“shaming,” “stigmatizing,” and call-outs

Something is amiss in recovery advocacy.

Earlier this week, the Surgeon General’s office tweeted the following paraphrase of a speech given by the Surgeon General. (Later clarified to be incorrectly transcribed.)

Addiction is not a moral failing and that it affects “good” families. Nice message, right? We need more influencers to say the same kind of thing, right? Not so fast.

Recovery advocates corrected him for using the word “addict” (some corrections were pretty generous, others were more scolding) and he responded with the following:

People with addiction have called themselves addicts for decades and I’m not aware of any in-group vs out-group differences in use.

John Kelly (2010) was the first person I recall focusing on the associations people have with various words related to people with addiction. That work has been extended by White, Wakeman, Ashford, and Brown.

This work started with words that have innate negative valences, like “abuse” and “dirty.” It’s since extended into all sorts of other words, like addict, relapse, and involves calls for “person-first language” (which emerged in the late 1980s for other populations).

My memory of the emergence of all of this attention to language was at the level of advocacy with storytelling. As a strategic matter, recovery advocates were encouraged to tell their stories with certain language that was found to be less likely to arouse bias and stigma.

On the one hand, this made pragmatic sense to me for advocacy efforts. On the other hand, this also felt backwards. Abandoning objectively neutral words because some people (usually people who hold a negative bias toward people with addiction) have attached negative associations to them seems like a recipe for tail-chasing. What happens when the new words acquire a negative association? Do we just keep changing terms as people with biases learn them and extend their bias to the new terms? (Also, who does this put in control of our language?)

We’ve already seen this happen. Opioid Replacement Therapy and Opioid Substitution Therapy were replaced by Medication Assisted Treatment, which is now on the bad list. This creates significant descriptive problems for the sake of stigma reduction–an early recovery advocacy goal was to distinguish treatment from recovery. The new preferred term, Medication Assisted Recovery, conflates treatment and recovery, undercutting a key message of methadone patient advocacy efforts.

From Walter Ginter, medication-assisted recovery advocate:

The problem with the methadone community is we have too many people who think methadone is a magic bullet for that disease—that recovery involves nothing more than taking methadone.

This view is reinforced by people who, with the best of intentions, proclaim, “Methadone is recovery.” Methadone is not recovery. Recovery is recovery. Methadone is a pathway, a road, a tool. Recovery is a life and a particular way of living your life. Saying that methadone is recovery let’s people think that, “Hey, you go up to the counter there, and you drink a cup of medication, and that’s it. You’re in recovery.” And of course, that’s nonsense. Too many people in the methadone field learn that opiate dependence is a brain disorder, and they think that that’s all there is to it. But just like any other chronic medical condition, it has a behavioral component that involves how you live your life and the daily decisions you make.

White, W. (2009). Advocacy for medication-assisted recovery: An interview with Walter Ginter.

So . . . I get the pragmatic and strategic reasons to encourage advocates to adopt certain language but question the wisdom of it. However, this has evolved from a strategy to be used by recovery advocates to a requirement of anyone making public statements on the topic, with call-outs for shaming and being an agent of stigma.

I also don’t understand whose wishes this represents. How many people with addiction object to or feel harmed by the term addict? Hasn’t our message been that we’re resilient and resourceful people who only want the same opportunities as everyone else–the elimination of discriminatory barriers to treatment, employment, school, etc?

I’ve also previously expressed anxiety before about treatment and recovery being drawn into culture war battles. (And, culture wars have only heated up over the last several years.) Of course, this isn’t a culture war hotzone, but the enforcement and call-outs give it a similar feel–that there are sides, and one side is righteous and fighting for justice, while the other side are agents of stigma, injustice, and discrimination.

  • At what point do some of these efforts to reduce stigma alienate potential allies? IDK.
  • How well do recovery advocates represent to the beliefs, preferences, and priorities of people with addiction? IDK. However, it’s difficult for me to believe that these reactions to this tweet are representative of the views of significant numbers of people with addiction outside of advocacy circles.


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3 responses to ““shaming,” “stigmatizing,” and call-outs

  1. As one of the authors of the paper cited, I’d like to make a couple points.

    -First, while our research may be fuel for various things, positive and negative, we are really just illuminating the psychological responses to certain terms. Of particular concern in the field, is how those without lived experience, particularly within the clinical and medical field talk to and about people with a SUD. This carries over naturally to the policymaker as well.

    -Second, as a person in recovery, as well as a scientist, we have gone to great lengths to include lived recovery experience in all of our work. A gap that I feel is particularly salient in the field. We have had one or more individuals in recovery on every paper we have written. Often, several authors are in recovery themselves and are acutely aware of the tensions in the field, which we seek to enlighten.

    -Third, I agree with this article. I have many concerns about what Dr. Kemp called the “Traces of unacknowledged interest and power” that I see within the advocacy movement. I am often perturbed by the co-opting of social justice language and ideas that are perverted to further agendas. These agendas vary from the mad scramble for government grant money to obvious pharma co-opting of doctors and organizations that promote unilateral medical solutions to the complex interdisciplinary issues related to SUD. It gets even more alarming when I see individuals co-opting social justice ideology to call for the dismantlement of free community-based resources that are available to anyone who seeks them. Especially considering the exorbitant and predatory nature of treatment, and the US healthcare system at large.

    -Fourth, the fundamental question is whether the plight of the individual with a SUD are improved through the advocacy movement in its current form. I think things may be marginally better in some areas for some people. Particularly the socially constructed “good kids” with “bright futures” who serve as an avatar for “doing something” about the foreign poisoning (aka opioid crisis). Will alterations in languages change things? The discourse itself is an act of political power. Whether that is the reclamation of pejorative labels, or person first language insistence. However, as we point out in our papers, language is a moving target. What is less-stigmatizing today will become tomorrows negative label. So linguistic research should run parallel to the field in dynamic ways, thus updating language and ideas as they move forward in time.

    -And finally, on a personal note, I am always pleased to see different takes on our work. The work we have done on language is unsurprisingly very popular. However, we have a wide variety of research we have done in the field. I would hope to see the other work we have done, specifically our attempts as scientists to separate out recovery science from addiction science as an inter-related but stand-alone field of inquiry, governed by its own theories, measures, and values, that can account for the myriad domains of recovery, treatment, and holistic wellness. I will link our introductory article on our grand theory as an example. My lab is currently hard at work designing and implementing the foundational aspects of recovery science, and are seeking to fundamentally shift the science of recovery as a whole. We are also re-situating the existing constructs, such as abstinence, recovery capital, and socio-ecological aspects of recovery into this new organizing framework. We have over a dozen theoretical papers planned for the next years or so.

    Recovery-informed theory (2019)

    Rest of my work can be found here.

    • The post was really intended to be a quick one focused on the reaction to the surgeon general’s tweet. It grew and included the reference to your work in an attempt to provide some context.

      My teaching and work schedule isn’t allowing for much heavy reading or posting these days. (And, your stuff rarely looks like a quick read.) I don’t know when my schedule will allow more posting, but I’ll also be more likely to post about your stuff when it’s more concrete and applied. (The audience in the forefront of my mind is my staff.)

      Thanks for the comment. You’ve published a lot recently, congrats. I wish you continued success.