A few days ago, I came across an article called ‘Language in psychiatry’ by Joseph M. Pierre and Allen Frances. I’d like to offer a linguistic perspective.
Let me first say that I like the article. The two authors understand well that there are no easy solutions. For example, they point out that if you replace ‘patient’, you will get ‘customer’, ‘client’, or ‘service user’, none of which are transparent and neutral. Pierre and Frances suggest that such labels sound cold and business-like, outside the context of care and I agree, I also prefer to be a patient, with all the connotations it carries. They go on to talk about the scope of ‘borderline personality disorder’, ‘major depressive disorder’ and ‘schizophrenia’, only to conclude that:
Ultimately, though, stigma isn’t caused by a name and isn’t remedied by replacing it with a euphemism. It’s caused by the way that other people regard someone affected by disease or disorder and the limitations of the ability of physicians to help.
The two psychiatrists are right. The well-known attempt by the Japanese government to reduce the stigma of mental illness by changing illness names failed (here is an account, but you can find much more). It turned out that stigma remained – label change has not done much. Why? Well, I don’t know, but I do know that just because we change one word for another, we don’t change reality (whatever it might be).
And here we come to the main point of this blog. Most discussions about the language of psychiatry (or, indeed, medicine in general) are about lexis. In other words, they are about what kind of words – mostly adjectives or nouns, we use to refer either to characteristics or to things, respectively. And for a linguist such discussions tend to be of minor importance without considering how these words are used. In other words, discussions of the ‘language of psychiatry’ do not consider its discourses, ‘ways of speaking’.
The example I would like to use to make the point comes from the ICD-10 (I wrote more about in my book on men’s experiences of depression). Let’s consider the diagnostic criteria of depression:
An additional symptom or symptoms from the following list should be present, to give a total of at least four:
(1) loss of confidence and self-esteem;
(2) unreasonable feelings of self-reproach or excessive and inappropriate guilt;
(3) recurrent thoughts of death or suicide, or any suicidal behaviour;
(4) complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation;
(5) change in psychomotor activity, with agitation or retardation (either subjective or objective);
(6) sleep disturbance of any type;
(7) change in appetite (decrease or increase) with corresponding weight change).
So, would you like to change any words? None seems particularly problematic and, in fact, I am not aware of anybody particularly unhappy with ‘loss of confidence’, ‘thoughts of death’ or ‘sleep disturbance’. No, the above words are not an object of any protests or campaigns, they are not particularly offensive, they do not carry any immediately obvious stigma. So, they are not put next to those words which were identified by Drs Pierre and Frances.
And here comes the linguist. I actually do have a problem with them and it’s because, wait for it, they are (mostly) nouns. This means that symptoms are rendered as things. Such complex, dilemmatic, extended in time processes as losing one’s confidence or thinking about killing oneself are rendered as obvious, clear, unproblematic objects to be spotted by the clinician. But what exactly constitutes indecisiveness or when does the process of weighing up the pros and cons of things become ‘indecisiveness’? There are of course no answers to such questions. Moreover, these nouns refer to actions – to thinking, feeling, doing, complaining, wanting or making – they are nominalisations (i.e. they render actions and processes as things). In the process, I think, they make symptoms more objective, almost universal, as if a suicide thought of John, a farmer in England, were like the suicide thought of Anna, a professor in Poland, or Manuel, a businessman in Spain.
Incidentally, no matter how I try, I still cannot identify individual thoughts amongst my thoughts. Probably, because I just think, that than ‘have thoughts’. Just imagine telling your loved one
I have thoughts about you.
I think of you.
So, there is no patient, no experience of illness, no distress, no suffering. All that which happens with the person who comes for psychiatric help is reduced to a few ‘objective’ categories which the diagnostician can apparently assess with ease. There is no context, no individuality, despite the fateful phrase of the mood being ‘definitely abnormal for the individual’. But the individual is never positioned as someone with a perspective. The individual gets nouns (sometimes adjectives) which are apportioned by the diagnostician making the assessment. The ICD constructs a version of psychiatry in which a patient is a set of symptoms which are to be harvested and treated by the clinician, as if these symptoms simply existed ‘out there’ or in the patient, for all suitably trained to see.
Before I’m subjected to criticism that, of course, psychiatrists and psychologists understand all this and they see the individual, I would like to refer you to an article by Justyna Ziolkowska, who demonstrates that psychiatrists use ICD categories directly in their interviews!
They simply confirm the diagnostic criteria, the nouns! So, please, do not tell me that psychiatry’s guides into the psychiatric interview teach us how it should allow the patient to open up and share their experience. I am yet to see such an interview, both in Polish (I have read transcripts of many interviews) and in English (I have read fewer, still, they were as awful). Does it mean that all interviews are like that? Of course not. But I am a bit tired of hearing the argument that I am the unluckiest researcher ever and only have transcripts of the ‘bad apples’.
But let me show you another piece of evidence. Here is an extract from clinical notes (translated from Polish):
Mood slightly lowered, affect well modulated, facial expression more lively. Coherent, logical thinking.
But, I’ve learnt my lesson – ‘real’ evidence comes in English. Polish psychiatrists are bad, British shrinks are ace. So, here is a snippet shown on the Animated and Excitable blog:
X presents with emotional lability and animated and excitable personal style.
Speech very animated and excitable
Animated and excited in interpersonal style.
These notes are very similar, aren’t they? And although you cannot be certain – causation is impossible to prove here, yet, such notes are situated in a ‘way of speaking’ reflecting that of the ICD (and the DSM, let’s be clear on that). So, what these notes do, just like the diagnostic manuals, is hide what actually happened between the clinician and patient. What did the patient say? What did the patient do? After all, this is what the basis of ‘emotional lability’ is, isn’t it? You didn’t do any ‘emotional lability’ blood test, did you? And no, I won’t get started on ‘logical thinking’, because I shall never end this blog post.
And here is my problem. As ‘we’ fight over a word here, a word there, arguing, for example, that ‘commit suicide’ is so bad, it should be banned, I would like a campaign against ‘suicidal thoughts’ (here is an earlier post on ‘suicidal thoughts’). This is because they blank the experience. ‘Suicidal ideation’ is not much better, though presumably more extended in time.
Even better, I would like a campaign for using verbs! I can even offer a few slogans for psychiatry (and probably for the rest of clinical professions):
Shrinks for verbs!
No verbs, no notes!
Patients do stuff!
Verbs are cool!
Do take your pick! Bascially, I would like my doctor to note that I think and not have thoughts, that I want something, not ‘have preference’. Instead of asking me what my ‘views, priorities, goals’ are, I would like the doctor to ask me what I think or want. Like a normal person! When they do, we might start a conversation.