Addictions Advisor: More Than Words — Addiction Language Evolves
The last 15 years have brought tremendous changes to the mental health field, specifically the reduction of stigmatizing language and visibility of mental illness in high-functioning celebrities, political figures, and our own communities. Much like other cringe-worthy references to individuals facing social, physical, and emotional complexity, pejoratives in the addiction treatment field are falling out of grace.
With the spotlight on opioid addiction, and focus across behavioral and physical health care on person-centered care, shaming and blaming language such as "addict" and "abuse" are now frowned upon in most addiction treatment circles. But what did it take to get here?
We know very well with the unrelenting statistics on the morning news that "those people" are our people—that "them" is us.
But change has been slow. Nuanced reform and transition to less stigmatizing language is happening across agencies and departments in state and national governments, but what about in therapy offices? In hospitals? Around the dinner table? In clinical supervision? How is the social work world embracing this less judgmental, recovery-oriented vernacular and using it in day-to-day interactions with clients and families? What about community and corporate stakeholders? Even those holding high positions in state government agencies overseeing mental and behavioral health initiatives have yet to adopt "disorder" vs. "abuse" or "person with substance use disorder" vs. "addict."
Language Represents Perspective
The impact of stigma runs much deeper. Per Sharon K. Davis, MSW, MA, CASAC, and Susan Palmer, LCSW, CASAC, cochairs of the NASW-NYC addictions committee: "There are so many stigmas about race and class as it relates to individuals seeking substance use disorder treatment. For example, the 'drug addict' was defined as one of the 'undeserving poor' when it came to services and responses. Often incarceration is the response—punishment for having an addiction. The opioid crisis has changed all that."
Treatment modalities have transformed over the years as well, with the evidence base growing for medication-assisted treatment for some substance use disorders and the dismantling of the longstanding notion that addiction is a moral failing. Molly Cherington, MSW, who works in health care innovation and administration for Los Angeles County's Correctional Health Services, credits the adoption of a trauma framework, and ultimately the movement toward trauma-informed care delivery, as integral to the reformed understanding of addiction not only as a disease but also as a widely experienced outcome of traumatic experiences. "Though it can't be assumed someone has a history of trauma if they are in treatment for a substance use disorder," Cherington explains, "the idea that substance use could be a coping mechanism for anything at all could support anyone [in] remembering the use of chemical substances is a behavior, not a person, and that there's also a person there with a complex set of stories, experiences, hopes, and goals."
Per Davis and Palmer: "We all know that terminology matters. What does it mean to define someone as a 'crackhead,' 'junkie,' 'pothead,' or 'drunk'? The DSM-5 … gives us the language for relating to our clients. Clients have diagnoses, and someone who meets the criteria for the [disordered] use of alcohol, for example, has been identified by the DSM-5 as 'a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two criteria, occurring within a 12-month period.' The language we use demonstrates an understanding and acceptance of the disease model of addiction whereby improving the way in which we receive the individual."
Whose Language Is It, Anyway?
As Davis and Palmer describe the DSM-5 diagnosis criteria for a substance use disorder, the NASW standards called out the same "change in conceptualization ... addiction is no longer viewed as an 'either/or' phenomenon" with regard to dependence or misuse. Not only has this change in diagnosis criteria sparked a cultural shift in how addiction is perceived but more individuals may meet eligibility criteria to receive services at earlier points in their disease.
One of the most highlighted changes in trade and academic addiction literature is the dropping of "addict," "alcoholic," and "abuser," and replacing the reference with "a person dealing with, or diagnosed with" a particular use disorder. This switch untangles the disease state from the identity and definition of a person, either self-imposed or public. However, the recovery community has not wholly embraced the change in clinical and political references. And for many, the self-identification as an "addict" may contribute to motivation toward treatment and long-term recovery.
Cherington also sees a place for language that persons in recovery use to self-identify: "I've talked with some people who have even found the language to describe themselves (e.g., 'I'm an addict') as a way to 'other' the part from which they'd like to disassociate. It's not for me to 'correct' anyone in their own use of identity language, but an opportunity to bring awareness of a need to separate or isolate addictive behaviors—as something shameful vs., for many, a means of survival until other resources are available—can be powerful."
Say This, Not That
The repercussions of continued use of stigmatizing language are beginning to segregate the old-school legacy treatment models from newer, evidence-based approaches to care that embrace and promote person-centered-care, and move away from the model of moral failing. Cherington says, "I think the conversations we have with our peers to understand and 'correct' without shaming can be powerful." Other resources, such as the NASW Standards for Social Work Practice With Clients With Substance Use Disorders, offers relatable and easily implemented strategies and philosophies throughout the publication that acknowledge the impact of terminology and word choice. Specific recommendations are given for attending to the influence of cultural issues on the presence of substance use disorders in individuals and communities.
Small Changes; Big Impact
There is work left to do in mental health care as a broad institution, and as the opioid crisis remains in the spotlight there are key barriers that still need breaking down in addiction treatment to continue on the path of destigmatization of substance use disorders. "Honestly, the system of care delivery doesn't work well. And that continues to make it look like individuals are 'failing' at their own treatment," Cherington says. There is strong sense that the system is challenging, regardless of means, creating too many opportunities for individuals to fall through the cracks and experience a stigmatized response to seeking treatment. Increased compassion and accuracy in the descriptive vocabulary of clinicians can power the cascade of change through institutions working to reduce or reverse the consequences of drug use on individuals and families.
— Kerianne Johnstin Guth, MSW, is a health care administrator for behavioral health and addiction medicine programs in Camden, NJ.