The Stigma of Addiction: What is it?
This was originally published for Hazelden Betty Ford’s monthly Recovery Advocacy Update. If you’d like to receive our advocacy emails, subscribe today.
By Jeremiah Gardner
In the history of recovery advocacy, one word has consistently permeated our lexicon.
We want to fight it. Shatter it. Reduce it. Eradicate it. Smash it. And, at the Hazelden Betty Ford Foundation, we want to end it.
So ubiquitous is it, we rarely reflect on what “stigma” means, uttering it as habitually and sometimes mindlessly as we might recite the Serenity Prayer for the millionth time, or say “I love you.” It’s meaningful, to be sure, but perhaps under-contemplated.
Stigma — defined as “a mark of disgrace or infamy, a stain or reproach, as one’s reputation” — is a galvanizing word because it infers some sort of discriminatory public attitude.
But what does it look like? And is all stigma unwarranted and/or counterproductive?
More importantly, what exactly is stigmatized — Substance use? Intoxication? Bad behavior associated with intoxication? Addiction? Asking for help? Sobriety? Recovery?
And where does stigma originate? Who is responsible for it? Is it really evidence of discrimination by other people and institutions, or does it lead to discrimination?
At the Hazelden Betty Ford, we enjoy indulging our philosophical muse and contemplating such matters — not in an effort to debunk anything, but to explore nuance.
And so, it was interesting a while back to discover in our organization’s library a 1955 recording of Marty Mann, one of America’s most influential crusaders against stigma and the subject of a planned film (which we eagerly anticipate!) by our friend Greg Williams.
Known by many as the first woman to achieve long-term sobriety in Alcoholics Anonymous (we published her wonderful biography), Mann became a prominent recovery advocate, advancing many decades ago the understanding that alcoholism is an issue of public health, not morality. In the talk we discovered, entitled “The Hidden Drinker” and, alternately, “The Hidden Alcoholic,” Mann explored the meaning of stigma and its impact, both overt and subtle, on the nation’s ability to address addiction.
She explained that most people with alcohol use disorders in America remain hidden. In other words, their illness is not acknowledged — perhaps not known. Why? Because, she says, no one wants to claim a disease associated with weakness and a lack of willpower. Many also have strong willpower in other areas of their life, and therefore figure they couldn’t have an alcohol use disorder, she explained.
Referring to a “conspiracy of silence” borne entirely of ignorance, Mann dived deeply into the stigma of addiction — what it is, where it comes from, and how it extends from individuals to institutions, impeding progress against this pervasive public health problem that costs the nation so much financially and socially.
Her solution: massive, constant, long-term education.
She said it worked in getting tuberculosis under control in the United States and is the most important work to be done if we are to reduce the impact of addiction, too. And she’s still right all these years later.
“Education of the kind I’m talking about designed to completely change public attitudes, not just on the intellectual level, but on the feeling and therefore acting level, is something that must be carried about by all means, at all times and for a long time to come,” Mann said.
“Yes, part of this constructive action is providing facilities — treatment facilities — but the heart of all that is and must be an information center — a place out of which this material can go through all the accepted mediums of communication — a central coordinating office for whatever facilities there may be but most particularly a center through which information — factual scientific information, concrete helpful information — can constantly be poured out to the public. This I think is vital,” she continued.
“I have seen again and again … groups get so engrossed in the setting up of treatment facilities that they forgot the need for their educational work. And when the educational work stopped, the flow of people to the treatment facilities also stopped. That is because the majority of our alcoholics are indeed still hidden. And our major job is to make it easy — to create an atmosphere where alcoholics and their families or friends may seek help without shame. This has got to remain our number one goal for a long time to come.”
You can listen to her entire talk — truly a historic message — below.
Our close friend and former colleague Patrick Krill appreciates the negative impact of stigma but once wondered if advocates should be less focused on it. In this article, he wrote: “Instead of devoting so much of our time and energy to convincing the world that having an addiction doesn’t make you a bad person, would we be better served by focusing more on prevention, education, and accessibility of treatment, or perhaps targeting the widespread cultural, commercial, and economic influences that push so many Americans toward drugs and alcohol in the first place?”
A fair question. I especially appreciate the last point about counteracting the forces that make substance use and related societal problems so common. At the same time, confronting stigma is about much more than helping others see people with addiction as decent folks. Ultimately, it’s about education and expanding understanding within the very institutions we’re counting on to dramatically expand and improve prevention, education and access to care.
The problem of stigma is not what people believe about our character. It’s what they don’t know about our disease.
It’s not that people like me are treated poorly or unfairly (though that can sometimes be the case). It’s that the condition we have is not well understood.
I remember when first running across a report assessing the prevalence and impact of chronic health conditions. The only problem was that its list of the 10 most prevalent chronic conditions did not include substance use disorder (which, according to many studies, affects more people than several of the other cited conditions do). The researchers said their study broke out substance use disorders by substance; in other words, opioid use disorder, cocaine use disorder and alcohol use disorder were all considered separate chronic conditions, preventing any one from making the top 10. Those who understand addiction well, though, know it’s important NOT to segment the disease according to substance of choice, especially when looking at it from a public health perspective. After all, most people with addiction misuse multiple substances, and that’s because the problem is the underlying health condition of addiction, more than the specific substances that activated it. As you might imagine, the report did not segment heart disease according to the different foods that can contribute to that disease — nor should it have.
The researchers didn’t intentionally neglect one of the nation’s biggest public health problems. They just didn’t understand addiction well, and work within an entire healthcare system that lacks understanding. In the end, their worthwhile look at the impact of chronic health conditions is missing one of the conditions that has the greatest impact on American health and healthcare. Multiply that example thousands of times throughout our institutions over decades and decades, and you begin to see how addiction has been marginalized. Not necessarily because others scorn people like me, but because they just don’t get it.
And until more people get it, our progress on the big priorities will remain slow and piecemeal. Marty Mann had it right: massive and long-term education is the key.
One of my favorite programs at the Hazelden Betty Ford Foundation is our Summer Institute for Medical Students (SIMS). Here’s why …
During their school clinical experiences, med students are exposed to the consequences of substance use frequently — in emergency rooms, for example — but usually without corresponding exposure to people in recovery. As a result, they never see or experience addiction as a health condition that can be overcome — until, that is, they get to our week-long immersive program, where they see the healing process up close. Invariably, they leave describing a profound experience — their ignorance displaced by understanding. All of a sudden, they get it. They get that addiction affects all sorts of people and is a health condition. They get that it impacts many other health conditions they’re accustomed to seeing and treating. And they remember why they decided to become human healers in the first place.
We don’t need more compassion, per se. We don’t simply need people to treat us better. But America does need more people to understand our disease accurately. To get it.
When they do, the compassion, care, investments and change will follow.
That’s what striving to end stigma means to me.
*This is an updated version of a 2017 article.
Jeremiah Gardner, director of communications and public affairs at the Hazelden Betty Ford Foundation, is a person in long-term recovery with a master’s degree in addiction studies and a background in journalism, public affairs, business and music.
