“Sticks and stones may break our bones, but words will never hurt me.” This is one of the biggest playground lies. The truth is that words matter. Names matter. It matters what we call ourselves. What other people call us, matters. And words stick with us for longer than the time it takes to heal from a physical injury.
Crazy. Manic. Depressed. Sad. Blue. High. Anxious. Psychotic. Hypersexual. Certifiable.
Most people have some idea of what these words mean. They’ve made their way into common parlance. We hear them on TV; we see images in advertisements for medication; we use these words ourselves. In casual, usually imprecise ways.
But they mean something particular to experts. Experts are working on the fifth edition of the Diagnostic and Statistic Manual, the psychiatrist’s encyclopedia, which names and classifies mental health challenges. It clusters symptoms and names them, thereby indicating who is normal, and who is not. And I’m not sure if this is a good or a bad thing.
Having a name can help. It can reassure you that you are not alone or peculiar. There are others who experience something like what you experience. And if that experience causes suffering and widens the door to death, there can be help. Naming mental health conditions helps doctors know what medications may help, and what medications will only make it worse. Naming mental health conditions can provide more opportunities for educational or governmental assistance when it’s needed. Naming mental health conditions can . . . .
But there’s also a danger. With the way medical and life insurance are currently structured, naming mental health conditions can raise premiums or get someone downright denied for the protection that is so desperately needed. (The Wellstone-Domenici Act instituted mental health parity laws, but it still doesn’t apply to individual health insurance and Medicaid.) And, as Dr. Michael First of Columbia University reminds us, naming mental health conditions can become a system of labeling that increases the stigma that people experience. I also wonder about what happens to children who are diagnosed. I believe that some will experience greater health. They will receive appropriate treatment and care. Treatment and care they might not have received without a diagnosis. And yet, I wonder how many children will be labeled and medicated, who in other circumstances might be considered eccentric, bright and idiosyncratic.
Years ago I went to a local support group of a national advocacy organization. As the meeting began, we were asked to introduce ourselves. Everyone went around the room saying their first name and the DSM classification of their challenge. “Hi, my name is Monica and I have . . .” I felt like I was trapped in an late night television spoof of Alcoholic Anonymous. Were we confessing something? Were we ashamed to give our full identity? Even worse, were people reducing their lives to their named diagnoses?
That didn’t work for me. Because my diagnosis is just shorthand. It’s a brief way of explaining some of what I live with. It’s probably most helpful for psychiatrists. Mental health conditions are as unique as the people who live with them. I have two good friends with the same diagnostic naming, and we have pretty different experiences of depression and hypomania. More importantly, my diagnosis is just one part of what can be said about me. There’s a lot more to me than this “name.” This “name” was given to me by people who write manuals.
It matters more what we name ourselves. The African American holiday of Kwanzaa highlights the principle of Kujichagulia, or self-determination. This principle reminds African Americans of how important it is “to define ourselves, name ourselves, create for ourselves, and speak for ourselves instead of being defined, named, created for and spoken for by others.” Proverbs 22:1a puts it this way, “A good name is rather to be chosen than great riches.”
Should we embrace or reject the labels that we are assigned? Should we rejoice when there are more labels for ourselves and our children? Or repel them? Sometimes they are helpful; they are useful shorthand. Indicating my gender, race, culture, class or sexual orientation are abbreviated ways of signaling some things about me. But only in a general way. I declare that I am more than one incident that happened to me. I am more than one set of experiences I have. I am more than my sadness. And yes, I am even more than my happiness. We all are.
There is value in this struggle over words. My friend and colleague Layli Phillips Maparyan writes, “Self-labeling is a psychologically and politically valuable process, yet labels and identities are socially negotiated through dialogue. People may or may not agree about how to name a thing, but the process of negotiating the label is healthy and inevitable.” In my ideal world, a doctor offers a name, explains the process of getting there, and then asks, “What would you call this? What is your name for yourself?” Together we decide – and we may decide on more than one name.
Ultimately, the revision of the DSM reminds us that medicine is a practice. It’s the experts’ best estimation given the evidence in front of them. Sometimes they get it wrong, and the effects can be disastrous. But they try again, to get as close to right as possible. And when they get it right, they can save lives.
Thank you for sharing your thoughts. Luckily, there is an opportunity for individuals to comment on the new changes to the DSM (http://www.dsm5.org/Pages/Default.aspx). I agree having a “diagnosis” does help with classification of symptoms, and more than not is more frequently used for insurance purposes. While I must use the tools of my trade, I also emphasis individual differences and often look for a goodness of fit with the person and the individual's environment. While the DSM cluster symptoms together to assist with classification related to treatment and billing purposes, it's also important to examine the individual's “utilization” of symptoms. For example instead of saying that person is “borderline”, consider, “that individual is borderlining”, the individual is basically using a cluster of symptoms to fulfill some unmet need or adhere to a faulty style of life which developed at some point in their life span. I have done this in my own life with my “diagnosis”, while it's more serious than saying, “I'm sad”, this allows me to recognize my behaviors, and look deeper into what may be happening in my life. But you're right, words can hurt us, until we realize we are so much more than words and a cluster of symptoms. Thanks for share your insights.
I like what you write here. The focus on particular behaviors are probably much more helpful than naming an individual's identity. I know that there is a need – again – I need to rant about health insurance later . . . but how tragic (in some ways) that so many clinicians have to conduct their healing work with an eye to “how to bill something.” Single payer anyone? : )
Hi Monica,
Your essay once again raised many excelent points. I would love to discuss this face to face at some time. Early in your post you write about being at a support meeting and feeling shamed by naming the diagnosis. For those in AA saying their addiction is a verbal reminder that they are powerless to their addiction. This does not mean that they give up or give in to it but rather in order to be in recovery the addict most always be aware and act accordingly to maintain sobriety. 12-step literature refers to this as acceptance. This is not approval only that in essense it is what it is. This is the hand that was dealt – play it well.
So I am left wondering. For persons who battle a mental illness whether it is servere, moderate or mild. Single episode, recurrent or in remission. Does naming it empower the individual to own it not as their identity but as an aspect of who they are, and therfore also be able to name how they recognize it, manage it and even use it to there advantage? You are right to point out that within the DSM anyone can identify with any of the symptoms at some time in their life. Treatment is indicated when these symptoms become disruptive. I like it when I meet and individual who says “Hi my name is “X” and I am a gratefully recovering “Y” !”
– Tracy
Tracy, thank you for your reflection. It would be good to talk about this offline. I appreciate 12 step programs and how important naming is in those contexts – from what I know of them. To say, “Hi, my name is Monica and I'm . . . or I live with . . . ” feel different than what happens in 12 step programs. I didn't and don't feel shame in my diagnosis; I just don't want to be reduced to it. I think it strips one of the complexity of one's life.
I'm trying to say that I think naming can be helpful and harmful in the context of mental health challenges. I think this might be quite different for those in 12-step programs. One reasons is that I'm not sure it's helpful to acknowledge that one is powerless to the condition. Most therapists and clinicians I know want people to claim their power in the midst of their condition, learn how to manage it, and live healthy interdependent lives.
Outside of the issues of stigma, the comparisons between mental health challenges and 12 step program seem fewer. I mean, would someone say, “I'm a recovering depressive”? This could, of course, be the bias of my personal experience. I may need to write a separate blog on health insurance, but outside of a clinical/ therapeutic context, is the naming really helpful? That's what I'm trying to ask. What do you think?
If it's truly kept within the context of the medical model, I believe there is a purpose to naming. I think an additional concern to consider here is the stigma associated with mental illness. I believe the 12 step approach is different, while the DSM will often list associated features, and differential diagnosis, rarely is there a connection between biological/chemical factors and a diagnosis. However, enough research has been done on addiction and some developmental disorders, which justifies categorizing alcoholism as a disease, and in the eyes of some, a more acceptable diagnosis to “identify with” and label one's self. There is less stigma associated with depression and anxiety disorders but greater stigma associated with personality disorders. When individual's think of borderline personality disorders, they may think of the character in fatal attraction, and less about irregularities in the limbic system or the individual's history of trauma. I think until there is a greater awareness of mental disorder within the general public, labeling is not helpful outside the clinical/therapeutic context.
I absolutely think that someone can say “I am a recovering depressive”. What science and observational data has shown is that a person who has a recurrent mood disorder lives with it much like a person with a more – I hate to say it like this – traditional chronic diagnosis (this is equally true for the addict). There will be good and bad runs with symptoms. Working a recovery program helps the individual be mindful of the daily steps you take to maintain optimal health(bio/psycho/social/spiritual). Also “powerlessness” refers to the fact that the illness was not choosen or deserved it just happened. As much as a person battling a disease may like to say “I don't feel like dealing with you today” to their illness it is unfortunately not a viable choice. In fact this usually leads to an increase in the experience of symptoms. Naming symptoms (I think and experience) gives clinician and client a common language to work with. I whole heartedly agree that words should be treated and crafted very carefully. When it comes to taking these words outside the clinical/ therapeutic context I see the risk it runs. The stories I could tell you about insurance companies would make you sick to your stomach. I can obviously talk ad nauseum about this topic and would love to have a conversation inperson. I'll inbox my number to you. Let's talk soon!!
I'm fine to agree to disagree about the “recovering depressive” thing. Perhaps you know folk who would say that. I am not one of them. : ) I think the powerlessness is quite different between mental health challenges and 12 steppers. I agree with you about the acknowledgment that the mental health challenge is not chosen or deserved. But I think there's more agency for those in 12 step programs than there is for those with mental health challenges. I'd rather compare mental health challenges to diabetes than I would to addiction. But that's just me.
I agree that a common language is needed for clinicians and clients, but why does the medical language win out? Why can't the clinician use whatever language a client finds useful – which might be more spiritual, cultural or something else? The medical model pervades and dominates with little questioning. There's a lot of money and power connected to that. But yes, I agree with you – it's the system that most of us have to work with right now. I'll say it again – single payer anyone? Talk with you soon.
Naming is both a political and personal necessity. Thanks for bold vulnerability of this piece.
Silence forces us to realize the our words, the units of our naming and recognition in the world, presuppose a reality which is prior to our naming and doing.
Charles H. Long, Significations