Affected Family Members’ Communicative Management of Opioid Misuse Stigma: Applying and Rethinking the Stigma Management Communication Typology

ABSTRACT Opioid misuse is a prevalent health problem in the United States with consequences extending past the person who misuses opioids to affected family members (AFM) through courtesy stigma. The goals of this study were to understand the stigma management communication (SMC) strategies employed by AFMs when they experience courtesy stigma and changes in strategies used over time. The findings from interviews with 34 AFMs suggest the SMC strategies they employ range from those that indicate acceptance of stigma and avoidance of stigma situations to strategies where AFMs actively challenge opioid misuse stigma. However, strategy use depended on the social context and AFMs’ perceptions of opioid misuse stigma at a given moment in time. Further, findings suggest changes in AFMs’ SMC strategies over time are related to changes in their perceptions of opioid misuse stigma. Theoretical and practical implications of how families manage stigma are discussed.


Stigma
Broadly, stigma is a social construct where negative attributes are assigned to a group of people, resulting in prejudice and discrimination (Link & Phelan, 2001). An emerging body of research demonstrates the stigmatization of people with substance use disorders (SUDs; Barry et al., 2014;Corrigan et al., 2009;Mannarini & Boffo, 2015). Compared to other psychiatric and health conditions, the public holds more negative attitudes toward people with SUDs (Barry et al., 2014;Mannarini & Boffo, 2015), are viewed as more dangerous and blameworthy for their condition (Corrigan et al., 2009); and the desire for social distance from people with SUDs is greater compared to people with other psychiatric or health conditions (Barry et al., 2014). People who misuse opioids may comprise a particularly stigmatized subgroup of persons with substance use issues, with stigma toward people with opioid use disorder exceeding stigma toward those individuals with alcohol or other drug use problems (Brown, 2015;C. -C. Chang et al., 2020).
Family members of people with SUDs are subject to family stigma, a type of courtesy stigma (Goffman, 1963), or stigma by association. Family stigma is defined as when some type of anomaly within a family, such as substance use or crime, leads to (a) negative perceptions and avoidant behaviors toward the family by others, (b) others' belief that the stigmatizing attribute is dangerous or different from social norms, and (c) others' belief that the entire family is in some way contaminated by the actions or attributes of one member (Park & Park, 2014). Park and Park (2014) suggested that AFMs experience emotional, social, and interpersonal consequences because of family stigma. For example, when courtesy stigma is internalized, family members can suffer emotional distress, caregiver burden, and social isolation (Mitter et al., 2019;Yin et al., 2020).
Few studies have examined family stigma toward AFMs affected by opioid misuse and other SUDs. A national survey found public stigma toward family members of people with substance use problems is greater than other health conditions, with family members often blamed for both the onset and resolution of their relative's substance use (Corrigan et al., 2006). The results of qualitative studies of families affected by substance use have indicated that family members are often judged or blamed for their relative's substance use and experience feelings of shame and hopelessness, which may deter help-seeking for AFMs (McCann & Lubman, 2018a, 2018bO'shay-Wallace, 2020;Weimand et al., 2020). Among adult family members of individuals who have misused opioids, greater self-stigma has been associated with higher levels of criticism toward the person with OUD and emotional overinvolvement (i.e., greater expressed emotion; Ellis et al., 2020). Thus, stigma may contribute to family interactions that put a strain on treatment and recovery efforts (Lee et al., 2015). For these reasons, the strategies AFMs use to manage stigma have important implications for health and social outcomes.

Stigma management communication
Theories of stigma communication are used to understand how stigma is constructed, perpetuated, and managed through communication. Smith's (2007) model of stigma communication identified three components of stigma communication: characteristics of stigma messages, cognitive and emotional reactions to stigma messages, and the effects of stigma messages on spreading stigmatizing attitudes. Stigma messages have specific characteristics (i.e., marks, labels, responsibility, and peril) which elicit emotional reactions (e.g., anger, disgust, fear) that evoke stigma attitudes. Once stigma attitudes are established, the sharing of stigma messages in communities can produce groups of solidarity and promote separation from the stigmatized group.
Meisenbach (2010) expanded on Smith's (2007) process of stigma messaging by developing a typology of communication strategies which stigmatized people use to cope with and manage their stigmatized identities. This typology classifies stigma management strategies into one of four quadrants based on whether an individual (a) accepts or challenges the societal perception of the stigma (i.e., public stigma) and (b) believes the stigma applies to themselves (i.e., personal stigma). Those individuals who accept the societal perception of the stigma and its application to themselves internalize it as part of their social identity and tend to use accepting strategies, such as silent acceptance or bonding with other stigmatized individuals (Quadrant 1). Those individuals who recognize that a social stigma exists but do not accept that it applies to them use avoiding strategies, such as hiding the stigma or distancing oneself from other stigmatized individuals (Quadrant 2). Those individuals who accept that the stigma applies to them but wish to alter the societal perception of the stigma will strategies to evade responsibility or reduce the offensiveness of the stigma (Quadrant 3). Those individuals who challenge the social stigma and its application to themselves use denial strategies, such as simple denial (i.e., the stigma does not exist), logical denials to refute the stigma, or open displays of the stigma (Quadrant 4).
Although Meisenbach's (2010) theory of stigma management communication (SMC) was developed to understand the process of stigma management by people who experience firsthand stigmatization, O'Shay-Wallace (2020) research supports the utility of SMC for understanding how people manage courtesy stigma as well. Like people with stigmatized conditions, people with courtesy stigma similarly experience negative consequences toward their health and relationships (Pescosolido & Martin, 2015). Though limited, qualitative research has begun to explore how AFMs experience and communicatively manage stigma, specifically as it relates to a family members' substance use (McCann & Lubman, 2018a;O'shay-Wallace, 2020). For example, O'Shay-Wallace (2020) found that AFMs report experiencing substance misuse-related stigma from both people within their extended family and people outside of their family and manage this stigma in several ways such as by avoiding stigma situations or proudly displaying the stigmatized attribute. However, O'Shay-Wallace (2020) also detailed how the ways some AFMs manage stigma do not clearly fit into the SMC typology and suggested that further research is needed to examine the fluidity of SMC strategies within the context of courtesy stigma.

Study aims
This study aims to (a) elevate the experiences of families affected by opioid misuse and (b) provide insight on the communicative strategies AFMs use to manage related stigma. Such insight is important as strategies can reflect the internalization of stigma, and certain strategies may have a more positive relationship to AFMs' health and social outcomes. Understanding the context surrounding how, when, and where varying strategies are used is a key step toward finding ways to help AFMs productively cope with their experiences. As such, findings may highlight helpful strategies for managing the stigma associated with a loved one's opioid use that have not yet been identified. AFMs' description of stigma management also may offer service providers insight into which strategies AFMs consider most useful. Further, SMC can be a primary vehicle for not only coping with courtesy stigma, but also for improving public perceptions of opioid misuse and related disorders as AFMs engage in strategies to challenge perceptions of stigma. To that end, the first research question is posed: RQ 1 : What strategies do family members use to communicatively manage the public and personal stigma of having a loved one who misuses opioids? Though most extant research presents Meisenbach's (2010) communication typologies as static (Hartelt, 2018;Noltensmeyer & Meisenbach, 2016), communication, including SMC, may be better understood as a process (Poole, 2013). In this way, the strategies AFMs use to communicatively manage stigma should be viewed as contextual, dependent on time and place. Meisenbach's (2010) theory is grounded in the acceptance and internalization of stigma, which both are affected by shifting social and political context, human development, and course or severity of the stigmatized attribute (Earnshaw et al., 2022). Studies of the experiences of people living with other concealable stigmatized identities reveal changes in stigma (Biggs et al., 2020;Vogel et al., 2013) and disclosure (Corrigan et al., 2013;Jones et al., 2016) over time. In this context, AFMs may find certain SMC strategies more acceptable or productive at different times throughout their experience with their loved one. A nuanced understanding of how stigma management changes over time will benefit providers supporting AFMs as they navigate family stigma. To this end, the second research question is posed: In what ways do family members' use of strategies for managing the stigma of opioid misuse change throughout their experience?

Procedures
Upon obtaining approval from the Wayne State University institutional review board, family members were recruited via e-mail from a pool of AFMs that participated in a prior survey study (Ellis et al., 2020). In the original study, participants were recruited through publicly funded treatment providers, support groups for family members, and our university's social media platform. These participants must have been residents of Michigan and identified as having a close family member (parent or stepparent, child, spouse, sibling or stepsibling) who experienced problems with opioid use. An e-mail script describing this study was sent to participants that had opted in to being contacted for future research opportunities. Potential participants were emailed up to five times with this script.
In-depth one-on-one interviews were conducted to collect data. Interviews ranged from 15 minutes to 1 hour and 36 minutes and averaged approximately 48 minutes (M = 47.45, SD = 18.66). Participants were 18 years of age or older who self-identified as having a close relative who misused opioids (i.e., AFM). Participants received a $25 Amazon e-gift card via e-mail along with debriefing materials that provided information about how to access support services for people impacted by substance misuse upon completion of their interview.
All interviews were audio-recorded and conducted via phone by one of five different research team members, some of whom were in recovery themselves or had loved ones with SUDs. It is important to acknowledge that our roles as people in recovery or family members of loved ones with SUDs likely influenced how we interacted with our participants and how we interpreted our data. However, we view our life experiences related to SUDs as an opportunity for reflexivity rather than a limitation (Carolan, 2003), as our experiences positioned us well to build rapport with AFMs and be sensitive to their experiences.
All interviewers were trained prior to conducting any interviews. Training took place over two sessions where all team members were briefed on interview procedures from recruiting through debriefing and qualitative interviewing practices. We also discussed the purpose of the project and talked through the entire interview guide as a group. All interviewers conducted a practice interview and team members that were less experienced with qualitative research were instructed to listen to audio from the first few interviews prior to conducting interviews on their own. The interviews were semi-structured, creating opportunities for AFMs to elaborate on aspects of their experiences that they deemed important and relevant. This approach to interviewing leaves room for "new and unexpected" phenomena to arise (Brinkmann & Kvale, 2015, p. 33).
The interview guide was crafted by a subset of the larger research team over the course of several meetings to address multiple research problems of interest to the entire team. Once a full draft was completed, the guide was sent to the entire team for feedback and was revised, with special attention paid to framing questions in a way that was not value-laden or judgmental of our participants' experiences. The interview guide had 18 primary questions, each with potential prompts, ranging in topic from questions about formal and informal support systems, how families talk about opioid misuse, seeking treatment for their loved one(s), and the grieving process for those whose loved one had passed away. The questions did not directly ask about stigma, but instead prompted AFMs to reflect on the assumptions they felt people make about those individuals who misuse opioids. The questions also prompted AFMs to share experiences where someone had said something negative about their loved one or another person who misuses opioids, as well as how they responded in these situations.
Audio recordings were professionally transcribed and subsequently verified by research team members, resulting in 554 pages of single-spaced transcripts. Interviews were conducted until data saturation was achieved, which was defined as when no new ideas or information relevant to the research questions and conceptual categories were arising in the interviews (Tracy, 2020). Saturation was achieved at approximately the 30 th interview, but we conducted four more interviews to ensure no new phenomena relevant to our research problem were arising.

Data analysis
The analysis was guided by Tracy's (2020) iterative approach using Dedoose qualitative coding software, which allows for both emergent themes and the use of existing theoretical frames and models. This approach also is phronetic (i.e., practical) in nature. As such, we intended for our analysis to produce findings that could guide practitioners' efforts as they work with clients impacted by substance misuse.
The iterative approach involves four steps: data immersion, primary-cycle coding, revising the codebook, and secondary-cycle coding (Tracy, 2020). Three research team members met twice during data immersion to talk through what was standing out to them in the data and brainstorm a code list. Constructs from SMC theory (Meisenbach, 2010) served as sensitizing concepts for our analysis as an initial way to focus and organize our first-level coding. Though some AFM experiences deviate from processes described in the theory, as we moved from the primary-cycle coding phase to secondarycycle coding, we found SMC to be a useful framework for further organizing our findings. Further, we felt our data could help refine and further explicate the constructs of SMC theory. Each team member wrote analytic memos as they conducted their analysis. We met five additional times throughout primary-and secondary-cycle coding to draft and refine our codebook and reflect on what we were learning from our data. For example, first-level codes such as "avoiding," "blaming," and "isolating" developed during primary-cycle coding were organized into hierarchical groups during secondarycycle coding centered around the four quadrants of the SMC typology based on which SMC strategy they represented. Each transcript was initially coded by one team member and subsequently reviewed by the second two team members.

Research question #1
The first research question posited about strategies do family members use to communicatively manage the public and personal stigma of having a loved one who misuses opioids. Although there were several exceptions, the findings suggested the strategies employed generally aligned with those strategies outlined in Meisenbach's (2010) typology. These strategies are related to AFMs' perceptions of stigma as applicable or not applicable to oneself as well as whether they felt the societal stigmatization of opioid misuse is valid and justified. The findings also suggested that the SMC strategies were fluid in nature, where the strategies employed varied based on the social context. Thus, while the strategies may have fit neatly into one quadrant of the SMC typology, AFMs did not distinctly fit into one single quadrant. For example, AFMs used SMC strategies from Quadrant 1 in some social settings and strategies from Quadrant 4 in other situations.
These findings are largely organized based on Meisenbach's (2010) SMC typology and grouped within four quadrants (see Table 1).

Quadrant 1 (Q1): Accepting public stigma and personal stigma
Family members tended to employ SMC strategies described in Q1 (i.e., accepting strategies) in situations where they felt the societal stigmatization of opioid misuse was valid and justified and that this stigma extended to them as a family member of someone who misused opioids. Two of the accepting strategies utilized by AFMs in this study included those strategies previously defined by Meisenbach's (2010) as passive acceptance and bonding with stigmatized others. The third accepting strategy used emerged from this study: internal attribution-making.
The first accepting strategy -passive/silent acceptance -is when a person does not address or display (dis)agreement with a stigmatizing comment they witness (Meisenbach, 2010). Family members engaged in passive behaviors to avoid the burden of speaking up. A son, for example, stated, "Usually, honestly, I just ignore it. I don't think it's worth getting in fights over it." This sentiment is further exemplified by a parent: If you want to say, did I have the cojones to speak up and say, 'Hey, wait a minute'? I really didn't. . . I felt like I had enough problems without having to reach out and find more conflict.
When faced with stigmatizing experiences, AFMs appeared to view challenging this stigma as a battle not worth fighting.
A second accepting strategy utilized among AFMs was bonding or socializing with other stigmatized people. Family members tended to seek support from people they felt understood their experiences because they had similar ones (i.e., other AFMs). This strategy is exemplified by a parent: "It's like with anything. If you've never experienced cancer in your family, you don't understand what it's like. It's the same thing [with opioid misuse]. It's hard to get support from people who haven't experienced what you are [experiencing]." Family members also described how bonding with stigmatized others was helpful to the coping process. As a daughter and sibling noted: "My best friend has a very similar situation with her own mother. So, that's been incredibly healing for me." This AFM described how connecting with a friend dealing with similar challenges contributes to their own healing. Overall, AFMs expressed placing trust in other people impacted by opioid misuse above others and valued the support they offered. A third accepting strategy used by AFMs is novel to this study: internal attribution-making. According to Weiner (2005), an internal attribution places the locus of control for an outcome (i.e., opioid misuse) on the individual, making it within their ability to control or change. Because internal attributions may represent "blemishes of character" (Goffman, 1963), they are likely associated with greater stigma than attributions that suggest opioid misuse is beyond an individual's control. When making attributions about where the responsibility for their loved one's opioid misuse lies, some AFMs placed the responsibility for misusing opioids on their loved one. In cases where the responsibility for opioid misuse was internally attributed, AFMs used language that implied their loved one's opioid misuse was the result of a choice the loved one made. For example, as one family member contemplated their loved one's opioid misuse, they said, "I don't know if I truly believe it's [addiction] a disease because I do still think it's a choice, too -even though I know it's not that easy [to stop]." When making internal attributions, AFMs indicated acceptance of the stigma toward opioid misuse generally as well as their loved one's opioid misuse.

Quadrant 2 (Q2): Accepting public stigma and challenging personal stigma
Family members engaged in avoiding strategies (Q2) in situations where they felt the societal stigmatization of opioid misuse was valid and justified but rejected that they were stigmatized as AFMs. Avoiding strategies exhibited by AFMs in this study include avoiding potentially stigmatizing situations and making favorable social comparisons. Avoiding stigma situations involves discursively and physically avoiding situations where one anticipates being stigmatized (Meisenbach, 2010). In this study, family members reported lying and engaging in secrecy to avoid stigma. One sibling clearly linked their secrecy to potential stigma: "You do find yourself not wanting to tell people what happened because of the stigma with it." Lying to avoid stigma was best exemplified by the following parent: We were embarrassed, obviously, and we were trying to maintain his reputation. My elderly parents were alive at the time . . . they'd be over at Christmas dinner or Thanksgiving and [he] wasn't there. He was either on the streets, in jail, or in rehab. My parents would say, 'Where's [he]?' and I would lie and say, 'Well, he's at his girlfriend's house in the suburbs of [city] having dinner.' As demonstrated here, in some cases, engagement in avoidance strategies functioned to protect their loved one's reputation and avoid embarrassment or shame. In this way, AFMs were managing two types of stigma: (a) courtesy stigma and (b) stigma toward their loved one.
A second avoidance strategy exhibited within this study was making favorable social comparisons, where one described their loved one's opioid misuse as less problematic than others' use. This strategy is most clearly conveyed by a daughter: "Hearing all of these other [addiction] stories that were so horrible, and I'm like, 'This is not me. I don't belong here.' So, I think there's a part of me that's like, 'My experience wasn't that bad.'" This AFM coped with their experiences by distancing themselves from other AFMs whose addiction stories struck them as more severe than theirs in efforts to minimize the internalization of courtesy stigma. However, in their efforts to minimize stigmatization from others, by making favorable social comparisons, AFMs inadvertently invalidated their own experiences and feelings around their experiences.

Quadrant 3 (Q3): Challenging public stigma and accepting personal stigma
Family members employed SMC strategies from Q3 in situations where they did not feel society's stigmatization of people who misuse opioids was valid or justified, yet still felt stigmatized as an AFM. Strategies in Q3 (i.e., explaining strategies) include making external attributions about a loved one's responsibility for misusing opioids and attempts to reduce the offensiveness of the stigma by minimizing it in some way. This set of strategies captures instances where people feel stigmatized and are working to change the public perception of a stigmatized attribute, such as opioid misuse (Meisenbach, 2010). We are using the concept "external attribution-making" in place of the SMC construct "evading responsibility" as we believe the latter concept is negatively value-laden and may reinforce stigma for AFMs by suggesting that AFMs are avoiding blame that is rightfully theirs. Rather, this strategy encompasses when people attribute control (i.e., responsibility) for an outcome, such as opioid misuse, externally (Weiner, 2005). When the locus of control is external, responsibility for initial or continued opioid misuse is described as beyond an individual's control (Weiner, 2005).
When engaging in external attribution-making around their loved one's opioid misuse, AFMs largely identified external loci of control. Such external attributions clearly described opioid misuse as beyond both their control as an AFM and beyond their loved one's control. When deferring responsibility away from themselves, AFMs described how they could not control their loved one's actions. For example, when talking about her son's opioid misuse, a mother stated, "I can't do anything about my son. He's chosen that [opioid misuse]." In this excerpt, the AFM redirected blame from herself and placed it on her son. Such transferal of responsibility may be in response to managing stigma related to perceptions that parents play a role in their child's substance misuse and may be unique to contexts of courtesy stigma.
When deferring responsibility away from their loved one, family members made several types of external attributions. Some AFMs felt the opioid use could be linked to life circumstances, such as a son who attributed his mother's opioid misuse to her father's death: "My mom lost her dad when she was around the same age as I lost her. I feel like that defined her.
[It] may have been a catalyst for her addiction." Further, AFMs also described how their loved one's opioid misuse was beyond their control due to the nature of addiction as a brain disease. This type of attribution was exemplified by a parent as they described their child's continued opioid misuse: "He does not want to do drugs, but it's a brain disease. You don't know how hard it is, and I see how hard it is for him, because I see him struggle every day." The lack of choice related to opioid misuse was echoed by a son as he discussed his father: "It's not something that people choose and control. . . It's something that I don't think anybody would want to put themselves through." Some AFMs also externally attributed the responsibility for their loved one's opioid misuse to medical use of prescription opioids. This type of attribution was exemplified by an AFM who discussed the impetus for their mother's opioid misuse: My mom's origination with it was like so many people's where a general practitioner doctor prescribed her 60 Vicodin for something. . . and then it got to the point where [she] was like, 'well, I feel like shit not taking the Vicodin,' and asking for extensions [of the prescription], and then, of course, just going to the streets [for opioids] just to keep not feeling like crap.
In each of these examples, the AFM attempted to alter the public's perception by deferring control away from themselves and the person who misuses opioids. These statements also reflect AFMs' attempts to challenge the stigma toward opioid misuse by rejecting the notion that their loved ones are making an active choice to become or stay addicted to opioids. As such, AFMs engaged in external attribution-making and logical denial strategies simultaneously.
Reducing the offensiveness is another SMC strategy in quadrant three that aimed to change the way other people perceive stigma related to opioid misuse through shifting the focus from the opioid misuse to more positive aspects of the loved one (i.e., bolstering) or minimizing the impact of the opioid misuse on others. Bolstering and minimizing were both used by AFMs to reduce the offensiveness of their loved ones' opioid misuse. A daughter and sibling used bolstering when describing their loved one: It's challenging people's thinking like, 'Okay, but what was that person like before it [opioid misuse]?' That's all they are to you is a drug addict or whatever? I like to have those kinds of debates with people and try to challenge their thinking, because I think that's the only way we can try to get rid of the stigma.
By shifting attention to the non-stigmatized aspects of their loved one, this AFM engaged in bolstering and was aware of how using this strategy could help challenge stigma attitudes by deflecting attention away from the stigmatizing attribute.
Minimization was used to exhibit how the loved one's opioid misuse did not inconvenience or harm others (Meisenbach, 2010). A parent utilized bolstering and minimizing in concert when discussing their child: "He was always just a great, kind, loving person. So, it happens to everybody. He wasn't a meanie. He wasn't a robber. He wasn't a murderer. He loved pets, was kind to old people, and it [opioid misuse] just unfortunately got him." When minimizing, AFMs emphasized how their loved one was not harming others or engaging in criminal activity such as larceny. In some cases, AFMs bolstered their loved one's positive traits in conjunction with minimizing their impact on others. In doing so, AFMs actively highlighted positive qualities about their loved one and refuted the idea that they were a burden to others in efforts to challenge stigma.

Quadrant 4 (Q4): Challenging public stigma and personal stigma
When AFMs challenged the societal stigmatization of opioid misuse and the application of the stigma to oneself, they engaged in three challenging strategies (Q4). One way AFMs challenged stigma in these situations was by providing logical arguments with evidence that refuted the basis of the stigma or discredited people who hold stigmatizing views (i.e., logical denial). Another Q4 strategy involves the simple denial of the existence of societal or personal stigma toward opioid misuse without explanation (i.e., simple denial). The third challenging strategy used by AFMs in this study included ignoring stigma messages and continuing the display of their stigmatized attribute in efforts to challenge the stigma (i.e., ignoring/displaying; Meisenbach, 2010).
Logical denials of stigma capture moments where people utilize arguments to discredit the person engaging in stigmatization or provide evidence that refutes the stigma (Meisenbach, 2010). A sibling described how they use this approach to challenge the stigma around opioid misuse: If I hear people say stuff now-because it is still very hurtful to hear people talk like that knowing that they're talking about someone like my sister-I kind of have taken the approach now of [saying], 'Well, just so you know, my sister died of this and this is why what you're saying is wrong, or hurtful, or incorrect.' Similarly, a daughter and sibling described a general desire to challenge others' thinking about the stigma around opioid misuse: "I like to speak up and I like to have conversations. . . because I like to challenge people's thinking about that [stigma]." Logical denials involved some sort of educational component where AFMs wanted to share information or teach others about opioid misuse to improve the publics' understanding of it, and subsequently mitigate stigma.
The simple denial strategy is a flat-out denial of the existence of or personal feelings of stigma (Meisenbach, 2010). This strategy occurs when an AFM denies any personal or public shame attached to their loved one's opioid misuse. A daughter engaged in simple denial when discussing her lack of shame regarding her mother's opioid misuse: "I'm not ashamed or anything. It's just something that doesn't really come up in regular conversation." This AFM denied any shame attached to their mother's opioid misuse. In cases of simple denial, AFMs appeared to be wholly disconnected from stigmatization related to opioid misuse and felt it did not impact their lives and/or their loved ones' lives.
The ignoring/displaying strategy involved ignoring the societal stigma around opioid misuse and publicly disclosing their loved one's opioid misuse, as exemplified by a parent and daughter duo who shared their experiences of opioid misuse with others: I work as a nurse at the hospital here in [city]. My daughter and I were asked to share our story at a SUD conference that [the hospital] put on for the very first time. . .that was pretty empowering for both of us.
Ignoring and displaying functioned as a form of advocacy where AFMs boldly displayed their stigmatized attribute publicly in efforts to challenge the stigma toward opioid misuse.

Research question #2
The second research question asked about the ways family members' use of strategies for managing the stigma of opioid misuse changed throughout their experience. The findings suggest that AFMs' strategy use shifted alongside changes in how AFMs thought about the stigma toward opioid misuse. Family members recounted how the experience of having a loved one who misused opioids led them to hold fewer stigmatizing attitudes toward other people who misuse opioids, not just people with which they were personally connected. AFMs also described these changes in how they perceived opioid misuse in concert with how they managed the stigma attached to their loved one's opioid misuse over the course of their experience.

Changes in stigma attitudes toward opioid misuse
In some instances, AFMs recognized a change in how they made attributions for opioid misuse, where they initially viewed the loved one's opioid misuse as a choice (i.e., internal attribution-making) but later shifted the locus of control away from the individual as they began understanding opioid misuse as a disease (i.e., external attribution-making). This shift in control is best exemplified by a parent: I remember getting off the phone with him [my son] and looking at my wife and saying, 'What the hell is going on?' We thought our kid made a stupid decision.
[That] a black cloud followed him around. . . We had no idea that there was this [opioid] epidemic brewing in our community with both suburban, inner city, and rural kids.
In this excerpt, the AFM acknowledged shifts in their attribution for their child's opioid misuse from being the product of poor decision-making (i.e., internal) to a disease they have little control over (i.e., external). This shift not only removed the locus of control from their loved one but placed it on society more broadly, making opioid misuse a public issue rather than a private family matter.
Family members also described how their experience of having a loved one who misused opioids changed how they view people with SUDs differently in general, beyond how they view their own loved one: I was prejudiced in a sense against them [people who misuse opioids]. That 'Oh, they're losers. They need to get their shit together.' Yeah. Just, 'Oh God, look at those people down there doing those drugs. Why don't they try and stop? Why don't they try and better themselves?' Without realizing now that nobody wants to be an addict, and nobody wants to be there. But it's a very difficult thing and. . . I didn't realize any of that. I just thought 'Oh, you're a drug addict.' This AFM described a shift in their attitudes from a stance of validating the societal stigmatization of people with SUD to rejecting this stigma. This shift was linked to a greater understanding of the difficulty people with SUD experience when trying to stop using substances, which they gained through their personal experience.

Changes in stigma management strategies
Family members' accounts of how they managed stigma revealed changes in their use of management strategies throughout the course of their experience. These changes appeared to be related to changes in perceptions of their own attitudes toward SUDs, or perceptions of the attitudes of others. For example, a parent described a shift from using accepting strategies (Q1) when experiencing stigma messages toward the beginning of their loved one's opioid problems to utilizing challenging strategies (Q4): At one time I would just cry inside. I'd go home and cry and get angry. But now, I just say things like, 'Well, unless you've been through it, you really can't understand. . . Unless you're in somebody's shoes, you really don't know. It's not the parents' fault. It's just something that you really should learn a little bit more about before you talk like that.' This AFM describes a shift from using a passive acceptance strategy to a logical denial strategy. Individuals chose to actively challenge stigma toward themselves by arguing against placing blame on parents, while also challenging the public stigma by educating others about the need for better understanding around opioid misuse.
Similarly, another parent described how over time they talked more openly about their child's opioid misuse: I probably didn't start sharing until six or nine months down the road with individuals at work . . . It took me a while. . . because I still had that blame, that shame, 'What did I do as a parent? What did we not see? What did we not know?' So, definitely once I opened up, it was freeing to say, 'We do. We have a daughter with [opioid] abuse disorder, and yes, we're going through some rough times.' This parent's experience represents a shift from utilizing avoiding strategies (Q2) to challenging strategies (Q4), where she began by hiding the opioid misuse but eventually displayed it publicly. The shift from hiding to displaying also was exhibited by a daughter who directly linked her feelings of shame with her decision to remain secretive (i.e., avoiding strategy; Q2) in the early stages of their loved one's addiction. As her experience progressed, however, she engaged in challenging strategies (Q4) to rebuke that stigma in efforts to encourage others to be open about their experiences and get support: In each of these shifts, the AFM's description of their experience represents a transformation from accepting the societal stigma and/or personal attachment of stigma to themselves as valid (Q1, Q2), to challenging both forms of stigma (Q4). AFMs who utilized challenging strategies had made a conscious decision to advocate for themselves, their loved ones, and others impacted by opioid misuse in efforts to mitigate stigma that serves as a deterrent to help-seeking.
Changes in perceptions about attributions surrounding opioid misuse seemed to play a role in AFMs' SMC strategies. For instance, AFMs commonly described how perceived changes in public attitudes toward people who misuse opioids affected their own perceptions of opioid misuse, and subsequently how they talked about their loved one. Such a shift was exemplified by a daughter as she talked about her mother's opioid misuse: Later on is when we talked a little bit more about it [opioid misuse], because it's just been in the last several years that it's like. . . 'That's [SUD is] a disorder. . . It's not a moral failing.' That's not where it [the conversation] was back in 2012 as much. It was just coming out that it [SUD] was a brain disorder, and that they didn't have control over the frontal [lobe] stuff that was happening. . . That whole shame and guilt was huge. That kept us from talking as much about it as I think we talked about it later. We talk about it later like it's a brain disorder, definitely.
This type of shift exemplifies a move from accepting (i.e., internal attribution-making; Q1) and avoiding strategies (i.e., hiding; Q2) to explaining (i.e., external attribution-making; Q3) and challenging strategies (i.e., displaying; Q4). In such cases, the AFMs used multiple strategies concurrently as they engaged in attribution-making (Q3) and displaying (Q4) simultaneously as they were not only displaying their loved one's opioid misuse but were also externally attributing the addiction to a brain disorder (Q3). Overall, changes in stigma management strategies from accepting and avoiding strategies (Q1, Q2) to those that explain and challenge stigma attitudes (Q3' Q4) are a salient finding. These preliminary findings suggest a relationship exists between changes in stigma attitudes and stigma management strategies.

Discussion
OUDs remain highly stigmatized, contributing to courtesy stigma experienced by close family members of individuals who misuse opioids. AFMs' experiences in this study represented the use of accepting, avoiding, explaining, and challenging strategies. While the strategies used were consistent with Meisenbach's (2010) four quadrant model in several ways, the findings also complicate the model and suggest a need to revisit how some of the strategies are conceptualized, especially in contexts of family stigma. Further, there is a need to highlight how stigma attitudes and management strategies of AFMs change throughout the course of their experience. More specifically, AFMs' lived experiences suggest the strategies they use fluctuate and are dependent on the social context and their current personal stigma attitudes toward opioid misuse. Such changes also offer implications for how families communicate as they cope with the stigma of having a loved one who misuses opioids.

Rethinking the SMC model
Our findings add to a growing body of literature that suggests a need to revisit how the SMC typology is conceptualized. This four-quadrant typology is one part of the overarching model of SMC. Since its conception, the SMC typology has been utilized to investigate how people communicatively cope with stigma. These investigations have affirmed the utility of this model, while also pointing to opportunities to strengthen it (see Brule & Eckstein, 2016;Hartelt, 2018;Noltensmeyer & Meisenbach, 2016;O'shay-Wallace, 2020;Romo & Obiol, 2021;Tikkanen et al., 2019). More specifically, consistent with this study, researchers have argued for the need to acknowledge how people may use strategies from more than one quadrant simultaneously (Hartelt, 2018;O'shay-Wallace, 2020;Romo & Obiol, 2021;Tikkanen et al., 2018), signifying a blurring of the lines between quadrants. For example, some family members utilized external attribution-making (i.e., Q3; explaining) and logical denial (i.e., Q4; challenging) at the same time.
Further, the emergence of a new stigma management strategy (i.e., internal attribution-making) in this study builds on previous arguments that suggest people make deliberate choices about their strategy use based on relational and contextual factors specific to their situation (Noltensmeyer & Meisenbach, 2016). We propose revising the SMC typology to add internal attribution-making to Q1 as a strategy used by individuals who accept public and personal stigma and place the locus of control for that stigma on the stigmatized individual. Novel SMC strategies have been presented in other research as well, such as modifying and questioning in the context of adolescent to parent child abuse (see Brule & Eckstein, 2016) and advocacy in the context of managing the stigma of alcoholism (see Romo et al., 2021). As the context of a stigma situation guides the choice of strategy, it is likely that new strategies will continue to emerge as the SMC theory is applied across stigma contexts.
Based on our findings and existing literature, we suggest the need to move away from thinking of stigma management strategy usage as the product of a rigid typology to a more flexible process that accounts for the simultaneous use of strategies across quadrants. People's experiences may reflect the use of multiple strategies that complement or contradict one another, dependent on the stigma situation, and thus may not fit squarely into one quadrant of the typology. Researchers and practitioners should consider how people's management of stigma may represent internalization of stigma (i.e., accepting and avoiding) or rejection of stigma (i.e., explaining and challenging) based on their unique use of coping strategies and the context within which they use them, rather than assuming that a strategy or a person's behaviors inherently indicate placement within one specific quadrant.

Implications for family communication & courtesy stigma
This study identified the use of SMC strategies among people who experienced family stigma, and not solely among people who are the direct recipients of stigma. In line with extant research (O'shay-Wallace, 2020;Ranjit et al., 2022;Tikkanen et al., 2018), this study affirms the relevance of SMC theory to those individuals experiencing courtesy stigma. For family members and other targets of courtesy stigma, ties to the stigmatized condition may be more easily concealed. As such, avoidance (Q2) strategies may be more feasible for those people experiencing courtesy stigma (i.e., AFMs) than for direct recipients of stigma (people with OUD). Compared to people managing stigma related to their own discreditable attribute, family members also appear to be better positioned to engage in challenging strategies as they may be perceived as more credible and deserving of empathy than people with personal histories of opioid misuse or OUD. Further, when engaging in external attribution-making (Q3), AFMs described OUD as not only beyond their loved one's control (i.e., "it's not their fault"), but also beyond their control as an AFM (i.e., "it's not my fault"). These findings highlight an important way SMC among those managing family stigma and other forms of courtesy stigma is distinct from people who directly bear a stigmatizing attribute, where AFMs manage both their own courtesy stigma as well as their loved one's stigma.
Thus, the ways family members communicatively manage courtesy stigma may differ from the ways people manage stigma related to their own discreditable attribute. Because some SMC strategies may lead to more effective coping with stigma than other strategies, it is important to understand these distinctions. The way family members communicate amongst themselves about their loved one's opioid misuse may impact family members' stigma attitudes and their subsequent approach to stigma management. Extant research suggests family communication about attributes (i.e., weight, mental illness) that can be stigmatized influences family members' own stigma attitudes (Asbury & Woszidlo, 2016;Flood-Grady et al., 2023). For example, open and frequent family communication is associated with anti-fat attitudes and likely influences the development and perpetuation of weight stigma overall (Asbury & Woszidlo, 2016). In the context of substance use, families that talk openly and frequently overall and specifically about their loved one's opioid misuse may indicate non-stigmatizing attitudes toward opioid misuse, and thus lead to the use of challenging strategies.
Contrarily, families that avoid talking about their loved one's opioid use or use language that indicates stigmatizing attitudes may tend to use accepting and avoiding strategies. Further, as the ways families talk about their loved one's opioid use changes (i.e., closed to open communication or vice versa), so may their stigma attitudes and resulting SMC strategy use. Additional factors, such as social support within and from outside of the family, relational turbulence or stability within the family, and family identity processes, may also be influencing stigma attitudes and strategy use. Future research should continue to investigate the ways family stigma management differs from other types of stigma management as well as how other family processes impact strategy usage.
Recent research has begun to answer previous calls for the investigation of predictors of SMC strategy use and relationships between SMC strategy use and relevant outcomes (see Brule & Eckstein, 2016;O'shay-Wallace, 2020). For example, Smith and Bishop (2019) found that having a strong meaning in life and having received unsupportive reactions from others upon disclosing their association with a stigmatizing attribute are predictors of SMC strategy use. In the context of courtesy stigma, Ranjit et al. (2022) found that reducing offensiveness (i.e., Q3; explaining) and passive acceptance (i.e., Q1, accepting) strategies were related to poor mental health outcomes. The findings from this study reveal that AFMs' efforts to minimize stigmatization from others toward themselves and their loved ones could result in invalidation of their own self-worth due to their status as a recipient of courtesy stigma, which may have negative outcomes for their health and quality of life. A great strength of SMC theory is its practical applicability across a wide range of stigma contexts (Brule & Eckstein, 2016). As such, future research should continue to explore these predictors and the implications of the use of specific strategies for individual's wellbeing, both qualitatively and quantitatively.

Translational section
The findings from this study can be used to inform practice for social workers and counselors working with family members experiencing family stigma, especially those with loved ones who misuse opioids and other substances. Practitioners can use findings from this study to inform their interactions with AFMs. For example, practitioners may informally assess the ways AFMs talk about their experiences of having a loved one who misuses opioids to discern whether they may be internalizing family stigma, and subsequently whether they are managing this stigma productively.
If the AFM appears to be using strategies associated with stigma internalization, such as isolation and avoidance, the practitioner can work with the AFM to find ways to more effectively cope with family stigma. For example, in this study, "bonding with the stigmatized" emerged as a particularly useful strategy for AFMs coping with internalized stigma and was sometimes described as helping AFMs to move from accepting to challenging strategies. As such, practitioners should consider linking AFMs with mutual support groups in the community or developing such groups where they do not exist. Further, the findings related to "attribution-making" and "logical denial" strategies highlight psychoeducation about the biopsychosocial model of addiction as a potentially effective component of individual or group interventions with AFMs. Helping AFMs to understand the many complex interrelated factors that contribute to the development of an SUD may help prepare them to engage in SMC strategies that challenge the societal perception of opioid misuse and OUD. Doing so may mitigate the emotional, social, and interpersonal consequences of family stigma outlined by Park and Park (2014).
This study also highlights the complexities surrounding the ways family members' use of SMC strategies may sometimes conflict and are likely to change throughout their experience. As such, practitioners can validate clients' experiences and reassure them that these changes and contradictions should not be considered maladaptive. For example, passive or avoidant strategies may be more acceptable to family members in the early stages of coping with their loved one's substance use, whereas challenging strategies may become appropriate as more time passes. Family members should not be pushed to engage in challenging strategies, but rather assisted in selecting strategies that are acceptable and feasible for them at a given time and place. For example, avoiding potentially stigmatizing people and situations, bonding with other AFMs, and ignoring or allowing stigmatizing comments to "roll off one's back" may all be effective strategies for AFMs in certain contexts. Practitioners can use this nuanced understanding of SMC to help AFMs develop strategies for communicatively managing the stigma associated with their loved one's substance use, based on where they are at in their own change process.

Limitations & future directions
Although this study provides rich data on the experiences of families affected by opioid misuse, the sample was a limitation to this study. Demographically, the study sample was primarily White (76.5%) and female (70.6%). Additionally, about a third (32.4%) of the sample included people that were involved in a statewide support group for AFMs. It is possible that people engaging in support groups for AFMs differ in their perceptions of stigma toward opioid misuse, which may subsequently impact the SMC strategies they employ. Attempts were made to diversify the sample by recruiting through our university's online portal. However, future research should examine stigma management strategies within and across demographic group differences.
Further research is needed to investigate the nuances of family stigma management and examine the impact of the communication strategies revealed in this study on AFMs' social/emotional health and public perception of opioid misuse. Future studies should also examine the pathways through which the perceptions of opioid misuse shift to be less stigmatizing for AFMs, and the processes through which this shift occurs. As identified in this study, there appears to be a link between shifts in stigmatizing attitudes and stigma communication strategies among AFMs. A mixed-methods longitudinal approach would help to illuminate this change process throughout the course of AFMs' experiences as they cope with their loved one's opioid misuse. It could be that a change in stigma attitudes is related to a change in communication. Alternatively, a shift in communication strategies (e.g., from avoidant to challenging) may help to reduce self-stigma and improve health outcomes. Developing a deeper understanding of the processes through which stigmatizing attitudes and stigma communication strategies shift over time might also inform interventions to support family members struggling with courtesy stigma related to their loved one's opioid misuse.

Conclusion
Stigma management strategies employed by family members impacted by opioid misuse may overlap and change. Family members engage in more confrontational SMC strategies as they reduce their own stigmatizing attitudes about opioid misuse. Additionally, SMC strategies do not always fit into one category identified by Meisenbach's (2010) as AFMs may utilize more than one strategy at a time and change their approach to managing stigma over the course of their experience. Further efforts are needed to help AFMs identify how the SMC strategies they use are associated with their own health and well-being and empower AFMs to adopt the stigma management strategies that are most effective for them. The current findings highlight how stigma management and communication may be key areas for the education and support of families affected by opioid misuse.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This project was supported by funding from a CSAP/CSAT State Opioid Response Grant (TI-18-015) and a CSAP/CSAT State Targeted Response to the Opioid Crisis (Opioid STR)/Substance Abuse and Mental Health Services Administration (SAMHSA) Grant (TI-17-004).