“Words matter” when it comes to substance use — do images matter too?
Stigma related to substance use disorder, including the language we use, influences the way we think, feel, and act towards people living with these conditions. Images may matter too. To build on global efforts addressing stigmatizing language when referring to individuals with substance use disorders, this study interviewed people with lived addiction and recovery experience to identify potentially stigmatizing images and their recommended alternatives.
Stigma negatively affects people with substance use disorder in a number of ways. Stigmatizing views of people with substance use disorder are common, such as inaccurate or unfounded thoughts like they are dangerous, incapable of managing treatment, or at fault for their condition; this stereotyping can lead others to feel pity, fear, anger, and a desire for social distance from people with a substance use disorder. Importantly, perceived stigma can reduce someone’s willingness to seek treatment for substance use disorder. Stigmatizing language also negatively influences health care provider perceptions of people with substance use disorder, which can impact the care they provide.
Efforts have been made to change stigmatizing language to refer to individuals with substance use disorders, such as the National Institutes of Health ‘Words Matter’ list which provides recommendations to clinicians and providers for person-first language to use and a list of terms to avoid. Similarly, the Recovery Research Institute manages the Addictionary which provides a list of common terms, definitions, and indications when a term is stigmatizing or antiquated.
At the same time, stigmatizing imagery (i.e., images that implicitly or explicitly reinforce stereotypes and prejudice towards stigmatized individuals) depicting drugs or substance use may also foster substance use disorder stigma.
Similar to language identified as stigmatizing, these images may impact the way members of the general population think, feel, and respond to people with substance use disorder. They may also affect how people with substance use disorder feel about themselves. This study used qualitative methods to identify stigmatizing imagery and corresponding alternatives for substance use disorder and explore the reactions of people with lived experience with substance use disorder to substance use disorder-related imagery.
HOW WAS THIS STUDY CONDUCTED?
This study conducted semi-structured qualitative focus groups and interviews online using videoconferencing from December 2020 to June 2022 with 14 individuals in recovery from range of substance use disorders (9 individuals across 3 focus groups, 5 individual interviews) to identify stigmatizing and non-stigmatizing imagery for substance use disorders.
In total, 46 images were used across 6 categories to elicit participant feedback and discussion: 1) treatment and patient services, 2) types of substance use disorder, 3) law enforcement contact, 4) court and pretrial proceedings, 5) carceral settings, and 6) reentry and community supervision. Participants categorized each image as endorsed (i.e., “do use”) or not endorsed (i.e., “do not use”) for public usage followed by probing questions to help record detailed responses and feedback for each image. Feedback was summarized to classify substance use disorder-related images as stigmatizing or non-stigmatizing and make recommendations surrounding substance use disorder-related imagery.
Participants were recruited through email and phone communication with Addiction Policy Forum’s (APF) network of individuals with lived experience, including individuals who receive clinical services from APF, participate in APF’s recovery programming, or serve on advisory boards. Individuals were eligible to participate if they were 18 years or older, spoke English, and identified as either a person in recovery or as a person with an active substance use disorder. The researchers additionally sought out participants with prior justice-involvement given intersections of substance use and criminal justice stigma. Whereas most individuals (9) participated in an online focus group, 5 individuals participated in individual interviews to accommodate participants’ schedules.
The researchers compiled images of addiction from the top ten print and web news outlets published in the 3 years prior to data collection. Examples of addiction-related and criminal justice imagery were then collected from the sources along with representative stock photo images sampled from commonly used websites and stock photography databases. In total, 46 images were used alongside the interview guide to elicit participant feedback and discussion. Participants categorized each image as endorsed (i.e., “do use”) or not endorsed (i.e., “do not use”) for public usage followed by probing questions to help record detailed responses and feedback for each image.
The online focus group format allowed for the researchers and participants to collaborate in real time. For example, all images provided initially to represent substance use disorder types (opioid use disorder, alcohol use disorder) were considered stigmatizing by participants. The researchers were then able to search the internet during the focus group for new images while participants provided feedback until images were found that were categorized as appropriate for use.
The study had slightly more female participants (8) than male (6). In terms of race/ethnicity, 4 participants identified as Black, 2 as Native American, 2 identified as Hispanic/Latino, and 1 as more than one race (Native American and White). The remaining 5 participants identified as White. The mean age was 44 years (range = 25—66). Participants represented a range of substance use disorder histories: 4 with an opioid use disorder, 3 with a stimulant use disorder (methamphetamine or cocaine), 3 with alcohol use disorder, and 4 with polysubstance use disorder. All participants identified as being in recovery, with a range of time in recovery from a few weeks to 26 years. The majority of participants reported a history of justice-involvement (86%). The geographic breakdown of participant locations was as follows: 3 resided in Illinois, 2 in North Carolina, and 1 participant in each of the following states: Idaho, Oregon, Georgia, Florida, Kentucky, California, Minnesota, New York and Missouri.
WHAT DID THIS STUDY FIND?
Treatment and patient imagery with distressed or unhappy individuals considered stigmatizing
Rejected photos include images of individuals who look like they are struggling in treatment or pictures that resemble private treatment websites, described by participants as overly dramatized and staged. Imagery that conveys a lack of interest in treatment was reminiscent of coerced treatment for one participant. Several participants expressed concern that photos depicting patients struggling in treatment could reinforce isolation and despair, and potentially depict receiving treatment as a negative experience.
Treatment and patient imagery depicting wellness, health, and vitality considered non-stigmatizing
Endorsed images included photos of hand-holding, people helping to pull a peer up a hill with a landscape and a bright sky in the background, a family holding hands, walking through a natural landscape, and individuals in a circle to illustrate group therapy or mutual aid support groups.
Discussion centered around utilizing photos of wellness, health, and vitality when depicting individuals receiving treatment for substance use disorder or in recovery. Participants shared that images including nature and landscape felt positive and reinforced themes of new beginnings and health.
Imagery with realistic depictions of actual substances considered stigmatizing; scientific depictions considered non-stigmatizing
Participants identified images of people using substances and paraphernalia (needles, syringes, spoons, or lighters) as both stigmatizing and triggering, with participants reporting that the images brought up urges or cravings to use substances. Instead, participants recommended using conceptual image options, such as molecular symbols of the substance use disorder type, definitions of the type of substance from the dictionary,
and typography.
Criminal justice imagery associated with the carceral system considered stigmatizing; images illustrating security and the promise of reentry and community reintegration considered non-stigmatizing
Statements and feedback from participants showed a negative reaction to depictions of individuals in handcuffs and being arrested; individuals in prison jumpsuits or handcuffs in court; and images of bars, rows of cells, individuals behind bars, and images of prison or jail structures that include barbed wire or gun towers.
A handful of participants added concerns about intersectionality and racism, responding to frequent images of White law enforcement officers arresting African American or Hispanic/Latino individuals. A participant shared: “A lot of these images that are used in this way don’t show White people getting arrested they show people who are not white getting arrested by white officers.” They continued: “I think it’s traumatic that a lot of the images used in this way don’t show white people getting arrested.” Participants expressed the importance of equal representation across different races and ethnicities in images, from depictions of law enforcement or other positions of authority to images of those who are justice-involved or requiring substance use disorder services.
Participants endorsed photos of police cars, sirens, or police stations as non-stigmatizing. Participants agreed with police representation of officers alone (without an individual being arrested or depicted unfavorably) and helping in the community in pro-social activities. Participants endorsed photos of empty courtrooms, a gavel, or the scales of justice to convey material or information related to the judicial system. If imagery of people is required, participants expressed preference for images of a judge, district attorney or other professional without defendants in the frame. Participants identified more acceptable imagery for individuals with lived experience to convey prison contexts, recommending images that focus on positive activities during incarceration and photos of modern, updated common areas, cafeterias, prison libraries, and individuals in classrooms and vocational trainings to indicate prison settings. Discussion demonstrated participants prefer aspirational, hopeful images to represent the promise of reentry and community reintegration.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
Generally, imagery depicting wellness, health, vitality, and the promise of reentry and community reintegration were non-stigmatizing, whereas images of individuals in distress, using substances, or being persecuted were stigmatizing. From the perspectives of these participants with lived addiction and recovery experience, drug use and drug paraphernalia imagery may trigger unpleasant reactions including craving while pictures of people behind bars were experienced as stigmatizing. The study findings can be helpful in informing imagery depicting addiction, individuals with substance use disorder, and individuals involved in the justice system for various fields, such as research, media, public health, and community-based programming.
Stigmatizing communications can promote inaccurate and harmful stereotypes about individuals with substance use disorder. For example, compared to when a person is described as “having a substance use disorder” participants viewed a “substance abuser” as less likely to benefit from treatment, more likely to benefit from punishment, more likely to be a social threat, and more likely to control their substance use without help. Half of the participants in this study worked in the healthcare field. A major implication of stigmatizing attitudes is how those attitudes affect the public’s behavior, particularly the attitudes and behaviors of individuals working in the healthcare field. Individuals with substance use disorder often report experiencing mistreatment by healthcare providers, including healthcare providers minimizing or not addressing their primary medical complaint, being talked down to, and even unnecessarily painful procedures to “teach them a lesson” and verbal abuse. Individuals with substance use disorder subsequently often avoid seeking medical treatment for fear of being mistreated by providers for using drugs.
Similar to stigmatizing language, stigmatizing images may impact the way the general public thinks, feels, and responds to people with substance use disorder. In particular, certain imagery could be promoting substance use disorder-related stigma that intersects with other stigmas. For example, images depicting Black, Hispanic, LGBTQ+, or justice-involved individuals using drugs may promote racism, xenophobia, homophobia, or criminal justice stigma alongside substance use disorder stigma. Moreover, because of the way substance use is criminalized in the U.S., many people with substance use disorder have a history of criminal justice involvement. And, stigma associated with both substance use disorder and criminal justice involvement has been shown to be related to greater psychological distress, decreased self-esteem, and greater social isolation.
Modifying imagery and language used to describe and represent individuals with a substance use disorder or criminal justice involvement is an intervention that researchers, institutions, and individuals can implement to reduce stigma of substance use disorder. More research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, as well as how stigmatizing vs non-stigmatizing images actually impact public attitudes and behavior.
One final caveat is that the study asked participants to reflect on images without additional context, but whether images are experienced as stigmatizing may depend on the story or text that they accompany. For example, a picture of someone behind bars may feel less stigmatizing if accompanying a news story on a community’s efforts to phase out criminal justice approaches to substance use than if accompanying a news story related to police arrests in response to public drug use.
Overall, this study based on the perspectives of individuals with, or in recovery from, substance use disorder not only points to potentially stigmatizing images, but offers non stigmatizing alternatives. However, identifying stigmatizing imagery and its effects on attitudes and behaviors is a new area of research, so this study is just a first step.
Although this study provided recommendations for non-stigmatizing imagery from individuals with lived experience of substance use disorder, the study did not test the effects of stigmatizing and non-stigmatizing imagery on public attitudes or behavior. Future research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, and how such images impact public attitudes, like the study reported here and the study reported here, and how such attitudes impact actual behavior.
The study included individuals with a range of substance use disorder histories and participants lived in many different states in the U.S., representing a range of experiences and perspectives. However, participants were recruited from Addiction Policy Forum (APF)’s advisory board, patient and stakeholder network, as well as from their network of individuals who receive clinical services or who participate in APF’s recovery programming. It is possible that these individuals may have had a greater vested interest in this topic than others. Additionally, the study sample only included individuals who could speak English. As the researchers noted, this potentially creates a bias since the lived experiences of non-English speaking individuals with justice involvement and substance use disorder may differ from their English-speaking counterparts. Considering that Hispanic individuals are the fastest growing subgroup of prisoners in the U.S. and currently comprise 30.2% of the U.S. prison population, future research should prioritize the inclusion of non-English speaking participants to test the current study’s findings.
BOTTOM LINE
Imagery depicting wellness, health, vitality, and the promise of reentry and community reintegration were perceived as non-stigmatizing, whereas images of individuals in distress and being persecuted were perceived as stigmatizing. Based on the strong negative reactions from participants, the study suggests images with drug use and drug paraphernalia or pictures of people behind bars should be discouraged. This is an important first step to understanding stigma associated with images, however, future studies can help clarify if imagery affects public attitudes toward individuals who use drugs and the degree to which imagery context matters.
For individuals and families seeking recovery:Language and imagery likely influence how we think, feel, and respond to individuals with substance use disorder. Using non-stigmatizing language and imagery is an important step to reduce substance use disorder stigma broadly, which could improve treatment and recovery outcomes for individuals with substance use disorder. Check out the Recovery Research Institute’s Addictionary for a list of addiction related terms, definitions, and words to avoid.
For treatment professionals and treatment systems:Language and imagery to describe and depict individuals with substance use disorder could impact a patient’s willingness to initiate treatment, and their experience in treatment. It’s important for healthcare providers to use non-stigmatizing language in their direct patient care and clinical notes, and treatment settings can use non-stigmatizing imagery when promoting their services. Check out NIDA’s Words Matter list for language recommendations for healthcare providers and the images from this study for ideas on non-stigmatizing images.
For scientists: This study was able to provide recommendations for non-stigmatizing imagery from the feedback of individuals with lived experience of substance use disorder. However, the study did not test the effects of stigmatizing and non-stigmatizing imagery on public attitudes or behavior. Future research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, and how such images impact public attitudes, like the study reported hereand the study reported here, and how such attitudes impact actual behavior. Future research should also examine the reactions and attitudes of healthcare providers to certain imagery, and if certain imagery changes beliefs and attitudes about individuals with substance use disorder in the same way that language does. Importantly, scientists can use the findings from this study to inform recommended images to use in study recruitment materials. The study recommends against the use of explicit depictions of alcohol or other drugs, as these were perceived as stigmatizing by participants. Instead, results suggest using scientific or medical imagery to depict alcohol or other drugs, such as molecular symbols, which were rated by participants as non-stigmatizing.
For policy makers:Public attitudes towards individuals with substance use disorder can influence public policy, which is important for dictating where addiction treatment centers can be located, workplace protections (or lack thereof) for people with substance use disorders, and housing regulations. Lack of protections or access to treatment can contribute to worse overall well-being for a person with substance use disorder. Public messaging using non-stigmatizing language and imagery is important for reducing public stigma broadly, which could ultimately improve treatment and recovery outcomes for individuals with substance use disorder. Check out NIDA’s Words Matter list for language recommendations appropriate for professionals and the images from this study for ideas on non-stigmatizing images.
Stigma negatively affects people with substance use disorder in a number of ways. Stigmatizing views of people with substance use disorder are common, such as inaccurate or unfounded thoughts like they are dangerous, incapable of managing treatment, or at fault for their condition; this stereotyping can lead others to feel pity, fear, anger, and a desire for social distance from people with a substance use disorder. Importantly, perceived stigma can reduce someone’s willingness to seek treatment for substance use disorder. Stigmatizing language also negatively influences health care provider perceptions of people with substance use disorder, which can impact the care they provide.
Efforts have been made to change stigmatizing language to refer to individuals with substance use disorders, such as the National Institutes of Health ‘Words Matter’ list which provides recommendations to clinicians and providers for person-first language to use and a list of terms to avoid. Similarly, the Recovery Research Institute manages the Addictionary which provides a list of common terms, definitions, and indications when a term is stigmatizing or antiquated.
At the same time, stigmatizing imagery (i.e., images that implicitly or explicitly reinforce stereotypes and prejudice towards stigmatized individuals) depicting drugs or substance use may also foster substance use disorder stigma.
Similar to language identified as stigmatizing, these images may impact the way members of the general population think, feel, and respond to people with substance use disorder. They may also affect how people with substance use disorder feel about themselves. This study used qualitative methods to identify stigmatizing imagery and corresponding alternatives for substance use disorder and explore the reactions of people with lived experience with substance use disorder to substance use disorder-related imagery.
HOW WAS THIS STUDY CONDUCTED?
This study conducted semi-structured qualitative focus groups and interviews online using videoconferencing from December 2020 to June 2022 with 14 individuals in recovery from range of substance use disorders (9 individuals across 3 focus groups, 5 individual interviews) to identify stigmatizing and non-stigmatizing imagery for substance use disorders.
In total, 46 images were used across 6 categories to elicit participant feedback and discussion: 1) treatment and patient services, 2) types of substance use disorder, 3) law enforcement contact, 4) court and pretrial proceedings, 5) carceral settings, and 6) reentry and community supervision. Participants categorized each image as endorsed (i.e., “do use”) or not endorsed (i.e., “do not use”) for public usage followed by probing questions to help record detailed responses and feedback for each image. Feedback was summarized to classify substance use disorder-related images as stigmatizing or non-stigmatizing and make recommendations surrounding substance use disorder-related imagery.
Participants were recruited through email and phone communication with Addiction Policy Forum’s (APF) network of individuals with lived experience, including individuals who receive clinical services from APF, participate in APF’s recovery programming, or serve on advisory boards. Individuals were eligible to participate if they were 18 years or older, spoke English, and identified as either a person in recovery or as a person with an active substance use disorder. The researchers additionally sought out participants with prior justice-involvement given intersections of substance use and criminal justice stigma. Whereas most individuals (9) participated in an online focus group, 5 individuals participated in individual interviews to accommodate participants’ schedules.
The researchers compiled images of addiction from the top ten print and web news outlets published in the 3 years prior to data collection. Examples of addiction-related and criminal justice imagery were then collected from the sources along with representative stock photo images sampled from commonly used websites and stock photography databases. In total, 46 images were used alongside the interview guide to elicit participant feedback and discussion. Participants categorized each image as endorsed (i.e., “do use”) or not endorsed (i.e., “do not use”) for public usage followed by probing questions to help record detailed responses and feedback for each image.
The online focus group format allowed for the researchers and participants to collaborate in real time. For example, all images provided initially to represent substance use disorder types (opioid use disorder, alcohol use disorder) were considered stigmatizing by participants. The researchers were then able to search the internet during the focus group for new images while participants provided feedback until images were found that were categorized as appropriate for use.
The study had slightly more female participants (8) than male (6). In terms of race/ethnicity, 4 participants identified as Black, 2 as Native American, 2 identified as Hispanic/Latino, and 1 as more than one race (Native American and White). The remaining 5 participants identified as White. The mean age was 44 years (range = 25—66). Participants represented a range of substance use disorder histories: 4 with an opioid use disorder, 3 with a stimulant use disorder (methamphetamine or cocaine), 3 with alcohol use disorder, and 4 with polysubstance use disorder. All participants identified as being in recovery, with a range of time in recovery from a few weeks to 26 years. The majority of participants reported a history of justice-involvement (86%). The geographic breakdown of participant locations was as follows: 3 resided in Illinois, 2 in North Carolina, and 1 participant in each of the following states: Idaho, Oregon, Georgia, Florida, Kentucky, California, Minnesota, New York and Missouri.
WHAT DID THIS STUDY FIND?
Treatment and patient imagery with distressed or unhappy individuals considered stigmatizing
Rejected photos include images of individuals who look like they are struggling in treatment or pictures that resemble private treatment websites, described by participants as overly dramatized and staged. Imagery that conveys a lack of interest in treatment was reminiscent of coerced treatment for one participant. Several participants expressed concern that photos depicting patients struggling in treatment could reinforce isolation and despair, and potentially depict receiving treatment as a negative experience.
Treatment and patient imagery depicting wellness, health, and vitality considered non-stigmatizing
Endorsed images included photos of hand-holding, people helping to pull a peer up a hill with a landscape and a bright sky in the background, a family holding hands, walking through a natural landscape, and individuals in a circle to illustrate group therapy or mutual aid support groups.
Discussion centered around utilizing photos of wellness, health, and vitality when depicting individuals receiving treatment for substance use disorder or in recovery. Participants shared that images including nature and landscape felt positive and reinforced themes of new beginnings and health.
Imagery with realistic depictions of actual substances considered stigmatizing; scientific depictions considered non-stigmatizing
Participants identified images of people using substances and paraphernalia (needles, syringes, spoons, or lighters) as both stigmatizing and triggering, with participants reporting that the images brought up urges or cravings to use substances. Instead, participants recommended using conceptual image options, such as molecular symbols of the substance use disorder type, definitions of the type of substance from the dictionary,
and typography.
Criminal justice imagery associated with the carceral system considered stigmatizing; images illustrating security and the promise of reentry and community reintegration considered non-stigmatizing
Statements and feedback from participants showed a negative reaction to depictions of individuals in handcuffs and being arrested; individuals in prison jumpsuits or handcuffs in court; and images of bars, rows of cells, individuals behind bars, and images of prison or jail structures that include barbed wire or gun towers.
A handful of participants added concerns about intersectionality and racism, responding to frequent images of White law enforcement officers arresting African American or Hispanic/Latino individuals. A participant shared: “A lot of these images that are used in this way don’t show White people getting arrested they show people who are not white getting arrested by white officers.” They continued: “I think it’s traumatic that a lot of the images used in this way don’t show white people getting arrested.” Participants expressed the importance of equal representation across different races and ethnicities in images, from depictions of law enforcement or other positions of authority to images of those who are justice-involved or requiring substance use disorder services.
Participants endorsed photos of police cars, sirens, or police stations as non-stigmatizing. Participants agreed with police representation of officers alone (without an individual being arrested or depicted unfavorably) and helping in the community in pro-social activities. Participants endorsed photos of empty courtrooms, a gavel, or the scales of justice to convey material or information related to the judicial system. If imagery of people is required, participants expressed preference for images of a judge, district attorney or other professional without defendants in the frame. Participants identified more acceptable imagery for individuals with lived experience to convey prison contexts, recommending images that focus on positive activities during incarceration and photos of modern, updated common areas, cafeterias, prison libraries, and individuals in classrooms and vocational trainings to indicate prison settings. Discussion demonstrated participants prefer aspirational, hopeful images to represent the promise of reentry and community reintegration.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
Generally, imagery depicting wellness, health, vitality, and the promise of reentry and community reintegration were non-stigmatizing, whereas images of individuals in distress, using substances, or being persecuted were stigmatizing. From the perspectives of these participants with lived addiction and recovery experience, drug use and drug paraphernalia imagery may trigger unpleasant reactions including craving while pictures of people behind bars were experienced as stigmatizing. The study findings can be helpful in informing imagery depicting addiction, individuals with substance use disorder, and individuals involved in the justice system for various fields, such as research, media, public health, and community-based programming.
Stigmatizing communications can promote inaccurate and harmful stereotypes about individuals with substance use disorder. For example, compared to when a person is described as “having a substance use disorder” participants viewed a “substance abuser” as less likely to benefit from treatment, more likely to benefit from punishment, more likely to be a social threat, and more likely to control their substance use without help. Half of the participants in this study worked in the healthcare field. A major implication of stigmatizing attitudes is how those attitudes affect the public’s behavior, particularly the attitudes and behaviors of individuals working in the healthcare field. Individuals with substance use disorder often report experiencing mistreatment by healthcare providers, including healthcare providers minimizing or not addressing their primary medical complaint, being talked down to, and even unnecessarily painful procedures to “teach them a lesson” and verbal abuse. Individuals with substance use disorder subsequently often avoid seeking medical treatment for fear of being mistreated by providers for using drugs.
Similar to stigmatizing language, stigmatizing images may impact the way the general public thinks, feels, and responds to people with substance use disorder. In particular, certain imagery could be promoting substance use disorder-related stigma that intersects with other stigmas. For example, images depicting Black, Hispanic, LGBTQ+, or justice-involved individuals using drugs may promote racism, xenophobia, homophobia, or criminal justice stigma alongside substance use disorder stigma. Moreover, because of the way substance use is criminalized in the U.S., many people with substance use disorder have a history of criminal justice involvement. And, stigma associated with both substance use disorder and criminal justice involvement has been shown to be related to greater psychological distress, decreased self-esteem, and greater social isolation.
Modifying imagery and language used to describe and represent individuals with a substance use disorder or criminal justice involvement is an intervention that researchers, institutions, and individuals can implement to reduce stigma of substance use disorder. More research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, as well as how stigmatizing vs non-stigmatizing images actually impact public attitudes and behavior.
One final caveat is that the study asked participants to reflect on images without additional context, but whether images are experienced as stigmatizing may depend on the story or text that they accompany. For example, a picture of someone behind bars may feel less stigmatizing if accompanying a news story on a community’s efforts to phase out criminal justice approaches to substance use than if accompanying a news story related to police arrests in response to public drug use.
Overall, this study based on the perspectives of individuals with, or in recovery from, substance use disorder not only points to potentially stigmatizing images, but offers non stigmatizing alternatives. However, identifying stigmatizing imagery and its effects on attitudes and behaviors is a new area of research, so this study is just a first step.
Although this study provided recommendations for non-stigmatizing imagery from individuals with lived experience of substance use disorder, the study did not test the effects of stigmatizing and non-stigmatizing imagery on public attitudes or behavior. Future research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, and how such images impact public attitudes, like the study reported here and the study reported here, and how such attitudes impact actual behavior.
The study included individuals with a range of substance use disorder histories and participants lived in many different states in the U.S., representing a range of experiences and perspectives. However, participants were recruited from Addiction Policy Forum (APF)’s advisory board, patient and stakeholder network, as well as from their network of individuals who receive clinical services or who participate in APF’s recovery programming. It is possible that these individuals may have had a greater vested interest in this topic than others. Additionally, the study sample only included individuals who could speak English. As the researchers noted, this potentially creates a bias since the lived experiences of non-English speaking individuals with justice involvement and substance use disorder may differ from their English-speaking counterparts. Considering that Hispanic individuals are the fastest growing subgroup of prisoners in the U.S. and currently comprise 30.2% of the U.S. prison population, future research should prioritize the inclusion of non-English speaking participants to test the current study’s findings.
BOTTOM LINE
Imagery depicting wellness, health, vitality, and the promise of reentry and community reintegration were perceived as non-stigmatizing, whereas images of individuals in distress and being persecuted were perceived as stigmatizing. Based on the strong negative reactions from participants, the study suggests images with drug use and drug paraphernalia or pictures of people behind bars should be discouraged. This is an important first step to understanding stigma associated with images, however, future studies can help clarify if imagery affects public attitudes toward individuals who use drugs and the degree to which imagery context matters.
For individuals and families seeking recovery:Language and imagery likely influence how we think, feel, and respond to individuals with substance use disorder. Using non-stigmatizing language and imagery is an important step to reduce substance use disorder stigma broadly, which could improve treatment and recovery outcomes for individuals with substance use disorder. Check out the Recovery Research Institute’s Addictionary for a list of addiction related terms, definitions, and words to avoid.
For treatment professionals and treatment systems:Language and imagery to describe and depict individuals with substance use disorder could impact a patient’s willingness to initiate treatment, and their experience in treatment. It’s important for healthcare providers to use non-stigmatizing language in their direct patient care and clinical notes, and treatment settings can use non-stigmatizing imagery when promoting their services. Check out NIDA’s Words Matter list for language recommendations for healthcare providers and the images from this study for ideas on non-stigmatizing images.
For scientists: This study was able to provide recommendations for non-stigmatizing imagery from the feedback of individuals with lived experience of substance use disorder. However, the study did not test the effects of stigmatizing and non-stigmatizing imagery on public attitudes or behavior. Future research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, and how such images impact public attitudes, like the study reported hereand the study reported here, and how such attitudes impact actual behavior. Future research should also examine the reactions and attitudes of healthcare providers to certain imagery, and if certain imagery changes beliefs and attitudes about individuals with substance use disorder in the same way that language does. Importantly, scientists can use the findings from this study to inform recommended images to use in study recruitment materials. The study recommends against the use of explicit depictions of alcohol or other drugs, as these were perceived as stigmatizing by participants. Instead, results suggest using scientific or medical imagery to depict alcohol or other drugs, such as molecular symbols, which were rated by participants as non-stigmatizing.
For policy makers:Public attitudes towards individuals with substance use disorder can influence public policy, which is important for dictating where addiction treatment centers can be located, workplace protections (or lack thereof) for people with substance use disorders, and housing regulations. Lack of protections or access to treatment can contribute to worse overall well-being for a person with substance use disorder. Public messaging using non-stigmatizing language and imagery is important for reducing public stigma broadly, which could ultimately improve treatment and recovery outcomes for individuals with substance use disorder. Check out NIDA’s Words Matter list for language recommendations appropriate for professionals and the images from this study for ideas on non-stigmatizing images.
Stigma negatively affects people with substance use disorder in a number of ways. Stigmatizing views of people with substance use disorder are common, such as inaccurate or unfounded thoughts like they are dangerous, incapable of managing treatment, or at fault for their condition; this stereotyping can lead others to feel pity, fear, anger, and a desire for social distance from people with a substance use disorder. Importantly, perceived stigma can reduce someone’s willingness to seek treatment for substance use disorder. Stigmatizing language also negatively influences health care provider perceptions of people with substance use disorder, which can impact the care they provide.
Efforts have been made to change stigmatizing language to refer to individuals with substance use disorders, such as the National Institutes of Health ‘Words Matter’ list which provides recommendations to clinicians and providers for person-first language to use and a list of terms to avoid. Similarly, the Recovery Research Institute manages the Addictionary which provides a list of common terms, definitions, and indications when a term is stigmatizing or antiquated.
At the same time, stigmatizing imagery (i.e., images that implicitly or explicitly reinforce stereotypes and prejudice towards stigmatized individuals) depicting drugs or substance use may also foster substance use disorder stigma.
Similar to language identified as stigmatizing, these images may impact the way members of the general population think, feel, and respond to people with substance use disorder. They may also affect how people with substance use disorder feel about themselves. This study used qualitative methods to identify stigmatizing imagery and corresponding alternatives for substance use disorder and explore the reactions of people with lived experience with substance use disorder to substance use disorder-related imagery.
HOW WAS THIS STUDY CONDUCTED?
This study conducted semi-structured qualitative focus groups and interviews online using videoconferencing from December 2020 to June 2022 with 14 individuals in recovery from range of substance use disorders (9 individuals across 3 focus groups, 5 individual interviews) to identify stigmatizing and non-stigmatizing imagery for substance use disorders.
In total, 46 images were used across 6 categories to elicit participant feedback and discussion: 1) treatment and patient services, 2) types of substance use disorder, 3) law enforcement contact, 4) court and pretrial proceedings, 5) carceral settings, and 6) reentry and community supervision. Participants categorized each image as endorsed (i.e., “do use”) or not endorsed (i.e., “do not use”) for public usage followed by probing questions to help record detailed responses and feedback for each image. Feedback was summarized to classify substance use disorder-related images as stigmatizing or non-stigmatizing and make recommendations surrounding substance use disorder-related imagery.
Participants were recruited through email and phone communication with Addiction Policy Forum’s (APF) network of individuals with lived experience, including individuals who receive clinical services from APF, participate in APF’s recovery programming, or serve on advisory boards. Individuals were eligible to participate if they were 18 years or older, spoke English, and identified as either a person in recovery or as a person with an active substance use disorder. The researchers additionally sought out participants with prior justice-involvement given intersections of substance use and criminal justice stigma. Whereas most individuals (9) participated in an online focus group, 5 individuals participated in individual interviews to accommodate participants’ schedules.
The researchers compiled images of addiction from the top ten print and web news outlets published in the 3 years prior to data collection. Examples of addiction-related and criminal justice imagery were then collected from the sources along with representative stock photo images sampled from commonly used websites and stock photography databases. In total, 46 images were used alongside the interview guide to elicit participant feedback and discussion. Participants categorized each image as endorsed (i.e., “do use”) or not endorsed (i.e., “do not use”) for public usage followed by probing questions to help record detailed responses and feedback for each image.
The online focus group format allowed for the researchers and participants to collaborate in real time. For example, all images provided initially to represent substance use disorder types (opioid use disorder, alcohol use disorder) were considered stigmatizing by participants. The researchers were then able to search the internet during the focus group for new images while participants provided feedback until images were found that were categorized as appropriate for use.
The study had slightly more female participants (8) than male (6). In terms of race/ethnicity, 4 participants identified as Black, 2 as Native American, 2 identified as Hispanic/Latino, and 1 as more than one race (Native American and White). The remaining 5 participants identified as White. The mean age was 44 years (range = 25—66). Participants represented a range of substance use disorder histories: 4 with an opioid use disorder, 3 with a stimulant use disorder (methamphetamine or cocaine), 3 with alcohol use disorder, and 4 with polysubstance use disorder. All participants identified as being in recovery, with a range of time in recovery from a few weeks to 26 years. The majority of participants reported a history of justice-involvement (86%). The geographic breakdown of participant locations was as follows: 3 resided in Illinois, 2 in North Carolina, and 1 participant in each of the following states: Idaho, Oregon, Georgia, Florida, Kentucky, California, Minnesota, New York and Missouri.
WHAT DID THIS STUDY FIND?
Treatment and patient imagery with distressed or unhappy individuals considered stigmatizing
Rejected photos include images of individuals who look like they are struggling in treatment or pictures that resemble private treatment websites, described by participants as overly dramatized and staged. Imagery that conveys a lack of interest in treatment was reminiscent of coerced treatment for one participant. Several participants expressed concern that photos depicting patients struggling in treatment could reinforce isolation and despair, and potentially depict receiving treatment as a negative experience.
Treatment and patient imagery depicting wellness, health, and vitality considered non-stigmatizing
Endorsed images included photos of hand-holding, people helping to pull a peer up a hill with a landscape and a bright sky in the background, a family holding hands, walking through a natural landscape, and individuals in a circle to illustrate group therapy or mutual aid support groups.
Discussion centered around utilizing photos of wellness, health, and vitality when depicting individuals receiving treatment for substance use disorder or in recovery. Participants shared that images including nature and landscape felt positive and reinforced themes of new beginnings and health.
Imagery with realistic depictions of actual substances considered stigmatizing; scientific depictions considered non-stigmatizing
Participants identified images of people using substances and paraphernalia (needles, syringes, spoons, or lighters) as both stigmatizing and triggering, with participants reporting that the images brought up urges or cravings to use substances. Instead, participants recommended using conceptual image options, such as molecular symbols of the substance use disorder type, definitions of the type of substance from the dictionary,
and typography.
Criminal justice imagery associated with the carceral system considered stigmatizing; images illustrating security and the promise of reentry and community reintegration considered non-stigmatizing
Statements and feedback from participants showed a negative reaction to depictions of individuals in handcuffs and being arrested; individuals in prison jumpsuits or handcuffs in court; and images of bars, rows of cells, individuals behind bars, and images of prison or jail structures that include barbed wire or gun towers.
A handful of participants added concerns about intersectionality and racism, responding to frequent images of White law enforcement officers arresting African American or Hispanic/Latino individuals. A participant shared: “A lot of these images that are used in this way don’t show White people getting arrested they show people who are not white getting arrested by white officers.” They continued: “I think it’s traumatic that a lot of the images used in this way don’t show white people getting arrested.” Participants expressed the importance of equal representation across different races and ethnicities in images, from depictions of law enforcement or other positions of authority to images of those who are justice-involved or requiring substance use disorder services.
Participants endorsed photos of police cars, sirens, or police stations as non-stigmatizing. Participants agreed with police representation of officers alone (without an individual being arrested or depicted unfavorably) and helping in the community in pro-social activities. Participants endorsed photos of empty courtrooms, a gavel, or the scales of justice to convey material or information related to the judicial system. If imagery of people is required, participants expressed preference for images of a judge, district attorney or other professional without defendants in the frame. Participants identified more acceptable imagery for individuals with lived experience to convey prison contexts, recommending images that focus on positive activities during incarceration and photos of modern, updated common areas, cafeterias, prison libraries, and individuals in classrooms and vocational trainings to indicate prison settings. Discussion demonstrated participants prefer aspirational, hopeful images to represent the promise of reentry and community reintegration.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
Generally, imagery depicting wellness, health, vitality, and the promise of reentry and community reintegration were non-stigmatizing, whereas images of individuals in distress, using substances, or being persecuted were stigmatizing. From the perspectives of these participants with lived addiction and recovery experience, drug use and drug paraphernalia imagery may trigger unpleasant reactions including craving while pictures of people behind bars were experienced as stigmatizing. The study findings can be helpful in informing imagery depicting addiction, individuals with substance use disorder, and individuals involved in the justice system for various fields, such as research, media, public health, and community-based programming.
Stigmatizing communications can promote inaccurate and harmful stereotypes about individuals with substance use disorder. For example, compared to when a person is described as “having a substance use disorder” participants viewed a “substance abuser” as less likely to benefit from treatment, more likely to benefit from punishment, more likely to be a social threat, and more likely to control their substance use without help. Half of the participants in this study worked in the healthcare field. A major implication of stigmatizing attitudes is how those attitudes affect the public’s behavior, particularly the attitudes and behaviors of individuals working in the healthcare field. Individuals with substance use disorder often report experiencing mistreatment by healthcare providers, including healthcare providers minimizing or not addressing their primary medical complaint, being talked down to, and even unnecessarily painful procedures to “teach them a lesson” and verbal abuse. Individuals with substance use disorder subsequently often avoid seeking medical treatment for fear of being mistreated by providers for using drugs.
Similar to stigmatizing language, stigmatizing images may impact the way the general public thinks, feels, and responds to people with substance use disorder. In particular, certain imagery could be promoting substance use disorder-related stigma that intersects with other stigmas. For example, images depicting Black, Hispanic, LGBTQ+, or justice-involved individuals using drugs may promote racism, xenophobia, homophobia, or criminal justice stigma alongside substance use disorder stigma. Moreover, because of the way substance use is criminalized in the U.S., many people with substance use disorder have a history of criminal justice involvement. And, stigma associated with both substance use disorder and criminal justice involvement has been shown to be related to greater psychological distress, decreased self-esteem, and greater social isolation.
Modifying imagery and language used to describe and represent individuals with a substance use disorder or criminal justice involvement is an intervention that researchers, institutions, and individuals can implement to reduce stigma of substance use disorder. More research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, as well as how stigmatizing vs non-stigmatizing images actually impact public attitudes and behavior.
One final caveat is that the study asked participants to reflect on images without additional context, but whether images are experienced as stigmatizing may depend on the story or text that they accompany. For example, a picture of someone behind bars may feel less stigmatizing if accompanying a news story on a community’s efforts to phase out criminal justice approaches to substance use than if accompanying a news story related to police arrests in response to public drug use.
Overall, this study based on the perspectives of individuals with, or in recovery from, substance use disorder not only points to potentially stigmatizing images, but offers non stigmatizing alternatives. However, identifying stigmatizing imagery and its effects on attitudes and behaviors is a new area of research, so this study is just a first step.
Although this study provided recommendations for non-stigmatizing imagery from individuals with lived experience of substance use disorder, the study did not test the effects of stigmatizing and non-stigmatizing imagery on public attitudes or behavior. Future research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, and how such images impact public attitudes, like the study reported here and the study reported here, and how such attitudes impact actual behavior.
The study included individuals with a range of substance use disorder histories and participants lived in many different states in the U.S., representing a range of experiences and perspectives. However, participants were recruited from Addiction Policy Forum (APF)’s advisory board, patient and stakeholder network, as well as from their network of individuals who receive clinical services or who participate in APF’s recovery programming. It is possible that these individuals may have had a greater vested interest in this topic than others. Additionally, the study sample only included individuals who could speak English. As the researchers noted, this potentially creates a bias since the lived experiences of non-English speaking individuals with justice involvement and substance use disorder may differ from their English-speaking counterparts. Considering that Hispanic individuals are the fastest growing subgroup of prisoners in the U.S. and currently comprise 30.2% of the U.S. prison population, future research should prioritize the inclusion of non-English speaking participants to test the current study’s findings.
BOTTOM LINE
Imagery depicting wellness, health, vitality, and the promise of reentry and community reintegration were perceived as non-stigmatizing, whereas images of individuals in distress and being persecuted were perceived as stigmatizing. Based on the strong negative reactions from participants, the study suggests images with drug use and drug paraphernalia or pictures of people behind bars should be discouraged. This is an important first step to understanding stigma associated with images, however, future studies can help clarify if imagery affects public attitudes toward individuals who use drugs and the degree to which imagery context matters.
For individuals and families seeking recovery:Language and imagery likely influence how we think, feel, and respond to individuals with substance use disorder. Using non-stigmatizing language and imagery is an important step to reduce substance use disorder stigma broadly, which could improve treatment and recovery outcomes for individuals with substance use disorder. Check out the Recovery Research Institute’s Addictionary for a list of addiction related terms, definitions, and words to avoid.
For treatment professionals and treatment systems:Language and imagery to describe and depict individuals with substance use disorder could impact a patient’s willingness to initiate treatment, and their experience in treatment. It’s important for healthcare providers to use non-stigmatizing language in their direct patient care and clinical notes, and treatment settings can use non-stigmatizing imagery when promoting their services. Check out NIDA’s Words Matter list for language recommendations for healthcare providers and the images from this study for ideas on non-stigmatizing images.
For scientists: This study was able to provide recommendations for non-stigmatizing imagery from the feedback of individuals with lived experience of substance use disorder. However, the study did not test the effects of stigmatizing and non-stigmatizing imagery on public attitudes or behavior. Future research is needed to understand if the images deemed stigmatizing and non-stigmatizing are consistent across different groups of people, and how such images impact public attitudes, like the study reported hereand the study reported here, and how such attitudes impact actual behavior. Future research should also examine the reactions and attitudes of healthcare providers to certain imagery, and if certain imagery changes beliefs and attitudes about individuals with substance use disorder in the same way that language does. Importantly, scientists can use the findings from this study to inform recommended images to use in study recruitment materials. The study recommends against the use of explicit depictions of alcohol or other drugs, as these were perceived as stigmatizing by participants. Instead, results suggest using scientific or medical imagery to depict alcohol or other drugs, such as molecular symbols, which were rated by participants as non-stigmatizing.
For policy makers:Public attitudes towards individuals with substance use disorder can influence public policy, which is important for dictating where addiction treatment centers can be located, workplace protections (or lack thereof) for people with substance use disorders, and housing regulations. Lack of protections or access to treatment can contribute to worse overall well-being for a person with substance use disorder. Public messaging using non-stigmatizing language and imagery is important for reducing public stigma broadly, which could ultimately improve treatment and recovery outcomes for individuals with substance use disorder. Check out NIDA’s Words Matter list for language recommendations appropriate for professionals and the images from this study for ideas on non-stigmatizing images.
