Saturday, 22 June 2013

Diagnosis, Political Correctness and Identity

Names are of profound importance. Psychological research summarised in this lovely New Yorker article  suggests that the sight and sound of the words we read, indeed the very shape of the letters that comprise them, is having an impact on how we think about what they represent. The relevance of this to the words that are used in the purportedly neutral medical field is obvious. Look at the word "Schizophrenia" below. Consider the unusually dense package of consonants which opens the word and then the harsh angular "Z" which cuts it in two. The Greek derivation of the two component elements (Skhizein & Phrenos) leads to a baroque and unusual spelling, which in turn lends a mystical, "other" quality to the word:

This visual example is taken from a benign text book about how to manage the social effects of Schizophrenia, but it still has a difficult and severe (some would even say stigmatising) label emblazoned right on its cover. In mental health, these labels are all around us.

Apart from the visual quality of mental health labels, there is also the troubling habit of slipping into using them as metanyms. Metanym is the substitution of a proper name with an alternative which actually represents something with which it is associated. This is what is going on when a health-care professional refers to someone as, say, "the depressive in room 10". I have seen many people object to the use of "Schizophrenic", and they are right to. While someone may meet the criteria for Schizophrenia, no-one is a "Schizophrenic"; it is not what the word is for.

Political Correctness:

One response to these problems of language and thinking is the judicious application of Political Correctness. Political Correctness is often maligned (with the derogatory "PC brigade" operating as a powerful if unfair rebuttal to well intentioned campaigners), but I'm with Stewart Lee, who mocks the naysayers and points out that it's an "often clumsy negotiation towards a formally inclusive language":

A politically correct and formally inclusive language of mental health problems would presumably not use words that are themselves unpleasant and would carefully caution against the over-extension of the labels beyond their originally intended use. The implications of disease (which implies infection) and of mental health problems as in some way characterologically definitive (as in personality disorders, where a person is seen as in some way defined by the label) should be strenuously resisted if clinicians want to avoid their diagnostic labels becoming simple insults.

Identity Politics:

Another approach is Identity Politics. A fantastic example is contained in this marvellously strident tweet by @ukschizophrenic:

An alternative to "politically correct" re-namings of DSM terms is for service users to accept them; to take them on as identities in themselves and, from this position, to assert their right to experience things in a particular way. I am unclear whether this stands as a reaction against diagnosis or a tacit validation of it. However, the gist of this tweet seems to be that @ukschizophrenic identifies to some extent with "Schizophrenia" and is simultaneously unimpressed by the notion that it is something to feel ashamed of. Just as LGBT groups took ownership of "queer" and "dyke" in order to neutralise their toxicity, there seems to be an emergence of a mental health identity politics online; Twitter's "Schizo-Tribe" is a brilliant example.

This movement makes it difficult for anti-diagnosis campaigners to say that they have the monopoly on taking patient experience seriously. If diagnosis is a useful way for people to make sense of their experience (and proponents of formulation have already accepted that the criterion we're interested in is "usefulness" rather than "truth") then to highlight the problems with diagnosis' validity seems irrelevant. Meanwhile, by claiming that a diagnosis is "stigmatising" or "colonising", anti-nosologists are privileging one group's experience over another's.

We seem to be left with an impasse; some people dislike diagnosis aesthetically and politically; others don't. A politically correct renaming of diagnostic terms may be worthwhile, but existing terms sometimes accurately capture the experience of those who receive them. The debate will not be won or lost on this territory.


  1. "This movement makes it difficult for anti-diagnosis campaigners to say that they have the monopoly on taking patient experience seriously."

    Spot on. And (British) organisation-level opinion is interesting. While the experience-specific HVN came out against DSM5, diagnosis-specific organisations are (obviously) interested in raising awareness of their diagnosis, not abolishing it. The major mental health organisations Mind, Rethink and Sane do not support the anti-diagnosis campaign.

    The anti-diagnosis campaign has no practical alternative to diagnosis, and it has no mandate to speak for service users as a whole. Indeed, it is actively campaigning against the best interests of most of us

  2. Just to clarify, the anti-diagnosis campaign I'm referring to is that run by a psychology society (not service users) in Britain. I totally understand many service users who are anti-diagnosis, and I understand why. The challenge for us all is to find a solution, or solutions, that both anti-diagnosis and pro-diagnosis service users find helpful.