December 1, 2020
Posted in:

This clip of Hunter Biden has garnered a lot of attention in recovery advocacy circles.

I have mixed feelings.

Her characterization of him being “in and out of treatment 7, 8 times” frames his relapses as a personal failure in a way she wouldn’t frame relapses in other chronic illnesses, even where behavioral strategies are considered important for recovery.

The first part of his response, “say it nicer to me”, made me uncomfortable. It’s possible I’d feel differently if the interviewer was a man, but it felt a little too close to telling her to smile.

Personally, I’m more inclined to tell people the impact of their messages and set a boundary than to tell them what to say and how to say it. (Though I also might get a little prickly during a lengthy interview that was nearly entirely focused on the bad things people say about my personal and professional life.)

What I liked a lot more was his reframing it for her, “sought treatment, for an issue, like most people.” He also told her it came across as insensitive.

One of the things that interesting here is that Robach’s characterization didn’t violate any language do’s and don’ts. Rather, she conveyed a lack of respect and seemed to frame his relapses as failures of character.

Language is important AND people can use all the right words while still conveying and perpetuating disrespect, judgement, and contempt. Further, people can use the wrong words while speaking from a place of respect, compassion, and equality.

Certain words can insert negative valences and embed assumptions into sentences and thoughts. Those words add bias. Discouraging use of these words makes a lot of sense to me.

Other words may not have an innate negative valence or embed assumptions, but can evoke bias held by listeners. Here, I’m not so sure that prescribing language makes sense–the bias is in the person rather than the language. Changing the language here might avoid evoking their bias, but the bias is still there. The bias emanates from the person, not the words.

(That said, avoiding these words might make sense in some contexts. For example, for public educators and people sharing their stories for the purpose of bias and stigma reduction. They would want to avoid evoking bias when trying to convey bias-reducing messages and information.)

We all want to reduce the bias, but how best to do that?

I don’t pretend to be an expert on bias reduction and I don’t presume there is one correct approach.

Undoubtedly, personal contact with people affected by addiction is a critical strategy. (However, even that is fraught. What may help reduce bias for one population, may increase bias for another. For example, while it’s sometimes disputed, education about addiction as an illness and the possibility of recovery may reduce bias toward people with addiction, that same strategy could inadvertently reinforce bias against people continue to use ATOD.)

In the case of language that adds bias, we can educate people about the bias it adds, the consequences of that bias, discourage its use, and provide alternative language.

Where the issue is bias in the person, rather than in their language, this seems more challenging. I wonder what treatment critics can teach us here.

Harm reductionists and treatment critics often criticize treatment as too directive and too confrontive. Motivational Interviewing is frequently pointed to as a better way.

In 2007, Bill White and Bill Miller published an article about confrontation that distinguished between confrontation as a goal vs. confrontation as a style:

In its etymology, the word “confront” literally means “to come face to face.” In this sense, confronting is a therapeutic goal rather than a counseling style: to help clients come face to face with their present situation; reflect on it; and decide what to do about it. Once confronting is understood as a goal, then the question becomes how best to achieve it. Getting in a person’s face is rarely the best way to help them open up to new perspectives. There is, as Hazelden observed in its 1985 recanting of aggressive confrontation, “a better way.” People are most able and likely to re-evaluate reality within safe, empathic, supportive and nonjudgmental interpersonal relationships that do not necessitate defensiveness.

MI asserts that resistance (or discord, or defensiveness) is a product of the relationship. If our goal is for them to come face to face with the the ways their attitudes and behaviors harm others and doesn’t align with their values or self-perception, MI believes that’s best accomplished in the context of a safe and nonjudgmental relationship. It’s in that context that we might be able to find, explore, and develop discrepancy. A confrontive style will interfere with achievement of our goal.

In the past week, there have been a couple of NYT stories that provoked a reaction from recovery advocates. One, about Diego Maradona, celebrated his legacy but click bait teasers said that his addiction “marred” his legacy. The other, about digital 12 step meetings and treatment, used the term “substance abuse” in the headline. I was also involved in a similar issue with a professional association publication where a piece had “substance abuse” in the title.

I detected no disrespect or contempt in the latter two articles, just use of discouraged words. The Maradona coverage seems more loaded with judgement and potentially stigmatizing language (even though it’s not clear to me that it didn’t align with his own framing of his SUD).

If I had to choose between prioritizing changing people’s words or changing their hearts in relation to ATOD problems, I’m much more interested in changing hearts. If we were to change their hearts, their words wouldn’t matter all that much. And, I guess all of this makes me wonder if all the attention on managing what comes out of their mouths, pens, and keyboards distracts us from changing hearts.

I’d also add that there are a lot of groups who are passionate about their particular cause and are trying to change language around their cause. For example, last night I listened to an interview with the founder of PETA who discourages the use of the words “pet” and “owner.” My point here is that members of the media and the public have a lot language direction coming at them, it’s enough that it’s difficult to keep up and enough to evoke some resistance that may have have much more to do with this context than SUDs in particular.

The text below is a post from a while back. It is about the Surgeon General’s attempt to tweet a destigmatizing message that addiction is a disease rather than a moral failing and it happens in good families, including his own. However, he used the word addict, which set off criticism of him for using stigmatizing language. I scrolled through the responses and, fortunately, the nastier responses appear to have been deleted.

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 contaminate the new words with their bias? (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 do-not-use 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.