An episode of “Changing the Conversation” podcast
Elizabeth Black and host Steven Samra discuss why words matter and the importance of using strengths-based, person-centered, trauma-informed language with people we serve.
February 7, 2022
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Steven Samra, Host (00:05): Hello, and welcome to Changing the Conversation. I’m Steven Samara, your host today. I’m a senior associate with C4 Innovations. We’re going to talk today about the importance of using language that we know is preferred by those we serve. My guest today is the Elizabeth Black, one of C4 Innovations’ trainers, and a subject matter expert in substance use disorders. Elizabeth, welcome.
Elizabeth Black, Guest (00:28): Thank you. It’s great to be with you today, Steven.
Steven (00:31): Just exciting to have you here, and it’s exciting because you and I have had similar conversations. You know my history, I have had a long opioid use disorder, a long history with opioids. I’ve experienced overdoses from opioid use. I’ve dealt with stigma and shame coming out of my 12 step work that just was really painful. And I’ve spent 20 plus years using medications to support and assist with my recovery. So having this long history of substance use and some mental health challenges, I’ve been the victim of a lot of inappropriate language.
Elizabeth (01:22): Yeah. Steven, you definitely have the street cred to be here as a part of conversation, because that’s just been a huge part of your journey. So I’m grateful that we have leaders like you that have been in the trenches. I wonder if you could give me an example of maybe how language has impacted you at some point in your journey in your recovery.
Steven (01:45): One of the things that happened to me that really sort of drove home the power of language and how language can impact me, us. I was having a conversation with a pharmacist and the pharmacist was listening to me speak about a number of issues and number of conditions. And when I mentioned that I had an opioid use disorder, he said, “Oh, you’re an addict.” And in that brief moment, everything that I have accomplished in my recovery over the last 22 years disappeared. And if you close your eyes right now and say the word addict, you know what you conjure up and that’s exactly what happened to me, standing in front of that pharmacist. And I was so ashamed and so embarrassed and frankly humiliated by how I had been described. I had been distilled down to the worst thing that anybody could imagine in their life. And I’m so much more than that. And I think that for me, really drove the importance of changing the language.
Elizabeth (03:08): Yeah. Steven, I can totally relate. So my drug of choice wasn’t opioids, it was alcohol. So there were different terms that were used for us, but even “alcoholic” doesn’t feel good to me. I didn’t want to go to AA meetings because they forced me to say that I was an alcoholic and that did not feel empowering. That felt stigmatizing and that felt like the person that was drinking in the back alley out of a brown bag. That’s an alcoholic, not me. And so just that one term created a huge barrier to get my foot through the door, to get the support that I needed. And that’s still something that continues on to today and why we’re having this conversation and why language is so important because it can throw up barriers where they might not otherwise be.
Steven (03:59): Absolutely, Elizabeth. Absolutely.
Elizabeth (04:00): And that’s why we in particular have to be very careful about the language that we use with the people that we serve, because we have all a lot of shame bombs that we’re having to sidestep all the time that people with other chronic diseases don’t necessarily have the same social stigma associated with it. We don’t shame people for having cancer. We don’t shame people from having heart disease. And even though the medical community decided a long time ago that substance use disorders are brain disorder, just like Parkinson’s or Tourette syndrome or Alzheimer, those other brain disorders that we know of.
Elizabeth (04:41): And we still don’t even shame people for that. But for some reason, when it comes to mental health and substance use disorders, there’s still this conventional wisdom of society as a whole, that is you just need to pull yourself up by your bootstraps, and you just need to do better and make better decisions and just choose not to use today. And we know that there’s so much more to it than that, that goes into it in a substance use disorder and simply just making a decision. And so we need to just need to make sure our language is reflective of that.
Steven (05:16): Where are the dinosaur words that could really use retirement at this point?
Elizabeth (05:23): Things that are commonly used by the general public, terms like “addict.” I know that’s still used by a lot of 12 step programs and a lot of people in recovery still use that term to refer to themselves. But that’s one of those words that I wish that we could retire sooner than later because just that term, “addict”, if you just listen to it, it just has so much weight to it, that a “person with a substance use disorder,” that feels a lot more empowering and a lot more like a mental diagnosis than like a scarlet letter. I feel like a “A,” that could also be used for addict as well as adult or adulterous, whatever originally was for. Also “alcoholic” is the same thing. Can we get away from that and use a “person with an alcohol use disorder” instead. Getting away from “substance abuse” and instead using “substance use” or “substance misuse.” I mean, we’re still trying to say the same thing, but we’re just trying to use terms that aren’t as heavily weighted these days, that people don’t have a knee jerk reaction to.
Steven (06:35): Even in the most sort of benign things, talking about medication assisted treatment and suddenly finding yourself feeling so on the outside that you are willing to continue risking your own life rather than to take a particular treatment or pathway that you’re pretty convinced would be a reasonable one to take, that’s done as a direct result of stigma. And it’s a direct result of how the language is used to separate us from them.
Elizabeth (07:10): Definitely. You and I have talked about a study. They sent a survey to 500 behavioral health, mental health, clinician so people with degrees and licenses, and they gave essentially a case synopsis of a person, and they were asked to provide treatment recommendations for this person. And so half of the 500 people when they got their case study, they referred to the person that they were offering recommendations on as a person with a “substance use disorder.” And the other half got a case synopsis, they were asking for recommendations from a person that was described as a “substance abuser.” Everything else was the same. The only thing that was different is half of them got one that said it was a person with a “substance use disorder.” The other one got the case study it said the person was a “substance abuser.”
Elizabeth (08:07): And the results of it are really not surprising to me because what they found out was the people that were given the case study, which described a person as a “substance abuser,” prescribed more strict and punitive interventions than did the people that received the case they the person that had a “substance use disorder.” And so those are people with master’s degrees and licenses in this field that are swayed by such a small change of words that compared to the population. What chance do the rest of us have if you have a license and you’re as easily manipulated by this. And so it really points to how important it is that we are using language that is empowering to people and that we’re really paying attention and being selective about what language we use. We’re working with a population that is so highly, what’s the word I’m looking to, highly vulnerable to shame, our words really do matter.
Steven (09:11): What you’ve highlighted is the incredible simplicity in which we can move into stigmatizing, frankly, really without even being aware of it. And as providers particularly, there’s a number of things that we can do to kind of at least mitigate it. I wouldn’t say we’ll ever be able to end it, just because language, it’s tricky. It can be sneaky and what isn’t stigmatizing today, may be so tomorrow. And then the final piece of this, and particularly when we’re talking about clinicians and even peers who are going to see more and more people, there’s a confirmation bias that can often occur to a provider because what they’ve seen over and over are folks who are pretty ill. Everybody now becomes pretty ill. And that confirmation bias occurs without being aware which is one of the biggest challenges, I think, providers face in identifying that implicit bias and then being able to grab hold of it and eradicate it from who they are.
Steven (10:29): How do you do that if you’re not even aware that it’s happening? I think all of us, it’s not just clinicians, although they’re in a position where their language often sets the stage and kind of moves that out into the public so that the language that they use has the potential to either fix or increase the stigma that’s associated with that. I don’t mean to put all that on the backs of providers, but it just talks again about the critical importance of the language we use and coming at these things, strengths based and person centered and always trauma informed. And if we can just keep that in mind, I think it’ll help impact some of that bias. I’m not sure.
Elizabeth (11:22): Yes. Exactly.
Steven (11:24): Elizabeth, any advice for practitioners that we haven’t already talked about that can really help identify and change the language for them?
Elizabeth (11:38): My biggest advice is just listen to the people that you serve. Ask them what do they prefer? What feels good to them? What’s empowering to them? What feels shameful to them? So some of us — and Steven, I know you’re in this category with me, we’re both kind of providers and people with lived experience. And so we kind of have our own perspective on what feels good to us and what doesn’t feel quite so great, but we’re also people in recovery. And so with new substances and new generations, there are new terms that are coming up, that people are identifying with. There are old terms that are being retired, and honestly, sometimes it can be kind of exhausting keeping up with what term is politically correct for this versus that.
Elizabeth (12:24): And this isn’t meant to be something that feels daunting to us, but more of just creating an awareness to make sure that the language that we’re using is conducive to recovery and is offering things like dignity and self respect and empowerment for those people that we serve. Language is how we interact with one another. And so making sure that we’re using language that is really strengths based, as you said, that’s based in empowerment. All of that is so important to the population that we work with. But then the question becomes what happens when we can’t quite agree on what language to use.
Steven (13:07): I’m just reminded of a conversation you and I had recently about the difference between MAT, MOUD and MAR. And these are all terms that describe medication assisted treatment or medications for opioid use disorder. Each one of those terms has with it the access to medications like methadone, naltrexone, and buprenorphine. All three of which have been heavily stigmatized in the past. So how do we make that decision? Elizabeth, do you have any recommendations or thoughts about that?
Elizabeth (13:55): I think that, that goes back to checking in with the people that you’re working with, so what language that they prefer. And it may be different from person to person. I know you and I have butted heads over this exact term. I know MAT is your preferred term, but at the same time, MOUD is my preferred term. And we both are kind of sticklers in that. So for me, in my personal practice, I’ve gotten away from saying MAT because MAT is medication assisted treatment. And so I say medication for opioid use disorder, just because there’s still so much stigma with MAT for reasons that you talked about in your own experience, that people aren’t accepting of MAT, they still rail against it. It’s not a part of the normal treatment process.
Elizabeth (14:50): And so I feel like calling it out as MAT, medication assisted treatment, distinguishes it from other types of treatment. And I think getting away with that distinction then just leaves us with this idea of broad idea of treatment as a part of that. We just implicitly understand that it includes medication. Just like we don’t say medication assisted treatment for diabetes. We just say treatment for diabetes. And we know that, that includes medication and long term lifestyle modifications. So I’ve gotten away from using MAT and I just use MOUD for that reason.
Steven (15:32): I think your response is awesome. And I don’t disagree on any of that. The biggest issue for me, related to the MAT versus MOUD versus MAR sort of controversy, is really around what each one of those stand for. So if you think about medication assisted treatment, I think everything you said was absolutely spot on. It is a part of the treatment. We don’t call out medications in other treatment. Why would we do it here? And I think that the term MOUD, medications for opioid use disorder, gets real specific. And I think the challenge that I had with that particular term was that it doesn’t have anything else connected to it. And I have a fear that because it is just medications for an opioid use disorder, it won’t be long. And we’ll hear the same kind of stigma because it’s connected to the meds.
Steven (16:30): And frankly, I think the very best term, is medication assisted recovery, because as you and I have talked about in the past too, taking the medication isn’t recovery, that’s treatment. Recovery comes after the medication has stabilized you and given you an opportunity to catch your breath and start focusing on the things that are important to you within your life beyond the challenge of your addiction. So Elizabeth, I think you’re spot on. I think these are the kinds of conversations that we’re going to have to continue having. We’re not going to make stigma go away anytime soon, but one thing I know we can do, we can change the language and when we do it, it’ll improve the care. Elizabeth Black, it was a pleasure to have you here today. Thank you for doing what you do.
Elizabeth (17:25): It was so good to be with you today, Steven. And right back at you.
Steven (17:28): And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (17:34): Visit c4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on Changing the Conversation.
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