Stigma and Language Change: The Problem with Low Hanging Fruit

Stop me if you’ve seen this before. You’re browsing the web for the latest harm reduction best practices and come across an infographic from a federal agency or county health department. The title is something like “Using Person-First Language” or “How Your Vocabulary Can Make A Difference.” There’s a bulleted list of words you should and shouldn’t use (“Instead of ‘drug user,’ try ‘person who uses drugs’”). You forward the infographic to your social media intern, who posts it on Facebook. Engagement is strong – a couple dozen likes, a few comments thanking you for the insight. This is stigma reduction in the modern age – but is it enough?

Indulge me with ten minutes of your time to explain how we’re missing the forest for the trees. Or in this case, the tree for the apples. A metaphor! I’ll come back to that.

But first, let’s jump in our proverbial time machine and travel back to Mrs. Walker’s algebra class. Painful memories, I know. Today, we’re learning conditionals. If X, then Y. “IF I stay awake for this entire lecture, THEN I’ll pass this class.” If only it were so easy. In logic, we call this condition (staying awake) NECESSARY but INSUFFICIENT. Sure, we NEED to stay awake to make the grade, but that ain’t gonna cut it alone. We also have to do our homework, participate in discussions, and pass the final exam (Hey, don’t blame me, it’s on the syllabus).

Language change is a NECESSARY but INSUFFICIENT condition for ending stigma: We can’t live in a humanizing world where people who use drugs are disparaged with unfair labels, but respectful language simply won’t be enough.

If you grew up in the South like me, you’re probably familiar with the phrase “Bless your heart.” If you grew up somewhere else, allow me to clarify: “Bless your heart” is not how we sympathize, it’s how we condescend. We smile and say, “Bless your heart,” but what we really mean is “Oh you poor, miserable fool.”

So let’s agree there can be a gap between the words we use and how we think and act. (If you’re a linguistics wonk, look up the debunking of the Sapir-Whorf hypothesis.) Then it’s reasonable to conclude that even if we had all the resources in the world to change the language of substance use, there’ll still be a huge swath of folks who use the right terminology but still hold prejudicial attitudes under the surface (“Those people who use drugs…bless their hearts.”).

Teach a man to say ‘fish’…

Okay, okay, so language change isn’t a panacea. But what’s the harm? At least we’re doing something.

Let me present my low hanging fruit hypothesis. In stigma reduction, language change is the lowest hanging fruit on the tree. We hand out flyers that read, “Use these words, not those words.” We put up billboards that say, “She’s more than her drug use, she’s someone’s daughter.” We start an “End the stigma” campaign website. Few resources, wide reach. Stigma, begone!

How about them apples?

Well, two problems. I’ll call them the mealy fruit problem and the poisoned fruit problem.

The mealy fruit problem: In ending overdose, let’s face it, stigma gets deprioritized. Most resources go toward improving treatment and harm reduction access and delivery. So we pick the simplest stigma intervention (language change) even if it’s mealy, full of worms, and less ripe than the fruit at the top of the tree. It’s not palatable, but it’s something. We wipe our hands and check stigma reduction off our list.

And hey, it’s important to prioritize improving the services we deliver. But I’d argue that stigma reduction is just as important. Stigma discourages people from seeking help, rendering harm reduction and treatment innovations moot. Stigma reduces equitable access to housing and employment, trapping people in the vicious cycle of use. Oh, and stigma may directly increase overdose risk. We need to reach for higher fruit, even if it means investing in a taller ladder.

The poisoned fruit problem: There’s an apple tree in the language change orchard that looks great. Even the farmers say its fruit is delicious! We feast until our bellies are full. But a few days later, cramps set in. Then fever. The apples were poisoned, and now we feel worse than when we started.

It turns out that language change can backfire, influencing attitudes and beliefs in the wrong direction! (Pat Corrigan writes all about it in “The Stigma Effect: Unintended Consequences of Language Change.) A prescient example is the disease frame of substance use disorders. If we call SUD a disease, the public may indeed feel more sympathetic toward people who use drugs. At the same time, the public is likelier to believe that people who use drugs lack control, increasing perceptions of dangerousness and desire for social distance.

Research also shows that telling people how to be less prejudicial can actually make them more prejudicial. Scientists call this reactance: Messages may threaten an individual’s sense of autonomy and cause them to double down on their preconceived notions.  And we just don’t have enough research in the area of substance use stigma to know whether this is happening. The problem in this poisoned fruit scenario is that, by the time we realize the fruits are poisoned, everyone’s gone home with a basket.

In summary, language change is usually good and sometimes bad, but never enough. So what should we do? Beyond educating the public, I see two priorities, one bottom-up and one top-down.

Let’s start with the on-the-ground solution. Try as we might, we will never completely erase the stigma of substance use. There are simply too many people to educate. Besides, attitudes are incredibly resistant to change. But what if we gave people who use drugs the tools to resist stigma? Research shows that certain psychotherapeutic approaches like Acceptance and Commitment Therapy can give folks the cognitive and emotional toolkit to feel less ashamed and more empowered to push through stigma. Absent resources, even a couple daily supportive text messages may be enough to move the needle, as we’ve shown in a recent pilot study (manuscript forthcoming). No, it’s not the responsibility of the marginalized to be resilient to injustice. But, until we can solve these giant social issues, every little bit helps.

Which leads to the top-down solution: Policy change. And specifically, civil rights protections for people who use drugs. Folks with SUDs get the short end of the stick when it comes to civil protections. Substance use is accommodated in the Americans with Disabilities Act, but protections are much weaker as compared with physical disabilities and other mental health challenges. In fact, current use of unregulated substances – whether or not it impacts work performance, and whether or not the use is labeled as dependence – remains legal grounds for discrimination. And there’s no wiggle room there. In the ten years following the ADA’s 2008 expansion, federal courts sided with plaintiffs with SUDs only once in 26 cases of employment discrimination. Punitive and prejudicial policies in employment, housing, education, and healthcare reinforce the message that substance use is an immoral and socially destructive act, and that people who use drugs deserve punishment, not support. It’s no surprise that substance use stigma remains higher than other conditions, like mental illness and HIV/AIDS, that have won more legal protections in the past three decades. So long as prejudice and discrimination against people who use drugs remain legally sanctioned, they’ll flourish in the social realm, too.

Heavy news, I know. But be hopeful: We know to pick the riper fruit, we only need a taller ladder.

Take that first step today: Tell a person who uses drugs that they are enough and they do deserve better. Then call your elected representatives and give them your best Howard Beale: “I’m mad as hell, and I’m not gonna take this anymore.”