Open Forum
Paying Attention to Language Mary V. Seeman, M.D.
Do we as mental health workers suggest by our language that patients are “other,” foreign, and different from ourselves? Do the terms with which we refer to patients reflect an unconscious attitude that they do not belong to “our set” and we do not belong to theirs? Do we stereotype our patients without intending to? By the words we use, do we intimate that whatever is wrong with our patients is a permanent flaw, a condition that will remain forever? These are the questions explored in this Open Forum. (Psychiatric Services 65:1164–1166, 2014; doi: 10.1176/appi.ps.201400089)
T
he 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, Dr. Seeman is with the Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada (e-mail: mary.seeman@ utoronto.ca). 1164
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 serPSYCHIATRIC SERVICES
vices. 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,
' ps.psychiatryonline.org ' September 2014 Vol. 65 No. 9
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 PSYCHIATRIC SERVICES
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.
' ps.psychiatryonline.org ' September 2014 Vol. 65 No. 9
It is difficult, but not impossible, to monitor and improve the way we speak (20). References 1. Carnaghi A, Maass A, Gresta S, et al: Nomina sunt omina: on the inductive potential of nouns and adjectives in person perception. Journal of Personality and Social Psychology 94:839–859, 2008 2. Speed E: Patients, consumers and survivors: a case study of mental health service user discourses. Social Science and Medicine 62:28–38, 2006 3. Heffernan K: Social work, new public management and the language of “service user.” British Journal of Social Work 36:139–147, 2006 4. McLaughlin H: What’s in a name: “client,” “patient,” “customer,” “consumer,” “expert by experience,” “service user”—what’s next? British Journal of Social Work 39:1101– 1117, 2009 5. Dickens G, Picchioni M: A systematic review of the terms used to refer to people who use mental health services: user perspectives. International Journal of Social Psychiatry 58:115–122, 2012 6. Gardiner M, Radian E, Neiman A, et al: Declaring label preferences: terminology research in mental health. Canadian Journal of Community Mental Health 30:121– 137, 2011 7. Reynaert CC, Gelman SA: The influence of language form and conventional wording on judgments of illness. Journal of Psycholinguistic Research 36:273–295, 2007 8. Mintz D: What’s in a word: the distancing function of language in medicine. Journal of Medical Humanities 13:223–233, 1992 9. Graf S, Bilewicz M, Finell E, et al: Nouns cut slices: effects of linguistic forms on intergroup bias. Journal of Language and Social Psychology 32:62–83, 2013 10. Sendén MG, Lindholm T, Sikström S: Selection bias in choice of words: evaluations of “I” and “we” differ between contexts, but “they” are always worse. Journal of Language and Social Psychology 33:49– 67, 2014 11. Wigboldus DH, Semin GR, Spears R: How do we communicate stereotypes? Linguistic biases and inferential consequences. Journal of Personality and Social Psychology 78: 5–18, 2000 12. Semin GR, Fiedler K: Cognitive functions of linguistic categories in describing persons: social cognition and language. Journal of Personality and Social Psychology 54:558–568, 1988 13. Rodin MJ: The informativeness of trait descriptions. Journal of Personality and Social Psychology 21:341–344, 1972 14. Beukeboom CJ, Finkenauer C, Wigboldus DHJ: The negation bias: when negations signal stereotypic expectancies. Journal of Personality and Social Psychology 99:978– 992, 2010
1165
15. Sekaquaptewa D, Espinoza P, Thompson M, et al: Stereotypic explanatory bias: implicit stereotyping as a predictor of discrimination. Journal of Experimental Social Psychology 39:75–82, 2003 16. Baratta AM: Revealing stance through passive voice. Journal of Pragmatics 41: 1406–1421, 2009
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17. Rosenman S: Metaphor, meaning and psychiatry. Australasian Psychiatry 16:391–396, 2008
19. Brink E, Skott C: Caring about symptoms in person-centered care. Open Journal of Nursing 3:563–567, 2013
18. Schoeneman TJ, Schoeneman KA, Stallings S: “I had emerged into light”: new sources and uses of metaphor of depression and recovery. Journal of Social and Clinical Psychology 23:354–358, 2004
20. Douglas KM, Sutton RM, Wilkin K: Can you mind your language? An investigation of communicators’ ability to inhibit linguistic bias. Journal of Language and Social Psychology 27:123–139, 2008
PSYCHIATRIC SERVICES
' ps.psychiatryonline.org ' September 2014 Vol. 65 No. 9
Paying Attention to Language Mary V. Seeman, M.D.
Do we as mental health workers suggest by our language that patients are “other,” foreign, and different from ourselves? Do the terms with which we refer to patients reflect an unconscious attitude that they do not belong to “our set” and we do not belong to theirs? Do we stereotype our patients without intending to? By the words we use, do we intimate that whatever is wrong with our patients is a permanent flaw, a condition that will remain forever? These are the questions explored in this Open Forum. (Psychiatric Services 65:1164–1166, 2014; doi: 10.1176/appi.ps.201400089)
T
he 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, Dr. Seeman is with the Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada (e-mail: mary.seeman@ utoronto.ca). 1164
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 serPSYCHIATRIC SERVICES
vices. 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,
' ps.psychiatryonline.org ' September 2014 Vol. 65 No. 9
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 PSYCHIATRIC SERVICES
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.
' ps.psychiatryonline.org ' September 2014 Vol. 65 No. 9
It is difficult, but not impossible, to monitor and improve the way we speak (20). References 1. Carnaghi A, Maass A, Gresta S, et al: Nomina sunt omina: on the inductive potential of nouns and adjectives in person perception. Journal of Personality and Social Psychology 94:839–859, 2008 2. Speed E: Patients, consumers and survivors: a case study of mental health service user discourses. Social Science and Medicine 62:28–38, 2006 3. Heffernan K: Social work, new public management and the language of “service user.” British Journal of Social Work 36:139–147, 2006 4. McLaughlin H: What’s in a name: “client,” “patient,” “customer,” “consumer,” “expert by experience,” “service user”—what’s next? British Journal of Social Work 39:1101– 1117, 2009 5. Dickens G, Picchioni M: A systematic review of the terms used to refer to people who use mental health services: user perspectives. International Journal of Social Psychiatry 58:115–122, 2012 6. Gardiner M, Radian E, Neiman A, et al: Declaring label preferences: terminology research in mental health. Canadian Journal of Community Mental Health 30:121– 137, 2011 7. Reynaert CC, Gelman SA: The influence of language form and conventional wording on judgments of illness. Journal of Psycholinguistic Research 36:273–295, 2007 8. Mintz D: What’s in a word: the distancing function of language in medicine. Journal of Medical Humanities 13:223–233, 1992 9. Graf S, Bilewicz M, Finell E, et al: Nouns cut slices: effects of linguistic forms on intergroup bias. Journal of Language and Social Psychology 32:62–83, 2013 10. Sendén MG, Lindholm T, Sikström S: Selection bias in choice of words: evaluations of “I” and “we” differ between contexts, but “they” are always worse. Journal of Language and Social Psychology 33:49– 67, 2014 11. Wigboldus DH, Semin GR, Spears R: How do we communicate stereotypes? Linguistic biases and inferential consequences. Journal of Personality and Social Psychology 78: 5–18, 2000 12. Semin GR, Fiedler K: Cognitive functions of linguistic categories in describing persons: social cognition and language. Journal of Personality and Social Psychology 54:558–568, 1988 13. Rodin MJ: The informativeness of trait descriptions. Journal of Personality and Social Psychology 21:341–344, 1972 14. Beukeboom CJ, Finkenauer C, Wigboldus DHJ: The negation bias: when negations signal stereotypic expectancies. Journal of Personality and Social Psychology 99:978– 992, 2010
1165
15. Sekaquaptewa D, Espinoza P, Thompson M, et al: Stereotypic explanatory bias: implicit stereotyping as a predictor of discrimination. Journal of Experimental Social Psychology 39:75–82, 2003 16. Baratta AM: Revealing stance through passive voice. Journal of Pragmatics 41: 1406–1421, 2009
1166
17. Rosenman S: Metaphor, meaning and psychiatry. Australasian Psychiatry 16:391–396, 2008
19. Brink E, Skott C: Caring about symptoms in person-centered care. Open Journal of Nursing 3:563–567, 2013
18. Schoeneman TJ, Schoeneman KA, Stallings S: “I had emerged into light”: new sources and uses of metaphor of depression and recovery. Journal of Social and Clinical Psychology 23:354–358, 2004
20. Douglas KM, Sutton RM, Wilkin K: Can you mind your language? An investigation of communicators’ ability to inhibit linguistic bias. Journal of Language and Social Psychology 27:123–139, 2008
PSYCHIATRIC SERVICES
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