April 2018
Destroying Addiction Stigma Once and For All: It's Time!
Flo Hilliard, M.S.
Director, Continuing Education
College of Rehabilitation and Health Sciences
Jacksonville University
Stigma has gone hand-in-hand with addiction for decades. As a professional in the field for nearly 30 years, traveling numerous paths as a clinician, grants director and educator across the country, I am discouraged. Today, I see only small pockets of non-shaming language and stigma reduction among professionals and advocates, and even less in the general public.
Why, despite the abundance of dollars, talent, and advocates working tirelessly, can we not seem to reach real success and change public perception? What needs to happen for addiction to be treated equally with other medical conditions like heart disease, diabetes, or cancer?
As a nation, we continue to use stigmatizing and shame-based language to describe people with Substance Use Disorders including those of us in the recovery community.
Vox writer German Lopez presented a powerful article, “The single biggest reason America is failing in its response to the opioid epidemic":
“Before this year, I just didn’t appreciate how much stigma towards addiction still colors America’s approach to drugs. That’s not because I didn’t know that stigma plays a big role, but because I didn't expect stigma to be nearly as all-consuming as it really is […] (emphasis added) On drug policy issues, over the past year I found myself frequently asking, ‘Okay, so we have the research and evidence here. Why don’t we do what’s being proposed?’” I’ve thought about this question myself for years. Then I realized as my teaching grew to more than just brain biology, peoples’ feedback became overwhelmingly and powerfully positive. Internal value shifts started taking place.
Here’s how I’ve found success: Destroying Stigma Has to Have Three Dimensions of Understanding and Education
We’ve used the term “disease” for over 40 years and practically no one believed it because until the 1980’s we had little technology or research to definitively show what organ “held” the disease of addiction – where and how it began.We were on the slippery slope of diagnosing by behavioral symptoms and sometimes physical ones after it progressed to near fatal stages. Today we have excellent research that clearly shows changes in the brain that lead to illogical and often deadly behavioral patterns for those with substance use disorders. We know where it begins and where addiction lives; and we need to focus on educating not only professionals, but the general public as well on the neurobiology of addiction "tied to the symptoms of illogical behavior."
The first time I spoke the words out loud at a recovery group—with much shame and remorse—“My name is Flo, and I’m an alcoholic,” instead of judgement or stigma, I received a resounding “HI Flo!” Afterwards there were hugs, smiles, and “glad you’re heres.” Ever so slowly I began to believe the non-judgement and and compassion of these people and true friendships grew. It was (and still is) a safe place.
The public forum is not a safe place. Our language needs to protect us in public. We need to find words and phrases that are simple but accurate and based on the evidence.
I have trained thousands of individuals across the country on the science of addiction and recovery. My training explains in very simple language the powerful story of what happens in the brain as addiction develops and how that creates the oftentimes illogical and negative behavior of those with SUDs. This education is imperative to eliminate stigma and the concept that “addiction is a choice” or a “moral failing.”
But we also need to go further.
Epigenetics is a big word that is intertwined with the term “lifestyle disease.” This is not a made-up term but a medically recognized category of disease causation recognizing that the way any person lives can prevent or cause disease. Addiction is one of the recognized “lifestyle diseases” but so is heart disease, stroke, obesity, type 2 diabetes and even some cancers. If this is the case, then why is it not treated as such?
Two points are salient here:
1) It’s a 100% sure bet that all of the people who develop an above-mentioned disease never sets a goal to contract that condition.We must explain to people that part of the human condition is that we all come into this world with vulnerabilities and some do better than others with keeping them in check.
With that in mind:
2) It’s also a sure bet that healthcare professionals, counselors and the general public would never deny a person more treatment or shame them if they relapsed from their recovery plan after being diagnosed with one of those diseases – except addiction. To those in the field this seems obvious. To those outside our field it is not.
Dr. John Kelly at Harvard University has published numerous articles on the link between language, stigma, and patient care in the health care field. In a January 2015 editorial ("Stop Talking 'Dirty': Clinicians, Language, and Quality of Care for the Leaading Cause of Preventable Death in the United States,") published in the American Journal of Medicine, Kelly writes, with co-authors Drs. Sarah Wakeman and Richard Saitz:
“These findings indicate that, even among well-trained clinicians, exposure to a term such as “abuser” creates an implicit cognitive bias that results in punitive judgments that may perpetuate stigmatizing attitudes.”
In order to destroy addiction stigma once and for all, we need to educate on the three dimensions: addiction is a disease or medical condition, addiction is the same as other chronic “lifestyle” diseases in its development, and stigmatizing language must be challenged and changed.
Similarly, there are other practices ingrained in the healthcare profession steeped in stigma. Is urine considered “dirty” or “clean” in any other health care test? How about patients getting “clean”? Are people with Type 2 diabetes regularly referred to as “the diabetic”? Yet as recently as last month I participated on a professional panel on the opioid epidemic and both an addictionologist and a psychiatrist repeatedly used the terms “the addict” and other stigmatizing language.
Importantly, however, the recovery community cannot put all the blame on the health care system and healthcare providers. We have to come to understand that we are partially to blame. We continue to perpetuate the very stigma we are trying to overcome. As is said in recovery rooms, it’s not our fault but it is our responsibility—in this case, to change the words we use when talking to the general public.
When we stand in public forums and say proudly, “I’m an addict” or “alcoholic” or tell our painful and moving stories using the words dirty, clean, drunk, and addict to describe ourselves we unconsciously give permission for the general public, professionals and the media to use these descriptors.
I believe I’ve finally realized why we do this.
The first time I spoke the words out loud at a recovery group—with much shame and remorse—“My name is Flo, and I’m an alcoholic,” instead of judgement or stigma, I received a resounding “HI Flo!” Afterwards there were hugs, smiles and “glad you’re heres.” Ever so slowly I began to believe the non-judgement and and compassion of these people and true friendships grew. It was (and still is) a safe place.
From SAMHSA's Center for the Application of Prevention Technologies:
Words Matter: How Language Choice Can Reduce Stigma
The public forum is not a safe place. Our language needs to protect us in public. We need to find words and phrases that are simple but accurate and based on the evidence.
In order to destroy addiction stigma once and for all, we need to educate on the three dimensions: addiction is a disease or medical condition, addiction is the same as other chronic “lifestyle” diseases in its development, and stigmatizing language must be challenged and changed.
How about: I’m in recovery from: a chronic medical condition called addiction; a substance use disorder that affects my brain functioning, an opioid addiction or alcohol use disorder, or any combination. These words paint an accurate picture of addiction in the public’s eyes: a medical condition that was not done deliberately, is not a weakness or moral failing, but one that can to be managed with a recovery that is supported.
Flo Hilliard holds a Master's in Health Science with a concentration in Addictions Counseling from the University of North Florida. For nearly 30 years she has worked as a clinician, lecturer, prevention specialist, video producer and grant writer in the field of addiction prevention, treatment and recovery. She trains about substance abuse, addiction and recovery to a wide variety of professionals from health related fields. Ms. Hilliard created the SOAR Project (Science of Addiction and Recovery) project, funded by the National Institute on Drug Abuse and Faces and Voices of Recovery.