For years I’ve planned to write a scintillating review of the words and phrases I now, as a wise and mature adult, refuse to use. The “c-word” (expelled in 1976) and “r-word,” (out forever in 1980), and “n-word” (never used) are notable, but they’re old and tired targets that most self-respecting people in the 21th century have also banished.
BTW, I got rid of tireless in 1988 (who doesn’t get tired, especially after the birth of a child, an all-nighter, or a long day’s work?). On a related note, I got rid of countless in the early 1980s, when, while studying statistics, it became obvious to me that everything was countable, unless you got too tired or too lazy to do the counting. But, even then it didn’t make much sense to just stop counting or to lose track and suddenly declare something countless. More than anything else, the word countless struck me as lazy. I would go with the lazy explanation for countless were it not for the fact that I also eliminated lazy from my vocabulary about 15 years ago when I read about Alfred Adler’s description of people who are lazy as not lazy, but instead people whose goals are beyond their reach and consequently, they experience discouragement (and not laziness).
More recently, I’ve grown weary of “the new brain-science” (how can it be that the media continues to refer to science from the 1990s as perpetually “new” but somehow the pleats in my pants have become so “old-fashioned” that I can no longer wear them in public?). On a related note, neurocounseling and neuropsychotherapy would be on my list for potential banishment, but because they’re new terms that people invented (along with polyvagal), purely for marketing purposes, they can’t be banished, because quite conveniently, I refuse to acknowledge their existence.
All this silly ranting about words makes me sound like a crank—even to myself. But as I get older, I find that worries over sounding like a crank are, in fact, more motivating than worrisome. Indeed, I’m embracing my intellectually snooty crankiness as evidence that I’m fully addressing the crisis inherent in Erik Erikson’s seventh psychosocial developmental stage: Generativity vs. Stagnation. Yes, that’s right, instead of stagnating, I’m cranking my generativity up to a level commensurate with my age.
In contrast to all these aforementioned banished or unacknowledged words, most people (who are otherwise reasonably intelligent) continue to use the term mental illness. As a consequence, the words mental illness have now risen to the coveted #1 spot on my billboard of eliminated words.
My preoccupation with avoiding term mental illness isn’t a news flash, as my University of Montana students would happily attest. For well over a decade, I’ve been explaining to students that I don’t use the term mental illness, and warn them, with what little roguish power I can muster, that perhaps when handing in their various papers throughout the semester, they also, at least for the time being and so as to not irritate their paper-grader, ought to follow my lead.
In my social life, whenever mental illness comes up in conversation, I like to cleverly state, “I never use the term mental illness unless I’m using it to explain why I never use the term mental illness.” This repartee typically piques the interest (or ire) of my conversational cohort, usually stimulating a question like, “Why don’t you ever use the term mental illness?”
“Wow. Thanks.” I say. “I thought you’d never ask.”
Three main cornerstones form the foundation for why I’ve made a solemn oath to stop privileging the words mental illness. But first, a tangential example.
This morning, once again, I’m awake at 3:30am, despite my plan to sleep until 7:00am. I know this awakening experience very well; I also know the label for this experience is insomnia, or, more specifically, terminal insomnia, or more casually known as, early morning awakening.
After this particular early morning awakening, I briefly engaged in meditative breathing until my thoughts crowded out the meditation. Having thoughts bubble up and crowd out meditative breathing is probably a common phenomenon, because neurotic thoughts, spiritual thoughts, existential thoughts, and nearly any thoughts at all, are nearly always far more interesting than meditative breathing.
A favorite statement among existentialists is that humans are meaning makers. As with many things existential, the appropriate response is something my teenage clients have modeled for me, “Well, duh.” Channeling my ever-present inner-teen, I want to respond to my inner-existentialist with a pithy retort like, “Yeah. Of course. Humans are meaning makers. Maybe we should talk about something even more obvious, like, we all die.”
What I find fascinating about the existential claim that humans are meaning makers is that existentialists always say it with gravity and amazement, as if being a meaning-maker is a profoundly good thing.
But, like life, meaning-making is not all good, and sometimes, not good at all. As I lay in bed along with my early morning awakening, it’s nearly impossible not to begin wondering about the meaning of the dream that woke me up (there was a broken anatomical bust of Henry David Thoreau in a small ocean-side creek at Arch Cape, Oregon); even more engaging however, is the so-called lived experience of terminal insomnia, and so my middle-of-the-night dream interpretation gets pushed aside for a more pressing question. “What’s the meaning of my regular waking in the middle of the night?” My brain, without consent, calls out this question, in an all-natural and completely unhelpful lived meaning-making experience. The explanations parade through my hippocampus: Could my awakening be purely physiological? Could it be that I missed my daily caffeine curfew by 30 minutes? Perhaps this is the natural consequence. But if so, why would I awaken now, after falling asleep as my head hit the pillow and sleeping for 4½ hours, instead of having a more easily explained experience of initial insomnia.
Of course, the most common explanation for early morning awakening is neurochemically filed in my brain and easily accessible. Without effort, I recall that terminal insomnia is a common symptom of clinical depression. I’ve known that for about 40 years. Now, by 3:45am, the various competing theories have completely crowded out my breathing meditation and will settle for nothing less than my full attention.
Is my terminal insomnia simply a product of the half-life of caffeine, or a full-bladder, or primary insomnia? Or is it something even more malignant, a biological indicator of clinical depression? Do I have a mental disorder? Although that might be the case, after briefly depressing myself with the contemplation of being depressed, I also begin refuting that hypothesis. My memory of taking an online “depression” test emerges, along with my score in the mild-to-moderate depression range. I might have believed the online questionnaire result, had it not been conveniently placed on the website of a pharmaceutical company and had it not culminated in the message, “Your score indicates you may be experiencing clinical depression. Check with your doctor. Lexapro may be right for you?”
Given that I’m absolutely certain that Lexapro isn’t right for me, the pattern analysis and search for deeper meaning breaks down here. I am a meaning-maker. I woke up at 3:30am. Now it’s 4am and I’m still awake. So what? It happens. When it does, I like to get up and write. It’s productive time. My stunning meaning-making conclusion is my usual conclusion: believing that I have a mental disorder is unproductive; in contrast, believing that I’m creatively inspired to write at 3:30am is vastly preferable and consistent with what Henry David Thoreau would want me to do in this moment.
What does all this have to do with eliminating the term mental illness from the human vocabulary?
Mental Illness Lacks a Suitable Professional Definition
Mental illness is a term without a professional or scientific foundation. Even the American Psychiatric Association doesn’t use mental illness in its latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The World Health Organization doesn’t use it either. I pointed out this fun fact while attending a public journalism lecture at the University of Montana. I asked the journalist-speaker why she used “mental illness” when the American Psychiatric Association and World Health Organization don’t use it. Initially taken aback, she quickly recovered, explaining that she and other journalists were trying to put mental health problems on par with physical health problems. That’s not a bad rationale. Mostly I want mental and physical health parity too, but what I don’t want is an assumption that all mental health problems are physical illnesses and therefore require medical treatments. Besides, whenever people make up (or embrace) non-professional and scientifically unfounded terminology to further their goals, their goals begin to seem more personal and political and less pure. In the end, I don’t think it’s right to make up words to negatively classify a group of fellow humans.
A side note: The American Psychiatric Association and World Health Organization are not left-leaning bleeding hearts; they would happily use mental illness if they felt it justified. Back in 2000, the authors of the 4th edition of the Diagnostic and Statistical Manual explained their reasoning:
The term “disorder” is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as “disease” and “illness.” “Disorder” is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here.
Broadly, my first reason for refusing to use the term mental illness is that it’s not used in the definitive publications that define mental disorders. It’s too broad and consequently, unhelpful. If mental illness isn’t good enough for the American Psychiatric Association and the World Health Organization, it’s not good enough for me.
Mental Illness is Too Judgmental
When asked about diverse sexualities, Pope Francis summarized my second reason for not using the term mental illness. He famously responded, “Who am I to judge?” I love this message and believe it’s a good guide for most things in life. Who am I (or anyone) to judge (or label) someone as having a mental illness?
You might answer this question by recognizing that I’m a mental health professional and therefore empowered to judge whether someone has a mental disorder; I’m empowered to apply specific mental disorder labels (after an adequate assessment). Sure, that’s all true. But I also have a duty to be helpful; although the communication of a diagnostic label might be helpful for professional discourse, insurance reimbursement, and scientific research, I don’t see how it’s helpful to categorize a whole group of individuals as “the mentally ill.” Hippocrates founded medical science. His first rule was “Do no harm.” As fun and entertaining as diagnosing other people and myself may be, I’ve come to the conclusion that doing so is often more harmful and limiting than good.
Think about it this way. Would it be any LESS helpful for us to delete the words “the mentally ill” and replace them with “people with mental health issues?” I think not. But you can decide what fits for you.
To the extent that it’s helpful to individual clients or patients, I’m perfectly fine with, after an adequate collaborative assessment process, diagnosing individuals with specific mental disorders. I believe that process, when done well, can help. What I’m against is using a broad-brush to label a large group of fellow humans in a way that can be used for oppression and marginalization. Why not just say that everyone has mental health problems and that some people have bigger and harder to deal with mental health problems. As Carl Jung used to say, “We’re all in the soup together.”
Mental Illness Resists De-stigmatization
Mental illness and its proxies, mental disease and brain disease, are inherently, deeply, and irretrievably stigmatizing. I know several different national and local organizations that are explicitly dedicated to de-stigmatizing mental illness. My problems with this is that the words mental illness are already so saturated with negative meaning that they resist de-stigmatization. The words mental illness instantly and systematically shrink the chance for therapeutic change and positive human transmorgrification.
If you look back in time, you’ll find that mental illness was created by people who typically have a political or personal interest in labeling and placing individuals into a less-than, worse-than, not-as-good-as, category. The terminology of brain disease and brain-disabling conditions are even worse. What I’m wishing for are kinder, gentler, and less stigmatizing words to describe the natural human struggle with psychological, emotional, and behavioral problems. If you’ve got some, please send them my way. I need help in my tireless efforts to let go of my crankiness and embrace hope, especially when I wake up in the middle of the night.
5 thoughts on “The End of Mental Illness, Part I”
Hi John, many thanks for a very interesting article. If I could just comment on a couple of points you raise:
I find that insomnia has become so common a topic amongst my patients and friends as to warrant further investigation. I’ve questioned everything about my own and my partner’s insomnia: diet, caffeine etc. My conclusion is that it is likely wifi and microwave related. Our sleep improved somewhat when we stopped using wifi. But we are bombarded by digital phone signals, neighbour’s wifi, and the coming 5G promises to be even worse news (see Dr Barrie Trower, microwave expert on youtube for more info).
I totally agree with you on the ‘mental illness’ subject. Its use also keeps people in the medical patient role, which can be very unhelpful in terms of recovery because as medical patients we tend to assume the position of 1. inferior to ‘expert’ direction and knowledge; 2. passive in our expectation that the expert will do something to us to fix us; 3. stay in the minset that we have a disease beyond our realm of responsibility. From a psychotherapy or personal growth perspective these can be real obstacles to overcoming our difficulties. As you mention, it’s also quite stigmatising for people.
Looking forward to reading more of your blog. All the best, Stephen
Thanks very much for sharing your perspective on insomnia and mental health/illness. My podcasting cohost is always harping on the screen-time wifi issue. . . and I think she’s right too. I hadn’t heard about the microwave issue and so I’ll check that out.
It sounds like we agree more or less completely on the mental health/mental illness language. My wish is for terminology that feels more empowering, more hopeful, and less stigmatizing.
I hope you’re doing great and sleeping well!
Thanks John, and you. All the best
John, I find this analysis very helpful, especially your concern about stigmatization and the tendency to treat mental distress as if it were a physical problem best addressed with a product. Thank you, once again.
Thanks Gary. I’ve struggled with the mental illness word for a long time. I know there are some people who find its use to be quite meaningful . . . but I worry about the political and marginalization function. And then when I think about the whole post-modern social constructionism perspective . . . then I worry that we’ve strengthened the concept of illness and weakened the concept of health. Lots to think about. I hope you and Joyce are doing great. We’re in Absarokee, but I hope to connect with you when we’re back in Missoula.