Visions Journal

How word choice shapes rights, responsibilities and power in mental health law and care

Iva W. Cheung

Reprinted from the "The Language We Use" issue of Visions Journal, 2018, 14 (1), p. 5

Psychologist and linguist Steven Pinker coined the term “euphemism treadmill” to describe the process by which a word or phrase that’s been introduced to replace an offensive term eventually becomes offensive itself.¹ We can find a fascinating—and perturbing—wealth of examples of the euphemism treadmill by diving into the history of mental health legislation.

In the UK, the Idiots Act (1886) made the clinical distinction between “idiots,” “imbeciles” and “lunatics.” This act was repealed by the Mental Deficiency Act (1913), which further classified people as “feeble-minded persons” or “moral imbeciles.” In 1930, the Mental Treatment Act replaced “lunatic” with “person of unsound mind,” which was itself replaced by “person suffering from mental illness” when the Mental Health Act came into effect in 1959.²

In BC, the Insane Asylums Act (1873) was the province’s earliest mental health legislation. It allowed physicians to commit people to institutions by issuing a certificate that read, “Such certificate shall be a sufficient authority to any person to convey the lunatic to the said Asylum, and to the authorities of to detain him therein so long as he continues to be insane.”³

Terms like “lunatic” and “imbecile” were meant to have specific legal and clinical definitions, but over time they migrated into the realm of casual, everyday use, where they were weighed down with stigma and fashioned into insults. Lawmakers faced the challenge of having continually to find new (and neutral) ways to describe people who needed mental health services.

More recently, those who receive and deliver mental health care have debated whether “patients,” “consumers,” “clients,” “self-advocates,” “people with lived experience” or another label is most appropriate for people who live with mental illness. Each label can be justified, but each also has weaknesses. “Consumers” confers agency and choice, but it also imposes a material, transactional flavour on the therapeutic relationship. “People with lived experience” acknowledges a person’s self-understanding and expertise, but it is also vague and redundant.

What sets these more recent discussions apart from more cringeworthy historical approaches (consider, for example, the 1961 School for Mental Defectives Act) is that we seem to have finally recognized the importance of calling people what they prefer to call themselves. Not only do labels hold power, but the one doing the labelling also holds power. Ensuring that people have the opportunity for self-identification and self-determination is a first step towards redressing the power imbalance resulting from centuries of social, cultural and political marginalization of people with mental illness.

A power imbalance between health care providers and patients exists almost everywhere, but in the realm of mental health care, patients (or service users) are also at the mercy of the state’s considerable power. For instance, BC’s Mental Health Act gives doctors the authority to detain a person with a mental disorder in hospital and give them psychiatric treatment against their will. I won’t delve into the debate about involuntary hospitalization (certification) here, but in my research interviews with people who’ve been certified, even those who felt that they ultimately benefited from their hospital stay have said that it was more dehumanizing than it needed to be. I think the language a person encounters while they are in the hospital plays a huge role in the experience.

Involuntary patients have to navigate a world of medical jargon and legalese. Unnecessarily complex language—especially in the fields of medicine and law—tends to confuse and exclude, reinforcing the power imbalance between those who provide care and make the laws and those seeking help. One of the easiest ways to make someone feel small is to use a word they don’t understand.

My doctoral research at Simon Fraser University focuses on how certified involuntary patients under the Mental Health Act are informed about their rights. When they are admitted to the hospital, involuntary patients are supposed to be given a government-issued information sheet (Form 13) about their rights. Whether that form is effective in communicating those rights to people with lived experience of certification had never been tested; that became one of my first areas of study.

My interviews and usability tests found that many people were confused by the bureaucratic and legal language on the form; they came away with misconceptions about what they could and couldn’t do as involuntary patients. But more important than the lack of clarity was how the language of the form made people feel. Some of my interviewees said that the unfriendly tone and wording (such as “you are a person with a mental disorder”) made them feel powerless, defective and alone. Legal terms like habeas corpus were intimidating and, in some cases, may have discouraged patients from asking about or exercising their rights.

Using plain language—clear, everyday terms and a conversational style—to explain mental health rights to involuntary patients may help level the playing field. Beyond being the ethical thing to do,⁴ ensuring that involuntary patients better understand their rights can have an important therapeutic effect. It can give them a sense of agency and self-determination, which may help engage them in their own recovery, however they want to define it.⁵

Plain language is only one part of the more general movement towards accessible and inclusive language—one that asks us to be mindful of whether the words or phrases we use without a second thought could in fact be stigmatizing towards particular minority groups, like people of colour, people with disabilities or people with mental illness.

This movement is not without critics, many of whom believe we’ve taken political correctness too far. For example, would you ask someone to stop saying “I have an insane amount of work to do” or “It was crazy fun”? One might argue that these sorts of descriptions are so widespread, so frequently used as generic intensifiers in non-offensive contexts, that policing this kind of usage is an overreaction. But when we use “insane” or “crazy” to describe something overwhelming, chaotic or irrational, aren’t we reinforcing stereotypes about mental illness?

I try to ask people affected by mental illness what terminology they’d prefer, but because they are a diverse group, my questions sometimes lead to interesting tensions. For example, many people prefer “person first” language, which emphasizes the human and doesn’t define them by the illness. Within this framework, someone is “a person with schizophrenia” rather than “a schizophrenic.” Others, such as those in the Mad Pride movement, have pushed back, embracing their differences by using “identity first” language, reclaiming labels like “mad” and “crazy”—much the same way that the LGBTQ2S+ movement has reclaimed the word “queer.” As this comparison shows, words that are empowering to some may be hurtful to others.

Language will evolve as connotations change, and we may never find terms that work well for everyone at the same time, but we have to keep critically examining our word choices when we talk about mental illness. Our only hope of stopping the euphemism treadmill is to stop the stigma that powers it.