Suicide by any other label…
Ever since I joined Twitter, I’ve seen many tweets about the importance of language in mental health care or research. Most make very similar points: there are words which are unhelpful, stigmatising or with assumptions ‘we’ don’t like. So, for example, we shouldn’t say ‘commit suicide’ (suicide is not a crime) or ‘schizophrenic’ (a person is more than their diagnosis). As much as I agree (sometimes strongly) with the tweets, I often responded, pointing out that language is not just a set of (problematic) labels. Here I want to respond at some length. This post will only start dealing with the issue.
But first let me say that linguists have dealt with loaded labels, propaganda, ‘weasel words’, manipulation for a very long time and we still have not found the way to change reality simply by changing the label. In other words, terrorists will not become freedom fighters (or the other way round) just because we say so. We also often see through ‘swarms’ or ‘floods’ of refugees. I’m not even certain that medical/scientific terms are the primary source of stigma. It’s worth adding quote from a recent issue of the Lancet:
However, until health-care systems seriously address the reduced standard of care received by people with mental health problems, the stigma can never be eliminated.
But what about language itself? In my view there are issues which are more important than the issue of label.
Lack of context. Let’s start with the language of symptoms. If you look at the depressive episode in the ICD10, you will see phrases such as these:
- depressed mood
- loss of pleasure
- reduced self-esteem
- ideas of self-harm or suicide
A linguist like me wants to ask: what on earth do you mean? Does it mean that I am sad? That I don’t apply for jobs, don’t enjoy the cinema? Or perhaps that I am desperate, can’t have sex and would like my airplane to crash? Or perhaps that I stopped answering phone calls, think that I should die and feel responsible for most of the ills of the world? Or perhaps… Complex stories and experiences are turned into abstract, decontextualised phrases that cannot possibly even begin to reflect those stories. Indeed, there is good qualitative evidence that clinicians use such phrases in interviews with patients (I will write about more).
Let me be clear. I do not suggest that ‘depressed mood’ be changed into, say, ‘low mood’, ‘unhelpful mood’, or ‘negatively experienced mood’. Rather, I want to preserve the verbs and not change them into nouns. In other words, I don’t want to change what we do, think, feel into acts, thoughts or moods – objects we observe in social vacuum. I would like to say: use labels all you want, but, please, acknowledge and preserve what I say! Preserve my story!
Perspective. Imagine you come home and say to your partner “I haven’t had a car accident.”. What would you be doing? In order for such a statement to make sense, you would need to be responding your addressee’s expectations that you would have an accident. Your utterance would be a challenge and a denial. If so, what would you be doing when responding to the following questionnaire items?
- 1-0. I am not sad
- 2-0. I am not discouraged about my future
- 5-0. I don’t feel particularly guilty.
- 6-0 I don’t feel I am being punished
- 8-0 I don’t criticize or blame myself more than usual.
- 9-0 I don’t have any thoughts of killing myself.
- 10-0. I don’t cry any more than I used to.
They are all ‘nil options’ in the much used Beck Depression Inventory. And, interestingly, they are all in the negative. The BDI assumes that I have depression, and yet it is used in screening. But should a questionnaire force me to challenge its assumptions? Should a depression scale suspect me of feeling guilty, being sad etc.? In my view, it should not. I should be only asked to ‘tell you’ something, and not have to wonder whether you, the clinician standing behind the instrument, might, just might, be right.
I’ll end here for the moment – more to come on this. Let me stress, though, yes, language matters. Labels are important, but by far and away not the most important.