Language Matters: Here’s Why We Say “Substance Use Issues”

At the Center for Optimal Living we talk about and are dedicated to helping people with “substance use issues.” Yet to arrive at this choice of terminology we had to consider—and reject—several alternative and often far more popular terms.

Let’s review the other options to explain why we turned them down:

 

“Substance abuse” is a go-to phrase for many people who work in this field and for the wider public. It forms part of many people’s job titles (e.g., “substance abuse counselor”) and is established enough to feature in the names of organizations as prominent as the Substance Abuse and Mental Health Services Administration (SAMHSA) or, in slightly different form, the National Institute on Drug Abuse (NIDA).

But many of us find this to be a stigmatizing term. Maia Szalavitz, a leading journalist and author in this field, has pointed out that the word “abuse” is most often connected with the victimization of one person by another (think “child abuse,” sexual abuse” or “domestic abuse”)—yet no such thing necessarily happens when a person uses drugs, problematically or otherwise.

A person who engages in “abuse” is by implication an “abuser”: Szalavitz also notes the research showing that even clinicians are more likely to favor punitive measures against people who are labeled “substance abusers” than they are when those same people are labeled as “having a substance use disorder.”

Our aim is to treat people with compassion and respect, so we think it’s time to retire “substance abuse(r)” for good.

 

“Substance misuse” is preferred by many people in the field and beyond who, with the best of intentions, wish to avoid the damaging negative connotations of “substance abuse.” The term is particularly common among UK professionals and organizations.

However, we’re a little uncomfortable with it. The prefix “mis-” means “wrongly,” as in “mistake,” “misspell” or (one for the politicians!) ”misspeak.” In order to stick to our principle of “meeting people where they’re at,” we need to avoid making any assumption that a person using substances is doing something wrong.

There’s also an element of absurdity to “substance misuse” in some contexts. A person who snorts cocaine, for example, is using it just as its manufacturers intended—in order to misuse cocaine, surely you’d have to do something like pour it into your ear, or ingest it in the belief that it will cure your insomnia or athlete’s foot?

We think there’s a better option out there.

 

“Addiction” is a culturally embedded word to describe the compulsion people may feel to repeatedly use substances or engage in other behaviors; “addicted” is part of our everyday language in a way that few of these other terms are.

Yet the word promotes some non-optimal assumptions. Chief among them is a dichotomous view of substance-related issues, of a world divided into people who are “addicted” and people who are not. We believe instead that substance use exists on a highly nuanced spectrum, from completely non-problematic to extremely problematic via many shades of gray, and that to help people effectively we must recognize and respect the many subtle differences between individual situations.

As such, the blanket categorization of “addiction” falsely simplifies matters in an inaccurate and unhelpful way.

We also unequivocally oppose labeling anybody as an “addict.” This stigmatizing word fails to put the person first, describing them instead in terms of their perceived condition—labeling a person with a disability as a “cripple” would be an equivalent.

What’s more, there’s some evidence to suggest that being labeled an “addict,” as if problematic substance use or a tendency to it is inevitably a permanent aspect of your life, can become self-fulfilling. For example, research has indicated that a belief in the disease model of alcoholism, which views problematic alcohol use or a tendency to it as a chronic, incurable condition, is a risk factor for resumed drinking (or “relapse”) among people who wish to abstain.

Meghan Ralston of the Drug Policy Alliance has written memorably about why she’s breaking up with the word “addict,” and why the rest of us should do the same.

We think she’s right.

 

“Substance use disorder” is the term used by the latest edition (2013) of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).

While this is a step forward from some of the more stigmatizing terms in this list, we avoid using it at the Center for Optimal Living for a few reasons. One is that deciding that somebody has a “disorder”—diagnosed as “mild,” “moderate” or “severe,” according to the number of a set list of symptoms they display—may not align with our view of substance use as occurring on a pure spectrum, involving many other interrelated factors and occurring in many ways that are not necessarily a problem. Another is that “disorder” can mimic “disease” by pathologizing one particular aspect of a person’s life and focusing on it excessively; our holistic approach is very different.

We find certain aspects of DSM questionable, such as the sole inclusion of “gambling disorder” in the “behavioral addictions” section while many behaviors that can clearly become compulsive and problematic, like sex, shopping or Internet use, are omitted. Therefore we don’t wish to bind our clinical work to the current DSM guidelines.

We help people regardless of whether or not they would qualify for a diagnosis according to the DSM criteria, so we don’t think “substance use disorder” is right for us.

 

We finally arrived at “substance use issues” because this phrase avoids the pitfalls of our other options by using neutral, non-judgmental, inclusive language:

“Substance” is more suitable for our general purposes at the Center than “drug” because “drug” may not cover something like sugar, for example. (And although alcohol is of course a drug, many people who hear the phrase “drug use” would not think to include alcohol.)

“Use” makes no value-judgement, unlike “abuse” or “misuse.”

“Issues” is preferable, for our general purposes, to “problematic substance use” or “substance use problems” so that we don’t begin with the assumption that a person’s substance use is a problem. Some substance use is certainly problematic. But we know that substance use can also be a non-problematic or even a positive element of a person’s life. Our job is to explore every situation with an open mind.

 

So there you have it: We help people with substance use issues!

 

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