by Keith Keller, February 25, 2024
Chapter 5
I’m Not the Language Police
“Words are, of course, the most powerful drug used by mankind.”
~ Rudyard Kipling
A long time ago, I worked as a technician in the local hospital’s operating room. I recall an occasion when, upon seeing that a patient had tattoos, a coworker remarked, “Oh, she’s a patron of the arts.” My colleague was making a sarcastic and demeaning observation regarding an anesthetized patient’s body art. I heard this patron phrase often enough that it stuck with me. Body art was less common than it is today.
At the time, organizations and facilities like hospitals actually had rules that employees’ tattoos could not be visible. This is much different today, of course, and suggests that over time the negative beliefs tend to shift in response to what people are used to seeing.
The Merriam-Webster online dictionary defines stigma as “a set of negative and unfair beliefs that a society or group of people have about something.” The body art anecdote is one example. In the context of substance use disorder (SUD), stigma refers to negative attitudes, beliefs and stereotypes, as well as the discriminatory behaviors directed toward people living with SUD. Stigma can be societal, institutional, and interpersonal.
Human beings are naturally wired to be social creatures. As we climbed the evolutionary ladder, being part of a tribe was necessary to survive. A significant vestige of this, a remaining sign, is an almost instinctive drive or desire for the approval of our group, or at least avoidance of disapproval. This is what psychologist Abraham Maslow referred to as “esteem” or “social needs” in his hierarchy of needs. Being ostracized, or cast out of the tribe, in primitive times was a threat to survival, so maintaining a good standing in one’s group or tribe was an important matter. In light of this, the phenomenon of stigma has a significant undercurrent that taps right into something basic in us, something survival related.
Substance use puts people in subtle and unsubtle opposition to their tribe. Addiction is socially unacceptable. Addiction is stigmatized.
We have all heard the words junkie and drunk used in reference to people with opioid or alcohol use disorders. Used in many contexts, those two terms are now considered prejudicial and marginalizing—stigmatizing. Some people even continue to identify themselves in that manner, possibly with the unintended consequences of perpetuating negative stereotypes while subconsciously reinforcing feelings of unworthiness and inferiority.
Language
As described previously, my recovery began in the traditional model approach of twelve-step peer support, Alcoholics Anonymous (AA). The custom at meetings of the AA fellowship has always been identification as an alcoholic. When introductions are part of a meeting’s format, it is customary to go around the room with each person in turn saying, “I’m _____, an alcoholic.” On first entering recovery, uttering those words aloud can be tremendously difficult. Once in the routine, it becomes automatic. Typically, all present at the gathering then respond by saying, “Hi, _____.”
Many choose their own little variation. “Hi, I’m a grateful recovering alcoholic named _____.”
This ritual, while more or less a formality today, signifies that person is identifying as a member of AA, as an alcoholic, and has taken the first step, admission of powerlessness over alcohol. This type of identification is also customary at other peer support fellowship meetings such as Narcotics Anonymous.
To an uninitiated observer, this ritual might seem a little strange, but not overly significant. However, to some, this identification ritual might seem counterintuitive. “You are identifying as your problem,” someone once said to me. My response was that, to me at least, the identification is synonymous with being in recovery.
A few years ago, I began working in a primary care-based addiction treatment program led by a forward-thinking behavioral health clinician. This program sought to follow and observe leading-edge approaches across the board. This included language that was person centered and strengths based, as well as best practice in terms of medical addiction treatment. It was made known to me, in a tactful manner, that some of my peer support vernacular wasn’t up to spec. In other words, my alcoholic/addict way of talking about people and addictions, the product of years of recovery in the traditional model and beyond, was no longer going to work in that behavioral health context of clinical treatment.
I didn’t know how to feel about that. To be truthful, I was a little bent out of shape.
So let me get this straight, I thought. People with no lived experience are not happy with the way someone with lived experience talks? The people who know about addiction from classrooms and books are upset with my language?
Just so I’m sure I understand, the people I’ve been seeing for years, who, when it comes to their turn to identify themselves at a meeting, say “I’m ______, and I’m a nursing/social work/fill-in-the-blank student here to observe,” have now decided they don’t like the way I’ve been speaking about my alcoholism for half my life?
Yeah, that’s pretty much it.
Well, okay then.
I had to sit with it for a little bit. Initially, it didn’t seem like a big deal; they were just changing up a few words. We weren’t supposed to say alcoholic and addict anymore. However, it was actually a lot more than that. It is a significant and sweeping change. It started to sink in.
I took baby steps. The first thing I could do was accept that there was a duality, two separate approaches to language. There is this new way that academics want to talk about addiction, and there’s the way people with addiction talk about addiction. And, of course, I do appreciate that smart, qualified, highly trained people with no addiction issues of their own were devoting their expertise to helping people with addiction. Duh, I woke up to that pretty quickly. Sure, I can make a few word substitutions... it’ll probably change again in a couple of years anyway.
But it was actually more significant, deeper, than just making a few substitutions. It taps directly into stigma. Societal, institutional, interpersonal. And self-stigma.
So, what are we talking about here? It’s a lot more than avoiding saying addict or alcoholic. However, that’s a good place to start. An addict has impaired control over substance use, and calling someone that, in a sense, reduces them to that. We’re talking about a person who is living with an addiction, or more specifically, a substance use disorder or some other reward-seeking behavior. Alcoholic also carries stigma and reduces an individual to the problems they have with alcohol despite harmful consequences. You don’t think it carries stigma? Given the choice, most people would rather have family, friends and coworkers know that they had shingles, excessive sweating or chronic flatulence before sharing that they are an alcoholic. That was certainly true of me.
It continued to sink in. I know firsthand that substance use disorder is horrible. And I also know that amazing recovery is possible and exactly what that means. And I certainly understand, have even been known to say, that the experience of addiction does not define me. It’s something that happened to me, not who I am.
The recommended approach is to bear in mind that we are describing a person who is experiencing something. Who I am is primary; what I experience is secondary. “Hi, I’m Keith, and I’m a person in long-term recovery from alcohol use disorder.” I know, it doesn’t exactly roll off the tongue, and it’s a little convoluted. That’s why it’s still considered acceptable to identify myself in the old, standard way if I am at a peer support meeting.
Another element in that identification, after being a person first, is stating that I’m in recovery, a strength by any definition. By ordering my identification person first, followed by strength based, and lastly including my chronic condition, I am basically flipping the script. I also chose to avoid the stigmatic terms alcoholism or alcoholic.
But wait, there’s more!
Some of the commonly used language of people with substance use disorder and people who work in the field of substance use disorder treatment confers stigma. While there is no malicious intent, many routinely used expressions and jargon are now considered to be, by implication, socially discrediting.
Consider this statement, which might be how someone describes their own recovery: “I’ve been clean for six months.” This is a perfect example of language that has been used for ages. The concern is this implies that someone is clean as opposed to dirty. The suggestion of something being dirty is stigmatic, if even subliminally. The same clean/dirty description is often used in the clinical area to describe the results of a urine drug screen—a clean urine specimen or a dirty urine specimen. While I am not the language police, and would respect someone’s right to refer to people or themselves as they choose, I would refer to anyone as a person in recovery as opposed to a clean addict. A urine drug screen is negative or positive, not dirty or clean.
Harm reduction adds a further element to the clean/dirty descriptor. In the harm reduction framework, a urine drug screen that is positive for a nonprescribed medication (as opposed to the stigmatic dirty with an illicit drug), while a reason to initiate a supportive discussion, is not a problem or proverbial strike against someone, implicit in the word dirty.
This is how language influences the way society and culture view substance use disorder, and indirectly and directly influences treatment and, ultimately, those receiving treatment.
Words
Moving on, consider the word drug. This can mean a prescribed medication or a substance used for psychoactive effect in a nonmedical context. Given that there are numerous appropriate indications for the medical use of psychoactive substances, using the term medication can prevent confusion or ambiguity. Illicit substances conveys judgment. In documentation, I’ve used nonprescribed substances. Sometimes street drugs is a good descriptor, but it’s in the gray area. Baby steps.
Marijuana has a past negative association and historical connections to discriminatory practices with Mexican migrants. Historically, the term marijuana was deliberately used to associate cannabis with Mexican culture, playing upon Reefer Madness (the 1938 anti-drug movie) type fears. Perception varies, and people still say marijuana without intending stigma. Last I checked, there is still a Marijuana Anonymous, but I’ve been saying cannabis for a while now.
Relapse is another term that has been in common usage for a long time. The term was used to denote the reoccurrence of active substance use disorder symptoms, or in vernacular, returning to active drinking or using. Implicit in the word, there has always been an undercurrent of moral failing or weakness. Substance use disorder recovery is now widely understood to be nonlinear, often with a series of smaller successes and failures early on. Susceptibility to resuming active use of a substance is high in the first 90 days of recovery, and especially so in the first 28 days according to Stanford professor of psychiatry Dr. Anna Lembke and National Institute on Alcohol Abuse and Alcoholism (NIAAA) Director Dr. George Koob. People are now encouraged to say resumption of, or resuming active use, or reoccurrence of symptoms.
MAT was called medication assisted treatment until recently. While it is a treatment for substance use disorder, and it does include medications, the concern was that it somehow draws a distinction between SUD and other chronic medical conditions. As an example, diabetes is treated with medications, but it’s not called assisted treatment. Hypertension, high blood pressure, is treated with medications, but it’s simply termed treatment.
When I worked in office-based addiction treatment, I would reinforce to my patients that they had a chronic condition that required treatment. Even going a little further, I would encourage them that, as people in recovery, this was an important concept, and that they belonged in that office waiting room every bit as much as people living with diabetes and hypertension. Medications for addiction treatment works just as well, and organizations didn’t have to change the names of their programs.
Substance misuse refers to use for intended or unintended purposes, or in quantities or dosages differing from directions. The term is negative and implies blame or judgment. The terms nonprescribed use, nonmedical use, or substance use are suggested instead. Also, negative and implicit of judgment are the terms substance abuse and substance abuser. These words have been demonstrated to create negative attitudes, the literal definition of stigma. Again, the best approach is person first, followed by strength based, and then the problem or diagnosis.
It bears mentioning at this point that all these terms are still more or less in common usage. Everything from book titles to organizational mission statements contain the words substance abuse and substance abuser.
Stigma
I am not the language police, as I mentioned somewhere earlier. However, I frequently find myself in situations where highly qualified recovery professionals are communicating with phrases like “the dirty urine screen indicates relapse to substance abuse.” Well, okay, that was dramatized for effect, but the point is that stigma is alive and well in the language of recovery professionals. The same people who are supposed to provide care and model attitudes and behaviors for the SUD population and general public alike haven’t gotten the memo yet. I’m not the language police, but I’m probably deputized in a sense.
The real purpose of redefining and reframing the way we communicate about substance use disorder is because there is a direct relationship with stigma. SUD “is the most stigmatized health condition in the world, with alcohol use disorder not far behind at fourth in the world,” according to the Recovery Research Institute.
Dr. John Kelly and his team undertook a study comparing subjects’ responses to questions about two hypothetical people; one person was presented to the subjects as a “substance abuser,” while the other was presented as “having a substance use disorder.” The study discovered that participants felt the substance abuser was less likely to benefit from treatment, while more likely to benefit from punishment. The substance abuser was also more likely to be blamed for their substance-related difficulties and was more likely to be socially threatening. Interestingly, 69 percent of the study’s subjects also answered that those having a substance use disorder would benefit from treatment, and 79 percent of subjects said the person with substance use disorder was not responsible for their condition.
The real question Dr. Kelly was asking is whether the language of stigma causes bias that affects clinical treatment. His Recovery Research Institute study shows that it does. How we talk about people affects how we think about people, and that affects how we treat people.
So, back to my coworker from years ago, who made the remark about someone with body art being a “patron of the arts.” There was nothing else memorable about that surgical case. I think the surgeon, the anesthetist, my body art maligning coworker who was the circulating nurse, and me passing the instruments all did our jobs. However, I also think my coworker’s remark stigmatized that patient, negatively affected my perception, and possibly the perception of others. While the effects of that type of stigma are subtle, believing someone won’t benefit from treatment is not.
What about self-stigma, when a person with a condition is exposed to stigma from society, an organization, or other people resulting in a negatively impacted self-image? One study found that individuals with alcohol disorders who perceived high stigma in the community were less likely to seek alcohol treatment services. Also, the likelihood of seeking treatment decreased as the perception of stigma increased. Perceived stigma was assessed using the perceived devaluation-discrimination (PDD) scale. The PDD scale is a 12-item tool that measures how much someone believes that most people will devalue or discriminate against someone with a mental illness. When people’s decision to get help is influenced by negative public opinion, this is a highly personal consequence of stigma.
Medicine has specialties that are considered high risk. The conditions, treatments and interventions, or populations might be complex; there is high potential for complications and poor outcomes, that is, serious harm. An example is treating gallbladder disease, which accounts for 1.8 million hospital visits annually. Gallbladder removal surgery is one of the most common operations. However, during this routine surgery, the surgeon must identify and ligate (tie, clip, or otherwise close off) involved structures called the cystic artery and the cystic duct. Damage to or failure to control these delicate bits of anatomy can result in uncontrolled bleeding or spillage of corrosive bile into the abdominal cavity. Not good! This illustrates how incorrect mechanical treatment can result in serious harm. It’s a clear-cut cause and effect.
In substance use disorder, language causes the unintended harm. Unfortunately, there is no definitive mechanical correction for substance use disorder. It can’t be removed surgically. While people with SUD do suffer physical effects, behavior is the focus of treatment. Just as the most skilled surgeon can inadvertently damage delicate structures causing harm to a patient, negative or inappropriate language is the equivalent for the person in recovery. Self-image and self-esteem are the delicate structures that can be damaged by stigmatizing language, even when it is accidental or well intentioned. The real harm of stigma is insidious, subtle and cumulative, but no less cause and effect.
Common Usage
The shift in commonly used recovery and mental health language is a top-down phenomenon. Part of the trend is a byproduct of research at high levels like the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA). To be fair, it also reflects the trend toward political correctness, but there is science supporting it. The rationale is sound.
So, it’s complicated. While it’s definitely seeping into the clinical and academic sectors, the new jargon is only halfway here. SOS Recovery, a New Hampshire recovery community organization (RCO) issues language guidance for its conference speakers that is spot-on and right up to the moment, requesting that addict, alcoholic, clean, substance abuse, etc., be avoided, and offering suggestions for the acceptable substitutes.
However, while facilitating a remote counseling appointment for a residential client, I heard a master’s level clinician from Boston Children’s Hospital use the term “clean time.” She was referencing AA meetings, saying there were people, “with a lot of clean time there.” As opposed to dirty time, I guess. The irony is that the RCO is a grant-funded, folksy place run by people with lived experience. Boston Children’s Hospital is recognized internationally as a clinical and academic hub.
At the extreme end, it’s getting a little disproportionate, and it is just hard to communicate information at times. I’ve seen guidance that suggests that instead of manipulative, I say resourceful. Instead of resistant, I should say chooses not to, isn’t ready for, or is not open to. Hostile or aggressive should be expressed as protective. Sometimes, we just need to say the word.
What I can totally get on board with is that suffers with really means working to recover from, or living with, and that an addict is a person living with substance use disorder. Victimization is turned into empowerment. I never heard anyone with a high body mass index called a food abuser; there is no place for expressions like substance abuse and substance abuser. We can be encouraged that something like body art, once heavily stigmatized, has become commonplace and accepted in our culture. It gives me hope that substance use disorder can make a similar progression in terms of understanding and social acceptance. It’s a process.
Finally, I had been wondering about the terminology in the names of the top federal agencies. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) were formed in 1970 and 1974, respectively. The Substance Abuse and Mental Health Services Administration (SAMHSA) is a newbie, formed in 1992. They are doing some wonderful work, but their burnt orange shag carpet names need to go.
It’s not a matter of having stationery they want to use up. It literally takes an act of Congress to change the names of these agencies. According to an email response from the NIDA Public Inquiries Team, “A proposal to rename NIDA the ‘National Institute on Drugs and Addiction’ was included in the President’s Fiscal Year 2024 Budget. Congress, which established NIDA’s current name in 1974, will need to pass legislation in order to implement a name change.”
Fewer than four years ago, I was taken aback that people working in the recovery field, having no lived experience themselves, seemed offended by the way people in recovery commonly spoke. Today, I have to stop and think about context when I see or hear the word alcoholic. I cringe at the term substance abuse. As evidenced by my 2018 Infinite Recovery Handbook, now in its third edition, with hundreds of language changes to the original manuscript that was started the year prior, my thoughts and beliefs have changed. I’m not the recovery language police, but I respect the power of words. Just as my approach to recovery language has shifted, so must the language of culture in general and recovery culture specifically. Stigma is the barrier to breaking old habits as well as the price we pay for not seeing people and their strengths ahead of their illnesses and problems.