Substance Use Disorder (SUD) refers to the use of alcohol and other drugs to the extent that it causes significant impairment, including health problems, disability, and failure to meet responsibilities such as work, school, and at home. The use of alcohol and other drugs, to this extent, is considered deviant behavior. The designation of deviance is socially constructed and influenced by culture, policy/politics, and governments. It is essential to discuss and understand the relationship between deviance and the social construction of reality. The social construction of reality refers to meaning or value that people give to ideas or objects through social interactions. Irving Goffman, the author of the Dramatological Theory (Goffman, 1973), suggested everyone has a role to play to make a good impression and saving face. The purpose of saving face is a motivation for people to act within social norms, again to save face. People who act outside of these social norms are labeled deviant, and, in the case of people who use alcohol and other drugs, those people have become stigmatized.
The word stigma is understood in the classical sense, for example, according to the Greeks, it refers to bodily signs designed to expose something unusual and wrong about the moral status of the signifier (Goffman, 1987). In those times, signs were cut or burnt into the body and advertised the bearer as a slave, criminal, etc. Today, we use the term to describe disgrace or how behavior is socially discrediting (Kelly, Saitz, & Wakerman, 2016). In the case of SUD, the shame from stigma causes people with the disorder not to get the treatment they need for their disease. People feel they should be able to stop using on their own, are worried they will lose their social networks, and become more socially distant and fear judgment.
Words matter, and word choices affect the perception and treatment of those with substance use disorder. By understanding stigma, the imbalance of power it represents, and the barrier it creates for people who seek treatment and live in recovery, we can, together, choose person-centered words like "a person with substance use disorder" versus and "addict" or "alcoholic."
From Badness to Sickness
Conrad and Schneider (1992) suggest deviance is an attributed designation versus an inherent characteristic. According to the labeling-interactionist tradition, collective action defines deviant behavior. These collectives are social entities, groups, and, most importantly, political systems. It becomes an agreed-upon designation that becomes legitimatized through the collection agreement. The classification of deviance does not require an explanation of the cause of the behavior. It requires an explanation of the cause of the meaning attached to the behavior (p.19).
There is value in understanding the nature of designations of conditions or behavior as deviance from social norms. A perspective these authors emphasize is the collective nuance; for example, the labeling-interactionist theory turns away from the individual and the causes of the behavior and views deviance as a social product that is relative to time, place, and audience. It can change from state to state with varying laws about cannabis use, for example, Deviance designations by those from special interest groups, who are more powerful, reinforce ideas of deviance. Ironically enough, even among people living in recovery from alcohol use disorder, collectively promote that using opioids is more deviant the alcohol use.
There is a conflict perspective when discussing the designation of deviant behaviors. This conflict is between the powerful and the powerless. Powerful groups produce a classification of deviant behavior, for example, the American Medical Association, State and the Federal Government, and religious organizations. These labels of deviance are applied to the powerless, such as a patient who needs cannabis to control pain and nausea from cancer treatment or person with opioid use disorder needing medication-assisted therapy.
The Harrison Act of 1914, an example of the power of the Federal Government, created a new group of people labeled as criminals by prohibiting cannabis and opiate use. Words such as potheads, stoner, and junkie came to define people with substance use disorder. Prohibition is another example of government influence on the social construction of deviance. Prohibition banned the use of alcohol for everyone. After the repeal of Prohibition, people with alcohol use disorder became known as drunks, drunkards, criminals, and criminally insane. Behaviors designated as deviant change over time, for example, who is responsible; whose fault is it? A criminal (or person with substance use disorder) is accountable for their behavior; a sick person, such as a person with cancer, heart disease, or diabetes, is not.
When the medical field acknowledged substance use disorder as a disease, it was considered a victory by people working in the behavioral health field because it legitimized a condition that is not willful. However, as Conrad and Schneider argue, the medicalization of abnormal behavior is political and has placed more power and control in the hands of medical personnel. The chapter from Conrad and Schneider's book From Badness to Sickness: Changing Designations of Deviance and Social Control (1992) is an essential discussion because it discusses crucial aspects of the power and control of deviance.
Deficit Discourse
Kenneth Gergen, a social psychologist and prolific writer and researcher takes the concept of the medicalization of deviant behavior one step further in his discussion about deficit discourse (2007). He suggests that self-definition and power relations walk hand in hand and that we have experienced colonization of ourselves by psychological science. This colonization influences the everyday language we use to think and describe ourselves.
Language serves as a significant medium for carrying out relations, it constructs and rationalizes reality. By acting within language, links of power and privilege become sustained and extended into the future. (para, 14). There are many examples of the good intentions of psychologists. However, conflict in discourse happens when science attempts to share knowledge and research to influence policy and sell psychological tests, books, programs, and practices. We can see this phenomenon among the requirements of managed care that allows only specific evidence-based practices.
In 1952 with the publication of the Diagnostic and Statistical Manual of Mental Disorders, there were 50-60 different psychiatric disturbances, by 1987, there had been three revisions, and 35 years later, there are 180-200. The tendency to promote the language of mental deficiency has drastically expanded the population of patients and makes the psychopharmacology industry and managed care programs fast-growing businesses.
Gergen suggests that it is not just the naming of defective self that is problematic, but that people are effectively "seduced" into identifying themselves as mentally ill by institutional cooperation. The discourse of "guilt," "need for spiritual fulfillment," and "getting right with God," does not invite therapy and medication, but prayer, spiritual consultation, and good deeds. One of the essential principles of Twelve -Step Recovery is serving others and doing good deeds (AA Big Book, 2001). Gergen suggests we resist this self-colonization in favor of enlightenment.
Conceptualizing Stigma
Bruce G. Link and Jo C. Phelan (2001), both from the sociology department of Columbia University, clarify the concept of stigma by understanding the challenges to the idea. The problems are related to the variety of ways it is investigated and understood and that many social scientists do not belong to the stigmatized groups and do not have the lived experience.
Link and Phelan suggest when elements of labeling, stereotyping, separation, status loss, and discrimination co-occur when there is an imbalance of power, the components of stigma can unfold. Like Conrad and Schneider, power and control are critical aspects of stigma. The more powerful groups of people, such as the government or the medical profession, assign labels to other groups of people that may share characteristics. Usually, the more powerful group will overly simplify, resulting in ambiguous lines of demarcation between groups. Consider the modern-day cannabis user. In one state, cannabis use is legal; in another state, medicinal use is legal, and in other states, cannabis use is illegal. The labels assigned to less powerful groups change over time, and even the words used to discuss stigma change.
Stereotypes and labels are in a relationship with each other. For stigma to happen, labels and stereotypes converge. This convergence of labeling, stereotyping, separation, and status loss, and discrimination allow stigma to manifest in an imbalance of power situation. According to a cognitive approach, labels and stereotypes are automatic, but words prime this cognition. Words have meaning, for example, words and categories are present at a preconscious level, placed there by socialization process, and people make split-second decisions based on socialization.
Stigma also occurs when people separate themselves in to "us" or "them." The linking of labels to undesirable attributes justify the belief one may warrant a negative label. This justification is when implicit bias occurs, and harm to a person is not perceived. Little damage is perceived when attributing bad characteristics to "them." Link and Phelan, make important points relevant to persons with substance use disorder. For example, people speak of persons as being alcoholic, versus a person who has cancer, diabetes, or other chronic illness. Primed with words, such as "is" versus "has" is a critical point in the concept of stigma.
As stigma unfolds, there is also a component of status loss and discrimination. Stigmatized people are set apart and linked to undesirable characteristics that lead to status loss and discrimination. There is a reduction in status in the eyes of the stigmitizer: a person with substance use disorder may not be qualified to be a leader in an organization, or they may experience inequality in social interactions. The disparities are subtle, and a single event that produced an unequal outcome may be difficult to identify; people might not be able to determine why a person with cannabis use disorder may not be trustworthy, but they just have a feeling.
This research adds to the understanding of the concept of stigmas like Conrad and Schneider suggest, there is an imbalance of power. Link and Phelan bring status loss and discrimination into the conversation. Status loss and discrimination influence a person's general life changes such as socio-economic status, educational, emotional well-being, medical treatment, and health.
Stigma and Social Inequality
Robin Room is a Professor and Director for the Centre for Social Research on Alcohol and Drugs at Stockholm University. Professor Room (2005) suggests that people from lower social classes experience stigma to a higher degree and with more severe consequences. Poor people suffer worse outcomes from substance use disorder than affluent people. The heavily moralized use of alcohol and drugs results in stigmatization and marginalization. Poverty exacerbates the moralization and stigmatization. This social inequality equates to social marginalization; people in poverty often lack social resources. Wealthy people experience less stigmatization and marginalization. They can purchase social protections; poor people cannot do this, causing people from lower socio-economic classes to suffer more greatly the effects of stigma. Substances (alcohol and drugs) represent a symbol of power. Alcohol and drugs also represent status symbols with accompanying exclusion and inclusion; not using sets one apart socially, using can lead to less social acceptance, and using but not able to stop using causes exclusion and marginalization. In addition to having social value and representing social behavior, substance use is intimate, taken into the body, in a general category of foodstuffs and drunks, what could be wrong with that?
This article informs the body of knowledge about the stigma because it discusses at length the relationship between poverty and substance use disorder. It also recognizes that even though, on the one hand, substance use disorder is known as a health disorder, it is thoroughly moralized and derogated and ranks high in social disapproval. In terms of the degree of social criticism, substance use disorder is rated very high. Social exclusion of intoxication is stigmatizing in itself. People living in poverty already live in social exclusion and inequality, substance use disorder further stigmatizes and marginalizes them.
Impact of Word Choices
The impact of word choices affects people with substance use disorder. Word choices are reflective of stigmatizing perceptions of people substance use disorder and impact personal and public support people have in getting treatment. This article by Ashford, Brown, and Curtis (2018) discussed research in reactions to positive language and negative language about substance use disorder. It measured both implicit and explicit bias. The implicit biases were rooted in the subconscious assumptions. There has not been a lot of studies about implicit bias, which makes this article very interesting. This study measured implicit association. It asked participants to classify two objective categories, for example, "substance abuse" and "person with a substance use disorder," with two categories, good and bad. The terms studied were substance abuser versus the person with substance use disorder, addict versus a person with a substance use disorder, alcoholic versus a person with alcohol use disorder, relapse versus recurrence of sue, opioid addict versus a person with opioid use disorder, medication-assisted treatment versus pharmacology, and medication-assisted recovery versus long-term recovery.
Additionally, the Bogardus Social Distance Scale was used to assess the comfort level of people in response to differences from themselves. For this study, the differences were individuals with substance use disorder, using both stigmatizing and non-stigmatizing labels. There were seven questions to measure the desire to allow: a) marry into the immediate family, b) exist within the immediate social circle, c) be a neighbor, d) be a co-worker, e) be a citizen in their country, f) be a visitor, g) comfort for excluding this person.
The results of the study demonstrate a more significant explicit bias from using timers such as "substance abuser" over terms that are person-centered. The results showed a negative association with words such as abusers and addicts. This study provides evidence for the importance of removing such words from our vocabulary. These findings are significant because it provides evidence that individuals do not seek treatment because of the fear of negative perceptions and provides support for using more positive variants when talking about or referring to a substance use disorder.
Pernicious Label
In White and Kelly's article (2011), the authors make it clear that the language used to label alcohol and other drug problems (AOD) exerts a significant influence on the people experiencing these problems. Language influences professional helpers, policymakers, and the way people are viewed. AOD is considered primarily in terms of medicine and illness, psychology and habits, social norms, morality, religion, and law. There are two terms the research agrees that need to removed from the vocabulary that describes substance use disorder; these terms are "abuse" and "abuser."
Abuse is technically inaccurate as it implies willful mistreatment. People do not abuse alcohol and other drugs; in fact, they treat substances with the most exceptional devotion and response, even at the expense of themselves. Using this term also reflects the misapplication of a morality-based language to describe a medical condition. Among medical diagnosis, abuse is a diagnostic term. The terms abuse/abuser also perpetuates stigma and, therefore, inhibits people from getting help, and contributes to social rejection, sequestration, and punishment. The terms "abuse/abuser" also imply that these are only bad choices, and people with substance use disorder are accountable for their decisions. Can you imagine if there was this same expectation of cancer patients? What would be the consequence/punishment for being forced to drink polluted drinking water in poor sections of town?
Abuse and abuser, are commonly used, and as White and Kelly indicate, there is a lot of work to be done to remove this label from our vocabulary. Major government agencies, such s the National Institute on Alcohol Abuse and Alcoholism, the Substance Abuse and Mental Health Administration, National Institute on Alcohol Abuse, and the Center for Substance Abuse Treatment, need to remove abuse from the names of their organizations. There are several professional journals such as the Journal of Substance Abuse Treatment that would contribute significantly to reducing stigma by taking this word out of their journal titles.
Barrier to Treatment
Unfortunately, the vast majority of people with substance use disorder do not enter treatment. Cunningham et al. (1993) compared three groups of subjects who indicated which factors affected their decision to delay or not seek formal treatment. Reasons cited included: embarrassment/pride, did not perceive they needed treatment, thought they could handle it on their own, negative attitudes toward treatment, monetary costs, and stigma. The stigma associated with the label "alcoholic" or with admitting to being a person with alcohol use disorder was the most common reason for not seeking help. This study from 1993, is crucial as it was ground-breaking towards acknowledging the stigma associated with substance use disorder and the barrier to treatment this stigma poses.
Addiction-ary
John Kelly, Richard Saitz, and Sarah Wakeman (2016) have been advocates for changing the conversation about alcohol and other drug problems. John Kelly is the founder of the Recovery Research Institute that advocates for a change in the language used to refer to alcohol and other drug use and people with substance use disorder. Language, Substance Use Disorders, and Policy: The Need to Reach Consensus on an "Addiction-ary" was one of the most important studies included in this literature review. The authors suggest coming to a consensus about the language we use and making this language reflect substance use disorder as a health condition. These are life-threatening conditions, and stigma that is perpetuated by language results in inhibiting people from seeking help because of the shame of the disease.
These authors suggest to "stop talking dirty," referring to terminology that evokes implicit punitive biases that compromise the quality of medical care. It also creates a barrier to self-disclosure and honesty and being fully engaged in treatment. Kelly et al. have established an "Addiction-ary" to reduce stigma and convey greater clinical and public health precision in communication around addiction disorders. The new language would be non-stigmatizing, person-centered language. This article encourages clinical and scientific communication in the field of medical and behavioral health, to fully consider the words they use as they report empirical findings. Scientific communication has an opportunity to use language that avoids attributions of personal choice and responsibility and focus on person-centered language that promotes help-seeking from a therapeutic system of care that values elimination of stigma through language.
References
Alcoholics Anonymous (2001). 4th Ed. Alcoholics Anonymous World Services, Inc. New York City, NY.
Ashford, R., Brown, A., & Curtis, B. (2018). Substance use, recovery, and linguistics: The impact of word choice on explicit and implicit bias. Drug and Alcohol Dependence, 189. Retrieved from http://search.proquest.com/docview/2100878951/
Conrad, P. and Schneider, J.W. (1992). Deviance and Medicalization: From Badness to Sickness. Temple University Press.
Cunningham, J.A., Sobel, L.C., Sobell, M.B., Agrawal, S., and Toneatto, T. (1993). Barriers to Treatment: Why Alcohol and Drug Abusers Delay or Never Seek Treatment. Addictive Behaviors Vol 18 pg 347-353
Gergen, K.J. (2007). "The Self: Colonization in psychology and society." Psychology's Territories: Historical And Contemporary Perspectives From Different Disciplines. 149-167. https://works.swarthmore.edu/fac-psychology/600.
Goffman, E. (1973). The presentation of self in everyday life. Woodstock, N.Y.: Overlook Press.
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Kelly, J.F. (2004). Toward an addictionary, Alcoholism Treatment Quarterly, 22:2, 79-87, DOI: 10.1300/J020v22n02_07
Kelly, J.F., Saitz, R., Wakeman, S. (2016). Language, substance use disorder, and policy: the need to reach consensus on an "addiction-ary. Alcoholism Treatment Quarterly. 34(1), 116-123.
Link, B.G. and Phelan, J.C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363–385. https://doi.org/10.1146/annurev.soc.27.1.363
Room, R. (2005). Stigma, social inequality, and alcohol and drug use. Drug and Alcohol Review. 24, 143-155.
White, W., & Kelly, J. (2011). Alcohol/drug/substance "abuse": the history and (hopefully) demise of a pernicious label. Alcoholism Treatment Quarterly, 29(3), 317–321. https://doi.org/10.1080/07347324.2011.587731