The wrong words
Tuesday, 21 February 2017
A few years ago a friend pulled me up on my language – I had described some bizarre decision or another as “crazy”, and he’d patiently explained that he found the commonplace use of the word as a pejorative actively insulting. It was something I’d never really reflected upon previously, and it’s caused me to pause ever since. (I would love to claim that I’ve stopped doing it altogether, but that simply wouldn’t be true. Instead I catch myself saying it and then wince internally, picturing my friend shaking his head with disappointment.)
Of course, as far as I’m concerned, “crazy” doesn’t mean “suffering from mental illness”. To me it’s a word that I invoke to describe an extraordinary level of folly. But such misappropriation of language can have consequences, whether by accident, or design. (Take, for instance, the use of the words “refugee” and “migrant” interchangeably in the media.)
In medicine of course, we like to pretend that the language we use is wholly about precision. We spend years studying the language as much as medicine itself. We re-label the entire human body with terms we believe to be inviolable, but which are largely alien to anyone outside the profession. (I am suddenly struck with a memory of sitting on a sofa shouting “popliteal fossa” at Richard Madeley as he stared out of my TV and berated the world for “not having a name for that bit behind your knee”.)
The study of all this arcana has a somewhat distancing effect from our patients, who are generally unaware that the “diagnosis” we’ve presented them with is really just their presenting complaint translated into Latin – but we allow it precisely because doing so ensures a level of certainty. If you tell me someone has a maculo-papular rash I am much more able to reliably predict the appearance than if you simply told me they looked “blotchy”. We risk losing a little of our connection with the patient, but we gain reproducible, consistent, reliable language. Language seemingly designed to be so awkward and boring that nobody would ever want to start using it in the real world. (Madeley was right. There is a name for that bit behind your knee, but no sensible person would use it in normal conversation.)
Of course, that barrier between the precise lexicon of medical terminology, and the vague fickle nature of spoken language has been chipped away at over the years. Shampoo commercials, bad medical dramas, and Practitioners of Woo have all taken their toll, but generally the wall has pretty much held strong. Now however, there seems to be a new threat, one that has caused confusion and chaos to millions of lives in a remarkably short period of time. I’m talking, like everyone else these days, about the new President of the United States. (I’m trying very hard not to reference him by name, as I have developed this weird superstition that saying it does much the same for him, as clapping does for fairies.)
The President is, in my social circle at least, the leading cause of people abusing the words “crazy”, “mad” and “lunatic”. The even scarier issue for me however, is the surprisingly large number of articles on the internet and social media which have moved beyond ambiguous terms referencing mental health issues, to actual diagnoses.
There are all sorts of weird and wonderful diagnoses floating around out there – including suggestions that he has dementia, or is illiterate – but the favourite seems to be one of narcissistic personality disorder. There are a bunch of problems with this (ignoring for a minute that it’s a pretty controversial diagnosis in its own right).
The obvious one is that no half way sensible psychiatrist should be diagnosing anyone’s mental health based purely on TV appearances and bizarre tweets. That’s simply not how it’s done, and pretending that all you need to do to assess someone’s psychological wellbeing is to watch The Apprentice and read a ghost-written autobiography, is to seriously underestimate and undermine, well, the entirety of Psychiatry as a profession. You don’t know if he’s ill, and I don’t know if he’s ill – chances are he doesn’t even know. The only thing we can say with any certainty is that if anyone has carried out an assessment on the man, they clearly didn’t conclude there was anything to stop him taking on the job.
Which brings me to the second point. If the President of the United States has a personality disorder, does that really prevent him from being President? I’m pretty sure it doesn’t. (If we’re going to be flippant about this, surely the desire to run an entire country should count as a DSM criterion in its own right anyway?) The rush by his detractors to pathologise his unpleasantness, doesn’t affect the President himself one iota, but does immediately demonise anyone with a real diagnosis. “We don’t like this man, so we’ve decided it’s because he has the same illness as you” is a pretty awful sentiment to be putting out there.
It also lets the President off the hook. Concluding that a world leader is not of sound mind is a cop out. It’s a trick to absolve you of the awkward mental process of trying to understand why they’re doing what they’re doing – which also happens to give them free reign to continue doing it. To achieve change we need to start figuring out how to address the roots of the issues, rather than scouring psychiatry textbooks for a get out clause.
So let’s stop this nonsense. No more throwing around medical diagnoses for people we’ve never even met, and for whom we have no business applying them. No more conflating controversial people with sick people. No more making excuses for our leaders’ mistakes – we should instead be explaining what’s wrong and why. No more using terms relating to health as pejoratives.
Anything else would be