My Twitter timeline has again featured reference to the article Drop the language of disorder. It reiterates the well-known postulate that psychology and psychiatry should change the way they speak (or write) and in this post I would like to consider what should be dropped and, if possible at all, what should be adopted instead.
Before I start, I would like to be clear that I am not so much interested in the arguments regarding how useful psychiatric disorders are, but only in the linguistic argument. What is it that clinicians should not say and, more urgently, what is it that they should say? I also would like to say that, on balance, I am fairly sympathetic with what the authors say, however, over the years, I’ve become much less enthusiastic toward their position. Such a statement could be unpicked, as I like the writing of some authors more than others. Here, it’s the ‘language of disorder’ I am interested in.
Let me start with what the article says. Peter Kinderman, John Read, Joanna Moncrieff and Richard Bentall talk about the ‘language of biological illness’, but offer no insight into what that might be. In fact, that sentence about the language of biological illness is countered with reference to evidence about usefulness of seeing distress in terms of disorders. I’d argue that one has nothing to do with the other. Later on in the article, they mention introducing the language of disorder, and the counterevidence is pathologisation of grief and I am still baffled what exactly one has to do with the other. I am even more baffled with the ease that the authors talk about some uniform ‘language of disorder’, as if it were clear and obvious what that might be.
Let me make two points. If I choose to speak of depression, as a means to refer to a particular set of experiences, am I using the ‘language of disorder’? Let’s make it more difficult, let’s assume that I’ve never heard of the DSM or the ICD and I still talk about depression. Am I using the language of disorder?
Well, perhaps in contrast to the authors, I would argue that I don’t. I simply choose a way to describe my experience, probably in line with the fact that I’ve heard it many times. My friends speak like this, media do, a nurse might have said something too. And so, I tap into a particular kind of discursive practice and speak like others. Let me say immediately that I doubt very much you can make an easy and direct link between, say, ICD and the way I speak.
But let’s turn things around. If you take ICD-10’s account of the depressive episode (commonly referred to as depression), you will see words such as
confidence, self-esteem, guilt, self-reproach, thoughts, indecisiveness, change in appetite, weight change, ability to concentrate.
By any stretch of imagination, such vocabulary can hardly be considered medical. Indeed, you can add words such as ‘emotion’, ‘personality’, ‘suicide’, ‘paranoid’ and also those are hardly medical (I’ve written about this in this post). So, are words like ‘emotion’ or ‘suicide’ indicative of the language of disorder? Surely, such an argument would be nonsense.
And here we come to the conclusion that the ‘language of disorder’ might be a completely empty signifier, one which is supposed to look cool, but offer very little, if any at all, substance. That is to say, I continue not to have any clue as to what exactly is the language of disorder that psychiatry should drop. Moreover, I actually don’t think the four authors know it, either.
So, what do they offer in lieu of the hated language of disorder. Well, you’ll be surprised to learn that they don’t offer much at all. They write:
We need a wholesale revision of the way we think about psychological distress. We should start by acknowledging that such distress is a normal, not abnormal, part of human life—that humans respond to difficult circumstances by becoming distressed. Any system for identifying, describing and responding to distress should use language and processes that reflect this position. We should then recognise the overwhelming evidence that psychiatric symptoms lie on continua with less unusual and distressing mental states. There is no easy ‘cut-off’ between ‘normal’ experience and ‘disorder’. We should also recognise that psychosocial factors such as poverty, unemployment and trauma are the most strongly evidenced causal factors for psychological distress although, of course, we must also acknowledge that other factors—for example, genetic and developmental—may influence the magnitude of the individual’s reaction to these kinds of circumstances.
And I keep being surprised. This, again, has nothing to do with language. The authors start with the exceedingly general and ambiguous statement that the system should:
use language and processes that reflect this position.
and I really don’t know what it means. What kind of language is it? Alas, the subsequent sentences offer no explanation. The authors actually don’t write about language at all. They write about what should be thought, perhaps, if pushed, we could say: what should be written, but there is nothing about bloody language. So, Peter and others, do you want more nouns? Verbs? Sentences in active or passive voice? Present tense?
What keeps irritating me in such arguments is the sleight of hand performed on me as the reader. The authors mention language as if it were something obvious and clear, and then ignore the language argument completely, only pretending to speak about it. And they don’t. They speak about an ideological position (with which, as I said, I have much sympathy), which they would like to be adopted. I do wish they were open about it. Say: do things like we suggest, we have better arguments, but stop saying: drop the language of disorder. I keep being disappointed by arguments against psychiatry, which suggest that psychiatry is not reaching out to the ‘real’ evidence, while at the same time offering bogus arguments about language.
In case you wonder – I do reject the argument that it’s only a short article and if it had been a proper and long one, we would have learnt about the language of disorder and the language of no-disorder. No, we wouldn’t.
So, what exactly should be adopted in lieu of the ‘language of disorder’? I have absolutely no idea. I actually would suggest that the authors don’t know it either.
But I want to end with two points about ‘the language of the article’. I hope you will have noticed that when the authors start offering an alternative, they change the speaking persona. From the writer talking about the world, all of a sudden they start speaking as ‘we’. And I would like to ask who exactly ‘we’ is. Is it you, the authors? Somehow, I don’t think so, as the ‘we’ talks in such broad terms that it cannot possibly be referring to the four authors, psych-celebrities as they are. No, all of a sudden the authors speak about psychology and psychiatry and probably for them. All of a sudden, so many people need those things and they all stand with the authors. But do they? On what grounds do the authors actually make such claims? As much as I like what the authors say, please don’t try to pull a fast one on me with your use of pronouns.
The second point that I want to make is in reference to this fragment:
While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word), understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits.
It angers me no end when seasoned psychologists and psychiatrists try to suggest that a diagnosis is a mere label. Is it really? Is it really about slapping a label on a person and saying, hey, this is now what you are, be gone? Surely, it’s not. I am really tired of this unhelpful reduction of what at least should be a process of coming up with an understanding. And of course, it all too often is not, but that is nothing to do with the diagnosis, let alone the diagnosis being just a label.
Incidentally, I hope it is also clear that the second sentence in the fragment is not about the label – it is about the system in which people who find their diagnosis useful find themselves in. And, quite frankly, I would much rather hear what the authors, who are part of that very system, do to change what they criticise. In addition, I am so beyond disappointed with four senior psych-people who undermine people who do not think like they do.
I would also suggest that the authors drop the language of pronoun and, in addition, drop the language of label. It would be much more helpful, if they try to write without such little tricks.
And so, what do we come to? I still don’t know what the language of disorder is. As I said, I actually, don’t think the authors do. Their argument has nothing to do with language or anything linguistic. But the language arguments are used because they are easy. They focus the mind on something seemingly simple like language (and who doesn’t have an opinion on language?!) and you don’t need to consider the complexity of the reality of mental health/illness, which now can be reduced to a word or two. The entirety of the diagnostic process is reduced to a label and, hey, presto, you have your scapegoat.
Drop ‘the language of disorder’ and you no longer have to wonder about models, diagnoses, let alone social contexts. You just need to change the words. You don’t need to wonder about people who use continue using the ‘language of disorder’. You don’t need to wonder about the labels which give you access to social security benefits, to medication, to psychotherapy. Change the language and people’s distress will go away. At long last, all those crap psychiatrists whom so many patients dread, will be free to be wonderful. I must admit that I find the simplicity of the language argument intellectually offensive.
Please, please, stop talking about language.