Words Can Hurt

Changing the words used to describe someone struggling with alcoholism or drug addiction may significantly alter the attitudes of health care professionals, even those who specialize in addiction treatment. Massachusetts General Hospital researchers have found that health professionals' answers to survey questions about a hypothetical patient varied depending on whether he was described as a "substance abuser" or as "having a substance use disorder." Their study will appear in the International Journal of Drug Policy and has been released online.

"We found that referring to someone with the 'abuser' terminology evokes more punitive attitudes than does describing that person's situation in exactly the same words except for using 'disorder' terminology," says John F. Kelly, PhD, associate director of the MGH Center for Addiction Medicine, who led the study. "Reducing the use of such stigmatizing terms could help diminish the shame, guilt and embarrassment that act as barriers, keeping people from seeking help."

The authors note that misuse of alcohol and other drugs is the leading public health problem in the U.S. and that, while treatment can be very successful, it is sought by only 10% of affected individuals. The stigma against addiction problems is often cited as a major reason for not seeking treatment. Even though the World Health Organization acknowledged "abuser" as a stigmatizing term 30 years ago, it remains in common usage. The current study was designed to determine whether calling someone "a substance abuser" versus "having a substance use disorder" led to different judgments about the individual's ability to regulate behavior, the need for treatment versus punishment and whether that person could be a social threat.

The investigators randomly distributed surveys to more than 700 mental health professionals attending two 2008 conferences focused on mental health and addiction. The surveys began with a paragraph describing the current situation of "Mr. Williams," who is having trouble adhering to a court-ordered treatment program requiring abstinence from alcohol and other drugs. On half of the surveys, he is referred to as a "substance abuser;" on the others, he is described as having "a substance use disorder," with the rest of the narrative being exactly the same. The survey consisted of 32 statements about Mr. Williams' situation, and participants were asked to indicate how much they agreed or disagreed with those statements.

More than 500 completed surveys were returned, and one third of the responding participants indicated they had a professional focus on addiction. While the way "Mr. Williams" was described did not significantly change whether respondents regarded him as a threat or thought he should be referred for treatment, participants who received the paragraph describing him as a "substance abuser" were significantly more likely to agree that he should be punished for not following his required treatment plan. They were also more likely to agree with statements implying that that he was more to blame for his difficulty adhering to the court requirements.

"Our results imply that these punitive attitudes may be evoked by use of the 'abuser' term, whether individuals are conscious of it or not, and suggest that this term perpetuates that kind of thinking," Kelly explains. "From the perspective of the individual sufferers, who often feel intense self-loathing and self-blame, such terminology may add to the feelings that prevent them from seeking help."

Kelly notes that terms like "abuser" are not used in other clinical areas -- individuals with eating-related problems are almost universally referred to as having an "eating disorder" and not as "food abusers." While national and international health agencies have advocated eliminating "substance abuser," the term remains in common use, even in literature from federal agencies.

"There's an old proverb that states, if you want something to survive and flourish, call it a flower; if you want to kill it, call it a weed," he adds. "Saying that someone has a substance use disorder conveys the notion that they are suffering from something that may be treatable, which of course is true. Anything we can do to eradicate or minimize stigma-related obstacles to treatment will help reduce the prodigious social impact these disorders have on individuals and society, and changing the way we refer to affected individuals is one simple and achievable step towards that goal."

Kelly is an associate professor in the Harvard Medical School Department of Psychiatry. Cassandra Westerhoff of the MGH Center for Addiction Medicine is co-author of the International Journal of Drug Policy study, which was funded by an MGH institutional grant.