A Phrase To Renounce For 2014: 'The Mentally Ill'

I wince every time I read it. So does the president-elect of the American Psychiatric Association, Dr. Paul Summergrad, he says.

I saw it most recently in The New York Times, in the headline pictured above and a recent masthead editorial: "Equal Coverage For The Mentally Ill." It's all over, from The Boston Globe — "New Era for the Mentally Ill" -- to The Wall Street Journal — "Crime and The Mentally Ill." Just about any media outlet you care to name.

What's so bad about "the mentally ill"? Isn't it reasonable shorthand in the usual headline space crunch?

In a word, no, says Dr. Summergrad, psychiatrist-in-chief at Tufts Medical Center and chair of psychiatry at Tufts University School of Medicine. He sees two main problems with it. First, the definite article, "the."

“Imagine if I said that about any other group. It suggests that people who suffer with these conditions are somehow other than us, and can be put in a discrete and often stigmatized category. It creates a sense of otherness that is not the reality, statistically, of these illnesses.”

Any other group? I try a thought experiment, the headline "Equal coverage for the women." Weird. "New era for the gays." Offensive. "Crime and the blacks." I get the point.

The term creates 'a notion that it's a uni-modal type of thing.  We need a more inclusive and more granular language.'

Second, Dr. Summergrad said, "there's the denotation of what mental illness means, but there's also the connotation. When people ask me, is it really possible that 25 percent of the population is mentally ill, what do they mean by that question?"

"That they think of it as something very extreme?'" I hazarded.

"Exactly, they mean that somebody has a form of very severe psychotic illness. But the reality is, what is a mental disorder? From a clinical standpoint, it means a disorder in various forms of mental functioning: thought, speech, emotion, behavior."

And those disorders are myriad and mixed and often of general medical origin, with a range of "everything from Autism Spectrum Disorders to Attention Deficit Hyperactivity Disorder, through Obsessive-Compulsive Disorder, anxiety disorders, post-partum depression, recurrent depressive illness, dementing illnesses which have profound effects not only on memory but on behavior. Parkinson's disease has high rates of very severe anxiety and depression."

So the term "the mentally ill" creates not just a notion of separateness and otherness, Dr. Summergrad said, but also "a notion that it's a uni-modal type of thing. And I think we need a more inclusive and more granular language."

I'd add a third argument against "the mentally ill," gleaned several years ago when I was writing a Boston Globe story about people who recover enough from their own mental illnesses to become "peer specialists" who help others with similar challenges.

Some newly minted peer specialists sat me down and re-educated me about the wrongness of using "the mentally ill" and the rightness of using "people first" language. A person is not defined by a diagnosis, they said. If you have a mental illness it doesn't define you any more than your heart disease defines you if you're a cardiac patient. A person is a person who happens to have depression or schizophrenia; the correct term is "people with mental illness."

That's the phrase I've used ever since, and I've come across "people first" language in other contexts. I once referred to patients as "diabetics" in a story about diabetes, but quickly converted it to "people with diabetes" when a specialist corrected me.

When I was writing recently about obesity and the increasingly widespread concept that it is a chronic disease, it made instant sense to me when advocates told me that I should write "people who have obesity" instead of "the obese" or "obese people."

Yes, "people first" language is less concise. But a couple of added words seem a small price to pay for according greater dignity to people facing extra challenges.

The Associated Press style guide, which is highly influential in journalism, moved a bit toward "people first" language last year. A summary notes:

The AP’s decision to stop using “illegal immigrant” is part of a larger shift away from labeling people and toward labeling behaviors. For example, the new entry on mental illness says to refer to people “diagnosed with schizophrenia” instead of “schizophrenics.”

Of course, there's an even bigger problem with "the mentally ill" — the whole use of the term "mental" — but it's too tough to solve with a couple of words.

Dr. Gene Beresin, executive director of Massachusetts General Hospital's Clay Center for Young Healthy Minds and a regular CommonHealth contributor:

"'Mental health,' in my view, reinforces the mind-body-and-environment split, and that is incorrect. Mental sounds like something ethereal, something out of body. We are creatures with minds, of course, but the illness is not mental, as few understand what consciousness is about."

Dr. Steven Schlozman, associate director of the Clay Center and also our regular contributor, adds: "I agree with Gene that it accentuates the Cartesian dualism that dogs our field." [Translation: Descartes saw the mind as non-physical, somehow separate from the brain.]

Also:

My beef with the term “mental health” in particular is that it is not well defined.  Is it a euphemism for “psychiatric?”  If so, why do we need a euphemism?  What’s wrong with saying “psychiatric”?  There’s nothing wrong with saying “cardiac”...Once the term has its own status as something different, we decide, without quite acknowledging it, that “mental health” is a euphemism for psychiatric health, and then psychiatric health necessarily becomes something culturally and even ontologically different.

The trouble, Dr. Beresin adds, is that "mental illness" tends to be stigmatized in a way that "medical illness" usually is not. He points out that medical illnesses generally have psychological and environmental components. "For example, high blood pressure is a combination of genetics (biology), stress, obesity, cigarette smoking and numerous other factors. So why don't we get upset when we hear 'he has hypertension?' The same argument should be made for so-called 'mental illnesses.' Post-traumatic stress disorder, for example, may be a result of a genetic vulnerability to anxiety, being trapped in a war zone, or being a survivor of a hurricane."

"Virtually all illnesses have biological, environmental and psychological components. We could say the same for migraines, ulcers, asthma or diabetes. But it does not make one feel uneasy if we say, "He has asthma.' On the other hand, 'He has depression or obsessive-compulsive disorder feels so very different. Is that because it is labeled 'mental?' Certainly. 'Mental' is an arbitrary negative label that segregates something psychic, personal or 'in the head' from the body and the environment. It also is very scary."

Scary? Scarier than heart disease? In a way.

"This is because of the myth that it is not treatable," Dr. Beresin says. "And that is certainly false. We have as good results as treating hypertension overall (considering medications, diet, exercise and stress reduction measures.) And the biggest horror is 'losing one's mind.' This, I think, is a fate worse than anything short of death. Once we separate mind, body and environment and believe the myth of losing one's mind, the myth of 'mental illness has its perpetual fuel.'

To which I would respond: Well, we don't want to fuel a myth, but where are we left? If psychiatrists themselves say "mental illness" and "mental health" are less than optimal terms, what words are we to use? Readers?