Tom Ogwang
Stigma is a complex social phenomenon. Put simply, it could be defined as “an attribute that discredits an individual in the eyes of society and results in the person being devalued, discriminated against, and labelled as deviant” [1]. Expanding on that, for stigma to take shape several interrelated elements must come together. In the first element, people must identify some social difference, and categorise it with a label accordingly. This labelling is critical, as language plays a major role in shaping people’s thoughts and beliefs[2]. The social categories identified may include people who use drugs and people who don’t, immigrants and citizens, LGBTIQ+ and heteronormative cultures, people of colour and white people, and so on[3].
In the second element, the categorizing labels are linked to dominant beliefs about the difference – stereotypes. In the third element, the stereotypes provide enough distinct social categories that they distinguish ‘us’ and ‘them’ as oppositional social identities. The above examples are commonly stereotyped into oppositional identities such as ‘criminals’ vs ‘good citizens’ or ‘deviant’ vs ‘normal’ people. The fourth element sees the stigmatised people experience status loss and discrimination that lead to unequal outcomes across every conceivable measure[4].
Discrimination is the lived experience of stigma – the negative social and material outcomes that arise from stigma, which includes lower quality of health care. Both stigma and discrimination rely on societal structures and systems that facilitate and create the conditions for their operation (for example, unequal power relations is one such condition)[5]. For these reasons stigma is harmful, distressing, and marginalising to the individuals and groups who experience it, whether based on fear and exclusion, authoritarianism, or even benevolent intentions[6].
The massive body of evidence on implicit bias and discrimination across stigmatized populations means examples of the harm of stigma abound. Research from Stanford University that systematically analysed police body camera footage of routine traffic stops shows white residents were 57 percent more likely than black residents to hear a police officer say the most respectful utterances, such as apologies and expressions of gratitude like “thank you.” Meanwhile, black community members were 61 percent more likely to hear officers say the least respectful utterances, such as informal titles like “dude” and “bro” and commands like “hands on the wheel”[7]. The study authors argued that these pervasive racial disparities in officers’ language use at best erode police-community relations. At worst they express and validate negative attitudes society holds toward people of colour, which those communities experience as institutionalised racism and deaths in custody. Such research makes it harder to trivialise or dismiss the language debate as mere “semantics” or “political correctness”, as similarly strong research abounds across all stigmatised groups, including drug using communities.
It is imperative the AOD policy, practice and research communities continue to build their understanding of how language influences the way individuals think about themselves and their ability to change, how it frames what society thinks about substance use and recovery[8] and how it influences institutional responses to substance use[9]. At the individual level, there is ample evidence the words we use to describe alcohol and other drug dependence can engender self-stigma, which occurs when a member of a target group internalises public stereotypes or prejudices[10]. This influences both whether people will seek help, and the quality of the help they receive. For instance, one study demonstrated those with alcohol use disorder perceiving a high degree of public stigma toward their condition were about half as likely to seek help as those perceiving low stigma[11]. For treating clinicians, words strongly influence the way they seek to work with people experiencing alcohol and other drug use disorders: in one Harvard study, when the term ‘substance abuser’ was used in a case vignette, clinicians were significantly more likely to favor punishment (a jail term) than when the individual was described in the vignette as having a ‘substance use disorder’[12]. It’s a short journey from the implicit bias found in that research to overt negative attitudes or discriminatory behaviours enacted by individuals acting on behalf of health or criminal justice institutions[13].
Structural stigma includes poorly chosen language, policies and actions that limit – whether intentionally or not – the opportunities of target groups. Labelling people involved in the criminal justice system – many of whose most serious offence relates to illicit drugs – ‘offenders’ for the entirety of their engagement with the criminal justice system, regardless of whether they have ceased all unlawful activity, is an overt example. Thesaurus alternatives to ‘offenders’ are ‘criminals, crooks, lawbreakers, wrongdoers, reprobates and delinquents’, all of which is language that squarely returns the individual back to the place and time of their offence, without hope of moving from there in any figurative sense until all engagement with the justice system is complete. The evidence of stigma we see across the brief examples demonstrated here, and which is experienced by all marginalised persons, is a violation of the human rights and dignity expressed in Article 1 of the Universal Declaration of Human Rights – All human beings are born free and equal in dignity and rights[14].
The QNADA rapid review of Queensland inquiries, reports and strategies relevant to the alcohol and other drug sector found evidence of stigma that powerfully shapes how the state addresses AOD use across a range of sectors[15]. It argues what is evident in many inquiries, reports and strategies is a morally bound perceptual distinction between alcohol and other drugs that defines one as being culturally acceptable and the other as immoral, illegal and deviant[16]. This returns us to the elements described above that result in stereotyped, oppositional categories, and that have been significant in how AOD policy and practice has manifested: for example, while high profile and at times experimental change in night time entertainment precinct management has been undertaken in an attempt to reduce alcohol related harm over the last ten years, responses to illicit drug use have remained largely unchanged during the same period. Far more than just words, at the institutional level language ‘influences recommendation acceptance, shapes the approach taken to implementation, program design and workforce development, and is used to inform future policy and legislative priorities’[17].
There is a lot of work to be done in the stigma and discrimination space. It isn’t overly complex though, and perhaps begins with the universal use of person-centred (or person-first) language to describe groups at the margins of society[18]. This is especially true of people who use drugs and who are also, for example, at the intersections of minority ethnicities, genders or sexualities. Given outstanding materials like this Language matters resource, not only does the AOD sector have its own waypoints, but it is well equipped to begin charting this journey outside its own boundaries and in such spaces as the media and other public discourses where the public gets most of its information about alcohol and other drug use.
—————————————
[1] Lancaster, K., Seear, K., Ritter, A. (2017) Reducing Stigma and Discrimination for People Experiencing Problematic Alcohol and Other Drug Use (Queensland Mental Health Commission).
[2] Volkow, N.D., Gordon, J.A., Koob, G.F. (2021) Choosing appropriate language to reduce the stigma around mental illness and substance use disorders. Neuropsychopharmacology. July 2021
[3] Link, B. G., & Phelan, J. C. (2001). Conceptualizing Stigma. Annual Review of Sociology, 27, 363-385.
[4] Ibid
[5] Lancaster, K., Seear, K., Ritter, A. (2017) Reducing Stigma and Discrimination for People Experiencing Problematic Alcohol and Other Drug Use (Queensland Mental Health Commission).
[6] Broyles,L.M., Binswanger, I.A., et al (2014) Confronting Inadvertent Stigma and Pejorative Language in Addiction Scholarship: A Recognition and Response. Substance Abuse 35:217-221
[7] Voigt, R., Camp, N.P., et al (2017) Language from police body camera footage shows racial disparities in officer respect. Proceedings of the Natural Academy of Sciences of the United States of America
[8] Broyles,L.M., Binswanger, I.A., et al (2014) Confronting Inadvertent Stigma and Pejorative Language in Addiction Scholarship: A Recognition and Response. Substance Abuse 35:217-221
[9] Wogen, J. and Restrepo M.T. (2020) Human rights, stigma, and substance use. Health and Human Rights 22(1):51-60
[10] Ibid
[11] Keyes K.M., Hatzenbuehler M.L., McLaughlin K.A., Link B., Olfson M., Grant B.F., (2010) Stigma and treatment for alcohol disorders in the United States. American Journal of Epidemiology; 172:1364–72. .
[12] Kelly J.F., Westerhoff C.M. (2010) Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. International Journal of Drug Policy 21:202–7
[13] Wogen, J. and Restrepo M.T. (2020) Human rights, stigma, and substance use. Health and Human Rights 22(1):51-60
[14] United Nations (1948) Universal Declaration of Human Rights. www.un.org/en/about-us/universal-declaration-of-human-rights
[15] QNADA (2021) Responsive Systems: A rapid review of Queensland inquiries, reports and strategies relevant to the alcohol and other drug sector.
[16] QNADA (2021) Responsive Systems: A rapid review of Queensland inquiries, reports and strategies relevant to the alcohol and other drug sector.
[17] Ibid
[18] Lancaster, K., Seear, K., Ritter, A. (2017) Reducing Stigma and Discrimination for People Experiencing Problematic Alcohol and Other Drug Use (Queensland Mental Health Commission).