Interview with Dr. John Kelly
Meet the Researcher: Dr. John Kelly, Harvard Medical School
Expert on stigma in addiction treatment and recovery
Interview with Great Lakes PTTC
Dr. John F. Kelly is the Elizabeth R. Spallin Professor of Psychiatry in the Field of Addiction Medicine at Harvard Medical School – the first endowed professor in addiction medicine at Harvard. He is the Founder and Director of the Recovery Research Institute (RRI) at Massachusetts General Hospital (MGH), the Program Director of the Addiction Recovery Management Service (ARMS), and the Associate Director of the Center for Addiction Medicine (CAM) at MGH. Dr. Kelly is widely known for his research on behavior change, implementing evidence-based practices for substance use treatment, reducing stigma associated with addiction, and how stigmatizing language affects treatment and recovery.
In the following email interview, Dr. Kelly responded to questions posed by Chuck Klevgaard, Prevention Manager for the Great Lakes PTTC.
What are the most significant findings from your studies on changing the language of addiction?
We've found that even when we don't mean it, certain terms—like substance abuser/drug abuse—can induce stigmatizing biases that increase perceptions that people with addiction disorders are more likely to benefit from punishment than treatment and are more dangerous and to be socially excluded. In contrast, using more medical terminology—like substance use disorder - may help mitigate some of those biases.
(See Dr. Kelly’s related research listed at the end of this article.)
We've also found that "stigma" is a multi-faceted construct and that certain ways of describing addiction may decrease some areas of stigma while simultaneously increasing others. In a recent national study we conducted, for example, we found that when someone with opioid addiction is described as having a "chronically relapsing brain disease," people blame that person less for having the addiction but are more likely to perceive that person as dangerous, to be socially excluded, and unlikely to recover. In contrast, describing someone as having an "opioid problem" has the exact opposite effect—they are perceived as more to blame for having the opioid addiction, but are viewed as less dangerous, to be socially included, and to be more likely to recover and get well. This suggests that we may need to choose particular terms to suit particular contexts and reach achieve certain messaging goals.
What does this mean for professionals working in different fields (e.g., clinicians, police, or judges)?
It means that we need to be more mindful about our use of language; to avoid "abuse" and "abuser" terminology and adopt person-first language (i.e., a person with or suffering from a substance use disorder as opposed to a "drug abuser.")
Also, we need to think carefully about the goal of the communication and messaging. Are we trying to increase prognostic optimism and decrease perceptions that someone with a drug use history is dangerous? In which case we may want to use biomedical terminology. In contrast, if we are trying to increase treatment engagement and retention, we might want to use more biomedical terminology to decrease personal blame/shame that can serve as a barrier to treatment.
This sounds to me to have implications that go beyond, sensitivity to individuals with addictions or disorders. What are the potential impacts of stigma for individual seeking care or working on recovery?
Stigma can affect public opinion and support for funding and policies as well, as increase personal blame and shame and reduce personal agency and change potential. The latter can prevent or delay help-seeking and prolong the clinical course and the impact of substance use disorder, which can ultimately mean increases in the likelihood of an early death for some.
How do we get it right in the field of substance use prevention?
Talk about these disorders in the correct way. Talk about risks and harms accurately. Educate people about the nature and impact of substance use, substance use disorder, and addiction. Use language and terminology that does not exacerbate stigmatizing attitudes. Increase exposure to people with lived experience in recovery who can serve to correct the stereotyped beliefs people may hold about "addicts".
How did you come up with the Addictionary? How is the resource being used in the field?
I wrote a paper back in 2004 talking about the need to reach consensus on an "Addictionary." I thought it was a clever play on words, or course, and thereafter began to focus on language and terminology and how it might be helpful or harmful when describing these highly stigmatized conditions and people who suffer from them.
This led me to conduct a series of experimental studies to examine these effects empirically. More recently, I became interested in creating an actual Addictionary that creates a unified and more precise lexicon that could be agreed upon in the field to help destigmatize addiction and reach consensus in our field. We put this up on our website (recoveryanswers.org) and people really appreciated it.
Also, subsequently, the national organization Facing Addiction became interested in our Addictionary® because in polling their 800+ national organizational members, reaching consensus on language and terminology was a top priority. We asked for further input from their members and the Addictionary® was updated. Like all dictionaries, it is a dynamic product that will change as language, culture, and consensus changes.
Click here to view the Addictionary®
Is it possible to change the national psyche? If so, what will things look like if we are successful?
It is definitely possible to change the national psyche surrounding alcohol and other drug addiction. It takes time. Culture can and does change with time and input. We are all a part of the culture so we can start the change by beginning to make these changes ourselves, as well as advocate for more changes ourselves if we believe there should be change in certain areas.
Concerted, consistent effort is needed to make change happen.
There is more momentum now, by far, than I can remember in my lifetime to make positive change in the area of substance use and addiction. Alcohol and other drug use is the top public health problem in most middle- and high-income countries around the world, including the U.S., so it's a worthy investment of our time in prevention, harm reduction, treatment, and recovery support services.
Resources to Prevent and Reduce Stigma from the PTTC Network
This comprehensive website provides an overview of stigma and its impact in various community sectors. The site includes links to webinar recordings on stigma along with downloadable print materials for use in outreach activities to prevent and reduce stigma.
Selections from Dr. Kelly’s research on stigma:
Kelly, J. F., Dow, S. J., & Westerhoff, C. (2010). Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms. Journal of Drug Issues, 40(4), 805-818.
Kelly, J. F., & Westerhoff, C. M. (2010). Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. International Journal of Drug Policy, 21(3), 202-207.
Kelly, J. F., Wakeman, S. E., & Saitz, R. (2015). Stop talking ‘dirty’: clinicians, language, and quality of care for the leading cause of preventable death in the United States. The American journal of medicine, 128(1), 8-9.
elly, J. F., Greene, M. C., & Abry, A. (2020). A US national randomized study to guide how best to reduce stigma when describing drug-related impairment in practice and policy. Addiction (Abingdon, England), 10.1111/add.15333. Advance online publication. https://doi.org/10.1111/add.15333