Taking care in stigma reduction: Guest Blog by Adam Holland and Lucille Seppi
Using mass media to combat stigma
Stigma can affect anyone who uses alcohol or other drugs, negatively impacting their health and wellbeing, and increasing the likelihood they experience drug-related harm. Fear of judgement or unkind treatment prevents many people from seeking support when they need it. And stigma amongst the public and policymakers can promote unevidenced and harmful policies, compounding international drug-related death crises.
Reducing stigma towards people who use drugs is imperative to reduce the harms they experience. Mass media is a potentially useful avenue to influence attitudes towards people who use drugs at scale, without requiring person to person contact. This could encompass a range of approaches, including websites, videos, phone applications, social media campaigns, online training programmes, billboards, and artwork.
To understand more about existing mass media interventions intended to reduce stigma towards people who use drugs, we collected all the academic literature we could find about their development or evaluation. We focused on interventions intended to reduce stigma towards people who use drugs which are illegal in most countries, like cannabis, cocaine, and heroin, rather than drugs which are legal in most countries, like alcohol and tobacco.
Whilst stigma is also a key issue for people who use legal drugs, people who use prohibited drugs can be affected by stigma in different ways, precisely because the drugs they use are illegal. This means the wider public may believe it’s more acceptable to treat them negatively, stigma reduction efforts are arguably more challenging, and different messaging approaches may be needed.
The Stigma Effect
Our findings highlighted the complexities of using mass media to reduce stigma. In some cases, it’s possible that well-intentioned campaigns may inadvertently reinforce negative stereotypes rather than eliminating them. Patrick Corrigan, a stigma researcher from the US, refers to this as the ‘stigma effect’.
For example, lots of the interventions we reviewed characterised drug dependence as a disease or medical condition. Whilst some people who are navigating challenges related to drug use find it useful to think in these terms, there’s mixed evidence on how it affects public attitudes. Medicalisation has been credited with reducing blame towards people experiencing drug dependence. On the other hand, research has shown that explaining things like drug dependence, depression, and schizophrenia in medical terms can sometimes increase perceptions of dangerousness and desire for social distance, which are other important aspects of stigma.
The way that some interventions discussed recovery from drug dependence may also have unintended consequences. Recovery is clearly an important concept for many people navigating challenges related to drugs. But sometimes interventions emphasised a need for recovery in ways that cast those who actively use drugs in a negative light.
For example, films featured individuals identified as in recovery describing their former selves (when they used drugs) in very negative terms – as violent, chaotic, and untrustworthy. Sometimes this turned into negative generalisations about the wider population of people who use drugs. Some interventions characterised recovery in terms of people becoming “functional members of society again” who are now able to look after their children (implying they couldn’t before). At first glance, this makes sense. By suggesting someone has recovered, they must have recovered from something. But it begs several questions: who has something to recover from? What does recovery mean? And who decides who needs to recover?
Many people who use prohibited drugs do so alongside productive professional, social, and family lives – just like most of the population who use legal drugs like alcohol and tobacco. Without understanding this spectrum of drug use, intervention recipients might assume that anyone who uses prohibited drugs is in a situation that they need to recover from. They might assume that anyone who uses prohibited drugs is unable to function unless they recover. And if recovery is understood as requiring abstinence, this can compound the idea that no drug use is compatible with a happy or productive life. This focus also downplays the role of social disadvantage, with the primary focus of recovery for many people being the context in which drugs are being used, for example housing insecurity, socioeconomic deprivation, and trauma, rather than the drug use itself.
What drives the stigma effect?
In his book about the Stigma Effect, Patrick Corrigan suggests there are three distinct motivations for reducing stigma. First, the service agenda: reducing stigma to overcome barriers to health and drug service engagement. Second, the rights agenda: reducing stigma to promote human rights and equitable opportunities. And third, reducing stigma to replace shame with dignity.
Whilst intervention developers will likely have mixed motivations for reducing stigma, some types of messaging may be more suitable for achieving certain aims. Framing drug dependence as a disease, and emphasising the benefits of recovery, for example, may encourage some people navigating challenges related to drug use to seek support – echoing the motivations of the service agenda. However, Corrigan highlights how an over-emphasis on this agenda can sometimes be contrary to the rights and self-worth agendas. If messaging motivated by the service agenda is not crafted carefully, it may further pathologise people with a stigmatised identity.
This is certainly not a criticism of the service agenda, or to say that encouraging people to access services when they have health or social needs is not important. There are well evidenced benefits of drug and healthcare services for people who use drugs, and stigma is a key barrier to access. But it highlights the need for nuance, and to consider the wider aims of stigma reduction – promoting the rights and self-worth of people who use drugs.
The apparent focus on the service agenda in most of the interventions we reviewed reflected the predominant involvement of people from healthcare backgrounds in their development. Likewise, many of the interventions were specifically intended for healthcare workers. Involvement of people who use drugs in intervention development was often absent or limited, and sometimes this was restricted to people who used to use drugs but are now abstinent.
Considering the rights agenda
People who use prohibited drugs do not have the same rights afforded to them as other members of society. Most obviously, they can be arrested and potentially incarcerated for doing something they may do in private with no direct impact on a third party. Meanwhile employers and landlords can legally discriminate against people who use prohibited drugs.
When thinking about the rights agenda, it’s helpful to consider the history and purposes of stigmatisation. The term ‘stigma’ originally described markings – brands, tattoos, or scarring – applied to indicate that individuals were socially undesirable, for example as a traitors, prisoners, or slaves. Later, the word evolved to refer to social labels rather than physical disfigurements. Whilst people who use prohibited drugs in contemporary society are not stigmatised in the original sense by way of physical disfigurement, they are labelled ‘drug user’ and given a criminal record – with tangible impacts on their opportunities and interactions with wider society. In both cases – physical disfigurement and social labelling – the stigmatised are subjugated and controlled by these markings, in ways which benefit the powerful stigmatisers. Stigma is, in this sense, a practice, and not a fixed attribute or identity.
Imogen Tyler, in her book The Machinery of Inequality describes how stigmatising labels like ‘immigrant’ and ‘benefit scrounger’ are weaponised by powerful groups in contemporary society – to scapegoat marginalised communities for wider social problems. This means the public don’t recognise the need to tackle socioeconomic inequalities, protecting those in positions of wealth and power.
Similarly, throughout history, people who use certain drugs have been demonised in ways that benefited others. The historic roots of laws which criminalise people who use certain drugs but not others originated from efforts to control particular marginalised groups, such as people immigrating to the US from China in the early 1900s, who policymakers associated with opium use. And in the 1970s punitive drug policies were used to target political opponents of Richard Nixon.
Very few of the interventions we reviewed attended to the roots of stigma towards people who use prohibited drugs or clarified the key role of criminalisation in perpetuating it. Tyler, and others, argue that without doing so, the underlying power structures driving stigma will persist, ensuring that stigmatised groups – such as people who use prohibited drugs – continue to have their rights ignored and eroded.
How do we know what works?
It’s not always clear that people are referring to the same thing when they talk about ‘stigma’. Stigma is an umbrella concept, which encompasses and is used to refer to a range of social phenomena. These phenomena include labelling, stereotyping, separation, status loss, interpersonal discrimination (enacted stigma), discriminatory laws and policies (structural stigma), service avoidance (due to anticipated stigma), and low self-worth (internalised- or self-stigma).
Authors sometimes emphasise a particular element of stigma, whilst ignoring others. This can be seen in the academic debates about whether stigma can be a force for good. Where proponents advocate for this view, because they see stigma as a tool to deter harmful behaviours, they’re normally not clear about what specific attitudes or behaviours they believe are justified. Nor do they take account of the many negative aspects of stigmatisation.
In the articles we reviewed, authors often didn’t provide a clear definition of stigma. When they did, definitions varied, considering stigma to be an attribute, process, identity; or equating it with specific negative attitudes or views. If we’re not clear what we’re trying to overcome, it makes it difficult to know when we’ve been successful. This is clear when we look at how evaluations of interventions attempted to quantify stigma.
In the articles we looked at, a wide range of attitudes were measured and referred to as stigma, with little overlap between studies. Metrics included blame, feelings (like anger, pity, or fear), perceptions of danger, desire for social distance, perceived appropriateness of social responses, and attitudes towards specific policies like criminalisation or coerced treatment. These are all elements of stigma, but they’re not the whole story. And sometimes the different attitudes or phenomena we measure could go different directions following an intervention. For example, medicalising drug dependence could decrease blame but increase perceived danger or desire for social distance.
Sometimes, authors measured things that weren’t clearly markers of stigma or its absence. For example – whether intervention recipients would help people who use drugs or be compassionate towards them. Whilst compassion is generally a good thing, it doesn’t necessarily reflect an absence of stigma if it’s assumed that just because someone uses drugs, they need help.
Considerations for future anti-stigma campaigns
This blog, and our research, isn’t meant to criticise the tireless work underway to combat stigma. What we have hopefully highlighted is… it’s complicated. And there is a risk that interventions could sometimes have unintended negative consequences.
It’s much easier to find problems than it is to find solutions. But there are some key things that jumped out at us when we looked at the range of interventions that have been developed…
1. We need to be clear about our reasons for reducing stigma, and why we’re prioritising certain elements of stigma in particular stigma reduction efforts.
2. Whilst all motivations to reduce stigma are valid, there is a relative lack of attention on the rights and self-worth agendas.
3. We need to ensure messaging about the nature of drug dependence and recovery are addressed with a suitable level of nuance.
4. If attempting to quantify (elements of) stigma, we need to measure a range of phenomena and attitudes to ensure that our messaging doesn’t have unintended negative consequences.
5. When attempting to reduce stigma towards people who use drugs, if we don’t campaign against and address criminalisation, we’re working with our hands tied behind our backs.
6. And finally, whilst we should involve a range of people who use or have used drugs in the development of anti-stigma interventions, it is particularly important to include those who experience the greatest marginalisation. In most cases, this is people who actively use prohibited drugs. Involving people who actively use drugs presents obvious challenges, because of… you guessed it… stigma, the very problem we’re seeking to address. If someone is outed as actively using drugs, this could have significant personal, professional, and legal ramifications. This, perhaps better than anything else, sums up the wicked nature of stigma, and the challenge we have ahead of us.
This longer blog was written by Adam Holland and Lucille Seppi, researchers from the University of Bristol. It describes findings from work their team has done exploring the content, format, and aims of campaigns intended to reduce stigma towards people who use drugs. It includes some key considerations relevant for anyone working to develop anti-stigma materials.
If you would like to read more about our review of mass media interventions intended to reduce stigma towards people who use drugs, it’s free to access it here.