WHAT’S IN A NAME
It was with a great deal of satisfaction that I recently noted that the sign in front of our mental health center announcing it to be a “Behavioral Health Care Center” had been removed. I have long held that such terms trivialize and obscure the problems facing those afflicted with mental illnesses. It is true that those illnesses provoke behavioral changes in many, but are we to treat the behavior or the illness responsible for the behavior? In a similar manner, if someone is choking, should we instruct him in relaxation exercises or proceed directly to the Heimlich maneuver?
The term behavior implies volition, and I seriously doubt anyone would choose to endure the suffering of a mental illness. It was initially used in reference to addiction and drug abuse, but now includes mental health for reasons beyond my understanding.
Most linguists agree that not only does thought affect language, but perceptions are affected by language. The latter scenario is in my opinion likely to affect how we think about mental illnesses and consequently those who are mentally ill. The one which is likely to raise my hackles the highest is the word client. For the past several years I have been on a mission to expunge that word from the vocabulary of anything having to do with treatment of Psychiatric patients. Not only have my efforts fallen short, I could not even influence the nurses who worked under my supervision to give up that vile word. Some seem to think that my abhorrence of the use of the word client to describe my patients is simply the bias of an old foggy MD, and I do confess to that charge.
My bias has to do with the origin and meaning of the word patient, which was from the Latin, patientem, which is roughly translated as “those who suffer”. My bias also extends to the belief that there is no more honorable profession on earth than the alleviation of suffering, and that those who suffer should be categorized differently than those who have a strictly business relationship. The mantra I have used for several years as follows: “accountant, lawyers, and hookers have clients, but we have patients” has fallen on deaf ears. The word client has been absorbed into every aspect of the mental health movement. The electronic medical record I used prior to my retirement referred to patients as clients. Likewise, the word is routinely used in communications from our state department of mental health. Even advocacy groups use the term.
In response to Shakespeare’s question, I suggest that there is a lot “in a name”. Granted, a name change does not change a rose; however if the rose is repeatedly referred to as a weed it might well change one’s opinion about roses. One might ask, how did emotionally suffering people seeking treatment come to be called clients. Advocates for the elimination of the stigma associated with mental illnesses frequently present them as analogous to other medical illness, such as diabetes, hypertension, heart disease etc, yet insist on using a non- medical term such as client to describe those in treatment. Besides, it makes no sense to separate psychiatric problems from mainstream medicine when studies of the brain now clearly demonstrate most if not all such illnesses to be due to medical disorders. Such separation of psychiatric problems from mainstream medicine has also given license for third party payers to discriminate by providing less coverage for mental illnesses, and undermines attempts to correct those inequities.
In my opinion the key to eliminating societal stigmatization is understanding, and I believe that it makes more sense to call a rose a rose and likewise to call one who suffers no matter the cause a patient. Some may feel it will lessen the stigma associated with mental illness to place it in a separate category from other medical problems; however I suggest the opposite to be true. Throughout history those suffering from any malady for which the cause was unknown would often be persecuted and shunned. As knowledge accumulated concerning the etiologies of such illnesses, there was less reason to fear and to blame them. Unfortunately, this understanding has been slow to develop in the area of psychiatric disorders. It is interesting to note that in Ancient Greece there was no distinction made between diseases of the brain and those of the body, but in the middle ages, discrimination and persecution was rampant as ignorance prevailed.
The brain is easily the most complex organ in the human body. We are said to have on average of 86 billion cells in our brain all of which have multiple connections to each other. It is little wonder that we have difficulty figuring out how it works and how to fix it when it goes off on a tangent. Many such disorders result in unusual if not bizarre behaviors which will often result in avoidance by others. In my opinion the research of the early part of the last century also placed undue emphasis on psychological factors to explain even the more serious illnesses. This can be laid at the feet of Freud, who although he made gigantic contributions to our understandings of human behavior, attempted to blame the more serious illnesses on childhood traumas. We now know that the schizophrenias, severe mood disorders, and such are due largely to genetic factors even though stress may expose one’s vulnerability. With the serendipitous discovery of drugs which appeared to have a positive effect on these illnesses, researchers set out to understand the mechanisms involved, and the science of neuroendocrinology was born. Although there have been exciting discoveries, we have barely scratched the surface.
There are many who find the renaming process advantageous. Insurance companies whose goal sometimes appears to involve denying as many payments as possible, generally substitute the term consumer for patient and provider for those who treat them. It raises the question, what is provided and what is being consumed? The obvious answer is their profits. It is no wonder they treat our patients and their doctors badly.
In a previous blog, I have said I think a shortage of physicians is a major source of our problems with the current medical system. Nowhere is this more apparent than in the field of psychiatry. As of 2013 there were 50,000 psychiatrists in the United States, and another 45,000 is needed according to a government survey. Since there is a heavier concentration in metropolitan areas it is obvious that the shortage is even more acute in less populated areas. With development of effective treatments this need is expected to expand.
Psychiatrists were the first to adopt the strategy of introducing “doctor extenders” to help fill the void.
Now many from these disciplines (social work, nursing, psychology, and counseling ) have become licensed to practice independently. Nurse practitioners in our state are now licensed to prescribe, and psychologists are attempting to gain the same privilege. I am told there is even a move underfoot to allow pharmacists to essentially practice medicine as we know it. Social workers and clinical counselors can now be licensed to practice independently. In short those physician extenders have in many cases become physician replacements. In my opinion, this phenomenon has also contributed to the use of non-medical terminology such as client, consumer, provider etc.
Psychiatric research as to the causes and effective treatments for mental illnesses has lagged behind other specialties, but we are now on the verge of taking giant steps in the right direction towards unraveling those mysteries. America has a checkered past in dealing with mental illnesses. Early in our history the traditions of incarceration, cruelty, punishment, and abuse common in European countries were carried over to the new world. Often their treatment was equal or worse than that inflicted on the worst criminals. Families also suffered since such illnesses were thought to be caused by character flaws, spiritual weakness, or demonic forces. It was frequently assumed that this indicated a failure on the part of the family which brought shame upon them. As a matter of fact the statement: “where did I go wrong?” is one I frequently heard from parents of my patients.
There have been valiant attempts to correct the stigmata, but none have had a long lasting effect. Dorothea Dix was the heroine who devoted her life to improving the lot of the mentally ill. In the nineteenth century largely through her efforts, so called asylums were constructed throughout the country with an emphasis on humane treatment. Lack of funding and/or interest allowed these facilities to deteriorate into what some called “human warehouses”, and there were reports of abuse and neglect. The cause was once again taken up by the civil rights movement of the sixties, and President Kennedy signed The Community Mental Health Act in 1963, which was designed to provide intensive, comprehensive treatment in local communities. There were funds allocated for the building of facilities throughout the country, many of which were not built, and state legislators were no more inclined to fund these facilities after the federal money ran out than they had been for their state hospitals.
Fifty years later, most mental health centers still in existence are under -funded and under staffed. Meanwhile although the stigma of mental illness may be lessened it is still with us as evidenced by the language we use to describe it, and how we treat its victims. True, we have liberated them from those awful state hospitals so that now they can live on the street or in jail.
It reminds me of the old Peter, Paul and Mary song “When will they ever learn?”