The Complexities of Guilt, Shame, Stigma, and Substance Use among a Sample of United States Substance Using Adults

Background: Guilt, shame, stigma, substance use (problematic/nonproblematic), and help-seeking intention, are complex interrelated constructs that have not been collectively examined in community substance using adults, with mere pieces of each construct previously studied in various populations. Guilt pertains to an action (i.e., I did something bad) whereas shame pertains to the person (i.e., I am bad). Guilt has been shown to function adaptively by prompting individuals to repair transgressive behavior where shame has been shown to function maladaptively by prompting individuals to withdraw and compound the global negative feelings of the self. Stigma of substance use is pervasive and leads individuals to feel othered, dehumanized, and less-than. This dissertation sought to examine these relationships and the potential moderating effects of shame and guilt. Methods: Two studies were executed, one cross-sectional electronic survey-based and the other an explanatory mixed methods approach using semi-structured interviews and Grounded Theory. For both studies, participants were recruited using Prolific, a well-known sampling agency. Study 1 participants (n = 1000) were randomly selected from a pre-screened sample (n = 5000) to receive the survey and were paid 3$. The survey assessed demographic items, substance use severity (alcohol and drug use), help-seeking intention, guilt and shame proneness, along with three stigma mechanisms. For study 2, a subsample of participants (n = 18) was invited to participate based on past/present help-seeking for substance use related concerns. Participants scheduled a one-time 60-minute virtual interview and were provided study procedures and informed consent prior to the interview and were paid 40$. Results: For study one, utilizing a multinomial logistic regression, guilt was found to significantly interact with internalized stigma; those with higher levels of guilt had decreased odds of group membership to a positive problematic alcohol or positive problematic alcohol and drug screen. The main effects of enacted- and internalized-stigma and guilt additionally significantly predicted group membership to positive problematic categories of substance use screens. For study two, a multiple regression analysis was conducted along with contextualizing the findings with participant narratives. Guilt significantly moderated the relationship between enacted stigma and help-seeking intention; among those with higher levels of guilt enacted stigma was a stronger predictor of help-seeking intention. Participant narratives echoed their experience of various stigma mechanisms, the effects of guilt, and related impacts on help-seeking intention. Conclusions: Guilt displayed protective behavioral effects by decreased odds of positive screens for disordered substance use and adaptive impacts on help-seeking intention in the presence of stigma. While anticipated stigma or shame did not predict problematic substance use screens or help-seeking intention, the mechanisms of internalized- and enacted-stigma displayed impacts on both outcomes of disordered use and help-seeking. Implications for public health include continued examination of guilt and the potential benefits of managing baseline guilt among substance using populations as a mechanism for decreased deleterious health outcomes. Also, the need to combat stigma in its various forms is vital and continues to be of utmost importance