Paying Attention to Language

The term we choose when referring to a patient, whether it be “person with mental illness,” “client,” “consumer,” “service user,” “survivor,” “expatient,” “person in recovery,” “stakeholder,” “analysand,” or “person with lived experience,” implies an array of related attributes.

Adjectives versus nouns

Adjectives, when used to describe a person, refer to a single property, but nouns evoke a plurality. Linguists illustrate this principle with the example of “blond” (1). The adjective refers only to a hair color, whereas the noun “blonde” is linked to an aura of glamour, sultriness, and relatively low intelligence.

Nouns elicit these kinds of mental associations in congruence with learned, conventional stereotypes. The “person with mental illness” label, for instance, is associated in the minds of many people with constructs such as irresponsibility, unpredictability, unreasonableness, incompetence, and, often, danger and violence.

Agency

Speed (2) has argued that the term we prefer to use to describe a patient reflects the degree of agency we impute to that patient. The word “patient” suggests a passive person treated by a paternalistic, overprotective physician. “Patients” are people who meekly accept their diagnosis and submissively comply with the prescribed medical regimen. By contrast, the “consumer” is a person who knows how to shop around to obtain optimal care. “Consumers” may, on the face of it, accept the medical model of mental illness, but they try to reform the model from within. The most empowered is the “survivor,” but “survivors” use their agency to resist, rather than to pursue, care. “Survivors” reject the medical model altogether. They reject the idea of diagnosis, preferring to identify themselves through their symptoms—for example, as “voice hearers” or “perfectionists” or “mood swingers.” Instead of adopting medical language in their writings, survivors are more inclined to slide into the language of victimhood, favoring terms such as “oppression,” “exploitation,” and “inequality” (2).

Heffernan (3) is of the opinion that the term “client,” implying professional control over service seekers, has been replaced by “consumer of services” and “service user.” She has voiced concern over the interchangeable use of the terms “service user” and “user” because the latter has several different meanings in English, many of them derogatory—for example, “someone addicted to drugs” or “someone who takes advantage of others.” McLaughlin (4) pointed out that the term “service user” emphasizes only one aspect of a person’s life, that of being a customer in the marketplace of mental health services. From McLaughlin’s perspective, the term narrows the territory of the clinician-client relationship, confining it to the provision and receipt of a service. McLaughlin made the further point that “service user” leaves out a potentially large group of individuals who are unable or unwilling to access services but who nevertheless require them and who should, therefore, belong to the same linguistic category. This drawback, if indeed it is one, is shared by most terms referring to patients.

Preferences

Many attempts have been made to ask patients about the term they prefer or the term that describes them best. Dickens and Picchioni (5) screened 13,765 abstracts to systematically review this burgeoning literature and concluded that when at least four choices are provided, the two terms most often preferred are “patient” and “client.”

A growing professional consensus favors “person” language—“person with depression” (6)—and this terminology is recommended by both the American Psychological Association and the American Psychiatric Association. Psycholinguists Reynaert and Gelman (7) found that when a possessive phrase referring to a made-up illness—“he has baxtermia”—was compared with a phrase using a noun— “he is a baxtermic”—or an adjective—“he is baxtermic”—the possessive phrase was perceived as the least permanent of the three, the least essentialist, and, consequently, the least prone to stereotyping and stigma.

Mintz (8), however, had earlier argued that diseases are not entities that one can “have” and that, therefore, “person” language is inappropriate to illness. According to Mintz, diseases, including mental illnesses, are fluid processes that change over time, so that verbs rather than nouns more accurately capture their nature—for example, “Pat sobs, mourns, despairs” is more informative than “Pat has depression.”

In groups and out groups

An interesting linguistic observation is that we speak differently about people from “our own set” than we do about strangers. Graf and colleagues (9) studied nouns and adjectives that represent nationality and found that we say, “I am Polish” but “She is a Pole.” The noun is used when we talk about “the other” and is associated with a greater tendency to typecast and to stereotype—for example, “I’m in therapy” (an adjectival phrase) but “She’s a patient.” Reynaert and Gelman (7) found that for their made-up illness (“he is a baxtermic” versus “he is baxtermic”), the noun always conveyed a sense of greater duration than did the adjective. Significantly, their research participants referred to mental illnesses with nouns (more permanent) and to general medical illnesses with adjectives (more transient). They expected mental illnesses to last, so they felt that the noun expressed it better. With respect to pronouns, linguists Sendén and colleagues (10) have shown that self-inclusive pronouns (I and we) are usually used in positive contexts, whereas self-exclusive pronouns (he, she, and they) more often appear in negative contexts. “We” emphasizes solidarity. “They” reflects social distance.

Concrete versus abstract

An important aspect of communication is the distinction between concrete and abstract terms. Verbs are more concrete than both adjectives and nouns, and the more abstract the term that is used to describe a person, the more the listener perceives the description as being permanent (11). Abstract constructs (and psychiatric diagnoses are cases in point), in addition to their assumed permanence, are by their abstract nature less verifiable than are concrete descriptions (of symptoms, for instance) and also more disputable (12). Symptoms may be transient, but while they are present, they can be verified and cannot be disputed. Being concrete, they are much more informative to listeners than are diagnoses (13).

Expectancy

Language also contains within it an expectancy bias (11). This refers to the observation that when a person does something unexpected or functions in an unexpected role, that fact is marked linguistically by the addition of an adjective—for example, “a female surgeon” versus simply “a surgeon.” Therefore, when a therapist says, “Pat’s a high-functioning schizophrenic,” it conveys the fact that high functioning is not expected of a person with this diagnosis.

There is more than one linguistic marker for the unexpected. Negation is another (14): “Pat has schizophrenia but is not violent.” “Pat is autistic but not stupid.” Introducing the negation suggests that violence or stupidity are to be expected. Circumlocutions and unnecessarily long sentences are further markers of inconsistency with stereotype (15). For example, a psychologist who is proud of his patient who has graduated from university might say, “The person with schizophrenia, Pat, whom I told you about, who had such a hard time in school but worked hard and got a lot of help from disability services at the university and I wrote letters for, got his degree.” It is evident from the circumlocution that this clinician never expected Pat to graduate. Through such linguistic markers, a stereotypic view of the person is, in fact, being transmitted more strongly than if one simply said, “People with schizophrenia do not function well, can be violent, and are very unlikely to get a university degree.”

Active versus passive voice

Another way of stereotyping is to use the passive voice to describe the patient’s experience—for example, the patient is overwhelmed, unbalanced, burdened, buffeted, blocked, broken, or possessed by illness. This suggests that the patient is a passive victim with no power to fight off his or her illness (16). The active voice evokes a different picture: the patient struggles, spins, falls, rises, overcomes, and recovers (17,18).

To sum up, in order to treat patients not as “other,” we need to be inclusive, not exclusive, to talk symptoms instead of diagnoses (19), and to use active-voice verbs to describe our patients, rather than adjectives and nouns. To avoid stereotyping, we need to avoid negation and circumlocution. It is difficult, but not impossible, to monitor and improve the way we speak (20).