Words matter. Our society's beliefs about substance abuse and compulsive behavior problems -- and the potential for change -- are built into the words we use to speak about these issues. The way we use certain words reflects and conveys our deeply held beliefs and attitudes. Why does our word choice matter when it comes to talking about substance use problems? Because unfortunately, the ingrained attitudes and feelings about substance use disorders at present are not positive and are mostly grounded in pessimism, skepticism, misunderstanding and fear.
Words like "addict," "abuser" and "alcoholic" are widely used indiscriminately to describe people who struggle with substance use issues and are laden with negative connotations for much of the culture. As a psychologist who treats substance use disorders I usually discourage my clients and their families from using these words to describe themselves or their loved one. I do this for a variety of reasons.
First, these words over-generalize and tend to whitewash important details about the people they describe. As they're commonly used, they are labels that lump together an incredibly diverse group as if they were all the same. They completely blur the reality that people struggling with substance use problems have dramatically different levels of problem, have the problem for different reasons, have different prognoses, and will take a variety of paths with their relationship to substances moving forward. People who use substances are more diverse than they are similar. When you refer to someone struggling with a substance use disorder simply as an addict or alcoholic, you are at risk of losing sight of all the distinctions and variations that matter tremendously. Additionally, it is highly likely that your audience is making a variety of automatic assumptions based on what the words mean to them. While you may mean something very specific when you use the word, the person listening to you may have very different ideas (and you can almost always assume not good ones).
You don't have to dig very deep to hear the negative connotations attached to these words (e.g., lazy, weak-willed, failing moral compass, diseased). In fact, it is not uncommon for them to be used as an insult. The easiest way to confirm this for yourself is to listen to the tone of voice that most people use when they refer to someone as "an addict." There is more often than not a tone freighted with toxicity, denigration, suspicion, and as a result stigma.
Stigma is the second reason I ask people to be thoughtful about these words. Research has shown us that fear of stigma is one of the main reasons people resist seeking help. Studies have found that even professionals in the field are at risk for having the negative connotations associated with these words creep into their work. John Kelly, a psychologist at Massachusetts General Hospital and a leader in the addiction treatment field, conducted a survey of health professionals who were asked to answer questions about a hypothetical patient who was described as either a "substance abuser" or as "having a substance use disorder." They found that referring to patients as a "substance abuser" resulted in more negative attitudes and assumptions about the patient. Specifically, the health professionals were more likely to agree that the client should be punished for not following a treatment plan and that their "character" was culpable. The study concluded that the choice of language was related to increased stigmatization.
Similarly, studies have found that when treatment providers refer to clients as "alcoholics," they are at risk for making negative assumptions that potentially effect how they treat the people they are supposed to be caring for. Terrie Moyers, a psychologist at CASAA in New Mexico who is one of the leaders in motivational treatment approaches, conducted research with substance abuse counselors and examined attributes these counselors attached to the label "alcoholic." She found that associated with this label were the beliefs that "alcoholics are liars," "cannot make good decisions for themselves," "have personality deficits that predate drinking," have special "spiritual deficits," and "need strong confrontation."
The final problem I have with using these labels to describe a person with a substance use problem is that people try to explain things through the use of these words. How many times have you heard people say "well, he's an addict, what did you expect"? In my work, I often hear clients say "I'm an addict, that's what we addicts do," or "yeah, over the holidays I started to withdraw more... but that's me being an alcoholic." Typically, what people are describing in these discussions are behaviors that the rest of the non-substance abusing world is likely to share in as well (lying to avoid conflict, hiding out when overwhelmed). The difference is that non-substance users don't explain their behavior by saying "I'm an addict." Referring to someone else or one's self as an "addict" seemingly explains a lot of behaviors neatly and under one heading. And the problem? When you explain things with false evidence, the real answers sneak out the back door. For example, "I'm an addict" is not a helpful explanation of why I lie a lot. Instead, I may have gotten into the habit of lying because I am ashamed or embarrassed or I got hit as a kid when I expressed myself. These are real reasons why the lying habit forms, not a reflection of an innate addict character trait. For this reason I DO stop clients from saying "I'm an addict" as an explanation for their behavior, because there is nothing to be learned from this labeling.
While I point out all these "label" problems, I know that there are many people who find connection when self-identifying as an addict/alcoholic and find immense comfort in being part of a community who relates to these words. In the context of the 12-step community, identifying as an addict or alcoholic can be a powerfully positive act. It is crucial to note however, that it is an act of choice. Calling oneself an addict is very different than being called an addict by someone else.
The fortunate news is that words are hugely powerful mediators of positive change. Some of our most successful treatments (e.g., Motivational Interviewing) are predicated on use of language by the therapist that is non-confrontational, respectful, conveys a sense of collaboration, and demonstrates empathy and understanding of the other person... all with words! Additionally, this approach places a lot of emphasis on facilitating certain language from the client, called "change talk," that has been demonstrated to predict positive change. So our language matters, and the language of the person we are trying to help matters.
From the perspective of cultural ease, I understand the pull to find one-word explanations, especially in our current world of sound bites. But the reality is that labeling anyone with a substance problem as an "addict," "alcoholic" or even "substance abuser" does stigmatize them in the real world, pushes too many people away from the help they need and want, and makes generic a problem that is profoundly complex. We cannot escape the reality that stigma is conveyed by word choice: once spoken, the genie cannot go back in the bottle. And while you may not feel anything negative about these words and may in fact relate to them deeply, it is important to not minimize the stigma they may carry for the person you are talking with. For example, many a well-intentioned therapist may say something like "I'm glad you're here Mr. Smith, and it's important that you've recognized you are an alcoholic." The potential internal dialogue of someone who just got this message? "I thought I was just drinking too much in the evening(!) Maybe this isn't the place for me... I'm not a drunk so should probably just try to deal with this on my own." While the alternatives are awkward and far from a sound bite, phrases such as "substance user" and "person with a substance problem" are more accurate and less at risk for pushing a person away from change. The scientific evidence is clear... words matter. They can open doors to change and expand our perspectives or they can set up barriers and roadblocks to understanding... I for one would like to keep them open.
Dr. Carrie Wilkens is the co-founder and clinical director of the Center for Motivation and Change. Dr. Wilkens specializes in motivational treatments and group psychotherapy, and has worked with traumatized populations in both individual and group modalities. She is most recently a co-author on the new book Beyond Addiction: How Science and Kindness Help People Change, a compassionate and science-based family guide for navigating the addiction treatment world, understanding motivation, and training in the use of CRAFT (Community Reinforcement and Family Training) skills. Dr. Wilkens' expertise is regularly sought by the CBS Early Show; Fox News; Newsweek; O, The Oprah Magazine; and Psychology Today.
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