Why the language we use to describe mental health matters

2nd May 2019
Challenging mental health inequalities
Antonis Kousoulis

Dr Antonis Kousoulis

Former Director of England and Wales

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This content mentions suicide or suicidal thoughts, depression, eating disorders and personality disorders. Please read with care. There are details of where to find help at the bottom of this page.

Perhaps it is not surprising that an area of health that has been systematically stigmatised for so many decades has historically settled for a discriminatory lexicon. Generations of people have grown up in societies that found terms like “psycho”, “schizo”, “loonie”, and “crazy” perfectly acceptable.

Stigma is not only an element of mental health, of course, but the extent to which it has permeated our language, compared to any other area of ill-health, is astonishing.

Many would argue that it is practice and not language that matters. But words are a barrier to help-seeking and a motivator for making discrimination acceptable.

It can be a provider of a context for many people, which further entraps them in a vicious cycle of thinking that they’re suffering from “something” that they really shouldn’t be – or worse, that this “something” is somehow defining them as lesser members of their communities.

Words are a barrier to help-seeking and a motivator for making discrimination acceptable.

Why do words matter?

A big body of research from the past few decades has helped better our understanding of how the human brain works and the associations it makes. Psychologists and behavioural economists, among other disciplines, have defined our thinking in terms of two “systems”.

“System 1”

  • Operates automatically and quickly, with little or no effort and no sense of voluntary control
  • Here, let’s call it our “Feely Brain”. This part of our brain is responsible for most of our day-to-day actions and has learned to distinguish between the unexpected and the expected. This makes activities such as walking, reading and understanding nuances of social situations effortless

“System 2”

  • Allocates attention to the effortful mental activities that demand it.
  • Here, we’ll call it our “Thinky Brain”. This part of our brain represents our conscious, reasoning self that makes decisions, solves complex mathematical calculations and helps us complete more complicated tasks like parking and writing.

Compared to our Thinky Brain, which is relatively young and immature in its development (talking in millennia terms), our Feely Brain has developed over millions of years. He includes natural skills that we share with other animals. In our human context, it completes several highly complex associations every minute that help us lead our normal lives.

Our Thinky Brain tends to be lazy and uninvolved unless prompted, so our Feely Brain largely guides our thinking. Our rapidly thinking Feely Brain is always looking to make simplistic causal connections (so that we can get the impression that what we first think is also what is true).

This is particularly important when it comes to our language. Evidence shows that our Feely Brain easily and effortlessly takes charge in producing a response to words. This is called “associative activation, " a simple result of seeing or hearing a word. A word brings an idea, and an idea triggers many other ideas. Our Feely Brain keeps making connections between all those ideas by resurfacing memories, which recall emotions that bring other reactions.

It is a cascade of activity in our brain that happens quickly, with no virtual conscious control. It produces a series, or a pattern, of cognitive, emotional and physical responses. That’s right, we respond to words without even realising it.

Types of words

If we understand the important processes that words trigger in our brains, we may decide that it is worth being more thoughtful in the words that we use to describe mental health. Some words, like “nutter” and “mental”, are clearly discriminatory and should not be used. Then there are words that have originated in different contexts and have evolved over the years, making them too emotionally charged to use in our modern context.

In a similar way that we would struggle to understand what someone meant by “Inbox”, “Unfollow”, and “Selfie” 10 years ago, the use of words like “psychotic” and “neurotic” are today outdated and stigmatising. Our language is evolving.

How we talk about mental ill-health in our immediate environment is also critical and evolving. An important example is a suicide. We often say that someone has “committed suicide”. The use of the word “committed” originates when suicide was considered a crime and a sin. You commit a crime, or you commit a sin. Suicide is neither. Thankfully we seem to be slowly getting towards a global consensus on this (though not entirely there yet).

Given the impact suicide can have on the bereaved family, friends and colleagues, it would be much more thoughtful to use expressions like “took his/her own life”, “ended his/her own life”, or “completed suicide”. If someone has attempted suicide and survived, sometimes we say they’ve been “unsuccessful” at taking their own life. However, when we say someone has been “unsuccessful”, it almost implies that we wanted them to “succeed”. Our language is emotionally charged.

Being more thoughtful

It is important not just how we talk about problems and diagnoses. Remember that 1 in 6 of us is experiencing high levels of distress or a common mental health problem every week therefore being respectful and thoughtful in our mental health-related language could do wonders for our brain’s “associative activation”, and, hence, the emotions of the people around us.

For example, we should avoid:

  • Describing someone who is organised as “OCD” – being clean, tidy and particular is not the same as living with clinical obsessive-compulsive disorder.
  • Talking about being “bipolar” when we experience everyday natural mood swings is not the same as living with bipolar disorder.
  • Saying “I’m depressed” or “that’s depressing” if we feel a bit sad is not the same as living with depression.
  • Using very problematic words like “psycho” to describe a person we dislike or “schizo” to describe a person’s reaction or personality stigmatises people living with schizophrenia.
  • Describing someone thin as “anorexic” misunderstands that anorexia nervosa is a mental health condition that is much more complex than just losing weight.
  • Saying “Ugh, I’m going to kill myself” when frustrated, embarrassed or when something is going wrong is insensitive to someone who is suicidal or someone who has lost a loved one to suicide.

Our identity

As we’ve covered before in this blog series, mental ill-health impacts fundamental parts of our personal identities, like our relationships, work performance and educational outcomes.

In the way we have framed our societies, people with long-term mental health problems can struggle to recover their personal identity (as a parent, spouse, co-worker, volunteer, student etc). Therefore, how we talk about this experience of mental illness could play a positive and influential role in the recovery process for millions of our fellow citizens.

Identifying someone as simply a “patient”, “service user”, or a “schizophrenic” implies that this is all the person is - that this diagnosis defines them. Instead, describing someone as experiencing mental illness can help to allow for other parts of their identity to still exist.

We often use the word “suffer” regarding mental ill-health. While acknowledging the actual impact and suffering that people experience is accurate, we also need to be careful not to imply that a diagnosis equates to a “life sentence” of suffering.

We now know that following a diagnosis, we can engage in positive recovery pathways, thrive in our workplaces and be dependable family members. So, if we instead use expressions like “people who use mental health services”, “people who experience mental health problems”, and “people living with depression”, we could achieve a more holistic and accurate view of the experience of ill-health.

Contrasting views

For people who have been in contact with mental health services, contrasting views about language may be worthy of reflection.

  • Some people reject the labels of diagnosis, while others find them helpful. For example, someone may find a diagnosis stigmatising but also essential when accessing benefits in the UK.
  • We often use the phrase “mental illness”. Some people regard this as unhelpful as there is no consensus on an agreed organic component to distress.
  • People may instead choose to talk about mental ill-health.
  • We at the Foundation often talk about “mental health problems”.
  • The word “recovery” has also been controversial because the term means many different things to different people.

Exploring people's thoughts around such terms can be useful to help us reach a shared understanding. For example, “Mad Pride” has been used to reclaim the language around mental health. It became a movement involving past and present users of psychiatric services. It seeks to reverse the negativity of experiencing poor mental health and stresses that people should be proud of their "mad identity".

This is further complicated from an evolutionary perspective. A lot of the activity happening in our Thinky Brain triggers emotions that would have been normal and protective some tens of thousands of years ago (e.g. our ancestors got angry to protect themselves against a threat and sad to ask for help and treatment). But for our Feely Brain and our language, negative emotions “have to be” problematic.

It can be useful to explore what thoughts people have around such terms, to help us reach a shared understanding.

How far have we come?

In recent years, we have come a long way in public mental health in terms of our attitudes around and our efforts to tackle the stigma of ill-health, but we are not there yet.

It remains true that several thousands of our fellow citizens experiencing symptoms of mental ill-health will not seek professional clinical help because of the stigma attached to mental illness and the fear of being misunderstood.

Media, retailers and social media have been playing a role in the persistent use of stigmatising, stereotyping and offensive language:

  • From Brexit being a “collective mental breakdown”
  • To “mental patient” Halloween costumes sold on the high street
  • From documentaries framed around the diagnosis behind homicidal behaviours
  • To Christmas cards highlighting “Obsessive Christmas Disorder”

We are still exposed to unhealthy imaging and expressions. The fact that there is a strong response to such unfortunate uses of words is encouraging.

The potential of humour to help address stigma is welcome, but as a rule of thumb, trivialising or “adjectivizing” diagnostic terms should have no place in our societies.

For too long, most campaigning efforts in psychiatry and public health have focused on increasing the understanding of the biological model of mental illness, i.e. the physical, organic and biological aspects of illness. We now know that social circumstances play a huge role in developing mental health problems. Research shows that while this increased understanding of biology leads to greater acceptance of professional help, it hasn’t really changed the attitudes towards people with mental illness.

A greater understanding of the social circumstances that we grow and live in – which expose us to risk or gather protection for our mental health – is needed. We cannot change this understanding unless our language evolves.

A collective responsibility

We need more efforts across society for everyone to be the change they’d like to see. We don’t need to wait until we get on the other end of the spectrum to change how we talk about mental health. And when it comes to talking, with great power comes great responsibility, so high-reach media should come on board this evolution.

Little by little, through citizen activism and a new generation of celebrities willing to open up about their own experience of mental health problems, our language is slowly catching up with the centuries of mystifying mental illness. We are now well beyond the times when we thought that if we locked up people experiencing symptoms we don’t understand, they might stop existing.

We know that mental health problems exist in our homes and communities, they are common and can be addressed through prevention, timely treatment and concentrated societal effort.

Addressing the crisis starts with talking about it in an appropriate way.

If you are feeling like ending your life or feel unable to keep yourself safe, please call 999 or go to A&E and ask for the contact of the nearest crisis resolution team. These are teams of mental health care professionals who work with people in severe distress. If you feel affected by the content you have read, please see our get help page for support.

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