psychology
punam21
punam.docx© 2020 American Psychological Association 2021, Vol. 6, No. 2, 151–162
ISSN: 2376-6972 http://dx.doi.org/10.1037/sah0000226
Perceived Stigma, Discrimination and Mental Health Among Women in Publicly Funded Substance Abuse Treatment
Atsushi Matsumoto, Claudia Santelices, and Alisa K. Lincoln
Northeastern University
Experiences of perceived stigma and discrimination are associated with a range of negative health outcomes. Individuals with substance use disorders and co-occurring mental health problems experience significant public stigma and discrimination associated with multiple aspects of identity. Less is known as to how these experiences of stigma and discrimination are associated with mental health among women in substance abuse treatment. This study examined experiences of perceived stigma and discrimination as well as associations among these experiences and poor mental health among women in publicly funded substance abuse treatment services. Structured interview data from 240 women (59% racial/ethnic minority, M SD age 33.42 9.16) include measures of devaluation stigma, perceived discrimination, and symptoms of psychological distress and posttraumatic stress disorder (PTSD) and open-ended questions exploring experiences of stigma and discrimination. Participants identified substance use as the most prevalent source of devaluation stigma and the most common reason for experiences of discrimination. Adjusting for covariates, discrimination was associated with higher severity of mental health symptoms ( p .001) and PTSD symptoms ( p .001). Devaluation stigma based on race, substance use, and mental illness were not associated with mental health indices. In addition, recent trauma experience partially mediated the relationships of perceived discrimination with mental health symptoms ( p .001) and PTSD symptoms ( p .001), after adjusting for covariates. These findings suggest importance of strategies to address experiences of discrimination to improve mental health of women in publicly funded substance abuse treatment.
Keywords: stigma, discrimination, substance abuse treatment, mental health, women
Women in publicly funded substance abuse treatment services tal health disorders (Substance Abuse and Mental Health Services face many barriers to recovery and overall well-being. In addition Administration [SAMHSA], 2017), with estimates of rates of to the limited number of culturally appropriate, trauma-informed co-occurring mental health problems among women, ranging from services and the complexity of navigating system to access support 20% to 60%, and a history of trauma through physical and/or for their health and social needs, experiences of stigma and dis- sexual assault, ranging from 55% to 99% (Greenfield, Back, Lawcrimination remain salient stressors that could further complicate son, & Brady, 2010; Lincoln, Liebschutz, Chernoff, Nguyen, & their mental health and process of recovery. Substance use disor- Amaro, 2006), highlighting the need for the development of ders affect more than 20 million adults (Kulesza, Larimer, & Rao, trauma-informed integrated treatment services for women with 2013; Lipari & Van Horn, 2017). Of these individuals, it is substance use disorders with co-occurring mental health problems estimated that 8 million present with additional co-occurring men- and a history of trauma.
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
StigmaandHealth
Despite this, about one third of individuals with substance use disorders report ever having attended treatment, and only 7.4% of individuals with co-occurring disorders of substance use and men-
152 MATSUMOTO, SANTELICES, AND LINCOLN
PERCEIVED STIGMA, DISCRIMINATION AND MENTAL HEALTH 153
tute for Health Equity and Social Justice Research, Bouvé College of Health Sciences, Northeastern University.
This study was supported by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Administration, Center for Substance Abuse Treatment grant 5H79TI025137 awarded to the principal investigator, Alisa K. Lincoln.
Special thanks to participants for sharing their experiences, to Rachel F. Rodgers in the Department of Applied Psychology for her assistance with statistical analysis, and to Harumi Harakawa and Courtney Mitterling for their support of a draft of the manuscript.
Correspondence concerning this article should be addressed to Alisa K. Lincoln, Institute for Health Equity and Social Justice Research, Bouvé College of Health Sciences, Northeastern University, 360 Huntington Avenue, 314 INV, Boston, MA 02115. E-mail: [email protected]
|
This article was published Online First April 6, 2020. tal health disorders report having received treatment for both Atsushi Matsumoto, Claudia Santelices, and Alisa K. Lincoln, Insti151 |
disorders (Kulesza et al., 2013, via SAMHSA, as cited in Priester et al., 2016). Women in substance use treatment services face many instrumental barriers that could interfere with their successful engagement in treatment, ranging from transportation, housing and medical and financial support to childcare and family responsibilities (Center for Substance Abuse Treatment [CSAT], 2009; Priester et al., 2016; Werner, Young, Dennis, & Amatetti, 2007). In addition, perceived stigma and discrimination are commonly cited barriers to treatment and retention among individuals with substance use disorders with co-occurring mental health problems (CSAT, 2009; Eliason & Amodia, 2006; Hammarlund, Crapanzano, Luce, Mulligan, & Ward, 2018; Jones, Hopson, Warner, Hardiman, & James, 2015; Priester et al., 2016). A meta-analysis of previous studies demonstrates that stigma and discrimination negatively affect health outcomes, particularly mental health outcomes with effects such as elevated levels of symptoms associated with depression, general psychological distress, posttraumatic stress disorder (PTSD), and the use of substances (Pascoe & Smart Richman, 2009).
The robust literature on perceived stigma and mental illness includes continued development of theoretical perspectives informing our understanding of multiple aspects of stigma including public stigma and self-stigma (Corrigan & Watson, 2002), devaluation and alienation (Link, 1987), stigma power (Link & Phelan, 2014), and frameworks for understanding complex stigma mechanisms (Pescosolido & Martin, 2015). Empirical studies have demonstrated the virtually ubiquitous presence of exposure to stigma and marginalization among people with mental illness and using mental health services as well as the impact of experiences of stigma on a range of mental health outcomes (Corrigan, Bink, Schmidt, Jones, & Rüsch, 2016; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Oliveira, Carvalho, & Esteves, 2016; Watson, Corrigan, Larson, & Sells, 2007). Here we draw upon the complex anatomy of stigma processes and its four mutually animating components delineated by Link and Phelan (2001). These four processes include distinguishing and labeling differences, linking stereotypes to these differences, distinguishing an esteemed “us” from a devalued “them,” and enacting status loss and discrimination—all relying on differences in social power. Finally, stigma has been proposed as a fundamental cause of population health inequalities, due to its pervasiveness, disruption of multiple life domains, use of multiple and changing pathways of effect, and negative impact on the health of populations (Hatzenbuehler, Phelan, & Link, 2013).
In contrast, stigma specific to substance use disorders and experiences of individuals in substance abuse treatment have not been as widely examined to date. A limited number of studies that addressed public stigma and substance use and abuse suggests that people with substance abuse problems endure high levels of public stigma as compared with other groups (Ahern, Stuber, & Galea, 2007; Kulesza et al., 2013; Yang, Wong, Grivel, & Hasin, 2017). In addition, previous studies conducted with individuals who use illicit drugs with several stigmatized statuses with respect to race, age, sex, sexual orientation, and poverty have shown that discrimination based on their drug use was the most salient form of discrimination that influenced their lives (Minior, Galea, Stuber, Ahern, & Ompad, 2003; Young, Stuber, Ahern, & Galea, 2005). Significant public stigma toward individuals with substance abuse problems has been attributed to the framing of substance use as a moral and criminal issue, leading to a greater degree of social disapproval with negative attitudes and beliefs (Ahern et al., 2007; Kulesza et al., 2013) as well as beliefs that substance abuse is a matter of personal control thereby blaming individuals who suffer from this condition (Livingston, Milne, Fang, & Amari, 2012; Yang et al., 2017). Consistent with findings of associations between perceived stigma and mental health symptoms in the general population, associations among perceived stigma and symptoms of depression and anxiety and a negative association with overall psychological functioning have been demonstrated among people who use substances (Ahern et al., 2007; Luoma et al., 2007; Schomerus, Matschinger, & Angermeyer, 2014). Furthermore, devaluation stigma, stigma-based rejection and alienation, and discrimination related to mental illness and substance use have shown significant associations with depressive symptoms in multiple studies (Ahern et al., 2007; Link, Struening, Rahav, Phelan, & Nuttbrock, 1997), and devaluation stigma related to use of substance abuse treatment is associated with lower self-esteem, higher depression and anxiety, and decreased quality of sleep among people in substance abuse treatment (Birtel, Wood, & Kempa, 2017).
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
Finally, women seeking publicly funded substance abuse treatment and those receiving treatment services experience stigma and discrimination associated with multiple characteristics and identities. Recent scholarship has begun to address multiple or layered stigmas primarily those experienced by people with HIV and mental illness (Brinkley-Rubinstein, 2015; Lekas, Siegel, & Leider, 2011; Lincoln et al., 2017; Logie, James, Tharao, & Loutfy, 2011; Rendina, Millar, & Parsons, 2018). One of the few qualitative studies on experiences of Black women with substance abuse and/or mental health treatment services (Jones et al., 2015) found stigmas associated with multiple identities of Black women based on race, gender and substance use as one of the critical factors that served as obstacles to recovery. Additional studies addressing multiple identities of women in substance abuse treatment settings are needed to better understand impact of multiple stigmas on health outcomes.
To begin to address this gap in literature, the current study examined experiences of perceived stigma and discrimination as well as associations among one aspect of stigma—devaluation (referred to hereafter as devaluation stigma), discrimination and mental health among women in publicly funded substance abuse treatment with co-occurring mental health problems. First, we describe discrimination and devaluation stigma experienced by our participants. Second, we examine the relationships among these experiences and mental health outcomes. And, third, we assess the mechanisms of association among discrimination, trauma and mental health outcomes.
Method
Participants and Procedures
Data for the present study came from SAMHSA-funded evaluation project designed to enhance community-based substance abuse treatment to meet the needs of women of color through integration of the trauma-informed substance abuse treatment services into a behavioral health home. The project was implemented at a publicly funded trauma-informed substance abuse treatment program that serves women from diverse race/ethnic identifications in urban neighborhoods located in Boston, Massachusetts. All women receiving treatment services at the study site who were at least 19 years of age, were not under legal guardianship, and were eligible to participate in the evaluation study. At admission into treatment, women were provided with the brief description about the study and were able to opt-in to be contacted by the research team for further information about the evaluation study protocol. Women who chose to participate provided written informed consent. All study protocols were approved by the Institutional Review Board at Northeastern University, and participants were recruited from January 2015 to March 2018.
Structured in-person interviews with participants were conducted in private spaces in the treatment facility and lasted approximately 1 hr. The interview consisted of survey questions related to demographic information and quantitative measures of health care utilization, health status, social support, HIV risk behaviors, experiences of devaluation and discrimination, trauma and mental health. In addition, open-ended questions on experiences of discrimination and treatment services were included in the survey. The responses were digitally recorded and participants who completed the interview received a gift card to a local retail store in exchange for their time. The evaluation protocol included all participants being contacted 6 months after baseline for a second in-person interview. In the following text, we present results from baseline interviews with participants ( N 240).
Demographic information. Participants reported their age, race, education, employment status, sources of income, number of children, homelessness in the last year, arrest history in lifetime, and questions about history of trauma in lifetime and last 30 days.
Measures
Dependent variables.
Brief Symptom Inventory–18 (BSI-18; Derogatis, 2001). The BSI-18 is a shortened version of the original BSI and was used to assess participants’ severity of mental health symptomatology. The BSI-18 contains a total of 18 items, six items each to measure each of the three subscales comprising Depression, Anxiety, and Somatization. The measure also provides a global severity index, which reflects an overall level of severity of psychological distress. Items are rated on a scale ranging from 0 ( not at all) to 4 ( very much) over the period of the last 7 days, with possible score for a global severity index ranging from 0 to 72. The BSI-18 has demonstrated good internal consistency and valid factor structure among community samples of people with substance abuse problems (Wang et al., 2010). In the present study, we used the instrument demonstrated strong internal consistency (Cronbach’s .93) and the global severity index.
Posttraumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997). The PDS was used to assess participants’ overall symptom severity associated with posttraumatic stress disorder (PTSD). The PDS contains a total of 17 items. These items are rated on a scale ranging from 1 ( not at all) to 4 ( almost always) over a period of the past month, with possible scores ranging from 17 to 68. The PDS has demonstrated high internal consistency and test–retest reliability with patients in an outpatient psychiatric setting (Sheeran & Zimmerman, 2002) and good convergent validity with the Structured Clinical Interview for DSM–IV (First, 1994) among a sample of individuals diagnosed with both PTSD and co-occurring alcohol use disorder (Powers, Gillihan, Rosenfield, Jerud, & Foa, 2012). Internal consistency within this sample was strong (Cronbach’s .95).
Independent variables.
Everyday Discrimination Scale (EDS; Williams, Yu, Jackson, & Anderson, 1997). The EDS was used to assess frequency in which participants have experienced various forms of interpersonal mistreatment in their daily lives. The EDS contains a total of nine items. Sample items included “You are treated with less courtesy than other people are,” “People act as if they think you are not smart,” and “People act as if they’re better than you are.” Participants were presented with a Likert-type response scale ranging from 1 ( never) to 6 ( almost every day), with possible scores ranging from 9 to 54. The EDS has demonstrated good internal consistency and construct validity with a community sample of African American adults (Taylor, Kamarck, & Shiffman, 2004; Williams et al., 1997). In the present study, this instrument demonstrated good internal consistency (Cronbach’s .81). Endorsed item was followed with an additional question about participants’ perception for reasons for discrimination. For each endorsed item, participants were asked to select one or more from a list of 13 potential reasons, such as “gender,” “race and ethnicity,” “education and income level,” “alcohol and/or drug use,” and “mental health difficulties.”
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
Devaluation stigma. Three items used to measure devaluation stigma associated with drug use (Ahern et al., 2007; Link et al., 1997) were modified for the present study to assess participant’s devaluation stigma due to the following three signifiers of social identities: race, substance use, and mental illness, with a total of nine items such as “Most people think that someone from my race, ethnicity, or color is not a good person,” “Most people believe that someone who uses alcohol/drugs is dangerous,” and “Most people think that someone who suffers a mental illness is unreliable.” Items were rated on a dichotomous response scale consisting of 0 ( disagree) and 1 ( agree). A subscale score was created by summing the response to each of the three items with possible scores ranging from 0 to 3; however, because of nonnormal distribution of responses for each subscale, the subscale score was dichotomized into 0 (endorsed agreement with none or at least one of three items) and 1 (endorsed agreement with at least two or three items). Within this sample, each of the subscale scores demonstrated good internal consistency (Cronbach’s for race .84, substance use .75, and mental illness .70, respectively). Additionally, four interaction terms were created to examine relationships of intersections of devaluation stigma based on one’s affiliation with more than one social identity with each of the dependent variables.
Qualitative Data
Our evaluation methodology included the addition of openended questions to explore how our participants make meaning and understand their multiple and complex experiences of stigma and discrimination. These questions were asked following the structured discrimination scales, and included an open-ended question designed to capture the participants’ perception of the most relevant reason for their experience of discrimination: “You have talked about different reasons as to why you have been treated differently by different people. According to you, which of these reasons has been the most important, or the one that has impacted you the most and why?”
Data Analysis
Descriptive analyses were examined to understand the demographic characteristics of the participants, as well as devaluation stigma, perceived discrimination, and severity of mental health indices including the severity of mental health symptomatology and PTSD symptoms. Bivariate correlations were performed to examine directions of associations among variables. Hierarchical multiple regression was used to test the significance of independent variables for each dependent variable. Regression analyses examining severity of mental health symptoms and PTSD symptoms included as covariates: level of education, perceived health status and experiences of trauma in lifetime and past 30 days in Step 1; perceived discrimination in Step 2; three subscales of devaluation stigma based on race, substance use and mental illness were entered in Step 3; and finally, each of the four interaction terms of the devaluation stigma subscales were entered. Additionally, mediation and moderation analyses were performed using bootstrapping analyses to examine the role of trauma experience in last 30 days in the relationships of discrimination with severity of mental health symptomatology and PTSD symptoms. Hierarchical multiple regression was performed using SPSS Version 25 (IBM Corp., 2017), and bootstrapping analysis was performed using PROCESS Macro Version 3.0 (Hayes & Little, 2018).
Responses to open-ended questions were brief, ranging from several sentences to a few paragraphs, and they were analyzed using the content analysis approach. First, responses to open-ended questions were transcribed verbatim, and second, through colorcoding, two trained research interns quantified and analyzed the presence of key words or concepts that participants used when answering questions related to the various sources of discrimination and stigma they experienced in everyday life. Selected interview quotes are included in this article to complement quantitative findings and assist in the narrative discussion.
Results
We examined bivariate correlations, and we treated variables associated with dependent outcomes as covariates in later models. Correlations among devaluation stigma related to race, substance use, mental illness, and discrimination scales were significant ( p .01) but not particularly strong, ranging from .18 to .31. Table 1 presents characteristics of the sample, including demographics and the variables of interests. The average age of participants was 33 years old ( SD 9.16). About one quarter of the sample (28.8%) were Hispanic, 25.4% Black, 5% other, and 40.8% White. Most of the sample (92.2%) were mothers to at least one child (92.2%), and about one third of the sample (34.2%) had less than high school education. Multiple sources of income in the last 30 days were reported, ranging from public assistance (71.3%), money from family and/or friends (37.9%), to disability assistance (34.2%). Eighty-three percent of participants had an arrest history, more than one half (57.1%) were homeless at some point during the last year. The mean score was 1.98 ( SD 1.01) for perceived health status. Participants had a mean BSI-18 of 16.66 ( SD 14.20), a mean PDS of 34.49 ( SD 13.56), and a mean EDS of 19.96 ( SD 9.65). Furthermore, about 73% of the sample reported having had an experience of trauma at least once in their lifetimem and about 30% of women reported at least one trauma experience in the last 30 days.
Frequencies of types of discrimination and the reasons for these types of discrimination endorsed by participants across all nine questions in the EDS are presented in Table 1. More than two thirds (74%) of participants endorsed having experienced at least one type of discrimination. The most common type of discrimination reported was having others act as though they are “better than you are,” which was endorsed by more than one half (58%) of participants. In addition, more than one half reported being treated with “less courtesy than other people are” (56%) and with “less respect than others” receive (53%). Participants were then asked about their perceptions of the reasons for these types of discrimination. The most frequently endorsed reasons across nine items in EDS were drug and/or alcohol use (27%) and race and ethnicity (15%), followed by education/income level (10%), neighborhood of residence (9%), mental health difficulties (8%), and gender (7%). Frequencies of types of devaluation experiences endorsed by participants are also presented in Table 1. Each type of devaluation due to substance abuse was endorsed by 85% of participants. The most prevalent was others believing that people “who use drugs and/or alcohol is unreliable” (95%), people think that “someone who uses drugs and/or alcohol is dangerous” (95%), and 87% endorsed that others think that “someone who uses drugs and/or alcohol is not a good person.” The sample also endorsed devaluation experiences because of mental illness. Seventy-seven percent of participants indicated that it is true that majority of people think that “someone who suffers a mental illness is unreliable” and that most people “believe that someone who suffers a mental illness is dangerous.” About one half (54%) agreed that others think that “someone who suffers a mental illness is not a good person.” Discrimination was significantly correlated (see Table 2) with severity of mental health symptomatology; however, there were no significant associations between independent variables, including devaluation subscales and interaction terms and the dependent variable of severity of mental health symptomatology. Discrimination was also significantly associated with severity of PTSD symptoms. The subscale regarding devaluation due to race and some interaction terms of other devaluation subscales were significantly associated with PTSD symptoms, all with small effect sizes.
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
The results of hierarchical multiple regression analyses for variables predicting severity of mental health symptomatology are presented in Table 3. In the Step 1, four covariates that represent individual characteristics were entered: education, perceived health status, trauma in lifetime and trauma in last 30 days. This model was statistically significant F(4, 208) 22.31, p .001, and explained 30% of variance in severity of mental health symptomatology. Three out of four factors including education, perceived health status, and experiences of trauma in last 30 days made a significant unique contribution to the model. Adding discrimination in the Step 2 explained an additional 7.3% of the variance in severity of mental health symptomatology after controlling for education, perceived health status, trauma in lifetime and trauma in last 30 days. This change in R2 was significant, F(1, 207) 24.20, p .001. Neither the addition of subscales nor interaction terms of devaluation in the subsequent steps yielded statistically significant contributions to an improvement of the model. The overall model with a total of 12 independent variables remained statistically significant F(12, 200) 10.24, p .001, and accounted for 38.1% of variance in the severity of mental health symptomatology. Three factors including discrimination, perceived health status and experiences of trauma in last 30 days remained statistically significant predictors with discrimination recording a higher beta value ( .31, p .001) than perceived health status (.26, p .001) and trauma in last 30 days ( .25, p .001).
The results of hierarchical multiple regression analyses for variables predicting severity of PTSD symptoms are presented in
Table 1
Sample Description, Endorsement of Each Item in the Perceived Devaluation Scale (PDS), and Reasons for Experiences of
Discrimination Endorsed Across Nine Items in the Everyday Discrimination Scale (EDS)
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
|
Demographic characteristic |
N |
% |
|
Gender Female |
240 |
100.0 |
|
Age M ( SD) |
33.42 (9.16) |
|
|
Race/Ethnicity White |
98 |
40.8 |
|
African American |
61 |
25.4 |
|
Latina |
69 |
28.8 |
|
Other |
12 |
5.0 |
|
Education Less than high school |
82 |
34.2 |
|
High school grad/GED/higher education |
157 |
65.4 |
|
Information not available |
1 |
0.4 |
|
Currently employed (yes) |
18 |
7.5 |
|
Sources of income in last 30 days (multiple answers apply) Wages or money from paid employment |
15 |
6.3 |
|
Public assistance |
171 |
71.3 |
|
Disability assistance |
82 |
34.2 |
|
Money from family members/friends |
91 |
37.9 |
|
Illegal sources |
9 |
3.8 |
|
Number of children None |
19 |
7.9 |
|
1 or 2 |
117 |
48.8 |
|
3 or 4 |
77 |
32.1 |
|
5 or more |
27 |
11.3 |
|
Having arrested at least once in lifetime (yes) |
198 |
82.5 |
|
Homeless in the past year (yes) |
137 |
57.1 |
|
History of trauma in lifetime (yes) |
174 |
72.5 |
|
Of individuals who reported lifetime trauma history, trauma experience at least once in the past 30 days (yes) |
51 |
29.9 |
|
|
Endorsement frequency of reasons for discrimination across nine items in the EDS ( N. 237) |
|
|
Ancestry and national origin |
61 |
3.6 |
|
Gender |
135 |
7.5 |
|
Race and ethnicity |
246 |
14.5 |
|
Sexual orientation |
41 |
2.4 |
|
Education and income level |
163 |
9.6 |
|
Physical disability |
33 |
1.9 |
|
Language |
59 |
3.5 |
|
Alcohol and/or drug use |
455 |
26.8 |
|
Neighborhood of residency |
158 |
9.3 |
|
Having less money |
151 |
8.9 |
|
Mental health difficulties |
141 |
8.3 |
|
Use of mental health services |
58 |
3.4 |
|
|
Endorsement of each type of devaluation stigma ( N 238) |
|
|
|
N endorsing % endorsing |
|
|
Perceived devaluation due to race, ethnicity, and color Most people believe that someone from my race, ethnicity, or color is dangerous |
93 39.1 |
|
|
Most people think that someone from my race, ethnicity, or color is not a good person |
98 |
41.2 |
|
Most people think that someone from my race, ethnicity, or color is unreliable |
91 |
38.2 |
|
Perceived devaluation due to alcohol and/or drug use Most people believe that someone who uses drugs and/or alcohol is dangerous |
225 |
94.5 |
|
Most people think that someone who uses drugs and/or alcohol is not a good person |
208 |
87.4 |
|
Most people think that someone who uses drugs and/or alcohol is unreliable |
227 |
95.4 |
|
Perceived devaluation due to mental illness Most people believe that someone who suffers a mental illness is dangerous |
183 |
76.9 |
|
Most people think that someone who suffers a mental illness is not a good person |
129 |
54.2 |
|
Most people think that someone who suffers a mental illness is unreliable |
184 |
77.3 |
Note. GED graduate equivalency diploma.
Table 4. In the Step 1, three covariates that represent individual characteristics were entered: perceived health status, experiences of trauma in lifetime and trauma in last 30 days. This model was statistically significant F(3, 203) 27.25, p .001, and explained 29% of variance in severity of PTSD symptoms. All three factors made a significant unique contribution to the model. Introducing discrimination in the Step 2 explained an additional 8.2% of the variance in severity of PTSD symptoms after controlling for perceived health status, trauma in lifetime and trauma in last 30 days. This change in R2 was significant, F(1, 202) 26.21, p .001. Entry of subscales and interaction terms of devaluation in the subsequent steps did not show statistically significant contributions to an improvement of the model. Finally, the overall model remained statistically significant, F(14, 192) 8.77, p .001, and explained 39% of variance in the severity of PTSD symptoms. Independent variables including discrimination, trauma in lifetime and trauma in last 30 days remained significant predictors with discrimination recording a higher beta value ( .32, p .001) than experiences of trauma in last 30 days ( .25, p .001) and trauma in lifetime ( .20, p .001). These results indicate that discrimination accounts for significant variance in the severity of mental health and PTSD symptoms over and above variance explained by individual characteristics: However, devaluation subscales and interaction terms did not serve as predictors of the dependent variables.
Table2
CorrelationsAmongPrimaryVariables
Variable
1234567891011121314
1
.Education
—
.019.050.142
.165
.002.056.160
.002.012.141
.012.198
.116
.Perceivedhealthstatus—
2
.109
.166
.341
.009.144
.041.009.008.051.008
.388
.266
.Traumainlifetime
3
—.273
.107.169
.344
.006.169
.153
.153
.153
.173
.395
4
.Traumainpast30days
—.357
.155
.004.059.155
.152
.059.152
.418
.430
5
.Discrimination
—.215
.041.085.215
.242
.089.242
.480
.493
6
.Devaluation:REC
—.182
.193
1.000
.935
.214
.935
.092.157
.Devaluation:SA
7
—.309
.182
.170
.442
.170
.049.009
8
.Devaluation:MI
—.193
.370
.964
.370
.057.025
.Interactionterm:REC
9
SA
—.935
.214
.935
.092.157
.Interactionterm:REC
10
MI
—.384
1.000
.092.164
11
.Interactionterm:SA
MI
—.384
.080.042
.Interactionterm:REC
12
SA
MI
—.092.164
.Mentalhealthsymptoms
13
—.621
14
.PTSDsymptoms
—
Note
.REC
race,ethnicityandcolor;SA
substanceuse;MI
mentalillness;PTSD
posttraumaticstressdisorder.
p
.05.
p
.01.
To further explore the role of trauma in last 30 days, in the relationship between discrimination and mental health symptomatology, mediation analysis was conducted controlling for relevant covariates including education, perceived health status and trauma in lifetime. Figure 1 shows the results of the mediation model of experiences of trauma in last 30 days in a relationship between discrimination and mental health symptomatology. As Figure 1 shows, the standardized regression coefficient between discrimination and trauma in the last 30 days was significant, as was the standardized regression coefficient between trauma in the last 30 days and severity of mental health symptomatology. In addition, a statistically significant standardized regression coefficient between discrimination and mental health symptomatology indicated a direct relationship. Furthermore, bootstrapping results based on 5,000 samples revealed a significant indirect effect of trauma in the last 30 days in the relationship between discrimination and severity of mental health symptomatology ( .45, SE .09; 95% bias-corrected confidence interval [CI; .03, .14]). Presence of both direct and indirect effects indicate that trauma in the past 30 days partially mediated the relationship between discrimination and severity of mental health symptomatology.
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
The mediating role of trauma in past 30 days in the relationship between discrimination and severity of PTSD symptoms was also considered while controlling for covariates including perceived health status and lifetime trauma experiences. As is shown in Figure 1, there were statistically significant association of the relationships of discrimination with trauma in the last 30 days and PTSD symptoms. In addition, the standardized regression coefficient between discrimination and PTSD symptoms was statistically significant. Results from bootstrapping based on 5000 samples showed a significant indirect effect of trauma in the last 30 days in the relationship between discrimination and PTSD symptoms ( .43, SE .09; 95% CI [.03, .15]). Presence of both direct and indirect effects show that trauma in the past 30 days Table 3
Hierarchical Linear Regression Models Predicting Severity of Mental Health Symptomatology
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
|
Step and variable |
B |
SE |
|
R |
R2 |
R2 |
Adjusted R2 |
|
Step 1 |
|
|
|
.548 |
.300 |
.300 |
.287 |
|
Education |
1.078 |
.439 |
.145 |
|
|
|
|
|
Perceived health |
4.869 |
.833 |
.347 |
|
|
|
|
|
Trauma in lifetime |
.736 |
2.114 |
.021 |
|
|
|
|
|
Trauma in last 30 days |
10.681 |
2.065 |
.317 |
|
|
|
|
|
Step 2 |
|
|
|
.611 |
.373 |
.073 |
.358 |
|
Education |
.814 |
.420 |
.109 |
|
|
|
|
|
Perceived health status |
3.581 |
.832 |
.255 |
|
|
|
|
|
Trauma in lifetime |
.186 |
2.014 |
.005 |
|
|
|
|
|
Trauma in last 30 days |
8.066 |
2.030 |
.240 |
|
|
|
|
|
Discrimination |
.460 |
.094 |
.309 |
|
|
|
|
|
Step 3 |
|
|
|
.614 |
.377 |
.003 |
.352 |
|
Education |
.804 |
.426 |
.108 |
|
|
|
|
|
Perceived health status |
3.661 |
.849 |
.261 |
|
|
|
|
|
Trauma in lifetime |
.144 |
2.054 |
.004 |
|
|
|
|
|
Trauma in last 30 days |
8.373 |
2.074 |
.249 |
|
|
|
|
|
Discrimination |
.464 |
.095 |
.311 |
|
|
|
|
|
Devaluation: REC |
1.568 |
1.684 |
.054 |
|
|
|
|
|
Devaluation: SA |
1.290 |
4.113 |
.018 |
|
|
|
|
|
Devaluation: MI |
.651 |
1.891 |
.020 |
|
|
|
|
|
Step 4 |
|
|
|
.615 |
.377 |
.000 |
.349 |
|
Education |
.804 |
.427 |
.108 |
|
|
|
|
|
Perceived health status |
3.662 |
.852 |
.261 |
|
|
|
|
|
Trauma in lifetime |
.144 |
2.059 |
.004 |
|
|
|
|
|
Trauma in last 30 days |
8.369 |
2.084 |
.249 |
|
|
|
|
|
Discrimination |
.464 |
.095 |
.311 |
|
|
|
|
|
Devaluation: REC |
1.021 |
18.553 |
.035 |
|
|
|
|
|
Devaluation: SA |
1.633 |
12.285 |
.023 |
|
|
|
|
|
Devaluation: MI |
.648 |
1.898 |
.020 |
|
|
|
|
|
Interaction: REC SA |
.278 |
9.375 |
.020 |
|
|
|
|
|
Step 5 |
|
|
|
.615 |
.379 |
.002 |
.348 |
|
Education |
.816 |
.427 |
.109 |
|
|
|
|
|
Perceived health status |
3.691 |
.853 |
.263 |
|
|
|
|
|
Trauma in lifetime |
.114 |
2.061 |
.003 |
|
|
|
|
|
Trauma in last 30 days |
8.338 |
2.086 |
.248 |
|
|
|
|
|
Discrimination |
.461 |
.095 |
.309 |
|
|
|
|
|
Devaluation: REC |
4.406 |
19.010 |
.153 |
|
|
|
|
|
Devaluation: SA |
3.575 |
12.515 |
.051 |
|
|
|
|
|
Devaluation: MI |
3.764 |
5.646 |
.118 |
|
|
|
|
|
Interaction: REC SA |
1.681 |
9.534 |
.121 |
|
|
|
|
|
Interaction: REC MI |
3.431 |
4.135 |
.282 |
|
|
|
|
|
Step 6 |
|
|
|
.617 |
.380 |
.001 |
.346 |
|
Education |
.811 |
.428 |
.109 |
|
|
|
|
|
Perceived health status |
3.653 |
.856 |
.260 |
|
|
|
|
|
Trauma in lifetime |
.139 |
2.064 |
.004 |
|
|
|
|
|
Trauma in last 30 days |
8.435 |
2.093 |
.251 |
|
|
|
|
|
Discrimination |
.465 |
.096 |
.312 |
|
|
|
|
|
Devaluation: REC |
9.240 |
20.260 |
.320 |
|
|
|
|
|
Devaluation: SA |
9.158 |
14.874 |
.130 |
|
|
|
|
|
Devaluation: MI |
10.233 |
20.868 |
.322 |
|
|
|
|
|
Interaction: REC SA |
.860 |
10.219 |
.062 |
|
|
|
|
|
Interaction: REC MI |
3.310 |
4.144 |
.272 |
|
|
|
|
|
Interaction: SA MI |
7.042 |
10.106 |
.481 |
|
|
|
|
|
Step 7 |
|
|
|
.617 |
.381 |
.001 |
.344 |
|
Education |
.822 |
.430 |
.110 |
|
|
|
|
|
Perceived health status |
3.642 |
.858 |
.259 |
|
|
|
|
|
Trauma in lifetime |
.143 |
2.068 |
.004 |
|
|
|
|
|
Trauma in last 30 days |
8.517 |
2.107 |
.253 |
|
|
|
|
|
Discrimination |
.462 |
.096 |
.310 |
|
|
|
|
|
Devaluation: REC |
32.586 |
60.650 |
1.129 |
|
|
|
|
|
Devaluation: SA |
6.483 |
41.089 |
.092 |
|
|
|
|
|
Devaluation: MI |
12.786 |
60.106 |
.402 |
|
|
|
|
|
Interaction: REC SA |
12.847 |
31.081 |
.924 |
|
|
|
|
|
Interaction: REC MI |
20.188 |
41.526 |
1.660 |
|
|
|
|
|
Interaction: SA MI |
4.697 |
30.469 |
.321 |
|
|
|
|
|
Interaction: REC SA MI |
8.615 |
21.089 |
1.446 |
|
|
|
|
Note. N 213. REC race, ethnicity and color; SA substance use; MI mental illness.
p .05. p .001.
Table 4
Hierarchical Linear Regression Models Predicting Severity of Posttraumatic Stress Disorder Symptoms
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
|
Step and variable |
B |
SE |
|
R |
R2 |
R2 |
Adjusted R2 |
|
Step 1 |
|
|
|
.536 |
.287 |
.287 |
.277 |
|
Perceived health status |
2.763 |
.799 |
.209 |
|
|
|
|
|
Trauma in lifetime |
8.353 |
2.043 |
.252 |
|
|
|
|
|
Trauma in last 30 days |
10.028 |
1.938 |
.320 |
|
|
|
|
|
Step 2 |
|
|
|
.607 |
.369 |
.082 |
.356 |
|
Perceived health status |
1.461 |
.795 |
.110 |
|
|
|
|
|
Trauma in lifetime |
7.516 |
1.934 |
.227 |
|
|
|
|
|
Trauma in last 30 days |
7.006 |
1.921 |
.223 |
|
|
|
|
|
Discrimination |
.450 |
.088 |
.326 |
|
|
|
|
|
Step 3 |
|
|
|
.614 |
.377 |
.008 |
.356 |
|
Perceived health status |
1.453 |
.810 |
.110 |
|
|
|
|
|
Trauma in lifetime |
7.060 |
1.964 |
.213 |
|
|
|
|
|
Trauma in last 30 days |
7.572 |
1.956 |
.241 |
|
|
|
|
|
Discrimination |
.445 |
.089 |
.323 |
|
|
|
|
|
Devaluation: REC |
1.397 |
1.608 |
.051 |
|
|
|
|
|
Devaluation: SA |
2.264 |
4.059 |
.033 |
|
|
|
|
|
Devaluation: MI |
2.723 |
1.802 |
.091 |
|
|
|
|
|
Step 4 |
|
|
|
.620 |
.384 |
.006 |
.359 |
|
Perceived health status |
1.466 |
.808 |
.111 |
|
|
|
|
|
Trauma in lifetime |
7.080 |
1.959 |
.214 |
|
|
|
|
|
Trauma in last 30 days |
7.495 |
1.952 |
.239 |
|
|
|
|
|
Discrimination |
.441 |
.089 |
.319 |
|
|
|
|
|
Devaluation: REC |
34.456 |
23.110 |
1.269 |
|
|
|
|
|
Devaluation: SA |
21.192 |
13.807 |
.306 |
|
|
|
|
|
Devaluation: MI |
2.983 |
1.806 |
.099 |
|
|
|
|
|
Interaction: REC SA |
16.665 |
11.621 |
1.279 |
|
|
|
|
|
Step 5 |
|
|
|
.620 |
.384 |
.000 |
.356 |
|
Perceived health status |
1.472 |
.811 |
.111 |
|
|
|
|
|
Trauma in lifetime |
7.088 |
1.965 |
.214 |
|
|
|
|
|
Trauma in last 30 days |
7.481 |
1.959 |
.239 |
|
|
|
|
|
Discrimination |
.440 |
.089 |
.319 |
|
|
|
|
|
Devaluation: REC |
35.383 |
24.157 |
1.303 |
|
|
|
|
|
Devaluation: SA |
21.086 |
13.863 |
.305 |
|
|
|
|
|
Devaluation: MI |
2.294 |
5.391 |
.076 |
|
|
|
|
|
Interaction: REC SA |
16.645 |
11.651 |
1.278 |
|
|
|
|
|
Interaction: REC MI |
.536 |
3.958 |
.047 |
|
|
|
|
|
Step 6 |
|
|
|
.620 |
.385 |
.001 |
.353 |
|
Perceived health status |
1.485 |
.813 |
.112 |
|
|
|
|
|
Trauma in lifetime |
7.098 |
1.969 |
.214 |
|
|
|
|
|
Trauma in last 30 days |
7.494 |
1.963 |
.239 |
|
|
|
|
|
Discrimination |
.437 |
.090 |
.316 |
|
|
|
|
|
Devaluation: REC |
25.766 |
31.696 |
.949 |
|
|
|
|
|
Devaluation: SA |
22.879 |
14.405 |
.331 |
|
|
|
|
|
Devaluation: MI |
8.484 |
23.562 |
.283 |
|
|
|
|
|
Interaction: REC SA |
11.987 |
15.315 |
.920 |
|
|
|
|
|
Interaction: REC MI |
.361 |
3.983 |
.032 |
|
|
|
|
|
Interaction: SA MI |
5.569 |
11.851 |
.400 |
|
|
|
|
|
Step 7 |
|
|
|
.625 |
.390 |
.005 |
.346 |
|
Perceived health status |
1.539 |
.826 |
.116 |
|
|
|
|
|
Trauma in lifetime |
6.612 |
2.020 |
.199 |
|
|
|
|
|
Trauma in last 30 days |
7.894 |
2.000 |
.252 |
|
|
|
|
|
Discrimination |
.437 |
.091 |
.317 |
|
|
|
|
|
Devaluation: REC |
28.621 |
32.252 |
1.054 |
|
|
|
|
|
Devaluation: SA |
27.061 |
19.706 |
.391 |
|
|
|
|
|
Devaluation: MI |
11.591 |
27.879 |
.386 |
|
|
|
|
|
Interaction: REC SA |
12.195 |
15.415 |
.936 |
|
|
|
|
|
Interaction: REC MI |
1.129 |
4.551 |
.099 |
|
|
|
|
|
Interaction: SA MI |
7.371 |
13.694 |
.530 |
|
|
|
|
|
Interaction: REC SA MI |
4.996 |
9.416 |
.052 |
|
|
|
|
Note. N 206. REC race, ethnicity and color; SA substance use; MI mental illness.
p .001.
Discrimination
Trauma in Past 30 Days
Mental Health Symptoms
β
=
.02**,
SE
= .00
β
=
6.57**,
SE
= 1.46
β
=
.56**,
SE
= .09
( β = .45**, SE = .09)
Trauma in Past 30 Days
β = .02**, SE = .004 β = 6.31**, SE = 1.40
Discrimination PTSD Symptoms
β = .55**, SE = .09
( β = .43**, SE = .09)
Figure 1. Path diagram and ( SE) for the mediating role of trauma in the past 30 days in the relationships between discrimination and mental health symptoms and discrimination and PTSD symptoms, adjusting for covariates. The number in parenthesis is the standardized beta weight for the indirect effect. p .001.
partially m mediated the relationship between discrimination and PTSD symptoms.
Although these quantitative analyses help us understand the mechanisms of association among experiences of discrimination and mental health outcomes among women in substance abuse treatment, responses to the open-ended questions provide additional knowledge and allow us to explore our participants’ understandings of the reasons for and impacts of these experiences on their well-being. Importantly, these diverse understandings of their experiences of discrimination provide evidence that different perceived reasons for discrimination bring differing impacts. Participants who identified substance use as the source of discrimination that was the most impactful, spoke most often of feeling judged and treated with disrespect as a result of their substance use. A 25-year-old White woman offered the following response:
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
[Unfair treatment] has a big impact on me. I’ve been judged my whole life because of my addiction . . . I’m very misunderstood. People judge me very quickly especially with being an addict, you get judged everywhere you go [including at the] doctor’s office, streets, stores, even in places like this [treatment facility]. You are constantly being judged and I know that’s taken some people out and they’ve lost their lives over it. Just because we’re addicts, we’re not bad people . . . We get treated unfairly, we get treated like we do not deserve as much as someone who is not an addict. But we have a disease, just like people with cancer. Until people have either been there or walked in our shoes or you know, they’ll never understand.
Another participant, a 37-year-old White woman, elaborated on substance use as a reason for her experience of discrimination.
I’m being judged by the things I’ve done in the past, or you know, some addiction problems that I have. I’m not being judged on my intellectual level, or by who I am as a person. I am being judged on substance [use] or being judged on a stigma of something as a whole, rather than a person. So, it affects me being able to express myself or move forward, in life any which way, whether it be with my work, trying to find work, or moving on with housing, or even having an intellectual conversation with somebody, if I’m being looked down on, or being judged, I’m not being taken as seriously as I need to be.
In contrast, participants identifying race/ethnicity as their main reason of discrimination never discussed feeling judged but instead most often described these experiences as being ubiquitous and situated in many places, from within one’s family, to public spaces such as restaurants/bars, commercial stores, and treatment settings themselves. Being looked down upon, spoken to in a condescending manner, or treated as less intelligent were commonly reported among this group. Importantly, participants who reported that racial discrimination was impactful for them along with discrimination associated with drug and alcohol use, described a distinction similar to that posed by Goffman (1963) between “discredited and discreditable” stigma as discrimination associated with race was not avoidable or correctible as it could be in the case of alcohol/drug addiction. A 23-year-old Black woman shared her experience of race/ethnicity as a reason for discrimination.
I recently went in a store, it was a high-end store, and me and a friend was looking at something, deciding if we were gonna get it or not, and a girl comes over, and she takes it out of my friend’s hand, smiled at us, and put it back on the rack like we couldn’t afford it. And it’s like, when you see us two together, you think we’re gonna do something crazy, I guess. And it’s like, we’re not doing anything! We’re buying; we’re picking out what we want, and we’re buying . . . I’m not a thief! . . . Both [unfair treatment due to substance use and race] are difficult to accept, but discrimination due to race is more vague or covert than discrimination due to drug use. I cannot do anything about my race, but I can do something about drug use.
In addition, a 50-year-old Hispanic woman offered the following comment about race/ethnicity as a reason for discrimination.
Because of my race, they think because I’m Hispanic, I’m an idiot. And to their surprise I’m educated, I have a degree, I have college, a college background, so they’re very surprised. Um the condescending piece is, I do not like anybody putting another individual down, I think that’s very—that’s just wrong, “treat those, the way you want to be treated”, that’s what I believe in.
Last, participants who identified mental health difficulties as the main reason for their experiences of discrimination spoke of not being understood, respected and/or trusted, as well as having to navigate within the margins of a private and public environment where they perceive a lack of empathy and understanding. A 33-year-old Black woman shared the following response:
Due to my diagnosis, it causes me to um, react to certain things differently from somebody that doesn’t have a mental health illness, which leads to me doing things that sometimes I do not remember, and I get criticized because of it, and not believed that I do not remember. Um, what happened that caused this person to reject, or disrespect me . . . But, you know, just the fact that other people, they’re going to put me down because of it [diagnosis of PTSD and depression], or make me feel negative because of it, when it’s not something that I want to be doing.
These data provide evidence that there are patterned understandings of the impact of discrimination and stigma on the well-being of women who experience multiple sources of discrimination and stigma. Experiences of moral judgment were not surprisingly more frequently reported among women who reported that discrimination associated with substance use was the “most important” reason for discrimination, whereas the inescapability of racial discrimination was stressed among women who saw this as the “most important” reason. Lastly, women who identified mental health as the “most important” reason for experiences of discrimination reported themes that echo strongly with stigma such as not being understood, respected or trusted, and the need to navigate space conscious of disclosure of their stigmatized identity.
Discussion
The current study aimed to increase understanding of the experiences of discrimination and devaluation stigma among women in publicly funded substance abuse treatment. The results revealed that substance use was the most prevalent source of devaluation stigma and the most common reason identified by participants for their experiences of discrimination. The results also demonstrated associations of perceived discrimination with severity of mental health indices, indicating that more frequent experience of discrimination was associated with higher severity of mental health and PTSD symptoms, after adjusting for covariates. Contrary to our expectations, the devaluation stigma variables including devaluation based on race, substance use, and mental illness as well as interaction terms created to capture intersecting identities of these social identities, were not related to mental health indices with the current sample of women. Furthermore, our analysis showed a partial mediation effect of an experience of trauma in last 30 days in relationships between discrimination and mental health indices after adjusting for covariates, suggesting that recent trauma experience might exacerbate the impact of discrimination on mental health outcomes. This finding is consistent with previous studies that reported an association between perceived discrimination and trauma among samples ranging from people of color and transgender adults to individuals with HIV, indicating experiences of discrimination can itself be traumatic (Brezing, Ferrara, & Freudenreich, 2015; Carter, 2007; Reisner et al., 2016).
These findings should be interpreted considering several limitations. The cross-sectional design of the current study prevents causal and temporal interpretations of the associations and our participants might differ from women in publicly funded substance abuse treatment who chose not to participate in the study. In addition, the current sample of women in publicly funded substance abuse treatment is largely low income and thus, further work is needed to understand the range of experiences of discrimination and stigma among women and men in other substance abuse treatment settings. Last, although m our open-ended questions provided insight into how our participants understood and made meaning of the multiple sources of discrimination in their lives, these data are limited as they were brief responses and were not intended to be fully qualitative interviewing including additional probes. Further mixed-methods and qualitative work is needed to more fully understand the experiences of people navigating multiple stigmatized identities and experiencing numerous sources of discrimination.
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
Although previous studies with a variety of samples have shown a strong empirical support for the associations between perceived discrimination and mental health outcomes, only a few have considered the association among individuals with substance use disorders and co-occurring mental health problems and addressed multiple sources of discrimination. A previous study conducted with men with dual diagnoses found positive associations of perceived discrimination, devaluation stigma and stigma-based rejection with symptoms of depression at baseline when men entered the treatment, reporting an enduring effect of perceived discrimination and the stigma on severity of depression symptoms over a 1-year period (Link et al., 1997). Additional studies conducted with samples consisting of individuals who use illicit drugs and those in substance abuse treatment found that discrimination related to drug use was associated with poor mental health (Ahern et al., 2007; Luoma et al., 2007). Our finding on the associations between perceived discrimination and worse mental health outcomes provide further support for findings from previous studies.
The current study did not find significant associations of devaluation stigma based on race, substance use, and mental illness or interactions of these social identities with mental health indices, including mental health symptomatology and PTSD symptoms. This finding was unexpected given that previous studies with individuals with mental illness have shown associations of devaluation stigma with lowered global functioning, self-esteem and treatment seeking attitudes (Conner et al., 2010; Link, Castille, & Stuber, 2008; Lundberg, Hansson, Wentz, & Björkman, 2007). Ahern et al. (2007) examined associations between the stigma including devaluation stigma and stigma-based alienation related to drug use, the latter defined as internalization of publicly endorsed stereotypes, and mental health among people using illicit drugs. They found that although no association was found between devaluation stigma related to drug use and poor mental health, stigma-based alienation related to drug use was associated with poor mental health, thereby suggesting a potential impact of internalization of public stigma on poor mental health. Additional studies are needed to discern roles of stigma variables including devaluation stigma and stigma-based alienation on mental health of individuals in publicly funded substance treatment settings.
In addition, a partial mediation effect of recent trauma experiences in the associations between perceived discrimination and mental health was found. This revealed that, in addition to direct associations between perceived discrimination and worse mental health, women who reported perceived discrimination also reported having a recent experience of trauma in last 30 days, which in turn, was related to higher severity of mental health and PTSD symptoms. Informed by the theoretical models that recognize discrimination as a potential source of traumatic stress (e.g., Carter, 2007; Meyer, 2003), these findings might be interpreted as suggesting perceived discrimination experienced by the current sample of women in substance abuse treatment contributes to chronic traumatic stress that exacerbates the impact of further traumatic experiences and subsequent mental health outcomes. Coupled with evidence of high rates of women with substance use/abuse reporting revictimization through intimate partner violence and physical and sexual assaults (Hien, Cohen, & Campbell, 2005; Hien, Nunes, & Levin, 1995), this finding further adds to the critical importance of addressing perceived discrimination to mitigate the associations among exposures to traumatic events and poor mental health.
Finally, our data suggest that women engage in complex processes of meaning making around the multiple sources of stigma and discrimination they experience. Among our participants drug and/or alcohol addiction was cited most frequently as the main reason for their experiences of discrimination, followed by race/ ethnicity. This might in part reflect the salience of addiction stigma among women navigating substance abuse treatment, our recruitment setting, but might also reflect the current social context and climate within which women in this northeastern city seek care. Importantly, our participants shared distinct meanings of experiences of discrimination associated with different perceived sources of the poor treatment; with addiction associated with judgment, and mental illness with a lack of understanding. Discrimination associated with race/ethnicity was described as pervasive, across contexts and settings, and perceived by some as the most insidious as unlike poor treatment associated with addiction and mental illness, from which recovery is a possible outcome, it was perceived as inescapable. Additionally, our participants echoed Goffman’s (Goffman, 1963) distinction between discredited and discreditable stigma and the varying impact of these experiences on their lives. These findings suggest the importance of acknowledging and addressing the multiple sources of exclusion experienced by women in substance abuse treatment to improve their mental health, well-being, and to promote positive treatment outcomes.
References
Ahern, J., Stuber, J., & Galea, S. (2007). Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence, 88(2–3), 188–196. http://dx.doi.org/10.1016/j.drugalcdep.2006.10.014
Birtel, M. D., Wood, L., & Kempa, N. J. (2017). Stigma and social support in substance abuse: Implications for mental health and well-being. Psychiatry Research, 252, 1–8. http://dx.doi.org/10.1016/j.psychres .2017.01.097
Brezing, C., Ferrara, M., & Freudenreich, O. (2015). The syndemic illness of HIV and trauma: Implications for a trauma-informed model of care. Psychosomatics, 56, 107–118. http://dx.doi.org/10.1016/j.psym.2014.10 .006
Brinkley-Rubinstein, L. (2015). Understanding the effects of multiple stigmas among formerly incarcerated HIV-positive African American men. AIDS Education and Prevention, 27, 167–179. http://dx.doi.org/10 .1521/aeap.2015.27.2.167
Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling
Psychologist, 35, 13–105. http://dx.doi.org/10.1177/0011000006292033
Center for Substance Abuse Treatment. (2009). Substance abuse treatment: Addressing the specific needs of women. Retrieved from https:// store.samhsa.gov/product/TIP-51-Substance-Abuse-Treatment-Addressingthe-Specific-Needs-of-Women/SMA15-4426?refererfrom_search_result
Conner, K. O., Copeland, V. C., Grote, N. K., Koeske, G., Rosen, D., Reynolds, C. F., III, & Brown, C. (2010). Mental health treatment seeking among older adults with depression: The impact of stigma and race. The American Journal of Geriatric Psychiatry, 18, 531–543. http:// dx.doi.org/10.1097/JGP.0b013e3181cc0366
Corrigan, P. W., Bink, A. B., Schmidt, A., Jones, N., & Rüsch, N. (2016). What is the impact of self-stigma? Loss of self-respect and the “why try” effect. Journal of Mental Health, 25, 10–15. http://dx.doi.org/10.3109/ 09638237.2015.1021902
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1, 16–20. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1489832/
Derogatis, L. R. (2001). Brief Symptom Inventory (BSI)–18. Administration, scoring and procedures manual. Minneapolis, MN: NCS Pearson.
Eliason, M. J., & Amodia, D. S. (2006). A descriptive analysis of treatment outcomes for clients with co-occurring disorders: The role of minority identifications. Journal of Dual Diagnosis, 2, 89–109. http://dx.doi.org/ 10.1300/J374v02n02_05
First, M. (1994). Structured Clinical Interview for DSM–IV (Version 2.0). New York: New York State Psychiatric Institute.
Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9, 445–451. http://dx.doi .org/10.1037/1040-3590.9.4.445
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice Hall.
Greenfield, S. F., Back, S. E., Lawson, K., & Brady, K. T. (2010). Substance abuse in women. Psychiatric Clinics of North America, 33, 339–355. http://dx.doi.org/10.1016/j.psc.2010.01.004
Hammarlund, R., Crapanzano, K. A., Luce, L., Mulligan, L., & 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, 9, 115–136. http://dx.doi.org/10.2147/SAR.S183256
Hatzenbuehler, M. L., Phelan, J. C., & Link, B. G. (2013). Stigma as a fundamental cause of population health inequalities. American Journal of Public Health, 103, 813–821. http://dx.doi.org/10.2105/AJPH.2012 .301069
Hayes, A. F., & Little, T. D. (2018). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: Guilford Press.
Hien, D., Cohen, L., & Campbell, A. (2005). Is traumatic stress a vulnerability factor for women with substance use disorders? Clinical Psychology Review, 25, 813–823. http://dx.doi.org/10.1016/j.cpr.2005.05.006
Hien, D. A., Nunes, E. V., & Levin, F. B. (1995, June 10–15). Violence, psychiatric comorbidity and gender: Predictors of outcome in methadone patients. Paper presented at the 57th Annual College on Problems of Drug Dependence, Scottsdale, AZ.
IBM Corp. (2017). IBM SPSS Statistics for Windows, Version 25.0 [Computer software]. Armonk, NY: Author.
Jones, L. V., Hopson, L., Warner, L., Hardiman, E. R., & James, T. (2015). A qualitative study of Black women’s experiences in drug abuse and mental health services. Affilia, 30, 68–82. http://dx.doi.org/10.1177/ 0886109914531957
Kulesza, M., Larimer, M. E., & Rao, D. (2013). Substance use related stigma: What we know and the way forward. Journal of Addictive
Behaviors, Therapy & Rehabilitation, 2, 782. http://dx.doi.org/10.4172/ 2324-9005.1000106
Lekas, H. M., Siegel, K., & Leider, J. (2011). Felt and enacted stigma among HIV/HCV-coinfected adults: The impact of stigma layering. Qualitative Health Research, 21, 1205–1219. http://dx.doi.org/10.1177/ 1049732311405684
Lincoln, A. K., Adams, W., Eyllon, M., Garverich, S., Prener, C. G., Griffith, J., . . . Hopper, K. (2017). The double stigma of limited literacy and mental illness: Examining barriers to recovery and participation among public mental health service users. Society and Mental Health, 7, 121–141. http://dx.doi.org/10.1177/2156869317707001
Lincoln, A. K., Liebschutz, J. M., Chernoff, M., Nguyen, D., & Amaro, H. (2006). Brief screening for co-occurring disorders among women entering substance abuse treatment. Substance Abuse Treatment, Prevention, and Policy, 1, 26. http://dx.doi.org/10.1186/1747-597X-1-26
Link, B. G. (1987). Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review, 52, 96–112. http://dx.doi.org/10.2307/ 2095395
Link, B., Castille, D. M., & Stuber, J. (2008). Stigma and coercion in the context of outpatient treatment for people with mental illnesses. Social Science & Medicine, 67, 409–419. http://dx.doi.org/10.1016/j .socscimed.2008.03.015
Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385. http://dx.doi.org/10.1146/annurev .soc.27.1.363
Link, B. G., & Phelan, J. (2014). Stigma power. Social Science & Medicine, 103, 24–32. http://dx.doi.org/10.1016/j.socscimed.2013.07.035
Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., & Phelan, J. C. (2001). Stigma as a barrier to recovery: The consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric Services, 52, 1621–1626. http://dx.doi.org/10.1176/appi.ps.52.12.1621
Link, B. G., Struening, E. L., Rahav, M., Phelan, J. C., & Nuttbrock, L. (1997). On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behavior, 38, 177–190. http://dx.doi.org/ 10.2307/2955424
Lipari, R. N., & Van Horn, S. L. (2017). Trends in substance use disorders among adults aged 18 or older [CBHSQ Report]. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/report_2790/ ShortReport-2790.html
Livingston, J. D., Milne, T., Fang, M. L., & Amari, E. (2012). The effectiveness of interventions for reducing stigma related to substance use disorders: A systematic review. Addiction, 107, 39–50. http://dx.doi .org/10.1111/j.1360-0443.2011.03601.x
Logie, C. H., James, L., Tharao, W., & Loutfy, M. R. (2011). HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Medicine, 8(11), e1001124. http://dx.doi.org/10.1371/journal .pmed.1001124
Lundberg, B., Hansson, L., Wentz, E., & Björkman, T. (2007). Sociodemographic and clinical factors related to devaluation/discrimination and rejection experiences among users of mental health services. Social Psychiatry and Psychiatric Epidemiology, 42, 295–300. http://dx.doi .org/10.1007/s00127-007-0160-9
Luoma, J. B., Twohig, M. P., Waltz, T., Hayes, S. C., Roget, N., Padilla, M., & Fisher, G. (2007). An investigation of stigma in individuals receiving treatment for substance abuse. Addictive Behaviors, 32, 1331– 1346. http://dx.doi.org/10.1016/j.addbeh.2006.09.008
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. http://dx.doi.org/10.1037/00332909.129.5.674
Minior, T., Galea, S., Stuber, J., Ahern, J., & Ompad, D. (2003). Racial differences in discrimination experiences and responses among minority substance users. Ethnicity & Disease, 13, 521–527.
Oliveira, S. E., Carvalho, H., & Esteves, F. (2016). Internalized stigma and quality of life domains among people with mental illness: The mediating role of self-esteem. Journal of Mental Health, 25, 55–61. http://dx.doi .org/10.3109/09638237.2015.1124387
Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-analytic review. Psychological Bulletin, 135, 531–554. http://dx.doi.org/10.1037/a0016059
Pescosolido, B. A., & Martin, J. K. (2015). The stigma complex. Annual Review of Sociology, 41, 87–116. http://dx.doi.org/10.1146/annurev-soc071312-145702
Powers, M. B., Gillihan, S. J., Rosenfield, D., Jerud, A. B., & Foa, E. B. (2012). Reliability and validity of the PDS and PSS-I among participants with PTSD and alcohol dependence. Journal of Anxiety Disorders, 26, 617–623. http://dx.doi.org/10.1016/j.janxdis.2012.02.013
ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers.
Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.
Priester, M. A., Browne, T., Iachini, A., Clone, S., DeHart, D., & Seay, K. D. (2016). Treatment access barriers and disparities among individuals with co-occurring mental health and substance use disorders: An integrative literature review. Journal of Substance Abuse Treatment, 61, 47–59. http://dx.doi.org/10.1016/j.jsat.2015.09.006
Reisner, S. L., White Hughto, J. M., Gamarel, K. E., Keuroghlian, A. S., Mizock, L., & Pachankis, J. E. (2016). Discriminatory experiences associated with posttraumatic stress disorder symptoms among transgender adults. Journal of Counseling Psychology, 63, 509–519. http://dx .doi.org/10.1037/cou0000143
Rendina, H. J., Millar, B. M., & Parsons, J. T. (2018). The critical role of internalized HIV-related stigma in the daily negative affective experiences of HIV-positive gay and bisexual men. Journal of Affective Disorders, 227, 289–297. http://dx.doi.org/10.1016/j.jad.2017.11.005
Schomerus, G., Matschinger, H., & Angermeyer, M. C. (2014). Attitudes towards alcohol dependence and affected individuals: Persistence of negative stereotypes and illness beliefs between 1990 and 2011. European Addiction Research, 20, 293–299. http://dx.doi.org/10.1159/ 000362407
Sheeran, T., & Zimmerman, M. (2002). Screening for posttraumatic stress disorder in a general psychiatric outpatient setting. Journal of Consulting and Clinical Psychology, 70, 961–966. http://dx.doi.org/10.1037/0022006X.70.4.961
Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/
Taylor, T. R., Kamarck, T. W., & Shiffman, S. (2004). Validation of the Detroit Area Study Discrimination Scale in a community sample of older African American adults: The Pittsburgh healthy heart project. International Journal of Behavioral Medicine, 11, 88–94. http://dx.doi.org/10 .1207/s15327558ijbm1102_4
Wang, J., Kelly, B. C., Booth, B. M., Falck, R. S., Leukefeld, C., & Carlson, R. G. (2010). Examining factorial structure and measurement invariance of the Brief Symptom Inventory (BSI)-18 among drug users. Addictive Behaviors, 35, 23–29. http://dx.doi.org/10.1016/j.addbeh.2009 .08.003
Watson, A. C., Corrigan, P., Larson, J. E., & Sells, M. (2007). Self-stigma in people with mental illness. Schizophrenia Bulletin, 33, 1312–1318. http://dx.doi.org/10.1093/schbul/sbl076
Werner, D., Young, N. K., Dennis, K., & Amatetti, S. (2007). Familycentered treatment for women with substance use disorders: History, key elements and challenges. Retrieved from https://ncsacw.samhsa.gov/ resources/family-centered-treatment.aspx
Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial differences in physical and mental health: Socio-economic status, stress and discrimination. Journal of Health Psychology, 2, 335–351. http://dx .doi.org/10.1177/135910539700200305
Yang, L. H., Wong, L. Y., Grivel, M. M., & Hasin, D. S. (2017). Stigma and substance use disorders: An international phenomenon. Current Opinion in Psychiatry, 30, 378–388. http://dx.doi.org/10.1097/YCO .0000000000000351
Young, M., Stuber, J., Ahern, J., & Galea, S. (2005). Interpersonal discrimination and the health of illicit drug users. The American Journal of Drug and Alcohol Abuse, 31, 371–391. http://dx.doi.org/10.1081/ADA-
200056772
Received August 22, 2019
Revision received January 30, 2020
Accepted January 30, 2020
