Self-medication as metaphor: why psychiatry should revise an (in) convenient narrative about substance use and mental disorders

Summary The term self-medication remains an influential narrative to explain why some patients with mental health problems use psychoactive substances. This Feature offers a conceptual critique of its broad use in psychiatry. We argue that self-medication often functions less as a testable explanatory model and more as a rhetorical metaphor: clinically convenient, yet scientifically under-specified and normatively loaded. Reviewing large epidemiological studies, ecological momentary assessment and longitudinal sequencing, we noted that while evidence supporting coping motives and negative reinforcement exist, they do not support adopting self-medication as the main mechanism for comorbidity or as a therapeutic interpretation of substance use. Our concern is that over-reliance on this metaphor can subtly shift clinical stance from curiosity to assumption, carrying three main clinical risks: (a) fostering paternalism, (b) diagnostic drift through reverse inference and (c) explanatory distraction. Moreover, medicalising substance use as self-medication does not necessarily reduce stigma and may paradoxically reinforce narratives of biological defectiveness. We propose a few safeguards for using this metaphor within rigorous clinical formulation: replacing assumptive language with structured motive-inquiry, recognising plural mechanisms and prioritising evidence-based addiction interventions over pharmaco-centric responses.