Courtesy Stigma among Family Members of Drug Users Scale

Abstract

The Courtesy Stigma among Family Members of Drug Users Scale (known natively as the Escala de Estigma de Cortesia entre Familiares de Usuários de Drogas — ECOFAD) is a specialized psychometric instrument designed to evaluate, quantify, and conceptualize the multidimensional manifestations of courtesy stigma experienced by relatives of people who use alcohol and other drugs. Grounded in sociological and psychological frameworks of associative stigma, the instrument captures how the societal discreditation, prejudice, and discrimination directed toward individuals with substance use disorders diffuse across interpersonal ties to affect their immediate kin. Originally engineered in Brazilian Portuguese by researchers affiliated with the Universidade Federal de Juiz de Fora (UFJF), the instrument addresses a critical gap in family and addiction psychometrics. The ECOFAD originated from an extensive systematic literature review and item-generation phase drawing upon both international scales and clinical observations, culminating in a preliminary 38-item pool distributed across tri-partite psychological domains: cognitive, affective, and behavioral. Following rigorous evaluation by an expert panel of psychometricians, addiction specialists, and family therapists, the scale exhibited exemplary content validity (Content Validity Coefficients: writing = 0.78, clarity = 0.82, relevance = 0.87). In empirical validation involving family members recruited from mutual help networks (such as Amor-Exigente, Al-Anon, and Nar-Anon), Exploratory Factor Analysis via parallel analysis corroborated a robust three-factor solution accounting for 48.7% of the total variance with outstanding goodness-of-fit indices (χ² = 651.457, df = 592, p = 0.04528; RMSEA = 0.034; CFI = 0.993; TLI = 0.992). The scale displayed exceptional internal consistency, registering a global Cronbach’s alpha of 0.94 (Affective dimension α = 0.89; Cognitive dimension α = 0.88; Behavioral dimension α = 0.82) and a split-half Spearman-Brown reliability coefficient of 0.95. High construct replicability was confirmed across dimensions via the H-index (Affective = 1.017, Cognitive = 1.000, Behavioral = 0.941). The ECOFAD constitutes an empirically validated, free, non-commercial instrument that enables mental health professionals, public health researchers, and clinicians to measure associative stigma, design tailored psychoeducational interventions, and mitigate family burden.

Keywords

Courtesy Stigma, Associative Stigma, Substance Use Disorder, Family Members, Psychometrics, Scale Validation, Affective Reactions, Behavioral Avoidance, Cognitive Bias, Social Isolation

Authors

The scale was developed and psychometrically validated by a collaborative team of Brazilian clinical psychologists, psychometricians, and public health researchers specializing in addiction studies, social stigma, and mental health interventions:

• Daniel Augusto Costa Maldonado: Master and doctoral researcher in Psychology at the Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, Minas Gerais, Brazil. His academic investigation centers on public health, clinical family psychology, psychometric development, and the psychosocial repercussions of addiction on family networks.
• Leonardo Fernandes Martins: Researcher affiliated with the Department of Psychology at the Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio), Rio de Janeiro, Brazil. His scholarly work focuses on quantitative methodology, psychological assessment, behavioral interventions, and epidemiological investigations into substance use.
• Pollyanna Santos da Silveira: Professor and researcher associated with the Universidade Católica de Petrópolis (UCP), Petrópolis, Rio de Janeiro, Brazil. Her research expertise encompasses behavioral medicine, community health psychology, stigma mechanisms, and the evaluation of social support structures.
• Telmo Mota Ronzani: Full Professor at the Departamento de Psicologia, Instituto de Ciências Humanas, Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, Minas Gerais, Brazil. A leading authority on substance use, public policies on drugs, and stigma in Latin America, Professor Ronzani serves as the corresponding author and director of the Center for Research, Intervention, and Evaluation in Alcohol and Other Drugs (CREPEIA/UFJF). Correspondence can be addressed via email to: [email protected].

Purpose

The primary clinical and epidemiological purpose of the Courtesy Stigma among Family Members of Drug Users Scale (ECOFAD) is to quantify the psychological, affective, cognitive, and social repercussions of courtesy stigma experienced by relatives of individuals with problematic substance use. Substance use disorders (SUD) are among the most deeply stigmatized health conditions globally. However, contemporary psychological literature historically neglected the collateral interpersonal toll suffered by kinship networks. Rooted in sociological models, family members are frequently subjected to secondary or associative stigmatization: the social derogation, moral blame, interpersonal estrangement, and institutional discrimination directed at them solely because of their familial connection to a person who uses psychoactive substances.

The development of the ECOFAD arose from specific theoretical, diagnostic, and clinical needs within health psychology, community mental health, and social work:

• Disentangling Objective Burden from Stigma Burden: While conventional assessment tools in psychiatric research emphasize objective family burden (such as financial strain, physical caretaking duties, and disruptive domestic behaviors), they frequently overlook the insidious intrapsychic and interpersonal impacts of courtesy stigma. The ECOFAD fills this measurement gap by directly operationalizing the perceived discrimination, internalized shame, and social avoidance directly attributed to societal prejudice.
• Overcoming Cultural Gaps in Psychometric Tools: A significant portion of stigma research originated within North American and Western European cultural environments. The ECOFAD was specifically constructed and standardized to capture the familial dynamics, community networks, and healthcare landscape of Latin America, particularly Brazil, where family interdependence, community gossip, and moralized attitudes toward drug addiction introduce distinct stigmatizing pressures.
• Informing Evidence-Based Psychoeducational and Clinical Interventions: Clinicians working within addiction treatment settings, such as Psychosocial Care Centers for Alcohol and Drugs (CAPS-AD) and private clinics, can utilize the ECOFAD during intake or routine clinical evaluations to identify family members exhibiting extreme subjective distress, guilt, or social withdrawal. By identifying elevated dimensions (e.g., severe social avoidance vs. heightened perceived judgment), therapists can tailor family psychotherapy, cognitive-behavioral reframing, and supportive interventions.
• Empowering Mutual-Help and Advocacy Groups: Grassroots mutual support organizations, including Al-Anon, Nar-Anon, and Amor-Exigente, play a foundational role in providing peer support to relatives. The ECOFAD offers a standardized evaluation instrument capable of measuring longitudinal change, therapeutic decompression, and social reintegration among members attending these support groups.
• Informing Public Health Policy and Anti-Stigma Campaigns: Policymakers and health researchers require robust, objective epidemiological data to design macro-level anti-stigma campaigns. The ECOFAD provides the empirical precision required to document the structural, interpersonal, and psychological toll of stigma on entire family units, supporting the allocation of mental health resources beyond the identified patient.

Psychological Construct

The core construct evaluated by the instrument is courtesy stigma (also termed associative stigma or secondary stigma), defined as the prejudice, negative stereotyping, discriminatory behavior, and subsequent internal psychological turmoil experienced by an individual due to their significant social, relational, or genetic association with a stigmatized person. In the context of addiction, courtesy stigma represents a complex, multi-tiered psychological phenomenon that unfolds across cognitive, affective, and behavioral channels.

The Tri-Partite Structural Formulation

During the foundational development of the ECOFAD, the construct was operationalized through a tripartite model of attitudes, incorporating the classic components of human behavior:

• The Cognitive Dimension: Encompasses beliefs, assumptions, interpretations, and attributions concerning societal judgment, family responsibility, and moral failure. Relatives often cognize that the wider public views their family unit as dysfunctional, negligent, or directly culpable for the drug use. This dimension captures cognitive distortions such as personalization of societal prejudice, anticipated rejection, and the belief that outsiders perceive their family lineage as intrinsically flawed.
• The Affective Dimension: Encompasses the pervasive emotional distress evoked by societal condemnation. Relatives experience intense shame (vergonha), vicarious embarrassment, deep sorrow, subjective guilt, helplessness, anxiety regarding exposure, and righteous anger when encountering depreciative comments. This affective overload often manifests as chronic psychological exhaustion and depressive symptomatology.
• The Behavioral Dimension: Reflects the functional and relational modifications executed by family members to cope with, conceal, or preempt stigmatizing interactions. This includes active social withdrawal, concealment of the family member’s substance use, avoiding inviting guests into the home, abandoning social and leisure gatherings, and terminating relationships with friends, neighbors, or colleagues to prevent embarrassment and interrogation.

Empirical Latent Subscales

Subsequent psychometric factor analysis resolved these tripartite components into three coherent, empirically supported factors that capture the experiential reality of family members:

• Factor 1: Perceived Discrimination and Emotional Repercussions (Discriminação Percebida e Repercussões Emocionais): This dimension measures the explicit realization that the outside world treats the family member differently, along with the immediate emotional fallout of that recognition. It evaluates external judgment, feelings of being blamed for the substance user’s actions, perceived social rejection, and the resulting feelings of anger, sadness, emotional overwhelm, and helplessness.
• Factor 2: Self-Stigma and Social Isolation (Autoestigma e Isolamento Social): This dimension evaluates the internal absorption and behavioral consequence of courtesy stigma. When family members internalize social stereotypes, they experience deep shame and subjective failure. Consequently, they enact defensive behaviors, including deliberate social withdrawal, breaking ties with peer networks, refusing to host people at home, and retreating into domestic isolation to hide the problem.
• Factor 3: Impact on Interpersonal Relationships (Impacto nas Relações Interpessoais): This dimension reflects the breakdown, alienation, and perceived avoidance occurring within the family’s broader relational sphere. It assesses the feeling that acquaintances, peers, and extended relatives are reluctant to approach the family, the feeling of losing personal and professional opportunities due to association, and the perception that society fundamentally misunderstands the chronic pain endured by the family.

Theoretical Framework

The structural and conceptual foundation of the ECOFAD rests upon the intersection of classical sociological theories of deviance, contemporary social-cognitive stigma models, and systemic family psychology.

Goffman’s Conceptualization of Stigma and Spoiled Identity

The theoretical bedrock of courtesy stigma was formulated by sociologist Erving Goffman in his seminal 1963 treatise, Stigma: Notes on the Management of Spoiled Identity. Goffman delineated stigma as a deeply discrediting attribute that reduces an individual from a whole, usual person to a tainted, discounted one. Crucially, Goffman recognized that stigma does not operate in isolation; it diffuses through social networks via what he termed “courtesy stigma.” Individuals who possess a normal social identity but maintain close structural, biological, or emotional ties to a stigmatized individual are themselves subject to stigma by association. Their social identity becomes similarly “spoiled” in the eyes of society. In substance use disorders, society views addiction not merely as a medical pathology, but often as a moral failure, deviance, or character flaw. By extension, the family is labeled as an enabler, a dysfunctional incubator, or an untrustworthy social unit.

Corrigan’s Social-Cognitive Model of Stigma

The operationalization of the ECOFAD is heavily guided by Patrick Corrigan‘s modern social-cognitive framework of stigma. Corrigan differentiates between public stigma (the broader society’s stereotypes, prejudices, and discriminatory actions) and self-stigma (the internal adoption and psychological internalization of those public attitudes). In the context of courtesy stigma, family members encounter a dual process:

1. Public Courtesy Stigma: Society holds stereotypes about relatives of drug users (e.g., “they are bad parents,” “they are codependent,” “they must have raised them poorly”), experiences prejudice (e.g., fear, pity, disdain), and engages in discrimination (e.g., social exclusion, withholding support).
2. Internalized Courtesy Stigma: When family members internalize these societal tropes, they experience self-blame, diminished self-efficacy, chronic guilt, and self-directed shame, which leads to behavioral withdrawal and self-imposed isolation.

Link and Phelan’s Conceptualization of Stigma

The scale aligns with Bruce Link and Jo Phelan’s (2001) sociological model, which characterizes stigma as the convergence of four interconnected components: labeling, stereotyping, separation (“us” vs. “them”), and status loss/discrimination, all occurring within an overarching power imbalance. For relatives of drug users, labeling occurs when the community categorizes them as “a drug user’s family.” This triggers negative stereotypes that lead to social separation, diminishing the family’s social capital and standing within their neighborhood, workplace, and religious community.

Family Systems Theory and the Stress-Coping-Support Model

Finally, the ECOFAD integrates concepts from Family Systems Theory (Bowen) and the Stress-Coping-Support Model (Orford et al.). A family is an interconnected emotional and functional system. The occurrence of substance use in one member disrupts homeostasis, inducing profound chronic stress across the unit. When external social networks react with condemnation rather than empathy, the family’s natural coping mechanisms are compromised. Instead of seeking community support, the family closes its operational boundaries, concealing the issue to guard against external hostility, which compounds family distress.

Validity

The psychometric validation of the ECOFAD followed rigorous international testing standards and Pasquali’s psychometric model, demonstrating excellent content, construct, and structural validity.

Content Validity Assessment

The initial instrument pool, consisting of 38 items derived from theoretical literature and international instruments, underwent content evaluation by a multidisciplinary panel of expert judges. This panel comprised psychologists, clinical psychometricians, family psychotherapists, and addiction researchers. The judges evaluated every individual item across three fundamental psychometric criteria using the Content Validity Coefficient (CVC) developed by Hernández-Nieto:

• Writing Quality (Linguagem/Redação): The CVC for item phrasing was 0.78. Although slightly below the preferred 0.80 cutoff due to extensive semantic recommendations made by judges to contextualize expressions for Brazilian demographics, over 82.0% of the individual items achieved a CVC above 0.70. Phrasing was modified and clarified based on expert feedback.
• Clarity (Clareza): The scale achieved an overall CVC of 0.82 for clarity, with 89.5% of the individual items surpassing the 0.70 threshold, confirming that the scale items were intelligible to respondents across diverse educational backgrounds.
• Theoretical Relevance and Pertinence (Pertinência Teórica): The instrument achieved an exceptional overall CVC of 0.87 for theoretical relevance, with 97.4% of the items exceeding the 0.70 benchmark. This verified that the proposed items mapped cleanly onto the cognitive, affective, and behavioral manifestations of courtesy stigma.

Following semantic adjustments and qualitative revisions, all 38 items were retained for the empirical validation study to ensure comprehensive coverage of the construct.

Construct and Structural Validity

Construct validity was evaluated empirically using a validation sample of family members of individuals who use alcohol and other drugs. Participants were recruited from mutual help groups (such as Amor-Exigente, Al-Anon, and Nar-Anon) across Brazil. The sample comprised adult men and women aged 32 to 78 years, representing diverse relational ties (parents, spouses, siblings, and adult children).

Data suitability was verified through sampling adequacy criteria. Exploratory Factor Analysis confirmed that the items effectively represented the courtesy stigma construct. Most items exhibited robust factor loadings and substantial communalities. Construct replicability was verified using the generalized H-index, which assesses how well a set of items represents a latent construct across replications. The indices were outstanding: 1.017 for the Affective factor, 1.000 for the Cognitive factor, and 0.941 for the Behavioral factor, comfortably exceeding the standard 0.80 threshold and indicating exceptional construct stability.

Reliability

The ECOFAD demonstrates strong reliability, displaying high internal consistency, split-half stability, and item discrimination across multiple testing paradigms.

Internal Consistency Metrics

Internal consistency was calculated using Cronbach’s alpha (α) for both the total instrument and its distinct empirical dimensions. Across all evaluated metrics, the ECOFAD comfortably exceeded conventional psychometric standards (α ≥ 0.70 for research instruments, α ≥ 0.80 for clinical assessment tools):

• Overall Scale: Global Cronbach’s alpha of α = 0.94, denoting high internal consistency and minimal measurement error across the complete item composite.
• Affective Dimension: Cronbach’s alpha of α = 0.89, demonstrating that items assessing subjective emotional distress, shame, sorrow, and guilt are cohesive.
• Cognitive Dimension: Cronbach’s alpha of α = 0.88, confirming strong internal consistency among items evaluating beliefs regarding blame, perceived societal judgment, and perceived familial failure.
• Behavioral Dimension: Cronbach’s alpha of α = 0.82, establishing reliable measurement of avoidance, social concealment, and relational withdrawal patterns.

Split-Half Reliability and Item Discrimination

The scale’s internal split-half stability was verified through the Spearman-Brown prophecy formula, which yielded a correlation coefficient of 0.95, confirming strong equivalence between test halves. Furthermore, corrected item-total correlation coefficients were calculated for each item. The vast majority of scale items comfortably exceeded the conventional psychometric threshold of 0.30, indicating that the items effectively discriminate between individuals with high versus low levels of experienced courtesy stigma. In initial empirical trials, only items 15 and 25 displayed lower corrected item-total correlations, which informed subsequent refinements regarding item retention and structural weightings.

Factor Analysis

The underlying dimensionality of the ECOFAD was investigated via Exploratory Factor Analysis (EFA), employing modern factor analytic principles suited for ordinal, polytomous psychometric data.

Dimensionality Extraction and Parallel Analysis

To determine the optimal number of latent factors, the empirical dataset was subjected to Parallel Analysis (Horn’s method) alongside visual inspection of the Scree Plot. Parallel analysis recommended the extraction of a three-factor structure, matching the theoretical conceptualization while outperforming unidimensional and two-dimensional models. The three extracted factors collectively accounted for 48.7% of the total explained variance in courtesy stigma scores, an adequate level of explained variance for broad psychological and sociological constructs.

Factor Loadings and Structural Indices

The exploratory factor solution demonstrated that items mapping to the affective domain and the majority of items within the behavioral domain exhibited high factor loadings (λ > 0.50) and robust communalities. Within the cognitive dimension, several items (specifically items 15, 18, 19, 24, and 25) displayed lower factorial weights and communalities relative to the broader item pool. This reflects the greater cognitive complexity and attributional diversity that relatives experience regarding responsibility and systemic societal judgment.

Goodness-of-Fit Parameters

Structural adjustment indices demonstrated that the three-factor model yielded an excellent fit to the empirical data:

• Chi-Square / Degrees of Freedom: χ² = 651.457, df = 592, p = 0.04528. The ratio (χ²/df = 1.10) reflects a good model fit.
• Root Mean Square Error of Approximation (RMSEA): 0.034 (with narrow 90% confidence intervals well below the conservative 0.05 threshold), indicating low approximation error in the population covariance matrix.
• Comparative Fit Index (CFI): 0.993, substantially surpassing the standard 0.95 benchmark for superior model fit.
• Tucker-Lewis Index (TLI): 0.992, confirming outstanding fit relative to the baseline null model.

In addition, the H-index values confirmed strong latent construct determinacy (Affective = 1.017, Cognitive = 1.000, Behavioral = 0.941), demonstrating that the extracted factors are reliable targets for individual-level scoring and cross-sample replication.

Instrument / Measurement Tool

• Test Name: Escala de Estigma de Cortesia entre Familiares de Usuários de Drogas (ECOFAD) / Courtesy Stigma among Family Members of Drug Users Scale
• Construct Measured: Courtesy Stigma (associative/secondary stigma) across cognitive, affective, and behavioral dimensions
• Target Population: Adult family members (parents, spouses, siblings, adult children, extended kin) aged 18 years and older who have a relative with an alcohol or other drug use disorder
• Validation Age Range: Adults aged 32 to 78 years (including young adulthood, middle age, and older adults)
• Test Type: Original self-report psychometric inventory / rating scale
• Administration Format: Standardized paper-and-pencil or electronic/digital administration
• Administration Time: Approximately 10 to 15 minutes
• Primary Language: Portuguese (developed and validated within Brazil)
• Response Format: Standardized 5-point Likert rating scale: 1 = Discordo totalmente (Strongly disagree), 2 = Discordo (Disagree), 3 = Não concordo nem discordo (Neither agree nor disagree), 4 = Concordo (Agree), 5 = Concordo totalmente (Strongly agree)
• Factor Structure:
  • Factor 1: Perceived Discrimination and Emotional Repercussions (Discriminação Percebida e Repercussões Emocionais)
  • Factor 2: Self-Stigma and Social Isolation (Autoestigma e Isolamento Social)
  • Factor 3: Impact on Interpersonal Relationships (Impacto nas Relações Interpessoais)
• Scoring Procedures: Item responses are scored continuously from 1 to 5 points. Composite factor scores and a global courtesy stigma score are computed by calculating either the sum or the arithmetic mean across items within each dimension and across the entire scale. Higher scores indicate greater levels of perceived courtesy stigma, greater emotional burden, higher internalized shame, and more severe social avoidance.

Permissions & Fee and Test Year

The Courtesy Stigma among Family Members of Drug Users Scale (ECOFAD) was developed and published in 2023 by Daniel Augusto Costa Maldonado, Leonardo Fernandes Martins, Pollyanna Santos da Silveira, and Telmo Mota Ronzani. In accordance with open-science principles and public health research ethics, the ECOFAD is a non-commercial, open-access psychometric instrument. There is no fee required for its administration in non-profit academic research, epidemiological surveys, public health evaluations, or routine clinical practice.

Researchers and clinicians wishing to employ the instrument, adapt it to other languages, or utilize it within structured healthcare services (such as Brazil’s Sistema Único de Saúde / CAPS-AD networks) are encouraged to contact the corresponding author, Professor Telmo Mota Ronzani, at [email protected]. Formal citation of the original validation paper published in Avaliação Psicológica is required in all derived academic publications, dissertations, theses, and public clinical reports.

References

• Corrigan, P. W., Watson, A. C., & Miller, F. E. (2006). Blame, racism, and credentialism: Portrayals of mental illness in the mass media. Mental Health and Social Inclusion, 10(2), 22–28. https://doi.org/10.1108/17459842200600017
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Simon & Schuster.
• Hernández-Nieto, R. A. (2002). Contributions to statistical analysis: The content validity coefficient and the coefficient of proportion analysis. Universidad de Los Andes.
• Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363–385. https://doi.org/10.1146/annurev.soc.27.1.363
• Maldonado, D. A. C., Martins, L. F., da Silveira, P. S., & Ronzani, T. M. (2023). Escala de Estigma de Cortesia entre Familiares de Usuários de Drogas (ECOFAD) [Construction of the Courtesy Stigma among Family Members of Drug Users Scale (ECOFAD)]. Avaliação Psicológica, 22(1), 92–102. https://doi.org/10.15689/ap.2023.2201.25055.10
• Orford, J., Templeton, L., Velleman, R., & Copello, A. (2005). Family members of people with alcohol, drug, or gambling problems: A framework for understanding and helping. British Journal of Social Work, 35(5), 841–863. https://doi.org/10.1093/bjsw/bch209
• Pasquali, L. (2010). Instrumentação psicológica: Fundamentos e práticas. Artmed.
• van der Sanden, R. L., Bos, A. E., Stutterheim, S. E., Pryor, J. B., & Kok, G. (2013). Experiences of courtesy stigma among family members of people with mental illness: A qualitative study. International Journal of Social Psychiatry, 61(1), 77–86. https://doi.org/10.1177/0020764014535754

Items of the Scale