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.
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.
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.