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Article 64

Stigmatization of Adolescents Who Use Alcohol and Marijuana

A Counseling Concern

Michael D. Brubaker, Laura A. Nabors, Jordan Pangallo, and Halley Shipley

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Paper based on a program presented at the 2012 American Counseling Association Conference, San Francisco, CA, March 21-25.

Although alcohol and marijuana usage rates among adolescents both remain high, their recent trends have diverged. Despite a slow decline in illicit drug use since 2001, recent usage has shifted upward for adolescents aged 12 to 17, with past month usage reaching 10.1% (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). This increase has been fueled largely due to increased marijuana usage, with the 2010 last month usage rate reaching 7.4% from a low of 6.7% in 2008 (SAMHSA, 2011). This recent trend has been attributed to a lower perceived risk in using marijuana (Johnston, O'Malley, Bachman, & Schulenberg, 2010; SAMHSA, 2011). Indeed, among youth, marijuana is viewed as the least risky of all illicit drugs (Johnston et al., 2010). Current alcohol usage rates declined slightly in 2010, as did binge and heavy usage rates, reported at 17.0% and 5.1%, respectively. While the trend is favorable, rates remain high (SAMHSA, 2011) as youth use these substances to negotiate their emotional and social developmental.

It is estimated that in 2010, 1.8 million youth aged 12 to 17 needed treatment for alcohol or drug dependence, yet only 138,000 (7.6%) actually received it. When considering alcohol dependence alone, the percentage of youth who receive treatment is even lower (6.1%; SAMHSA, 2011). There are many reasons why individuals would not receive treatment. One reason is the concern that getting treatment would invoke a negative opinion by neighbors or community members (Luoma et al., 2007, SAMHSA, 2011). Other barriers to treatment included lacking health coverage and the cost of treatment as well as a lack of “readiness” to quit or a decision to manage the problem without treatment (Kertesz et al., 2006; SAMHSA, 2011). As a significant portion of adolescents who need treatment do not receive the care they need due to perceived stigma and other barriers, it is important that we better understand barriers to receiving treatment and stigma toward those who have received treatment. Through greater awareness of current barriers, including stigma, as well as facilitators to treatment, counselors may be better equipped to support adolescents and their families who all may benefit from addictions services.

Stigma as a Barrier to Treatment

Perceptions of barriers to care have been understood as an enabling factor, which can either promote or inhibit substance abuse treatment, within Andersen’s (1968/1974) utilization theory. It is important to note that Anderson did not use the term enabling in the sense that it is commonly understood in substance abuse treatment education. By his definition, enabling factors are the supports or barriers that contribute to the outcome of obtaining treatment. In the lives of adolescents, these enabling factors are especially important as these youth are minors often receiving parental support and are highly influenced by their peers and other adults.

Stigma is viewed as a barrier to participating in treatment. There are two categories, public stigma and self-stigma (Corrigan, 2004). Public stigma is based on negative stereotypes, prejudice, and discrimination; individuals may avoid seeking treatment as a way to avoid negative consequences of being associated with a socially devalued group (Corrigan, 2004). Alternatively, self-stigma is described as a set of negative beliefs about the self that may become internalized, thus causing emotional consequences such as low self-esteem, which can be minimized by avoiding treatment (Corrigan, 2004). The negative views that are internalized are a reflection of negative societal attitudes. Thus, it is assumed that addressing public stigma will also address self- stigma, as both are rooted in public sentiment. Individuals with substance abuse problems are perceived to think that their families will abandon them, their friends will give up on them, and they will get paid less at a job than a person without a substance abuse problem (Luoma et al., 2007).

Individuals who abuse alcohol are more negatively viewed by peers than those with mental illnesses, a difference explained by the concept that teens with a substance abuse problem are feared as they are perceived to be dangerous and are more likely to be avoided (Corrigan et al., 2005; Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999). Fellow teens express greater anger, less helpfulness, and less sympathy towards adolescents who use substances over those who have a mental illness (Corrigan et al., 2005). There are more negative thoughts about individuals who are believed to be able to control their mental illness, and adolescents with substance use problems are viewed more negatively because they are the ones who decide to abuse substances (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). As a result, these individuals are less likely to receive help, be avoided, and experience negative attitudes from others based on fear and anger toward them (Corrigan et al., 2003). The stigma that comes with having substance abuse problems and seeking treatment for them can have a negative impact on other aspects of the abusers life. Employers are less willing to hire those with a substance abuse problem and most women will not want to marry an individual who has a substance abuse problem (Link, Struening, Rahav, Phelan, & Nuttbrock, 1997). Furthermore, individuals who abuse substances have reported that they have been denied medical treatment, housing, and equal wages due to their condition (Link et al., 1997).

Opinions of drug users may differ based on the type of drug being used. The Monitoring the Future studies (Johnston et al., 2010) have found that since the 1980s the perceived riskiness of regular marijuana use has decreased, yet a clear majority (80-84%) disapproves of such ongoing use. When considering experimental marijuana use, these rates are nearly cut in half, with a minority (45-49%) disapproving. This drug has had the greatest change in disapproval over time with young teens (Johnston et al., 2010). Heroin, crack, and cocaine powder were seen as more risky than marijuana. Methamphetamine and ecstasy were seen as too dangerous to even try (Johnston et al., 2010).

Receiving treatment is seen to have a great amount of stigma. Individuals who willingly or unwillingly receive treatment have many issues to face. Individuals who have already been to treatment feel more stigma related rejection than people who have not been to treatment, and this increases as the treatment visits increase (Luoma et al., 2007). Unfavorable or offensive messages about people who have been in treatment for substance use are very common to hear from individuals who have never had such a problem (Luoma et al., 2007). Interestingly, persons with substance abuse problems express concern that both the community and medical provider will place judgment when they visit their primary care doctor for their substance related problem (Fortney et al., 2004.). In turn, public stigma inhibits individuals from seeking out substance abuse treatment (Keyes et al., 2010), especially in rural areas where a primary care provider may be the only option of treatment (Fortney et al., 2004). Counselors have an important role in reducing barriers to seeking treatment and reducing stigma toward individuals who engage in substance use. In order to develop interventions to inform counselors, research assessing barriers and stigma, such as the current study, are needed.

Although there is much research in the area of stigma related to general substance abuse and treatment, there is little information comparing public attitudes towards adolescents using different drugs. Also, there is little research on the influence of treatment on people’s attitudes. The purpose of this study is to identify the differences in stigmatizing attitudes towards adolescents who use alcohol or marijuana. Additionally, judgments of adolescents who use alcohol and received treatment and adolescents who used marijuana and received treatment were examined. Participants read vignettes and then provided information about their attitudes toward adolescents portrayed in one of the four previously mentioned conditions versus a control condition, which was a vignette describing an adolescent who drank in moderation. Further, this study aimed to uncover the public perceptions about barriers and ways to promote treatment for adolescents with substance use problems.

Methods

Participants

Participants were students 18 years or older enrolled in a mid-sized urban, Midwestern university (n = 193). Seventy percent were female, 81% Caucasian, 12% African American, and 7% identified in other ethnicities. Ages were distributed as follows: 25.5% 18-20 years old; 61.5% 21-30 years old, and 13% 31 and older. In terms of recovery experiences and training, 7% identified as being a recovering addict, 3% identified as being a recovering alcoholic, and 6% identified as having an associate’s degree in substance abuse counseling. Participants were recruited with convenience sampling methods from various classrooms across campus, public locations, and from a student subject pool.

Procedures

This study was approved by a university-based institutional review board. Participants read an information form describing the consent process. No incentives were provided in this study. Next, if they chose to volunteer to participate in the study, they were randomly assigned to read one of five vignettes describing a male adolescent who either (1) had difficulties due to marijuana use and had received treatment several times; (2) had difficulties due to marijuana use and had not received treatment; (3) had difficulties due to use of hard liquor and had received treatment several times; (4) had difficulties due to use of hard liquor and had not received treatment; or (5) a normal adolescent who occasionally drank beer at parties. Following their reading of their vignette, they completed a question assessing their liking of the adolescent (using a Likert scale). After this they wrote their answers to questions assessing their views of barriers to treatment and factors that would promote treatment.

Procedures for Qualitative Data Analyses

Four research assistants and the principal investigator reviewed responses provided by students three times. A Grounded Theory approach (Strauss & Corbin, 1990), using memoing, was used to uncover themes in the data. Reviewers developed a list of possible themes describing participants’ answers about barriers and factors that would promote treatment. Final themes for were selected based on consensus. Next, the research assistants reviewed the transcripts two more times to select quotes representative of each theme. In a fourth team meeting, the research assistants and one of the investigators finalized themes and representative quotes for each question. This information is presented in Tables 2 and 3 and this information is described in the results section.

Table 1

Means and Standard Deviations for Vignettes

Note. a Denotes statistically significant differences between the means of both the adolescent who drinks too much and received treatment and the adolescent who uses marijuana too much and needs help in comparison to the typical adolescent. b Denotes statistically significant differences between the adolescent who drinks too much and received treatment and the adolescent who uses too much and received help.

Table 2

Please describe the barriers that may keep this adolescent from receiving substance abuse treatment services.

Quantitative Results

Of the study participants, 180 completed the question assessing liking. Results of a one-way ANOVA for the five vignettes for a questions about liking the adolescent yielded significant results, F(1, 175) = 5.25, p <. 001, partial eta squared = .107. Means and standard deviations for vignettes are presented in Table 1. Tukey’s follow-up tests were used to investigate differences among means for the five vignettes. Results indicated that participants reading the vignette about the typical youth (not abusing substances) provided higher liking ratings than for participants reading about the youth who drank too much and received treatment (p = .003) and the adolescent using marijuana too much (p = .009). Participants reading about the adolescent who used marijuana too much and received treatment provided more positive liking ratings than those who read about the youth who drank too much and received treatment (p = .019). Other comparisons did not yield significant results.

Qualitative Results

Question 1: Barriers

Table 2 shows the themes for the question “Please describe the barriers that may keep this adolescent from receiving substance abuse treatment services.” Students reported their perceptions of the barriers to treatment for an adolescent. Nine themes were discovered to represent key barriers: youth in denial; parents in denial; treatment being too expensive; lack of natural support; the right treatment not being available; peer pressure; fear of repercussions related to being in treatment; the adolescent having low self-esteem; and a lack of success when previously seeking treatment. The themes for barriers and representative quotes are presented in Table 2. Coders reported that denial of substance use either by the adolescent or the parents was often reported as a treatment barrier. Peers’ views could act as supports to seeking treatment or a reason not to enter treatment. Participants reported that several factors related to the adolescents’ own beliefs could serve as barriers to seeking treatment. Adolescents with low self-esteem or who had negative experiences in treatment or were afraid of legal repercussions could be less likely to want to enter treatment.

Question 2: Promote Receiving Services

Table 3 shows the themes for the question “What factors might promote this adolescent’s receiving substance abuse treatment services?” Seven themes emerged: natural support; adolescent wants treatment; affordable; positive peer pressure; encouragement from school; already receiving counseling; and alcohol related incidents with the adolescent or family and friends. Participants reported that having positive support from family and friends would increase the likelihood of seeking substance abuse treatment. Adolescents who want to receive treatment have a greater chance of receiving treatment. Students noted that school encouragement from counselors and currently receiving counseling affect adolescents seeking treatment. Participants noted adolescents who are exposed to alcohol related problems are more likely to seek treatment. For example, if the adolescent’s family member struggles with a substance abuse problem or the adolescent himself/herself gets in legal trouble. Treatment programs being affordable will positively affect treatment seeking.

Discussion

This study revealed many important aspects about stigma and barriers for adolescents who are in need of treatment services. Only two types of students were viewed negatively in comparison to the “normal” adolescent, those who drank too much and had received treatment and those who used marijuana too much and did not seek treatment. Consequently, the combination of factors, substance of choice and treatment, appear to be relevant, given these results. When an adolescent receives treatment after having problems related to drinking liquor, it may be assumed that this youth is not able to control his/her drinking or is really drinking large and toxic amounts of liquor. When one is expected to be able to control his/her usage and is not able to do so, peers begin to fear him/her, thus resulting in greater stigma (Corrigan et al., 2003, Corrigan et al., 2005). It was surprising that the results for marijuana use did not follow a similar pattern. In contrast, not seeking treatment and using marijuana was viewed in a more negative fashion. An adolescent who uses marijuana and does not seek help may be viewed as breaking social norms without attempting to correct this behavior. We did not assess participants’ reasons for their choices and examining this information might provide an explanation of why marijuana use was perceived differently.

Table 3

What factors might promote this adolescent’s receiving substance abuse treatment services?

When comparing the two groups who sought treatment, those who had problems related to marijuana and sought treatment were more liked in comparison to those who used alcohol and sought treatment. Participants for this study might have believed that daily use of alcohol was more risky than daily use of marijuana, which may have accounted for differences in their responses (Johnston et al., 2010). For example, a teen who is arrested for driving while intoxicated is putting others’ lives at risk, while one arrested for marijuana possession is not necessarily directly harming another at the time of his/her arrest. Given the recent trends towards marijuana legalization, society may view treatment as unnecessary, and even produce sympathy for those who are in treatment. This would also be consistent with the fact that marijuana is viewed as less addictive than alcohol (Nutt, King, Saulsbury, & Blakemore, 2007). Therefore, participants might have perceived the adolescent in treatment for marijuana use as being less severely addicted and this could have resulted in greater liking of this youth. As mentioned, however, without assessing reasons for the liking ratings provided by the participants, these ideas are merely speculative.

These contrasting findings are important for counselors to understand as they develop interventions for adolescents with substance use problems. A counselor should not assume that just because alcohol use may be more acceptable, those adolescents receiving treatment for alcohol abuse problems may still experience rejection and negative attitudes. Adolescents who share this attitude may resist treatment and need additional supports to enter treatment. Relatedly, parents and friends may also share this additional stigmatizing attitude and their views can have further negative influences on adolescents, in terms of their desire and willingness to seek treatment services. Counselors can play an important role in educating family members about the wisdom of addressing alcohol related problems early and the potential consequences when help is not obtained.

While quantitative data showed that negative perceptions exist, qualitative data for this study illuminated ways to improve service accessibility and provision. This was a key contribution of the findings of this study. For instance, participants’ responses to types of barriers to seeking treatment and ideas for promoting treatment were often related. This was expected, given that overcoming barriers is a common method to increasing the chances that there will be favorable view of treatment. The barriers mentioned by participants were interesting and represented factors related directly to the youth, their immediate social supports, and society as a whole. For instance, denial among youth and their parents was directly related to public stigma. It may be that individuals and their families deny problems in order to protect themselves from the shaming effects of acknowledging that an adolescent has a substance problem. When counselors are able to reduce the stigma of receiving substance abuse services, they are likely to promote natural supports, which we define as supports from family members, neighbors, teachers, and the like. Peer pressure may be turned from negative to positive, when stigma is addressed. It is important that social marketing campaigns that bring attention to the negative consequences of using substances, particularly alcohol, also attempt to lessen treatment stigma. Esteem building for these youth may be achieved through current counseling and targeted messages that show young people thinking positively about themselves when seeking help.

Additionally, it is important that youth understand that there are many positive gains that can be attained from participating in treatment that outweigh the negative repercussions of seeking care (Link et al., 1997; Luoma et al., 2007). Parental and peer support can be instrumental in conveying this understanding. Motivational interviewing (Miller & Rollnick, 2002) techniques can be useful in this regard, where adolescents may consider both the positive and negative aspects of receiving help. As youth may be motivated by their own consequences as well as vicariously learning from family members with problems, they may see treatment as a positive way to avoid future consequences that could occur if help is not obtained. In the process of demythologizing the stigma of treatment, youth may see how they are disempowered by these negative messages, even to the point of protecting themselves from publicly acknowledging that they need help.

The cost of treatment was a common theme. When treatment is cost prohibitive and parents do not have adequate insurance to cover these expenses, youth will not be able to get the help they need. Therefore, it is essential that school and mental health counselors advocate for treatment services for youth in their communities. Youth may even participate in fund-raisers for local adolescent treatment centers, showing their support for this cause and the youth who need treatment services. By raising awareness among fellow youth and their communities, they can be empowered to reduce treatment stigma, raise consciousness about barriers to treatment, and seek funding partners. Corrigan (2004) suggested several strategies to diminish stigma, and chief among these was contact with stable members of society who are in recovery (Corrigan, 2004). Perhaps one useful strategy would be to have a group of youth engage in an education campaign in partnership with youth who identify as being in recovery and their families. One source could be through Alanon/Alateen (www.al-anon.alateen.org), where information and contacts may be made.

Several factors may have limited the generalizability of the findings of this study. First, a sample of convenience was used, and opinions of youth in university settings may not reflect wider societal attitudes. Second, this was an analog study, and thus subject to the limitations of these types of studies. Third, as mentioned, recording information about why participants provided their liking ratings would have provided information to understand why views for treatment of marijuana use and alcohol use differed. Moreover, we utilized only a few questions to assess quantitative responses and findings might provide more information if additional questions, such as wanting to interact with the adolescent in social settings versus work settings were addressed. On the other hand, our interest was in acceptance of the youth and the questions we analyzed were pertinent to our research question. Similarly, we examined views of only two substances, which may be considered “gateway” drugs. It will be important in future studies to examine young adults’ perceptions of youth using other, more “dangerous” substances, such as cocaine or heroin.

In conclusion, study findings indicated that college students may have more favorable opinions of those who use marijuana compared to those who use alcohol. Reducing barriers to treatment may increase the chances that adolescents will receive treatment and developing interventions to help adolescents and families recognize denial may reduce barriers to treatment. Promotion of the benefits of treatment and the long- term change it can produce, may encourage adolescents to seek treatment. Future research focusing on adults’ conceptualization of what successful treatment accomplishes for an adolescent and how adolescents who receive such treatment can be easily reintegrated into their community will provide additional information for professionals working with adolescents who use substances and their families. Qualitative studies are needed with those who meet substance dependence criteria in order to determine the barriers that they are encountering and their relationship to substance use and treatment stigma. With further research, it is anticipated that more effective strategies for supporting youth who need treatment may be developed along with evidence-based prevention strategies.