Putting People First: It's Time to Speak Accurately About Addiction

February 15, 2018

Since this is my first blog post for Psych Congress Network, let me tell you a little bit about my journey. I am a mid-career certified nurse-midwife who along the way developed a burning interest in mental health and neuroscience. I am in the process of finishing my residency in my training to become a psychiatric­–mental health nurse practitioner (PMHNP).

We American nurse-midwives are the ideological descendents of women who practiced the other “world’s oldest profession.” On American soil, our mothers are the black granny midwives of the South. We have always spoken with respect about the capacities of our patients, in awe of what their female bodies and resilient spirits can do. My professors in midwifery school were all second-wave feminists. I was taught that language matters, and therefore to be mindful about using “person-first” terms. This concept comes from the community of people living with disabilities, and reminds us to refer to people not by their disability or condition, but first and foremost by their humanity.

I’ve exported that same zeal to empower my patients, to “midwife” their deliverance and redemption from suffering, to the mental health clinic. Imagine my surprise when I overheard conversations between patients and providers such as: “Let’s tell it like it is. You’re an addict” and “You are choosing to keep smoking even though it is causing you problems.” I hear and see the words “addict,” “dependence” (without evidence for such), “abuser,” “relapse,” and “clean and sober” regularly.

Stigma is a major barrier to treatment for the estimated 23 million Americans who suffer from substance use disorders. Societies tend to feel less sympathy for and less inclination to help those individuals who suffer from illnesses that are perceived to be caused (“it’s their fault”)  and maintained (“why don’t they just stop”) by the afflicted themselves.1 The fact that addiction involves disordered brain reward circuits, stress reactivity, and executive functioning2 is not reflected in such attitudes.

In 2010, two studies by John F. Kelly, PhD, of Harvard Medical School and colleagues were published. In one, two almost identical vignettes were presented to mental health clinicians attending a conference. In the first vignette, the protagonist was referred to as “a substance abuser,” while the other described the protagonist as having “a substance use disorder.” The first vignette garnered more punitive and less hopeful attitutes towards the “substance abuser.”3 The second study, sampling a somewhat more general population, did away with the vignettes and simply presented questions about a “substance abuser” vs a person who “has a substance use disorder.” The substance abuser was seen as more willfully misbehaving, more deserving of punishment instead of treatment, and a greater threat to society, compared with the person with the substance use disorder.1

Dr. Kelly presented his findings to the White House Office of National Drug Control Policy (ONDCP), which released a memo under the Obama adminstration a year ago entitled “Changing Federal Terminology Regarding Substance Use and Substance Use Disorders.”4 ONDCP is currently working on a glossary of suggested terminology. The Huffington Post published a handy version of the work in progress last month.5 In the meantime, Dr. Kelly, as director of Massachusetts General Hospital’s Recovery Research Institute, and colleagues have produced an “Addiction-ary,” a comprehensive guide to addiction-speak for providers, counselors, and policy-makers.6

These tools can help us begin to use less stigmatizing language with our patients who present with substance use disorders. Undoubtedly, the recommended terminology is at times unwieldy. Person-first terminology often is unwieldy when we first adopt it. We have all cut corners to communicate about patients at work, sacrificing respect for the patient as an individual in the interest of saving time and energy. Furthermore, on any given day, any of us may feel biased against people whose behavior we think falls somewhere in the spectrum of inconvenient to repugnant. But let’s tell it like it is. We are all potential vectors of stigma. Understanding this, we can choose to don the gloves of person-first language to prevent stigma transmission to our patients, for some of whom stigma can be fatal.

References

1. Kelly, JF, Dow, SJ, Westerhoff C. Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms. Journal of Drug Issues. 2010;40(4):805-818.

2. Volkow ND, Koob GF, McLellan AT. Neurobiologic advances from the brain disease model of addiction. New England Journal of Medicine. 2016;374(4): 363-371.

3. Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. International Journal of Drug Policy. 2010;21(3):202-207.

4. Changing federal terminology regarding substance use and substance use disorders. Office of National Drug Control Policy & Michael P. Botticelli. http://bit.ly/2ClFNMn. Published January 9, 2017. Accessed January 26, 2018.

5. Ferner, M. Here's one simple way we can change the conversation about drug abuse. Huffington Post. March 3, 2015. https://www.huffingtonpost.com/2015/03/03/drug-addiction-language_n_6773246.html. Accessed January 26, 2018.

6. Addiction-ary. Recovery Research Institute. http://www.recoveryanswers.org/addiction-ary/. Accessed January 26, 2018.

7. Kelly JF, Saitz R, Wakeman S. Language, substance use disorders, and policy: the need to reach consensus on an “addiction-ary”. Alcoholism Treatment Quarterly. 2016;34(1):116-123.

8. Walsh C. Revising the language of addiction. The Harvard Gazette. August 28, 2017. https://news.harvard.edu/gazette/story/2017/08/revising-the-language-of-addiction/. Accessed February 15, 2018.


Mousumi Mukerji is a certified nurse midwife who earned her master’s degree in nursing from Yale University, New Haven, Connecticut. She has provided prenatal, intrapartum, gynecological, and primary care to women throughout the United States and across the lifespan. Mukerji received a certificate in the assessment and management of perinatal mood disorders from Postpartum Support International in 2016. She will complete the psychiatric-mental health nurse practitioner program at the University of California, San Francisco in March 2018. She has research experience on the knowledge, attitudes, and beliefs about HIV/AIDS in India. Her future career interests lie in maternal mental health, trauma therapy, and psychotherapies.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.