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Improving healthcare for substance users:
the moderating role of psychological
flexibility on stigma, mental health, and
quality of life
Mahvia Gull, Zartashia Kynat Javaid, Kamran Khan and Husnain Ali Chaudhry
Abstract
Purpose –Stigma is a major impediment to human rights in health care that causes discrimination,
isolation and the exclusion of individuals from essential health-care services. It fosters fear, leading to
negative stereotyping of individuals based on their social, cultural or health status and undermines their
dignity and respect, consequently violating their right to health. Therefore, the purpose of this study is to
evaluate the moderating role of psychological flexibility in the relationship between stigma (enacted,
anticipated and internalized), mental health and the quality of life of substance users.
Design/methodology/approach –This study was based on a cross-sectional design and included 200
male patients with an age rangeof 18–65 years from 23 rehabilitation centers in four cities in Pakistan. The
purposive sampling technique was used, and the sample size ranged from 4 to 23 participants for each
site. Four scales were used to measure stigma, general mental health, quality of life and psychological
flexibility in substance users.
Findings –The data were analyzed using SPSS and Smart PLS, which showed that stigma (enacted,
anticipated and internalized) had a detrimental effect on substance users’ mental health and quality of
life. Additionally, psychological flexibility acts as an efficient moderator betweenthem.
Originality/value –This research unveils the moderating role of psychological flexibility in mitigating
stigma’s adverse effects on individuals with substance use disorders. Future investigations should
prioritize interventions aimed at enhancing psychological flexibility to ameliorate the repercussions of
stigma, ultimately enhancing the well-being and quality of life of substance users.
Keywords Stigma, Mental health, Quality of life, Psychological flexibility, Substance use disorder
Paper type Research paper
Introduction
In accordance with the Universal Declaration of Human Rights, “all human beings are born
free and equal in dignity and rights”. The Department of Health explicitly states that human
rights are fundamental to health care in general (Cachat-Rosset and Klarsfeld, 2023;Dick,
2018;Qu, 2022). In its 2007 publication, Human Rights in Healthcare: A Framework for
Local Action, the Department of Health states that human rights should be viewed as “a
vehicle for making principles such as dignity, equality, respect, fairness, and autonomy
central to our lived human experience” (p. 13). Therefore, it is believed that fundamental
values such as respect and dignity support the rights that are explicitly stated in human
rights legislation (Riggirozzi, 2021;Md. Tahir et al.,2022). Establishing human rights “real”
in the experiences of those receiving medical care is the main goal. A significant turning
point in the emphasis on human rights for people receiving mental health services was the
incorporation of the perspective of human rights in the work of mental health. The central
Mahvia Gull is based at the
Department of Psychology,
Foundation University,
Rawalpindi Campus 2,
Rawalpindi, Pakistan.
Zartashia Kynat Javaid is
based at the Department of
Applied Psychology,
Government College
University Faisalabad,
Faisalabad, Pakistan.
Kamran Khan is based at
the Department of Business
Administration, COMSATS
University Islamabad, Wah
Cantt, Pakistan.
Husnain Ali Chaudhry is
based at the Department of
Business Administration,
Preston University, Kohat,
Pakistan.
Received 29 August 2023
Revised 22 October 2023
Accepted 28 October 2023
DOI 10.1108/IJHRH-08-2023-0072 ©Emerald Publishing Limited, ISSN 2056-4902 jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
claim of Mann et al.’s (1994) mental health and human rights perspective is that promoting
human rights and promoting health are inextricably linked and are both necessary for
human well-being (Kola et al.,2021). Priority must be placed on the state’s responsibility to
recognize the varied impacts of specific mental health problems on a marginalized or
stigmatized group (Parsons et al.,2019;Gatenio Gabel and Mapp, 2020). This study begins
by emphasizing the need to consider stigma and discrimination as violations of the human
rights and dignity of individuals with substance use disorders (SUDs). It examines the
impact of stigma on the mental health and quality of life of substance users and the role of
psychological flexibility in health care. Recognizing that a great deal of research is being
conducted from a variety of perspectives on the notion of human rights, few consider
stigma among substance users to be the illicit core problem for human rights.
In the international context of human rights, they are regarded as intrinsic to every individual
and the foundation for equal and undisputable rights (Sæteren and Na
˚den, 2021).
According to Goffman’s analysis, this explains why we instinctively label as offensive,
perilous or weak those we consider to be different from us in some way (Gull et al., 2022).
Additionally, stigmatizing a person who is different invalidates her entire being and reduces
her to a lower status (Zandy, 2019). As a result, someone who is stigmatized might believe
that he is not accepted or treated equally, which can lead to feelings of worthlessness,
shame and self-hatred (Wakeman, 2019). Therefore, individuals who struggle with both
mental health and substance use issues are exposed to a variety of stigmatizing factors that
work together to jeopardize their mental health (Gostin et al.,2020).
Investigations into the stigmatization of people with SUDs have been conducted from a
variety of perspectives, including those of the general public, health-care providers, family
and patients receiving substance abuse treatment. There is a lot of evidence that health
workers have stigmatizing attitudes and practices (Corrigan, 2004,Schulze, 2007), and
clients of mental health services have said that both general practitioners and psychiatrists
treated them in a stigmatizing way (Thornicroft et al., 2007). According to Stuart et al.
(2011), coercive treatment threats, inadequate information, the perception of a lack of
capacity for responsible action and patronizing or humiliating behavior are examples of
discrimination and stigma in health-care settings.
Furthermore, stigma exerts a profound and multifaceted impact on individuals grappling
with SUDs. This negative societal perception and discrimination engender a pervasive
sense of shame and self-blame, further compounding the already formidable challenges of
addiction (Chang et al.,2023). Stigmatizing attitudes can lead to social isolation, eroding
vital support networks precisely when they are needed most. Moreover, the internalization of
stigma can erode self-esteem and self-efficacy, undermining one’s belief in their ability to
overcome addiction. The constant fear of judgment and discrimination can lead to
heightened stress, anxiety and depression, exacerbating the burden of SUDs (Chang et al.,
2022;Saffari et al.,2022). This cumulative toll not only impedes recovery but also
perpetuates a cycle of poor mental health, ultimately diminishing the quality of life for those
already struggling with SUDs (Fung et al., 2022).
To comprehend the comprehensive impact of stigma on individuals with SUDs and their
mental health-related health-care rights, it is crucial to delineate how stigma operates at
various societal levels and within individuals (Buribayev et al.,2020;Gul and Aqeel, 2021).
Furthermore, drug use can influence the extent and strength of stigma manifestation
(Williamson, 2022). Stigma can be categorized into three distinct types, including self-
stigma, enacted stigma and anticipated stigma. Enacted stigma, also known as perceived
discrimination, refers to individuals’ beliefs regarding past experiences of discrimination
(Wakeman, 2019;Chang et al., 2020). Compared to individuals suffering from other forms of
mental illness, people with SUDs are more likely to encounter stigma and discrimination
from the public. Moreover, those actively engaged in SUDs may experience greater public
stigma than those in recovery (Conklin, 2021).
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
On the contrary, anticipated stigma, also known as felt stigma, refers to the extent to which
individuals believe they will face discrimination in the future. Furthermore, prior research has
demonstrated that anticipated stigma is a robust predictor of psychological distress
(Camacho and Quinn, 2023;Van Brakel et al.,2019). When individuals anticipate stigma
within the health-care system, they are more likely to avoid or underuse essential health-
care services (Quinn et al., 2019).
Internalized stigma occurs when a person with a SUD internalizes negative stereotypes
(“Because I have a mental illness, I am incompetent”) that lead to behavioral futility and
other psychological adversities such as demoralization, hopelessness, lowered self-esteem
and self-efficacy, decreased treatment adherence, decreased quality of life and limited
social support, with overall poor outcomes (Wakeman, 2019). According to Harnish et al.
(2012), self-stigma is a subjective process characterized by “negative feelings (about
oneself), maladaptive behavior, identity transformation, or stereotype endorsement”. It
refers to the negative self-perceptions and demoralization that result when societal stigma
about mental health is internalized and applied to the self (Degan et al.,2021;Chang et al.,
2023).
According to earlier research (Jackson et al., 2010; Earnshaw et al.,2013), the causes of
stigma also matter. Because of this, the stigma framework postulates that stigma will
manifest differently in different people (for example, stereotypes about pill-shopping from
doctors, discrimination via lack of trust, social estrangement from family members, legal
consequences, etc.) and the impact of stigma may vary depending on from whom it is
experienced. The stigma associated with SUDs can have negative effects on a person’s
quality of life and their general mental health (GMH), mainly because of a lack of life
opportunities such as employment, accommodation, education, civic engagement,
emotional well-being, functional impairment, dual diagnosis, relapse risk and coping
strategies (Alonso et al., 2009;Chang et al.,2016). Primarily, the major effect is on quality of
life (QOL), which we took into account in this study as defined by the World Health
Organization (WHO) as “individuals perception of their place in life in the light of the society
and system of values in which they live and in accordance with their goals, expectations,
standards, and concerns” (Cai et al.,2021;Saffari et al., 2022). The QOL provides a non-
symptom-based evaluation of how patients believe they are doing in various aspects of their
lives and how treatment affects the burden of SUD (Ates et al.,2023). In addition, it has
been shown that a higher QOL prior to treatment predicts better outcomes for patients with
SUDs (Ko
¨hlerov
aet al.,2023). As a result, QOL is increasingly recognized as an important
construct in SUD research and clinical practice (Chang et al., 2014).
To reduce the impact of stigma in different areas of life during the past ten years, one
process that might be pertinent for stigma reduction is psychological flexibility, the capacity
to actively embrace one’s private experiences in the present moment and engage or
disengage in patterns of behavior in the service of chosen values (S
anchez-Mill
an et al.,
2022;Hayes et al.,2006). This process, as it applies to stigma, involves a combination of
flexible awareness of one’s private experiences in the present moment, including
stigmatizing thoughts; defusion of stigmatizing thoughts (e.g. recognizing thoughts as
merely thoughts as opposed to literal truths); and willingness to have stigmatizing thoughts
as opposed to ineffectual forms of avoidance (such as thought suppression or avoiding
situations where stigmatizing thoughts occur); relating to oneself and others apart from
one’s thoughts and feelings about them; clarifying valued patterns of actions during social
interactions; or adhering to patterns of valued engagement with others, even when
stigmatizing thoughts and feelings seem to get in the way (Doorley et al., 2020;Hayes et al.,
2006). Similar to the process of stigmatization, a behavioral pattern labeled as greater
psychological flexibility is under verbal control. Conversely, greater psychological flexibility
is conceived as being under the contingency of positive reinforcement and responsive to
the nature and change of the environment (Twohig et al.,2015). In contrast, stigmatization is
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
predominantly under the contingency of negative reinforcement, including verbal
entanglement and avoidance (Wilson and Murrell, 2004). In terms of mental health stigma, if
a person’s behavior choices are flexible and sensitive, the literal influence of a stigma-
related verbal network is unlikely, and a person is seen more as a unique person than as a
collection of verbal labels or categories (Hayes et al.,2002). Addressing and mitigating
psychological flexibility can have a significant impact on improving the well-being and
treatment outcomes of individuals struggling with SUDs and mental health issues.
Scientific studies play a crucial role in informing policies, interventions and health-care practices
in different countries. In the context of Pakistan, understanding the intricacies of SUDs, stigma,
mental health and quality of life through a scientific lens is imperative for several reasons. First,
SUDs have become a significant public health concern globally (Room et al., 2001). The
prevalence of SUDs, including drug addiction and alcoholism, continues to rise rapidly, leading
to significant social, economic and health repercussions (Crisp et al.,2000). Scientific research
is instrumental in identifying the underlying causes, risk factors and extent of the problem,
enabling policymakers and health-care professionals to develop effective prevention and
treatment strategies (Schomerus et al.,2011). Second, a scientific study can shed light on the
specific types of stigma prevalent in Pakistan and their impact on mental health and quality of
life. By identifying these factors, intervention programs can be designed to combat stigma
effectively and promote a more inclusive and supportive society for substance users. Third,
mental health is intricately linked to SUDs. Individuals with substance abuse issues often
experience co-occurring mental health disorders such as anxiety, depression and post-
traumatic stress disorder (Buribayev et al.,2020). Scientific studies examining the relationship
between mental health and substance use can facilitate a better understanding of the complex
interplay between these conditions. This knowledge can inform the development of integrated
treatment approaches that address both mental health and substance abuse effectively, thus
improving the overall well-being and quality of life of substance users. Lastly, considering
human rights in health care is essential for promoting equitable access to prevention, treatment
and rehabilitation services for substance users (Gul and Aqeel, 2021). By examining the role of
psychological flexibility as a moderating factor, a scientific study can provide insights into the
barriers faced by substance users and how these barriers intersect with societal stigmatization
and mental health issues. Such research can inform the development of policies that safeguard
the rights of substance users, ensuring that they receive compassionate and evidence-based
care that respects their dignity and autonomy.
Therefore, the aim of the study is to investigate stigmatizing attitudes toward people with
SUDs from different perspectives (the general public, GPs, mental health and addiction
specialists and clients in treatment for SUDs). The research questions are as follows:
RQ1. Stigma (enacted, anticipated or internalized) is negatively associated with mental health.
RQ2. Stigma (enacted, anticipated or internalized) is negatively associated withquality of life.
RQ3. Psychological flexibility is positively associated with mental health.
RQ4. Psychological flexibility is positively associated with quality of life.
RQ5. Psychological flexibility moderates the relationship between stigma, its type, quality
of life and mental health, where higher psychological flexibility weakens the
negative impact of stigma on mental health and quality of life. Figure 1 presents the
study model.
Method
Study design
This study used a cross-sectional research design and purposive sampling techniques for
participant selection. The study was conducted within the timeframe of January–June 2023.
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
Participants
The study included 200 male patients undergoing SUD treatment. Their average age was
35 years (standard deviation ¼10.3), spanning from 18 to 65 years. We collected data from 23
rehabilitation centers situated across four distinct locations in Pakistan: Rawalpindi (5 centers),
Islamabad (7 centers), Peshawar (7 centers) and Lahore (4 centers). Each of these centers
provided both residential and outpatient services for alcohol and substance-use treatment.
The number of participants in each center varied, ranging from 4 to 23 participants per center,
reflecting the diversity and distribution of participants across the study sites.
Inclusion criteria
Broad eligibility standards that were representative of real-world traits were used. The study
team and the treatment team met to determine who was qualified to participate. They had to
be between the ages of 18 and 65, have a diagnosis of an SUD based on the DSM-V’s
structured clinical interview, indicate mild to moderate severity, specify early to sustained
remission and include all ten classes of drugs except coffee. Participants need to have
completed two months of residential treatment with a general orientation toward the
universal 12-step programs for addiction recovery, psychotherapy, psychosocial programs,
medication management and general health care.
Exclusion criteria
We excluded those who could not participate, whose significant cognitive impairment, in the
opinion of the unit staff, would make it impossible for them to participate, or whose presence
of a serious disturbance would make it impossible for them to follow the rules of informed
consent or the study protocol.
Instruments
Initial screening. At the outset, a structured demographic sheet was administered to gather
baseline data on a variety of demographic factors (age, education, marital status,
Figure 1 Framework conceptualizing the variables of the study
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
socioeconomic status, etc.), the duration of the illness, the reasons for drug use, information
about relapses, the length of treatment, a brief personal and family history, a list of
psychiatric medications and other mental health components.
Substance-use stigma mechanism scale. Smith et al. devised substance-use stigma
mechanism scale in 2016 to distinguish between two stigma sources (family members and
health-care professionals) that may stigmatize a specific population of substance users. It
describes the stigma mechanisms (implemented, anticipated and internalized) associated
with substance abuse. It evaluates the following items and is comprised of five subscales:
three items related to enacted stigma from family (e.g. “Family members have looked down
on me”) and three items related to enacted stigma from health-care workers (e.g. “Health-
care workers have given me poor care”). In addition, three items concern anticipated
stigma from family members (e.g. “family members will treat me differently”) and three items
concern anticipated stigma from health-care professionals (e.g. “health-care professionals
will provide me with substandard care”). This list contains six items related to internalized
stigma, such as “I feel ashamed of having used alcohol and/or drugs”. Each of the 18 total
items has a five-point Likert scale score. Each participant’s response ranges from 1 (least
stigmatizing) to 5 (most stigmatizing) for each item. The scale does not contain any
products with reverse coding. Cronbach’s alpha values for subscales quantifying
substance-use stigma were initially between 0.90 and 0.95 (Smith et al.,2016).
General health questionnaire
GMH was assessed using the 12-item variant of the General Health Questionnaire (GHQ-
12; Goldberg et al., 1997). The GHQ-12 is a 12-item self-report scale that is extensively
used and well validated for screening the general population for mental health problems.
Higher scores indicate greater psychological distress. Participants respond on a four-point
Likert scale, typically varying from “better than usual” to “much worse than usual,” resulting
in scores ranging from 0 to 36. GHQ-12 has demonstrated excellent internal consistency,
with Cronbach’s alpha ranging from 0.82 to 0.88 (Goldberg et al.,1997;Goldberg and
Williams, 1988; Muto et al., 2011). Studies have reported that the GHQ has a stable factor
structure and excellent predictive validity (Goldberg et al.,1997;Vallejo et al.,2007).
Quality of life scale
Based on an integrative theory of QOL, the QoL-5 is a generic, validated instrument
encompassing overall quality of life (Lindholt et al.,2002). The QOL questionnaire was
selected because the instrument has been described as beneficial for measuring the
overall QOL of samples from the general population and across various illness domains
(Ventegodt et al., 2003a,2003b). It consists of five subjective QOL statements: two
questions on mental and physical health, two questions on the quality of the relationship
with significant others (partners and friends) and one question on existential QOL, which
refers to the relationship with oneself. Responses are scored on a five-point scale ranging
from very poor to very excellent. It has also been demonstrated to be a valid and reliable
instrument (Ventegodt et al., 2003a,2003b).
Acceptance and action questionnaire
The Acceptance and Action Questionnaire (AAQ-2; Hayes et al., 2004) is the most
commonly used measure of psychological rigidity and experiential avoidance. The AAQ-2
consists of seven items that assess the capacity to tolerate difficult or painful internal
experiences in pursuit of personal values. On a seven-point Likert scale, responses range
from “never true” (1) to “always true” (7). Lower scores reflect psychological flexibility,
whereas higher scores reflect experiential avoidance (Bond et al.,2013). In validation
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
investigations, the AAQ-2 has demonstrated high internal consistency, with Cronbach’s
alpha ranging between 0.86 and 0.90 (Bond et al.,2013;Fledderus et al., 2010).
Procedure
Different rehabilitation facilities were visited in an effort to find participants. Of the 28
rehabilitation facilities that were visited, 23 gave permission for data collection. The
average weekly treatment schedule at these centers included 34h of therapy,
psychoeducational sessions or educational groups. First, we informed the
rehabilitation administration about our project, provided questionnaires and obtained
written permission for data collection. On a designated day, we interviewed
interested participants in a group room, inviting those who met inclusion criteria.
Prior to the administration of the actual surveys, the research team gave each
prospective participant a broad overview of the study and a set of eligibility-
determining evaluation questions. It was highlighted that participation was entirely
voluntary. The researcher went over the consent paperwork, gave participants a copy,
collected the signed consent forms and reviewed them again. After that, participants
answered a series of questions, which normally take about 30min to complete.
Following that, the study concluded, and the researcher expressed gratitude to all the
participants for their involvement.
Statistical analysis
SPSS was used for demographic analysis, while all other analyses were conducted using
Smart PLS. The structural equation model was used to do moderation analyses for all
dependent variables, which are GMH and quality of life, to look at the role of psychological
flexibility in the relationship between enacted, anticipated and internalized stigma. The
model enables testing the conditional effect (i.e. the effect of one variable on another,
conditioned on a third or interaction) by estimating the effect of X on Y at a certain point (or
points) along the moderator and testing whether this effect is significant. The statistical
significance of simple moderations was established at the 95% confidence intervals (CIs).
Result
Demographics
The average age of the 200 male participants was 35 years. The vast majority of them are
middle-class, married and uneducated workers. Marijuana is the most frequently used
narcotic. See Table 2 for a comprehensive breakdown of demographics.
Cronbach’s alpha, composite reliability (CR) and average variance extracted (AVE) are vital
metrics for assessing the internal consistency, reliability and convergent validity of latent
constructs. These metrics enable researchers to ensure the robustness of the measurement
model, enhancing the accuracy of the overall analysis. Table 2 shows all three. As a
measurement of reliability, Cronbach’s alpha was calculated for each construct. The value
of all constructs varied from 0.74 to 0.91, which is higher than the minimum threshold of 0.7.
Furthermore, CR was used to analyze the reliability of variables. All values were between
0.83 and 0.94, exceeding the threshold of 0.7 (see Table 1). On the other hand, for
convergent validity, AVE was considered to hold a threshold value greater than 0.5.
A standardized coefficient and effect table presents the strength and direction of
relationships between variables in a standardized manner and provides a clear reference
for assessing their relative influence in a statistical model. Table 3 aids in understanding the
significance and contributions of different factors within the analysis. The table depicts the
path and effect of a significant negative relationship between anticipated and internalized
stigma and GMH and quality of life. Whereas enacted stigma is negatively significantly
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
associated with quality of life and positively significant with GMH. Furthermore, the
moderator, which is psychological flexibility, is positively significant between internalized
stigma and GMH, whereas it is negatively non-significant in quality of life. Also,
psychological flexibility is negatively significant between enacted stigma, GMH and quality
of life and positively significant between internalized stigma, GMH and quality of life. The
complete model’s path diagram is depicted in Figure 2.
Table 2 Constructs validity and reliability
Constructs
a
CR AVE
Anticipated stigma 0.863 0.907 0.581
Enacted stigma 0.793 0.848 0.549
Internalized stigma 0.749 0.834 0.581
General mental health 0.879 0.892 0.510
Psychological flexibility 0.917 0.942 0.663
Quality of life 0.897 0.991 0.612
Notes:
a
= Cronbach’s alpha; CR = composite reliability; AVE = average variance extracted
Source: Table by the authors
Table 1 Sample characteristics (n¼200)
Variables n%
Age (years), M 6SD 35.03 8.20
Duration of substance use 7.37 4.85
(years), M 6SD
Education
Illiterate 74 37
Elementary 57 28
High school 51 25
Graduate 18 9
Marital status
Single 89 44.5
Married 111 55.5
Job
Student 44 22
Officer 21 10.5
Worker 81 40.5
Self-employment 54 27
Socio-economic status
Lower 27 13.5
Middle 144 72
High 29 14.5
Substance type
Alcohol use 10 5
Marijuana 51 25.5
Cocaine 13 6.5
Opiates 38 19
Amphetamine 31 15.5
Sedatives 29 14.5
Other 28 14
Any other illness
Yes 61 30.5
No 139 69.5
Notes: N= number of participants; % = percentile
Source: Table by the authors
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The path model was analyzed to inspect the direct and indirect path estimates and to
analyze the moderating effect of the study model. The structural model was run through
bootstrapping (5,000) to generate path coefficients (beta), t-values and p-values. Table 4
shows the moderation analysis of this study, where AS significantly negatively influenced
GMH (
b
¼0.142, SE ¼0.030, p<0.001) and QOL (
b
¼0.068, SE ¼0.034, p<0.001),
and the interaction of PF and AS moderated the positive influence between GMH (
b
¼
0.115, SE ¼0.044, p<0.001) and QOL (
b
¼0.336, SE ¼0.062, p<0.001), which shows
that a higher level of PF weakens the negative strength of the relationship between AS,
GMH and QOL. Also, ES significantly negatively influenced GMH (
b
¼0.134, SE ¼0.026,
p<0.001) and QOL (
b
¼0.158, SE ¼0.030, p<0.001) and the interaction of PF and ES
Table 3 Standardize coefficients and effects
Path Total effect
Anticipated stigma !General mental health 0.505
Anticipated stigma !Quality of life 0.110
Enacted stigma !General mental health 1.026
Enacted Stigma !Quality of life 0.142
Internalized stigma !General mental health 0.138
Internalized stigma !Quality of life 0.057
Psychological flexibility !General mental health 0.063
Psychological flexibility !Quality of life 0.021
Psychological flexibility Internalized stigma !General mental health 0.078
Psychological flexibility Internalized stigma !Quality of life 0.013
Psychological flexibility Enacted stigma !General mental health 0.266
Psychological flexibility Enacted stigma !Quality of life 0.026
Psychological flexibility Anticipated stigma !General mental health 0.145
Psychological flexibility Anticipated stigma !Quality of life 0.064
Notes: p<0.001; indicates the significance of the p-value
Source: Table by the authors
Figure 2 Path diagram
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moderated the positive influence between GMH (
b
¼0.107, SE ¼0.055, p<0.001) and
QOL (
b
¼0.210, SE ¼0.063, p<0.001), which shows that a higher level of PF weakens the
negative strength of the relationship between ES, GMH and QOL. Besides, IS significantly
positively influenced GMH (
b
¼0.059, SE ¼0.614, p<0.001) and QOL (
b
¼0.418, SE ¼
0.180, p<. 001) and the interaction of PF and IS moderated the positive influence between
GMH (
b
¼0.415, SE ¼0.157, p<0.001) but negatively influenced QOL (
b
¼0.012, SE ¼
0.071, p<0.001), which shows that a higher level of PF weakens the negative strength of
the relationship between IS and GMH but is not significant in QOL.
Discussion
The stigma associated with SUDs has been widely acknowledged as a significant barrier
to effective health-care and social integration. Stigmatizing attitudes and discriminatory
practices violate the fundamental human rights of affected individuals to receive appropriate
medical treatment and support. Recognizing SUDs as a health issue rather than a moral
failing is crucial for de-stigmatization efforts. Integrating psychological flexibility into
health-care interventions aligns with the principles of human rights, ensuring that individuals
receive care that addresses both their medical and psychological needs. Consequently, the
purpose of the study is to assess the moderating role of psychological flexibility on the
relationship between type of stigma, GMH and quality of life. The findings of this study
allow us to comprehend the stigma associated with substance use from the perspectives of
consumers, family members and health-care professionals. The most prevalent stigmatizing
behaviors described came from family, self-help groups, the general public, clients of
addiction treatment centers and medical professionals. These behaviors included mocking,
judging, distance, apathy, physical and verbal abuse and overprotection (Simha et al.,
2021). The aggregate results of this investigation confirmed the study’s primary objectives.
Consistent with previous research, this study provides evidence that enacted, anticipated
and internalized stigma are detrimental to individuals’ mental health and quality of life. The
presence of enacted and anticipated stigma highlights the importance of creating inclusive
environments and addressing discriminatory practices to improve the overall well-being of
affected individuals (Camacho and Quinn, 2023;Van Brakel et al.,2019). The moderating
effect of psychological flexibility further emphasizes its potential as a protective factor
against the impact of enacted and anticipated stigma. Psychological flexibility
encompasses the ability to adapt one’s behavior and thoughts to changing circumstances
Table 4 Measurement of inner model
Constructs
b
SE t-Statistics p-Values Decision
AS !GMH 0.142 0.030 4.680 0.001 Supported
AS!QOL 0.068 0.034 2.036 0.042 Supported
ES !GMH 0.134 0.026 5.219 0.001 Supported
ES !QOL 0.158 0.030 5.212 0.001 Supported
IS !GMH 0.059 0.028 2.090 0.037 Supported
IS !QOL 0.418 0.041 10.323 0.001 Supported
PF !GMH 0.376 0.614 3.877 0.001 Supported
PF !QOL 0.048 0.180 0.115 0.909 Not supported
PF IS !GMH 0.415 0.157 2.656 0.003 Supported
PF IS !QOL 0.012 0.071 0.183 0.855 Not supported
PF ES !GMH 0.107 0.055 1.964 0.050 Supported
PF ES !QOL 0.210 0.063 3.318 0.001 Supported
PF AS !GMH 0.115 0.044 2.649 0.008 Supported
PF AS !QOL 0.336 0.062 5.404 0.001 Supported
Notes: AS = anticipated stigma; GMH = general mental health; PF = psychological flexibility; IS = internalized
stigma; QOL = quality of life; ES = enacted stigma
Source: Table by the authors
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
while staying connected to personal values. Therefore, individuals with higher levels of
psychological flexibility may possess stronger coping mechanisms, resilience and adaptive
responses to stigma experiences (Hayes et al., 2006).
Contrary to the hypothesis, psychological flexibility did not moderate the relationship
between internalized stigma and mental health or quality of life. This suggests that the
detrimental effects of internalized stigma may be deeply ingrained, making it more
challenging to mitigate through psychological flexibility alone. Other factors, such as
severity of substance use, co-occurring mental health disorders or social support, may have
played a more substantial role in determining mental health and quality of life outcomes
(Denton, 2014). Although crucial, psychological flexibility might have taken a back seat to
these other factors. Future research could explore alternative factors or interventions that
may enhance the well-being of individuals significantly affected by internalized stigma.
Overall, this study underscores the importance of targeting stigma reduction efforts across
all dimensions and emphasizes the role of psychological flexibility as a valuable asset in
mitigating the adverse impact of enacted and anticipated stigma. Moving forward,
interventions focusing on building psychological flexibility skills and addressing internalized
stigma are needed to promote positive mental health outcomes and enhance the quality of
life for individuals with mental health conditions.
Implications
This study sheds light on the negative impact of stigma and discrimination, especially on
those who are substance users, and also highlights the interconnectedness of mental
health, substance use, stigma and quality of life. It underscores the need for integrated care
models that address both mental health and SUDs simultaneously. This integration can help
address the stigma-related challenges faced by individuals with SUDs and improve their
overall well-being. Further, it expands the understanding of the negative consequences of
stigmatization and provides empirical evidence to support the need for anti-stigma
interventions in health-care settings. Also, these findings suggest that promoting
psychological flexibility can be an effective strategy to enhance the well-being of individuals
facing stigmatization. Consequently, health-care providers can incorporate techniques that
foster psychological flexibility, such as acceptance and commitment therapy, into their
treatment approaches to improve outcomes for substance users. Overall, it provides
valuable insights for health-care professionals, policymakers and researchers, with
implications for the development of effective interventions and policies to improve the well-
being of individuals facing substance-use-related stigma.
Limitations and suggestions
The current study has a few limitations. First, this study used a small sample size and only
included male participants; future research should investigate a larger and more diverse
population. Second, this was a cross-sectional study; future research should test the
relationships proposed with this study in longitudinal studies using different sampling
techniques to increase generalization of the study. In this investigation, there is a single
moderator. Future research should include additional variables or devise experimental
studies that incorporate whole-body third-wave therapy. Additionally, the present study did
not assess the severity of SUD among the participants. Therefore, future studies could use
validated instruments such as the ASSIST-11 to quickly measure the severity of SUD.
Conclusion
In conclusion, this research has the potential to drive evidence-based interventions, reduce
stigma, improve mental health outcomes and promote the rights and well-being of
substance users. Only through rigorous scientific investigation can we comprehensively
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
address the challenges faced by this vulnerable population and work toward creating a
more inclusive and supportive health-care system for substance users globally.
References
Alonso, J., Buron, A., Rojas-Farreras, S., De Graaf, R., Haro, J.M., De Girolamo, G., and ESEMeD/
MHEDEA 2000 Investigators (2009), “Perceived stigma among individuals with common mental
disorders”, Journal of Affective Disorders, Vol. 118 Nos 1/3, pp. 180-186.
Ates, N., Unubol,B., Bestepe, E.E. and Bilici, R. (2023),“The effect of perceived social support on quality
of life in Turkish men with alcohol, opiate and cannabis use disorder”, Journal of Ethnicity in Substance
Abuse, Vol. 22 No. 2,pp. 316-336.
Bond, F.W., Hayes, S.C. and Barnes-Holmes, D. (2013), “Psychological flexibility, ACT, and
organizational behavior”, Acceptance and Mindfulness at Work, Taylor and Francis, Routledge,
pp. 25-54.
Buribayev, Y., Khamzina, Z., Belkhozhayeva, D., Meirbekova, G., Kadirkulova, G. and Bogatyreva, L.
(2020), “Human dignity - the basis of human rights to social protection”, WISDOM,Vol.16No.3,
pp. 143-155, doi: 10.24234/WISDOM.V16I3.404.
Cachat-Rosset, G. and Klarsfeld, A. (2023), “Diversity, equity, and inclusion in artificial intelligence: an
evaluation of guidelines”, Applied Artificial Intelligence, Vol. 37 No. 1, p. 2176618, doi: 10.1080/
08839514.2023.2176618.
Cai, T., Verze, P. and Bjerklund Johansen, T.E. (2021), “The quality of life definition: where are we
going?”, Uro, Vol. 1 No. 1, pp. 14-22.
Camacho, G. and Quinn, D.M. (2023), “Neighborhood ethnic composition and social identity threat: the
mediating role of perceived discrimination”, The Journal of Social Psychology, pp. 1-15.
Chang, C.C., Wu, T.H., Chen, C.Y. and Lin, C.Y. (2016), “Comparing self-stigma between people with
different mental disorders in Taiwan”, Journal of Nervous & Mental Disease, Vol. 204 No. 7, pp. 547-553.
Chang, K.C., Wang, J.D., Tang, H.P., Cheng, C.M. and Lin, C.Y. (2014), “Psychometric evaluation, using
Rasch analysis, of the WHOQOL-BREF in heroin-dependent people undergoing methadone maintenance
treatment: further item validation”, Health and Quality of Life Outcomes, Vol. 12 No. 1, pp. 1-9.
Chang, C.-W., Chang, K.-C., Griffiths, M.D., Chang, C.-C., Lin, C.-Y. and Pakpour, A.H. (2022), “The
mediating role of perceived social support in the relationship between perceived stigma and depression
among individuals diagnosed with substance use disorders”, Journal of Psychiatric and Mental Health
Nursing, Vol. 29 No. 2, pp. 307-316.
Chang, C.-C., Chang, K.-C., Hou, W.-L., Yen, C.-F., Lin, C.-Y. and Potenza, M.N. (2020), “Measurement
invariance and psychometric properties of perceived stigma toward people who use substances (PSPS)
among three types of substance use disorders: heroin, amphetamine, and alcohol”, Drug and Alcohol
Dependence, Vol. 216, p. 108319.
Chang, C.-W., Chen, J.-S., Huang, S.-W., Potenza, M.N., Su, J.-A., Chang, K.-C., Pakpour, A.H. and Lin,
C.-Y. (2023), “Problematic smartphone use and two types of problematic use of the internet and self-
stigma among people with substance use disorders”, Addictive Behaviors, Vol. 147, p. 107807.
Conklin, T.M. (2021), “Mental illness stigma: strategies to address a barrier to care”, Women’s
Healthcare: A Clinical Journal for NPs, Vol. 9 No. 2, doi: 10.51256/whc042116.
Corrigan, P. (2004), “How stigma interferes with mental health care”, American Psychologist, Vol. 59
No. 7, p. 614.
Crisp, A.H., Gelder, M.G., Rix, S., Meltzer, H.I. and Rowlands, O.J. (2000), “Stigmatisation of people with
mental illnesses”, British Journal of Psychiatry, Vol. 177 No. 1, pp. 4-7.
Degan, T.J., Kelly, P.J., Robinson, L.D., Deane, F.P. and Smith, A.M. (2021), “Health literacy of people
living with mental illness or substance use disorders: a systematic review”, Early Intervention in
Psychiatry, Vol.15 No. 6, pp. 1454-1469, doi: 10.1111/eip.13090.
Denton, M. (2014), “Hoping against hope: the prison-to-community transition experience of men with co-
occurring severe mental illness and substance use disorder”.
Dick, D. (2018), “Free and equal in dignity and rights: a national conversation on human rights”, available
at: https://policycommons.net/artifacts/3749949/free-and-equal-in-dignity-and-rights/4555877/
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
Doorley, J.D., Goodman, F.R., Kelso, K.C. and Kashdan, T.B. (2020), “Psychological flexibility: what we
know, what we do not know, and what we think we know”, Social and Personality Psychology Compass,
Vol. 14 No. 12, pp. 1-11.
Earnshaw, V.A., Smith, L.R., Chaudoir, S.R., Amico, K.R. and Copenhaver, M.M. (2013), “HIV stigma
mechanisms and well-being among PLWH: a test of the HIV stigma framework”, AIDS and Behavior,
Vol. 17 No. 5, pp. 1785-1795.
Fledderus, M., Bohlmeijer, E.T., Smit, F. and Westerhof, G.J. (2010), “Mental health promotion as a
new goal in public mental health care: a randomized controlled trial of an intervention enhancing
psychological flexibility”, American Journal of Public Health, Vol. 100 No. 12, p. 2372.
Fung, X.C.C., Chang, K.-C., Chang, C.-C. and Lin, C.-Y. (2022), “Stigma and quality of life in substance
users: Methods and applications”, in Patel, V.B. and Preedy, V.R. (Eds), Handbook of Substance Misuse
and Addictions, Springer, Cham, doi: 10.1007/978-3-030-67928-6_179-1.
Gatenio Gabel, S. and Mapp, S. (2020), “Teaching human rights and social justice in social work
education”, Journal of Social Work Education, Vol. 56 No. 3, pp. 428-441, doi: 10.1080/
10437797.2019.1656581.
Goldberg, D. and Williamas, P. (1988), “A user’s guide to the GHQ NFER-nelson Windsor”.
Goldberg, D.P., Gater, R., Sartorius, N., Ustun, T.B., Piccinelli, M., Gureje, O. and Rutter, C. (1997), “The
validity of two versions of the GHQ in the WHO study of mental illness in general health care”,
Psychological Medicine, Vol. 27 No. 1, pp. 191-197.
Gostin, L.O., Habibi, R. and Meier, B.M. (2020), “Has global health law risen to meet the COVID-19
challenge? Revisiting the international health regulations to prepare for future threats”, Journal of Law,
Medicine & Ethics, Vol. 48 No. 2, pp. 376-381, doi: 10.1177/1073110520935354.
Gul, M. and Aqeel, M. (2021), “Acceptance and commitment therapy for treatment of stigma
and shame in substance use disorders: a double-blind, parallel-group, randomized controlled
trial”, Journal of Substance Use, Vol. 26 No. 4, pp. 413-419, doi: 10.1080/14659891.
2020.1846803.
Gull, M., Aqeel, M., Kanwal, A., Khan, K. and Akhtar, T. (2022), “Cultural adaptation and validation of the
others as shamer scale: a barrier to effective health-care assessment”, International Journal of Human
Rights in Healthcare,doi:10.1108/IJHRH-05-2022-0039.
Harnish, R.A., Johnson, G.E., McMichael, G.A., Hughes, M.S. and Ebberts, B.D. (2012), “Effect of
migration pathway on travel time and survival of acoustic-tagged juvenile salmonids in the Columbia river
estuary”, Transactions of the American Fisheries Society, Vol. 141 No. 2, pp. 507-519.
Hayes, S.C., Luoma, J.B., Bond, F.W., Masuda, A. and Lillis, J. (2006), “Acceptance and commitment
therapy: model, processes and outcomes”, Behaviour Research and Therapy, Vol.44 No. 1, pp. 1-25.
Hayes, T.B., Collins, A., Lee, M., Mendoza, M., Noriega, N., Stuart, A.A. and Vonk, A. (2002),
“Hermaphroditic, demasculinized frogs after exposure to the herbicide atrazine at low ecologically
relevant doses”, Proceedings of the NationalAcademy of Sciences, Vol. 99 No. 8, pp. 5476-5480.
Hayes, S.C., Strosahl, K., Wilson, K.G.,Bissett, R.T., Pistorello, J., Toarmino, D., … McCurry, S.M. (2004),
“Measuring experiential avoidance: a preliminary test of a working model”, The Psychological Record,
Vol. 54 No. 4, pp. 553-578.
Kola, L., Kohrt, B.A.,Hanlon, C., Naslund, J.A., Sikander, S., Balaji, M., Benjet, C., Cheung, E.Y.L., Eaton,
J., Gonsalves, P., Hailemariam, M., Luitel, N.P., Machado, D.B., Misganaw, E., Omigbodun, O., Roberts,
T., Salisbury, T.T., Shidhaye, R., Sunkel, C., Ugo, V., van Rensburg, A.J., Gureje, O., Pathare, S., Saxena,
S., Thornicroft, G. and Patel, V. (2021), “COVID-19 mental health impact and responses in low-income
and middle-income countries: reimagining global mental health”, The Lancet Psychiatry,Vol.8No.6,
pp. 535-550, doi: 10.1016/S2215-0366(21)00025-0.
Ko
¨hlerov
a, M.Z., Fis
ˇerov
a, Z. and P
av, M. (2023), “Physical activity habits and their effects on quality of
life in patients with addiction: data from the Czech Republic”, Current Psychology, pp. 1-8.
Lindholt, J.S., Ventegodt, S. and Henneberg, E.W. (2002), “Development and validation of QoL5 for
clinical databases. A short, global and generic questionnaire based on an integrated theory of the quality
of life”, The European Journal of Surgery, Vol. 168 No. 2, pp. 107-113.
Mann, J.M., Gostin, L., Gruskin, S., Brennan, T., Lazzarini, Z. and Fineberg, H.V. (1994), “Health and
human rights”, Health and Human Rights, Vol. 1 No. 1, p. 6.
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
Md Tahir, F.S., Onn, N.E. and Fauzi, H. (2022), “Right to health v. Right to smoke during COVID-19
pandemic in Malaysia”, International Journal of Law, Government and Communication,Vol.7No.28,
pp. 60-74, doi: 10.35631/ijlgc.728005.
Parsons, H., Houge Mackenzie, S., Filep, S. and Brymer, E. (2019), “Subjective well-being and leisure”,
Springer, pp. 1-10, doi: 10.1007/978-3-319-69627-0_8-1.
Qu, X. (2022), “Confucianism and humanrights - exploring thephilosophical base for inclusive education
or children with disabilities in China”, Disability & Society,doi:10.1080/09687599.2022.2143324.
Riggirozzi, P. (2021), “Everyday political economy of human rights to health: dignity and respect as an
approach to gendered inequalities and accountability”, New Political Economy,Vol.26No.5,
pp. 735-747, doi: 10.1080/13563467.2020.1841144.
Room, R., Rehm, J., Trotter, I.I., R.T., Paglia, A. and U
¨stu
¨n, T.B. (2001), “Cross-cultural views on stigma,
valuation, parity, and societal values towards disability”.
Sæteren, B. and Na
˚den, D. (2021), “Dignity: an essential foundation for promoting health and well-being”, In
Health Promotion in Health Care - Vital Theories and Research, pp. 71-84, doi: 10.1007/978-3-030-63135-2_7.
Saffari, M., Chang, K.C., Chen, J.S., Chang, C.W., Chen, I.H., Huang, S.W., … Potenza, M.N. (2022),
“Temporal associations between depressive features and self-stigma in people with substance use
disorders related to heroin, amphetamine, and alcohol use: a cross-lagged analysis”, BMC Psychiatry,
Vol. 22 No. 1, p. 815.
S
anchez-Mill
an, H.A., Alicea-Cruz, A.J. and P
erez-Pedrogo, C. (2022), “Measuring psychological
flexibility: the cultural adaptation and psychometric properties of the AAQ for substance abuse among
Spanish speaking population in correctional and community settings”, Journal of Contextual Behavioral
Science, Vol. 23, pp. 31-37.
Schomerus, G., Lucht, M., Holzinger, A., Matschinger, H., Carta, M.G. and Angermeyer, M.C. (2011),
“The stigma of alcohol dependence compared with other mental disorders: a review of population
studies”, Alcohol and Alcoholism, Vol. 46 No. 2, pp. 105-112.
Schulze, R. (2007), “Current methods for meta-analysis”, Zeitschrift Fu
¨r Psychologie/Journal of
Psychology, Vol. 215 No. 2, pp. 90-103.
Simha, A., Ahmed, S., Prasad, R., Dinesh, A.S., Kandasamy, A. and Rao, N.P. (2021), “Effect of national
cultural dimensions and consumption rates on stigma toward alcohol and substance use disorders”,
International Journal of Social Psychiatry, Vol. 68 No. 7, doi: 10.1177/00207640211028611.
Smith, L.R., Earnshaw, V.A., Copenhaver, M.M. and Cunningham, C.O. (2016), “Substance use stigma:
reliability and validity of a theory-based scale for substance-using populations”, Drug and Alcohol
Dependence, Vol. 162, pp. 34-43, doi: 10.1016/j.drugalcdep.2016.02.019.
Stuart, H., Arboleda-Florez, J. and Sartorius, N. (2011), Paradigms Lost: Fighting Stigma and the Lessons
Learned, Oxford University Press.
Thornicroft, G., Rose, D., Kassam, A. and Sartorius, N. (2007), “Stigma: ignorance, prejudice or
discrimination?”, British Journal of Psychiatry, Vol. 190 No. 3,pp. 192-193.
Twohig, M.P., Vilardaga, J.C.P., Levin, M.E. and Hayes, S.C. (2015), “Changes in psychological flexibility
during acceptance and commitment therapy for obsessive compulsive disorder”, Journal of Contextual
Behavioral Science, Vol. 4 No. 3, pp. 196-202.
Vallejo, M.A., Jorda
´n, C.M., Dı
´az, M.I., Comeche, M.I. and Ortega, J. (2007), “Psychological assessment
via the internet: a reliability and validity study of online (vs paper-and-pencil) versions of the general
health questionnaire-28 (GHQ-28) and the symptoms check-list-90-revised (SCL-90-R)”, Journal of
Medical Internet Research,Vol.9No.1,p.e2.
Van Brakel, W.H., Cataldo, J., Grover, S., Kohrt, B.A., Nyblade, L., Stockton, M., Wouters, E. and Yang, L.H.
(2019), “Out of the silos: identifying cross-cutting features of health-related stigma to advance measurement
and intervention”, BMC Medicine, Vol. 17 No. 1, pp. 1-17.
Ventegodt, S., Merrick, J. and Andersen, N.J. (2003a), “Quality of life theory I. The IQOL theory: an
integrative theory of the global quality of life concept”, The Scientific World Journal, Vol. 3, pp. 1030-1040.
Ventegodt, S., Merrick, J. and Andersen, N.J. (2003b), “Editorial: a new method for generic measuring of
the global quality of life”, The Scientific World Journal, Vol. 3, pp. 946-949.
Wakeman, S.E. (2019), “The language of stigma and addiction”, The Stigma of Addiction An Essential
Guide, Springer International Publishing, Cham, pp. 71-80. doi: 10.1007/978-3-030-02580-9_5.
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
Wilson, K.G. and Murrell, A.R. (2004), “Values work in acceptance and commitment therapy”,
Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition, Guilford Press,
pp. 120-151.
Williamson, L. (2022), “Substance use disorders, stigma, and ethics”, The Stigma of Substance Use
Disorders, Cambridge University Press, pp. 68-87, doi: 10.1017/9781108936972.005.
Zandy, J. (2019), “Universal declaration of human rights”, Radical Teacher, Vol. 113, pp. 54-55, doi:
10.5195/rt.2019.591.
Further reading
Chang, K.-C., Chen, H.-P., Huang, S.-W., Chen, J.-S., Potenza, M.N., Pakpour, A.H. and Lin, C.-Y.(2022),
“Comparisons of psychological distress and self-stigma among three types of substance use disorders
receiving treatment-as-usual approaches: real-world data from a nine-month longitudinal study”,
Therapeutic Advances in Chronic Disease, Vol. 13, pp. 1-12.
Chen, I.-H., Chang, K.-C., Chang, C.-W., Huang, S.-W., Potenza, M.N., Pakpour, A.H. and Lin, C.-Y.
(2022), “Temporal associations between problematic use of the internet and self-stigma among people
with substance use disorders: a cross-lagged model across one year”, Journal of Psychiatric Research,
Vol. 156, pp. 339-348.
Chin, F. and Hayes, S.C. (2017), “Acceptance and commitment therapy and the cognitive behavioral
tradition: assumptions, model, methods, and outcomes”, in Hofmann, S.G. and Asmundson, G.J.G.
(Eds), The Science of Cognitive Behavioral Therapy, Elsevier Academic Press, pp. 155-173, doi:
10.1016/B978-0-12-803457-6.00007-6.
Dindo, L., Van Liew, J.R. and Arch, J.J. (2017), “Acceptance and commitment therapy: a transdiagnostic
behavioral intervention for mental health and medical conditions”, Neurotherapeutics, Vol. 14 No. 3,
pp. 546-553, doi: 10.1007/s13311-017-0521-3.
Ghaleh Emamghaisi, Z. and Atashpour, S.H. (2019a), “Effectiveness of acceptance and commitment
therapy on self-criticism and feeling of shame in methamphetamine users”, Journal of Substance Use,
Vol. 25 No. 4, doi: 10.1080/14659891.2019.1704082.
Ghaleh Emamghaisi, Z. and Atashpour, S.H. (2019b), “Effectiveness of acceptance and commitment
therapy on self-criticism and feeling of shame in methamphetamine users”, Journal of Substance Use,
Vol. 25 No. 4, pp. 372-376, doi: 10.1080/14659891.2019.1704082.
Hammarlund, R.A., Crapanzano, K.A., Luce, L., Mulligan, L.A. and Ward, K.M. (2018), “Review of the
effects of self-stigma and perceived social stigma on the treatment-seeking decisions of individuals with
drug- and alcohol-use disorders”, Substance Abuse and Rehabilitation, Vol. 9, pp. 115-136, doi:
10.2147/sar.s183256.
Hayes, S.C. (2004), “Acceptance and commitment therapy, relational frame theory, and the third wave of
behavioral and cognitive therapies”, Behavior Therapy, Vol. 35 No. 4, pp. 639-665, doi: 10.1016/S0005-
7894(04)80013-3.
Lee, E.B., Homan, K.J., Morrison, K.L., Ong, C.W., Levin, M.E. and Twohig, M.P. (2020), “Acceptance
and commitment therapy for trichotillomania: a randomized controlled trial of adults and adolescents”,
Behavior Modification, Vol. 44 No. 1, pp. 70-91, doi: 10.1177/0145445518794366.
Lee, C.-T., Lin, C.-Y., Ko
os, M., Nagy, L., Kraus, S.W., Demetrovics, Z., Potenza, M.N., Ballester-Arnal, R.,
Batthy
any, D., Bergeron, S., Billieux, J., Burkauskas, J., C
ardenas-L
opez, G., Carvalho, J., Castro-Calvo,
J., Chen, L., Ciocca, G., Corazza, O., Csako, R.I., Fernandez, D.P., Fernandez, E.F., Fujiwara, H., Fuss,
J., Gabrhelı
´k, R., Gewirtz-Meydan, A., Gjoneska, B., Gola, M., Grubbs, J.B., Hashim, H.T., Islam, M.S.,
Ismail, M., Jim
enez-Martı
´nez, M., Jurin, T., Kalina, O., Klein, V., Ko
¨lto†, A., Lee, S.-K., Lewczuk,
K., Lochner, C., L
opez-Alvarado, S., Lukavsk
a, K., Mayta-Trist
an, P., Milea, I., Miller, D.J., Orosov
a, O.,
Orosz, G., Ponce, F.P., Quintana, G.R., Garzola, G.C.Q., Ramos-Diaz, J., Rigaud, K., Rousseau,
A., Tubino Scanavino, M.D., Schulmeyer, M.K., Sharan, P., Shibata, M., Shoib, S., Sigre-Leir
os, V.,
Sniewski, L., Spasovski, O., Steibliene, V., Stein, D.J., Strizek, J., U
¨nsal, B.C., Vaillancourt-Morel, M.-P.,
Van Hout, M.C., Bo†the, B. and Sungkyunkwan University’s Research Team (2023), “The eleven-item
alcohol, smoking and substance involvement screening test (ASSIST-11): cross-cultural psychometric
evaluation across 42 countries”, Journal of Psychiatric Research, Vol. 165, pp. 16-27.
Levin, M.E., Haeger, J.A., Pierce, B.G. and Twohig, M.P. (2017), “Web-Based acceptance and
commitment therapy for mental health problems in college students: a randomized controlled trial”,
Behavior Modification, Vol. 41 No. 1, pp. 141-162, doi: 10.1177/0145445516659645.
jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j
Lo Coco, G., Melchiori, F., Oieni,V., Infurna, M.R., Strauss, B., Schwartze, D., Rosendahl, J. and Gullo, S.
(2019), “Group treatment for substance use disorder in adults: a systematic review and meta-analysis of
randomized-controlled trials”, Journal of Substance Abuse Treatment, Vol. 99, pp. 104-116, doi: 10.1016/
j.jsat.2019.01.016.
Luoma, J.B. and Platt, M.G. (2015), “Shame, self-criticism, self-stigma, and compassion in acceptance
and commitment therapy”, Current Opinion in Psychology, Vol. 2, pp. 97-101, doi: 10.1016/j.
copsyc.2014.12.016.
Luoma, J.B., Guinther, P.M., DesJardins, N.M.L. and Vilardaga, R. (2018), “Is shame a proximal trigger
for drinking? A daily process study with a community sample”, Experimental and Clinical
Psychopharmacology, Vol. 26 No. 3, pp. 290-301, doi: 10.1037/pha0000189.
Meier, B.M., Raw, M., Shelley, D., Bostic, C., Gupta, A., Romeo-Stuppy, K. and Huber, L. (2022), “Could
international human rights obligations motivate countries to implement tobacco cessation support?”,
Addiction,Vol.118No.3,doi:10.1111/add.15990.
Shorey, R.C., Elmquist, J., Gawrysiak, M.J., Strauss, C., Haynes, E., Anderson, S. and Stuart, G.L. (2017),
“A randomized controlled trial of a mindfulness and acceptance group therapy for residential substance
use patients”, Substance Use & Misuse, Vol. 52 No. 11, pp. 1400-1410, doi: 10.1080/10826084.2017.
1284232.
Yang, L.H., Wong, L.Y., Grivel, M.M. and Hasin, D.S. (2017), “Stigma and substance use disorders: an
international phenomenon”, Current Opinion in Psychiatry, Vol. 30 No. 5, pp. 378-388, doi: 10.1097/
YCO.0000000000000351.
Corresponding author
Zartashia Kynat Javaid can be contacted at: zartashiakynat@gcuf.edu.pk
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