A few weeks ago, I read a tweet from Dr. Javeed Sukhera about terminology and mental health.
The tweet had ‘gone viral,’ and it’s stayed in my mind since then.
Next time someone says "mental health" what if we took out "mental" and just said "health?"
"I need time off for my health."
"I need to take care of my health."
"My (insert relationship) is struggling with their health."
"I work in community health"#mentalhealthishealth
— Javeed Sukhera MD PhD (@javeedsukhera) April 26, 2019
As you can see, this tweet received thousands of likes and hundreds of replies. I’m a fan of this way of thinking (and discussing and writing about) the constraints and affordances of specific terms, in specific contexts of use.
As a literacy and language person, the question I see implied in Dr. Sukhera’s tweet is: in the context of everyday conversations, can the term mental in the phrase mental health stand in the way of our recognizing mental health as connected to health overall?
Many providers I have met recognize their responsibilities to all patients, as well as the challenges and promises of reducing health disparities. And they want to grasp their opportunities to grow in this arena.
May is National Mental Health Awareness Month. And I’ll suggest there are some steps you can take today, to help you be aware of the terminology you use around mental health.
Removing obstacles
When I’m teaching a course or giving a workshop, I’m a big fan of removing obstacles. I ask myself, “Is there any way to make it easier for someone to take one step from where they are now? To move a little closer to their hoped-for goal?” And then, together, we get to work removing some obstacles.
This can take different forms. For instance, say your goal is for your organization to have better representation from different groups at its regular meetings. I’ve written before about how changing the time or location of these meetings can remove an obstacle to participation.
Another goal might be to educate a patient about a condition or course of treatment. When they’re in the clinical encounter, patients can be paying attention to any number of people and thoughts, and emotions can run high. So to get around those obstacles to learning, I’ve advised giving patients materials with multimodal options to take home and share with others.
In the case of mental health, if the goal is shifting the tide on the stigma around mental illness, it seems one obstacle could be the words we use.
More specifically, providers may be using words unintentionally that suggest or reinforce negative attitudes and assumptions toward
- patients, clients, or families;
- treatment;
- or the nature of mental health.
And you may be doing this without knowing it.
Starting with stereotypes
Stigma may be at their most harmful when they exist within patients, toward themselves. As I see it, disrupting this process is one of the implied purposes behind any research on stigma in mental health.
Several recent studies analyze specific language use in relation to mental health stigma. I’ll use these studies as illustrations of different ways it’s possible to step back and analyze language-in-use in everyday contexts. And then I’ll relate it to how providers can take a look at their own words and phrases, around mental health.
This first study is helpful, as it draws attention to how stereotypes find expression in ordinary language and everyday activities. Gaming With Stigma: Analysis of Messages About Mental Illnesses in Video Games studies video game playing “as a daily activity for many youths that replaces other media forms (eg, television); it serves as an important source of knowledge and can potentially impact their attitudes and behaviors.”
The researchers intentionally based their keyword search on what we might consider stereotypical terms for mental illness, using words such as “asylum,” “insane,” “crazy,” “mad,” “madness,” “mental,” “psycho,” “psychotic,” “psychosis,” and “schizophrenia”’
The researchers found that
The majority of the games we reviewed (97%, 97/100) portrayed mental illness in negative, misleading, and problematic ways (associating it with violence, fear, insanity, hopelessness, etc).”
Overall, many game elements “perpetuated well-known stereotypes and prejudices.”
Now I’m not suggesting anyone here is using terms in their practice like these researchers used in their study. Let’s take another step.
Going beyond overtly negative terminology
Language is not always so blatant as the keywords from the video game research. There are subtler ways that language can signal negative attitudes.
I’ve written before about the subtle harms done by microaggressions. An important takeaway is that microaggressions can be uttered by people, aimed at those they love. The same may be said here. Stigma are reproduced and maintained even between romantic partners.
That is to say, you don’t have to hold negative views of mental illness, or people with mental illness, to use terminology with negative associations.
Another recent linguistic analysis of the language of mental health stigma—this time, in UK media–provides a helpful example of how stigma can hide.
In Stigma: a linguistic analysis of the UK red-top tabloids press’ representation of schizophrenia, the researchers “explored the language used in popular national newspapers when writing about schizophrenia and considered how this may have contributed to the processes of stigmatisation towards people with this diagnosis.”
Whereas the video game study focused on overtly negative language and its ability to contribute to stigma, this study found that
while the press has largely avoided the use of words that press guidance has steered them away from (e.g. ‘schizo’ and ‘psycho’), they still use a range of graphic language to present people with a diagnosis of schizophrenia as frighteningly ‘other’ and as prone to violence.”
This range of graphic language nonetheless may contribute to stigma, as the researchers conclude:
“This repetition of negative stereotypical messages may well contribute to the processes of stigmatisation many people who experience psychosis have to contend with.”
This study is one of several that draw attention to linguistic frames, which work indirectly and by association. Here is another study that found “framing can serve as a tool in creating anti-stigma messages.”
What might this have to do with providers?
It’s possible that part of the challenge lies in how hard it is to notice the words and phrases we’re actually using (versus what we think we’re saying). This is partly because of the ways we use words and phrases in real life, whether in a personal or professional context.
This social nature of language is part of its power and complexity. We tend to be on an autopilot of sorts; we use the words and phrases we’re used to using, and those used by the people around us.
Our workplaces have ways of naming and defining
- The terms we use
- The concepts we are concerned with
- The causes we ascribe to particular factors (see Street, 2011)
Beneath the surface of every aspect of health policy and practice are particular configurations of values, ideals, beliefs, and priorities.
So I’m inviting you to look beneath the surface. Specific bits of language—words and phrases–work their ways into and through our various professional and personal contexts. They come out of our mouths. They land in our policies (where they then wield even more power).
And even as well-intentioned people, we might be saying things we’d consciously disavow. This has been my professional and personal experience for nearly 20 years, and it’s the journey of a lifetime.
Being aware of, catching, and then replacing language can help your words flow from your values. As I’ve said before,
Since language is powerful enough to contribute to health disparities, I suggest it is powerful enough to reduce them.
Let’s contribute to shifting the tide on the stigma around mental illness.
What you can do today
- Consider the values implied in your words, examples, and explanations. And be ready to make some changes, and advocate for others.
- Study the positive in your practice. What have you said that helped? Maybe you opened a conversation? (Silence and listening count, too). Share with your colleagues.
I’ll assert that no one, including me, can ‘empower’ you to respond appropriately to the myriad differences among attitudes toward health—mental and otherwise—you will encounter across your whole professional career.
What makes more sense is for you to bring to your practice an awareness of different possible responses or values to mental health that might relate to your patients, your students, your research, and your organizational commitments.
Then allowing yourself to pay attention to your language.
You can interrogate your terms and phrases—including the assumptions beneath them. Then, it’s down to you, to choose the appropriate words and actions for your specific context.
This process can be aided and supported with expert help, outside information, and additional resources. And, I highly recommend, a community of practice.
