate of participants
acknowledging stigma in our study. In addition, these measures were originally developed for use in
seriously mentally ill population and thus some of the items may not apply particularly strongly to a
substance abuse population, thus limiting our ability to make generalization about mean levels of stigma
4.2. Multiple dimensions of stigma
Our results supported the idea that the different measures of perceived stigma, stigma-related rejection,
and internalized shame (self-stigma) are conceptually and empirically distinct (Link et al., 2004). They
correlated with each other and non-stigma measures in a coherent fashion. One explanation of our pattern
of results is that experiences with stigma-related rejection might produce both higher levels of perceived
stigma and higher levels of internalized shame. This explanation could account for the pattern of findings
in which past stigma-related rejection was moderately correlated with both perceived stigma and
internalized shame, while the former two were only slightly correlated with each other. Determining
whether any of these hypotheses are correct cannot occur from our cross sectional data and we thus await
studies that include a longitudinal component.
This study also found that internalized shame was more highly related to measures of psychological
functioning and quality of life than experienced rejection and perceived stigma. This result suggests that
self-stigma might be a more appropriate target for stigma-related interventions in a substance abusing
sample than perceived stigma or teaching them how to avoid rejection.
4.3. Relationship between stigma and previous treatment
Our sample demonstrated that experiences with stigma-related rejection continued to be related to
number of previous episodes of treatment even after controlling for other explanatory variables. These
results are supportive of the Link et al's (1989) modified labeling theory which holds that stigma begins to
impact people with behavioral disorders once they have officially received a label from the treatment
establishment. Our results are similar to those of Semple et al. (2005) who found that in their sample of
methamphetamine abusers, those who had previously been in treatment reported higher levels of stigma-
1341 J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
relatedrejectionthan thosewhohadneverbeen intreatment. In general,ourdataare suggestiveofthe idea
that stigma-related rejection may occur with increasing frequency with greater numbers of treatment
episodes. One alternative hypothesis is that those with the most serious problems are those most likely to
return to treatment and also those most likely to suffer from stigma. However, our data argue against this
hypothesis in that stigma-related rejection continued to predict number of treatment episodes even after
controlling for current severity. Another alternative hypothesis is that greater levels of stigma-related
return to treatment for those experiencing more enacted stigma. This hypothesis conforms somewhat with
old who reported higher levels of perceived stigma were more likely to prematurely discontinue treatment
disentangle these alternative explanations.
4.4. Secrecy coping
Higher levels of secrecy coping were related to lower levels of psychological flexibility, lower quality
of life, more experiences of stigma-related rejection in the past, higher internalized shame, and most
strongly with perceived stigma. Particularly interesting was the finding that those reporting employment
problems in the last 30 days reported higher levels of secrecy coping. One reasonable explanation is that
these people who were engaging in a behavior (job seeking) at a rate that required fairly high levels of
concealment. In our sample, secrecy coping was positively correlated with a number of negative
variables. These results need to be interpreted in light of the probable limited psychometric properties of
this measure of convenience which only demonstrated an alpha of .57 in this study. More research is
needed to examine the adaptiveness of disclosure in relation to context. For example, in supportive
environments, where one is likely to obtain help because of disclosure, perhaps disclosure would be more
helpful. In other situations, such as job interviews, where one is likely to be the subject of enacted stigma
for disclosure, concealment might be more adaptive. Future studies might usefully examine whether
disclosure level might interact with the general level of social support, or whether context specific (e.g.,
workplace) disclosure might be more or less adaptive.
4.5. IV drug users and those with legal problems
experiences of stigma-related rejection. A factor further strengthening the idea that IV drug status may be
stigma variables, they did not significantly differ on variables suggestive of overall functioning (such as
psychological flexibility, global mental health, or quality of life). While our results are suggestive of the
idea that IV users may be more often the targets of stigma than other drug users, it is not clear what the
The primary behavioral impact of greater levels of experienced stigma in this population may be greater
concealment of their drug using status, an interpretation which would be consistent with our findings.
Our data were not supportive of the idea that people with current contact with the legal system
encounter more stigma. In fact, in this sample, those with current legal problems actually reported less
1342J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
internalized shame, higher psychological flexibility, and less stigma-related rejection. We do not have an
adequate explanation for these findings. Besides the obvious interpretation that people with legal
involvement do not experience more stigma, another possible interpretation is that participants in with
legal problems may have tended to minimize their level of distress or problems perhaps because of fear of
this information being used in legal proceedings.
4.6. Measurement issues
Our results, as well as the general lack of literature on stigma in this population, demonstrate a need for
several new scales related to substance abuse stigma, as well as refinement of existing scales. As a result
of the lack of previous measure development work, probably the largest weakness in this study is the lack
of information on the psychometrics of our measures of perceived stigma, stigma-related rejection, and
secrecy coping, all previously unstudied scales. These items were taken directly from Link et al. (1989)
whom also did not report psychometric properties of these items. Additionally, the AAQ, while usually
demonstrating adequate alphas in most studies had a poor alpha in this study of .52, thus making
questionable the unidimensional character of this scale in our study.
Our stigma scales may also suffer from problems with content validity. These measures were directly
adapted from scales specifically created for use with a seriously mentally ill population. Thus, we may not
have documented the existence of some forms of stigma on our scales or included some forms which,
while relevant to the seriously mentally ill, might not be very relevant for those with substance abuse
problems. Qualitative research could help determine what items might be usefully added or removed from
our measures of perceived stigma and stigma-related rejection.
Perusal of individual items from the stigma-related rejection scale adapted from Wahl (1999) seems to
suggest that this scale may not be a unidimensional measure of experiences with stigma-related rejection.
For example, the scale includes items such as “I have worried that others will view me unfavorably
because I have been in treatment for my substanceuse,” which while probably being linked to experiences
with rejection, does not directly report on experiences of rejection. The scale could probably use
development of new items measuring other forms of rejection and removal of items that do not clearly
measure the central construct.
No measure specific to self-stigma has been created, so we were required to use a measure of
internalized shame. We believe that the notion of internalized shame overlaps considerably with the
construct of self-stigma, but it does not measure it exactly. The need for a direct measure of self-stigma
appears strong, particularly in light of the data which show that our measure of internalized shame was
highly related to outcomes of interest. Another paper examining early outcomes from an open trial of an
intervention targeting self-stigma suggests that treatment can reduce self-stigma as measured by this
internalized shame scale (Luoma, Kohlenberg, Hayes, Bunting, & Rye, in preparation). Also needed is a
scale focused on additional forms of enacted stigma besides interpersonal rejection, such as employment-
related discrimination, discrimination in social services, and housing discrimination.
An additional measurement issue brought to light in this study is the difference between reports of
ongoing, regularly experienced stigmatizing events, and lifetime prevalence of these events. For example,
our scale of stigma-related rejection measures ongoing rejection experiences, rather than total past
experiences. It could be that these two measures could relate quite differently to outcome. For example, as
a result of past stigma-related rejection, someone might now be concealing their current or past use of
substances so that they do not experience further enacted stigma. This person might report having a
1343 J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
relatively high lifetime prevalence of enacted stigma, but report little ongoing stigma. However, the
concealment that resulted from past experiences with enacted stigma may continue to have effects on the
Aweakness of this study is the complete reliance on self-report. In the area of stigma this is particularly
difficult due to the social desirability of the relevant domains. Future studies would usefully include
measures of the context in which the person lives, such as attitudes of staff at the treatment centers, or
perhaps measures of the attitudes of a sample of the population in the area where the person lives or their
familymembers. Additionally, measures such as the Implicit Attitudes Test (Greenwald, Nosek, & Banaji,
2003) might be useful to get around the problems of social desirability. Finally, it is possible that because
measures were not presented in a counterbalanced order, there may have been systematic, unexplained
error due to participant tiredness or boredom.
4.7. Other weaknesses
Another issue is that in conducting analyses for this study, a large number of individual statistical tests
were conducted, thus increasing the risk of type I error. We decided to take this risk, rather than reducing
the alphato somethingbelow.05 becauseat thisbeginningstate of thisarea of researchwe would prefer to
have a variety of leads to track down and eliminate as possibilities rather than make type II errors and
conclude that possible relationships are not there and thus have fewer leads for future studies. Our best
estimates suggested that only 20% or less of the potential population (those in treatment at the time of the
study) completed our survey, leaving the possibility of a recruitment selection bias. This limits our ability
to confidently generalize these results to the whole population of those in treatment.
This study presents a first, limited investigation into the experiences of stigmatization in a group of
people in recovery from substance abuse. As there was no comparison group, this limits our ability to
speak to which experiences of stigmatization might be at particularly high rate in this population versus
other stigmatized populations (e.g., mentally ill, HIV+individuals). Future studies would usefully include
multiple stigmatized groups to allow for examination of processes of stigmatization that might be shared
versus divergent across groups.
4.8. Implications for practice
While preliminary, the results of this study suggest that stigmatization is commonly perceived by
people in recovery. As the primary organizational point of contact for people in recovery, it may be
important for addictions treatment centers to attend to the impact of stigma on their clients. Policies and
procedures could be examined for the possibility of their contributing to stigma towards clients. There
may also be room for intervention with service providers, who unfortunately are not immune to
stigmatizingtheir ownclients. Onestudy(Hayes,Bissetet al., 2004;Hayes,Strosahl etal., 2004) haseven
found preliminary evidence for an intervention based on Acceptance and Commitment Training that may
successfully reduce stigmatizing attitudes and behavior in counselors.
This study presents a unique, but limited addition to an underexamined area of research: stigma in
substance abuse. As a beginning study, it brings up more questions than answers, but it may open a
pathway for other researchers to follow. We hope that others will pick up the challenge and begin to
answer some of the questions brought up by this study and help us understand how generalizeable these
results are to other people in recovery.
1344 J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
The present project was funded by a grant from the Center for Substance Abuse Treatment, Substance
Abuse and Mental Health Services Administration, Grantee TI12899. This project was designed and
implemented as part of the Nevada Practice Improvement Collaborative.
Cook, D. R. (1987). Measuring shame: The Internalized Shame Scale. Alcoholism Treatment Quarterly, 4, 197−215.
Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614−625.
Corrigan, P., & Watson, A. C. (2002). The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice,
Cunningham, J. A., Sobell, L. C., Sobell, M. B., Agrawal, S., & Toneatto, T. (1993). Barriers to treatment: Why alcohol and drug
abusers delay or never seek treatment. Addictive Behaviors, 18, 347−353.
Flanagan, J. C. (1978). A research approach to improving our quality of life. American Psychologist, 33, 138−147.
Fulton, R. (1999). The stigma of substance use: A review of the literature. A report submitted to the committee on stigma and
addiction at the Centre for Addiction and Mental Health.
Fulton, R. (2001). The stigma of substance use and attitudes of professionals: A review of the literature. A report submitted to the
committee on stigma and addiction at the Centre for Addiction and Mental Health.
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall, Inc.
Greenwald, A. G., Nosek, B. A., & Banaji, M. R. (2003). Understanding and using the Implicit Association Test: I. An improved
Scoring Algorithm. Journal of Personality and Social Psychology, 85, 197−216.
Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., et al. (2004). The impact of acceptance and
commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse
counselors. Behavior Therapy, 35, 821−835.
Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., et al. (2004). Measuring experiential
avoidance: A preliminary test of a working model. The Psychological Record, 54, 553−578.
area. Journal of Studies on Alcohol, 43, 273−288.
Klingeman, H. K. H. (1991). The motivation for change from problem alcohol and heroin use. British Journal on Addiction, 86,
Kushner, M. G., & Sher, K. J. (1991). The relation of treatment fearfulness and psychological service utilization: An overview.
Professional Psychology: Research and Practice, 22, 196−203.
Link, B. G. (1987). Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of
rejection. American Sociological Review, 52, 96−112.
Link, B. G., Cullen, F. T., Struening, E., Shrout, P., & Dohrenwend, B. P. (1989). A modified labeling theory approach in the area
of mental disorders: An empirical assessment. American Sociological Review, 54, 100−123.
Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., & Phelan, J. C. (2001). Stigma as a barrier to recovery: The
consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric Services, 52, 1621−1626.
Link, B. G., Struening, E. L., Rahav, M., Phelan, J. C., & Nuttbrock, L. (1997). On stigma and its consequences: Evidence from a
longitudinal study on men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behavior,
Link, B. G., Yang, L. H., Phelan, J. C., & Collins, P. Y. (2004). Measuring mental illness stigma.Schizophrenia Bulletin,30, 511−541.
Luoma, J.B., Kohlenberg, B.S., Hayes, S.C., Bunting, K., & Rye, A.K. (in preparation). Reducing the stigma of substance abuse
through acceptance and commitment therapy: Model, manual development, and pilot outcomes.
Page, S. (1983). Psychiatric stigma: Two studies of behaviour when the chips are down. Canadian Journal of Mental Health, 2,
Page, S. (1993). Effects of the mental illness label in 1993: Acceptance and rejection in the community. Journal of Health and
Social Policy, 7, 61−68.
1345 J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346
Penn, D. L., & Martin, J. (1998). The stigma of severe mental illness: Some potential solutions for a recalcitrant problem. Download full-text
Psychiatric Quarterly. Special Issue: New Frontiers in the Psychiatric Rehabilitation of Schizophrenia, 69, 235−247.
Perlick, D. A., Rosenheck, R. A., Clarkin, J. F., Sirey, J. A., Salahi, J., Struening, E. L., et al. (2001). Stigma as a barrier to
recovery: Adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar effective disorder.
Psychiatric Services, 52, 1627−1632.
Ritsher, J. B., & Phelan, J. C. (2004). Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry
Research, 129, 257−265.
Room, R. (2004). Stigma, social inequality, and alcohol and drug use. Drug and Alcohol Review, 24, 143−155.
Rosenfield, S. (1997). Labeling mental illness: The effects of received services and perceived stigma on life satisfaction.
American Sociological Review, 62, 660−672.
Scambler, G. (1998). Stigma and disease: Changing paradigms. Lancet, 352, 1054−1055.
Semple, S. J., Grant, I., & Patterson, T. L. (2005). Utilization of drug treatment programs by methamphetamine users: The role of
social stigma. The American Journal on Addictions, 14, 367−380.
Sher, I., McGinn, L., Sirey, J. A., & Meyers, B. (2005). Effects of caregivers' perceived stigma and causal beliefs on patients'
adherence to antidepressant treatment. Psychiatric Services, 56, 564−569.
Sirey,J.A., Bruce, M.L., Alxopoulos,G. S.,Perlick, D., Raue, P., Friedman, S. J.,et al. (2001). Perceived stigma as a predictor of
treatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry, 158, 479−481.
Smart, L., & Wegner, D. M. (1999). Covering up what can't be seen: Concealable stigma and mental control. Journal of
Personality and Social Psychology, 77, 474−486.
Sobell, L. C., Sobell, M. B., & Toneatto, T. (1992). Recovery from alcohol problems without treatment. In N. Heather, W. R.
Miller, & J. Greeley (Eds.), Self-control and the addictive behaviors (pp. 198−242). New York: Maxwell Macmillan.
Starr, S., Campbell, L. R., & Herrick, C. A. (2002). Factors affecting use of the mental health system by rural children. Issues in
Mental Health Nursing, 23, 291−304.
Tuchfeld, B. S. (1981). Spontaneous remission in alcoholics: Empirical observations and theoretical implications. Journal of
Studies on Alcohol, 42, 626−641.
Tucker, J. A., Vuchinich, R. E., & Gladsjo, J. A. (1994). Environmental events surrounding natural recovery from alcohol
problems. Journal of Studies on Alcohol, 55, 401−411.
Vieweg, B. W., & Hedlund, J. L. (1983). The General Health Questionnaire (GHQ): A comprehensive review. Journal of
Operational Psychiatry, 14, 74−81.
Wahl, O. F. (1999). Mental health consumers' experience of stigma. Schizophrenia Bulletin, 25, 467−478.
Wright, E. R., Gronfein, W. P., & Owens, T. J. (2000). Deinstitutionalization, social rejection, and the self-esteem of former
mental patients. Journal of Health and Social Behavior, 41, 68−90.
1346J.B. Luoma et al. / Addictive Behaviors 32 (2007) 1331–1346