Editor’s Note: “Words Matter: A Conversation About Stigma, Substance Use, and COVID 19,” will be a two-hour virtual workshop held Friday, Sept. 25, from 10 a.m. to 12 noon. It will include people in recovery speaking about their experiences of stigma, nationally recognized journalists, and world-renowned researchers.

The event is part of a strategic, three-year anti-stigma campaign, with system-level interventions, by RICARES, the Rhode Island Communities for Addiction Recovery Efforts community agency, one of the leading community recovery groups in the state. It is being co-sponsored by the City of Providence.

The Sept. 25 conference will feature: Dr. John Kelly, director, Recovery Research Institute at Harvard/Mass General; Maia Szalavitz, a nationally recognized journalist author of Unbroken Brain; Machiste Rankin, an outreach specialist at RICARES; Ashley Perry, an intervention case manager at Project Weber/RENEW, and Diego Arene-Morley, program manager at RICARES.

The initial target of the initiative is the news media. The goal is to get three television channels, three radio stations, and three online news platforms to publicly pledge to adopt the Associated Press guidelines by the end of 2020, as a way to leverage all Rhode Island news media to adopt a policy of using person-centered and scientifically accurate language around substance use.

To help set the stage for this virtual workshop, ConvergenceRI invited Ian Knowles, program director at RICARES, to provide some history and context around the work on stigma.

PROVIDENCE – The national history of stigma toward people with addictions has endured for centuries.

• In 1673, Increase Mather, minister of the Old North Church in Boston, in his sermon, “Woe to Drunkards,” declared: “Drink in itself is a good creature of God ...and to be received with thankfulness, but the abuse of drink is from Satan; the wine is from God, but the drunkard is from the Devil.”

• In 1912, a psychological text stated: “Two types of [psychological] organization favor the acquisition of habits of excessive or morbid use of alcohol: the underdeveloped type, and the degenerate, over-sensitive, or otherwise morbid nervous organization.”

• A 2014 survey found that 80 percent of the respondents described individuals suffering from addiction as weak or lacking will power.

When we work against stigma, we are not dealing with simple lack of knowledge and misunderstandings; we are attempting to change deeply held attitudes and beliefs.

Stigma is different from disapproval of particular behaviors – it’s not necessarily linked to the actions of an individual, but rather to what is assumed about ‘someone like that.’

Stigma causes us to de-individualize people – to treat people as a category, a label, a behavior.

We know that the stigma associated with addiction, toward people with addictions, and even toward people in addiction recovery, is a primary and long-standing barrier to both recovery initiation and recovery sustainability.

Negative outcomes for individuals with addictions are further aggravated by stigma experienced at the level of the public, the self, and the policies of private and governmental institutions.

How stigma works
Stigma [an attribute, behavior or condition that is socially discrediting] manifests in several ways for individuals with addictions. A large body of research indicates that public stigma [the prejudice and discrimination endorsed by the general population that affects a person] is persistent, pervasive, and rooted in the belief that addiction is a personal choice reflecting a lack of willpower and a moral failing. So, for example, public stigma leads to support for criminalization rather than care.

Stigma exists at cultural, institutional, interpersonal, and intrapersonal levels. There is no physical or psychiatric condition more associated with social disapproval and discrimination than addiction to alcohol and/or other drugs.

Stigma bars people from housing, meaningful employment, and education – the very things that promote successful long-term recovery.

The traditional anti-stigma campaigns, efforts to reduce public stigma through communication and education messaging, are seldom grounded in anything more than intuition. In the current addiction crisis, anti-stigma initiatives are being rolled out by state agencies in the absence of evidence on how best to reduce negative attitudes, correct misperceptions, or target messages to various audiences.

Problematic language, messaging
One of the most common and problematic educative messages states that ‘addiction is a disease.’ Our experience is that this message is a very helpful framing for people in early recovery because it mitigates their self-stigma [the internalization of society’s negative views that feed depression and anxiety and can, in turn, drive more severe and dangerous use]. The framing gives people another explanation for their addiction besides being a weak-willed moral failure.

However, studies suggest that biological explanations as an anti-stigma strategy show contradictory effects and real harms. For example, the national “Disease Like Any Other” effort aimed to reduce public stigma by framing mental illness as being on a par with other chronic diseases, such as diabetes. But it was shown to have failed to reduce, and by some measures actually increased, stigma.

The available evidence indicates that the most successful anti-stigma campaigns are long-term, multi-component, and multi-level efforts.

Three-year strategy
RICARES has developed a three-year, anti-stigma campaign with three targeted system-level interventions. The first year seeks to target the language in the press and media; the second year will target the use of person-centered and non-stigmatizing language by health care workers; and the third year will target non-discrimination language in the workforce.

Why have we focused on language? We are addressing language because it is identified as a major contributor to stigma and there is sufficient evidence to identify the approach as effective.

William White wrote: “Words have immense power to wound or heal. The right words catalyze personal transformation and offer invitations to citizenship and community service. The wrong words stigmatize and dis-empower.

Words like “addict” and “alcoholic” reduce us to a stereotype or diagnosis. Words like “clean” imply that we were tainted and soiled [rather than ill]. “Substance Abuse” implicitly compares us with child and spousal abuse.

There is significant evidence that changing language mitigates stigma. For example, a 2010 study clearly delineates the effect of the “substance abuse” term. In the study, 314 people, half of whom were health care professionals, responded to questions related to how they perceived or felt about two people actively using drugs and alcohol.

One person was referred to as a “substance abuser” and the other was referred to as “having a substance use disorder.” The result was that participants felt overall that the ‘substance abuser’ was:

• Less likely to benefit from treatment

• More likely to benefit from punishment

• More likely to be socially threatening

• More likely to be blamed for their substance related difficulties

• More able to control their substance use without help

The study conclusion was that the term “substance abuser” elicits a more punitive implicit cognitive bias whereas the term “substance use disorder” elicits a more therapeutic attitude. Thus, the “abuser” label may perpetuate stigmatizing attitudes and serve as a barrier to help seeking. We believe that it is clear that this perception is pervasive among the general public.

Why have we focused on the media this year?
William White, [an Emeritus Senior Research Consultant at Chestnut Health Systems and past-chair of the board of Recovery Communities United], identifies five social institutions that directly or indirectly benefit from the stigma attached to addiction and addiction recovery: the criminal justice system, the child welfare system, the alcohol, tobacco and pharmaceutical industries, specialty sector addiction treatment, and the news media.

About the news media, White writes: “For a couple of centuries now, illicit drugs, illicit drug users and illicit drug sellers have been demonized by the media, while at the same time the media is the primary advertising vehicle for [the legal use] drugs. The alcohol and other drug problems of celebrities are sensationalized. Drugs are identified as being primarily responsible for many societal problems, such as crime and violence. The media uses emotionally alarming language and lurid and fear-evoking images, not to inform, but to promote and sell products.”

Most Americans rely on the mass media for information about the scope of the drug problem and get most of the information about serious mental illness or drug addiction from the news media. Further, research shows that most individuals with mental illness and addiction depicted in the media are those exhibiting abnormal or deviant behavior [e.g., violence], while few stories portray those who have success within treatment. Such depictions in turn affect the public attitudes about those affected by health and social problems.

Reinforcing stigma
The media reinforces the social stigma associated with addiction. Media reporting does not use pejorative and stigmatizing terms such as ‘retard’ for people with a developmental disability, or ‘lunatic’ for a mentally ill person. But reporters continue to use ‘addict,’ ‘alcoholic’ and ‘substance abuser.’

A final point: It is tradition [and can be personally transformative] for people in recovery to claim these labels. We are not challenging how people in recovery self-identify. That's a different question. However, the fact that people in recovery use this language to self-identify does not license journalists or other outsiders to use it.

As the campaign kick-off event, RICARES and our partners are calling on the newspapers, television stations, radio, and other media to simply follow the 2017 Associated Press guidelines on how to write and speak about addiction in the media.

“Words Matter: A Conversation About Stigma, Substance Use, and COVID 19” will be a two-hour virtual workshop, that will include people in recovery speaking about their experiences of stigma, nationally recognized journalists, and world-renowned researchers. Our simple goal is that three television channels, three newspapers, three radio stations, and online platforms will publicly pledge to adopt the AP guidelines by the end of 2020. ‘Words Matter’ is scheduled for the morning of Friday, Sept. 25, from 10 a.m. – 12 noon.

We expect that this will be a first step toward all Rhode Island media adopting a policy of using person-centered and scientifically accurate language. Registration for the (free) event is at: https://www.eventbrite.co.

Ian Knowles is program director at RICARES and a frequent contributor to ConvergenceRI.