Words Matter

“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.