It’s Time to Clean Up the Language of Addiction

Last updated on November 4th, 2019

When I worked in the field of obesity treatment, I would discourage my clients from “talking dirty.” No problem if they swore or talked about sex – the issue was talk in which they put themselves down, labeled themselves in a pejorative way, or presented their behavior in moralistic terms.

People often did this when discussing how they deviated from their weight management plans – for instance, “I was bad this weekend;” “I blew it;” “I pigged out;” or “I’m just a fat slob.” It would be unconscionable for professional weight management counselors to use this kind of talk, accusing clients of “eating like a pig,” or engaging in “fat behavior.”

…when it comes to addiction treatment and recovery, where I now focus my work, there’s a fair amount of “dirty” talk on the part of both clients and professionals.-Anne Fletcher

Yet when it comes to addiction treatment and recovery, where I now focus my work, there’s a fair amount of “dirty” talk on the part of both clients and professionals. In the biz, you hear a lot less language like “druggie,” “crack head,” “drunkard,” and “doper” to describe clients, but there’s still too much verbiage floating around that isn’t productive and may be even harmful.

In doing the research for Inside Rehab, I heard clients characterized as dishonest, narcissistic, and selfish. (Sometimes clients described themselves this way.) One staff person said that “terminal uniqueness” is the type of resistance he encounters most, describing it as an attitude of, “I’m different; no one understands me; that might work for them, but it isn’t going to work for me.” The truth is, everyone with a substance use disorder is unique – despite the common notion that “all addicts are the same.”

As I learned at an early age when kids made fun of me for having “Dumbo” ears, the “sticks and stones” adage isn’t really true – names can really hurt you.

It’s time to clean up some everyday language in the world of addiction treatment and recovery. Following are some examples that many would consider outmoded but I still hear used all the time.

Clean

While best-selling author David Sheff has some very important things to say, I cringed when I learned that the title of his latest book on addiction would be Clean*. Professionals regularly talk about “clean” and “dirty” urine tests when they could just as easily use the neutral terms “positive” to reflect someone’s use of drugs and “negative” to reflect non-use. If someone with diabetes has too much glucose in his or her urine or blood, do we label it a “dirty” test?

What does “clean” mean? To me, it infers that people with substance use disorders are “dirty” when they’re using.-Anne Fletcher

Recently, I heard a well-intentioned mother of a son who’d wreaked havoc in her family’s life say, “He’s welcome to come back home when he’s clean.” What does “clean” mean? To me, it infers that people with substance use disorders are “dirty” when they’re using. Given the widely held view that “addiction is a disease” or chronic disorder, it’s difficult to conceive of such language being used when someone isn’t fully compliant with treatment goals for any other chronic disorder. Would we say that a person with diabetes or high blood cholesterol who has trouble with medication compliance or sticking to a diet is “dirty”?

How do we define “clean” anyway? Is it being 100 percent drug- and alcohol-free? Given that many people who struggle with substance use disorders are not able to achieve abstinence, and “progress not perfection” is accepted practice by many experts in the field, there are no definitive guidelines for what “clean” is or should be.

* Some people have questioned my use of the word “sober” in the title of my book, Sober for Good, because it implies that abstinence is the only accepted goal for people with alcohol use disorders. However, I explain that, according to Webster’s dictionary, the word “sober” does not necessarily equate with abstinence. Although the majority of the 222 former serious problem drinkers who had at least 5 years of sobriety when I interviewed them had chosen abstinence, some were able to resume drinking alcohol moderately, without problems. I still considered them “sober for good.”

Relapse

In 2010, addiction treatment and recovery historian William L. White, M.A. and Sadé Ali, M.A., CADC, senior associate with Altarum Institute in Washington, DC wrote a thoughtful paper arguing that the terms “relapse” and “lapse” have moral and religious roots and that they should be replaced with more neutral and precise terms depicting experiences of people with substance problems who resume use following voluntary periods of non use. (“Lapse” is used to distinguish a brief period of alcohol or drug use from a “relapse,” which has been defined in different ways but is typically considered a return to more extended and excessive use.)

They point out that lapse and relapse come with such historical “baggage” as abandonment of religious faith (a lapsed Catholic); moral failing (lapse in grace); deviation from accepted standards (lapse in judgment); and deterioration in discipline or ability (lapse in memory or into bad habits.) “These terms entered medicine at a time health conditions were thought to be inextricably linked to a person’s religious or moral conduct,” and were applied to people who’d returned to drinking during the temperance movement after publicly signing a temperance pledge, White and Sadé note.

The preferred term for this situation and that some experts now prefer for a return to regular use in someone with a substance use disorder is “recurrence.”-Anne Fletcher

They did an Internet search, comparing the number of times “lapse” and “relapse” were associated with various terms for alcohol and other drug problems versus other medical and behavioral health conditions and found that the terms were used far more frequently for substance problems. The preferred term for this situation and that some experts now prefer for a return to regular use in someone with a substance use disorder is “recurrence.” For instance, rather than say, “Susan relapsed right after she got out of rehab,” one would say, “Susan resumed drinking” or “Susan experienced a recurrence of her alcohol use disorder when she was discharged from treatment.” We wouldn’t say that someone whose cancer returns or someone with diabetes whose blood sugar spikes because of eating too many candy bars has relapsed, would we?

White and Sadé propose that, in the spirit of focusing on what’s being embraced rather than on what’s being avoided, “relapse prevention programs” be redesigned as “recovery support programs.” When considering alternatives to lapse and relapse, they suggest that the emphasis be moved solely from “not using,” to more fully include language such as wellness, quality of life, life meaning and purpose, and citizenship.

Alcoholic and Addict

“Once an alcoholic, always an alcoholic.” That’s what a young woman told me her psychiatrist said to her during their first visit upon returning to her after a stint in rehab for a co-occurring alcohol use disorder and depression. What an onus for a young person to bear for the rest of her life. Another young man at an adolescent rehab I visited must have introduced himself as “an addict” 10 times in a 90-minute group session. When later I asked his counselor why this was done, she replied, “It’s to remind them of why they’re here.” One psychologist I interviewed for Inside Rehab told me she thinks it can hurt young people “to frame their identity around whether you’re an addict or not. After a lot of time in traditional rehab and 12-step groups, they may not get exposure to other ways young people get a sense of identity—for instance, being a student.”

Another professional who works with young people said that they don’t even use the word “addict” because “defining someone in terms of their problems is a great injustice.” He went on to describe a session with a mother and son during which an intern told the mom, “Your son is an addict, and he has to come to terms with this first.” The upshot was that the mom became defensive, and the boy asked to go to the bathroom – proceeding to climb out the window, never to be seen by the program again. Usually, the program does not force people to admit their problems, instead helping them to look at their strengths. The director said, “This frees them up. They need to believe in themselves to be successful. And I think the labeling interferes with that.”

They need to believe in themselves to be successful. And I think the labeling interferes with that.-Program Director

In professional diagnostic terms, the words “alcoholic” and “addict” don’t even exist any more. “Alcoholism” was abandoned in 1980 as a diagnosis in favor of alcohol dependence and alcohol abuse, which in turn disappeared in the current DSM-5 that now employs the classifications of mild, moderate and severe substance use disorders, which we should be using. (These are delineated according to substance: alcohol use disorder, cannabis use disorder, and so on.) Although “addiction” is commonly used to describe severe problems related to compulsive and habitual use, it is not used as a diagnostic term in the DSM-5 “because of its uncertain definition and its potentially negative connotation.”

***

In the end, says William White, “Language matters. It is far more than superficial concerns about political correctness. The labels applied to individuals affect how they are perceived by others and how they perceive themselves. Stigma and discrimination are couched in a language that reinforces stereotypes and elicits fear. Language that focuses on the person is more respectful and less stigmatizing than language that defines a person in terms of an illness.”
What are some other terms you think that we should re-examine in the field of addiction treatment and recovery?

Photo Source: istock

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