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. Author manuscript; available in PMC: 2021 May 1.
Published in final edited form as: Stigma Health. 2019 Jul 25;5(2):158–167. doi: 10.1037/sah0000182

Risk Factors for Self-stigma among Incarcerated Women with Alcohol Use Disorder

Kelly E Moore 1, Michael D Stein 2,3, Megan E Kurth 2, Lindsey Stevens 4, Maji Hailemariam 5, Yael C Schonbrun 2,4, Jennifer E Johnson 5
PMCID: PMC7583578  NIHMSID: NIHMS1042924  PMID: 33102697

Abstract

Alcohol use disorder (AUD) is a highly stigmatized condition, often associated with negative stereotypes such as being morally weak, incompetent, unpredictable, and aggressive. People with AUD are at risk of experiencing self-stigma, a social-cognitive experience in which people think others hold negative stereotypes about them, expect to be treated unfairly, and/or believe that negative stereotypes are personally accurate. Women in the criminal justice system with AUD in particular are at risk of experiencing self-stigma due to intersecting sources of disadvantage. Given that self-stigma can lead to treatment avoidance and dropout, it is important to understand risk factors for self-stigma to inform prevention and intervention efforts in the justice system. Incarcerated women with AUD (n=185) completed measures of alcohol self-stigma as well as a variety of theoretically relevant risk factors including sociodemographics, baseline levels of stress and depression, and alcohol-related factors (i.e., length of drinking history, frequency/amount of use, consequences of use, physician advice to stop, belief that legal involvement is related to alcohol use, alcohol-related charges, self-efficacy to quit, readiness for treatment, pressures to enter treatment, factors that influence treatment) and other stigmatized conditions (drug use, exchanging sex, and homelessness). Results showed that experiencing more consequences of alcohol use, pressures to enter treatment, and perceived stress were associated with internalized stigma and anticipated/enacted stigma. This study begins to identify which incarcerated women with AUD are most at risk of experiencing self-stigma that may interfere with alcohol treatment.

Keywords: alcohol use disorder, self-stigma, internalized stigma, incarceration, women

Alcohol use disorder (AUD) is a stigmatized (i.e., socially undesirable) condition associated with pervasive negative stereotypes such as being dangerous, aggressive, short-tempered, blameworthy, irresponsible, unpredictable, weak-willed, lazy, and dependent on others (Gibbs et al., 2011; Lyu, Lee & Bejerano, 2017; Schomerus et al., 2014, Schomerus, 2014; Birtel, Wood, & Kempa, 2017). People in stigmatized groups, including people with AUD, often perceive negative stereotypes about their group (i.e., perceived stigma), agree with negative stereotypes (i.e., stereotype agreement), fear and expect judgment or unfair treatment (i.e., anticipated stigma), and believe that negative stereotypes are personally accurate (i.e., internalized stigma). Broadly, these social-cognitive experiences are considered self-stigma (Corrigan, Watson, & Barr, 2006; Brown et al., 2015; Fortney et al., 2004), and each can have unique impacts on behavior (Corrigan et al., 2006; Moore, Stuewig, & Tangney, 2016).

Self-stigma is associated with depression, shame, hopelessness, low self-esteem, low social support, social avoidance, low self-efficacy to overcome stigma-related challenges, and avoidance of community institutions, including treatment settings (Birtel et al., 2017; Fortney et al., 2004; Gavriele-Fried & Rabayov, 2017; Lyu et al., 2017). In particular, internalized and anticipated stigma are often associated with less treatment-seeking (Chartier et al., 2016; Keyes et al., 2010; Oleski et al., 2010; Radcliffe & Stevens, 2008) as well as less engagement and retention in treatment (Britt et al., 2015, Kaushik et al., 2016; Ali et al, 2017; Fung et al., 2007; Ociskova et al., 2016). Given that alcohol use disorder (AUD) is one of the most prevalent and severe mental disorders (Schomerus et al., 2011), and that alcohol self-stigma (i.e., embarrassment, fear of receiving treatment for alcohol use) has increased as a reason for not seeking treatment in the U.S. in the past 10 years (Chartier et al., 2016), it is critical to understand and prevent factors that increase risk for alcohol self-stigma in order to ensure that people with AUD seek and remain in treatment.

Alcohol Self-stigma among Justice-Involved Women

Certain stigmatized individuals may be more at risk of experiencing self-stigma, and thus more vulnerable to poor treatment outcomes. Intersectionality theory suggests that membership in multiple devalued groups can exacerbate the effects of stigma, meaning that individuals who have other stigmatized qualities (i.e., racial/ethnic or sexual minority status, gender, low socioeconomic status, criminal history, mental illness) may be more vulnerable to experience self-stigma (Cole, 2009; Oexle & Corrigan, 2018). In addition to the presence of other devalued conditions, social and psychological problems as well as elements of the stigmatized condition (e.g., severity of mental illness, severity of criminal record) may increase risk for self-stigma (LeBel, 2012).

Although several studies have examined substance use self-stigma among community or psychiatric populations, there is less research on self-stigma among more marginalized, high-risk populations, such as those in the criminal justice system (van Olphen et al., 2009). Over 10 million people cycle through the criminal justice system each year in the U.S. (Zeng, 2018). Alcohol use can prompt justice system involvement via engagement in reckless behavior while intoxicated (e.g., assault, disorderly conduct, driving under the influence; Greenfield, 1998). Studies show that around 36% of convicted offenders were under the influence of alcohol at the time of the offense (Greenfield, 1998); 25% of women and 40% of men on probation reported being under the influence of alcohol at the time of the offense and 62% of them had participated in an alcohol treatment program previously (Greenfield, 1998). Thus, AUD is overrepresented in the criminal justice system. Less than a third of inmates who have drug or alcohol use disorders receive treatment (Bronson et al., 2017). Further, people in the criminal justice system are subjected to stigma about incarceration and having a criminal record (LeBel, 2012; Pogorzelski et al., 2005; Moore et al., 2016), are often members of multiple devalued groups (Brinkley-Rubenstein, 2015; Hartwell, 2004), and experience numerous psychological and social problems that interfere with adaptive functioning. As a result, it is important to examine alcohol self-stigma (i.e., one potential barrier to treatment entry) among people in the criminal justice system.

Women in the justice system may be especially at risk of self-stigma and its consequences. Women are more likely than justice-involved men and women in the community to have histories of trauma and mental health problems (Kulesza et al., 2016). In addition, women of color and those with a lower social economic status are sometimes targeted by disciplinary policies (Racine et al., 2015), which may increase their risk of internalizing negative stereotypes related to substance use. Furthermore, women with AUD in the justice system may engage in other stigmatized behaviors or be part of other devalued groups such as being homeless, exchanging sex for substances or money, or using illegal drugs; the intersection of such stigmatized conditions may provide further challenges to their self-concept. Indeed, perceived and internalized stigma about alcohol use are more common in women than men (Fortney et al., 2004; Crisafulli, 2016), and female inmates report higher levels of alcohol use than males at the time of their index offense (Greenfield, 1998).

Risk Factors for Alcohol Self-stigma

Consistent with intersectionality theory, research among psychiatric and community populations demonstrates that several devalued demographic factors are associated with substance use self-stigma (Brown et al., 2015; Silveira et al., 2018; Fortney et al., 2004; Lyu et al., 2017). Higher levels of self-stigma related to alcohol/crack use (i.e., measured as perceived stigma, stereotype agreement, alienation and social withdrawal because of stigma, and perceived inability to overcome stigma) are found in racial/ethnic minorities who have lower educational attainment (Silveira et al., 2018). Substance use self-stigma (i.e., internalized stigma, anticipated stigma) is also higher among people who are unemployed (Brown et al., 2015; Silverira et al., 2018). Research is mixed with regard to gender differences in substance use self-stigma, with some studies showing no differences (Silveira et al., 2018; Brown et al., 2015). However, among people receiving treatment for alcohol/crack use, women have been found to have higher levels of substance use self-stigma compared to men (Silveira et al., 2018).

There are several behavioral, psychological, and social problems found to be associated with substance use self-stigma. Less perceived social support, more severe depression, lower self-esteem, and more frequent and severe substance use are associated with perceived stigma about substance use (Birtel et al., 2017) as well as anticipated and internalized stigma about substance use (Brown et al., 2015; Smith et al., 2016; Lyu et al., 2017). In psychiatric/community populations, internalized stigma specific to alcohol use is higher among individuals with higher depression symptoms, a longer history of problems with alcohol, who have lower self-efficacy to refuse alcohol, who have been voluntarily hospitalized, who have had at least 21 hospitalizations in their life for alcohol-related reasons, and do not perceive their friends and family as being supportive (Schomerus et al., 2011; Lyu et al., 2017).

Present Study

Alcohol self-stigma has traditionally been examined among people with alcohol use disorder (AUD) in primary care or alcohol treatment settings, but has not been examined quantitatively among women in the criminal justice system who have many intersecting devalued characteristics and other risk factors that could prompt alcohol self-stigma and subsequent treatment failures. It is unclear whether previously examined factors are associated with alcohol self-stigma among this uniquely marginalized population. Further, there may be additional risk factors for alcohol self-stigma among incarcerated women, such as the degree to which alcohol is perceived to cause legal problems, the presence of alcohol-related charges, or the presence of other stigmatized conditions. This study examined a comprehensive set of risk factors, including sociodemographics (i.e., age, race, education level, income), psychological factors (i.e., stress, depression), alcohol-related factors (i.e., longer history of and more severe alcohol use, more consequences of use, viewing alcohol as related to legal involvement, presence of an alcohol-related charge, physician advice to stop drinking, lower self-efficacy to quit, more readiness to enter treatment, more pressures to enter treatment, more factors that influence treatment completion), and other stigmatized conditions (i.e., drug use, sex trading, and homelessness) that may be associated with four distinct aspects of alcohol self-stigma among incarcerated women. These aspects included perceived stigma (specifically about alcohol use treatment, referred to as “perceived stigma about treatment”), agreement with common stereotypes about people with alcohol problems (i.e., “stereotype agreement”), acceptance of negative stereotypes as personally accurate (i.e., “internalized stigma”), and fear of being treated unfairly/prior experience with unfair treatment due to alcohol use (i.e., “anticipated/enacted stigma”).

We hypothesized that the more disadvantaged women were (with regard to sociodemographics, psychological symptoms, alcohol-related factors, and other stigmatized conditions), the more self-stigma they would report, particularly internalized and anticipated/enacted stigma. Perceived stigma, which develops over the course of one’s lifetime and is not directly focused on the self, is often predicted by factors that are less relevant to the stigmatized condition, such as sociodemographics or psychological functioning. In contrast, internalized and anticipated/enacted stigma, which are self-focused, are often predicted by factors directly related to the stigmatized condition, which in this case would be alcohol-related.

Method

Participants and Procedures

Data were drawn from the baseline assessment of an ongoing randomized controlled trial (RCT) that evaluates the effectiveness of promoting linkage to 12-step self-help groups to reduce alcohol use among women with AUD exiting the justice system (Authors, date). The sample includes incarcerated women in pre-trial detention (Mean days incarcerated = 12.0, SD = 10.5), which means they had just been incarcerated and were awaiting trial to determine their sentence. Eligible participants were enrolled from May 2014 to October 2016 and: 1) were in the participating jail and either unsentenced or serving very short sentences (expected to be released in the next two months); 2) were at least18 years old; 3) lived within 20 miles of our research offices and planned to remain in the area for the next 6 months; 4) met 3 or more DSM-5 criteria for AUD in the last 90 days; 5) did not expect to attend residential alcohol or drug treatment upon release; and 6) spoke English. Research staff were able to access the jail 4 hours per weekday and met with participants in two private rooms. Researchers attempted to screen all women shortly after their intake at the jail. Potential participants were informed that: (1) a decision not to participate in the research will have no impact on their legal status or sentence; (2) the study has a Certificate of Confidentiality; and (3) no information provided during the study will be shared with any criminal justice system staff. The study protocol was reviewed and approved by the institutional review board for the protection of human subjects in research, and complied with the special protections pertaining to behavioral research involving prisoners (OHRP, 2005). Research staff approached 340 women for the RCT, and 5 refused to be screened, leaving 335 screened of whom 185 were consented, enrolled, and completed the baseline assessment, comprising the sample analyzed in this study.

Measures

Alcohol Self-Stigma.

Alcohol self-stigma was assessed with an adapted 17-item version of the depression self-stigma questionnaire (Kanter, Rusch, & Brondino, 2008). The scale contains 4 subscales capturing different aspects of self-stigma: perceived stigma about treatment (4 items; “People will see a person in a less favorable way if they come to know that he/she received treatment for alcohol use”, α = 0.812), stereotype agreement (4 items; “Other people with alcohol use are morally weak”, α = 0.731), internalized stigma (4 items; “Others view me as unable to handle responsibility because I use alcohol”, α = 0.875) and anticipated/enacted stigma (5 items; “Some people who know I use alcohol have grown more distant” and “Since starting alcohol I worry about people discriminating against me”, α = 0.841). In addition, a single item that best captures the affective component of internalized stigma (i.e., “People’s attitudes about alcohol make me feel worse about myself”) was isolated as a separate subscale, as such shame-related elements of internalized stigma have been considered especially problematic for functioning and therefore may have unique risk factors. Items are rated on an ordered categorical scale ranging from 1 “completely disagree” to 7 “completely agree”.

Sociodemographic factors.

We assessed several demographics via self-report, including age, race/ethnicity (i.e., Caucasian/White vs. racial/ethnic minority), years of education completed, and legal income in the past year (i.e., <$10k, $10k to $19,999, $20k to $29,999, $30k to $39,999, $40k to $49,999, $50k to $59,999, $60k to $69,999, $70k or more).

Baseline psychological distress.

We assessed baseline depression using 3-items from the 12 item Short-Form Health Survey (Ware, Kosinski, & Keller, 1996) that capture depression symptoms in the past 4 weeks (e.g., “Have you felt downhearted and blue?”; “Have you had a lot of energy?”); responses were rated on a scale of 0 (None of the time) to 5 (All of the time) (α =0.611). Baseline stress was assessed using the 4-item perceived stress scale (PSS; Cohen, Kamarck, & Mermelstein, 1983; e.g., “In the last month, how often have you felt that you were unable to control the important things in your life?”). Responses were rated on a scale of 0 (Never) to 4 (Very often).

Alcohol-related factors.

We assessed several factors specific to alcohol use. We had five measures of alcohol use severity. First, participants were asked to specify the number of months they “had a problem with drinking.” Second, pre-incarceration alcohol use was assessed using the Timeline Followback (TLFB) calendar-based interview (Ehrman & Robbins, 1994; Miller 1995; Sobell & Sobell, 1992) at the baseline assessment point (in jail). The TLFB is a reliable and valid method for assessing alcohol use (Johnson & Zlotnick, 2008; Stein et al., 2002; Zlotnick, Johnson, & Najavits, 2009). Participants answered the following question as part of the TLFB calendar interview: “In the two weeks prior to your arrest, how much alcohol did you drink each day?” and then discussed each day of the week to prompt recall. One standard drink was defined as one beer, one 5-ounce glass of wine, or 1.5 ounces of hard liquor. As a measure of total alcohol consumption, we calculated the average number of drinks consumed on each of the 14 days prior to jail admission. Third, we assessed consequences of alcohol use using the 15-item Short Inventory of Problems (SIP-2R; Miller, Tonigan, & Longabaugh, 1995), adapted from the Drinking Inventory of Consequences (Miller et al., 1995). The SIP has 5 subscales; physical, social, intrapersonal, interpersonal, and impulse control consequences; responses are rated on a scale from 1 (Never) to 3 (Daily or Almost Daily) and were summed to create a total scale score. An example item is “I have failed to do what is expected of me because of my drinking”. Versions of the SIP have been shown to be reliable and valid for people with alcohol use problems (Kiluk et al., 2013; Bender et al., 2007) and the alpha in this sample was 0.929. Fourth, participants were asked, “Has a doctor or other health care professional ever told you that you had problem with drinking?”; responses were rated yes or no. Fifth, if participants currently reported having been charged with possession of alcohol in an open container, minor possession of alcohol, or driving while intoxicated they were coded as having an alcohol-related charge.

We used two measures to assess participants’ thoughts about modifying their alcohol use. First, self-efficacy for alcohol cessation was assessed using the following item, “How successful do you expect to be in quitting using alcohol at this time? Be realistic about this, based on your past experiences and present strength of motivation. On a scale from 1 to 10, with 1 representing the lowest expectation of success and 10 representing the highest expectation of success, please give yourself a rating of your own expectation of success in quitting using alcohol. Remember, the higher the number, the greater your expectation of success.” Second, select scales from the Circumstances, Motivation, and Readiness (CMR; DeLeon, 1993) measure were used to assess readiness for treatment, external pressures to enter treatment, and factors that influence treatment completion. The CMR has 18 items and 4 subscales, 3 of which were examined herein; circumstances 1 capturing external pressures to enter treatment (e.g., “I am sure that my family will not let me live at home if I do not get treatment for my alcohol use” and “I am sure that I would have come to treatment without the pressure of my legal involvement”, α =0.643), circumstances 2 capturing factors that interfere with treatment completion (e.g., “I am worried that I will have serious money problems if I get treatment for my alcohol use.”, α =0.487), and readiness to enter treatment (e.g., “I’ll do whatever I have to do to get my life straightened out.”, α =0.860). A single item from the circumstances 1 scale (i.e., “I am sure that I would go to jail if I didn’t enter treatment”) was removed and analyzed separately because of its unique relevance to incarcerated women. Responses were rated on a Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree). This measure has been shown to be reliable and valid in several studies (DeLeon, Melnick, & Kressel, 1997; DeLeon et al., 2000).

Other Stigmatized Conditions.

We assessed engagement in sexual trading using the item: “In the past 3 months, have you had sex to receive money, drugs, clothes, food, transport, a place to stay, or other things from anyone other than your main sexual partner?” Responses were yes or no. We assessed homelessness prior to incarceration by asking participants where they slept in the past 3 months; if they reported sleeping on the streets or in a shelter, they were coded as having experienced homelessness. We assessed drug use prior to incarceration by asking participants whether they used any drugs in the past 90 days including cannabis, opiates, cocaine, hallucinogens, amphetamines, sedatives, heroin, or methadone or buprenorphine (i.e., which indicates prior opioid use); endorsement of any drug was coded as 1.

Analysis Plan

We present descriptive statistics to summarize characteristics of the sample and bivariate correlations to illustrate the associations between demographic, psychological, alcohol-related, and other stigmatized condition risk factors with each self-stigma subscale and the one internalized stigma item. Because we were interested in analyzing a comprehensive set of variables that may predict alcohol self-stigma, we first ran bivariate correlations among variables of interest to explore associations between risk factors and alcohol self-stigma scales. To reduce the number of variables being analyzed (i.e., and minimize multicollinearity), variables non-significant (p > .05) at the bivariate level for each stigma sub-scale (see Table 2) were not included in multivariate analyses. We then used blocked multivariate linear regression models with categories of predictors. Predictors were grouped conceptually, and predictors that were significant at the bivariate level were entered as follows: sociodemographics (i.e., age, race/ethnicity, education level, income) in Block 1 and baseline psychological distress (i.e., stress, depression) in Block 2. Alcohol-related factors capturing severity (i.e., number of months with an alcohol problem, frequency/amount of use prior to incarceration, self-reported consequences of alcohol use, physician-identified alcohol problem, the presence of an alcohol-related charge), readiness to modify use (i.e., self-efficacy to quit, readiness for treatment, pressures to enter treatment, factors that influence treatment completion) were entered in Block 3, and other stigmatized conditions (i.e., trading sex, homelessness, drug use) were entered in Block 4. We used chi square statistics for the full model and each block to assess fit, and examined variance explained in self-stigma scale outcomes. We examined tolerance levels to assess multicollinearity among predictors.

Table 2.

Product-Moment Correlations of Risk Factors with Alcohol Self-stigma Sub-scales (n = 185).

Alcohol Self-stigma Subscales
Perceived Stigma about Treatment Stereotype Agreement Internalized Stigma Anticipated/ Enacted Stigma Internalized Stigma-1 itema
Sociodemographics
Age .18* .14 .18* .14 .03
Non-Latino White (Yes) −.07 −.12 .08 .01 .02
Education (Years) .21** .01 .23** .16* .18*
Income .18* .00 .14 .03 .07
Baseline Psychological Distress
Depression .09 .06 −.15* −.08 −.08
Stress −.02 −.07 .20** .22** .18*
Alcohol-related Factors
Months w/ Alcohol Problemb −.03 .01 .18* .09 .02
Mean Drinks/Day prior to Incarcerationb −.03 .07 .17* .09 .05
Short Inventory of Problems .13 .12 44*** 41*** .33***
Physician Advice (Yes) .10 .07 29*** 34*** .22**
Sees alcohol use as related to legal involvement (Yes) .00 −.00 37*** 27*** 25***
Alcohol Related Charge .05 −.01 .06 −.02 −.01
Self-Efficacy to Quit −.05 −.06 −.03 .04 .08
CMR Readiness −.06 −.01 .31*** 27*** .26***
CMR External Pressures to Enter Treatment .09 .09 43*** 30*** 27***
CMR Factors that Influence Treatment Completion −.03 −.03 −.13 −.08 −.10
Other Stigmatized Conditions
Exchanged Sex Last 3 Mos. (Yes) .11 .07 .22** .13 .07
Homelessness Last 3-Mos (Yes) .07 .03 .13 .03 −.03
Drug use Last 3-Mos (Yes) −.02 −.00 .15* .05 −.01
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Note.

*

p<.05

**

p<.01

***

p<.001;

a

One item representing internalized stigma was isolated as a separate outcome in analyses: “People’s attitudes about alcohol make me feel worse about myself.”

b

Log transformed.

Results

Bivariate correlations are displayed in Table 2. Only sociodemographic factors were associated with the subscale capturing perceived stigma about treatment: incarcerated women who were older, more educated, and had higher income perceived more stigma about treatment for alcohol use. No risk factors were significantly associated with the stereotype agreement subscale. Being more educated and reporting more stress, in addition to some alcohol severity factors (i.e., more self-reported consequences of alcohol use, having been told by a physician to stop drinking, believing that legal involvement is related to one’s alcohol use) were associated with the internalized stigma subscale, the single item reflecting the belief that other people/you personally think you are inferior because of alcohol use, and anticipated/enacted stigma (i.e., experience/anticipation of being treated unfairly). In addition, having a longer history of a drinking problem and drinking more prior to incarceration were associated with internalized stigma (subscale only). With regard to thoughts about modifying alcohol use, greater readiness for treatment as well as more external pressures to enter treatment were associated with internalized stigma (subscale and 1 item) and anticipated/enacted stigma. Having exchanged sex and using drugs in the past 3 months were associated with internalized stigma (subscale only).

Bivariate significant associations were entered into multivariate regression models predicting each self-stigma subscale outcome (except stereotype agreement, which was not associated with any risk factors at the bivariate level). Tolerance levels were in the acceptable range (i.e., <.80) and did not suggest problems with multicollinearity. Results of each multivariate regression are displayed in Table 3. Only more education and higher income were risk factors for perceiving stigma about treatment, and these factors explained 7.3% of the variance in perceived stigma about treatment. More baseline stress was a risk factor for internalized stigma (subscale), anticipated/enacted stigma, and the single internalized stigma item. The only risk factor that significantly predicted the internalized stigma (subscale) above and beyond sociodemographics and baseline psychological distress (8.9% of total variance explained) was reporting more external pressures to enter treatment. After adding alcohol-related risk factors, a total of 29.8% of the variance in the internalized stigma subscale was explained. Reporting more problems associated with alcohol use was also a risk factor for the single internalized stigma item, above sociodemographics and baseline distress, which resulted in a total of 7.8% of the variance being explained in this item. All risk factors explained a total of 17.3% of the variance in the single internalized stigma item. With regard to anticipated/enacted stigma, reporting more consequences of alcohol use on the Short Inventory of Problems, and reporting more external pressures to enter alcohol treatment were risk factors above and beyond sociodemographics and baseline psychological distress. Block 1 and 2 risk factors explained 12.9% of the variance in anticipated/enacted stigma, and the addition of Block 3 explained a total of 32.9% of the variance. Other stigmatized behaviors/conditions (drug use, homelessness, sex trading) were not predictors of stigma in multivariate analyses.

Table 3.

Multiple Linear Regressions of Alcohol Self-Stigma Subscales on Sociodemographics, Psychological Distress, and Alcohol-related Factors (n = 185).

Alcohol Self-Stigma Subscales
Perceived Stigma about Treatment b (se) Internalized Stigma b (se) Anticipated/ Enacted Stigma b (se) Internalized Stigma-1 item b (se)
Block 1: Sociodemographics
 Age 0.06 (0.04) 0.010* (0.05) 0.68** (0.21)
 Non-Latino White (Yes)
 Education (Years) 0.41* (0.19) 0.60* (0.21) 0.16** (0.06)
 Income 0.73** (0.37)
Block 2: Baseline Psychological Distress
 Depression −0.59 (0.44)
 Stress 1.39** (0.52) 1.36** (0.52) 0.50** (0.16)
Block 3: Alcohol-related Factors
 Months w/ Alcohol Problem 0.93 (0.60)
 Mean Drinks / Day Prior to Incarceration −0.00 (0.31)
 Short Inventory of Problems 1.38 (0.91) 2.03* (0.81) 0.55* (0.26)
 Physician Advice (Yes) 1.47 (0.91) 1.57 (0.95) 0.32 (0.32)
 Return to Jail if Continued Use (Yes) 0.16 (0.49) 0.09 (0.45) 0.05 (0.15)
 Alcohol Related Charge
 Self-Efficacy to Quit
 CMR Readiness 0.19 (0.65) 0.21 (0.65) −0.05 (0.23)
 CMR External Pressures to Enter Treatment 1.31* (0.66) 1.26* (0.63) 0.19 (0.21)
 CMR Factors that Influence Treatment Completion
Block 4: Other Stigmatized Conditions
 Exchange Sex Last 3-Mos. (Yes) 2.24 (1.16)
 Homelessness Last 3-Mos (Yes)
 Drug Use Last 3-Mos (Yes) 0.40 (0.94)
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Note.

*

p<.05,

**

p<.01,

***

p<.001

Discussion

This study examined a comprehensive set of risk factors and their association with distinct components of alcohol self-stigma among a marginalized population of incarcerated women with AUD. Drawing from intersectionality theory, we hypothesized that disadvantage in the form of sociodemographics, psychological symptoms, alcohol-related risk factors, and other stigmatized conditions would increase risk for self-stigma. Our hypotheses were partially supported.

Perceived Stigma about Alcohol Treatment

Contrary to our predictions, women who were more educated and in a higher income bracket had greater risk of perceived stigma about treatment. Though this appears inconsistent with intersectionality theory, this finding is consistent with some studies of substance use stigma (Luoma et al., 2007). People with multiple sources of social disadvantage may perceive less stigma due to the stigmatized behavior being more accepted in their environment. In contrast, stigmatized individuals may perceive more stigma when they are in institutions of higher education, “formal” or high-paying jobs, or other environments wherein exposure to the stigmatized behavior is less common (Copenhaver et al., 2007; Apel & Sweeten, 2010). Notably, perceived stigma is not considered to be universally harmful; views about the self (i.e., in the form of anticipated or internalized stigma) are often viewed as more proximal and thus relevant to treatment-seeking behavior (Corrigan et al., 2006; Earnshaw et al., 2013). However, perceived stigma about treatment is described as a reason for not seeking needed substance use treatment among higher income, insured populations, whereas the numerous logistic and other barriers to treatment access are often more pressing among underserved, low-income populations (Ali et al., 2017).

Anticipated/Enacted and Internalized Stigma

Several risk factors were related to anticipated/enacted stigma (i.e., experiences of rejection, worries about future treatment due to alcohol use) and internalized stigma (i.e., belief that others look down on you, looking down on yourself as a result of alcohol use) among incarcerated women. At the bivariate level, women who reported more physiological, psychological, social and other problems as a result of their alcohol use, recognized alcohol as a factor in their legal involvement, had received a physician’s advice to stop drinking, reported higher readiness to enter treatment, perceived more external pressures to enter treatment, and had other stigmatized conditions (i.e., drug use, sex trading, homelessness) were more likely to endorse internalized and anticipated/enacted stigma. Interestingly, many of these risk factors (i.e., problem recognition, readiness for treatment, physician advice) may be desirable attributes in promoting abstinence and help-seeking behavior. Consistent with prior research and theory, physician advice or intensified need/readiness to seek treatment may also solidify the personal application of official labels, such as alcoholic, that can be harmful to the self-concept (Link et al., 1989). In particular, external pressures (e.g., family, legal) to enter alcohol treatment emerged as a significant predictor of the internalized stigma subscale in multivariate models. Research on substance use stigma demonstrates that one of the primary sources of stigma for individuals with substance use problems is family. Individuals with substance use problems frequently report concealing their substance use from their family to avoid embarrassment and judgment (Earnshaw et al., 2013; Luoma et al., 2007), 75% report that their families endorse negative stereotypes and would treat them unfairly if they knew about their substance use (Ahern, Stuber, & Galea, 2007), and many report that their family members who are aware of their substance use do not trust them (Earnshaw et al., 2013). Legal pressures (e.g., mandated treatment, suspension of driver’s license, incarceration, probation) are another primary source of stigma that has the potential to influence one’s self-concept. People with substance use disorders often report that they are viewed as “criminals” by justice system staff (Brinkley-Rubenstein, 2015). Family and legal pressures are both typically associated with substance use treatment entry (Weisner & Matzger, 2002), and interestingly, these external pressures were not significantly associated with perceived stigma about treatment in this study. Women with AUD may agree with these external pressures that treatment is important and beneficial, and yet these pressures may still contribute to feelings of low self-worth and shame (i.e., internalized stigma). It may be that people with AUD enter treatment, but experience shame and avoidance in the context of treatment, which may interfere with their ability to trust treatment providers and engage in or benefit from treatment. Our results suggest that family members, legal system authorities, or healthcare professionals’ pressuring individuals with AUD to enter alcohol treatment, despite the good intentions, may have unintended consequences for women’s self-concept.

Recognizing more consequences of alcohol use (i.e., physical, psychological, interpersonal, legal, financial) predicted anticipated/enacted stigma and the single internalized item that captured feeling worse about one’s self due to stigma. Studies have demonstrated that more “severe” stigmatized behavior (e.g., injection drug use as opposed to other drug use, violent criminal history as opposed to nonviolent) is associated with higher levels of perceived, enacted, and anticipated stigma (LeBel, 2012; Luoma et al., 2007). Because such behaviors are associated with more negative stereotypes, individuals who engage in them are more likely to form negative expectancies about future interactions with community members, believing stereotypes are personally accurate, and are more at risk of experiencing negative psychological and behavioral consequences of internalized stigma such as shame, depression, and social withdrawal.

Consistent with intersectionality theory, incarcerated women who had higher baseline levels of stress were at risk of internalized and anticipated/enacted stigma. Legal system involvement is often identified as a major source of stress, and this finding makes sense; women who had more stressful circumstances and felt less capable of coping with their circumstances prior to incarceration may also feel less capable of overcoming stigma-related stressors. Alternatively, it may be that past stigma-related stressors such as feeling judged by family or community members or being fired/not hired due to alcohol use prior to incarceration may contribute to perceived stress, partly explaining this association; prospective research would be necessary to clarify the direction of this relationship.

Limitations

This study has both strengths and limitations. Strengths include a large (n = 185) dataset reflecting an understudied and high-risk population (jailed women with diagnosed alcohol use disorder) and a multifaceted assessment of self-stigma. First, while our sample allows an examination of this unique perspective of incarcerated women, we included no comparison, non-incarcerated cohort of drinkers to test the wide variety of variables we examined here for their association with alcohol self-stigma. Second, there is little heterogeneity in quantity/frequency measures of alcohol use in this long-term, heavy-drinking sample. Third, the study was cross-sectional, and while we document historical factors associated with self-stigma, we couldn’t determine whether this self-stigma will relent or increase following release from jail. Similarly, our analyses did not allow us to determine the direction of association, how much self-stigma was a result or cause of factors such as stress or depression. Moreover, some of the alcohol-related factors (e.g., Short Inventory of Problems) included items that had conceptual overlap with self-stigma, possibly inflating the association (though the strongest correlation between the SIP and self-stigma scales was 0.44, suggesting distinct constructs). Fourth, our study participants were female jail inmates, therefore, findings of this study may not be generalizable to other justice-involved populations (e.g. prison inmates, who often commit more stigmatized offenses and serve longer sentences) or to men, as there are previously established gender differences in AUD (Nolen-Hokesema & Hilt, 2010). Along these lines, we did not assess for self-stigma related to criminal justice system involvement, which may be an important variable to include in future research (Moore et al., 2016). Finally, we attempted to analyze the most parsimonious multivariate models possible by excluding variables that were not significantly associated with self-stigma at the bivariate level, but multivariate models still included numerous variables that may have increased the risk that we would find a significant association by chance. Additional studies should be conducted to replicate these relationships.

Treatment Implications

This study has several treatment implications. Research suggests that internalized and anticipated stigma in particular are most often linked to treatment avoidance and disengagement (Britt et al., 2015, Kaushik et al., 2016). Indeed, in community populations, people with AUD who have higher levels of internalized stigma are less likely to seek professional substance use treatment (Schomerus et al., 2011). Women with AUD who are incarcerated (whether for substance- or non-substance-related reasons), and who have high levels of stress, legal/family pressures to enter treatment, and consequences of alcohol use are at risk of experiencing internalized and anticipated/enacted stigma that can later impact their treatment engagement and adjustment. To prevent self-stigma among incarcerated individuals who are often mandated to receive treatment, legal systems could facilitate warm handoffs and coordinated care with treatment providers, and family members could support their loved ones in receiving treatment and be active participants in their treatment (e.g., Community Reinforcement and Family Training; Kirkby et al., 1999). Attempts to reduce internalized and anticipated stigma cognitions and expectancies, the associated affective states (e.g., shame, anxiety), and the behavioral consequences (e.g., avoidance) among incarcerated individuals with AUD may help further facilitate treatment engagement and success. There are interventions aimed at reducing self-stigma associated with substance use (Luoma et al., 2008), but they are rarely if ever implemented in the justice system. There is a need for these treatments specifically for criminal justice populations and settings.

Table 1.

Background Characteristics (n = 185).

n (%) Mean (± SD) Median Range
Sociodemographics
 Age 35.93 (± 9.92) 34 18 – 68
 Non-Latino White (Yes) 121 (65.4%)
 Education (Years) 11.79 (± 2.23) 12 7 – 21
 Incomea 1.56 (± 1.11) 1 1 – 8
Baseline Psychological Distress
 Depression 2.02 (± 1.08) 2 0 – 5
 Stress 1.66 (± 0.89) 1.8 0 – 3
Alcohol-related Factors
 Mos. w/ Alcohol Problem 152 ( ± 134.0) 120 1 – 564
 Mean Drinks/Day Prior to Incarceration 7.49 (± 6.48) 5.78 0.13 – 30.6
 Short Inventory of Problems 1.98 (± 0.77) 2.13 0 – 3
 Physician Advice (Yes) 113 (61.1%)
 Sees Alcohol Use as Related to Legal Involvement (Yes) 3.52 (± 1.43) 4.00 1 – 5
 Alcohol Related Charge 14 (7.6%)
 Self-Efficacy to Quit 7.81 (± 2.07) 8.00 1 – 10
 CMR Readiness 3.71 (± 0.86) 3.71 1 – 5
 CMR External Pressures to Enter Treatment 3.23 (± 1.07) 3.33 1 – 5
 CMR Factors that Interfere with Treatment Completion 3.82 (± 0.82) 4.00 1 – 5
Other Stigmatized Conditions
 Exchanged Sex Last 3-Mos. (Yes) 36 (19.5%)
 Homelessness Last 3-Mos (Yes) 21 (11.4%)
 Drug use Last 3-Mos (Yes) 102 (55.1%)
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Note.

a

Ordered response ranging from 1 “< $10,000” to 8 “$70,000 or more. About 68.9% reported an income < $10,000 in the last year.

Acknowledgments

This research was supported by the National Institute on Alcohol Abuse and Alcoholism under Grant #R01AA021732 awarded to MDS and #L30DA044652 awarded to KEM by the National Institute on Drug Abuse. All authors declare that they have no conflicts of interest to disclose.

References

  1. Ahern J, Stuber J, & Galea S (2007). Stigma, Discrimination and the Health of Illicit Drug Users. Drug and Alcohol Dependence, 88, 188–196. 10.1016/j.drugalcdep.2006.10.014 [DOI] [PubMed] [Google Scholar]
  2. Apel R, & Sweeten G (2010). The impact of incarceration on employment during the transition to adulthood. Social Problems, 57, 448–479. [Google Scholar]
  3. Ali MM, Teich JL, & Mutter R (2017). Reasons for not seeking substance use disorder treatment: Variations by health insurance coverage. Journal of Behavioral Health & Services Research, 63–74. [DOI] [PubMed] [Google Scholar]
  4. Bender RE, Griffin ML, Gallop RJ, & Weiss RD (2007). Assessing negative consequences in patients with substance use and bipolar disorders: Psychometric properties of the Short Inventory of Problems (SIP) The American Journal on Addictions, 16, 503–509. [DOI] [PubMed] [Google Scholar]
  5. Birtel MD, Wood L, & Kempa NJ (2017). Stigma and social support in substance abuse: Implications for mental health and well-being. Psychiatry Research, 252, 1–8. [DOI] [PubMed] [Google Scholar]
  6. Brinkley-Rubinstein L (2015). Understanding the Effects of Multiple Stigmas Among Formerly Incarcerated HIV-Positive African American Men. AIDS Education and Prevention, 27(2), 167–179. 10.1521/aeap.2015.27.2.167 [DOI] [PubMed] [Google Scholar]
  7. Bronson J, Stroop J, Zimmer S, & Berzofsky M (2017). Drug use, dependence, and abuse among state prisoners and jail inmates, 2007–2009. Bureau of Justice Statistics. [Google Scholar]
  8. Britt TW, Jennings KS, Cheung JH, Pury CL, & Zinzow HM (2015). The role of different stigma perceptions in treatment seeking and dropout among active duty military personnel. Psychiatric Rehabilitation Journal, 38, 142–149. [DOI] [PubMed] [Google Scholar]
  9. Brown SA, Kramer K, Lewno B, Dumas L, Sacchetti G, & Powell E (2015). Correlates of self-stigma among individuals with substance use problems. International Journal of Mental Health and Addiction, 13, 687–698. [Google Scholar]
  10. Chartier KG, Miller K, Harris TR, Caetano R (2016). A 10-year study of factors associated with alcohol treatment use and non-use in a U.S. population sample. Drug and Alcohol Dependence, 160, 205–211. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cohen S, Kamarck T, & Mermelstein R (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396. [PubMed] [Google Scholar]
  12. Cole ER (2009). Intersectionality and research in psychology. American Psychologist, 64, 170–180. [DOI] [PubMed] [Google Scholar]
  13. Copenhaver A, Edwards-Willey T, & Byers BD (2007). Journeys in social stigma: The lives of formerly incarcerated felons in higher education. Journal of Correctional Education, 58, 268–283. [Google Scholar]
  14. Corrigan PW, Watson AC, & Barr L (2006). The Self–Stigma of Mental Illness: Implications for Self–Esteem and Self–Efficacy. Journal of Social and Clinical Psychology, 25, 875–884. [Google Scholar]
  15. Crisafulli MA (2016). Problem recognition among individuals with alcohol- related legal offenses: The impact of personal and perceived stigma. ProQuest Dissertations Publishing. [Google Scholar]
  16. DeLeon G, Melnick G, Kressel D, & Jainchill N (1994). Circumstances, Motivation, Readiness, and Suitability (The CMRS Scales): Predicting Retention in Therapeutic Community Treatment.” The American Journal of Drug and Alcohol Abuse, 20(4), 495–515. 10.3109/00952999409109186 [DOI] [PubMed] [Google Scholar]
  17. DeLeon G, Melnick G, & Kressel D (1997). Motivation and readiness for therapeutic community treatment among cocaine and other drug abusers.” The American Journal of Drug and Alcohol Abuse, 23, 169–189. 10.3109/00952999709040940 [DOI] [PubMed] [Google Scholar]
  18. DeLeon G, Melnick G, Thomas G, Kressel D, & Wexler HK (2000). Motivation for treatment in a prison-based therapeutic community. American Journal of Drug and Alcohol Abuse, 26, 33–46. [DOI] [PubMed] [Google Scholar]
  19. Earnshaw VA, Bogart LM, Dovidio JF, & Williams DR (2013). Stigma and Racial/Ethnic HIV Disparities: Moving toward Resilience. American Psychologist, 68, 225–236. 10.1037/a0032705 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Ehrman RN, & Robbins SJ Reliability and Validity of 6-Month Timeline Reports of Cocaine and Heroin Use in a Methadone Population. Journal of Consulting and Clinical Psychology, 62, 843–850. 10.1037/0022-006x.62.4.843 [DOI] [PubMed] [Google Scholar]
  21. Fortney J, Mukherjee S, Curran G, Fortney S, Han X, Booth BM (2004). Factors associated with perceived stigma for alcohol use and treatment among at-risk drinkers. The Journal of Behavioral Health Services & Research, 31, 418–429. [DOI] [PubMed] [Google Scholar]
  22. Fung MT, Tsang HWH, Corrigan PW, Lam CS, & Cheng W (2007). Measuring self-stigma of mental illness in China and its implications for recovery. International Journal of Social Psychiatry, 53, 408–418. [DOI] [PubMed] [Google Scholar]
  23. Gavriel-Fried B, & Rabayov T (2017). Similarities and differences between individual seeking treatment for gambling problems vs. alcohol and substance use problems in relation to progressive model of self-stigma. Frontiers of Psychology, 8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Gibbs DA, Olmsted KL, Brown JM, & Clinton-Sherrod M (2011). Dynamics of stigma for alcohol and mental health treatment among army soldiers. Military Psychology, 23, 36–51. [Google Scholar]
  25. Greenfield LA (1998). Alcohol and crime: An analysis of national data on the prevalance of alcohol involvement in crime. Bureau of Justice Statistics. [Google Scholar]
  26. Johnson JE, Zlotnick C (2008). A pilot study of group interpersonal psychotherapy for depression in substance-abusing female prisoners. Journal of Substance Abuse Treatment, 34, 371–377. [DOI] [PubMed] [Google Scholar]
  27. Kaushik A, Kostaki E, & Kyriakopoulos M (2016). The stigma of mental illness in children and adolescents: A systematic review. Psychiatry Research, 243, 469–494. [DOI] [PubMed] [Google Scholar]
  28. Keyes KM, Hatzenbuehler ML, McLaughlin KA, Link B, Olfson M, Grant BF, & Hasin D (2010). Stigma and treatment for alcohol disorders in the United States. American Journal of Epidemiology, 172, 1364–1372. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Kiluk BD, Dreifuss JA, Weiss RD, Mogenstern J, Carroll KM (2013). The short inventory of problems – revised (SIP-R): Psychometric properties within a large, sample of substance use disorder treatment seekers. Psychology of Addictive Behaviors, 27, 307–314. 10.1037/a0028445 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Kirby KC, Marlowe DB, Festinger DS, Garvey KA & LaMonaca V (1999) Community reinforcement training for family and significant others of drug abusers: A unilateral intervention to increase treatment entry of drug users. Drug and Alcohol Dependence, 56(1), 85–96. [DOI] [PubMed] [Google Scholar]
  31. Kulesza M, Matsuda M, Ramirez JJ, Werntz AJ, Teachman BA, & Lindgren KP (2016). Towards greater understanding of addiction stigma: Intersectionality with race/ethnicity and gender. Drug and Alcohol Dependence, 169, 85–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. LeBel TP (2012). Invisible Stripes? Formerly incarcerated persons’ perceptions of stigma. Deviant Behavior, 33, 89–107. doi: 10.1080/01639625.2010.538365. [DOI] [Google Scholar]
  33. Link BG, Cullen FT, Struening E, Shrout PE, & Dohrenwend BP (1989). A modified labeling theory approach to mental disorders: An empirical assessment. American Sociological Review, 54, 400–423. [Google Scholar]
  34. Luoma JB, Twohig MP, Waltz T, Hayes SC, Roget N, Padilla M, Fisher G (2007). An investigation of stigma in individuals receiving treatment for substance abuse. Addictive Behaviors, 32, 1331–1346. doi: 10.1016/j.addbeh.2006.09.008 [DOI] [PubMed] [Google Scholar]
  35. Luoma JB, Kohlenberg BS, Hayes SC, Bunting K, & Rye AK (2008). Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes. Addiction Research and Theory, 16, 149–165. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Lyu KY, Lee K, & Bejerano IL (2017). Factors related to internalization of stigma for alcohol dependence among Korean men. Social Behavior and Personality, 45, 127–142. [Google Scholar]
  37. Miller WR, Tonigan JS, & Longabaugh R (1995). The drinker inventory of consequences (DrInC). Project MATCH Monograph Series, 4, 319–322. [Google Scholar]
  38. Moore KE, Stuewig JB, & Tangney JP (2016). The effect of stigma on criminal offenders’ functioning: A longitudinal mediational model. Deviant Behavior, 37, 196–218. doi: 10.1080/01639625.2014.1004035 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Nolen-Hokesema S, & Hilt L (2010). Possible contributors to the gender differences in alcohol use and problems. The Journal of General Psychology, 133, 357–374. [DOI] [PubMed] [Google Scholar]
  40. Ociskova M, Prasko J, Latalova K, Kamaradova D, & Grambal A (2016). Psychological factors and treatment effectiveness in resistant anxiety disorders in highly comorbid inpatients. Neuropsychiatric Disease and Treatment, 12, 1539–1551. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Oleski J, Mota N, Cox BJ, & Sareen J (2010). Perceived need for care, help seeking, and perceived barriers to care for alcohol use disorders in a national sample. Psychiatric Services, 61, 2010, 1223–1231. 10.1176/appi.ps.61.12.1223 [DOI] [PubMed] [Google Scholar]
  42. Oexle N, & Corrigan PW (2018). Understanding mental illness stigma toward persons with multiple stigmatized conditions: Implications of intersectionality theory. Psychiatric Services, 69, 587–589. 10.1176/appi.ps.201700312 [DOI] [PubMed] [Google Scholar]
  43. Pogorzelski W, Wolff N, Pan K, & Blitz CL (2005). Behavioral health problems, ex-offender reentry policies, and the Second Chance Act. Public Health Consequences of Imprisonment, 95, 1718–1724. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Racine E, Bell E, Zizzo N, & Green C (2015). Public discourse on the biology of alcohol addiction: Implications for stigma, self-control, essentialism, and coercive policies in pregnancy. Neuroethics, 8, 177–186. [Google Scholar]
  45. Radcliffe P, & Stevens A (2008). Are drug treatment services only for ‘thieving junkie scumbags’? Drug users and the management of stigmatised identities. Social Science & Medicine, 67, 1065–1073. 10.1016/j.socscimed.2008.06.004 [DOI] [PubMed] [Google Scholar]
  46. Room R (2005). Stigma, social inequality and alcohol and drug use. Drug and Alcohol Review 24, 143–155. [DOI] [PubMed] [Google Scholar]
  47. Schomerus G, Matshinger H, Lucht MJ, & Angermeyer MC (2014). Changes in the perception of alcohol-related stigma in Germany over the last two decades. Drug and Alcohol Dependence, 143, 225–231. [DOI] [PubMed] [Google Scholar]
  48. Schomerus G, Corrigan PW, Klauer T, Kuwert P, Freyberger HJ, Lucht M (2011). Self-stigma in alcohol dependence: Consequences for drinking refusal self-efficacy. Drug and Alcohol Dependence, 114, 12–17. [DOI] [PubMed] [Google Scholar]
  49. Schomerus G, Lucht M, Holzinger A, Matschinger H, Carta MG, & Angermeyer MC (2011). The stigma of alcohol dependence compared with other mental disorders: A preview of population studies. Alcohol and Alcoholism, 46, 105–112. [DOI] [PubMed] [Google Scholar]
  50. Schomerus G (2017). Childhood trauma and self-stigma of alcohol dependence: Applying the progressive model of self-stigma. Stigma and Health. Advance online publication 10.1037/sah0000112 [DOI] [Google Scholar]
  51. Schomerus G & Corrigan PW (2014). The stigma of disease and disability: Understanding causes, and overcoming injustices. American Psychological Association, 57–72. [Google Scholar]
  52. Silveira PS, Casela AL, Monteiro ÉP, Ferreira GC, Freitas JV, Machado NM (2018). Psychosocial understanding of self-stigma among people who seek treatment for drug addiction. Stigma and Health, 3, 42–52. [Google Scholar]
  53. Smith LR, Earnshaw VA, Copenhaver MM, & Cunningham CO (2016). Substance use stigma: Reliability and validity of a theory-based scale for substance-using populations. Drug and Alcohol Dependence, 162, 34–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Smith SM, Dawson DA, Goldstein RB, Grant BF (2010). Examining perceived alcoholism stigma effect on racial-ethnic disparities in treatment and quality of life among alcoholics. Journal of Studies on Alcohol and Drugs, 231–235. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Sobell L, & Sobell M (1992). Timeline Follow-Back for Alcohol Consumption. PsycTESTS Dataset. 10.1037/t06202-000 [DOI] [Google Scholar]
  56. Stein MD, Charuvastra A, Anderson B, Sobota M, Friedmann PD (2002) Alcohol and HIV risk taking among intravenous drug users. Addictive Behavior, 27, 727–736. [DOI] [PubMed] [Google Scholar]
  57. Stolzenburg S, Tessmer C, Corrigan PW, Böttge M, Freitag S, Schäfer I, Freyberger HJ, Schomerus G (2017). Childhood trauma and self-stigma of alcohol dependence: Applying the progressive model of self-stigma. Stigma and Health. Advance online publication. doi: 10.1037/sah0000112 [DOI] [Google Scholar]
  58. Van Olphen J, Eliason MJ, Freudenberg N, Barnes M (2009). Nowhere to go: How stigma limits the options of female drug users after release from jail. Substance Abuse Treatment, Prevention, and Policy, 4. doi: 10.1186/1747-597X-4-10 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Ware JE, Kosinski M, & Keller SD (1996). A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34, 220–233. [DOI] [PubMed] [Google Scholar]
  60. Weisner C & Matzger H (2002). A prospective study of the factors influencing entry into alcohol and drug treatment. The Journal of Behavioral Health Services & Research, 29, 226–137. [DOI] [PubMed] [Google Scholar]
  61. Zeng Z Jail inmates in 2016. Bureau of Justice Statistics; 2018. [Google Scholar]
  62. Zlotnick C, Johnson J, & Najavits LM (2009) Randomized controlled pilot Study of cognitive-behavioral therapy in a sample of incarcerated women With substance use disorder and PTSD.” Behavior Therapy, 40, 325–336. doi: 10.1016/j.beth.2008.09.004 [DOI] [PMC free article] [PubMed] [Google Scholar]

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