The Use and Misuse of Language by Addiction Counselors, Part II
This is the second part of a three-part series focusing on terms related to addiction and their correct and incorrect uses.
According to the National Institute on Alcohol Abuse and Alcoholism, binge drinking is defined as a pattern of alcohol consumption that brings the blood alcohol concentration (BAC) level to 0.08 percent or more (n.d.). This pattern of drinking usually corresponds to five or more drinks on a single occasion for men or four or more drinks on a single occasion for women, generally within about two hours. It is also sometimes used to describe an extended period of heavy drinking by someone who has a severe alcohol use disorder.
“Client” vs. “Patient”
The term “client” is often used to describe the individual being assessed and/or treated by nonmedical clinicians, usually other than psychologists. The term is universally used in state alcohol and drug standards and in publically funded treatment programs. However, consider that if the people we treat are “sick” or suffer from a disease, it is more appropriate to characterize them as “patients” regardless of who provides the treatment or funding or reimbursement for treatment. Attorneys have clients. Accounts have clients. Prostitutes have clients. We have patients. Additionally, during utilization review with payers, the use of the term “patients” rather than “clients” is likely to resonate with the reviewer and fit with the type of people who have conditions for which insurance pays.
The term can be problematic. The term originally was coined by the National Association of Children of Alcoholics (NACoA) and it identified an important syndrome often found in adult children of alcoholics, characterized by dependence on the needs of, or control of, another. It also often involves placing a lower priority on one’s own needs, while being excessively preoccupied with the needs of others. However, in common usage it was applied so broadly as to lose any specificity (“95 percent of the world is codependent and the other 5 percent is in denial!”). It is sometimes applied to people who actually meet criteria for a personality disorder. Most importantly, it does not exist in any generally accepted diagnostic classification, such as the DSM-IV, DSM-5, ICD-9-CM or ICD-10-CM. Caution should be exercised in using the term “codependence” to justify admission or continued treatment when doing a utilization review with a managed care reviewer, so as not to create a credibility problem.
“Compliance” vs. “Adherence”
“Compliance” implies going along, acquiescing or submitting because of external pressure in contrast to adherence which implies more internal motivation. Patients in treatment comply with treatment and may sound like they are making progress while they are really “doing time,” not “doing treatment.” Furthermore, adherence is strength-based and patient-centered.
“Comorbidity” is a medical term for illnesses that coexist, regardless of primacy or causal connections. In behavioral health, it was previously referred to as “dual diagnosis,” but now referred to as “co-occurring.”
More commonly called “aftercare,” it usually refers to the professionally or peer-directed treatment (usually group) that occurs after the completion of primary treatment and is designed to solidify the gains made in treatment, facilitate the process of coping with the stresses of early recovery, and reduce the potential for relapse.
While this term may be used to describe nonproblem drinking, it is more frequently used in the context of an individual who has an alcohol use disorder and appears able to return to nonproblem or social drinking. While this may be possible for individuals with a mild severity alcohol use disorder—alcohol abuse in the DSM-IV—it appears not possible for someone who has a severe alcohol use disorder (e.g., alcohol dependence in the DSM-IV).
The current term replaces “dual diagnosis,” and describes the concurrent existence of two or more types of disorders. While commonly used to describe the coexistence of a substance use and mental health disorder, it is not limited to that. For example, a patient may have an opioid dependence, a chronic pain disorder, hepatitis C, and a major depressive disorder. The term does not speak to causal relationships between the disorders or which is primary and which secondary. The advantage of this term over “dual diagnosis” is that it does not limit co-occurring disorders to only two disorders and avoids the mistake of interpreting the term as being limited in application to only having both an alcohol or drug use disorder and a mental health disorder.
This term is used in a number of different ways. In general usage, it is described as the state of relying on or needing someone or something for aid, support, or the like. In the section on substance use disorders of the DSM-IV, it was a diagnosis of a more severe level of disorder made by meeting three or more of the seven dependence criteria. However, it is no longer a diagnosis in the DSM-5. It is also used to reference physiological reliance on a substance (see “Addicted” vs. “Physiologically Dependent”) and used as a synonym for addiction as in “drug dependence.”
This is the metabolic process by which toxins are changed (broken down) into less toxic or more readily excretable substances by the body. The period of time over which this takes place is dependent on a number of factors including the half-life of the drug, the age and physical condition of the patient, and different substances used concurrently. The term is very commonly misused to describe treatment provided to alleviate adverse physical or psychological reactions to the withdrawal process. The new ASAM Criteria has replaced the term “detoxification” when used to describe a level of care, the setting or the medical management processes with “withdrawal management.”
“Discharge” vs. “Transfer”
Discharge denotes the termination of an episode of treatment while transfer implies movement from one type of treatment or level of care to another. The terms are sometimes used interchangeably because of insurance benefit language.
This term may have made its first appearance in the book The Disease Concept of Alcoholism, written by E. M. Jellinek in the 1950s. The results of the brain research during the last decade have conclusively proven that addiction is a chronic, relapsing brain disease. If in fact that is now a recognized fact, why do we still refer to is at a “concept?” When speaking about the disease, it is more appropriate to refer to it as the “disease model.”
A term used to describe the concurrent existence of two types of disorders, usually a substance use and mental health disorder. The concept of “dual” inaccurately limits the number of concurrent disorders to two (see “Co-occurring Disorders”).
This term is often used to denote the age of onset of a substance use disorder in older adults. Although there is not total agreement in the literature as to what constitutes that age, the dividing line between early- and late-onset is often identified as forty-five years of age, regardless of the age of the individual at the time of the assessment. Because of their long histories of use by the time a treatment intervention occurs, early-onset alcoholics are more likely to have more serious medical and possibly psychiatric problems, multiple treatment experiences, family estrangement, and fewer social supports. The likelihood of successful recovery appears poorer than for late-onset alcoholics, who often develop the disorder as a result of the stresses of aging (retirement, widowhood, loneliness, isolation, etc.). Late-onset alcoholics have a history of accomplishment prior to the onset of the alcoholism including education, job skills, employment history, and family connections and are generally assumed to have better coping skills than early-onset alcoholics.
“Gambling disorder” is now part of the Substance-Related and Addictive Disorders section in the DSM-5. The term “gambling disorder” replaces “pathological gambling,” listed as an impulse control disorder in the DSM-IV and commonly referred to as “compulsive gambling.” It frequently co-occurs with substance use disorders and its diagnostic criteria are very similar to those for substance use disorders.
This is the belief that the use of certain drugs predisposes use to another, usually more serious drug use. Cannabis is often referred to as a gateway drug and the research is mixed. The belief probably comes from awareness that people, particularly adolescents, who use marijuana are also likely to use other, more “serious” drugs. What is missing is the documentation of a causal relationship between marijuana and the other drug use. People who use substances are likely to use a variety of psychoactive substances. However, if we examine the belief of a causal connection between use of a specific drug and later use of other drugs, we find that the drug most frequently used by heroin addicts before their heroin use is alcohol, yet people are unlikely to postulate a causal relationship between drinking and later heroin use. If there is a gateway drug, it might be tobacco and although there is no evidence of a causal relationship between smoking and other drug use, smoking is commonly found associated with other drug use and preceding or co-occurring with the other substance use disorders (think smoking among alcoholics). It is apparent that to find adolescents who are using alcohol and/or other drugs in school, one needs only to find adolescents who smoke.
“Graduation” (From Treatment)
This is a term often used in place of discharge. One graduates when one completes an educational or academic experience. Since addictive disorders are illnesses requiring treatment, and education alone does not change behavior—if it did no one would still be smoking—graduation is an inappropriate term to apply to discharge from treatment. If an individual is hospitalized for the treatment of asthma, they do not “graduate” from the hospital. The use of the term might stem from the still common use of fixed length treatment—the twenty-eight-day, inpatient treatment program.
“Habilitation” vs. “Rehabilitation”
Rehabilitation implies return to an earlier level of successful functioning. There are patients, who because of the age at which they began using substances or other reasons, have no history of successful functioning prior to their use of substances. For them, the more accurate term is “habilitation,” developing that level of successful functioning for the first time. Habilitation is differentiated from rehabilitation by the necessity for more skill-building activities.
This term is incorrectly used to describe addiction. A habit implies certain behaviors which become routine, repetitive, and which can be positive (good habits like exercising regularly) or negative (bad habits like biting one’s nails). Addiction is a disease and to refer to it as a habit minimizes its seriousness.
Another undefined term which could mean anyone who drinks and weighs over 250 pounds.
The next and final installment of “Counselor Concerns” will pick up where we left off and discuss terms such as “motivation,” “recovery,” and “tolerance.”
National Institute on Alcohol Abuse and Alcoholism. (n.d.) Moderate and binge drinking. Retrieved from http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking