Language: Abandoning “Addiction”

Editor’s Note: Today’s post comes from Brooks Hudson, a PhD student in history at Southern Illinois University. Brooks is joining Points as a contributing editor for the 2018-2019 year, so look for more posts from him to come. Enjoy!

Historians change their language for all sorts of reasons, specifically when it dehumanizes other people. The humanities have abandoned pejorative and race-based terms, whether it’s “negro,” “colored,” or “oriental.” We understand these terms are powerful and demean others. Similarly, individuals with disabilities no longer face the indignity of having their medical condition be synonymous with who they are as people. Within the last century, we discarded “mentally retarded,” “lunatic,” “imbecile” and “feeble-minded.” Now, we use first-person language, for example, “a person with a mental or physical disability.” Within my lifetime, it’s gone from acceptable to unacceptable to use homophobic language to paint the LGBTQ community as “deviant” or prone to “unnatural desires.” Only in the last five years have mental health professionals acknowledged this mistake and declared that transgender individuals do not suffer from mental illness (“gender identity disorder”). This revision is from the updated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Progress has stalled when it comes to another health issue, however: “drug addiction.” Interestingly, another revision in the DSM-5 was taking out “addiction”—partially because of its “uncertain definition”—and replacing it with substance use disorder. Adoption of this change is underway, but not too many historians are breaking down barricades to enter the debate.

There are a thousand reason to reject “addiction.” It is imprecise. It is laden with value judgements. It is embedded in a history of religious rhetoric. It cannot be separated from largely fact-free government propaganda campaigns, not to mention the newspapers archives that are filled with word, usually within graphic and hysterical accounts that have little basis in reality.

Few have adequately addressed this issue. Fewer have proposed ways to resolve it. Arguably, the closest attempt might be Bruce Alexander’s Globalization of Addiction. In it, he dedicates an entire chapter to disentangling the various meanings of the word, marking distinct usage by subscript—admittedly, a distracting strategy, though one that reduces misinterpretation.

Screenshot 2018-08-24 15.18.28

In the nineteenth and twentieth century the temperance movement transformed the word addiction into a rhetorical weapon that bolstered an abstinence-only ideology. At first, it applied specifically to excessive drinking. Its marriage to Protestant fervor is evident in phrases such as “lost their soul to alcohol,” or association pairings like “demon” with “rum.” Sensational images and scary archetypes transferred to other psychoactive substances like opium and cocaine. Then addiction cemented itself into a broader anti-drug lexicon: “drug fiends,” “hopheads,” “opium drunkard.” The implicit idea of this language is not redemption but damnation. “Drug fiends” were “lost souls.” They were “hopeless.” They were “ruined.”

By the twentieth century, the elasticity of the word encompassed everything, including possession and personal use. Ever since, language has been a straightjacket. The main problem is the word addiction doesn’t differentiate between use and destructive use. Henry Smith Williams noticed this phenomenon a century ago in Drug Addicts Are Human Beings. He talked about the large swath of productive citizens that used morphine and held down jobs and had meaningful family lives but were treated like violent criminals. In fact, most would not have met the clinical diagnosis for a substance use disorder. Yet, they remained “addicts.” Descriptions like “honest addicts” filled the gap somewhat, but “substance use disorder” is a better term. It prevents lumping together groups that should be separate: those who consume psychoactive substances and those who consume psychoactive substances but whose use results in distress and negative consequences.

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“Honest addict” referred to in Williams’s “Drug Addicts Are Human Beings” (1938)

There are real-world implications to our language choice. Dr. John Kelly, who practices psychiatry at Harvard Medical School, conducted studies on the effect of stigmatizing language. His work found that physicians are susceptible to cognitive biases simply by varying word choice. In one study, he gave identical vignettes to mental health professionals. In one, he referred to the condition as “a person with a substance use disorder.” In the other, he referred to a “substance abuser.” He found that, among trained physicians, using “substance abuser” elicited a punitive rather than a therapeutic response.

These insights are gaining attention outside medicine. News organizations, including the Associated Press, changed their Stylebook to be closer align with these insights. The AP recommends “journalist should avoid words like alcoholic, addict, user and abuser unless they are in quotations or names of organizations.” Even the government has been open to these changes. Before leaving office, the Obama administration encouraged agencies to use the DSM-5’s language when appropriate.

Intuitively, people know this but haven’t thought about other words associated with abuse. In other contexts, abuse means one person harming another person, with some notable examples including physical abuse, child abuse, domestic abuse, sexual abuse, and emotional abuse. Adopting this new terminology might come across as “political correctness.” In reality, it’s about erasing stigma. Experts see stigma as a major barrier standing in the way of treatment. The best example of a country that has successfully managed to combat stigma is Portugal. In the 1990s, Portugal had some of the highest heroin usage and overdose rates in Europe. They also had similarly high rates of drug-related diseases like HIV and AIDS. In 2001, Portugal decriminalized all drugs and those trends dramatically decreased. The trends were so shocking that even The Washington Post appeared baffled by the results a few years ago, highlighting the rarity of Portuguese overdoses in a headline titled, “Why hardly anyone dies from an overdose in Portugal.”

People on the ground and studies confirm that ending the fear of punishment and easing the stigma surrounding drug use lead more people to seek treatment. For historians, the debate isn’t about ideology versus non-ideology, since both terms embody values. Instead, “substance use disorder” embodies something resembling neutrality and precision. The alternatives embody language that perpetuates stigma and failed policies.

Editor’s Note: Researchers at the University of Pennsylvania have recently released a new study that corresponds with Hudson’s ideas. It calls for an end to the use of the terms “addict” and “alcoholic,” preferring terms like “person who uses substances.” The researchers’ ideas are illustrated in the charts reprinted below. What are your thoughts on this subject? Feel free to comment below, or tweet us @PointsADHS. 

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Screenshot 2018-08-24 15.45.26

 

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3 Comments

  1. A problem with using value free terms is that they have no value. They do not convey the greater, richer reality of a state of being. Take, for example, this description of Falstaff; “I’ll be no longer guilty of this sin; this sanguine coward, this bed-presser, this horseback-breaker, this huge hill of flesh,—” How much richer and meaningful it is than to say his BMI is >30!

    Certainly there are times that value free terms serve a purpose, but there are also times that a value conveyed serves a more important purpose (as weakly shown in the Recovery Dialects Graphic above). Imagine a world with value laden personal characteristics removed. There would certainly be less hatred and divisiveness, but there would also be less sense of belonging.

    So, good luck on removing negative values and keeping positive ones 🙂

  2. This message from MAPS Forum reveals older history of the word “addict” and points at the still disputed issues of
    who decides use is destructive, and whether to count negative consequences inflicted by prohibition.

    ###M 3228 ### 2001-01-25 06:58:40 ######../2001-January/003204.html ############################L 188026
    From: Lee Bonnifield lee at planetc.com
    Subject: Addiction

    [Andrew Sewell MD]
    One could argue that the question, “Is addiction inherently harmful” is a
    tautology, because harmfulness is part of the definition of addiction.

    [Lee Bonnifield]
    Harmfulness is a relatively recent change in the definition. Here are
    some extracts from the 1971 Oxford English Dictionary showing a
    variety of ways the word has been correctly used, by year.

    1577 … I perceive myself something addict & tyed with the bonds of
    singular & great friendship.

    1577 … Addicting myself with you ynto the same business.

    1580 … The people are so peevishly addicted that they esteeme
    Wealthe above Wisdome.

    1588 … To destroy the queen, & all her people addicted to her.

    1590 … We be virgins, and addicted to virginitie.

    1592 … That God will addict the fourth part of this world .. unto
    death and hell.

    1597 Shaks. … To forsweare thinne Potations, and to addict
    themselues to Sack.

    1604 Shaks. … Each man to what sport and revels his addiction leads
    him.

    1611 Bible … They haue addicted themselves to the ministery of the
    Saints.

    1634 … For every man to search into the addiction of his Genius, and
    not to wrest nature.

    1645 … With the same affections therfore, and the same addicted
    fidelity.

    1655 … We sincerely addict ourselves to Almighty God.

    1660 … He was much addicted to civil Affairs.

    1662 … His genius addicted him to the study of antiquity.

    1670 … The greatest part of the day he addicts either to Study,
    Devotion, or other Spiritual exercises.

    1675 … The genius, faculties, addictions, and humors of men of all
    ages.

    1675 … His own proper Industry and Addiction to Books.

    1703 … Much addicted to Merchandise.

    1709 … Bishop Cheney, who was .. most addicted to Luther.

    1735 … Look upon it only as a solemn Addiction of him to his
    Master’s Service.

    1771 … His majesty is much addicted to useful reading.

    1779 … His addiction to tobacco is mentioned by one of his
    biographers.

    1789 T Jefferson … Such an addiction is the last degradation of a
    free and moral agent.

    1846 … Such persons will addict themselves to history or science
    rather than to creative art.

    1850 … Being himself addicted to his Art.

    1865 … They are fanatics in their addictedness to the dance.

    1865 … The blacks are more addicted to stealing where slavery
    exists.

    1909 … As shown by post-mortem examinations in morphia addicts.

    1925 … Even many working men are night club addicts.

    [Sewell]
    (This is not the “official” definition because the official
    definition changes from time to time but all the elements are there).

    [Bonnifield]
    Is there a website showing the official definitions for each year
    since say 1960?

    The tobacco company executives were denounced as liars for testifying
    that tobacco is not addictive, but I think they were truthfully using
    an older definition that included a vague clause about “affecting
    judgment.”

    I’m often confused by definitions with multiple clauses separated by
    commas. I’m not sure whether the clauses are intended to be joined
    with “and” or with “or”. It often makes a significant difference, and
    sometimes multiple sentences separated by periods are equally
    ambiguous. I think I have sometimes seen definitions of “addiction”
    that include something like “or continues to use despite clear
    evidence of harmful consequences.” Then I have to wonder whether any
    terms relating to behavior are necessarily referring to behavior of
    the addict, or could the behavior of someone else count.

    If an official definition were stated like that, cannabis user Jack
    while maintaining stable behavior could suddenly become addicted due
    to a change in the behavior of employer John. Jack suffers the harmful
    consequence of losing his job, or is subjected to police scrutiny for
    daring to apply for employment, because of the changed behavior of
    John who has decided to test urine for past-month cannabis use. Would
    the definition require Jack to be called an addict in that case? If
    someone would post “the” official definition I’d like to see if I
    understand how the “ands” and “ors” are intended to be distributed.

    I also wonder if it is specified to whom the harmful consequences
    occur. George Washington wrote a letter to Martha advising her on
    the purchase of slaves so that she would be less likely to buy those
    “addicted to running away” IIRC. In that case the consequences are not
    harmful to the addict, they are harmful to the person labeling the
    addict.

    Is addiction a medical term, or a political one? Is it sometimes as
    simple as John applying the word “addiction” when John sees Jack do
    something John doesn’t like. John tells Jack to stop, and Jack keeps
    doing it, and John threatens Jack, and John hurts Jack, and Jack still
    won’t stop despite the harmful consequences. It is politically
    expedient, if John can enlist the majority to back him up, to
    characterize the situation as a problem with Jack (Jack is addicted)
    rather than as a problem with John (John is intolerant.) Then the bad
    consequences are called the consequences of Jack’s action, not of
    John’s.

    Or is “addiction” a philosophical term, making implications about free
    will and who possesses it? If the situation is too balanced John can
    gain the upper hand and reduce Jack’s status by implying Jack has lost
    the power to control his own actions. This tactic removes from Jack
    the protection of the state because Jack is not regarded as a fully
    competent human with free will.

    ===============================================
    quotes from Thomas Szasz, The_Untamed_Tongue, 1990:

    “Drug laws are our dietary laws: Doctors are our rabbis; heroin, our
    pork; addicts, our unclean persons.”

    “If a person takes a drug prescribed for him by a psychiatrist and
    claims that it makes him feel better, that proves mental illness is a
    bona fide disease; but if he takes a drug prohibited for him by
    legislators and claims that it makes him feel better, that proves he
    is an addict.”

    ” ‘I regard relationship addiction as a definable, diagnosable and
    treatable disease process,’ declares Robin Norwood, a psychotherapist
    and author of the 1985 best seller, Women_Who_Love_Too_Much. Drug
    addiction, alcohol addiction, tobacco addiction, sex addiction,
    relationship addiction — diseases, one and all. Surely, we are in the
    grips of a medical fundamentalism no less bizarre or extreme than the
    religious fundamentalism of the Iranians. Ironically, we belittle the
    behavior of religious fundamentalists as irrational, when in fact they
    recognize their behavior for what it is: religious fundamentalism;
    whereas we deny that our behavior is a species of fundamentalism and
    insist that it is science blended with compassion.”

    ===============================================

  3. An excellent piece highlighting some of the ‘real world implications of language’ and their historical context. A few points I might make.

    There are some inherent challenges to the important issue of seeking more humanising language that also reflects the complexity of addiction and its near infinite factors. Humans fundamentally try to make sense of the world and their experiences, and will often seek to do so in the most cognitively efficient way. A simple labelling term is therefore advantageous in some ways, thus shifting lay terminology will always be somewhat against the tide and will need strategic policy led initiatives. We have seen some progress in the mental health field, but also observed limitations such as the false assumption that increasing understanding automatically leads to changes in attitudes or behaviours.

    So, seeking a change in stigmatising or other problematic language is desirable, but as Heather has argued ‘The concept of addiction is necessary to point to the puzzle of why human beings persist in behaving in ways they know are bad for them’ (i). We need conceptual frameworks but also to recognise their limitations.

    One interesting approach is the Power Threat Meaning (PTM) Framework which highlights the many problems within the ‘DSM mindset’ and proposes a broader approach to understanding problems of mental health (and addiction) (ii). Within the PTM, people’s responses to life experiences are further contextualised (i.e the powers, threats and meaning exerting upon their experiences and responses). The PTM seeks a ‘much-needed radical shift towards nondiagnostic theory and practice’ and thus to move away from DSM ‘diagnosis’ approaches derived from Western physical health medicine.

    As such, positive shifts in language are important, but need to be seen in the broader context of structural and individual challenges to de-stigmatision and empowerment of these experiences. History no doubt offers us many more valuable lessons.

    (i) https://academic.oup.com/alcalc/article/48/6/646/446750
    (ii) http://journals.sagepub.com/doi/abs/10.1177/0022167818793289?journalCode=jhpa

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