Person-First Language Reduces Stigma

Let's Talk Addiction & Recovery Podcast
Rear view of a group a friends walking towards the sunset in a rural area and carrying food for a summer picnic.

Words can hurt, and words can heal—especially words used by health care professionals concerning substance use and mental health disorders. Listen in as psychiatrist Stephen Delisi, MD, talks with host William C. Moyers about the power of choosing person-first language to reduce bias, stigma and shame (internalized stigma) around the disease of addiction. Quite literally, the difference between using the term "alcoholic" or "a person with alcohol use disorder" can be life-changing.

It is language that is intentionally putting the person as a human being first as their identity before any deficit or illness that they might have.

Dr. Stephen Delisi

0:00:13 William Moyers
Welcome to another interview in this series of Let's Talk podcasts. Brought to you by the Hazelden Betty Ford Foundation. I'm your host, William C. Moyers. In each podcast I sit down with an expert to discuss the issues that are at the essence of Hazelden Betty Ford's mission. From prevention of substance use and cutting-edge research, to treatment, recovery support, and how technology is increasingly becoming a force of hope, help, and healing for people, families, and communities to overcome addiction. We are recording this podcast in the midst of the pandemic of coronavirus. And that requires us to take precautions here in the studio which means that our guest, Dr. Stephen Delisi, and I are in separate rooms. But we are on the same page when it comes to today's focus. Reducing the stigma and bias of substance use disorders with first-person language. Or I guess I could say person-first language. Dr. Delisi is the medical director of our organization's professional education solutions and his resume is vast in academic, professional, and yes, even personal experience. On all things addiction, treatment, and recovery. Tell us, Steve, where does your passion for this field come from?

0:01:24 Dr. Stephen Delisi
William, thanks—first of all thanks for the invitation to return and do this podcast in the midst of COVID-19.

0:01:32 William Moyers

0:01:32 Dr. Stephen Delisi
It's very weird to be in a separate room. But as you say, we're—we might be in separate rooms but we are together in terms of what we're gonna be talking about. My entire career has been dedicated to working with individuals suffering from substance use disorders and co-occurring mental health. And my passion comes from helping those who our health system has historically not helped. One of the excitements of what's currently happening is that people are taking note and people want to understand better how do we treat and integrate addiction treatment. And that has been just a passion of mine from the very beginning. Both in terms of family and personal experiences with these illnesses that we talk about and as a medical professional, 20 years now in the field, it is seeing lives transformed and hope and healing happening right in front of you. That's where my passion comes.

0:02:37 William Moyers
And it comes across loud and clear. Thanks for all of that.

0:02:40 Dr. Stephen Delisi
Thank you.

0:02:41 William Moyers
Steve, it's really interesting—you are a medical professional, you're a medical doc—

0:02:44 Dr. Stephen Delisi
I am, yes.

0:02:44 William Moyers
You're the Medical Director of Professional Education Solutions. Why does PES need a Medical Director?

0:02:51 Dr. Stephen Delisi
Yeah so first, just to explain for our listeners what PES is, Professional Education Solutions, it is the external facing training and consultation team that Hazelden Betty Ford has developed over the past three years now. That division is a new division for our organization. And it is the team that is moving outside the boundaries of our organization and working with other health systems, states, county, public health, clinical, medical facilities, helping them to integrate addiction and co-occurring mental health treatment into their systems of care. Where did it come from? It grew out of the opioid crisis that this nation faces. And as the nation and health care in general saw just how damaging and dangerous this illness was, they started a call and say hey, Hazelden Betty Ford, we know that you have this comprehensive opioid response with the Twelve Steps. You've integrated evidence-based clinical addiction services with behavioral health services, with medical services, how did you do that and can you help us in doing that? And so, that's where PES began and as we started to work with federally qualified health centers, community mental health centers, hospital systems, the role of Medical Director was seen as important and I stepped in. and it has been a wonderful opportunity.

0:04:31 William Moyers
Let's talk about person-first language to reduce stigma and bias. Now we know how important it is to reduce the stigma around addiction, there's a lot of it, but what is person-first language, Steve?

0:04:42 Dr. Stephen Delisi
Yes. Great place to start. What am I talking about when I say person-first language? It's not something that people have always heard about. It is just as it sounds. It is language that is intentionally putting the person as a human being first as their identity before any deficit or illness that they might have. So an example of non-person first language would be calling someone a diabetic or a hypertensive. Or a paranoid schizophrenic. Person-first would say an individual suffering from diabetes. A person who has high blood pressure. Or, an individual suffering from the illness schizophrenia. So, it's a spin in terms of what we say first. Some people will claim that that's semantics and it's just words. But we're gonna talk about today how those words have real meaning and make a big difference.

0:05:45 William Moyers
So why is that important when we're dealing with people who are struggling with a substance use disorder or addiction to alcohol and other drugs or an addict or an alcoholic?

0:05:555 Dr. Stephen Delisi
Yes. Yeah. Absolutely. Our field, the addiction field, has been too slow in incorporating person-first language. We're starting to hear about it and I'm so excited about this topic and the invitation to have this discussion with you on this. We're not that far away from times when someone who was suffering from an alcohol use disorder was referred to as an inebriate. And someone who struggled with a drug use disorder being a junkie or addict. And someone who had co-occurring mental health issues being termed a lunatic and sent to the insane asylum. Now, many of us will cringe listening to those terms today, so we've made progress, but we still often in the health care system and in general population, we still often will refer to people as an addict, an alcoholic, or a substance abuser. If you listen, that is not person-first. That is defining the identity of the individual by the disease that they have. So rather than alcoholic, we refer to an individual who is suffering from an alcohol use disorder instead of an addict or junkie, that's an individual who is suffering from an opioid use disorder or a methamphetamine use disorder. That's what we're talking about today. And it makes a big difference because non-person first blames the individual for their behaviors and implies that they are willfully choosing those behaviors rather than see them as a person first and the behaviors as a symptom of an illness with which they are suffering.

0:07:45 William Moyers
So how does that then affect someone's treatment in a health care system?

0:07:49 Dr. Stephen Delisi
So, we now have empirical data, thanks to John Kelly and his colleagues out at Harvard. A decade ago they began a series of experiments. They did it 2010, there was a repeat in 2013, there's been additional by other teams as recently as 2018, looking specifically at hey, are the—are these just words? Or do they have an impact on the health care system? And so what they did—brilliant research—they created case histories. Stories of people who had addiction. They made two versions of those stories. In one, they referred to the individual as a substance abuser. In the other, they referred to the individual as a person with a substance use disorder. Everything else in the history, William, everything else in the story, was exactly the same. And then they looked and they said what was different? In health professionals, in attorneys, and in the general population, what they found is that when the story labeled the individual a substance abuser, the health professional believed that that individual was responsible for their behaviors. That rather than medical treatment they needed punitive measures. And that their prognosis was very poor. When the story included a person suffering from a substance use disorder, then they saw the behaviors as symptoms of an illness would prescribe a medical treatment, and saw that there was hope for healing. It fundamentally shifted how they were going to be seen by the health professional, the attorney, or the general population. What the treatment was and what the outcome was. Just by that word.

0:09:43 William Moyers
So person-first language is as important for the professional who's providing the service, the care, as it is for the person who is suffering from the illness.

0:09:52 Dr. Stephen Delisi
Yes it is. One of the other lines of research that we can draw upon to understand how important this is is that the most cited reason why an individual suffering from a substance use disorder and co-occurring mental health, one of the number one reasons they cite for not seeking treatment or leaving treatment is the experience of bias, stigma, and the internalized stigma of shame. And so, if our language is increasing that implicit negative bias or stigma, it's gonna drive people away. The very people we wanna treat—they're not gonna come into treatment because of the language that we used.

0:10:37 William Moyers
And yet the irony of that Dr. Delisi is that when we go to a Twelve Step meeting, you'll often times hear people say, 'Hi, my name is William, I'm an alcoholic.' Or if you go to a Narcotics Anonymous meeting, they'll say, 'Hi, my name is William and I'm an addict.'

0:10:53 Dr. Stephen Delisi
That's right.

0:10:54 William Moyers
How do you square those?

0:10:56 Dr. Stephen Delisi
Absolutely. Critical. Thank you so much for that question. In this conversation. When I'm talking about the use of person-first language and being intentional about using non-stigmatizing language, I am talking right now to my colleagues in the health care field and to the general population, the individuals who are not themselves suffering from a substance use disorder or are in recovery. That's who I'm talking to. I am not talking to the individual that you describe. The individual who is in the throes of an addiction or is in recovery and is reaching out to the AA or NA community. That is choice. That is the individual choosing to use the language that is socially normed to that subculture. In those meetings, the use of that language does not have the same connotations and bias and stigmatization as it does if a health care professional is saying it in their office or if someone in the public is using that language.

0:12:07 William Moyers
So it's okay then?

0:12:08 Dr. Stephen Delisi
For many people, and in many of those meetings, it's not just okay, but it is the appropriate norm to that culture. Now, I do wanna say that if I have an individual who is suffering from a substance use disorder and they are in my office and I am their physician, and I am hearing through their non-person-first language about themselves, if I am hearing their own negative biases and shame and stigma towards themselves, then I will point out that they may want to think about the person-first language and talk about themselves as being an individual who is suffering from their substance use disorder. But I am absolutely in this discussion, I am not speaking to individuals who are self-identifying and choosing the language that they do. That's—that's autonomy. But I am speaking to my colleagues, yes.

0:13:06 William Moyers
Are there other examples of where a person-first language needs to be addressed?

0:13:11 Dr. Stephen Delisi
Yeah. There are. Certainly within the context of the co-occurring mental health issues, we need to be more intentional specifically in this field. As we make progress and as I hear colleagues talking about an individual with an alcohol use disorder, that's wonderful. That's person-first. But then I hear them go on to say that this person with an alcohol use disorder is also a borderline. Or, this individual with a cocaine use disorder is a florid bipolar. Now what's just happened? They've used person-first in one aspect but then they have labeled the individual based on behavior and given them an identity that is judgmental and pejorative. What I prefer to hear is this is an individual with an alcohol use disorder who also has had a chronic history and lifetime of trauma. And with that has a lot of instability of their mood. Now I'm hearing clinical terms. Or this is the individual with a cocaine use disorder and also struggles with a bipolar disorder. That's the language that we're looking for.

0:14:20 William Moyers
You certainly are articulate and knowledgeable on this issue. Candidly I had never heard much about it until I was preparing for these interviews and you provided with this information. So where are we in the addiction treatment field and where are we just in general medicine around the importance of person-first language?

0:14:40 Dr. Stephen Delisi
We're making slow progress.

0:14:42 William Moyers

0:14:43 Dr. Stephen Delisi
Part of what I appreciate in terms of the position that I hold is being able to speak outside of Hazelden Betty Ford. We as an organization, through our advocacy, is pushing forward the change of language and how language can help. John Kelly's group out at Harvard and the recovery research institute has an "addiction-ary" that you can google. And it will help you to better understand the words that are more person-first and less stigmatizing. Before we close on this discussion, I think I also wanna expand to talk about how in the here and now, we are still in the throes of this opioid crisis. And with COVID-19 and of social isolation, of social distancing, we are in fact seeing increase in use. And an increase in overdose deaths. In this very time, it is critically important that we're using person-first language but also non-stigmatizing clinically accurate language when we talk about evidence-based treatment. And what—specifically I'm referring to is we have FDA-approved empirically based medications that can significantly help individuals with an opioid use disorder. But we refer to them as methadone maintenance. Or, opioid substitution or opioid replacement therapy when talking about methadone or buprenorphine which is the active ingredient of Suboxone that I think a lot of our listeners will have heard of. When you use those terms, you are perpetuating the bias and myth that the medications are nothing but substituting one drug for another. Which, a lot of physicians still believe. And more troubling, people with opioid use disorder and the recovery community, often sees that people on methadone or the buprenorphine have simply substituted one drug for another. We can change that by referring to these medications as what are. They are medications for the treatment of opioid use disorder. Similar to if you are on an SSRI for depression, we don't call it serotonin replacement therapy.

[Moyers chuckles]

0:17:15 Dr. Stephen Delisi
Right? We call it an antidepressant, a medication to treat their depression. I just want to have the same language apply to these medications.

0:17:24 William Moyers
So last question on that—in that spirit then, what is it that we need to do next? Say here we are in the summer of 2020, what needs to happen both within Hazelden Betty Ford and as Hazelden Betty Ford is a leader in this discussion and in this change around person-first language? What needs to happen next?

0:17:43 Dr. Stephen Delisi
We need to all intentionally use the person-first language so that we're modeling it and showing it in our everyday life. We need to educate. We need to get out and speak in discussions like this, but in a broader audience. That has started. There have been the major authorities in medicine and addiction medicine stating the need for change in this language. But that's not enough. We need to educate everyone so that it becomes just part of our vernacular. And we need to make sure that people understand this is a part of what perpetuates the stigma and the bias. It isn't just words, William. Language has the power to either hurt or to promote hope and healing. And we need to be in the business of educating towards the use of words that promote hope and healing for those who are suffering from these illnesses.

0:18:46 William Moyers
Thank you so much, Dr. Delisi for bringing that passion and articulating that to this podcast today. I am very confident that this Let's Talk podcast, our discussion today, will help exactly to advance that person-first language to reduce stigma. Dr. Stephen Delisi, the Medical Director of Professional Education Solutions at Hazelden Betty Ford, thanks for joining us today. [turns to camera] And thanks to all of you for tuning in. Be sure to keep coming back for more in our series of Let's Talk podcasts. On behalf of our Executive Producer Lisa Stangl and all of us at Hazelden Betty Ford, please stay safe and stay healthy, in these times, as always.

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