The Real Harms of Abusive, Stigmatizing Language in Addiction Treatment

March 11, 2020

Ironically, the conversation that spurred a peer-support specialist at a buprenorphine program to yell me out of the room was about abusive communications.

It was nearing the end of our day at Memorial Outpatient Behavioral Health in Florida last year. Our day consisted of a series of group therapy sessions beginning at 9am and ending with a noon lunch. As usual, we sat and ate sandwiches and engaged in semi-structured conversations led by the peer-support staff.

One of the patients, a young mother whose heroin use during pregnancy led to a child services case, told us that her caseworker threatened that if she had any future children they would also be taken—despite the fact that she was engaged in her treatment and other mandated services. The group members murmured various versions of shock and disgust. But the peer support specialist felt differently. She immediately began to admonish the young mother, saying that her caseworker was only “being real.”

I wasn’t having it.

When I told her there was nothing “real” about threatening her that way, especially while she had an open case and was trying to succeed in recovery, the peer worker went into a rage. She began shouting at me that I “didn’t know shit,” belittled my journalism work, and when I got up to leave in order to avoid escalation, continued to swear and yell at me until I was out of the building.

I was disappointed not just at her behavior, but also that nobody from the program followed up with me to see if I was okay. I wasn’t. At that time in my life, my work was just about the only thing I had to feel good or proud about, and everyone at the program—including the staff member who yelled at me—was aware of that. Putting me down in front of my peers, cussing at me and publicly denying the validity of my work were all forms of targeted humiliation—the very opposite of what a treatment recovery program should provide.

Yet experiencing verbal abuse from treatment staff is a relatively common complaint.

“When we treat people like dirt, we can’t expect them to build rapport with professionals or to engage in their progress.”

One patient in Southern California, who asked to remain anonymous, told me about the dosing nurse at her methadone clinic who called her “dirty” and threatened to revoke her take-home doses when she was prescribed medication containing codeine as aftercare for three root canals. “It’s made me question if I want to continue if I have to keep hearing [negative] comments and such,” she said.

Another patient at a methadone clinic in Ohio told me she is transferring facilities because bullying behavior from a nurse got so out of hand.

“When we treat people like dirt, we can’t expect them to build rapport with professionals or to engage in their progress,” said Robert Ashford, a recovery scientist at the University of the Sciences in Philadelphia who has extensively studied the impact of language on addiction care. “That’s not a lack of compliance or motivation; people don’t want to be treated that way, so it naturally reduces positive outcomes.”

Ashford’s remarks should be self-evident, but it’s all too common for patients to receive escalated blame for reacting in a normal manner to abuse from staff—such as being considered “non-compliant” if they don’t immediately return, or considered angry, over-reactive or “violent” if they talk back.

But it’s not just obviously egregious cases of bullying and abuse that can erode trust and lead to negative outcomes for patients. An increasing body of research is now showing that the words people use when describing addiction, treatment and people who use drugs has a palpable impact on patient care—even words so commonly used in these settings that most patients expect to hear them and often use them themselves. Like “addict,” “substance abuse” and “clean/dirty” to describe drug test results.

One study found that the terms “addict” and “substance abuser” led people to hold distinctly negative associations about the people they described. Another found that replacing less obviously pernicious terms, like “relapse” and “medication-assisted treatment,” with “recurrence of use” and “pharmacotherapy,” resulted in more positive views of people with substance use disorders.

Addiction medicine physician Sarah Wakeman also published a paper in which she argues that “’medication-assisted treatment’ implies that medications are a corollary to whatever the main part of treatment is. No other medication for other health conditions is referred to this way … to truly change outcomes, we must also alter the language of treatment.”

“Language matters generally because it’s the primary way we communicate … it doesn’t matter if it’s verbal or written or sign language,” Ashford told Filter. “We take our cues for how we interact and see the world [from] the words we use.”

When it comes to overcoming stigma in addiction treatment settings, he admits that a change in language won’t solve all the inequities embedded in these settings and in wider society. He just argues that it’s a free and simple way to create a noticeable, positive shift in a patient’s experience.

“When people say ‘substance abuse’ [for example], they mean substance misuse, and they both mean the same thing but they evoke different emotional reactions,” he said. “It’s already inherently negative, but we don’t need to remind [the patient] of the worst thing they can imagine by using words we have been socialized to think of as the worst things in the world.”

A key component to understanding and utilizing the power of language is to recognize its inherent fluidity.

Language has a very real impact on the way we perceive ourselves and others, as demonstrated by Ashford’s research. But there is still variation in the way individuals engage with language, especially when it comes to self-identification. Just as treatment should be individually tailored to the patient, it’s important to recognize and respect the words people choose to use to describe themselves and their experiences. For example, Ashford identified “substance misuse” as more positive than “substance abuse,” but some members of the harm reduction community prefer terms like problematic or chaotic drug use, because they feel “misuse” implies a mistake, which can continue to hint at flawed behavior.

In Ashford’s research, “addict” was strongly associated with negative perceptions, and “relapse” also had some negative associations. But that doesn’t mean we should chastise people for self-identifying with these terms. I have written about my own inclination to sometimes self-identify as a “junkie,” as a way of reclaiming a word that has been weaponized against IV drug users, while also displaying my allegiance to a community that has been pushed to the edges of society. But I do not take kindly to someone from outside of that community calling me a junkie, and I would never use the term to describe another person without their consent.

A key component to understanding and utilizing the power of language is to recognize its inherent fluidity. What might be acceptable or even affectionate when spoken between members of a community can weaponize into hate speech in other circumstances.

“When I see a patient and they self identify as a cocaine or heroin addict…I don’t correct them,” said Lipi Roy, a clinical assistant professor at NYU Grossman School of Medicine and an internal medicine physician who specializes in addiction, but she also notes that language can affect the way providers view their patients, even if they don’t realize it.

“When we use stigmatizing, punitive language…[such as] ‘dirty’ or ‘clean’ urine, ‘addict,’ ‘lush,’ ‘alcoholic,’” she told Filter, “healthcare professionals view or see people with addiction as manipulative, less motivated, angry, violent, and they spend less time in clinic with them and all of that adds to suboptimal care.”

It’s hard to find an addiction treatment facility where staff do not employ terms that research has identified as harmful.

“When it comes to addiction, we describe patients as ‘substance abusers;’ we refer to urine toxicology screens as ‘dirty’ with drugs; with our language we imply patients are inflicting the morbidity of the disease on themselves and are thus undeserving of care,” wrote Wakeman in a letter published in the American Journal of Public Health.

Despite this expert consensus, it’s hard to find an addiction treatment facility where staff do not employ terms that research has identified as harmful.

“Addict” is a mainstay of 12-step groups, which are integrated into most US treatment programs. Although “substance abuse disorder” was replaced by “substance use disorder” in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders as long ago as 2013, “substance abuse” remains a refrain in program literature. “Clean” and “dirty” won’t be easily scrubbed from treatment lexicon, no matter how cringe-worthy they sound once you stop to think about their implication.

For many patients, this issue is compounded by court involvement. Criminal and family court systems view drug use through the lens of illegality. The patient is an offender who made a choice to break the law; therefore even when these systems acknowledge the role of addiction by offering or mandating treatment, there is still an inherent element of perceived immorality.

A Leon County, Florida Drug Court Program Expectations pamphlet, for example, highlights this reality by mocking the very clients it claims to be serving. For example, it claims to be providing a “PRIVILEGE,” and even goes as far as calling addiction the client’s “issues,” neatly wrapped in quotations to erase any question of whether this is intended to be condescending.

While other diversion court contracts appear to utilize a modicum more professionalism, the attitude is consistent. And until drug addiction is uncoupled from criminality, it is unlikely to change. So even when patients are able to find evidence-based providers who make conscientious language choices, if they are court-involved, they are still going to be dealing with derogatory framing.

My experience in Florida felt like an abusive extension of the degrading paternalism that shapes far too many modern addiction recovery programs. I could only feel proud of myself if the program allowed it; I could only share my opinion if it gelled with theirs.

Not every treatment facility has staff who threaten and yell at patients, or engage in other obvious acts of abuse. But when we make seemingly small choiceslike aligning someone who uses drugs problematically with an act of “abuse,” or describing someone who used a substance as “dirty”we further a culture of stigma and degradation. Enough of that, and it starts to no longer seem outlandish for a treatment staffer to tell a patient that she “don’t know shit.”


Photo by Brett Jordan on Unsplash

Elizabeth Brico

Elizabeth is a journalist from the Pacific Northwest. Her work has appeared in publications including Vox, Tonic/Vice, TalkPoverty, HealthyPlace and The Establishment. She has an MFA in Writing and Poetics from Naropa University. She also writes about trauma, addiction and recovery on her blog, Betty's Battleground.

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