Labelling What’s this
- Author:
Alexandef
Human beings, as well as consumer goods, can be labelled ‘Damaged in transit’, but my immediate concern in this article is not so much with the ways in which people can be damaged as they go through life, but with the damaging effect of the labelling process itself. Although labelling people may appear to be necessary, far from helping them to discover who they are, the label may act as a means of alienating them from themselves and from others.
Labels and names are a basic part of our culture ‘What’s your label?’, ‘Are you wearing your dog-tag?’ ‘Give a dog a bad name and it sticks’, ‘A rose by any other name …’, ‘The name of the game’. We name babies, battleships and bargain basements. We name streets, hotels, hospitals and highways. Without names we would be lost.
Primitive man felt that he only gained power over his environment when he was able to give names to objects around him. Just as he felt that painting the image of a bison on his cave wall gave him a better chance of hunting down the beast, so giving a name to objects and animals and people gave him magical power over the named object. The name giver became an important member of the early tribe.
In much the same way, in families, we feel uneasy until the child has been given his name. We cannot wait to baptise him, christen him or, if there is no strictly religious content, at least to have a little party where all the family meets to greet and name its latest member. So too with the growing child. Watch him reach out for objects. First of all he puts them to his mouth in an attempt to swallow them. Swallowing is the only way a young child can grasp and keep an object. Later, he haltingly gives things their name we say that he comprehends them or apprehends them - another way of saying he grasps their significance and feels that he has some control over them. A child has his family name, but that only tells him to whom he belongs; his own personal name, his ^labelling labelling labelling labe Filing labelling labelling labellin(YOUR LABEL? Mitchell given name, helps him in his first stumbling steps towards a personal identity - knowing who he is, and therefore who he can become. The medical condition of amnesia in which we temporarily lose our awareness of our own name and the names of people and places around us, is distressing not only because of the sensation of being lost, not knowing where one is, but also in being lost in a very basic sense - being lost to oneself, loss of identity, loss of self-control and loss of control over circumstances and events.
Names and labels can be very important in establishing a person in his own right, but the labelling process can also be used in a destructive, de-humanising way - when it is used to categorise. Here, the naming or labelling process is used not to allow someone freedom to be uniquely himself, but to restrain and confine him in a category, in a class, in a box.
Once we have pigeon-holed people, we don’t want them wandering about - that makes a mess of our classification - we like them to keep still and to be good classified material. Our labelling of them is to restrict their freedom so that we may have greater freedom ourselves. It is a thing that I do to you because it helps me. I may justify this by saying that it helps me to help you, but ultimately it is in my interests and it may not be in yours, no matter how well I dress it up.
This de-humanising categorisation, if carried to its extreme, reduces the human being to a cypher, a number, beloved of computer programmers and the testers of public opinion. Give me your opinion as ‘Yes’ or ‘No’ and this will be translated into the presence or absence of an impulse on an electronic tape: the essence of a person reduced to a minute electrical impulse, reduced ultimately to a plus or a minus.
But this is required for progress; there is so much information and knowledge around these days that c>2 we can only make sense of it if we react to it in this way, or so say the rationalisers. The basic question is whether we can ever comprehend the beauty of a flower reflected in a silent pool by means of digits, classifications and labels.
What is a general problem is a problem also in psychiatry. This branch of medicine began by giving names and labels to things in the great era of descriptive psychiatry in which order could only come out of chaos by isolating out symptoms, signs and behaviours and giving them names. Only then could one person communicate with another, but what was not captured nor communicated was the experience of the person now to be labelled as ‘patient’. This era was followed by categorising psychiatry: the named phenomena had to be ordered and grouped into commonly occurring situations or syndromes, later to be classed as ‘illnesses’. We must know to which group a patient belongs, not only to order the relevant treatment but to hazard a guess at the likely outcome. Thus we enter into the great era of medical model psychiatry employing words such as ‘diagnosis’, ‘aetiology’, ‘symptomatology’, ‘treatment’ and ‘prognosis’.
Shadowy world
The mentally disturbed are understood in terms of the illness which they exhibit and which, hopefully, the doctor can modify if not actually cure. But this was not enough: the experience of the patient became important - not only what others could observe directly in him - but how he felt, however mistily, deep down inside himself. This change of emphasis took us into the shadowy world of feelings and attitudes, the world of people (not organisms) confronting other people, the world of inter-personal psychiatry. What goes on between two people does not occur in a vacuum: each of the two people (the dyad), impinges on others in triads, fours, fives, sixes, dozens. The interaction of three persons, in which there are endless permutations of two against one, becomes the basic interactional unit of what is now social psychiatry. Here we can label the process, name the interaction, but is that the same as pigeon-holing symptoms, categorising patients?
Surely there is all the difference in saying ‘That person is a schizophrenic’ and saying ‘That person is reacting in a schizophrenic-like way’. In the one the person is caught, trapped for ever in a single frame of what is meant to be a moving picture; in the other he still has room for manoeuvre, still has room for change. Who knows, he may even give up reacting like a schizophrenic and react more like you and me. This is not just a matter of semantics. It reflects how we feel about people, how we judge them ultimately, how we relate to them. And it matters very much whether you are the categoriser or the one categorised.
A case is still made out for labelling in psychiatry which really means making diagnostic labels. Many doctors hold passionately that diagnosis is essential, just as much as others hold that it is dangerous and limiting so to do. Those who are for diagnosis as part of the art and part of the skill say that it is essential for understanding. We cannot know what we know until we can objectify it in some way, give it an identity by giving it a name which is universally agreed. No one really argues about John Smith: he either is or is not John ‘of those Smiths’. Sharing knowledge
There is not really any room for subtle shades of opinion which may only serve to make us trip up over our own clever feet. And understanding is a prerequisite for communication. If I am not going to keep all my knowledge to myself, if I intend to share it with you, we must have a common language, a common naming of things. As we communicate we discover what we know and, perhaps more important, what we don’t know and thus research is born. Research means looking for answers to what is at present unanswerable or unanswered. It means asking ‘What is that?’ before we ask ‘How is that?’ or ‘Why is that?’ Then again, it is said that diagnosis is necessary before we can plan a course of management. Of course, we could do nothing, or do things by chance, but that would neither be rational nor scientific; also it would not be economic. We need the quickest and the best returns for our effort. We have to know what we are to treat, before we can begin to treat it. But also, we have to know what it is before we can say how likely treatment is to succeed and how long it is likely to take.
Power struggles
These are all very logical and sensible arguments if we are operating within a purely medical framework in which the person to be helped is to be not only ‘a patient’ (ie, one who has to suffer), but also ‘patient’ (ie, one who has to wait for others to minister to him). But life is rarely as pure as that. We live in an economic world of competition in which we struggle with and against each other. This very naming process, this diagnosing, is brought into the world of power struggles between those who are fit and strong, and those who are deemed (largely by the others) to be unfit and weak.
This can be seen clearly in the conflict between staff and patients. The staff, the doctor or nurse or social worker or occupational therapist or psychologist, can be tempted into saying ‘It’s my job to define what is wrong with you and it is so and so. Your diagnosis is this or that.’ This is quite legitimate, but it results in a ‘one-up’ - ‘one-down’ situation in which the staff put themselves in a position of apparent omniscience or, at least, are in danger of doing so.
It can be even more subtle than this. Putting a label on a patient can invalidate the patient - ‘You are an invalid, and what you say is therefore invalid. You are sick because your label says so.’ Diagnosis can therefore become a way of restraining people and of rendering them even more impotent than they were when they started. To say someone is neurotic, psychotic, psychopathic or schizophrenic is not just a scientific descriptive statement. It can become a way of making a value judgement about the patient and putting him down.
An assumed label
Of course, this can also work to the patient’s advantage in that he can assume a label and use it against the family or against society by saying, ‘Here, look at me. I am sick. This label says so, and if I am sick you can’t expect me to be responsible for myself.’ Patients may be disordered and yet still responsible for themselves to a degree. Being disordered does not automatically invalidate a person, but having an illness label nearly always does, or is used as if it does. What is needed in psychiatry, to help both staff and patients, and society too, is some system which embodies the following: (a) clear thinking, (b) conceptual frameworks and (c) unambiguous language. If we can develop these, then we can make not just a diagnosis but a diagnostic formulation, which is not just a limiting label, but is, ideally, a comprehensive statement about the person and his predicament. Such a statement should tell us where the person has come from, where he is at the present time, what he is capable of in the future. Ideally it should give freedom to the person to grow, by suggesting help if he needs it. Further, he should be involved in working out the formulation. He is not just malleable clay in another person’s hands, but someone who has the capacity (or, at least, should be given the chance of showing if he has the capacity) to join with the staff in working out where he stands. Making the formulation then becomes a collaborative effort and not a proscriptive restraint.
William James once wrote - ‘I am done with great things and big things, great institutions and big success, and I am for those tiny invisible molecular moral forces that work from individual to individual creeping through the crannies of the world like so many soft rootlets, or like the capillary oozing of water yet which, if given time, will rend the hardest monuments of man’s pride’. Our diagnostic labels are in danger of becoming some of our hardest monuments of pride, gods to be served rather than servants to serve us. Abandoning labels in favour of looser descriptions may be seen by some as a retrograde step, yet what is the profit of using labels to open up communication between us, if we find that what we have to communicate is, at best, a pale shadow of reality and, at worst, a chain that limits the freedom of those we seek to help and, ultimately, of ourselves ?
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