Published in The Counselor, July 1989
By J. Renaud
We want you to stop using the inaccurate, biased and judgmental term “substance abuse” now.
The expression “substance abuse” perpetuates ignorant and moralistic attitudes toward people with chemical dependency. Few health professionals have the nerve to openly oppose the disease nature of chemical dependency. The facts of both science and insurance reimbursement stand in their way. Yet many of these same professionals, at heart, still blame the victims of the disease for the problems which the disease causes. We chemical dependency counselors face diminished career hopes so long as we fail to challenge such attitudes.
In common English usage, the word “abuse” implies wrongfulness and willfulness. Your tire warranty becomes invalid if the dealer has evidence you abused the gas pedal. Child abusers go to jail. Not too long ago, boys and girls were forbidden to engage in what was called self-abuse. The word abuse calls up in the public mind something ugly, ranging from the contemptible to the abhorrent.
“Abuse,” you may concede, can be a confusing word, but what is so objectionable about the word “substance”? At first glance the word seems merely vague, but deeper study reveals “substance” to be, in this context, a maze of intentional confusion. The word has been made into an instrument of denial. Since the late 1960s and early 1970s, the term ‘substance abuse’ has served the interests of those who would criticize the drug involvements of others but excuse such use (including the use of alcohol) in themselves. Popular mental theories permitted the use of the term in this way.
These mental theories tried to explain most life problems, including alcohol and drug problems, as basically arising from errors in upbringing. An overweight person, for example, was seen as trying to compensate for some childhood upset by comforting the-now-adult self with food. An otherwise neutral substance, food became a problem because how the person chose to use it. Fashionable mental opinion at the time gave no value to the concept that genetic factors might affect weight gain. Back then, fat people were seen as “self-destructive,” if not just foolish or ignorant, or weak lacking will-power.
According to the same theories, a tobacco smoker was seen to be compensating for interruption of breastfeeding or some other oral deprivation. Quitting tobacco, such opinion held, was hard simply because the user had become conditioned to the habit of smoking. Clearly, then, smokers could have psychotherapy for their oral fixation or deconditioning for their behavior problem. Again, the substance of tobacco was not seen at the problem. Only today, with the help of the Surgeon General, do we finally realize that nicotine is more addictive than even opioids, and that will-power is irrelevant. But back then, smokers were just seen as people who were unwilling to change.
Substance, in the late 1960s and early 1970s, thus began to e defined in the sense of any material thing that was neutral in itself, but could be abused by mistake or perverse actions which turned out to be a convenient rationale. Those doing the defining, by and large, were people who themselves used drugs. Among them were mentally-oriented opinion leaders who, in search of an interesting livelihood, had become involved in various aspects of alcohol and drug problems. These opinion leaders included drug counselors, various flavors of therapists, writers, researchers and bureaucrats. This was a group strongly influenced by the drug experimentation fad then present among many educated, middle-class professionals. As one prominent promoter of the fad wrote in 1972, “I will insist that we accept the fact that drugs — intelligently used as tools to enter other states of consciousness — are potentially beneficial.” “…the drug problems is an effect of conceptions about drugs and … is can only be solved by changing those conceptual models.” (Andrew Weill, The Natural Mind, Houghton Mifflin, 1972).
Drugs as a Tool of Wisdom
So the term “substance” helped the new drug enthusiasts to feel better about their own choices and convince others as well. Like Andrew Weill, they believed that drugs themselves weren’t a problem, just how people felt about them. As long as drugs were feared, drugs would be troublesome. When drugs were no longer feared, the former source of trouble could become a source of wisdom. If drugs were just another substance, like food or tobacco, that could be used depending upon the choice of the enlightened person, then what was the problem with a bit of drug experimentation? Because, after all, who will admit to being among the non-enlightened? Given this analysis, drug experimenters could rationalize any ill-effects. They could reassure themselves that the people who did actually develop problems with drug or alcohol use did so out of ignorance and narrow-mindedness. Such persons were clearly to blame for their own difficulties.
The term “substance abuse” has become a socially convenient code word. On one hand, it sounds technical, professional, and therefore permissible. On the other, by the negative associations with the word abuse, it expresses the real distain which most people who use the term actually feel for OUR PATIENTS. Use of a code word allows the satisfaction of looking down on others while appearing not to. Disdain itself thus becomes deniable.
Now the willful abuse of alcohol and other drugs does concern our field. However, abuse is not a major issue as compared to dependency The area if abuse has more to do with law enforcement and behavior modification while dependence deals with a disease process. Professionals have sincere disagreements as to the exact boundary between abuse and dependence, but none argue that they are the same thing.
The Tail of the Elephant
So how is it that common parlance has come to let the abuse word, especially in the form “substance abuse,” stand for the entire field? How come one of our profession’s highest levels of government visibility is called the “Substance Abuse and Mental Health Services Administration” (SAMHSA)? The part is trying to stand for the whole, the tail of the elephant. Even SAMHSA itself, as far back as 1988, declared: “ When talking or writing about alcohol or other drugs, there are phrases that SAMHSA recommends and supports or previously used phrases … To emphasize that alcohol is a drug, it is recommended that the phrase ‘alcohol and other drugs’ (AOD) be used instead of ‘substance abuse’.”
The cause for why negative terminology persists lies in the semi-hidden public hostility toward chemically dependent people. Powerful interest groups stand to gain from continuation of this hostility. These interests excel in the manipulation of such code words to control public attitudes. They label OUR PATIENTS as abusers which paints these ill people as perpetrators, not victims. The heat thus moves away from the alcohol sellers and drug pushing pharmaceutical companies. Blame shifts to OUR PATIENTS, who have been branded a self-gratifying misusers of otherwise benign products.
The politicians too, can relax. Blaming the alcoholics and drug addicts as abusers, officials can call for jails and “safe” injection sites instead of getting honest with voters about the costs of untreated dependency. So long as chemically dependent people can be blamed for their illness, insurance companies will continue to refuse proper reimbursement for care. Employers, unions, schools and clubs will continue to discriminate.
So long as chemical dependency can be viewed as a disorder of behavior or choice-making. Or a sub-branch of some mental defect, then inappropriately trained people will try to treat it. Physicians, psychologists, social workers and miscellaneous therapists, without any sort of chemical dependency certification, will feel themselves qualified to intrude on OUR WORK. They will take out patients, or our authority, or both.
We chemical dependency counselors may be succeeding in certifying ourselves, but how do we assure the competence of other professionals who often set the policy which we must follow? So far, we have not been able to do much in this area. The trend of terminology against us symbolizes our lack of progress. Many tasks need doing for the future of our professional, but no one deserve more attention than cleaning up our language.