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To all this, we must add the cases where the person with an addiction has access
to the current account or credit cards and makes improper and sometimes reckless
uses of family money, either to sustain substance consumption, or to cover previ-
ously contracted debts. This not only aggravates economic difculties, but can also
generate serious family conicts, eroding trust and the sense of nancial security in
the home.
15.5.2 Impact onFamily Structure andRelationships
The appearance of an addictive disorder deeply affects the family relationships,
transforming the dynamics as the caregiver assumes new responsibilities. These
responsibilities increase as the person with addictive behavior loses functionality in
their daily life, which often generates an imbalance in power relations and the dis-
tribution of tasks within the home (Edwards & Steinglass, 1995). Consequently, this
imbalance can produce signicant emotional wear among family members, espe-
cially in the primary caregiver, and thus contribute to the emergence of problems
such as chronic stress, anxiety, and depression among caregivers (Marín-Navarrete
etal., 2016).
It should be remembered that addiction does not appear suddenly, but has a tra-
jectory and, therefore, is not the same at every stage of the process. In fact, as addic-
tion progresses, family relationships can deteriorate due to the feeling of
abandonment experienced by other household members, who often perceive that the
needs of the person with an addiction are prioritized over family needs (Brown
etal., 2015). The time the caregiver spends with their own family can be threatened
and, as a result, generate intrafamily conicts that result in a progressive emotional
distancing, even leading in some cases to denitive breaks in affective relationships
(Orford, 2013). Children, in particular, may experience feelings of abandonment or
neglect, as the caregiver is focused on the needs of the person with an addictive
disorder. This situation can lead to behavioral problems and poor school
performance.
15.5.3 Impact ontheMental Health oftheCaregiver
The responsibility of caring for someone with a dependency generates an intense
emotional and psychological burden, so the impact of addiction on the mental health
of the caregiver is considerable. As seen earlier, the consequences of an addictive
disorder on daily life, relationships, and the economy result in high levels of stress
and anxiety, due to the unpredictable nature of addiction and the constant attention
required by the person with an addictive disorder. All of this leads to an emotional
burden that can deteriorate the general well-being of those who care for them. Being
a process, in which more time in treatment is required as a predictor of therapeutic
15 The Role oftheCaregiver intheAddiction Treatment Process
212
success, the stressful situation can last for weeks or months. Continuous exposure
to stressful situations, beyond the onset of anxiety disorders, can lead to a prolonged
release of the hormone cortisol, whose excessive release is associated with various
health problems, including a decient functioning of the immune system (Sapolsky,
2004). Chronic stress can lead to generalized exhaustion, also known as Burnout
Syndrome.
Also, the overload of care can lead to symptoms of depression, due to the feeling
of guilt and failure that has been previously discussed. These feelings, along with
emotional exhaustion, increase the vulnerability of the caregiver to mood disorders.
To all this is added a perception of low social support, that is, caregivers feel that
they cannot share their difculties with others for fear of being judged or misunder-
stood (Brown etal., 2015).
The courtesy stigma, which affects people close to the person with addictive
disorders, is also often suffered by the caregiver (Favina etal., 2024; Maldonado
etal., 2023). When the person with an addiction is a family member, this courtesy
stigma can spread to the rest of the family nucleus, causing conict situations, a
greater emotional burden, and repercussions on the well-being of the family
environment.
Also, the mental health of the caregiver can be compromised when their relation-
ship with the person with an addiction reaches a point of codependency, that is, the
commitment to their recovery becomes personal and with blurred boundaries. In
these cases, caregivers personally assume the responsibility for the patient’s recov-
ery; if the person with an addiction relapses or does not progress as expected, it can
generate frustration and feelings of guilt (Lowang & Singh, 2023).
15.6 Care oftheCaregiver
One of the key elements regarding the role of the caregiver is, precisely, their care.
As described in the previous section, each of the responsibilities and functions per-
formed by the caregiver carries a physical and emotional burden that is difcult to
manage, especially when it comes to relatives or close friends of the person with an
addictive disorder and who are not care professionals. Therefore, it is necessary to
address the health of the caregiver and, next, some strategies will be proposed for
this purpose.
15.6.1 Regarding Emotional Coping
Those who care for people with addictions must face an intense and prolonged emo-
tional burden, which produces emotional exhaustion, which can become pathologi-
cal, with the development of disorders such as anxiety and depression. It is essential
that the health system and addiction professionals recognize the needs of the
A. V. Infer et al.
213
caregiver and offer emotional and therapeutic support to manage stress and exhaus-
tion. The well-being of the caregiver is not only crucial for their own mental health,
but it is also key to the success in the treatment of the person with an addictive dis-
order; an exhausted or sick caregiver cannot respond to the needs of the person with
an addictive disorder to recover from their addiction. In fact, previous studies have
determined that the caregiver of a person with an addictive disorder suffers more
emotional burden than people who care for those who suffer from other mental
pathologies, such as dementia (Soellner & Hofheinz, 2024). Moreover, this burden
is even greater in situations where there is domestic violence (Hsu, 2024).
Psychological interventions aimed at the caregiver are, therefore, essentials. These
interventions, such as cognitive-behavioral therapy or support groups, have proven
to be effective in helping caregivers manage their emotions and develop strategies
to cope with stress (Sampogna etal., 2023). When caregivers feel guilt or over-
whelmed by their role, they need to be provided with skills for emotional manage-
ment, training, and ongoing support to learn to take care of themselves while caring
for their loved ones. The emotional well-being of the caregiver will result in greater
therapeutic efcacy.
Another source of emotional tension arises when the patient expresses wishes
contrary to medical recommendations, something that forces the caregiver to make
difcult decisions, considering the patient’s physical well-being, mental health, and
autonomy. Adequate training on handling conict situations can be key to minimiz-
ing the consequences of all these types of sources of emotional stress (Marín-
Navarrete etal., 2016). In this regard, it is interesting to mention initiatives like that
of Renati etal. (2022), which present the design of an application that serves to offer
tools for emotional management, self-care, or information on how to deal with
stress, which seems to be yielding good results.
15.6.2 Regarding Codependency andPersonal Boundaries
The relationship between the caregiver and the person suffering from an addictive
disorder can reach a point of codependency, where, due to a lack of clear boundar-
ies, the emotional dynamic leads the caregiver to become excessively involved in
the life of the person with an addiction. Therefore, it is essential that training and
psychological support also focus on recognizing the signs of codependency and
establishing healthy boundaries, in order to experience less emotional exhaustion.
For example, one of these healthy boundaries should be aimed at not personally
assuming responsibility for the patient’s recovery.
The acquisition of self-care skills, with activities such as physical exercise, med-
itation, and access to psychological therapies is a convenient and benecial process
to avoid the consequences of codependency. Likewise, the establishment of own
support networks can be a space where they can share their experiences and feelings
without fear of being judged. Similarly, therapeutic interventions aimed at caregiv-
ers, such as family therapy or support groups for codependents, are essential to help
15 The Role oftheCaregiver intheAddiction Treatment Process
214
them understand the boundaries between their own well-being and the recovery
process of the person with an addictive disorder.
15.6.3 Regarding Chronic Stress (Burnout)
As mentioned in the previous section, burnout or emotional exhaustion is a set of
symptoms, common among caregivers of people with addictions, caused by chronic
stress due to emotional and physical overload, which can lead to a feeling of help-
lessness, chronic fatigue, and even end up in a depression (Shishkova & Bocharov,
2022). Caregivers must develop strategies to prevent burnout, such as the develop-
ment of skills to manage stress and the implementation of clear boundaries.
Dedicating time to recreational activities, regular physical exercise, healthy eating,
and adequate rest, can be useful activities to maintain mental and physical well-being.
In cases where burnout has already set in the caregiver, psychological therapies,
such as cognitive-behavioral therapy or acceptance and commitment therapy, have
proven to be effective in helping them develop coping strategies for difcult situa-
tions (Levin etal., 2024; Ng etal., 2024). Psychotherapy also offers a safe space
where caregivers can express their frustrations and concerns.
15.6.4 Regarding Stigma andIsolation
The social stigma inherent in addictions not only affects the people who suffer from
them, but also the people who accompany them in their recovery process who often
experience social isolation, shame, or even rejection from friends and family, the
so-called courtesy stigma, mentioned earlier. Caregivers who feel stigmatized are
more prone to develop symptoms of anxiety and depression. Therefore, they must
have access to support networks that offer them a safe space where they can share
their experiences and thus break with isolation.
The development of a strong support network, informal (family and friends) or
formal (support groups), is essential to decrease the impact of stigma and isolation
on caregivers. In fact, support groups for caregivers have proven to be effective in
reducing stress and isolation, by allowing them to connect with other people going
through similar situations. In addition, community resources, especially NGOs, also
play a crucial role in providing education and tools for caregivers to have more cop-
ing skills for the burden of taking care of a person with an addictive disorder.
Interventions that focus on strengthening the social skills of the family, such as the
one proposed by Hatmanti etal. (2023), in which they propose organizing a family
nursing method with a support-based educational system focused on families sup-
porting teenagers addicted to smartphones. Or the one proposed by Kalra and Tung
(2024), where they emphasize the importance of interventions that emphasize
A. V. Infer et al.
215
strengthening support systems and various aspects of families with personalized
approaches.
Regarding stigma, it is worth noting that women often take on the role of caregiv-
ers in a more intense way, which aggravates the burden they bear. The traditional
concept of women as being protective, the fundamental pillar of the family, uncon-
ditional lover, and with unlimited capacity for self-sacrice, has been an image
generated by the dominant social representations and gender stereotypes. (Negrete
Carballo & Edith García Cerón, 2023). In a landscape where it is still difcult to
disassociate from the idea of the man as the provider and the woman in charge of the
home and domestic care, women, both in their role as mothers and wives, have pre-
dominantly carried the responsibility of supporting family members with addic-
tions, often being the last and most unconditional resource. According to Santos and
Martin (2009), who focus on the case of relatives with alcoholism, the situation can
lead caregivers to isolation and exhaustion, possibly leading them to stop frequent-
ing social environments for fear that the patient will drink and cause humiliating
scenes. Therefore, the care and attention to caregivers must necessarily have a gen-
der perspective, which allows a deeper understanding of the roles and the physical,
psychological, and social overload that falls on women.
15.7 Final Considerations
Throughout the chapter, an attempt has been made to break down, from different
perspectives, the role of informal caregivers of other people with addictive behav-
iors. This is a role not chosen, imposed by circumstances, and often invisible, which
is very difcult to face. Therefore, an attempt has been made to respond to the dif-
ferent challenges that a caregiver must face. These challenges involve, rst of all, as
precise a conceptual approach as possible, where it is understood what responsibili-
ties the caregiver is assuming without any type of training, ranging from logistical
support in day-to-day life, to purely emotional support. On the other hand, there has
been an in-depth discussion about another key aspect, which is the impact, more
direct or indirect, on the life of the caregiver, in the economic, family, and psycho-
logical areas. Taking into account all of the above, if anything stands out from this
chapter, it is the section dedicated to the care of the caregiver. The informal care-
giver needs tools and specic attention on how to deal with the situation that has
arisen, without losing their own health along the way. They must, therefore, have
access to emotional coping tools, how to establish personal boundaries, deal with
stress, cope with the stigma associated with addictions, and not fall into the isolation
that can be caused by having a relative or close person with addictive behaviors,
whether out of shame, the aforementioned stigma, or simply not knowing how to
deal with complex situations in social environments.
Finally, and by way of conclusion, it is worth noting that the care of a person with
an addictive disorder is not only the responsibility of the family or the close social
environment that suffers from this problem. Society as a whole and Public
15 The Role oftheCaregiver intheAddiction Treatment Process
216
Administrations must assume their part of the responsibility in the care and atten-
tion to the needs of caregiver families. The family or the close environment will not
ask for help if they do not know they can ask for it because they are unaware of the
services available to them. Addictions arise, in part, because there is a social context
that encourages or facilitates them; therefore, the responsibility in dealing with
them must be collective.
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219© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
T. Mota Ronzani (ed.), Social Stigma and Drug Use,
https://doi.org/10.1007/978-3-031-94813-8_16
Chapter 16
Stigmatization ofWomen Who Consume
Alcohol inaRural Indigenous Community
inCentral Mexico
MarcelaTiburcioSainz, JazmínMoraRíos, andPilarBernal Pérez
16.1 Introduction
The word “stigma” comes from the Greek στίγμα, Latin stigma, which refers to the
tattoos given to slaves and criminals to mark their status or crime. These tattoos
were brief inscriptions or initials, mainly on the forehead, and marked the greatest
type of social degradation in Greek and later Roman civilization (Setién-García,
2020). One of the principal scholars on the subject was the sociologist Erving
Goffman, who dened social stigma as an attribute or mark carried by some indi-
viduals, whose “discrediting effect is very extensive; sometimes it is also called a
failing, a shortcoming, a handicap” (Goffman, 2022, p.2). According to Goffman,
when these marks are related to psychology, they are called character defects.
Nowadays, a mark on some aspect of identity that is considered negative places
a heavy burden on a person; it causes others to disapprove and point them out,
which limits and devalues them. That is, the negative value carried by stigma exists
in close relation to the norms, beliefs, and attitudes in the context surrounding the
person affected.
The aim of this chapter is to explore the experiences of stigma of women in an
Indigenous community in central Mexico who use alcohol. It rst presents a review
of the literature on the subject, followed by an analysis of the narratives of women
from the community, where the production and consumption of the traditional
M. TiburcioSainz (*) · P. Bernal Pérez
Department of Social Sciences in Health, Ramón de la Fuente Muñiz National Institute of
Psychiatry, Mexico City, Mexico
e-mail: tibsam@inprf.gob.mx; pilar.bp@tec.mx
J. MoraRíos
Direction of Epidemiological and Psychosocial Research, Ramón de la Fuente Muñiz
National Institute of Psychiatry, Mexico City, Mexico
e-mail: morarj@inprf.gob.mx
220
alcoholic beverage pulque is an ancestral practice, with particular beliefs and values
that accept and privilege men who drink it, but disapprove of and condemn
women who do.
In recent years, the United Nations, through the United Nations Ofce on Drugs
and Crime (UNODC, 2020), has called on member countries to combat the stigma-
tization of people who use substances. Such stigma is a global problem with numer-
ous effects on the lives of users that interfere with getting appropriate care. In
Mexico, a study of the perceptions of people who use substances found that there is
greater negative perception of illegal drug users than of those who use alcohol
(Bustos etal., 2022). Social tolerance towards alcohol is greater, mainly in rural
areas of the country, and is present in people’s lives, so that when there are problems
related to its use, it takes up to 10 years for them to seek help (Natera etal., 2007).
In an interesting review, Davis and O’Neill (2022) identied some barriers to
treatment for alcohol use in rural communities. Prominent among these are the
doctor- patient relationship, barriers with health service providers, the remoteness of
care services, lack of privacy, internalized stigma, social prejudice, addiction as a
moral rather than health issue, and health care workers’ stigmatization of patients.
Lipsky etal. (2016) understand discrimination as one or more stressful events that
can affect people’s well-being; their research suggests that discrimination is related
to alcohol abuse and mental disorders, and that Hispanic women who use substances
suffer greater discrimination.
16.2 The Social Burden ofBeing aWoman inMinority
Ethnic Groups
There are certain factors that characterize ethnic minorities in Mexico, specically
the Indigenous population: (a) social marginalization, (b) the stigmatization of dif-
ference, (c) inequality and lack of recognition, (d) scarcity of material resources,
and (e) challenges to survival (Bari, 2002; Navarrete, 2008). These factors contrib-
ute to precarious living conditions for the community in general, and for those with
alcohol use problems in particular. In the case of Indigenous women, discrimination
is associated with) symptoms and manifestations of mental health problems such as
depression and anxiety in vulnerable populations (Romer, 2003). The disadvantages
are even greater due to gender differences in social and cultural roles (Camacho
etal., 2022). Generally speaking, in various ethnic groups and societies, being a
woman implies a disadvantageous social burden, and it therefore creates a social
problem.
There is growing interest in the question of gender inequalities in health care. It
is becoming increasingly important to understand the impact of these inequalities
on various areas of women’s lives, for example in access to health resources, in
cultural diversity, in social inequality, and in their interconnections (Llort-Suárez
etal., 2013). While there have been advances in legislation, and in the recognition
M. TiburcioSainz et al.