The World Drug Report highlights a steady increase in the number of people who use drugs and suffer with drug use disorders (United Nations Office on Drugs and Crime [UNODC], 2023). It goes on to suggest that despite there being 39.5 million people worldwide suffering from drug use disorders in 2021, only 1 in 5 people with drug use disorders received drug treatment. Likewise, global estimates on alcohol use disorders are also alarming with figures showing that 283 million adults live with this disorder (World Health Organization [WHO], 2018). Within the United Kingdom, alcohol and drug use remains a significant problem with drug-related deaths having significantly increased over the past 20 years (National Records of Scotland, 2023; Office for National Statistics, 2023). With regard to alcohol use, 1 in 5 people in Scotland drink harmful levels of alcohol, and in the United Kingdom rates of alcohol dependence associated with visits to general practitioners are 171 per 100,000 for men and 76 per 100,000 for women (Birtwistle et al., 2022; Thompson et al., 2017).

Problematic substance use is frequently linked with mental health conditions, can harm physical health, and can exacerbate inequalities for those using substances (UNODC, 2023; WHO, 2018). However, the consequences of substance use can go beyond the health and well-being of the individual. Substance use can have social and economic consequences to societies (i.e., costs associated with justice sector and costs associated with lost workforce productivity and unemployment), and it is acknowledged as a leading contributor to disease burden in family members (Mattoo et al., 2013; Orford et al., 2013). Such burden is a result of numerous problems associated with the role of caring for a family member who uses substances including, for example, financial strain, frequent quarrels, disruptions in daily life, perceived neglect, feelings of loneliness, and domestic violence (Bortolon et al., 2016; Di Sarno et al., 2021; Richert et al., 2018). Although the exact number of British family members affected by a relative's substance use is uncertain, globally over 100 million family members are impacted by a relative's addictive behavior (Orford et al., 2013).

Female family members are at particularly high risk of experiencing such burdensome issues (Di Sarno et al., 2021; Richert et al., 2018). This is partly because women are more likely to hold primary caregiving duties than men (National Alliance for Caregiving, 2009) and also because they often adopt coping strategies to deal with substance use in the family (e.g., self-blame, and avoiding social interaction as a response to feeling shame associated with the substance use problem in the family; Orford, 2017).

The negative physical and mental effects of substance use on the health of family members have been consistently demonstrated. This includes, but is not limited to, increased rates of mood and anxiety disorders, high levels of stress, low overall physical health status, and high rates of health-care utilization (Bischof et al., 2022; Orford, 2017). However, despite the high vulnerability of these family members to a range of negative consequences, they remain largely underserved by national policies and health programs (Di Sarno et al., 2021).

By recognizing the family as a potential system of support for change, family members can play an important role in the treatment and recovery process of people who use substances (Orr et al., 2014). However, it needs to be acknowledged that there are significant challenges linked with supporting a relative who uses substances, and often the situation is aggravated by the presence and experience of stigma and discrimination that they may encounter as a result of their family member's substance use (Wilkens & Foote, 2019).

Courtesy stigma

Goffman (1963) defined stigma as an “attribute that is deeply discrediting” that led to the individual in question being seen as an outsider and as less socially desirable (p. 4). Link and Phelan (2001) expanded upon this to suggest that stigma is a convergence of stereotyping, labeling, discrimination, and a decline in social standing, all of which are reinforced within a distinct power structure. Furthermore, it is recognized that stigma not only impacts the individual but can also affect people who are in contact with the person who is part of a discredited group, a phenomenon that Goffman has defined as “courtesy stigma” (Goffman, 1963).

For family members of individuals who use substances, courtesy stigma can exist in different forms including gossiping (McDonagh et al., 2019), exclusion from activities (Wangensteen et al., 2020), and degrading verbal abuse (O'Shay-Wallace, 2020). In the face of such stigma, family members often end up hiding the substance use problem in the family and retreat from society, which can lead to further isolation (McDonagh et al., 2019). Moreover, when individuals repeatedly face stigma, the stigma can become internalized as self-stigma; that is, the person adopts a stigmatized view of themselves (Eaton et al., 2020). The process of self-stigmatization has been described in relation to a feeling of shame and embarrassment (McCann & Lubman, 2018). When self-perception is affected in this way, it can impact family members' overall sense of self, leaving them feeling attacked, defensive, and in some way defective (Liahaugen Flensburg et al., 2023; O'Shay-Wallace, 2020).

One of the most concerning consequences of courtesy stigma in the context of substance use in the family is the barrier it can create for family members looking for and accepting support from health professionals (McDonagh et al., 2019). Research carried out in Brazil found that on average it takes approximately 3 years for family members to seek and receive support after discovering a substance use problem (Sakiyama et al., 2015). The negative impact of societal stigma in relation to substance use has been noted as a possible reason for this delay in seeking support, as family members might feel inclined to downplay or conceal the substance use issue to potentially avoid the associated shame. Similarly, McDonagh et al. (2019) suggested that for many families substance use remains a taboo topic, and the fear of judgment and subsequent embarrassment act as a barrier for many who would benefit from support.

Although it remains small, there is an international literature on the strain and stresses that substance use places on family members, which provides detailed knowledge of the challenges faced by them (Fotopoulou et al., 2015; McCann & Lubman, 2018; Orford et al., 2019). Although it is known that such challenges are experienced globally, research has also suggested that the way family members cope with the substance use problem in the family may be influenced by factors such as relationship with the person who uses substances (e.g., parents, partners, siblings; O'Shay-Wallace, 2020). However, less is known about the experience of courtesy stigma across different groups of family members and how it is related to other negative experiences such as parent-blame.

Parent-blame

Although courtesy stigma has the capacity to affect all family members, it is typically the parents of individuals who use substances who experience the most severe criticism and often carry the additional weight of blame (O'Shay-Wallace, 2020). The notion of judgment and blame around parental, and in particular maternal, performance is an independent but interconnected field of research to courtesy stigma (Francis, 2012). Although courtesy stigma and parent-blame overlap, the former is the stigma experienced as a result of the parents' proximity to a stigmatized individual and the latter is the experience of being directly stigmatized because of their perceived blameworthiness for their children's discrediting attributes (Francis, 2012).

Malle et al. (2014) propose the theory of blame, which suggests that blame is a multifaceted series of cognitive and emotional processes, and it is considered to be a social act that regulates norms and criticizes violations. Their theory outlines a communicative pattern of blaming, whereby the person assigning blame directly confronts the individual who committed the norm violation, and subsequently shares information about that individual with others in the group, thus warning others to keep their distance. In evolutionary terms, this is expected to ensure that the individual who is being blamed experiences discomfort, reacts, and conforms in order to remain within their community because otherwise they are ostracized, and this would threaten their ability to survive.

The theory of blame (Malle et al., 2014) can be considered in relation to the judgment and subsequent level of acceptance that parents feel from members of the various groups that they are a part of. With regard to parenting, the individual role of parents in the raising of children has increasingly become a matter of scrutiny. When outcomes arise that deviate from societal norms, parents—rather than society—are subjected to blame (Francis, 2012; Jensen, 2018). Indeed, Francis (2012) suggested that the degree of perceived parent-blame differs depending on the nature of the child's difficulties. Specifically, parents of children under 18 years old whose problems were framed in terms of a “moral failure” (such as those who were in contact with the criminal justice system or who used substances) were most likely to feel blamed by society. Within research exploring the experience of parents of people who use substances, the feeling of being targeted and blamed because of their child's condition has been recognized and linked to feelings of insecurity, shame, and a fear of judgment (Earnshaw et al., 2019; McCann & Lubman, 2018; O'Shay-Wallace, 2020). This in turn can lead to the internalization of blame as self-blame (Francis, 2012) which, in the context of parenting, refers to the inclination to attribute fault to oneself for being the cause, contributor, or intensifier of their children's difficulties (Moses, 2010).

The experience of courtesy stigma and blame affects not only individual family members but also the overall family dynamics. Research indicates that such experiences can lead family members to feel a range of complex emotions toward the person who uses substances, including embarrassment, fear, stress, and resentment (Dallos & Draper, 2015; McDonagh et al., 2019; O'Shay-Wallace, 2020). These feelings can lead family members themselves to blame the person using substances, creating an atmosphere of fear, criticism, and rejection within the family. This, in turn, can amplify feelings of shame and isolation (Dallos & Draper, 2015).

This study

Given the knowledge that courtesy stigma can act as a barrier for family members seeking support for themselves (McDonagh et al., 2019), this study aims to explore the nature and impact of courtesy stigma and parent-blame experienced by parents of individuals who use substances and how the parents cope with these experiences. Gathering this information is important as it can assist practitioners working with parents of people who use substances to better understand possible psychological barriers they might face to seeking and receiving appropriate support. Using the theory of blame, which describes both the nature and purpose of blaming and the subsequent reaction of the individual who is blamed, we have designed the study to capture both the nature and consequence of blame and stigma. Specifically, the research addresses the following questions: How do parents experience courtesy stigma in relation to their children's substance use? How do parents experience blame in relation to their children's substance use? What is the psychological and social consequence of courtesy stigma? What is the psychological and social consequence of parent-blame experienced in relation to their children's substance use? How do parents cope with perceived courtesy stigma and parent-blame?

METHOD

This study involved qualitative interviews with mothers of adults (age 18 years and above) with substance use problems in Scotland and England. We used semistructured interviews to explore individuals' experiences in detail. Ethical approval was granted by Glasgow Caledonian University's School of Health and Life Sciences Ethics Committee.

Recruitment and participants

Convenience sampling was used to reach out to parents who met the study inclusion criteria. The original intent of the research was to recruit both mothers and fathers, though only mothers participated. Eligibility criteria were parents of adult (18+) children with a history of problematic substance use (e.g., has required treatment or support in relation to their substance use) and speak fluent English. For the purpose of this study, and during recruitment, we defined substance use to include illicit drug and alcohol use. We recruited online through the social media platform Twitter and via organizations that support family members of substance using individuals in Scotland and England (either via the organizations' email or by circulating flyers in the organizations' venues). The flyer outlined the purpose of the study, details of the interview process, inclusion criteria, and a link to a survey that collected participant data. Participants followed the link to complete an eligibility screening and establish contact with the author, EOD. Interviews were scheduled through email at times convenient for the participants. Participants were recruited between December 2022 to January 2023.

Eight mothers participated in the study. Six participants identified as White Scottish and two participants identified as White British. The age range of the mothers' children was between 22 and 38 years. All participants had had contact with services that specialized in offering support to family members who are affected by substance use.

Data collection

Semistructured interview guides were used to conduct in-depth interviews. This was informed by previous studies conducted by Cohen-Filipic and Bentley (2015) and O'Shay-Wallace (2020) on parents' perception and experience of stigma and blame. The interview covered participants' understandings and perceptions of substance use, its causes and impacts, coping strategies used, and perceptions about other people's reactions and thoughts about the problematic substance use of their child. Example questions include the following: “How do people respond when you talk about your child's substance use?,” “What do you think other people think are the reasons that your child has experienced substance use challenges?,” “How do you feel experiences of stigma impact you personally?,” and “What has been your experience seeking support?” All interviews were conducted remotely (by phone or online video, depending on the participant's preference) and, simply because some participants talked at length in their responses, these lasted between 30 and 80 minutes. Although some participants chose to participate in the interview via online video, only the audio was recorded. Throughout the data collection process, our team regularly reviewed the data quality in relation to the study's scope. After interviewing six participants, we were close to having sufficient data to answer the research questions, with Interviews 7 and 8 not introducing any new ideas, which helped to determine when to stop collecting data.

Data analysis

Interviews were transcribed verbatim and checked for accuracy. To ensure anonymity, all identifiable information was removed from transcripts and participants were assigned pseudonyms. Thematic analysis, which was facilitated by the use of NVivo 1.7.1, was conducted in line with the steps outlined by Braun and Clarke (2006). After the initial phase of data familiarization and in-depth discussion with the research team, a descriptive coding framework was developed by author EOD as part of the second phase. During the third phase, the codes from across the eight interviews that represented similar concepts were gathered and organized into draft themes and subthemes. In line with the fourth phase, these groupings were then shared for review by the research team to ensure their coherence. The review of themes involved reading through the codes and extracts in relation to the proposed themes, refining any codes, and considering the validity of the proposed themes in relation to the data set. Through the process, the team discussed discrepancies and applied revisions where needed. Finally, during the fifth phase, themes and subthemes were labeled so that they clearly described the content and could be used to construct a narrative around the research questions.

RESULTS

The result of the analysis yielded three themes with subthemes. These themes were (1) the spreading impact of stigma; (2) parent-blame: navigating social pressure and its consequence; and (3) reactions to the stigma, blame, and strain.

Theme 1. The spreading impact of stigma

Marked and contaminated

Due to the way that people treated them, several participants expressed the perception of having a child with substance use problems as akin to being contaminated. They shared how they felt that people around viewed them as someone with an illness, which caused other members of society, as well as their own family and friends, to experience and express a range of emotions, including awkwardness, discomfort, fear, and anger. In the same way that an infection may deter people from engaging with an individual, the mothers felt like people avoided them in order to keep themselves safe. As Shona noted, “You can actually physically see people pull back. People don't want to be associated with you because of it. I'm assuming because they think it's kind of contagious, you know.” Eva also reflected that people were repelled by the substance use problem of her child because they saw it as something “dirty, grubby and uncomfortable.” Furthermore, the stigma experienced as a result of the participants' connection with their child was frequently felt as a perceivable mark against them. Kathy described it “as if you're walking about with a bell around your neck,” highlighting how permanent, exposed, and ashamed the mothers felt.

Absence of understanding and empathy

Reflecting on the origins and nature of the courtesy stigma that they experienced, all of the mothers described how an absence of understanding around substance use often fueled insensitivity and a lack of empathy from friends, family, and members of the public. They described how their children had been labeled, accused, discriminated against, and abused because of their substance use.

As a result of substance use being framed as a moral issue, the majority of mothers described how they experienced little empathy from people to whom they mentioned their child's predicament. As Kathy described, “They automatically tag him with this label. They don't become interested. They no longer even support yourself. It's a case of, well you know, he's doing it to himself.” In this account, Kathy suggests that instead of recognizing a person who is going through a difficult time, people tend to focus solely on their behavior and pass judgment, denying them and family members the support they require. A number of mothers shared their experiences of the absence of care, noting the contrasting reactions when discussing family members with other health issues that do not attract stigma, which only intensified the pain caused by the lack of empathy.

Rejected and marginalized

Throughout their stories, the women consistently expressed a sense that their family and friends actively avoided acknowledging the issue, leaving them to face an overwhelmingly stressful life on their own. The majority of mothers conveyed how their families avoided discussing their child's difficulties, offering a range of explanations such as shame, embarrassment, discomfort, fear, and a resistance to confronting their own problems. As Shona explained, “People don't want to see it. Well, the immediate family don't want to. They just want to brush it under the carpet and just forget about it rather than try and understand or be compassionate.”

Furthermore, two of the mothers expressed how family members not only avoided the problem but they also rejected their child from the family all together. Kathy exclaimed how “it's like he never existed. It's as if we have two children not three and whether that's stigma or not, I mean, that's just hurtful!” The emotional impact caused by the family's failure to acknowledge their child or their child's difficulties seemed, for many of the mothers, worse that the direct discrimination or stigma they experienced. The majority of mothers experienced a sense of exclusion within their family and friend groups, where they felt they had no safe space to openly discuss their difficulties. This not only resulted in feelings of rejection but also left them with no outlet within their closest circles to express the challenges they were encountering.

All of the women expressed the intense strain that the substance use had for them and their family. They described the life that they lived as dramatic, unpredictable, and traumatic. Five of the women expressed how they often felt like they were only just surviving or close to breaking point, yet the majority of the women described the challenge of finding people within their social circles who could offer opportunity for them to talk.

As well as the problem of being ignored by family members, two of the participants reflected on the way they felt invisible to the professionals that their children were working with. Despite the often-crucial role that the mothers had with regard to caring and fighting for their children (and often their grandchildren), the mothers shared how they felt that parents “had no voice” and were “pushed to the side” (Mary) when it came to interactions with professionals. Again, they reflected on the way that this left them feeling insignificant, further marginalized, and with their experiences disregarded.

Theme 2. Parent-blame: Navigating social pressure and its consequence

Separate from the stigma that the parents experienced because of the link with their children's substance use, the mothers described a persistent feeling of blame.

Blamed as a parent

The mothers described a feeling of being judged as a parent and blamed for their children's substance use difficulties. They shared that this feeling came from their own family, friends, professionals who they had been in contact with, and the wider public. Jo described an interaction with staff in the accident and emergency hospital where her son was taken following physical injury that had occurred when he was under the influence of alcohol:

So you got to remember, I was in a really heightened state. And I'm hearing this [clinical assessment] as an interrogation. Like I've done something wrong. They were asking all these questions, but all I was hearing was “why haven't you seen your son?… you've not been a good mum to him” … it just felt as if we were being … like it was our fault, and we'd done something wrong.

With hindsight, Jo acknowledged that the hospital staff were probably not directly blaming her. However, she described how previous experiences of judgment and blame create a “filter of how you perceive the world sees you” and increases a sensitivity to feelings of blame.

Not only did the participants describe how they felt blame in relation to the way they had raised their children, but they shared how people also made assumptions about their own behavior. As Kathy suggested, “People automatically assume that it's because you've taken your eye off the focus when you are bringing up your kid or maybe it's something that they're doing because that is what they've seen at home.” This captures Kathy's perception that people make judgments that she must have neglected her parental responsibilities or that her child's behavior is a direct consequence of a disruptive home environment. Kathy's statement reflects her feelings of being unfairly targeted and the frustration that arises from the narrow and judgmental narratives surrounding parenting and substance use.

Finally, although less direct, several of the participants reflected on the way that others would offer misplaced and unhelpful advice about ways they might handle the situation and about their role as a parent. This only left them feeling judged, looked down upon, and increasingly alone because it showed that other people did not understand their situation and that these people still assumed that they would be able to manage the situation better.

Different expectations between mothers and fathers

Five of the mothers reflected on the different expectations that they felt society placed on mothers compared to fathers and how this increased the feeling of being held responsible and blamed for their children's behavior and problematic substance use.

This is a wee bit of a stereotype, and I don't mean it that way … but the dad doesn't have to do as much for their kids. They can go out and have fun. That's just fine. They pick them up for school two days a week and it's like “oh my goodness, the dad does this and the dad does that”… I just think society's got different expectations on mums than they do with dads. And I think there's a heavier burden on mothers. (Jo)

In this context, Jo contemplates her personal experience and perspective on the existence of an imbalance concerning societal expectations placed on mothers. In comparison to mothers, she shared how she felt fathers are less prone to being criticized or held responsible for certain outcomes or behaviors such as their child's substance use. Indeed, despite the mothers reflecting on how they were often the ones to “pick up the pieces of everyone else's mess” (Shona), which they described as involving dealing with the consequences of their child's substance use and often being the main contact with different professionals such as social work and people within the treatment team, the judgment and blame directed toward the women was felt particularly strongly and they questioned whether fathers would experience the same.

Impact of blame

The majority of the participants expressed how feelings of culpability and scrutiny left them constantly trying to comprehend and analyze the factors in their family's past that contributed to the issues of substance use. In this sense, parent-blame became self-blame as the mothers attempted to identify how they were at fault. Eva described the questioning she went through:

Did I take my eye off him? Did I miss something? Because all of the counseling you ever have, all you hear about is that it all goes back to childhood, and I think … what was it about their childhood that they were really unhappy about?

This highlights the persistent introspective thinking and self-doubt in relation to Eva's child's substance use. The reflection on counseling suggests that she recognized that society holds a common belief that negative or traumatic childhood experiences can impact a person's later substance use. Consequently, the mothers scrutinize their children's childhood in an attempt to identify potential sources of unhappiness that may have contributed to their current situation. Overall, the quote reflects Eva's consciousness of a dominant public discourse that might influence blame, a deep desire to understand and find explanations for her child's substance use, and her struggle with feelings of personal accountability.

Although some mothers acknowledged their ability to resist judgment and expressed their own realization that they are not responsible for their children's choices, two mothers specifically discussed the enduring emotional distress caused by the lingering sense of blame. As Ruby commented, “it makes me feel worthless as if I can't do anything right or I am doing everything wrong. I definitely feel this the majority of the time.” Here, Ruby reflects on how the blame that she experiences, alongside the ongoing challenge of supporting her child who is struggling, leaves her feeling a painful sense that she is failing as a parent, which is a persistent cause of suffering in her life.

Theme 3. Coping with the stigma, blame and strain

In response to the daily stress and the stigma and blame that the mothers felt, they described a number of strategies to deal with these issues.

Avoidance

All of the women described feeling the need to withhold details about the substance use problem of their child and the need to be careful about who they shared information with. This includes avoiding discussions with professionals due to fear of social services intervening or because they knew they could lead to insensitive or abusive comments. As Barbara described, “I just wouldn't get into conversations because I couldn't bear them to say the hurtful things, you know. It's like putting a knife through you. So, I suppose then, there are very few people who I open up to.” In this context, Barbara describes her efforts to prevent the discomfort and pain of challenging conversations by selectively filtering and avoiding discussions that might give rise to stigmatizing and offensive remarks. Indeed, Jo described how she feared the gossiping and details “spilling out” and consequently, she exercised caution in choosing whom she trusted and confided in. Most of the mothers explained how they redirected discussions or refrained from sharing information in order to shield themselves and their children from hurtful remarks. However, one participant reflected on her choice to avoid certain conversational topics with friends in order to protect and spare her friends from experiencing any discomfort.

In addition to avoiding conversations, two of the mothers described how they withdrew from socializing altogether, leading to the loss of friendships and increasing isolation. They attributed this to feeling exposed and ashamed, acknowledging that they had become the subject of gossip among even the closest people in their life.

Fighting the judgment

Having felt blamed and stigmatized because of their children's substance use, several of the participants described instances where they had objected when others had used offensive language or were acting judgmentally. In response to frequently misplaced advice and to people telling her how to parent her child, Ruby described how important it had become for her to develop confidence in her decision-making and be assertive in the way she communicated her position: “It's just difficult because everybody has an opinion, but they're not living it. I was getting pulled in every direction, the friends, the family and now I'm just like ‘no, this is what I'm doing!’” This quote reflects the overwhelming weariness of being judged and advised by people who do not have a full understanding of the situation or firsthand experience of what it is like supporting someone who uses substances. It also highlights how important it has been for Ruby to develop a capacity to resist the different pressures.

Several of the mothers described how they had noticed a change in themselves and had become more understanding and less judgmental of other people's situations. Indeed, not only was there evidence of the mothers' developing awareness and confidence in confronting instances of societal stigma that was directed toward their children or themselves, but Kathy described how she had “literally become a warrior against stigma. I will fight battles just to clear a person's name because it's just horrid.” Indeed, in the majority of discussions, there was a strong sense of passion regarding the recognition of the harmful impact of stigma and a shared commitment to advocate for the rights of those who have been marginalized, including individuals, family members, and communities.

Self-care

Given the level of stress that was persistent in their families, participants had developed strategies to safeguard their well-being. These included seeking validation, implementing measures to maintain a sense of structure and normalcy, focusing on hope, identifying small positive moments to counterbalance the negative experiences, and engaging in activities that could generate a sense of pleasure. Several of the mothers highlighted the importance of creating time and space away from the situation where they could step into an environment that was just theirs; where they knew they would not be judged, they could be free to be themselves, and they could momentarily take a break from the strain of being a parent.

The importance of family support groups

All of the women described how important family support groups had been in terms of having people to talk to and a space free from judgment. Several women described how the groups had been a vital place where they could learn and become more knowledgeable about the nature of substance use and ways of coping. Furthermore, two of the women described how they had been assigned key workers who were able to give one-to-one support and regular check-ins, creating for them a space to feel heard. Above all, the women unanimously shared that the overwhelming success of the groups was the power of peer connection and solidarity.

Counter to the misplaced judgment that the women were often used to, Barbara reflected how the family support group that she attended had been there to help her during a particularly challenging incident with her child. She shared that “they were there immediately to help, to just listen and not make decisions for me, because I came to the conclusions myself, but I wouldn't have if that group hadn't been there.” Her experience spoke of the accepting nature of the group and the willingness to offer listening support in a way that many of the women did not have through their family or friends. In contrast to the familiar feeling of loneliness that was created from the judgment and stigma, the group helped the mothers in appreciating that it wasn't just their own families experiencing such situations, but that others were going through similar challenges. This recognition provided them with a sense of solidarity, reassuring them that they were not alone in their experiences.

DISCUSSION

Although previous research exploring the views of parents of people who use substances has highlighted evidence of stigma and discrimination, there has been a lack of research that has distinguished between the experience of courtesy stigma and parent-blame. As such, this study explored these related but distinct experiences that mothers of people who use substances face. Findings suggest that stigma and blame leave mothers feeling judged and alone when navigating complex family dynamics, but that family support organizations offer accepting spaces to counter judgment and generate a sense of connectedness.

With regard to courtesy stigma, the participants described how they felt like they were marked and contaminated by the association with their child's behavior. They shared how misunderstanding about the nature of substance use led to a lack of empathy and they described how they felt looked down upon and excluded. These findings were in line with previous research exploring the stigma experienced by family members of people who use substances (Mardani et al., 2023; McCann & Lubman, 2018; O'Shay-Wallace, 2020) and reflect Goffman's (1963) original theoretical position that stigma extends and spreads outwards from the individual who has been discredited.

One of the key findings within the study relating to the stigma faced by individuals who use substances was the perception among mothers that people unfairly judged their family member as undeserving of support. Similarly, the mothers noted a corresponding lack of attention or care offered to them, reflecting how the stigma extended to impact the family unit. Whether or not people feel like they merit support can influence their decision to seek help (McDonagh et al., 2019), and our study highlights how these decisions may be affected by public perception. These findings are important to consider when reflecting on reasons why people may not reach out for help and can inform initial contact with family members who may or may not have internalized beliefs that they are deserving of care.

Parent-blame, on the other hand, represented a feeling of direct criticism toward the mothers because of their parenting. Participants shared instances where they had been blamed by family, friends, and professionals. Furthermore, the internalization of blame was also evident when several mothers described how they had become hypersensitive to this type of judgment, and they reflected on the way they filtered conversations and anticipated blame. Although previous research has also found evidence of blame directed to parents by family members and professionals (Cohen-Filipic & Bentley, 2015; Francis, 2012), our findings go further in highlighting that mothers may feel that these interactions shape their future behavior. In light of Malle et al.'s (2014) theory of blame, whereby the individual who is being blamed is at risk of being rejected from the community, thus threatening their safety and chance of survival, this hypersensitivity to judgment is perhaps understandable. Indeed, the feeling of rejection and being ostracized was a key theme that ran through all of the mothers' experiences, though whether this was more linked with courtesy stigma, parent-blame, or a mixture of both, requires further exploration.

One of the most frequent behavioral responses to parent-blame that the mothers reported was their own continual scrutiny of their past and their attempt to identify instances in their child's life where they could have intervened and prevented the initiation of problematic substance use. This has been reported elsewhere (Eaton et al., 2020; Jackson & Mannix, 2004), though the mothers in the current study acknowledged that their continuous examination of past experiences was intensified due to their awareness of the prevailing societal perception that individuals dealing with substance use problems often had a turbulent upbringing. As Corrigan and Miller (2004) reflected, when discussing significant mental health challenges the prevailing tendency is to assign responsibility to inadequate parenting abilities, parental shortcomings, and incompetence. Given this is the dominant discourse within our society, the mothers' insecurities and experiences of self-blame are understandable.

One of the common responses to courtesy stigma and self-blame, which all of the women described, was a tendency to engage in avoidance. This came in different forms, which ranged from being cautious and selective in sharing information to distancing themselves from others and avoiding social interactions altogether. The acts of hiding, secrecy, and avoidance are common consequences of stigma and have been described in previous research exploring the experience of family members of people who use substances (Fotopoulou et al., 2015; McCann & Lubman, 2018; McDonagh et al., 2019). In our study, women described how they resorted to avoidance primarily as a means of safeguarding themselves and their families against courtesy stigma in the form of derogatory remarks and discriminatory actions, which ultimately caused them distress.

The participants recounted the ongoing stress, drama, and tension stemming from their child's substance use, noting how stigma and blame exacerbated these challenges within the family. This led to feelings of embarrassment, shame, and isolation. Dallos and Draper (2015) emphasized the advantages of involving families in addiction treatment, as it enables the exploration of intense emotions and helps diminish blame and contempt between different individuals within the family. This approach fosters positive changes in family dynamics and ensures care for all members. Unfortunately, our findings suggest that family members' voices are not always taken into account despite the potential benefits of attending to the needs of all family members. Further research investigating the effects of courtesy stigma and parent-blame on family dynamics and treatment outcomes would be valuable.

The distinction between courtesy stigma and parent-blame is a challenging one. In mothers' own reports, there was evidence for processes relating to both concepts, though the distinction between stigma and blame may appear narrow at times. However, we contend that this reflects the nature of the behavior being scrutinized here, namely, substance use. The excessive and problematic use of substances such as alcohol and illegal drugs has a long history of being associated with “deviance” (Kaplan, 1995; Reynolds et al., 2023) and Scambler (2006, 2009) has argued that stigma can be attributed when a behavior is outside of an individual's control and that pity is a common emotional reaction in such contexts. In contrast, where an activity departs from social norms it may be more common to invoke blame. Thus, it may be that parent-blame and stigma are closely related constructs when considered within the context of substance use behaviors.

Limitations, strengths, and future research

An important limitation of this study is the small and relatively homogeneous sample. Although recruitment adverts sought views from all parents, only mothers responded and participated. This gender imbalance is not uncommon in research exploring issues around stigma and parenting (Eaton et al., 2016). Furthermore, Macfadyen et al. (2011) proposed that fathers may be less inclined to participate due to undervaluing their own views compared to those of mothers, a tendency which seems to be exacerbated in situations where mothers have more interactions with health-care professionals (Macfadyen et al., 2011).

In addition, all participants in the current study had experience with family support groups, and the experiences of parents not attending such groups may differ from participants of this study. In fact, our findings highlight that family support organizations, which offer both guidance and a sense of solidarity, had been helpful in reducing the impact of self-blame and stigma. Moses (2010) noted how parents can often go through a process of unblaming whereby earlier perceptions of self-blame are reevaluated and modified over time and in relation to their situation and external support. It may be useful for future research to also include the views of parents who have not benefitted from the support of family groups so that the process of unblaming can be better understood, which can, in turn, help practitioners who are supporting family members to reframe harmful internal messages.

With regard to the methodology, although only audio recording was implemented in all interviews, those conducted using video may have benefitted from the addition visual “presence” as compared to telephone interviews. However, recent evidence indicates that this was unlikely to have had any impact on data equivalence (Oates et al., 2022). In addition, although our study was not designed to explore differences in individual characteristics of the mothers (e.g., socioeconomic status, educational level), the families (e.g., living with the substance using child, single mothers), and the children (e.g., age group, type of substance use), we acknowledge that these factors might impact the experience of stigma and self-shame.

Implications

All of the participants spoke highly of the services that were already in place and supporting family members of people who used substances. This was contrasted with the other health-care services that their children were trying to access, which they often described as unfit for purpose. Given how the mothers persistently felt excluded and silenced, this emphasizes the importance of finding ways of including them in the treatment process and of showing empathy in relation to the strain that they are also going through. Indeed, research has shown that interventions that involve family members not only result in improved treatment outcomes for the individual who is using substances, but they also improve health outcomes for the rest of the family (Ventura & Bagley, 2017).

Professionals working with mothers directly should be sensitive toward signs of internalized courtesy stigma and parent-blame in order to assist them in reframing their perception of the situation in a less detrimental manner. This might involve identifying instances when they excessively question the causes of their child's substance use, observing when they adopt exaggerated notions of responsibility or hold cognitive distortions. By doing so, professionals can help mothers recognize self-blame and confront unhealthy thought patterns. These interventions, which have been used to address distorted thinking patterns in parents of children with chronic pain (Palermo et al., 2016), as well as parents of children who resist attending school (Minamitani & Matsumoto, 2018), have proven effective in mitigating the negative effects of self-blame.

Several mothers in our research emphasized that they not only experienced rejection from friends and family members but also frequently felt disregarded in decisions relating to the care of their family member. This is despite their significant contributions to supporting their loved ones through recovery and frequently taking on the role of kinship carers for their grandchildren. These findings highlight the importance of developing a holistic approach that can include, where possible, the views of family members.

Finally, the power of peer support in dismantling feelings of stigma and blame, as well as helping people feel a part of a community and less alone, was significant. Increasing awareness and availability of these valuable resources will help empower family members who are affected by problematic substance use.

Conclusion

This research has explored the experience of courtesy stigma and parent-blame among mothers of children who use substances. The mothers in this study shared experiences of stigma and blame from family and friends as well as managing judgment and false assumptions directed toward them from the wider public. As a result of these encounters, the mothers frequently internalized these experiences, leading to feelings of rejection, social isolation, and self-blame. These feelings were particularly challenging to navigate amid the already intense stress within the family dynamics. Peer groups and guidance from family support organizations offered a lifeline for the women and helped to reduce the negative impact of stigma and blame. These findings should be used to guide future investigations that differentiate between courtesy stigma and parent-blame, as well as to inform practical decisions regarding the interventions and messaging that professionals working with parents can employ.