Language Matters: Talking About Addiction and Recovery
Sept Recovery at Any Age Treating Addiction Among Our Nations Youth
Ask the Expert:
John Kelly , Ph.D., Associate Professor in Psychiatry at Harvard Medical School, Associate Director of the Massachusetts General Hospital (MGH)-Harvard Center for Addiction Medicine, and Program Director of the MGH Addiction Recovery Management Service (ARMS)
I am unsure of the correct language to use when speaking about substance abuse and recovery. What are inappropriate terms and what are correct terms to use?
There are a variety of terms used to describe substance-related conditions and individuals suffering from them. When referring to substance-related conditions in a general sense, the term “abuse” is often used (e.g., “substance abuse problems”). However, it is better to avoid using the abuse term for generic purposes for two main reasons. First, it confuses the general meaning which attempts to convey a broad range of problems with the specific DSM diagnostic category of “abuse”. Because of this, when referring to the broad range of problems in a general way it may be better to use “substance misuse” or “substance-related problems/conditions”. (See Kelly, 2004, and White and Kelly, 2010, for further elaboration). Second, it naturally tends to give rise to the “abuser” label. This is concerning as experimental research has shown that describing someone as a substance “abuser” evokes more blaming and punitive attitudes toward that person than if that same individual is described as “having a substance use disorder” (Kelly & Westerhoff, 2010). So, using person-first language and medical terminology may be optimal (i.e., an individual having, or suffering from, a substance use disorder) and may reduce stigma. This is already done in other mental health areas. Individuals with eating-related problems, for example, are nearly always referred to as “having an eating disorder” and not as “food abusers”.
How can I shift the language around substance use disorders and addictions that is used by my friends and family?
I think the main thing that we can do is to lead by example and begin to use these de-stigmatizing terms ourselves. Also, when appropriate, we can politely point out that using certain terms, such as “abuser”, has been shown to negatively influence perceptions regarding the controllability and cause of substance-related problems, leading to more punitive and blaming attitudes toward sufferers, even when that may not be the intention of the individual using the term.
How can language impact the success of an individual’s recovery, both positively and negatively? And, what are examples of the types of language I should use in order to positively impact and support those around me?
Language is used to convey meaning. The problem is that the use of certain descriptive terms may confer meaning that alters the perception of that person unintentionally. If we use the “abuse” or “abuser” term, for example, it appears that we may inadvertently perpetuate stigmatizing attitudes that lead people to perceive an individual with an addiction problem as really just engaging in willful misconduct, and therefore should be blamed and punished. Since these terms are commonly used in our society in and outside the field, the upshot could be that these stigmatizing beliefs are internalized by sufferers leading to self-blame, shame, and fear of societal retribution. This, in turn, leads to secrecy and a lower likelihood of acknowledgement of a substance-related problem and of seeking help. Use of person-first, medical terminology (e.g., substance use disorder, alcohol use disorder; drug use disorder) may convey the notion that the individual is a human being first, that they are suffering from an established and recognized condition, and that it falls within the realm of science and medicine. Using language, such as “my friend has a substance/alcohol/drug use disorder” or, “my friend suffers from a substance-related condition” captures these elements, which may decrease shame and increase the likelihood that such individuals will seek appropriate services sooner.
The media’s portrayal of substance use and some show’s language regarding people with substance use disorders is sending the wrong message to the public. How can I change this?
We can change the media’s misuse of certain stigmatizing terms by first making sure that substance use disorder treatment professionals, policy makers, researchers and organizations are leading by example and adopting non-stigmatizing terms wherever possible. We are then in a better position to begin to educate the media about the potentially negative impact of using certain terms. When my experimental study was published that compared the impact on attitudes of using the “abuser” term versus the “substance use disorder” term one of the staff at the media office where I work wrote a press release. In the process, she told me that she had realized she had been using the wrong terms and how helpful it was to see this study for her own future use. I think this kind of dissemination of empirical knowledge can effect this kind of changes as people simply become more aware. Terms such as “inebriate” and “drunkard”, were also commonly used at one time, but are no longer used. It will take time to shift from using terms such as “abuse” and “abuser” as these older terms are so culturally embedded in our language, but we have to start somewhere.
In the “Language Matters” program, you spoke about various studies that looked at both the neurological and psychological factors associated with substance use language and societal stigma. Can you provide citations of the findings you discussed? Additionally, how do I include this information in my discussions with friends and family members to highlight the importance of using the correct language to decrease stigma?
The studies I cited in my talk were: Kelly, JF, and Westerhoff, C. (2010), International Journal of Drug Policy; Kelly, JF, Dow, SJ, and Westerhoff, C. (in press), Journal of Drug Issues; and Kelly, JF (2004) Alcoholism Treatment Quarterly. The impact of alcohol and other drug use on the brain and the resulting impairments in impulse control is documented in several places. The World Health Organization has a downloadable pdf document on the neuroscience findings at: http://www.wpro.who.int/NR/rdonlyres/5B7BC004-34C3-4844-BB22-D210F1FDB9EA/0/ENG_Neuroscience_summary.pdf. To include this kind of information into discussion with family and friends can be useful. It is helpful to let them know that due to genetic and neuroscience findings from the past 25 years, including brain imaging studies, there is now no doubt that alcohol and other drug use disorders are genetically influenced (like other health disorders), and that their use causes brain changes that can dramatically impair individuals’ ability to control substance use despite negative consequences.
6) It has been my experience in dealing with alcohol and other chemical misuse over the past 25+ years that there is a distinct difference between chemical dependency and a true, genetic based addiction. I see both as a self-medication for imbalances in limbic system function as it interacts with the higher levels of thought processing. One, dependency, as a temporary physiological and psychological response to the chemical. The true addiction has the added factors of genetic and epigenetic underpinnings and is actually a self-medication for genetically based imbalances in limbic system functions. In other words, diagnosable mental illness that has gone undiagnosed, with alcohol and/or street drugs becoming a self-medication. My question then is: Do you find this to be the case as you view it?
There are multiple pathways into substance dependence and the presenting patterns of substance use and degrees of related impairment are highly varied. Because we do not have any robust biomarkers that yield the presence of the disorder it means we have to rely on behavioral indices to determine the presence of the substance dependence (addiction) syndrome. These are usually obtained by clinical interview and self-report using the seven criteria of the dependence syndrome and, thus, the diagnosis' validity depends on accurate self-awareness and observation. Because of this, and the fact that only three or more criteria must be met for a threshold diagnosis to be made (i.e., it is based on a prototypic or polythetic classification) there is an apparent acknowledgement that the substance dependence syndrome can be present in different forms. As the individual uses greater amounts of the substance over time it may be that the syndrome becomes more homogeneous as more criteria are met. As Griffith Edwards noted in his original formulations of the syndrome "not all elements need be present, or present to the same degree, but with mounting intensity the syndrome is likely to show increasing coherence". There is some evidence for this but it is not watertight. In an attempt to delineate clinically meaningful subtypes or subgroups of dependent individuals, a number of typologies have been proposed in the past 100 years aided more recently by computer-facilitated, data-driven, subtypes(e.g., Silkworth, Jellinek, Babor, Cloninger, Hesselbrock, Moss). Although, some of these subtypes have intuitive appeal and match some of my own clinical observations, we are yet to detect robust subtypes that warrant a specific clinical approach. Pharmacogenetic research has begun to focus on how some genotypes (e.g., those with the a certain mu opioid receptor gene) may differentially benefit from certain targeted medications and may help us identify more robust clinical subtypes. For some, self-medication is a pathway to substance dependence and may reflect a certain genotype. Time and more research in these areas will hopefully answer these questions.