various emotional states, a fact that highlights how vocabulary profoundly shapes our experiences - for better, and for worse. It is argued here that the chronic use of coded and stigmatizing language in the field of addiction treatment reflects a diseased system of thinking that quite possibly perpetuates the mediocre outcomes long associated with addictive services in the U.S. (Naqvi & Morgenstern, 2015; Brandon, et al., 2007; Miller, et al., 2001).

​

Little over a century ago, professionals widely used the term “lunatic” to diagnosis mental illness. The term represented a precursor to diagnoses of Schizophrenia and Bipolar Disorder, the archaic term still apt to trigger disturbing images of the mentally ill as dangerous. The term, after all, derives from the Latin word luna, or moon, and speaks to the ancient notion that a full moon can transform man into beast. It is no surprise, then, that those with severe mental illness were once segregated from society over what is now known as the asylum era. Not long ago, those with psychiatric disorders were routinely warehoused in asylums, handcuffed to barbaric institutions by the diagnosis of "lunatic" and all the implications drawn from such a damning label.   

​

Over the latter half of the 20th century, mental health advocates increasingly lobbied therapists and providers to use person-first language in the delivery of care, to safeguard against stigmatization and the type of bias that “lunatic” stoked earlier on.  The effect of that advocacy and its push to humanize the struggle of mental illness is obvious today in the candor found across the internet. Case in point, NBA player Kevin Love and actor Dwayne Johnson revealed long-standing struggles with depression in 2018, with both men thankful in the days and weeks afterwards for all the public support their revelations garnered.  Such openness from two hypermasculine figures was simply unheard of twenty-five years ago. 

​

While public opinion of mental illness now favors a more compassionate narrative with regards to depression, Bipolar Disorder, and so forth, it still expresses a harsh tone in relationship to those with addictive disorders. It is a tone role-modeled by addiction providers. Arguably, the field of addiction treatment is delayed in its evolution compared to other sectors of the mental health system.  That fact never glares more embarrassingly than in the use of the terms "addict" and "alcoholic". A pair of pejoratives still used with gross regularity in clinical meetings, academic papers and professional conferences, the terms have somehow escaped reform.

 

As with all stigmatizing language, the above pejoratives force fit an identity on people, regardless of what the individual believes. More broadly, stigmas outcast people into subgroups, with such marginalization placing people with addictions at particular risk of discrimination and isolation. Fundamentally, stigmatization discounts the individual’s history and its influence on the development of addictive behaviors. Instead of conceptualizing addiction as an attempt to relieve chronic distress grounded in a trauma history, a profound loss, a refractory depression, or years of neglect, many simply argue that it is the nature of the “addict” to use.  Once an addict, always an addict, the saying goes.

​

The moral model of addiction treatment remains prevalent, as it has over the last century. It is the reason why popular definitions of an “addict” still incorporate such contemptible adjectives as “criminal,” “entitled,” “manipulative,” “childish,” “selfish,” and a slew of other slights that imply character defects as the root cause of addiction.  Despite accumulating evidence that neuroadaptations drive addictive behaviors on a biological level (Goldstein, et al., 2009; Koob, 2009), providers still routinely reference character flaws in conceptualizing treatment. The contempt as commonly displayed by addiction providers represents an artifact from early 20th century Oxford evangelism. The “addict”, the evangelical movement proclaimed, is defective at the core and can only be salvaged through a spiritual awakening. To continue, only those awoke and in a morally exulted position can shepherd such salvation. As history has borne out time and again, there exists an inherent risk in like ideologies.

​

Contemporary ideals surrounding therapy foster dyads with minimal-to-no power differential. Modern techniques encourage clinicians to be conscious of and to correct any idealization to emerge over the course of therapy. The enduring evangelical influence on addiction treatment, in hard contrast, often breeds a sense of moral superiority among providers. The risk, as hinted at above, is elucidated in research that notes a link between excessive morality and aggressive tendencies (Bandura, 2002). In short, research concludes that piousness promotes callousness. Excessive morality can shape a tendency to devalue, to see others as less than or somehow corrupted in comparison to an idol. Devaluation, in turn, serves as a substrate to aggression. Whittle down someone’s value as a person, and harming him or her becomes ever justifiable. In the field of addiction treatment, the devaluing effect of stigmatization segues into the use of such punitive interventions as tough love, medication bans, "natural consequences", residential black outs and so on. As research has demonstrated, like interventions elevate the risk of treatment drop out. 

​

Clinically, the concrete thinking associated with stigmatizing language and stereotypes can handicap a clinician’s ability to monitor counter-transference. Overly concrete clinicians are prone to splitting, the morally inspired provider, of course, self-assuming the role of ‘good object’ in relationship to the so-called addict.  It is an epidemic, really, in addiction treatment, with clinicians often using clients as waste bins to dispose of their own insecurities and shame (Szalavitz, 2012). And shame, research has proven, hastens treatment drop out (Brener, et al., 2010; Van Boekel, et al., 2013). Moreover, the longer that counter-transference remains unchecked, the easier it becomes for a provider to dismiss and discredit what a client might have to say.  That is, the more likely a clinician will stop listening. Over time, a deaf therapist will also suffer the loss of empathy. 

​

Research has established how stigmatizing language can prime even seasoned therapists to push for more punitive interventions (Kelly, & Westerhoff, 2010). Intuitively, the more that a provider acts as a disciplinarian, the less he or she will be able to nurture rapport and trust in therapy. What drug counselors call “resistance” in many cases signals a healthy response to stereotyping, people pushing back against hostile, biased clinicians. Along the same lines, Moyer & Miller (2013) determined that those with addictive disorders fair better receiving no treatment at all compared to those treated by clinicians with low empathy skill (Miller, Walters, & Bennett, 2001).

​

The research is clear - stigmatizing language limits clinicians and their ability to exercise empathy. At the risk of stating the obvious, a therapist’s empathic understanding represents the quintessential variable in predicting a successful outcome to therapy. Without it, resistance to treatment is inevitable, at no fault of the client.   

  

What other field in mental health or medicine accepts such wide spread discrimination? Would an oncologist ever refer to a patient as a “cancer”? Not likely. Despite the fact that 60 to 90% of cancer cases can be traced back to lifestyle (Anand, et al., 2008), cancer patients are not subjected to the same discrimination that those with addictions routinely face in treatment. Quite the contrary, with five of the top 50 charities in the U.S. organized to advance cancer treatment and research; not a single charity among the top 50 is dedicated to help those with addictions (Forbes Magazine, 2018). Annually, the fight against cancer receives more than 6 times the amount of funding in government monies and charitable donations compared to addiction services. Even with the historic appropriation of $4 billion in 2018 via a congressional push to combat the country’s drug crisis, cancer funds still doubled addiction dollars in 2019. Is it any wonder, then, that the survival rates among cancer patients have dramatically improved over the last quarter century, while rates of relapse remain stagnant? More money equals more research, improved training and more talented clinicians.

​

Addiction affects more people than cancer, proves as lethal and places four times the financial burden on the country’s economy compared to cancer (National Cancer Institute, 2018; National Institute of Drug Abuse, 2017). And, addictions can be implicated as the etiology in the majority of cancer cases. Yet, the advocacy surrounding cancer dwarfs that related to addiction. Then again, why would we expect more compassion from the general public when addiction providers themselves so regularly vilify those that they are responsible to help?

​

The institutional use of stigmatizing language risks shaping a culture of contempt that promotes the type of biases and punitive interventions associated with treatment failure. Such a culture gives programs license to externalize fault onto a client if and when treatment stalls. Instead of amending a treatment plan or processing staff’s counter-transference to resolve a client’s resistance, the morally bounded provider causally decides that a client either is not ready for or serious about treatment, setting the stage for an administrative discharge or A.M.A. Research suggests, however, that if you are a provider who uses the term “addict” in your practice of addiction treatment, you may be an impediment to change, not the impetuous to it. Simply, you may be part of the problem.  

​

- Kevin Murphy  2019