I was
alerted to a brief article entitled “Destigmatizing Drug Abuse Is a Dopey Idea.”
The author, a senior fellow at the American Enterprise Institute (apparently a
right-wing think tank), calls attention to recent trends in the substance abuse
field to change the language of addiction in ways that minimize stigma. We now
almost universally employ what is sometimes referred to as “people-centered
language.” For instance, instead of using the term “addict” or “substance
abuser,” which defines people solely by their disorder, we prefer to use the
phrase “person with substance use disorder,” simply to acknowledge that he or
she is still a person!
This
article’s author thinks that all of this is nuts and perhaps wants to return to
the good old days when we called a drunk a drunk and a junkie a junkie. While
her argument is more than a little mean-spirited, it is not without some merit.
The author cites, as one example, the trend to call men who hit their wives
“intimate partner violence users” instead of “batterers” or “perpetrators.” (At
least our field is consistent!) My worry is that modifying the language can
unintentionally minimize the severity of the problem. We can’t lose sight of
the fact that substance use disorder and domestic violence are extremely
serious and often deadly problems.
* * *
I
was first introduced to the importance of language many years ago, when I
started to work as a psychologist. At treatment programs for people struggling
with substance abuse, patients are asked to undergo urinalysis testing to
assess what types of drugs they are using. Patients (and professionals) often
refer to the results as either being “clean” or “dirty.” My mentor was strict
about avoiding this language. He taught me that when patients say that they are
“dirty,” they are often telling us what they think about themselves, and we
need to be sensitive about that.
Much
of the attention directed toward language addresses the thorny issue of stigma.
Stigma, which can come from the person with the disorder (self-stigma) or from
society (public stigma), is a badge of shame. The American Psychological
Association defines stigma as “the
negative social attitude attached to a characteristic of an individual that may
be regarded as a mental, physical, or social deficiency. A stigma implies
social disapproval and can lead, unfairly, to discrimination against and
exclusion of the individual.”
What we worry about is that disproportionate
social disapproval might increase the amount of embarrassment a person feels
about his condition. It might even harm the quality of treatment he receives
when the disapproval comes from a health practitioner. Our patients often
discuss the precise moment when their physician reads in the chart that he or
she has a history of substance use disorder – the entire facial expression
changes immediately, and a previously warm and friendly doctor can become terse
and quite prickly.
* * *
But here is the twist. Social disapproval is
not always a bad thing. We rely on social disapproval to prevent a lot of
disruptive behavior, from substance misuse to bullying to crime. The concept of
stigma is complicated because some social disapproval is quite valuable. The
same can be said about shame. While humiliation can be incapacitating, a little
shame might motivate behavior change. For years, our rabbis have relied on this
formulation!
Let us take another example to add more
complication. A patient of mine complains that his family is always watching
their wallets and purses when he is at home. It feels undignified and
stigmatizing. Yet he admits that he has stolen from his family in the past to
support his addiction! In fact, theft is often a defining feature of the
disorder. It is all very complex.
There are at least two forces that drive the
momentum to change the way we speak about addiction. The first is purely
humanistic: We hope to be a kinder and more benevolent society that accepts the
fact that many people have challenging problems and deserve to be treated with
dignity and respect. In fact, a large part of the current drive to consider
addiction as a brain disease stems from the very humanistic position that
people should not be blamed for their own disorder.
The second is to provide a possible strategy
for one of the most perplexing mysteries in the field: Why do so many people
who have substance use disorder fail to seek treatment? For almost any other
psychiatric or medical condition, people generally want to have their problem
fixed. Why is having a substance use disorder different? Why do many people
with this disorder go years before seeking care, and only do so with cajoling
and pressure from outside sources?
Our field hopes that part of the answer to
these questions lies not only in the person with the disorder but in
circumstances that prevent treatment-seeking: economic and transportation
liabilities, poor access to care, and so forth. These issues might be something
that, as a just society, we can correct. We add to this list the presence of
stigma. Is it possible that many people with substance use disorder do not seek
treatment because they are simply ashamed of presenting their problem to a
health professional? It is certainly not unreasonable to think that stigma
might account for some people’s unwillingness to address their problem, though,
of course, the issue is obviously quite complex and difficult to fix.
One thing I know for sure is that many people
in our community struggle with substance abuse problems. Some are trying to
juggle their own substance use and family (as well as religious) obligations. Others
are married to a spouse with substance use disorder. Still others have a child
who is starting to drink or use drugs and neglecting responsibilities. I have
spoken with many of these people. I know that they feel ashamed, worried, and
often frightened.
I would like to think that all of this means
that we need to be kinder toward each other and more tolerant of our
weaknesses. Children and adults with substance use disorder often feel alone in
our community with nowhere to turn. Families of people with substance use
disorder feel isolated and are often afraid to share this knowledge with
professionals. Exercising non-judgmental goodwill and sympathy to people and
families struggling with substance use disorder might not help them solve these
very significant and often scary problems. But, as our grandmothers were known
to say, it wouldn’t hurt.
