David Romprey walked up to me one day when I was in the middle of planning the next new 16-bed facility in a community setting for people who were in our state hospitals in Oregon. Progress was in the making.
He asked why I called these places 16-“bed” facilities. Answering matter-of-factly what seemed obvious, I replied that these residences, nicely furnished in pleasant neighborhoods, had 16 beds. Looking me straight in the eye, as he always did, David asked me, “Do you think we’re lying around prostrate all the time?”
“OK, David, you have me.”
And not for the first time with this incredible advocate who had once been locked up in a forensic hospital himself.
The words we use are important in shaping our view of the world, of people, and of residences. This got me thinking more about terminology and the many ways in which we in the field of mental health have seen “them” lying around prostrate all the time.
Let’s start with the distinct difference between a patient and a person. There is no doubt that many will protest that a patient role is exactly what gives dignity to time honored professional relationships. The doctor cares for her or his patients. What’s wrong with that? The answer for a changed paradigm would be that “patient” too often has meant a relatively passive role in which the professional treats, the patient receives. That leads to another distinction.
A raging debate brings another set of words to consider. Do people “suffer from a mental illness” or do they “recover from mental health challenges”? Is this all about a “chemical imbalance” or are what we’ve called mental illnesses more accurately understood as a “normal reaction to abnormal situations”?
When these words come up in discussions—which, in my opinion, are far too infrequent and usually heated–the defensive polarizations on both sides divide rather than open dialogues.
Do we diagnose rather than seek an in-depth understanding with each person of “what happened”? If we listen, we will hear many voices who feel they’ve experienced far more of the first and not enough of the second.
Are we seeking “stabilization” or “recovery?” Do people we’re listening to really have “Serious and Persistent Mental Illnesses (SPMIs)”? Are serious mental illnesses in contrast to comical illnesses? Do “Chronic Mental Illnesses (CMIs)” predict ongoing disability for everyone with a diagnosis of schizophrenia? The best long-term research on outcomes contradict this as a general rule. Even worse, should we refer to real people as “SPMIs” or “CMIs”? Do these terms impersonalize and discriminate? In my last professional positions before retirement, I asked staff to stop using these terms and reconsider them in favor of “people with mental health challenges” who are capable of recovery.
A person active in the process of recovery doesn’t fit very well the image conjured by the almost universal use of the term “consumer.” I still hear many people in the movement toward recovery refer to themselves as consumers. My hope is this will change—I keep visualizing a person’s wide open mouth just waiting to receive the next dispensation, or pill, or other forms of “treatment.” Is our work together all about “compliance” (with medications or other treatment)? Showing up for appointments? Reality for some who have crossed legal lines (usually as a result of alcohol and drug use) is that compliance is written right into diversion agreements to stay out of hospitals or jails or prisons. Aside from these circumstances, would we be better off thinking about “optimizing” medication or other forms of treatment?
For some time, advocates have objected to the term “case management” saying that they are not “cases who need management” with a strong preference again to be considered “people active in recovery.”
One could go on with contrasting terms: “Treatment plan” vs. “Recovery plan.” “Peer supports” vs. “group therapy.” “Auditory hallucinations” vs. “Hearing voices.” “X number of bed facilities” vs. “community residences for x number of persons.” Some of these terms we are going to have to use for various reimbursement and licensing purposes. But could we advocate at some point to revise Medicaid law to shift from “medically necessary” to “health necessity”? Could we be blunter about “stigma” really being a form of “discrimination”?
Finally, is anyone who is uncomfortable with the terms used in traditional and mainline psychiatry “anti-psychiatry”? My hope is that reflecting on the words we use will lead to a productive and ultimately progressive conversation and that we agree to disagree at times. But ultimately find our way toward evidence-based approaches to recovery.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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