Medicine Policy Reading Systems

The Word is Not the Thing, And…

This past week I finished reading McCloud’s Understanding Comics: The Invisible Art.[1. I purchased Understanding Comics to learn a different perspective about storytelling. I am not a routine reader of comics. Regardless, I do recommend this book. It is a thoughtful and fun read, and it’s a comic book.] The second chapter, “The Vocabulary of Comics”, reiterates a major point in Hayakawa’s Language in Thought and Action:

The first of the principles governing symbols is this: The symbol is NOT the thing symbolized; the word is NOT the thing; the map is NOT the territory it stands for.

McCloud uses René Magritte’s “The Treachery of Images” to welcome the reader to “the strange and wonderful world of the icon”:

I’m using the word “icon” to mean any image used to represent a person, place, thing or idea.”

This idea that “the word (or icon) is not the thing” is relevant to a recent opinion piece, “Beware the Word Police“, in the academic journal Psychiatric Services:

Frequent calls for changing diagnostic labels to decrease stigma may result in unintended consequences. Condemning incorrect language by policing word choice oversimplifies the depth of work involved to increase opportunities for people with mental illness. This Open Forum reviews three unintended consequences of using scolding language.

The author of that opinion piece, Patrick Corrigan, lists these three unintended consequences:

  1. the word police’s focus on “just changing terms” misrepresents the depth and persistence of bias and bigotry
  2. word police are a major barrier to the essential goals of stigma change
  3. word police may undermine stigma change at the policy level

I’m One of Those People who avoids using the words “addict”, “schizophrenic”, or “diabetic”. I instead say “individual with a substance use disorder”, “person with a diagnosis of schizophrenia”, or “someone with diabetes”.

While I agree with all the authors above—words and icons aren’t the thing, they only represent the thing; the use of different words does not equate to actual reduction in discriminatory behaviors—I also believe that, as a society, The Royal We have come to agree that certain words have certain meanings.

For example, if I describe a person as a “diabetic”, what comes to mind? Perhaps you think of a family member who has diabetes and has excellent management of her blood sugars. Maybe you think of the person who goes to the emergency department multiple times a month due to high blood sugars and non-healing wounds. Or maybe you’re thinking about the growing number of people who struggle to pay for insulin to treat their diabetes. The range of ideas that come to mind with the word “diabetic” is broad.

But if I say someone is an “addict”, what comes to mind? Maybe you think of a senior vice president of a major business who wears tailored suits, but most people don’t. When I teach and ask audiences—comprised of health care professionals or otherwise—to list what comes to mind when I say “addict”, the list always includes things like

  • dirty
  • mean
  • desperate
  • selfish
  • etc.

(When the audience is comprised of health care professionals, I remind them that, right now, they are likely working with someone with a substance use disorder… and that person won’t disclose how much s/he is suffering because they feel shame about the presumed characteristics of “addicts”.)

It is true that the word “addict” is NOT the person with a substance use disorder. However, we, as a society, have somehow arrived at the agreement that the word “addict” describes someone who is dirty, has no self-control, etc.

Even though a different word doesn’t change the actual thing, the different word can change the idea about the thing. A different word can have a different definition, different associations.

Again, if I describe someone as “schizophrenic”, what characteristics comes to mind?

But what if that person with schizophrenia is your neighbor? works as a barber? works at Microsoft? is raising two kids? just earned her graduate degree? volunteers at the animal shelter? is the owner of that plot in the community garden that is overflowing with flowers and vegetables?

If different words can change the idea about the thing, then different words can help people change their behaviors about the thing.[2. To be clear, insight does not always result in behavior change. Even if the psychoanalysts argue otherwise.] In regards to the “word police” piece above, shifts in ideas and behaviors can drive improvements in health and social policy. This can lead to a reduction in stigma. The Royal We can develop new agreements for these different words. And using different words is sometimes easier than changing definitions for the same word (e.g., consider racial slurs).

Maybe I am falling into the “word police” camp. However, I do agree that behavior change is the ultimate goal, since what we do matters more than what we say. As with many things, the solution is somewhere in-between: Let’s work on word choice to help shift ideas and behaviors, but also remind ourselves that the word is not the thing.