Comparing stigmatising attitudes towards people with substance use disorders between the general public,GPs,mental health and addiction specialists and clients

Abstract

Background:

Substance use disorders (SUDs) are among the most severely stigmatised conditions; however, little is known about the nature of these stigmatising attitudes.

Aims:

To assess and compare stigmatising attitudes towards persons with SUDs among different stakeholders: general public, general practitioners (GPs), mental health and addiction specialists, and clients in treatment for substance abuse.

Methods:

Cross-sectional study (N = 3,326) in which stereotypical beliefs, attribution beliefs (e.g. perceptions about controllability and responsibility for having an addiction), social distance and expectations about rehabilitation opportunities for individuals with substance use disorders were assessed and compared between stakeholders.

Results:

Individuals with substance use disorders elicited great social distance across all stakeholders. Stereotypical beliefs were not different between stakeholders, whereas attribution beliefs were more diverse. Considering social distance and expectations about rehabilitation opportunities, the general public was most pessimistic, followed by GPs, mental health and addiction specialists, and clients. Stereotypical and attribution beliefs, as well as age, gender and socially desirable answering, were not associated with social distance across all stakeholders.

Conclusion:

The general public and GPs expressed more social distance and were more negative in their expectations about rehabilitation opportunities, compared to mental health and addiction specialists and clients. Although stigmatising attitudes were prevalent across all groups, no striking differences were found between stakeholders.

Keywords

Social stigma substance-related disorders social distance stereotyping social perception attribution beliefs

Introduction

Substance use disorders (SUDs) are among the most severely stigmatised conditions in Western countries. People with SUDs more often evoke disapproval and negative opinions than people with other mental illnesses (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Room, Rehm, Trotter, Paglia, & Üstün, 2001; Schomerus et al., 2011). Stigmatisation refers to a process that starts when a group of persons is labelled based upon certain characteristics, for instance homosexuality or having a SUD. Subsequently labelled persons are linked to undesirable characteristics, so-called stereotypes, and as a consequence may experience status loss or discrimination. Stigmatisation of people with SUDs has been investigated from different perspectives such as among the general public, healthcare professionals and clients in treatment for substance abuse. For instance, the Dutch general public showed high intentions to impose far-reaching restrictions to people with SUDs which minimises their participation within society (Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013a). Also among healthcare professionals, negative attitudes exist for working with clients with SUDs (Gilchrist et al., 2011; Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013b). It was also found that experiences of rejection and anticipation of discrimination were prevalent among individuals in treatment for SUDs (Luoma et al., 2007).

The stigma attached to SUDs acts upon different life domains and can have adverse consequences for the quality of life of individuals and their life opportunities such as employment or housing (Alonso et al., 2009; Link & Phelan, 2006). In addition, stigma may prevent individuals from seeking professional help for SUDs. In the United States, only a quarter of people with lifetime alcohol dependence received treatment (Hasin, Stinson, Ogburn, & Grant, 2007); for drug dependence this was only 38% (Compton, Thomas, Stinson, & Grant, 2007). Comparable percentages were found in a national survey among the Dutch population (De Graaf, Ten Have, & Van Dorsselaer, 2010). Angermeyer (2003) demonstrated that stigma and fear of negative reactions are barriers for seeking treatment.

Although SUDs evoke strong negative reactions, there is a lack of knowledge about the nature of stigmatising attitudes. Familiarity with stigmatising conditions and contact with people who are subject to stigma are known to mitigate negative attitudes and contribute to more understanding (Corrigan, Edwards, Green, Diwan, & Penn, 2001; Penn et al., 1994). Therefore, it is expected that attitudes towards individuals with SUDs will be less negative among people who have more experience or who are more frequently confronted with SUDs. In this study, we assess stigmatising attitudes of stakeholders in a continuum of familiarity with SUDs. The stakeholders range from almost no familiarity among the lay public to professional experience in working with SUDs and personal experience with having SUDs. Since general practitioners (GPs) act as gatekeepers to specialised treatment for SUDs, this is a crucial group of healthcare professionals. Obviously, mental health and addiction specialists are more involved in the healthcare provision for individuals with SUDs. Finally, we investigated the perspective of individuals in treatment for SUDs.

The aim of the study is to investigate stigmatising attitudes towards people with SUDs from different perspectives (general public, GPs, mental health and addiction specialists, and clients in treatment for SUDs). These groups of stakeholders vary in their level of experience and contact with people with SUDs. The research questions are as follows: (1) What are stigmatising attitudes (operationalised as stereotypes, attribution beliefs, social distance and rehabilitation expectations) regarding people with SUDs? (2) What are the differences in stigmatising attitudes between groups of stakeholders who differ in their level of familiarity with SUDs? (3) Which factors contribute to the tendency to maintain social distance from people with SUDs and do the groups of stakeholders differ? It is hypothesised that less familiarity with SUDs is associated with more stigmatising attitudes.

Methods

Procedure

Respondents in four groups of stakeholders filled out a questionnaire. For a detailed description of the data collection among the Dutch public and health professionals, see previous published studies (Van Boekel et al., 2013a; Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2014). Data from the Dutch public were collected among a nationally representative Internet panel (Longitudinal Internet Studies for the Social sciences (LISS) panel, administered by CentERdata). A random subsample of 10,150 addresses is drawn each year using a 10% random sample of population registers. For this study, an online questionnaire was sent to a random sample of the panel consisting of 3,691 individuals. Two reminders were sent to increase the response rate. In total, 2,793 individuals (response rate 75.7%) participated.

GPs were recruited using a random sample of 800 GPs which was drawn from the database of the Netherlands Institute for Health Services Research (NIVEL). GPs received a personal letter with an invitation to fill out a web questionnaire. Two reminders were sent to increase the response rate. The final reminder comprised a paper questionnaire with a prepaid envelope. The response rate was 23.0% (N = 180).

Mental health and addiction specialists were recruited via two general psychiatry services and two specialised addiction services across the Netherlands. The general psychiatry services mainly focus on treatment of mental health problems, whereas specialised addiction services are mainly focussed on treating substance use problems. The four organisations were each asked to select a minimum of 50 specialists from diverse divisions and with different functions in order to recruit a representative sample. Three organisations selected divisions, and within these divisions specialists were approached to participate. One organisation selected specialists from the entire organisation. In total, 224 mental health and addiction specialists working in four different organisations were invited by e-mail to fill out a web questionnaire, and personal reminders were sent. The response rate was 74.6% (N = 167).

The recruitment of clients in treatment for SUDs took place in the same four organisations. Employees were asked to select at random a minimum of 50 clients from different divisions and approach them to participate. However, it appeared that it was not possible or appropriate to invite each client since some clients were under the influence or currently in a crisis situation. Since random sampling was unrealistic, a convenience sample was used consisting of 186 clients in treatment for SUDs.

Measures

The questions were the same for the respondents across the four groups of stakeholders. All questions referred to ‘someone with an addiction’, which was clearly explained at the start of the questionnaire as ‘people who are addicted to alcohol or illicit drugs’.

Attitudes and stigma towards people with SUDs were operationalised as (1) stereotypical beliefs, (2) attribution beliefs, (3) expectations with regard to rehabilitation chances and (4) social distance. Stereotypical beliefs about people with SUDs were assessed by seven items. The items enquired to what degree respondents agreed with stereotypes such as ‘someone with an addiction’ … ‘is intelligent’ or ‘is criminal’ (1 = totally disagree to 5 = totally agree). The stereotypes were based upon previous research investigating opinions about psychiatric patients in the Netherlands (Van’t Veer, Kraan, Drosseart, & Modd, 2006).

Attribution beliefs regarding SUDs were measured using five items which were based on questions from the Attribution Questionnaire (Corrigan et al., 2002; Reisenzein, 1986) and the Attitudes and Beliefs about Alcoholism and Alcoholics Questionnaire (Crawford & Heather, 1987). Two statements measured the perception of controllability and responsibility for SUDs: ‘someone with SUD is in control of this addiction’ and ‘someone with SUD is responsible for this’. Three statements assessed the degree to which respondents agreed that SUDs could be treated successfully, whether SUDs are a disease and whether SUDs are a consequence of a weak personality (1 = totally disagree to 5 = totally agree).

To explore the level of perceived stigma within society, respondents were asked their perception of the chances for individuals with SUDs to lead a normal life. Respondents were asked to what degree they thought someone with SUD can easily find a place to live, find a job and have or maintain an intimate relationship compared to ‘other’ people (1 = definitely not to 5 = definitely).

Social distance determines the tendency of people to shun contact with persons with certain conditions (Whatley, 1959). The items were adapted to serve the purpose of this study. Respondents were presented with nine hypothetical situations in which they were confronted with a person with SUD, all varying in levels of intimacy. For instance, ‘would you be willing to have a person with SUD to come and live next door to you’ or ‘sit next to you on the train’? (1 = definitely not to 5 = definitely). An overall mean score was calculated for the nine items measuring social distance, and cases with four or more missing values were coded as missing. A high score indicated high social distance towards people with SUDs. The Cronbach’s alpha for the nine items measuring social distance was .90 indicating appropriate internal consistency.

Background information about the respondents was gathered (see Table 1). Socially desirable answers might be expected considering the nature and content of the questions. Therefore, the tendency to answer in a socially desirable way was verified by means of the 10-item social desirability scale (Crowne & Marlowe, 1960). Among the general public, data about the tendency to answer in a socially desirable way were available for 2,189 respondents (78.4%). Social desirability in answering was also assessed among GPs and mental health and addiction specialists.

Table 1.

Background information of the respondents by group of stakeholders.

	General public (N = 190)	General practitioners (N = 180)	Mental health and addiction specialists (N = 167)	Clients (N = 186)	p
	% (N)	% (N)	% (N)	% (N)	p
Mean age ± SD	49.06 ± 17.57	47.60 ± 9.47	43.52 ± 10.97	40.92 ± 12.33	≤.001^a
Gender	≤.001^b
Men	50.0 (95)	46.1 (83)	44.9 (75)	67.7 (126)
Women	50.0 (95)	53.9 (97)	55.1 (92)	31.2 (58)
Urbanisation in place of practice
Very strongly urbanised	11.1 (21)	22.2 (40)
Strongly urbanised	31.6 (60)	23.9 (43)	–	–	.018^b
Urbanised	20.0 (38)	15.6 (28)
Slightly urbanised	26.8 (51)	23.3 (42)
Not urbanised	10.5 (20)	15.0 (27)
Level of education	≤.001^b
Low education	37.4 (71)			50.0 (93)
Middle-level education	30.0 (57)			36.6 (68)
High education	32.6 (62)			11.3 (21)
Type of healthcare organisation	.008^b
Mental health service			53.3 (89)	39.2 (73)
Specialised addiction service			46.7 (78)	60.8 (113)
Frequency working with substance abuse	–	≤.001^b
Never		–	0.6 (1)
Few times per year		28.9 (52)	1.2 (2)
Monthly		42.8 (77)	6.6 (11)
Weekly		23.3 (42)	21.0 (35)
Daily		5.0 (9)	70.7 (118)
Position of mental health and addiction specialists	–	–
Nurse position			54.5 (91)
Agogic position (e.g. social worker)			15.6 (26)
Medical position (e.g. psychiatrist)			6.6 (11)
Psychological position (e.g. psychotherapist)			12.0 (20)
Other position (e.g. prevention, aftercare)	–		11.4 (19)
Type of substance use disorder
Alcohol use disorder				34.9 (65)
Drugs use disorder				33.3 (62)
Alcohol and drug use disorder				29.6 (55)
Type of treatment
Online or ambulatory				41.3 (75)
Aftercare				2.7 (5)
Ambulatory methadone maintenance programme				2.2 (4)
Day treatment programme				6.5 (12)
Inpatient treatment				36.6 (68)
Half-way house/supported living Korsakoff				8.1 (15)
Social desirability scale (mean ± SD)	5.79 ± 2.07	5.85 ± 1.97	5.91 ± 1.67	–	.852^a

SD: standard deviation.

Total numbers in rows do not add up to 100% due to missing responses.

Results of analysis of variance with the Welch Robust test were as follows: age, F(3, 355) = 13.426; social desirability scale, F(2, 312) = .161.

Results of chi square tests were as follows: gender, χ²(3) = 26.120; urbanisation of place or residence/practice, χ²(4) = 11.891; level of education, χ²(2) = 24.011; type of healthcare organisation, χ²(1) = 6.991; frequency working with substance abuse, χ²(4) = 190.765.

Statistical analyses

The study design was unbalanced due to unequal sample sizes in the groups of stakeholders. Non-parametric tests can be an alternative when assumptions for parametric testing are violated. However, non-parametric testing was not adequate since one objective was to investigate the association of social distance with stereotypical and attribution beliefs, using linear regression analyses. In addition, unequal sample sizes made it difficult to interpret the magnitude of significant results. Therefore, a random subsample of 190 individuals was drawn from the total sample of the general public. We compared the means on all measures between the random subsample of the general public (N = 190) and the total sample of the general public (N = 2,793) to test whether the random subsample was significantly different. It appeared that both groups were similar. In addition, the results of the parametric analyses using the random subsample were quite similar to the non-parametric equivalents (Kruskal–Wallis and chi square tests) using the total sample of the general public. Therefore, the results of the parametric tests using the subsample will be reported.

SPSS version 19.0 was used to conduct the analyses. A probability level of p ≤ .01 was applicable. Descriptive analyses were carried out to explore stigmatising attitudes across all stakeholders and to illustrate background information by group of stakeholders. The four groups were compared for mean age, gender and tendency to answer in a socially desirable way. Analyses of variance (ANOVAs) were conducted to compare stereotypical beliefs, attribution beliefs, expectations with regard to rehabilitation chances and social distance between the four groups of stakeholders. For most variables, the assumption of homogeneity of variance was violated. However, the ANOVA is fairly robust to violation of this assumption when sample sizes are equal which also supports our decision to use a random subsample of the general public. The robust Welch F test was used to correct for violation of the assumption of homogeneity of variances. To compare the groups of stakeholders in pairs, Games–Howell post hoc tests were used. The effect size estimate omega squared (ω²) was used since ω² is robust in cases when one of the assumptions is being violated (Volker, 2006). The interpretation of ω² was as follows: ω² ≤ .06, small effect; ω² > .06 < .14, medium effect and ω² ≥ .14, large effect.

Multiple linear regression analyses were performed to predict social distance towards people with SUDs. Predictor variables were age, gender, stereotypical beliefs, attribution beliefs and tendency to answer in a socially desirable way. The regression analyses were carried out separately for each group of stakeholders in order to detect differences in variables predicting social distance. To test whether the effects of the predictor variables on social distance were different for each group of stakeholders, the unstandardised regression coefficients were compared according to the test recommended by Paternoster, Brame, Mazerolle, and Piquero (1998). Pearson correlation coefficients between the variables included in the regression analyses were obtained to investigate whether multicollinearity was present (see Table 2). Multicollinearity was not a problem since Pearson correlations were all below .5, variance inflation factor (VIF) values below 5 and tolerance values above .2.

Table 2.

Pearson correlations among all variables included in the regression analyses.

Variable^a	1	2	3	4	5	6	7	8	9	10	11	12	13	14
1
2	.14*
3	−.02	.16*
4	−.26*	−.13*	.02
5	−.34*	−.16*	−.05	.31*
6	.22*	.03	−.05	−.08	−.27*
7	−.23*	−.13*	−.05	.25*	.33*	−.12*
8	.31*	.16*	.00	−.11*	−.27*	.34*	−.20*
9	.23*	.03	.05	−.16*	−.26*	.23*	−.21*	.43*
10	.24*	.09	.04	−.17*	−.22*	.20*	−.19*	.33*	.29*
11	.18*	.11*	−.00	−.12*	−.08	.07	−.02	.13*	.17*	.12*
12	−.04	.03	.03	.07	.16*	−.03	.12*	.01	−.07	.04	.34*
13	−.01	−.08	.08	.06	.07	−.02	.18*	.00	−.01	−.02	.16*	.18*
14	−.03	−.13*	.05	.09	.06	−.03	−.04	−.04	.05	.01	−.17*	−.20*	.05
15	.28*	.16*	.03	−.17*	−.16*	.13*	−.09	.24*	.23*	.27*	.27*	.16*	−.05	−.19*

1: social distance, 2: age, 3: social desirability scale; Stereotypical beliefs – 4: are intelligent, 5: are trustworthy, 6: tend to be aggressive, 7: able to maintain a regular job, 8: tend to cause disturbances, 9: are self-neglecting, 10: tend to be criminal.

Attribution beliefs – 11: perceived responsibility, 12: perceived controllability, 13: addiction can be treated successfully, 14: addiction is a disease, 15: addiction is the consequences of weakness.

p < .01.

Results

In total, the answers of 723 respondents were considered in the analyses. The mean age of the respondents was 45.61 years (standard deviation (SD) = 13.50, range 16–85 years). Table 1 shows background information by group of stakeholders. The tendency to answer in a socially desirable way was not significantly different between the groups.

Overall attitudes

Respondents across all groups often had a neutral opinion on most of the stereotypes, such as people with SUDs are intelligent or tend to be criminal. However, the stereotypes that people with SUDs tend to be aggressive and are self-neglecting prevailed among a great number of respondents (Figure 1). Figure 2 shows that across all groups respondents perceived the controllability over SUDs as low, whereas respondents are rather confident that SUDs can be treated successfully. Across all groups, respondents agree to a large extent that SUDs are a disease. Furthermore, respondents across all groups reported a high tendency to maintain social distance towards individuals with SUDs. The respondents were not optimistic about the chances for individuals with SUDs to rehabilitate. Many respondents choose the option ‘probably not possible’ for finding a place to live (49.5%), for maintaining a normal job (52.0%) and having a relationship (41.4%).

Figure 1.

Stereotypical beliefs by group of stakeholders.

Figure 2.

Attribution beliefs by group of stakeholders.

Comparison of attitudes between stakeholders

The groups of stakeholders were compared for their stereotypical beliefs, attribution beliefs, social distance and their expectations with regard to rehabilitation chances (see Table 3). Although the ANOVA showed significant differences in stereotypical beliefs between the stakeholders, the effect sizes indicated that these differences were rather small. No significant difference was found for the stereotype that people with SUDs are able to maintain a regular job. Overall, the general public and GPs were somewhat more negative in their stereotypical beliefs compared to mental health and addiction specialists and clients.

Table 3.

Means and ANOVAs to compare stereotypical beliefs, attribution beliefs, social distance and rehabilitation chances by group of stakeholders.

	General public¹ M (SD)	General practitioners² M (SD)	Mental health and addiction specialists³ M (SD)	Clients⁴ M (SD)	F(df)	p	ω²
	N = 190	N = 180	N = 167	N = 186	F(df)	p	ω²
Stereotypical beliefs^a
People who have an addiction …
… are intelligent	2.84 (0.57)*³⁴	3.00 (0.47)	3.08 (0.46)*¹	3.16 (0.71)*¹	9.59(3, 397)	≤.001	.04
… are trustworthy	2.04 (0.74)*³⁴	2.22 (0.70)*³⁴	2.51 (0.74)*¹²	2.49 (0.76)*¹²	16.95(3, 397)	≤.001	.06
… tend to be aggressive	3.88 (0.64)*³⁴	3.86 (0.62)*³⁴	3.56 (0.65)*¹²	3.57 (0.72)*¹²	13.25(3, 397)	≤.001	.05
… are able to maintain a regular job	2.88 (0.80)	3.03 (0.72)	2.95 (0.79)	3.05 (0.94)	1.66(3, 396)	.175	.00
… tend to cause disturbances	3.55 (0.75)*³⁴	3.41 (0.66)³⁴	3.17 (0.61)*¹²	3.12 (0.83)*¹²	13.49(3, 396)	≤.001	.05
… are self-neglecting	3.61 (0.70)*³⁴	3.61 (0.66)*³⁴	3.32 (0.61)*¹²	3.29 (0.88)*¹²	11.10(3, 397)	≤.001	.04
… tend to be criminal	2.96 (0.65)*²³⁴	2.67 (0.63)*¹	2.60 (0.59)*¹	2.71 (0.87)¹	11.38(3, 397)	≤.001	.03
Attribution beliefs^a
Someone with an addiction is responsible for this	3.62 (0.85)*²³	3.33 (0.81)*¹³	2.96 (0.89)*¹²⁴	3.42 (1.06)*³	17.26(3, 397)	≤.001	.06
Someone with an addiction is in control of this addiction	2.54 (1.03)¹²	2.24 (0.74)*¹⁴	2.23 (0.76)*¹⁴	2.70 (1.19)*²³	10.29(3, 396)	≤.001	.04
Someone with an addiction can be treated successfully	3.81 (0.73)	3.65 (0.61)	3.81 (0.68)	3.81 (0.85)	2.64(3, 397)	.049	.00
Addiction is a disease	3.22 (1.04)*²³⁴	4.03 (0.67)*¹	4.17 (0.77)*¹⁴	3.78 (1.18)*¹³	36.64(3, 393)	≤.001	.13
Addiction is the consequence of weakness	3.06 (0.96)*²³⁴	2.66 (0.86)*¹³⁴	2.04 (0.83)*¹²	2.22 (1.11)*¹²	44.08(3, 397)	≤.001	.15
Mean score social distance^b	3.89 (0.63)*³⁴	3.72 (0.53)*³⁴	3.38 (0.62)*¹²	3.22 (0.77)*¹²	38.01(3, 394)	≤.001	.14
Rehabilitation chances^a
Expectation of chance to find a place to live	2.12 (0.79)*⁴	2.21 (0.83)*⁴	2.38 (0.91)	2.69 (1.05)*¹²	12.49(3, 392)	≤.001	.05
Expectations of chance to maintain a normal job	1.85 (0.67)*⁴	1.99 (0.75)*⁴	2.07 (0.75)*⁴	2.48 (1.04)*¹²³	16.35(3, 392)	≤.001	.08
Expectation of chance to have a relationship	2.26 (0.91)*³⁴	2.17 (0.80)*³⁴	2.60 (0.95)*¹²	2.87 (1.06)*¹²	20.62(3, 392)	≤.001	.08

ANOVAs: analyses of variance; SD: standard deviation; df, degree of freedom.

Scores ranged from 1 to 5 in which higher scores represent more agreement or more positive expectations for rehabilitation.

Sum scores ranged from 1 to 5 in which higher scores represent more social distance.

Statistically significant (p ≤ .01) on Games–Howell post hoc test to compare groups in pairs.

More substantial differences between the stakeholders were found in their attribution beliefs (Table 3). The general public disagreed more that SUDs are a disease compared to GPs, mental health and addiction specialists, and clients (F(3, 346) = 36.39, p = ≤.001, ω² = .13). Furthermore, the beliefs that SUDs are the consequence of someone’s weakness were significantly different between the stakeholders, with a medium effect size (F(3, 397) = 44.08, p = ≤.001, ω² = .15). The general public, and GPs to a lesser extent, agreed more that SUDs are the consequence of weakness compared to mental health and addiction specialists and clients. The effect sizes for the remaining attribution beliefs indicated small differences between the stakeholders.

Social distance was significantly different between the stakeholders with a medium effect size (F(3, 394) = 38.01, p = ≤.001, ω² = .14). The general public reported the highest level of social distance towards people with SUDs, followed by GPs, mental health and addiction specialists, and the least social distance was reported by clients. Expectations regarding chances for people with SUDs to rehabilitate were also significantly different with medium effect sizes in the domain of finding a job and having a relationship (finding a job: F(3, 392) = 16.36, p = ≤.001, ω² = .08; having a relationship: F(3, 392) = 20.62, p = ≤.001, ω² = .08). The differences between stakeholders showed the same pattern that was found for social distance: clients reported more confidence that individuals with SUDs have possibilities to rehabilitate, whereas the general public and GPs expressed more doubts.

Predicting social distance

Regression analyses to predict social distance with stereotypical and attribution beliefs were performed for each group of stakeholders separately (see Table 4). The model to predict social distance with the predictor variables showed the best fit among the general public (R² = .311, GPs R² = .178, mental health and addiction specialists R² = .282, clients R² = .212). However, among the general public, mental health and addiction specialists, and clients, none of the variables were significant predictors of social distance. Among GPs, the perception that someone with SUD is personally responsible was associated with increased social distance. No association between social distance and age, gender and the tendency to answer in a socially desirable way was found.

Table 4.

Regression analyses to predict social distance by group of stakeholders.

	General public¹				General practitioners²
	B	SE	β	t	B	SE	β	t
(Constant)	2.653	.692		3.833	3.732	.747		4.996
Age	−0.001	.003	−.031	−0.368	0.001	.005	.020	0.228
Gender^a	0.138	.105	.102	1.313	0.078	.093	.071	0.839
Social desirability scale	0.012	.027	.035	0.435	−0.008	.022	−.029	−0.366
… are intelligent	−0.143	.099	−.118	−1.440	−0.102	.093	−.091	−1.092
… are trustworthy	−0.175	.079	−.194	−2.203	−0.106	.070	−.136	−1.514
… tend to be aggressive	0.068	.087	.068	0.784	0.036	.072	.041	0.499
… regular job	−0.091	.073	−.108	−1.254	0.001	.063	.002	0.021
… disturbances	0.038	.093	.041	0.408	0.048	.073	.058	0.656
… are self-neglecting	0.029	.083	.030	0.351	0.009	.073	.010	0.119
… tend to be criminal	0.161³	.085	.161	1.903	0.148³	.074	.166	1.996
… perceived responsibility	0.120	.079	.148	1.520	0.145	.055	.217	2.633*
… perceived controllability	−0.009	.053	−.014	−0.166	−0.042	.063	−.056	−0.667
… addiction can be treated successfully	0.074	.072	.082	1.029	−0.154⁴	.071	−.174	−2.169
… addiction is a disease	0.029	.049	.044	0.585	−0.021	.065	−.026	−0.326
… addiction is consequences of weakness	0.088	.059	.126	1.498	−0.031	.052	−.050	−0.606
	Mental health and addiction specialists³				Clients⁴
	B	SE	β	t	B	SE	β	t
(Constant)	4.339	.748		5.801	1.980	.789		2.510
Age	−0.001	.004	−.024	−0.321	−7.473E-5	.006	−.001	−0.013
Gender^a	−0.018	.091	−.015	−0.202	0.012	.146	.007	0.083
Social desirability scale	−0.043	.027	−.118	−1.625
… are intelligent	−0.111	.101	−.082	−1.097	−0.020	.103	−.018	−0.193
… are trustworthy	−0.115	.064	−.138	−1.787	−0.193	.099	−.199	−1.945
… tend to aggressive	−0.036	.072	−.037	−0.494	0.050	.105	.044	0.480
… regular job	−0.148	.061	−.193	−2.416	−0.072	.079	−.087	−0.906
… disturbances	0.186	.088	.185	2.119	0.062	.090	.066	0.683
… are self-neglecting	−0.056	.087	−.056	−0.642	0.105	.085	.121	1.232
… tend to be criminal	−0.194¹²	.079	−.188	−2.450	0.043	.088	.048	0.487
… perceived responsibility	0.129	.053	.187	2.421	0.027	.069	.037	0.394
… perceived controllability	0.048	.064	.059	0.743	0.002	.067	.004	0.036
… addiction can be treated successfully	−0.172⁴	.072	−.192	−2.382	0.124²³	.081	.139	1.544
… addiction is a disease	0.157	.063	.198	2.507	0.116	.059	.179	1.969
… addiction is consequence of weakness	0.098	.055	.135	1.800	0.073	.069	.100	1.059

B: unstandardised coefficients, SE: standard error; β: standardised coefficients; GP: general practitioners.

Significantly different unstandardised β coefficients are printed in bold with corresponding number of different group.

R²: general public = .311, GPs = .178, mental health and addiction specialists = .282, clients = .212. Adjusted R²: general public = .231, GPs = .049, mental health and addiction specialists = .209, clients = .117.

Men were the reference category.

Statistically significant (p < .01).

Discussion

All stakeholders, but most of all the general public, maintained great social distance towards individuals with SUDs. People with SUDs evoke stereotypes such as aggressiveness, causing disturbances and being self-neglecting. The expectations about the chances for individuals with SUDs to find a place to live, to have a relationship and to maintain a normal job were moderately negative.

Although the differences were small, the public had the most negative views of people with SUDs, followed by GPs, mental health and addiction specialists, and clients. Stereotypical beliefs did not differ to a large extent between the stakeholders, while attribution beliefs differed more between the groups. The general public endorsed SUDs less as a disease compared to the other groups of stakeholders, and attributing SUDs to a weak personality was more frequently reported by the general public and GPs. Social distance was also significantly different between the stakeholders. The general public reported the greatest tendency to shun contact with persons with SUDs, followed in order of diminishing social distance by GPs, mental health and addiction specialists, and clients. The same pattern was found for expectations with regard to opportunities for individuals with SUDs to rehabilitate. Stereotypical beliefs and attribution beliefs did not predict social distance across all groups. An exception was perceived responsibility which was associated with increased social distance among GPs. Age, gender, and socially desirable answering were not associated with social distance. This was surprising since previous evidence indicates that an older age was related to more social distance towards people with mental illnesses (Angermeyer & Matschinger, 1997; Jorm & Oh, 2009). For the effect of gender and social desirability on social distance, conflicting evidence exists (Henderson, Evans-Lacko, Flach, & Thornicroft, 2012; Janulis, Ferrari, & Fowler, 2013; Jorm & Oh, 2009). Overall, no striking differences were found between the stakeholders in their attitudes towards people with SUDs.

Our findings are in line with the hypothesis that more contact and familiarity are associated with reduced social distance towards a stigmatised group (Allport, 1954; Corrigan, Green, Lundin, Kubiak, & Penn, 2001). In addition, we found that contact was associated with more positive expectations about the opportunities for individuals with SUDs to rehabilitate. However, contradictory findings were found in other studies comparing different stakeholders who vary in their degree of familiarity. Some studies found the same pattern as we did, namely, that more contact or familiarity was related to reduced social distance among different mental illness diagnoses and stakeholders (Grausgruber, Meise, Katschnig, Schöny, & Fleischhacker, 2007; Jorm & Griffiths, 2008). However, an association of familiarity with stigmatising attitudes was not always found. For instance, in two studies investigating social distance towards persons with schizophrenia and SUDs, familiarity was not related to social distance (Janulis et al., 2013; Van Dorn, Swanson, Elbogen, & Swartz, 2005). An Australian study addressing stigmatising attitudes towards people with mental disorders showed no differences in social distance between the general public and healthcare professionals, and also revealed that mental health professionals held less stigmatising attitudes compared to GPs and the general public (Reavley, Mackinnon, Morgan, & Jorm, 2014). Others have suggested that, in particular, mental health specialists may be an exception to the contact hypothesis, since the majority of the clients they see are not feeling well (Jorm & Oh, 2009; Nordt, Rossler, & Lauber, 2006). This is also referred to as the clinician bias, namely, that the view of health professionals is limited to patients who have more severe problems or diagnoses (Hugo, 2001; Thornicroft, Rose, & Kassam, 2007). In addition, the effects of contact on attitudes depend on certain conditions such as equal status between persons and common goals (Allport, 1954; Corrigan, Mueser, Bond, Drake, & Solomon, 2008). These conditions may not be present in the contact between a health professional and clients. Hence, it is possible that the contact hypothesis is not applicable for all mental illness diagnoses, all types of contacts and all measures of stigmatising attitudes.

Our study shows that endorsement of the disease concept for SUDs and attributing SUDs to personal weakness were different between the stakeholders. The general public disagreed more that SUDs are a disease and agreed more that SUDs are the consequence of someone’s weakness. GPs also agreed more that personal weakness is a cause of SUDs compared to the other stakeholders. Differences in attribution beliefs were also found in a Finnish study that compared the population, professionals and clients in their support for different models of SUDs and perceptions of responsibility and controllability (Koski-Jannes, Hirschovits-Gerz, & Pennonen, 2012). Van Dorn et al. (2005) who compared perceptions of the causes of schizophrenia also found variation in these perceptions between stakeholders. Clients were more likely to endorse ‘own bad character’ as a cause of schizophrenia. Differences in attribution beliefs between stakeholders are not remarkable since historically diverse causal models of addiction have been supported. However, nowadays the treatment of SUDs is a combination of approaches such as the medical, psychological and sociocultural explanation of addiction (Center for Substance Abuse Treatment, 1997). The focus in treatment is now more on the clients’ responsibility and empowerment. This change in approach to SUDs might be noticed to a different degree by the stakeholders. In sum, attribution beliefs might be dependent on the mental illness diagnosis, familiarity with and knowledge about a diagnosis, and cultural values and standards.

Attention should be paid to the following limitations of this study. The generalisability of clients’ attitudes and opinions was limited since only people in treatment for SUDs were included. A great number of people with SUDs do not seek treatment and were not represented in our sample. The heterogeneity in professions in the subsample of mental health and addiction specialists was another limitation. Although low response rates among GPs are highly prevalent, mostly due to lack of time or interest (Barclay, Todd, Finlay, Grande, & Wyatt, 2002), the low response rate among GPs limited the representativeness of this subsample.

Another limitation was that data collection and recruitment were not conducted simultaneously across the groups of stakeholders. Although all respondents filled out the questionnaire within a short time span, certain events during that period may have influenced the answers, such as negative media messages concerning SUDs. However, to our knowledge no major stigma-related issues happened in this time period. In addition, the different recruitment processes may have influenced the response rates for the separate groups of stakeholders. The cross-sectional design made it impossible to investigate causality between the variables. Furthermore, attitudes and opinions about people with SUDs were assessed in general, by which the difference in attitudes that alcohol versus drug abuse evoke was unknown. Respondents were asked in general about their attitudes towards people with SUDs instead of using hypothetical vignettes providing extra background information about the person. Since stigmatisation refers to negative attitudes towards a whole group, we believe the short description which we used better reflects actual situations in which stigmatisation may occur.

The comparison of different groups of stakeholders strengthens this study and provides the opportunity to compare attitudes between groups that differ in their familiarity with people with SUD. Furthermore, the inclusion of the client perspective was a surplus in investigating stigmatising attitudes. Adding a scale to assess social desirability in answering and the fact that questions were not asked face-to-face strengthens the results of this study since these factors may contribute to more tolerant answers (Henderson et al., 2012).

In conclusion, all stakeholders expressed a strong tendency to maintain social distance towards individuals with SUD. Although no striking differences were found, the contact hypothesis was confirmed; stakeholders with less familiarity reported a greater desire for social distance compared to stakeholders who are more closely associated with SUDs. This study provides insight into stigmatising attitudes towards persons with SUDs from different perspectives. However, no predictors were found for the desired social distance. This underlines the necessity to further investigate attitudes towards persons with SUDs. In particular, qualitative research is needed to explore more in-depth the factors and processes that contribute to negative attitudes. Investigating whether attitudes change when more information is provided about the circumstances in which a person became addicted to alcohol or illicit drugs might also be valuable. Such research may provide insight into strategies to reduce stigma related to SUDs since such insight is rather limited (Livingston, Milne, Fang, & Amari, 2011).

Footnotes

Acknowledgements

Data of the general public were obtained from the Longitudinal Internet Studies for the Social sciences (LISS) panel administered by CentERdata. The authors would like to thank the MESS (An Advanced Multi-Disciplinary Facility for Measurement and Experimentation in the Social Sciences) project for providing the data of the general public. In addition, we are grateful for the participation of healthcare professionals and clients from the mental health and specialist addiction services GGzE, Dijk en Duin, Novadic-Kentron and Brijder Verslavingszorg. All authors have approved the final article. All authors were involved in the design of the study and the preparation of the article.

Ethical approval

According to the Central Committee on Research Involving Human Subjects, the data collected among individuals in treatment for substance use disorders were not complying with the Dutch law on medical research in humans, since it did not concern a medical-scientific study and clients were not imposed to a certain behaviour or subject of certain proceedings. Therefore, ethical approval by an accredited Medical Ethics Committee (MEC) was not required.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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