What if I told you that forming stigmatizing thoughts and emotions was “normal?” Huh? It’s true; normal but not OK. Let me explain.
Among the many factors that contribute to stigma are two ubiquitous, unavoidable, and well-understood psychological phenomena: attributions and counter-transference. Both of these phenomena are useful for our effective functioning in the world. However, each has a dark side that yields unintended consequences, including stigmatizing individuals, groups, or conditions.
Attributional Theory was developed in the field of Social Psychology and focuses on the interpretations we develop to explain why things happen. As each of us navigates the world, we routinely make conscious, intentional efforts to explain, understand, and figure out the “why” of what we encounter. My computer freezes, and I start ticking through my list of possibilities. Was I trying to run too many programs at once? Did the information technology (IT) department decide this was the best time to install an update? Did my virus scan start? Over time, many of our attributions become automatic, effortless, and outside of awareness. They work like habits, operating in the background without using our limited cognitive resources. Our automatic attributions are often tinged (or even saturated) with emotion. I don’t feel the same about you if I assume I have been inconvenienced on purpose rather than by mistake. And I don’t feel the same about you if I assume pain and suffering in your life is self-inflicted as opposed to the consequence of external factors out of your control.
In a study conducted at the University of Alabama, college students were asked to list the causes of alcohol and drug problems. They also completed a survey that measured their attitudes and beliefs toward people with these problems. Through qualitative analyses, they found that the explanations the students formulated coalesced into five clusters, which the researchers labeled “Biological,” “Self-Medication,” “Familial,” “Social,” and “Hedonistic.” These were further consolidated into two groups, broadly “Medical” and “Moral” explanations. Importantly for understanding stigma against those who experience problems with drugs or alcohol, these researchers also found that students whose explanations aligned most closely with the Moral model had the highest level of stigma on the Stigma Attribution Scale. This study provides clear evidence that person-centered attributions (rather than external attributions) about why people develop an addictive disorder foster stigmatizing beliefs.
If attributions are normal, and mostly helpful in negotiating life, what can be done about their dark, stigmatizing side? It is axiomatic that we can’t change something until we gain awareness of it. Having accessed awareness, we must also be willing to make a change. Awareness and willingness form the foundation of personal change. Each of us should dispense with the self-congratulatory belief that, unlike other people, we are free from stigmatizing and biased attributions. We’re not! If, on the other hand, we engage in the private work of self-examination and the self-change effort needed to better align our attributions with an evidence-based, disease-centered understanding of addictive disorders, we will have made a crucial start.
The concept of counter-transference was developed by Sigmund Freud to aid in understanding how the personal, private history of the psychoanalyst “shows up” in the context of conducting psychoanalysis with patients. This phenomenon sometimes impedes and harms the therapeutic process. Today, this concept, often described using different terminology, is also a core element of behavioral and cognitive-behavioral psychology. Namely, we are the product of our learning histories – we are shaped into whom we are by the accumulated rewards and punishments we have experienced. There is no escaping this: I bring the core of “me” into every interaction I have.
Each of us is exposed over the course of our lives to both subtle and overt messages about alcohol, drugs, and life problems precipitated by their use. Further, given the high prevalence of substance use in our culture, virtually all of us have encountered someone whose life is (or has been) adversely affected by substance use. For some of us, the relationship is with someone very close (e.g., a family member), and for others, the exposure has been more distal, such as a friend, coworker, or neighbor. Those encounters make an enduring imprint on our thoughts and emotions and, ultimately, on our behavior. Experiences that were painful or traumatic leave especially potent emotional traces.
One illuminating study that sheds light on how this psychological phenomenon impacts are attitudes toward individuals with an addictive disorder was conducted in a large cohort of medical residents across training years and medical specialties.2 Each participant filled out a questionnaire asking about their satisfaction in working with patients with different mental health conditions, the worthiness of those patients for receiving medical care, and the likelihood of benefit from medical care. Collapsed across experience and specialty, participants rated individuals with a substance use disorder (alone or comorbid with schizophrenia) less satisfying to care for than individuals with schizophrenia alone or with major depression. Further, the more experience the residents had (i.e., the more advanced in their specialty training), the more negative their attitudes toward those with a substance use disorder. Moreover, emergency physicians, who often encounter these patients in the moments of their greatest need, had the most negative attitudes of any specialty. In sum, the increasing experience of residents with those suffering with substance use disorders served to increase rather than decrease their stigmatizing attitudes. This is a striking example of how cumulative experience can augment stigmatizing attitudes.
Of course, we don’t have the luxury of freeing ourselves from autobiographical influences and their attendant emotional consequences. But by becoming more self-aware about these influences, we can take an important step toward eliminating stigmatizing counter-transference. If we have not yet attained competence in managing our own issues and negative attitudes toward substance use disorders, the best option, seemingly, might be to minimize contact with those who suffer with an addictive disorder. However, this is neither a satisfying nor effective option. Indeed, it is through increased contact and interaction – especially with individuals who experience remarkable and rapid positive changes when participating in treatment – that we can revise our attitudes and address our stigmatizing beliefs.
In sum, if we have a willingness to critically examine our attitudes toward substance use and those suffering with addiction, we will do well to think about both the attributional and experiential factors that have fostered our beliefs. This work is for each of us.
References
1. Henderson NL & Dressler WW. Medical disease or moral defect? Stigma attribution and cultural models of addiction causality in a university population. Cult Med Psychiatry 2017; 41(4): 480-498.
2. Avery JD, Taylor KD, Kast KA, et al. Attitudes toward individuals with mental illness and substance use disorders among resident physicians. Prim Care Companion CNS Disord 2019; 21 (1): 18m02382.