The Ideal
Removal Of Diagnostic Labels
We, as practitioners, like to imagine a world where diagnostic labels of “disorder” are no longer required. We feel that such labels do not sufficiently depict the vast array of human experiences and thus are inadequate for addressing human distress in the context of our world. We understand that pragmatically we live in a world where labels have social currency and we are trying to get to grips with that whilst also having our eyes on an idealistic long-term future where people’s emotional distress still feels validated without having to be labelled as disordered.
The Need For Validation; Exploring Other Ways Of Offering It
One major advantage of a mental health diagnosis can be the social recognition and validation it provides to a young person in distress. A diagnosis acts as a formal official social passport that is experienced as validating their pain, hurt and anguish. Their emotions can no longer be minimised, dismissed, belittled or questioned by those around them and the relief this can potentially provide in the short term may be necessary and possibly lifesaving in some cases. However, why do we need a formal social passport in the form of a diagnosis to validate people’s feelings? Are there other ways of validating and respecting a person’s lived experience without providing them with a label of disorder so society stops disbelieving, questioning and minimising their pain? Because in some ways, labelling emotions as ‘disordered’ may dismiss people’s emotional pain -particularly in the long-term.
At Jigsaw, The National Centre for Youth Mental Health, we suggest some ways of offering validation that do not depend on diagnostic labels. For example:
We offer validation by consistently bearing witness to and sitting with distress and emotions. This may also involve a development of our language when it comes to emotions. For example, being better able to name and describe emotions and to have a better awareness of what affects our emotions and their possible functions:
- “Oh wow, yes that sounds like such deep sadness. Doesn’t sadness have such a way of letting us know when something is wrong/something is missing/something has been lost.”
We provide validation by offering the language of inclusion and understanding rather than the language of disorder and deficit – a psychological rather than medical explanation/formulation:
- “I’m not sure that sounds like there’s something wrong inside of you. That sounds like some big unfair things have happened that have had a really difficult impact on how you feel.”
We offer validation through empowerment – by working with people’s creativity, strengths and interests that are emotionally and spiritually fulfilling rather than focusing on how they are not fitting the narrow confines of traditional society.
- Example: Promoting trades and creative arts rather than limiting people’s options in life to State Exams.
We use critical thinking, at times, as a method of self-validation which may be more meaningful than challenging a person to adapt themselves to the norm all of the time e.g.
- “If I feel this feeling, maybe others do too and maybe that’s important to listen to in order to exact change and ensure my/other people’s points of view are represented.”
Uncomfortable and upsetting feelings can be powerful communicators about the perils of the status quo and consequently, powerful communicators of possible change, reform and transformation. A healthy balance between individual and systemic critical thinking offers more opportunity for creativity, regeneration and empowerment.
Witnessing, being present with and sharing in a common feeling with others automatically creates a sense of solidarity and community. The byproduct of this is that a young person may then notice they are not different, flawed or in some way “less than” due to these feelings. It changes the questions from “Why do these feelings keep coming back?” “Does it mean that there’s something wrong with me?” to “Why do so many people feel this way” “Does it mean that there’s something wrong with the norms and expectations of the world?” Turning the reflection outwards towards societal values creates an opportunity to talk about norms that often remain unquestioned and unchallenged.
Where We (The Collective) Are At Right Now:
How To Work and Survive In A Mental Health System That Uses Deficit Based Language
The reality of working in the mental health system is that a lot of young people we meet in the therapy room have previously used a mental health service or attended a mental health professional in some capacity. Alongside this, young people may have researched their distress online through search engines or through social media prior to seeking out more formal supports. The dominant vernacular present online and in mental health services is one that tends to describe distress through a medical lens which usually references a series or cluster of “symptoms”. The presence or absence of these “symptoms” (which are typically thoughts, feelings or behaviours) alongside the frequency, intensity and duration indicate whether a person meets the criteria for a mental health “disorder”.
When we meet young people in a therapeutic context, they are typically primed with some level of a mental health vernacular, and it represents the sociocultural context which they are steeped in every day. If a young person feels attached to or aligns with the diagnostic language that they have been exposed to and conditioned by, we don’t necessarily believe or feel it is the most helpful approach to immediately criticise, deplatform or devalue the medical and diagnostic paradigm. Equally, if young people who have pre-existing mental health diagnoses attend our non-diagnostic mental health service, it is not our focus or priority to lessen or diminish the potential benefits a young person may have received/perceived from a diagnosis. We believe, as a starting point, we can both give due respect and consideration to the utility and value a diagnosis may have provided in the past and begin to look at expanding a young person’s narrative about themselves beyond the language of disorder and deficit.
In practice, this looks like us personally/professionally not using the language of disorder and symptoms when it is not necessary to do so (which tends to be 99% of the time as far as we have seen). Where it does feel important to have discussions using this language is when the young person themselves is bringing it. In this instance, we will endeavour to explore all avenues of emotional/mental health language with the young person so that they are fully informed about the benefits and challenges of using this language in reference to themselves.
Most young people are not aware that medicalised language can be a contentious issue when it comes to emotional/mental health language. Many young people will have this discussion and still choose to use medicalised language when it comes to their mental health. This is not something that we would ever try to take from them. As long as the young person has informed consent with regards these labels then we feel we are in a better position to explore their understandable human experiences with them and help them with their challenges. We believe it is also important to explore the possibility of meeting a young person’s emotional and contextual needs through parental and professional advocacy rather than through a diagnosis as a first port of call.
Expanding Not Replacing The Narrative As A First Step
The reason we feel it may be more helpful to start off by expanding a young person’s narrative is, in part, due to the possible initial threat this may pose to their identity and to the accommodations and benefits they have accessed through a formal diagnosis. A gentler approach to self-exploration and being curious may be to begin to relate to the diagnosis differently and to wonder if other narratives could also be true for them alongside their diagnosis e.g. “Could it be true or plausible that I have Generalised Anxiety Disorder and also that my feelings of anxiety and fear are understandable responses to feeling unsafe and under threat?”
We hold multiple and conflicting narratives about ourselves all the time but typically there tends to be a dominant story or narrative that overrides the sub-narratives. Over time, by continually building and working on expanding a person’s narrative and subsequently their identity, it is possible for a sub-narrative (e.g. my distress is understandable, and it is painful to sit with) to become a dominant narrative and for a previously dominant narrative (e.g. I have a disorder because I can’t cope well enough) to become a sub-narrative. Expanding rather than immediately replacing the narrative (both at an individual and systemic level) allows space for exploration, confusion, patience, curiosity and compassion to co-exist. Rushing the process to immediately replace may act as a barrier to genuinely bringing people along the journey of reform and change. People need space and time to question new ideas and feel safe enough to critically analyse both new and old ideas and narratives at a person and societal level.
Young people are likely unaware of the controversy that relates to psychiatric diagnoses and that professionals do not always agree on this model of mental health. We have found that immediately letting young people know that labels are contested does not necessarily land the way we might hope. Such information needs to be digested gently and over time if we are to help young people to feel fully informed. There can be a jarring effect to posing a stark alternative to the dominant narrative from the beginning but this alternative is likely to land better when a young person has gone on the journey of co-creating their story and reflecting on the utility of multiple narratives. At that point, if they are interested then it may be helpful to point them towards accessible resources on more contextual models of emotional well-being.
At times, we have seen in the therapy room how young people, when offered the alternative perspective that “somehow their emotional responses make sense”, can have multiple “light bulb moments” where they start to piece together their story and connect the dots. When we meet young people where they are at with their language and then seek out opportunities to go on the journey of exploration with them, we are much more likely to open doors to meaningful conclusions. They may still hold tight to the language of disorder but at least they are making more sense of where their emotions have come from. They can then take the first steps to acknowledging that the blame need not be on them for their difficult emotions and there may be more than meets the eye when it comes to the human condition.
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