Thursday, 6 March 2014

The Language of Mental Health

The language of mental health can be baffling for the most fluent speaker. Being new to the vocabulary must be overwhelming. In our field words get un-moored from their more familiar meanings and float into new configurations. While academics may delight in such shifts, a drift into jargon can be a sign that somewhere a plot is being lost. What follows is a half-baked and entirely partial view of some troublesome words:

"Bipolar": This may win the award for the topic with the most balls talked about it. Luckily ace blogger Charlotte Walker never seems to miss a chance to point out the excesses that surround Bipolar-talk. From the idea that it is "fashionable" because Stephen Fry has it, to the extraordinary presumptuousness of Darian Leader's views on the subject, Bipolar Disorder has had a funny recent history.

"Clinical Judgement": Much as clinicians would like to know the "correct" answer to any given ambiguity, we cannot avoid making judgements in clinical practice as in life. I judge that something I say will provoke aggression, I judge whether it would be good for someone to try this or that therapeutic intervention. Even when guided by evidence, our judgements involve reasoning from the general to the particular. Often these sorts of decisions get called "clinical judgement". While this may have a superficial accuracy (judgement about clinical issues is undeniably clinical in some sense) it also seems calculated  to cloak a professionals pronouncements with spurious authority. What lay-person can successfully argue against a "clinical judgment"? When do professionals start to acquire it? I am just 2 years into a clinical training program, but already I have been encouraged by mentors to use my "clinical judgement". I am not saying my judgements don't count for something, and equally they are presumably worth less than those of a seasoned professional who has seen hundreds of cases; but judgements can, by their nature, be contested. If offering them with the haughty prefix "clinical" makes that harder to do then something fishy is probably going on.

"Distress": We could here examine the words "disease" or "disorder" but they have been so thoroughly gone over by various mental health theorists that I have little to add. As a result of that ongoing contention, the safest way currently to talk about mental health problems is to call them "distress". This inoffensive term has banality on its side, but seems to equate the existential terror of a psychotic break with the frustration of having had a bad day at work. Unsatisfactory.

"Evidence Based Practice": A noble ideal, but seldom followed as closely as it might be, and utterly useless if the people who are supposed to provide it are under-qualified to interpret the very evidence upon which their practice is based.

"Formulation": I can't really argue with this use of language. A Psychological Formulation is roughly the same thing as a formulation in regular language use. Alright Formulation, you can go.

"Group": When I worked in mental health, any constructive-seeming activity that more than three people did together could be packaged up and classed as a "group" to make it sound like a bone fide mental health intervention rather than just some people doing something worthwhile. "Cleaning group"; "cooking group"; "young person's group" are all genuine examples. It drove me up the wall.

"Healing": I am extremely skeptical about "healing", which we can use describe our own experience, but not to make promises to others. Health interventions can be shown to change various sorts of "symptom scores", but I am not aware of a decent "healing" measure, in psychology at least, that has much construct validity. We should probably calm it on the "healing" talk.

"Identity Politics": I think that the notion of "mad" identity is fascinating, and has a long way to run in combating mental health stigma. How compatible is it with the movement against psychiatric diagnosis? On the one hand we have the notion of neurodiversity and a distinct "mad-identity", which calls for accommodation of a range of different neural-cognitive types. On the other hand, there's the tendency to focus on people's commonalities while denying that differences could be meaningfully "diagnosable". These two ideas are not incompatible, but they are very different directions of travel. Twitter's @SchizoTribe account is "run by Schizophrenics" for anyone "with a Schizophrenic illness". This makes me wonder if denial of the existence of an illness is no less an infringement of someone's identity than making a diagnosis; an idea with which I think psychologists have to engage more seriously.

"Manipulative": I once had the good fortune to work on an excellent female inpatient ward. Prior to the hospital's opening we were given a very good talk about how frequently it is said of people with personality disorders that they are being "manipulative". The take home lesson was that this word should not be used to describe the behaviour of vulnerable people as it stigmatises their actions. I agree entirely, and I would add that the feeling among staff of being-manipulated is nonetheless sometimes very real. If you feel like you are being manipulated then you are very likely in the presence of someone who is generally deprived of something they feel they desperately need. Your feeling manipulated is not the result of something perpetrated by conniving, dastardly-patients, it is a circumstance arising from an adaptive response to a subjectively desperate situation.

"Practice-Based Evidence": The rejoinder to Evidence Based Practice. This is espoused by clinicians who feel the information we can glean from "clinical experience" (see "clinical judgement") is marginalised by nomothetic research. Is this true? Maybe, but let's be clear, even the most experienced clinician does not have experience which equates to a meta-analysis of multiple RCTs documenting health outcomes for thousands of people. This is not just a numbers game either, it's about a long view and the systematic ruling out of confounds and examination for bias. Experience and case reporting is very valuable but it has a different, complementary, role to play in the development of reliable knowledge.

"Recovery": Imagine asking a doctor the following question: "Can you help me recover?" What would you hope for them to say? The answer would surely involve an estimate of how likely you are to feel better on the basis of information about your problem and likely interventions. In mental health recovery means...something else altogether. I would not descry the general thrust of "recovery-oriented" approaches, but the fact that we find it so hard a word to define suggests that our use of it is in a state of disrepair. There is a difference between the advocacy of therapeutic optimism alongside societal accommodation of the needs of a diverse range of people, and telling clients-regardless of their difficulties-that you can do something that will help them "recover".

"Service User": I have a personal dislike of this awkward little two word phrase. Who wants to be a "user" of anything, let alone anything so non-descript as a "service". Strictly speaking this usage ought to unite people who use oncology services, mental health services and those who go to a garage get their car checked over. In reality it seems mainly to apply in mental health, a field sufficiently fraught that it needs as banal a vocabulary as it can muster. I am not advocating some fightback for the word "patient" per se, instead I try as far as possible to refer to people as "person", "individual" or, ideally, whatever they feel comfortable with.

"Survivor": I wouldn't begrudge anyone the use of "survivor" as a way of talking about their identity; being a psychiatric patient seems a tremendous ordeal to say the very least. However this post by Natasha Tracy gives an alternative view on the ways this word has come to be used.

"Therapy": (See also "Group"). Examples: "eco-therapy" "insulin-coma therapy". If something sounds like a good idea (spending time in nature) then lets explore the reality of how helpful it can be. If it doesn't (putting someone into an artificial coma and seeing what happens when we bring them round) then that may tell us something too. As the Mental Elf's close relative the Mental Sprite might say: image is nothing, evidence is everything.

"Validity": Often used alongside the phrase "psychiatric diagnosis has no..." Less often (with notable exceptions) accompanied by a description of what sort of information would be taken to satisfactorily rebut the claim.

"Wellness": In a situation where you can't sensibly talk about "illness", you are equally debarred from a sensible discussion about what constitutes "health". Luckily the language of "wellness" is sufficiently elastic that mental health professionals can, if they choose, be both paternalistic (deciding what is and is not in line with "wellness") and hypocritical (denying they are engaging in value judgements). Enter "wellness" which, like "recovery", can mean everything and nothing all at once.


  1. I am still completely unclear as to what a "formulation" is. It is clearly not supposed to be a synonym for "diagnosis", though that makes the most intuitive sense to me. What exactly is going on here?

  2. In CBT, the way I tend to explain formulation at first is as "the story so far" -- a way of working with a person to help them put their problems into the wider context of their current situation, their history, their strengths and supports ... and, most of all, their behaviour* (e.g. using the five-Ps model; Dudley & Kuyken, 2006). It then functions as a guide for the therapeutic process: i.e. what goals do we agree make sense in this context; what exactly are we going to do to move towards them?

    Ideally, formulation remains a process, and a collaborative one, throughout therapy: so if new information emerges that client and therapist believe is salient, it can be incorporated into the formulation and that in turn may suggest a different focus (e.g. different cognitions to work with; different behavioural approaches to try; etc).

    It's an under-researched aspect of clinical psychology, certainly. But, in my personal experience, it's one of the most useful tools for two people in a therapy room to use.

    * Showing my therapeutic bias there, but hey.