“Abuse” is an ugly word. “Child abuse,” “sexual abuse,” “physical abuse,” “emotional abuse,” “domestic abuse.” And then, of course, there’s “substance abuse.”
But one of those things is not like the others: In all of the other types of abuse, there is a perpetrator who is harming a victim. In substance abuse, however, it makes no sense to argue that the victim is the poor innocent line of methamphetamine or a glass of Chardonnay. The damage done—both by the problem and by the term—is focused primarily on substance users themselves. The label is far from innocuous, and I vote that we retire it.
Debates over language often seem absurd or trivial. However, they make a difference in how issues are framed and therefore what solutions are proposed. Frame addiction as “substance abuse” and it is easy to see why it should be a crime, but call it “substance use disorder” and it sounds like something to be treated medically. If we want to make progress in ending stigma, we should think hard about the words we use.
In the case of “substance abuse,” there is empirical evidence of the harm that this framing can do. In a 2010 study, researchers surveyed over 500 mental health practitioners at a conference—two thirds of whom had Ph.D.s. Participants were asked to determine treatment for two hypothetical patients who were identical except that one was labeled as having a “substance use disorder” and the other was said to be a “substance abuser.”
The “substance abuser” label encompasses the whole person, defining him or her by dysfunction. In contrast, the “substance use disorder” tag simply describes one problem, rather than an entire identity.
Despite their training, the practicing clinicians favored a more punitive approach when the patient—who was described as having relapsed during court-ordered treatment—was labeled as being an abuser as opposed to having a disorder. More clinicians supported jail or community service rather than further treatment for the “substance abuser.”
This is one reason why the recent revision of the DSM—psychiatry’s diagnostic manual—no longer includes “substance abuse” as a diagnosis. The term brings up stigmatizing associations between abusive behavior and drug taking—even though the vast majority of people with drug problems do not engage in child abuse, sexual abuse, or domestic violence. While the DSM revision made many mistakes—for example, it conflates the milder substance-problem diagnosis with the more severe one (mild problems do not require abstinence and the last thing we need is more reason to apply “one size fits all” treatment in this area), the editors were right to get rid of the abuse label.
But there is another reason why labeling someone a “substance abuser” or as having a “substance use disorder” matters. That is, the “substance abuser” label encompasses the whole person, defining him or her by dysfunction. In contrast, the ”substance use disorder” tag simply describes one problem, rather than an entire identity.
It will be hard to get rid of a term that is so ubiquitous that it is enshrined in the name of the research agency of the federal government that studies drugs (the National Institute on Drug Abuse) and in the most popular (though actually ineffective) prevention program, DARE, or Drug Abuse Resistance Education. But advocates in other areas have managed to remove many other similarly common and—dare I say—abusive terms from public dialogue and polite company.
Advocates for people with mental illness have long argued for language that puts “people first”: In this case that would mean that instead of using the terms “addict” or “alcoholic,” use “person with addiction” or “person with alcoholism.” While in principle I agree, in practice I occasionally slip because the phrase makes for clunky language. Still, I think that using “people first” language forces the writer to think about stigma and how they are portraying their subjects. While it probably has a less conscious effect on readers, it at least subliminally asserts the fact that those who suffer from these effects are human. We have been seen as objects by other people for too long.
As much as anything, having a politically correct term for a condition chosen by those affected also signals that our activism is coming of age and gaining power. (For example, ironically many autistic people actually reject the “person first” approach and prefer the term “autistics” because they do believe that their condition defines their identity—and the media is beginning to use this language as activists have spoken out about it.)
People with addiction also need to think hard about other language we use. Take the terms “junkie” or “dope fiend.” I think they are acceptable only if used ironically or by people who have addictions—just as stigmatizing words for black people or gay people are only acceptable when used by members of those groups. I also believe that when we use these terms about ourselves, we need to consider their implications: Am I using this word because it is the right one for the situation or because I still have remnants of the self-hate that the stigma of addiction exacerbates?
If we want to be understood as patients with an illness like any other, careful use of language is essential—as is making sure we do not inadvertently further stigmatize ourselves. For example, consider the commonplace assumption that addiction is always accompanied by compulsive lying and other criminal behavior.
In fact, many people with addictions do not lie except when it comes to hiding their condition—and some do not dissemble even then if the conditions of their life permit this. Research shows that addicted people tell the truth about their use (as correlated with objective measures like urine tests) so long as acknowledging their use will not be used against them. The connection between addiction and lying is in part an artifact of the criminalization of some drugs. The rest of the link can be accounted for by the fact that people with personality disorders like antisocial personality disorder are not only more likely to become addicted and more likely to be criminals, but more likely to be compulsive liars.
The same is true for the link between violence and drug problems: Violence among drug users is linked to drug prohibition, antisocial personality disorder, and to having grown up with violence, not addiction per se. Most drugs—with the exception of alcohol—are not themselves pharmacologically linked with violence, and when they are, the perpetrator almost always has a prior history of it. Addiction doesn’t typically make people into unrecognizable monsters: It exaggerates the problems they already have.
If we want to fight addiction, then, it is important that we separate out the contribution of addictive disorders to the problems seen in people with addictions. Addictions are not caused by “character defects” and they don’t call forth immoral behavior from out of the blue. The way to start is by being careful about what we call ourselves, about what we see as the essential characteristics of addiction and how we understand our condition.