Are Treatment Providers Really Trying to ‘Break the Stigma’ of Addiction?
There is a rally call from people with addictions, their loving family members, and treatment providers: We need to break the stigma of addiction!
We spoke about stigma regularly in staff meetings at the treatment agency where I worked, as the reason why more people don’t get the treatment they need. It comes up in almost every Twitter discussion hosted by addiction treatment providers. “How do we break the stigma of addiction?”
The stigma of addiction – the belief that people with substance use disorders should be ashamed, that addiction is a personal failing – is as prevalent as the confusion about whether addiction is a disease, a behavioral health issue, a brain disorder, a family problem, an attachment wound, or a character flaw.
While drug addiction and mental illness are both chronic, treatable health conditions, the American public is more likely to think of addiction as a moral failing than a medical condition.-Colleen L. Barry
According to a recent study, addiction is more stigmatized than other mental health problems. “While drug addiction and mental illness are both chronic, treatable health conditions, the American public is more likely to think of addiction as a moral failing than a medical condition,” says study leader Colleen L. Barry, a professor at John Hopkins Bloomberg School of Public Health.
The John Hopkins study highlighted another reason why stigma matters – people are more interested in getting needed help for sick people than bad people. Respondents in the study were more likely to support discriminatory policies against people struggling with addiction than mental illness and more likely to oppose policies aimed at helping them. For example, 21 percent of respondents opposed offering insurance parity for mental illness, while 43 percent opposed parity for the treatment of addiction.
While the study is eye-opening, we don’t need researchers to tell us that stigma exists for people with substance use disorders. Surely there are many reasons, including the illegality of drug use and the societal cost, but it is our language that deserves a critical look.
Addiction treatment is a field where you can still find providers talking about their patients as “master manipulators,” “selfish” and worse. A quick look online at Twitter and addiction blogs reveals the problematic language we are still hooked on. “Grandiosity and self-centeredness are issues with all recovering addicts,” tweets a Dean of Addiction Studies. “We see manipulation as wrong, but the addict doesn’t necessarily share our values,” writes the author of a popular recovery website. As providers, we are educators to our patients and their families, but just what are we teaching?
As providers, we are educators to our patients and their families, but just what are we teaching?-Lara Okoloko
Certainly substance dependence is not the only health problem that is both behavioral and physiological. Treatment for diabetes, hypertension, obesity, and depression, all include pharmacological and behavioral interventions. Yet the addiction treatment culture often speaks out of both sides of its mouth, calling to end stigma for the “disease of addiction” while still using moralistic language to talk about patients.
In what other area of medicine do we describe the symptoms of a disorder in values statements? Does someone who compulsively vomits after meals not share the value of health? Does someone who cries every day not value happiness? We don’t talk about people with depression as slothful and self-centered, or diabetics as undisciplined, but we still describe some of the symptoms or behaviors of addiction in terms of moral depravity.
The problem of moralistic language extends into the treatment rooms. Although the phrase is absent from the pages of the “Big Book” of Alcoholics Anonymous, the term “felons, liars, cheaters and thieves,” is common in AA meetings to refer to alcoholics. So common that it is even the name of a Seattle AA meeting. Or consider “Moral Reconation Therapy,” which seeks to advance the stunted moral reasoning of its patients. Although developed with criminal offenders in mind, it is used in many outpatient and inpatient addiction treatment agencies unaffiliated with the criminal justice system. “Poor moral reasoning is common within at-risk populations,” explains one Washington State addiction treatment provider using MRT.
For example, describing a patient as an ‘adolescent with an addiction’ rather than ‘an addict’ reminds us that they are more than their diagnosis.-Lara Okoloko
One group calling for change is the editorial team of the journal Substance Abuse, who recently called on its authors to recognize the power of language to “intentionally and unintentionally propagate stigma” for people with substance use disorders. They are asking authors to avoid slang terms that perpetuate negative stereotypes and to use “people-first language” which puts the person before the description of their disorder. For example, describing a patient as an “adolescent with an addiction” rather than “an addict” reminds us that they are more than their diagnosis.
While some of the terms that the editors suggest will be banned from their publication are obviously offensive such as “junkie,” “dope fiend” and “strung out,” other words may seem innocent enough. Referring to urine screens as “clean and dirty” or a person with a substance use disorder as a “user” or “abuser” are all phrases that may seem harmless but still are the language of moral failing, not medical care. Even the terms “addict” and “alcoholic” are problematic in that they are not person-first and are not a medical diagnosis. Although it is a mouth-full, person-first language acknowledges the patient as primary and the diagnosis as secondary, as in “people with substance use disorders.”
Referring to urine screens as ‘clean and dirty’ or a person with a substance use disorder as a ‘user’… are all phrases that may seem harmless but still are the language of moral failing, not medical care.-Lara Okoloko
Language is at the heart of the problem of stigma. As professionals, we set the tone with our words. Speaking about substance use disorders as a moral failing is exactly the language that cements stigma in place. As providers of care, it is our responsibility to examine how we contribute to the very stigma we want to break. We can be the change we want to see. Let’s clean up our language, even if it is sometimes a mouth-full.
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