Challenging thoughts from a psychiatrist
Reprinted from the "The Language We Use" issue of Visions Journal, 2018, 14 (1), p. 32
I am a psychiatrist.
Has that put you off already? Do you assume or know what I’m going to say? Or what I’m going to do or think? Or what I’m wearing and what my voice sounds like?
In my experience, the language we use to discuss mental health issues shapes how we see ourselves and our experiences. That’s one of the underlying principles of a course called “Living Life to the Full” (LLTTFTM), a cognitive-behavioural therapy (CBT) approach to living a resilient life, which I and colleagues have developed over the past 15 years and which is now being used across Canada by the Canadian Mental Health Association (CMHA). One of the focuses of the approach is on the importance of language in our view of self and our personal well-being.
For example, we can label ourselves as “distressed,” or we can think of ourselves as “mentally ill.” Perhaps we “want help” or we think we “need a diagnosis.” Maybe we “have a problem” or perhaps we “face a challenge.” Do we have “symptoms” or do we have “personality traits”? Do we “want support” or do we “need treatment”?
Many discussions of mental health and well-being involve technical jargon and a terminology of diagnosis. In contrast to physical disease, the stigma surrounding mental health issues often leads us to use a judgemental language when it comes to our own mental health and the mental health of others. This can also affect how we understand and access the health care system. Even my title of “psychiatrist”—and whether I “am” a psychiatrist or simply “work as” a psychiatrist—influences how people see me and the help I can offer.
When something goes wrong with our physical body, we often address the issue quickly. While it’s human to avoid things that seem difficult or scary, many physical health problems feel straightforward and relatively easy to deal with. For example, if you went on holiday and broke a leg, you would probably not think twice about getting hospital treatment, and you would probably tell friends and family all about it when you came home. Most people would—all the while complaining about the pain and the hassle, how we couldn’t find our insurance documents and how long the emergency-room wait was.
Yet when it comes to our mental health, we are often less likely to seek help. We know that over 50% of people facing marked distress at a level that a psychiatric diagnosis could be made never go near the health care system. That figure is fairly constant across many countries and continents.1
Let’s say, for example, it wasn’t your leg that broke on holiday, but your ability to cope. Perhaps you experienced a panic attack for the first time or felt so depressed or scared that you ended the holiday early and returned home. Would you tell family and friends what had happened as freely as you might have shared news about a leg fracture? Perhaps not. That sort of reticence is often the result of the stigma that characterizes our own concerns and society’s views of mental illness and mental health supports.
One would hope that in these enlightened times it would be easier to have frank, open and supportive discussions about mental health and well-being. In some ways, it’s easier than it once was, but in spite of national and local anti-stigma campaigns, stigma still has the power to influence our perspectives—and it remains one of the primary reasons that people fail to access mental health services.2
In the UK, where I work, the Asylum Acts of the 19th century set the groundwork for establishing a number of mental asylums. Initially intended as places of safety (literally, places for people seeking asylum), they also had unintended effects. The large, imposing buildings were generally constructed at the end of impressive, often tree-lined drives with a 45-degree bend in the middle. Members of the wider community passing the entrance to the asylum wouldn’t be able to see up the drive to the building. When an individual was admitted to the asylum, he or she would, quite literally, go “round the bend,” away from the rest of society.
Such history plays a significant role in our perceptions today. Many people would, I suspect, experience more internal resistance to the idea of seeing a psychiatrist than to the idea of seeing a podiatrist. That internal resistance may be reinforced externally as well, in the form of negative comments from family and friends. Even when someone does decide to seek mental health care, there are other barriers to receiving treatment. Again, one of the foremost of these is language.
One of the hallmarks of any profession is a dedicated, complex and often technical language. Doctors, psychologists and therapists of all sorts often spend years learning that specialist language. Among other things, it helps them demonstrate their knowledge, training and experience—a knowledge and experience that can justify salaries and specialist roles. Yet that same language can also potentially create barriers to accessible care.
For example, practitioners of cognitive-behavioural therapy use the abbreviation “CBT” freely. Yet to others, “CBT” may mean “Chicago Board of Trade,” perhaps, or “computer-based training” or (for a computer programmer) “closed beta test.” Even if someone knows the term “cognitive-behavioural therapy,” how many people today regularly use the word “cognitive” to discuss their own thinking? Instead, we talk about “worries,” or things being “on our mind.” “Cognition” and “CBT” have specific meanings in the context of mental health care.
Other terms widely used in the context of CBT reinforce this. Certain thoughts and beliefs are redefined as “negative automatic thoughts,” “schemas” or “dysfunctional assumptions.” Our worries may show “dichotomous reasoning” or “selective abstraction.”
Each term describes an element of the experience of people in distress. They are helpful in discussions about theoretical models of anxiety and depression and essential for research, diagnosis and effective communication amongst practitioners. But they are not part of most people’s everyday vocabulary, and they can represent a barrier in discussions between practitioners and non-practitioners, who may not have the same contextual understanding of the language. When practitioners use them to describe an individual’s personal experience, they may inadvertently discourage that individual from taking the opportunity to engage personally in his or her mental health care.
Not all health practitioners use exclusively specialist terminology. Most health workers know the importance of using more accessible language and adjust their communications as a result. So, when someone with low mood struggles to live life as they did before, they may not enjoy things as much as they used to, and they may sleep poorly and feel exhausted. Some practitioners might use the specialist term “negative reinforcement” to describe the general reduction in activity levels that results from these sorts of circumstances. But other practitioners know that it’s far easier to discuss an individual’s experiences if they talk about how “it’s such a relief not to have to do things that seem such a struggle.”
Similarly, practitioners can identify a vicious cycle of reduced activity, or we also explain to the client that this describes a common human experience—in which the less you do, the worse you feel, and the worse you feel, the less you do—a situation that is familiar to many of us.
This way of working underlies the Living Life to the Full approach. The power of the CBT model is in its capacity to help people work out why they feel the way they do. This understanding is essential for enabling people to take control of their experiences and make changes to improve their quality of life.
Ensuring that CBT is a tool that everyone can use is central to how I like to think and work. I’m passionate about ensuring that the language we use in CBT is assessible to everyone. It’s hard enough to make changes in our lives when low mood or stress occurs, without having to spend significant time learning a lot of technical terms. Far better to focus our energies on the process of positive change. Using accessible, everyday language also has the benefit of normalizing common problems such as depression/low mood and anxiety/stress and other mental health problems; they are common human experiences that can affect anyone. This normalization helps to reduce the stigma as well.
It has been a privilege working with CMHA on the LLTTFTM initiative. The organization shares that passion to ensure equal access to help and support for all. The organization also recognizes the power of language to engage people or to push people away. The LLTTFTMcourse encourages individuals to ask questions of themselves and others so they can experience those “a-ha” moments—moments of insight that help us recognize and understand what is going on inside or outside ourselves.
The Living Life to the Full approach also understands that people learn in different ways—through books and reading, by attending classes or by working online. Course materials are designed to be visually inviting, and they also use humour to keep users engaged. People can choose how they want to learn, working on change at their own pace with support from a coach.
In short, the Living Life program at CMHA aims to help people live life to the full. Who wouldn’t want that.
To learn more about Living Life to the Full courses or booklets available across Canada in English and French, and with adaptations for youth and older adults, see www.livinglifetothefull.ca.
About the author
Professor Williams is Emeritus Professor of Psychosocial Psychiatry, University of Glasgow, UK, Director of Five Areas Limited (www.fiveareas.com) and President of the British Association for Behavioural and Cognitive Psychotherapies. His main work is in the development and evaluation of CBT approaches, including the Living Life to the Full resilience course
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Stuart, H. (2016). Reducing the stigma of mental illness. Global Mental Health, 3, e17. http://doi.org/10.1017/gmh.2016.11.