Is it Time for Person-First Language in Addiction Treatment? (William White and Alisha White)


People evolve a language in order to describe and control their circumstances...[language] is a political instrument the most crucial key to identity. --James Baldwin (From James Baldwin: A Biography by David Leeming)

Person First Language ImageEffective social movements rising within marginalized and stigmatized communities inevitably challenge words and images thrust upon them by the dominant culture to denigrate and denote their inferior social, economic, and political status. The twin challenges such movements face from the civil rights and women's movements to the disability rights movement are to expunge (or repurpose) objectifying, disempowering words and images and  forge new words and images that convey respect, inspire new possibilities, and invite inclusion. The import of such efforts far transcends matters of superficial political correctness. Changes in language are critical instruments of identity reconstruction and key signposts of broader changes in social policy and social norms. Such changes are also a means through which members of the dominant culture and cultural institutions can make symbolic amends for past misdeeds. This brief essay offers a series of observations about language related to alcohol and other drug problems, with particular reference to use of the terms alcoholic and addict within the popular culture, the professional field of addiction treatment, and within indigenous addiction recovery support institutions.

There is a long history of the cultural use of objectifying labels to designate differentness and implied inferiority--labels that have contributed to social, economic, and political marginalization and even to campaigns of genocide. While the latter reference may seem extreme to open this discussion, the reader should be reminded that people with severe alcohol and other drug problems have been subjected historically and globally to economic marginalization, political disenfranchisement, prolonged penal and medical institutionalization, legally mandated sterilization, unconscionably harmful medical interventions, and campaigns of mass extermination (e.g., within the German Third Reich's campaign of racial purification).

A major thrust within health and disabilities reform movements has been to purge prejudicial language that dehumanizes and objectifies people. Such language obliterates personhood by reducing the individual to a socially discredited category: diabetic, epileptic, schizophrenic, manic depressive, blind, mentally ill, disabled, handicapped, retarded, Mongoloid, deaf and dumb, the obese. The recent trend within reform movements has been to replace such objectifying "I-It" language with "I-Thou" language--the latter commonly referred to as "people first language", e.g., person with (or affected by) diabetes, epilepsy, etc. While there have been continued discussions and debates within affected communities regarding the best choice of language (see here as example), person-first language has become the acceptable and preferred choice of language for describing people with varied limitations within common professional, cultural, and legal communication (e.g., see People First Respectful Language Modernization Act of 2006).

Stigmatized persons and communities have limited strategies available to respond personally or collectively to the sting of the pejorative words foisted upon them from the dominant culture. They can try to ignore such insults, but such passive acceptance only deepens the personal and collective wounds of such shaming insults. They can protest the use of such language a strategy most effective when imbedded within a larger social protest movement. They can also transmute and repurpose the offending language in a way that neutralizes its poison and gives it new meaning within in-group communications. This is historically evident in the ways that communities of color and the LGBT now LGBTQIA community have, through a process of subcultural alchemy, incorporated use of historically offensive words within these communities to signal in-group affiliation, status, and pride. By alchemy, we mean the appropriation and transformation of externally imposed language used to express repugnance to something chosen and positively reframed as a symbol of mutual identification and affirmation.

There is a long history of "problem first language" used to morally isolate people with severe AOD problems. Since the early 1900s, persons entering treatment for such problems have been labeled inebriates, dipsomaniacs, habitu's, addicts, alcoholics, problem drinkers, and substance abusers. An equally long history of such designations pervades popular culture in the U.S., including such terms as drunkard/drunk, sot, tippler, wino, boozer, alky/alki/alkie, rummie, rumhound, dope fiend, doper, junky, viper, speed freak, crack head, crack whore, meth head, tweeker, and stoner, to name just a few. Recently, suggestions have been made that the addictions field and the larger culture abandon all such terms, and like the larger health care and disabilities fields, embrace person-first language (See here, here, and here).

The rise of a new recovery advocacy movement has stirred a re-examination of the language used within the alcohol and drug problems (AOD) arena (see here, here, here, and here). Much of this focus has been on eliminating the stigmatizing alcohol/drug/substanceabuse? language from popular and professional discourse (see here and here), but there have also been discussions about other potentially stigmatizing language (e.g., clean/dirty designations, lapse/relapse) and how to best refer to people who have AOD problems and people who once experienced, but no longer experience, such problems (See here and here). Debate regarding the latter designation has for the past 150 years produced such adjectives as redeemed, repentant, reformed, dry, former, ex-, arrested, cured, recovered, and recovering. The rather quaint term sobriate perhaps a takeoff on inebriate, has also been used in some quarters, as has the more recent term recoveree.

We have closely followed these developments both within the addictions field and within related social movements. To assist addiction professionals and recovery support specialists prepare for these coming language debates, we would offer the following four predictions.

  1. Use of the terms alcoholic and addict will come under increasing scrutiny, criticism, and disuse within the addictions field and within allied health and social services fields on the grounds that such terms lack clinical precision, objectify those being served, and contribute to the social stigma attached to addiction and addiction recovery.
  2. The terms alcoholic and addict will continue for some time as preferred language of self-identification and mutual identification within some indigenous recovery cultures (e.g., meetings of Alcoholics Anonymous and Narcotics Anonymous). The use of these terms in public communications will continue to contribute to public misunderstandings of the meaning of recovery (e.g., public assumptions that someone identifying themselves as an alcoholic/addict is still actively addicted or has not yet achieved stable recovery). This public confusion will lead some people in recovery to migrate towards the use of such terms of self-identification as "alcoholic/addict in long-term recovery" or "person in long-term recovery".
  3. This dichotomy between the language of addiction research/policy/treatment and the language of many people in recovery will lead groups of the latter to distinguish between in-group and out-group communications. This is already happening via the messaging training for advocates involved in Faces and Voices of Recovery and many local recovery advocacy organizations. Over time, the terms alcoholic and addict are likely to diminish and then cease in professional and public communications.
  4. In the meantime, the differences between in-group and out-group and professional communications will raise questions regarding who can and cannot use terms like alcoholic and addict. Eventually, these terms will be relegated for proper use only among those who have been experientially privileged to use such language (e.g., those who have directly experienced addiction). This will be analogous to a person with a disability referring to themselves as a "crip", participating in "crip culture", and serving as a "crip activist" or performing as a "Krip-Hop" artist, while being offended by outsiders people or professionals without the lived experience of disability using this same language.

Changes in language can represent superficial adaptations to external pressure for change or represent fundamental shifts in public attitudes and policies and professional principles and practices. We should never underestimate the power of language. As the sage advice of Don Coyhis, the leading figure in the Native American Wellbriety Movement, suggests: Words are important. If you want to care for something, you call it a "flower"; if you want to kill something, you call it a "weed".

About the Authors: William L. White, MA, is Emeritus Senior Research Consultant at Chestnut Health Systems; Alisha White, PhD, is Assistant Professor in the English Department (English Education, Dis/ability Studies, Arts-Based Research) at Western Illinois University.