From personal tragedy to personal challenge: responses to stigma among sober living home residents and operators

Abstract

Sober living homes for people attempting to maintain abstinence from alcohol and drugs can act as a buffer against the high rates of substance misuse that are endemic to many urban environments. Sober living homes and other group homes for people with disabilities have faced persistent opposition from neighborhood associations, which raises the question of stigma. This article describes the responses of sober living home residents and operators to the threat of stigma across a diverse set of neighborhoods. Ten focus groups were conducted with 68 residents and operators of 35 sober living homes in Los Angeles County, California, between January 2009 and March 2010. Results showed that few residents reported experiences of blatant stigmatization by neighbors; however, they were well aware of the stereotypes that could be ascribed to them. Despite this potential stigma, residents developed valued identities as helpers in their communities, providing advice to neighbors whose family or friends had substance use problems, and organizing community service activities to improve the appearance of their neighborhoods. With their attention to local context, sober living home residents and operators challenge the personal tragedy approach of much traditional advocacy on health-related stigma.

Introduction

Relapse is a common problem among people recovering from alcohol and drug use disorders, with some estimates of its one-year incidence exceeding 80% (Marlatt and Donovan, 2005). Group homes that help people maintain long-term abstinence from alcohol and drugs – typically referred to as “sober living homes” – can act as a buffer against the relapse risks that are endemic to many urban environments (Jason et al., 2008). Sober living homes (SLHs) and other group residences for people with disabilities have faced opposition from neighborhood associations (Gibson, 2005), despite the lack of evidence that they increase crime or decrease property values (American Planning Association, 1999; Colwell et al., 2000; Galster et al., 2002). Fair housing advocates have argued that such opposition limits the locations of SLHs to poor areas with relatively high levels of illicit drug use and trafficking, as well as greater concentrations of alcohol retail outlets, thus disproportionately exposing SLH residents to relapse “triggers” (Parker, 2010). Coupled with high housing costs, opposition to SLHs may contribute to a kind of structural discrimination (Link and Phelan, 2001) in which people in recovery are at increased risk for relapse because of their extremely limited housing options.

In conflicts over the locations of SLHs and other group homes, people with substance misuse and mental health problems have often been characterized as uniformly dangerous (Gerrard, 1994). Research on opposition to group homes, however, generally supports the claim of Dear and colleagues (1997: 474) that “over time, the familiarity and awareness promoted by physical proximity may act to weaken the social distance placed between self and Other.” For example, Cook (1997) compared the attitudes of neighbors of group homes with those of people living in similar neighborhoods without group homes, and he found that perceived threats to personal safety and property values were actually less common among the neighbors of group homes. Similarly, a study in Northern Illinois compared the attitudes of neighbors living directly next door to SLHs with those of neighbors living a block away (Jason et al., 2008), and showed that next door neighbors had more favorable attitudes toward SLHs than did the more distant neighbors, again suggesting that physical proximity reduces opposition to group homes. To our knowledge, however, no studies have focused on how SLH residents and operators perceive their neighbors, some of whom may represent threats to the continued recovery of SLH residents and the viability of SLHs. The current analysis was conducted to understand how SLH residents and operators perceive and respond to these potential threats, using data from a series of 10 focus groups conducted in Los Angeles (LA) County, California. Research describing the perspectives of SLH residents and operators could inform the development of more effective practices in the field of supportive housing for substance misuse recovery.

Background

The persistence of neighborhood opposition to SLHs raises the question of stigma, which can be defined as a product of social contexts in which people who possess (or are believed to possess) a particular attribute are associated with a derogatory stereotype and judged by others as inferior (Green, 2009). Research on stereotypes has found that the terms “drug addict” and “alcoholic” evoke images of individuals who are not only visibly ill, but also morally weak, “spineless,” and blameworthy (Dean and Poremba, 1983; Dean and Rud, 1984). In an international study of attitudes toward 18 stigmatized health conditions, respondents gave consistently higher stigma ratings to “drug addiction” and “alcoholism” than they did to “chronic mental disorder,” probably because substance misuse is still largely regarded as an immoral or inept lifestyle choice for which affected individuals are fully culpable (Room, 2005). Substance misuse is also associated with other stigmatized conditions or behaviors such as HIV infection (Cohn, 2002), homelessness (Burt, 1996), and commercial sex work (Flom et al., 2001). These co-stigmas have helped to ensure that substance misuse retain its potency as a sign of a defective character rather than a chronic and potentially fatal health condition (Winger et al., 2004).

The concept of stigma has been central in explanations of poor access to health and social services among people with substance use disorders. Approximately 25% of a sample of illicit drug users in New York reported that they had not received medical care because of their drug use, and 34% had not obtained housing for the same reason (Ahern et al., 2007). A population-based survey of U.S. adults found that respondents with alcohol use disorders were less likely to use health and social services for these conditions if they believed that “most people” were prejudiced against individuals who had ever received such services (Keyes et al., 2010). Previous work also suggests that stigma is associated with poor mental health in this population. In a longitudinal study of men with substance use disorders and mental illness, depressive symptoms at one-year follow up were independently associated with scores on a stigma-related “rejection experiences” scale (Link et al., 1997). Using similar measures, Luoma and colleagues (2007) found that stigma-related rejection experiences were positively associated with poor mental health and stress, and negatively associated with overall quality of life, among substance misuse treatment patients. To the extent that stigma contributes to emotional distress (Sinha, 2007), it also threatens the maintenance of abstinence from alcohol and drugs among people in recovery. In a qualitative study of substance-misusing women in San Francisco, problems obtaining jobs and housing because of a history of drug-related crimes were reported to cause shame and negative self-evaluative thoughts, which subsequently led to drug and alcohol relapse (Van Olphen et al., 2009).

Enacted and felt stigma

Since Goffman’s seminal work (1963), a number of investigators have developed conceptual frameworks to study health-related stigma, applying different terminologies to several similar theoretical constructs. One such framework, sometimes referred to as the “hidden distress model,” hinges on the core dichotomy of “enacted stigma” and “felt stigma” (Scambler, 2009). Enacted stigma refers to instances of discrimination or other types of overt rejection experiences such as avoidance, hostile staring, or rude comments. Felt stigma is a broad, multi-dimensional construct that encompasses shame or embarrassment, anxiety about encountering enacted stigma, and a personal identity as someone who has been diagnosed or otherwise associated with a stigmatized condition (Carricaburu and Pierret, 1995; Gray, 2002; Scambler, 2009).

The concepts of felt and enacted stigma have been useful in studies of people with a wide range of conditions, including epilepsy (Scambler and Hopkins, 1986; Jacoby, 1996) autism (Gray, 2002), and HIV disease (Green 1995; Carricaburu and Pierret). Studies of adults with epilepsy (Scambler and Hopkins, 1986) and of parents of autistic children (Gray, 2002) found that the self-consciousness and embarrassment around a stigmatized condition caused more distress than did specific instances of enacted stigma; upon probing, respondents typically could not recall occasions on which they suspected they were targets of enacted stigma. Possible explanations for this discrepancy include the “stigma coaching” of protective, well-intentioned family members and service providers (Scambler, 2009), as well as repeated exposure to the content of sensationalistic media coverage, wherein people with a stigmatized condition come to believe that the general public harbors a great deal of hostility toward them. Psychiatric disorders are also likely to shape the experience of felt stigma, if they are accompanied by perceptions of rejection and personal devaluation. Such perceptions often characterize substance-specific withdrawal syndromes, which can persist for months or years after the generally expected timeframe for acute withdrawal has ended (Center for Substance Abuse Treatment, 2011). Despite its usefulness in studies of a wide range of health conditions, this important distinction between felt and enacted stigma has not, to our knowledge, been used in studies of SLHs or other group homes for people with disabilities.

For people who are able to hide their stigmatized condition and pass as “normal,” felt stigma can be more distressing than enacted stigma, because of the risks of unintentional disclosure and of “living a life that can be collapsed at any moment” (Goffman, 1963; pg. 87). Although a personal history of substance misuse is not easily detectable in casual social interactions, previous work suggests that a large proportion of substance misusers are secretive about this aspect of their lives. An evaluation of an HIV prevention program for methamphetamine users found that approximately 85% of respondents endorsed questionnaire statements such as “I try to hide all signs of my meth use from others,” and “I have kept my meth use a secret” (Semple et al., 2005).

Modified labeling theory

Originally developed in the study of people with mental illness, the modified labeling theory of Link and colleagues (1989) is also relevant to the issue of stigma among SLH residents. Applied to the SLH population, this theory would posit that socialization leads substance misusers to believe that most people endorse negative stereotypes of residents of group homes; these stereotypes become personally relevant for recovering substance misusers when they move into SLHs. Thus, for SLH residents, home is not a private “back stage” where concerns about the presentation of self are temporarily suspended (Goffman, 1959), but the very place where their stigma becomes most salient, simply by virtue of the fact that they live in a group home. Awareness of this label may lead SLH residents to cope by secrecy and withdrawal from their communities, and even from other SLH residents, which could in turn constrain their social contacts, opportunities for employment, and general progress in recovery (Link et al., 1989). However, findings on perceived discrimination from the social psychology literature would suggest that some SLH residents respond to stigma not with secrecy and withdrawal, but with more “empowered” strategies such as compensating for their disadvantage through hard work and organizing collective efforts to reduce stigma through education or other activities (Shih, 2004).

Intra-group stigmatization

The stigma of substance misuse can be amplified for individuals who are also members of other marginalized groups, such as racial/ethnic minorities, sexual minorities, and people with histories of incarceration (Minior, et al., 2003; Van Olphen et al., 2009). However, this predicament of “double stigma” is distinct from the phenomenon of intra-group stigmatization, of which Goffman wrote: “The stigmatized individual exhibits a tendency to stratify his ‘own’ according to the degree to which their stigma is apparent or visible. He can then take up in regard to those who are more evidently stigmatized than him the attitudes that the normals take toward him” (1963, pg 107). Data from the Ontario Student Drug Use Survey showed greater stigmatization of drug users by teenagers who actually used drugs than by those who reported no history of drug use (Adlaf et al., 2009). Ethnographic work in New York found that illicit drug users invoked the stereotype of the “crack head” to stigmatize others who used crack cocaine, expressing their disdain in terms that were strikingly similar to those that are often directed at people using any type of illicit drug (Furst et al., 1999). Although the SLH population is known to be diverse in racial/ethnic backgrounds, sexual orientation, and other potentially stigmatizing characteristics (Jason et al., 2008; citation omitted for blinded review), previous work has not focused on the phenomena of double stigma or intra-group stigmatization among SLH residents.

These divergent theories highlight the importance of empirical work on how SLH residents and operators perceive their relationships with neighbors, as well as with each other. Previous research on the stigmatization of substance misusers has emphasized the prevalence and correlates of perceived stigma, and the “NIMBY” (Not-In-My-Backyard) literature has focused largely on whether neighbors believe that group home residents are threats to public safety or private property (Gibson, 2005; Piat, 2000; Cook, 1998). The current article highlights a relatively neglected perspective, by focusing instead on how SLH residents and operators perceive and respond to the potential threats of stigmatization in their neighborhoods. Using data from focus groups in LA County, California, we examine felt and enacted stigma among SLH residents and operators, and describe the strategies that they have used both to overcome stigma and to construct valued identities in recovery. We also describe double stigma and intra-group stigmatization among SLH residents, and the implications of these findings for practice and research are discussed.

Research design and methods

This study is a product of a partnership with the LA County Sober Living Coalition (LASLC), a non-profit community-based organization of independent SLHs. Los Angeles County is a relatively mature SLH market, having been one of the first U.S. metropolitan areas to experience major growth in SLHs after World War II – in part due to the rise of unemployment and alcohol misuse among newly returned veterans (Polcin, 2001). Consisting of approximately 100 separate municipalities, LA County is also an extremely diverse geographic area, with substantial representation of ethnic and cultural minority communities and large inequalities in income and wealth (Dear, 2000; Nickelsburg, 2007). We recruited study participants from 35 SLHs, representing approximately 12% of houses registered with the LASLC. The study protocol was reviewed and approved by the Charles Drew University Institutional Review Board (IRB). The lead investigator also obtained a Certificate of Confidentiality from the National Institutes of Health (NIH), which protects researchers from being forced to disclose information that could be used to identify study participants for any criminal, civil, administrative, or legislative proceeding (NIH, 2010).

Study sample

Between January 2009 and March 2010, we conducted 10 focus groups with 68 adults aged 18 and over who lived in or operated SLHs for at least one week. Eight focus groups were conducted with SLH residents, and two groups were conducted with SLH operators. Stratified purposive sampling techniques were used for the resident groups. A referral list maintained by the LASLC categorizes SLHs into the following five types: 1) women only, 2) men only, 3) women with cohabitating children, 4) gay men, and 5) both women and men (“co-ed”). We conducted five focus groups homogenized by these same categories. In addition to these five focus groups, we conducted two groups with veterans of the U.S. armed forces (Vietnam era and Iraq/Afghanistan), one group with young people with dual diagnosis (YPDD), and two groups with SLH operators – for a total of 10 focus groups. The focus group with co-ed residents consisted entirely of women, to provide opportunities to discuss any issues about living with male SLH residents. Sober living home operators are generally advised not to establish co-ed houses, in part to prevent the harassment of female residents (Ken Schonlau, personal communication, June 15, 2008). The focus groups with veterans were conducted because previous work suggests that substance misuse and housing problems are more common among U.S. veterans than the general population (Rosenheck et al., 1994). The focus group with YPDD – i.e., individuals aged 18 to 25 who had a substance use disorder and at least one other psychiatric disorder – was conducted because LA County is a destination for runaway youths and young adults who often become involved in the street-level drug economy. To recruit participants, the lead author attended monthly meetings of the LASLC and gave brief informational presentations about the study; he also distributed flyers that included a contact phone number and e-mail address for individuals who were interested in participating. All residents and operators who were screened were eligible for the study.

Study sample characteristics

There was an average of 7 participants per focus group, with a total study sample size of 68. Approximately 60% of the participants were men. The average age of participants was 41. There was approximately equal representation of African Americans (34%) and non-Latino whites (35%), followed by Latino/as (19%), Native Americans (6%), Asians (2%), and people of mixed race/ethnicity or other backgrounds (2%). Approximately 24% of the sample self-identified as gay, lesbian, or bisexual; 60% had never been legally married, and 40% had never attended college. The three most commonly reported substances of misuse were alcohol (65%), cocaine (37%), and stimulants (34%). Among the SLH residents (n = 58), the average time in continuous abstinence from substances was 25 months. Eight of the 10 SLH operators identified as recovering substance misusers, with an average of 159 months (i.e., 13 years) in continuous abstinence.

Data collection

Focus groups were used because they allow participants to discuss and explore topics together in a naturalistic, conversational manner (Morgan, 1996). After the consent process, participants completed a short demographic questionnaire. The primary objective of the focus group script was to elicit participants' views about how SLHs can help improve resident recovery outcomes. The focus group script consisted of two general questions about the advantages and disadvantages of SLHs, a question about participants’ perceptions of their neighborhood, and a “brainstorming” exercise on what participants thought were the most important characteristics of SLHs. Probes consisted largely of requests for clarifications or elaboration on participants’ comments. Data collection was an iterative process wherein the moderator followed the flow of conversation as appropriate, while ensuring that all groups were asked the same core set of questions. Each group lasted for approximately 90 minutes and was facilitated by two moderators. Payment of $40 per participant was provided.

Data analyses

Digital audio recordings of focus groups were transcribed verbatim. Data coding emphasized description rather than conceptual refinement or theory development. The lead investigator read the transcripts first, using a combination of inductive codes and a priori themes from the focus group script. Codes representing the constructs of felt and enacted stigma were added to the preliminary code list, based on our review of the literature. Following a discussion and revision of these preliminary codes, an additional analyst independently read and coded the transcripts, to confirm preliminary codes, develop additional codes, and collapse redundant codes. Agreement between the two analysts’ coding was estimated using the Kappa statistic, which was found to be 0.65 —indicating substantial agreement (Landis and Koch, 1977); minor disagreements were resolved through discussion. We used Atlas.ti 6.0 for the analysis of the transcripts.

Results

Focus group participants described several instances of enacted stigma, although the sources of stigma varied between residents and operators. Residents encountered enacted stigma from law enforcement officers, whereas operators were stigmatized by neighbors. In all SLH resident focus groups, felt stigma was most often expressed as an awareness of stereotypes about group home residents; in the women’s and gay men’s groups, felt stigma was also evident in admissions of shame about substance misuse. Several participants in the men’s and gay men’s groups expressed stigmatizing attitudes toward SLH residents with severe mental illness, even though participants in these same groups disclosed their own diagnoses of depression, bipolar disorder, and PTSD. An unexpected finding in the SLH resident groups was the emergence of what could be called “project identities,” which are produced, according to Castells (1997:8), “when social actors, on the basis of whatever cultural material is available to them, build a new identity that redefines their position in society.” Several participants had developed strong bonds with their neighbors that challenged negative stereotypes of substance misusers and helped them to live as valued individuals in the community. Awareness of the potential for conflict with neighbors motivated SLH residents and operators toward greater civic participation, and several participants gave examples of the practical and emotional support they provided to non-SLH community members. Residents also described public activities aimed specifically at managing impressions of SLHs, such as hosting “open house” parties and initiating community service activities.

Enacted stigma

In addition to the stigma of substance misuse, the majority of SLH residents in this study were members of other demographic and cultural groups that are often negatively stereotyped, such as racial/ethnic minorities, sexual minorities, and people with mental illness. An Iraq/Afghanistan veteran said that the initial opposition to his home was motivated by “that stereotype of crazies running around the neighborhood, hardened criminals, drug addicts, sleeping-on-the-lawn type of thing.” The comments of several participants suggested that belonging to multiple stigmatized groups was a salient aspect of their identities and their everyday lives. Responding to another participant’s questions about the etiology of bipolar disorder, a 31-year-old participant in the gay men’s group said, “You’re born with that… Just like you’re born with addiction, you’re born gay, you’re born black, you’re born white, you know?” At the intersection of several stigmatized identities – specifically, the triple stigma of being a substance misuser, an African American, and a gay man – a 23-year-old YPDD group participant described an incident of enacted stigma in his neighborhood:

Speaker: I was walking one morning and a police officer pulled me over… I had my headphones on, so of course, I’m not going to hear [him] because I always put my headphones up blaring… . [The officer] was like, “Didn’t you hear us talking to you?” And I was like, “Um, no,” and he was like, “Well, where do you live?” And I was like, “[Name of SLH].” He was like, “That’s a sober living [home], right? … Can you turn around because it looks like you have a pipe in your back pocket.” Of course, I had no pipe… He was also like, ‘What’s your drug of choice?’ And I was like, “Crystal meth,” and he was like, “Crystal meth? Black people don’t do crystal meth. They do crack.”…

Moderator: This is a cop talking?

Speaker: Yeah, this is a cop talking to me like this, and so, finally he let me go, but I was just like, oh, my goodness!

In the SLH operators’ groups, the most vivid account of enacted stigma concerned a home with several male parolees. A 57-year-old operator described the humiliation of seeing his residents essentially strip-searched in front of their neighbors during a “parole sweep” – i.e., an unannounced inspection in which parole officers can enter a home, without a warrant, where parolees reside: “They took everybody in the house. They made them take all their shirts off in the front yard, and photographed their tattoos for gang-related things in the front yard.” Covering his face with his hands, he said, “I was so humiliated for them.” He claimed that the memory of this event continued to undermine his residents’ sense of safety at home, saying, “Now my other guys are terrified to be in the house with any parolees.”

Very few SLH residents reported enacted stigmatization by their neighbors. As one participant said, “I haven’t had the personal experience of it. It’s more of hearing on the news about it.” However, participants were aware of the labels that could be applied to them as recovering substance misusers and residents of group homes. On the community’s reaction to SLHs in general, one of the Vietnam veterans said, “The neighbors like to fight when they find out that they’ve got a bunch of dope fiends moving to the neighborhood.” His awareness of this label, however, did not affect his relationships with neighbors, as he was quick to add that “the people around [sober living homes] respect the people in there for doing what they’re doing… . They just leave you alone, or they talk to you as a human. I’ve never run into any negativity from – personally – from neighbors, no matter who they were.” By contrast, SLH operators described several instances of opposition from neighbors, especially in the initial months after opening their SLHs; however, these conflicts were usually resolved over time through negotiation and trust-building. The process of overcoming stereotypes of group home residents could be facilitated by the shared cultural backgrounds and personal experiences of SLH operators and other community members. Apparently acting from a sense of blame, a 71-year-old African-American man assuaged angry members of a neighborhood association by appealing to their religiosity:

They invited me down to their meeting… . I got screamed at and hollered at and I had an opportunity, in my opening statement – and I asked everybody to drop their heads and pray with me, and I asked them for forgiveness, forgiving me for bringing it into their neighborhood. And that kind of like slowed them down a little bit.

This operator said that the neighbors were initially “skeptical about having addicts and alcoholics in the neighborhood.” The turning point in his dealings with them was the disclosure that recovering addicts and alcoholics were already there, in the neighbors’ own families: “It just so happened that one of the neighbors next door, her son was in recovery, and he had went through a sober living house. And what happened is they accepted [my promise] that I’d oversee it and make sure it wouldn’t be a disruption to the community.” By contrast, another operator who faced continual opposition to an SLH he opened on the same upper-middle class block where he grew up said, “The home owners there now are the sons and daughters that I grew up with.” He added, ironically, “Some of them are ones that I got loaded with [on alcohol or drugs],” which suggests that having shared histories of substance misuse did not always bridge the gap between SLHs and neighbors. This operator continued to have tense relationships with them, even though he had “knocked on every door” and distributed informational pamphlets before opening his SLH.

Intra-group stigmatization

A key policy in most SLHs is that relapse results in immediate eviction, because one resident’s relapse is likely to cause, in the words of several participants, a “chain reaction” or “domino effect” of relapses that can “go through the house like cancer.” Many SLH operators use urine testing to confirm substance use among residents who are suspected of relapse, and study participants’ descriptions of these testing practices and eviction policies suggested substantial variation across SLHs in their implementation. Not all residents were evicted for relapses, nor were they stigmatized, perhaps due to the belief that relapse is an expected part of recovery for some people (Marlatt and Donovan, 2005). A 21-year-old participant in the men’s focus group described the responses of housemates to his relapse:

My house, there’s really supportive people and they were like, ‘Hey, it’s all right, man. It’s okay. You relapsed one time, wow. Just make sure you don’t do it again’… They’re really not like, ‘Man, you're a loser. You relapsed.’ They’re not like that.

Several participants described testing practices that were designed specifically to prevent disclosure of the identity of a resident suspected of relapse. A participant in the gay men’s group described one such practice: “When they think that someone is getting high, they’ll randomly pick a couple of other people so that they just don’t point that one person out.” In contrast to this more circumspect approach to confirming a relapse, someone in the men’s group said that he and his housemates had recently been warned by their SLH manager about the consequences of “dirty” test results. He also commented on the vigilance with which residents would report each other for suspected relapses:

They just do not play around… The other day, they found a beer can in our trash. That was just -- someone picked it up off the street and put it in our trash. And we got tested -- everybody got tested in the house and we got the breathalyzers and we got the piss test, and [the SLH manager] said, “You come back dirty, you might as well just go to your room and pack up your stuff.” Everybody in our house will not tolerate that. Everybody will go tell the manager.

Intra-group stigmatization was apparent in several comments about SLH residents with severe mental illness. A 27-year-old participant in the men’s group described how he had initially labeled residents after moving into his SLH: “I knocked it in the beginning because I looked at the people that were there and I was saying, ‘I don’t want to be around a bunch of messed-up people and stuff,’ but that was just the same. There’s no difference.” Later in the discussion, however, he warned other focus group participants about SLH residents whom he perceived as exceptionally different: “I deal with a lot of different guys, guys that are medicated. There’s guys that are just different and if you’re in there, just be prepared.” A participant in the gay men’s focus group expressed a stigmatizing attitude toward residents with schizophrenia:

I have two schizophrenics that are now in the house… That kind of bugged me a little bit because it’s supposed to be sober living, so I thought these people were just like -- now we got like mental patients… They’re crazy and it’s like, this is not the place for them… This is not a mental ward.

This comment is notable, because five of the six participants in this same focus group identified themselves as having histories of mental illness, and they openly discussed the etiology and management of their conditions at several points in the discussion. Similarly, the participants in the YPDD group – all of whom had more than one psychiatric diagnosis – responded with laughter when one of them said that he liked his home “even though there’s some crazy people there.”

Felt Stigma

Felt stigma was evident among participants who struggled with shame about their pasts, and who sometimes used secrecy and withdrawal strategies for coping with shame. For example, a participant in the women’s group indicated that she had been secretive about her housing situation with friends: “I have friends who said to me, ‘Oh, I didn’t know you were that bad,’ when I told them I was in sober living… Some of my friends don’t even know. They think I’m on vacation.” For a 31-year-old participant in the gay men’s group, the “driving force” of his shame was embodied as extreme restlessness: “When I can’t go to [12-step] meetings or I can’t sit still during a meeting, it’s because my shame is overwhelming me.” When asked what he was ashamed of, he responded, “Just the whole addiction part.” Even though the need for abstinence-related social support is a main reason for moving into a SLH, he and another participant in the group still had a tendency to isolate themselves from other SLH residents.

A participant in the women’s group expressed a general concern that SLHs were labeled by “people out there” not as homes, but as treatment facilities for patients at much lower levels of functioning: “[It’s] hard for people out there to understand what it is… People generalize – treatment, rehab, sober living, all kind of into one… Society sees it all as one.” Although she reported no incidents of enacted stigma, she suggested that this label originates in the public’s lack of knowledge of SLHs, concluding, “So it seems like there still is a stigma to it, maybe just because people don’t know.”

Project Identities

An unexpected finding in the focus groups was the notion that a history of substance misuse, as well as experiences such as poverty and incarceration, could become a source of strength for people in recovery. For example, two participants – one in the women-with-children group, and one in the gay men’s group – argued that they were better able to respond to adversity because they had survived substance misuse and incarceration. A 31-year-old mother defined her social position as a single mother recovering from substance misuse in stark contrast to people who “have college degrees and all that stuff.” Referring to the general public’s perceptions of addicts, she asserted that people who have lived through substance misuse and poverty are better adapted to cope with economic recessions, and that the perspectives gained from these experiences are as valuable as those provided by formal education:

In our addiction, we made the wrong choices… . but it does not make another person that ain’t been in that experience any better than us because they will fall harder than we have, because we have the survival skills… . Therefore, if they were to fall because of their bankruptcy, they wouldn’t know what to do. They’re not experienced as we have and we’re not experienced as they have. See, they have master’s degrees, they have college degrees and all that stuff, something that us addicts don’t have… . But we had to go through a certain length of the process to get where we at when we’re trying to better our life.

A 41-year-old participant in the gay men’s group believed that public disclosure of his substance misuse and other stigmatized personal attributes had an educational or therapeutic benefit for others in recovery, which transformed shame-filled experiences into assets. Disclosure of his status as a recovered addict, an ex-offender, and a gay man with HIV disease was critical, because, he said, “If I can help one person learn from my mistakes so they wouldn’t have to go through that, then I feel like it was worth it.” Sitting next to him in the focus group, one of his housemates referred to this participant as “Mr. Social, the cruise ship coordinator,” because he organized “sober dances,” parties, and other social gatherings. These events also served as a kind of stigma-reduction strategy: “We throw parties and stuff [at the SLH]… I’m all about having fun and if I can do that in sobriety and help bring that to the house, so that so many different people with so many backgrounds can see that it’s okay, it just helps me.” This participant also emphatically rejected secrecy as a response to stigma. About his parents’ shame over the fact that he had served a two-year prison sentence for selling drugs, he said, “They’re like, ‘You don’t need to tell anybody where you’ve been. No one needs to know.’ I said, ‘You know what? I don’t care if they know. I’m not going to lie anymore, because that’s what got me here in the first place. I’m not going to be ashamed of my being gay. I’m not going to be ashamed of the HIV. This is who I am.”

Community inclusion and stigma reduction

Low social contact is widely believed to contribute to prejudice and stigma, and several participants believed that their neighbors’ lack of social contact with SLH residents was a key reason for the persistence of negative stereotypes of substance misusers. In an attempt to dispel these stereotypes, the Iraq/Afghanistan veterans hosted a block party with food and entertainment so that the neighbors could, as one participant said, “see that we’re just like everybody else.” A 25-year-old veteran, who described the initial attitude toward his home as “Support the troops, but not in our neighborhood,” said that his relationships with neighbors improved greatly “thanks to the block party, where they could actually meet us.” Local community service was another stigma-reduction strategy used by SLH residents to show that they were an integral part of their neighborhoods; however, these activities took place in a context marked by power differentials. As a woman in the co-ed group said:

The city council listens to the neighbors more than they listen to us. So we need to be a positive [influence] -- I know our house, we’re starting to get involved in street work, cleaning, go up the block and just pick up papers and pull weeds and get involved, have some positive influence, because [the neighbors] are the ones that can make or break us pretty much.

Residents and operators of SLHs assumed local helping roles, perhaps because their communities were confronted by other problems that are more immediately threatening than residents recovering from substance misuse. A 23-year-old participant in the YPDD group was proud to find himself frequently in a position to help others: “When I go to the Gay and Lesbian Center… I hear a whole bunch of questions, like ‘I have a friend that has a drug and alcohol problem.’ I’m like, “Here’s the [business] card, call” – and it’s like you’re a natural walking resource.” In regard to neighborhood opposition, an operator of three SLHs mentioned the strategic advantage of the fact that “Three out of the seven City Council members have children who’ve been through [name of SLH]. So that always helps.” In addition, one of his SLHs had neighbors with a personal stake in the availability of supportive housing: “The doctors next door to our main place, two of their kids have been through our place. So they now give our [residents] extremely affordable medical care.” Operators also functioned as informal sources of information on substance misuse in their communities, as described by an operator of an SLH for women:

I have community members, church members, women’s groups come to me all the time seeking help and solutions to a personal problem they have with someone that they love… Neighbors and friends, once they get past their shame about it, really reach out and use places like we have and connections like we have as a resource to meet their needs.

Neighbors also sought information for their own substance misuse, as indicated by a 67-year-old operator of a SLH for men: “The young ones will come down and talk to us and ask us, ‘What can I do? I got a problem with alcohol’… because they sit outside and drink and play dominos on the weekend and throughout the week.” He and his partner developed valued identities in these relationships with neighbors—some of whom were likely to come from families dealing with substance misuse: “The house next door to us is a foster care, and the kids kind of look up to my partner and I. We talk to them all the time.”

Several SLH operators believed that one of their main contributions to the local community was a more productive workforce. An operator who held informal resume-writing and interview skill-building sessions in the garage of his SLH used the metaphor of “an ecosystem” to characterize the relationships between local employers and SLH residents – who, he added, “make good workers when they’re clean and sober.” Another operator described a number of former SLH residents whom he regularly encountered working in local businesses, concluding, “A sober living home that has been trying to do the right thing over a period of time, simply feeds people back into the community to tax-paying responsible positions.” Instead of emphasizing the employability of her residents, an operator of a SLH for women said, “I sort of look at myself as a healer – yeah, healing folks, sending them back out into the world to heal more and take that healing energy out there with them.”

Discussion

In previous studies using the concepts of felt and enacted stigma, one of the most provocative findings has been that respondents with high levels of felt stigma were unable to recall specific instances in which they were overtly stigmatized by others (Scambler and Hopkins, 1986; Gray, 2002). However, previous qualitative research on shame among substance misusers has included striking descriptions of enacted stigma. A study in South Wales described routine “public shaming rituals” during which police officers degraded injection drug users by dumping their syringes and other personal belongings onto the sidewalk while conducting body searches in full public view (Rhodes et al., 2007: 579). Similarly, we found that the most vivid accounts of enacted stigma also involved humiliating confrontations between law enforcement officers and SLH residents in public spaces. Several political theorists have taken the position that such tactics can be a valuable expression of social norms (Devlin, 1965; Kahan, 1998). For example, Etzioni (2001) suggested that key drug policy objectives would be served if young drug dealers were sent home with their heads shaved and without their pants after a first offense. Goffman (1963) also noted that stigma can function as a formal means of social control; however, it is questionable whether any benefit can be gained from a policing practice that leaves SLH residents “terrified to be in the house with any parolees.”

Recent reviews have called for more attention to stigma as a process that reproduces social inequalities in larger political and cultural contexts (Scambler 2006; Parker and Aggleton, 2003; Pescolindo et al, 2008). The “personal responsibility” rhetoric around welfare-to-work programs has often likened “welfare dependency” to drug addiction, drawing heavily on the stigma that has long been directed at impoverished, non-working people (Barkkowski and Regis, 2003). In this policy context, claims that SLHs help residents become “good workers” transitioning to “tax-paying responsible positions” suggest the extent to which the people operating and residing in these homes must work to gain acceptance from local government officials, law enforcement, and neighbors – the latter group being referred to as “the ones that can make or break us pretty much” by one SLH resident. Portraying themselves as responsible citizens, participants enumerated an array of community service activities that they organized not only to improve the appearance of their neighborhoods, but also to manage the impression they gave to the public.

Disability activists have asserted that social service providers often reinforce the notion that individuals with stigmatized, chronic health conditions are incapable of improving their own lives, or the lives of others (Charlton, 1998; Sayce, 2000). Previous work has shown that people with severe mental illness often provide their caregivers with needed emotional and practical support (Greenberg et al., 1994; Horwitz et al, 1996). In a previous article, we reported that SLH residents characterized the reciprocal exchange of support in their homes as constituting an alternative family structure (citation omitted for review); however, we are not aware of any study describing the support that SLH residents and operators provide to their surrounding communities. In a challenge to the personal tragedy paradigm of health-related stigma and disability, several participants in the current study claimed the identities of a “healer” or “natural walking resource” who provided advice and service referrals to neighbors and other community members who were dealing with substance use problems of their own, or of their friends or family. This integration of SLH residents into local communities conflicts with the expectations of the modified labeling theory (Link et al, 1989), because the threat of being seen as “dope fiends” or “crazies” did not lead SLH residents to withdraw and avoid social contact with neighbors. On the contrary, respondents marshaled what Green (2009) has called the “personal challenge” to substance misuse stigma, wherein people in recovery extricate themselves from felt stigma by creating identities as newly moral and responsible citizens.

Several SLH residents voiced attitudes that suggested a degree of intra-group stigmatization of “guys that are medicated” or “crazy” people with disorders such as schizophrenia, even though some of these same participants spoke frankly about their own histories of mental illness. Stigma toward this specific SLH subgroup merits more attention in future research, particularly in light of a previous study showing that SLH residents had significant increases in a measure of interpersonal tolerance over a 24-month period (Olson et al., 2009). It is important to note that the stigmatizing attitudes expressed by these study participants did not include reports of enacted stigma or harms against severely mentally ill SLH residents; it is possible that the participants used the focus groups as an opportunity to express frustrations that they otherwise kept hidden at home.

This study has several limitations. Sober living home residents did not discuss their own experiences with relapse in any detail – in fact, only one resident reported relapsing while living at his current SLH; for this reason, we are unable to assess in depth the relationship between felt stigma and relapse risk in SLHs. As noted in the results, a number of SLH residents identified themselves as having psychiatric disorders, symptoms of which can manifest as perceptions of stigma-related rejection and personal devaluation. In previous work, researchers studying the effects of stigma on mental health have acknowledged the methodologic limitations of assessing these two constructs at the same time point (Link et al., 1989; Luoma et al, 2007); longitudinal study designs and ethnographic observations of interactions among SLH residents, operators, and community members may be useful in evaluating the potential impact of stigma on both substance use relapse and mental health.

Conclusions

Taking issue with earlier research that framed chronic disability as a tragic “loss of self” or a “biographical disruption” that requires “narrative reconstruction,” Shakespeare and Watson (2010) noted that “there appears to be little interest in what happens after the biography has been disrupted or the narrative has been reconstructed.” The same criticism could be directed at a great deal of the descriptive work that has accumulated on the prevalence and correlates of health-related stigma. Previous empirical work has included little information on collective responses to substance misuse stigma, such as activism or education; indeed, efforts to educate others about substance misuse and mental illness have been conceptualized largely as personal coping strategies rather than constructive action aimed at broader social change (Link et al., 1995; Luoma et al., 2007). In contrast to the personal tragedy framework, the current study discovered several indigenous personal challenges to stigma among SLH residents and operators, and these practices could inform the development of rights-based interventions in the future (Parker and Aggleton, 2003). The SLH residents and operators in this study made tangible contributions to their neighbors such as social gatherings, personal advice, and referrals to health and social services – and created valued identities for themselves in the process. The potential impact of these investments in the community – for local individuals and families, as well as for SLH residents themselves – would be a promising focus for future work.