On language-use guidelines

I tend to protest against simple all-or-nothing guidelines of language use for healthcare professionals. Apart some particular contexts, such instructions tend to be counteruseful and, in my view, should not be proposed. This post is about one such set of guidelines.

Before I start, let me repeat, with some exasperation, that this post is, again, about the context. What works for one person, might but, importantly, might not work for another. And so, apart from guidelines of offensive language (and I do understand that various people might understand it differently, but there you are), any rules of language use in clinical (and not only) context are more than likely to fail. In fact, I would suggest that there are, perhaps, two reasonable guidelines. One is: don’t make any guidelines, the other is, if you must have a guideline, follow the person you speak to.

And here we come to the example I want to give. The document was quoted in a Twitter exchange under my tweet that, as a patient, I can speak about my illness in any way I please. Such statements tend to be greeted with understanding, especially, by psychologists, but then @RoseAnnieFlo quoted the Guidelines on Language in Relation to Functional Psychiatric Diagnosis.

Let me be blunt. This document is as far away as possible from any negotiation, acknowledgment, let alone acceptance of my language and, in the process, the way I, a patient, construct my experience. I am very disappointed with it and, I suppose, this post is partly an expression of this disappointment.

The document introduces three principles, which, the authors say:

are intended to suggest a range of possible alternative descriptions, and it is left to authors to decide which might be most appropriate in a given context.

I hope you are all in awe of the ‘tolerance rhetoric’. Alas, it disappears very quickly. The first two principles are introduced by these two sentences:

  1. Where possible, avoid the use of diagnostic language in relation to the functional psychiatric presentations.
  2. Replace terms that assume a diagnostic or narrow biomedical perspective with psychological or ordinary language equivalents.

Bloody hell, that’s a bit forceful, isn’t it? Do I, as a psychologist, get to choose? Note that while principle 1 is introduced with the hedge (roughly, an expression modifying the range of the sentence) ‘where possible’, principle 2 is just an order! Where is the choice, for pity’s sake, the alternatives I was promised in the introduction? Could I at least be allowed to consider replacing? Or do I just get on replacing or else?

To be honest, I would suggest replacing ‘principle’ with ‘commandment’ and have it engraved on a stone tablet!

But let’s consider principle 3. This is the situation when the psychologist cannot not use ‘the narrow biomedical’ as opposed to the non-adjectivised psychological wonder-language. There is recipe for this as well. Apart from “indicating awareness of its problematic and contested nature” (obviously psychological language is natural, uncontested and comes from God or evolution, depending on your worldview), you could also use:

quote marks round the diagnostic term, and explaining the reasons for this either in the text or in a footnote.

In case you wonder, yes, this applies also to service user accounts. Well, let’s face it, social stigma just isn’t enough, so psychology can always pile on and make sure that patients are made to look stupid for using the, you know, problematic, contested, narrow(-minded) biomedical and what have you. You can always count on psychology and its quote marks.

Of course, there is more. I have already suggested the subtle normalisation of psychological terminology contrasting it with the ever negatively valued psychiatric one. The bad language is just replaced with the ‘neutral one’. Could I just ask whether the authors of the guidelines actually believe that? Can you really stomach this lovely juxtaposition of “psychological or ordinary language”, which introduces just a smidgeon of ambiguity as to the meaning of ‘or’ and perhaps a hint of a suggestion that ‘ordinary’ can be used as a replacement for ‘psychological’? Really?!

Now, I understand that replacements for the words you don’t like come straight from the ideological assumptions you make. In general, I am actually sympathetic – I do like your stressing of social contexts. But where my sympathy ends, is where you simply impose things on me just because you can. You see, personally, I really do prefer being a patient, mental illness, for me, is not ‘emotional distress’ and I really prefer to be treated rather than ‘supported’. ‘Supported’, I really can’t help it, is just patronising for me and it helps you underscore your superiority and my weakness. But I am happy to accept that it’s just me. Do I count, though?

Yes, I hate being asked about my symptoms, but this is because most doctors and psychologists don’t actually understand what a symptom is. Incidentally, whenever I explain, they seem puzzled, which is consistently a source of merriment.

Now, I fully understand why clinical psychologists want to attract attention to the language which is used in clinical settings. I think it is very important how clinicians talk to their patients (look at Rose McCabe’s research). Yet, to be honest, I am much more interested in clinicians being able to ask me a sensible question, listen to my answers and not ignore them. It is waaaay more important than whether they call me a patient or a service user, or whether they use the word ‘anti-psychotic’ and not ‘neuroleptic’ or the other way round (yes, I read Moncrieff’s wonderful account of the name change). While I accept that there might be patients who care a lot about this, myself, I don’t and you can call me Little Bloody Red Riding Hood for all I care, if you actually can help me suffer less. And I write this in my apparently eminently ignorable ‘insignificant pain’ while you are having another battle of language about which I really don’t care. Really, words cannot express how much I don’t care.

And this is where we come to the non-linguistic point of this blog. When I read the introduction to the document, I was struck by its rationale. I hoped at least for some Dariusz-centred rhetoric. But no, it’s not about me and my suffering at all. In fact, this document is about this:

In this rapidly-changing context, new guidelines for language use in DCP professional documents and publications are needed to ensure consistency with the emerging evidence, with a psychological perspective, and with our publically-stated position.

You actually don’t give two hoots about me, the document is to make sure that your publically-stated position is enforced. And if you, my readers, wondered, what is the source of the strong, unrelenting language, here you have your answer. No, it’s not about ‘helping people’ or giving them choice or all this rhetorical crap (I do beg your pardon). No, it’s about making sure that everybody toes the line.

At the end of the document you ask for feedback. Here is mine: Shred it!

 

 

2 Comments
  1. Dariusz Galasinski

    Thank you for your comment. I have a brief response.

    1. When you say ‘unhelpful’ or ‘harmful’, I would like to know who exactly you mean. Such adjectives are not and should not be used as universal characteristics. They are in relation to people. Please, tell me who you mean.

    2. I agree with you that the current MH care pathologises quite a number of ‘normal’ experiences, yet, this is nothing to do with language. Please do not reduce psychiatry and psychology to a few dozen nouns. There is really quite a lot more to psychiatry and psychology than the much hated ‘labels’. It is also not the labels which are responsible for the biomedical model of MH care. Not even close.

    3. You are very optimistic about ‘informing the writing’. No, it’s not. It’s commanding.

    4. I keep being puzzled by the simplicity of the assumption that changing a few words will somehow change the world. In fact, history suggests that it’s not the case at all. Psychiatry has changed terminology a number of times, all to no avail. And yet, claims about ‘influence of language’ with reference to diagnostic labels are made time and again with no respect to reality. And so, how do you actually know that changing or removing the labels will (dramatically) improve the care people receive. Will they not get medication? Why? WIll they be listened to better? Why? There are quite a lot of such questions.

    5. I am at a loss how you arrived at the conclusion that I dismiss the importance of language. This cannot be further from the truth. What I am dismissing is attempts to police language use to the point of disallowing words which might be (and from the discussion on TT I know are) helpful to a number of people.

    I also dismiss this incessant focus on diagnostic nouns whose removal will cure MH care. It will not. Language is important – language not a few dozen nouns.

  2. As someone interested in the influence of language in the mental health arena, I read your blog with interest.

    I was left puzzled by your negative reaction to the DCP-guidance document and the indignant tone of your article. Publications offering advice on language are commonplace in professional organisations – the Royal College of Psychiatry has something similar – and aim to inform the writings of their membership. The contents of such documents are exclusively for the consumption of the relevant professionals and are in no way trying to restrict the freedoms of lay people to use words or phrases of their choice when describing their emotional pain.

    Like you, I’d energetically defend the rights of individuals to describe their suffering in any way they feel best conveys their own unique experiences. By contrast, I believe that mental health professionals (and high-profile opinion shapers, such as celebrities, journalists and programme makers) carry a responsibility not to perpetuate unhelpful and/or harmful messages about the nature of human suffering. The use of biomedical language to describe distress and overwhelm does just this. Diagnostic labels and medical terminology collude with an ‘illness like any other’ approach to mental health problems, the currently dominant paradigm of Western psychiatry, and there is compelling evidence that this framework for making sense of human suffering leads to a range of negative consequences for those seeking help from services. These disadvantages include greater stigma; less hope of recovery; more passivity and the overuse of psychotropic drugs.

    In addition, the language routinely used when talking about human suffering is likely to influence the kind of services that are, ultimately, on offer to those in need. Thus, our current biologically-skewed psychiatric service, with its drug-and-monitor approach, will be strengthened by biomedical language while innovative alternatives (for example, societal changes around life adversities, peer support, psycho-social approaches) will be neutralised, undervalued, or deemed to be less appropriate endeavours. Being seen – at best – as discretionary extras, these non-medical options will be neglected and underfunded.

    So, in summary, I believe your disparagement of the DCP document on the basis of it striving to censor how people describe their emotional pain is an attack on a straw man. More importantly, by dismissing the importance of language in the mental health sphere you are – inadvertently or otherwise – discouraging much-needed reform of the current psychiatric system.

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