This was such a thoughtful, nuanced, and deeply humanistic piece. Thank you both for the clarity and gentleness with which you approached it.
One thought it stirred for me is about the “sick role” and its unspoken contract. Sociologists outline the benefits of the sick role (support, care, legitimacy), but in practice there are also many obligations woven in. We expect the sick person to minimize their suffering, to comply with treatment (even if it's painful or results in a loss of dignity or autonomy), to “fight,” to contribute when able, to not overburden others, etc. In that light, I sometimes wonder if the relief of receiving a diagnosis isn’t just about gaining benefits, but about being granted permission to set down some of those obligations -- obligations which can, of course, be a heavy and sometimes unbearable burden.
Expanding our view of the sick role as including both benefits and obligations seems to explain why a diagnosis of cancer rarely feels like relief, while in other contexts a label can feel like an immense unburdening. It's the "relief" from those obligations that feels therapeutic. Diagnosis soothes -- even when it does not better explain, change, or treat the underlying condition, or erase any suffering -- because it loosens the burden of expectation.
Of course, humans are hypersensitive to situations where we worry others are accepting our gifts of time, care, and attention without fulfilling our expectations of what they will do in return. So we cannot help but attune to how well this balance between the benefits and obligations of the sick role is negotiated. Certainly, the old paradigm of "diagnosis as stigma or burden", where the sick person suffered all the obligations of the sick role but without the benefits like care, support, and empathy, was certainly a worse way of managing this trade-off. Stigma shows us the cruelty of obligations without benefits, while relief shows us the kindness of being allowed, if only for a moment, to set some obligations down.
And yet, setting down obligations is a tricky dance. Each burden we put down may become one that others must carry. Who decides whose load is heaviest? Perhaps part of our work is simply to recognize that this balance between benefits and obligations is always being negotiated, and to approach that negotiation with humility and care.
Absolutely fascinating and rings true for many people I've observed. And I think it's often NOT about prelude to treatment or accomodations. I've encountered many people who seemed to have gained a lot of relief and peace from the diagnostic label *even if the label was nothing but the concise explanation for their cluster of symptoms*. To use a simplistic example, it seems to go like this: "I'm not shit at maths, I have dyscalculia" --- even though "dyscalculia" is literally a word used to mean being bad at maths. I'm not oversensitive, I have RSD, even tho RSD is *literally* a name give to oversensitivity to rejection. Etc etc etc. I don't understand this at all, on a personal level, but I suspect it might be related to the fact that many people see *mental dysfunction without a medical used label* as a MORAL FAILURE. Which is very sad in itself.
Perhaps for socio-evolutionary reasons and as part of an "agency tracking" module in our mind, we seem to be very interested in tracking "whose fault" something is.
If one particular person is shit at maths, we might suspect that perhaps they had a poor teacher (i.e. it was the teacher's fault). But if all the other students of that teacher turned out fine, or if the student had multiple teachers, we might then move on to suspect that it's that particular student's fault (perhaps they are lazy, or they didn't pay attention in class or whatever). By "finding out" that that person has dyscalculia, this allows us to "realize" that it's "not their fault". Finding out that something is "not your fault" brings a lot of psychological relief.
It's a silly linguistic trick, as you pointed out, but apparently a powerful one.
I think this is spot on! Medicalized label = “nobody's fault” (unless it's a construct such as cptsd, then we get clear “mummy's fault”). It also shows in popularity of “born this way” advocacy for culturally controversial practices or preferences.
This is such an interesting and important topic- the meaning of diagnostic labels, either by patients or doctors. I think I would differentiate this somewhat from placebo or nocebo effect; your ADHD doesn't get better because you name it, your self-esteem does. Or vice-versa, if you get a label you don't want. But maybe I'm wrong.
I think those powerful moments of a clinician-given diagnosis being helpful are correlated with how accurate that diagnosis is perceived to be- how much it accords with the patient's experience- and to what degree something can be done about it. Also in there is whether the patient is actually seeking a descriptive diagnosis, and whether that has eluded them with past treatment. In other words, how much build-up there has been, how much struggle and yearning for an explanation. The relationship and manner of delivery factor in.
Sometimes people come to doctors seeking validation of a diagnosis they believe they have. The power/expiation of a name. It is really interesting that you point out patients do better when doctors come across as certain. This can create a challenge, if a doctor is uncertain as yet, or turns out to be wrong.
As someone who has had unexplained symptoms, I'm very aware of the shame and pain of blank looks on the faces of doctors. We come to doctors for answers, and we learn in medical school to name things. I want certainty, and a name, as a patient, but as a doctor I don't always have those things.
Interesting. Thx for sharing! This piece reminds me a lot of a section in my book "Scale-Smart" where I use the idea of a "Rumpelstiltskin effect" a bit more generally, but essentially with the same overarching theme: name it to tame it!
Here's the book section:
» The first core operation on mental matter is conceptualizing—or, in a phrase, name it to tame it. Much like in the fairy tale Rumpelstiltskin, the moment we give something a name, we begin to gain power over it. Until then, it stays fuzzy, slippery, lurking at the edges of thought. But once named, a concept crystallizes. It becomes a unit you can see, hold, think about—and, crucially, work with. To conceptualize is to give form to the formless. It’s the act of shaping mental mist into a defined object. And the tool we use for that is language. A name—no matter how arbitrary—acts like a handle. Without a handle, an idea might still exist, but it’s hard to pick up, turn over, or connect to anything else. With a handle, everything changes. Now you can grasp the idea. Move it. Share it. Build on it. This isn’t just a poetic metaphor. Research in cognitive science, linguistics, and psychology confirms a simple truth: naming is one of the most powerful acts the mind can perform. When you give something a name—be it an emotion, a challenge, or a recurring pattern—you’re not just labeling it. You’re mapping it into your inner world. You lift it to become a citizen in your personal mental ecology. In that sense, conceptualizing is how our World 2 carves meaning out of the chaos of World 1. Your brain doesn’t just absorb information—it interprets it through concepts. And concepts are made up of categories, distinctions, and—crucially—names.[^wittgenstein] Say you’re concerned about your weight, your back aches, and you’ve caught a cold. When you label this cluster “unhealthy,” you compress a web of sensations into a single idea: health. That unit becomes easier to monitor, talk about, and influence. Psychologists call this a chunk.[^miller] Linguists call it a signifier.[^saussure] Neuroscientists might call it a label that rewires perception by engaging regulatory circuits in the brain.[^lieberman] In every case, the function is the same: to make something handleable. That’s why naming an emotion—“anxiety,” “resentment,” “anticipation”—can reduce its grip. Studies show that labeling feelings calms the amygdala and activates the prefrontal cortex.[^lieberman] It’s like naming the monster in the dark: it doesn’t vanish, but it becomes less terrifying. Once you can name what you’re feeling, you’ve already begun to work with it.
There is definitely power in a name, and I appreciate the meta aspect that there is power in giving a name to the concept of giving something a name.
I saw someone else share the idea of Rumpelstiltskin Effect in another blogpost and it helped me give a name to a related phenomenon I've been thinking about a lot lately. Namely that a diagnosis being sought is often not diagnosis for the person seeking it, but for a child in their care. The parent gets many of these positive Rumpelstiltskin effects from having their child diagnosed, even if the child doesn't necessarily. The parent is relieved of ambiguity, and benefits from being able to reframe a child's behaviour as a medical or psychiatric issue. Indeed, for many people, their first diagnoses were not self sought, but imposed by caregivers. I'm thinking of as Rumpelstiltskin by Proxy.
Great article. I recall a client telling me, with great importance, that they had been diagnosed with idiopathic hypersomnia. If you break the name down 'idiopathic' means of unknown cause, 'hyper' means too much, and 'somnia' means sleep. So the medical diagnosis was essentially 'you're sleeping too much and we don't know why' yet those words clearly carried great meaning and significance for this person. It's a great reminder of how much visibility and validation often matters.
Thanks for this interesting summary (and the original article, which this summary prompted me to read).
The *positive* effect of 'naming the thing' is I think undeniable in many cases. As some have suggested (and as you noted in your article) there are also, in some cases, negative effects. I resisted 'schizophrenia' for many years for fear of those negative effects (both public and personal). Agreeing to the label a couple of years ago has led to some of those negative effects. But it cannot really be 'undone' (and I don't wish to undo it anyway, for reasons that aren't relevant here).
In light of both positive and negative effects, I wonder whether it doesn't make sense to pursue a more neutral account of what is going on when a thing gets 'named' (whether that's naming something that previously lacked a name -- Fricker's other famous example along these lines is 'sexual harassment' -- or applying an existing name -- 'schizophrenia', say -- to a particular case)?
I don't have an account to offer, but 'naming the thing' does seem to involve activities such as: 'putting the thing into a category', 'making it possible to talk about the thing', 'making the thing a conceptual reality', 'enabling comparison of the thing with other things', and so on. Naming gives one conceptual, and sometimes also legal, social, etc., control of a thing. It is easy to see how 'naming', understood as involving or enabling these activities (and probably more), can have both positive and negative effects (including both at the same time).
What a fantastic read, as always. Thank you Awais.
I’m reading, ‘Shamanism the timeless religion’ by Manvir Singh and there echoes of your article in his book, and vice versa. A small thing, but it’s exciting for me to see the crossover between an Anthropologist and a Psychiatrists understanding of healing and, I guess, an appeal to authority.
People need to know that their struggle isn't their fault (it often isn't). But, that doesn't mean it's not their responsibility (it usually is). Diagnosis is often an alleviator of shame. When you lift shame, healing can begin.
The guest writer's name and profile picture evoke the image of a dead classic author. I mean this in the most complementary sense. I love the sound of that name.
Really great paper and an important phenomenon, which is somewhat surprising hasn't been studied so far, even though it intuitively falls within the well-developed field of placebo science. I guess that, even if non-etiological in themselves, labels can be beneficial to the degree that they allow patients to draw meaningful causal connections, to the point that the possibility of healing gets already implied in the diagnostic framing (a diagnosis of 'medically unexplained symptoms', otoh, completely forecloses that possibility, as do many biogenetic explanations: https://pubmed.ncbi.nlm.nih.gov/30426319/).
Fascinating and resonant. I thought for no second would you relate this to demonology, and then you immediately did. Shows a breath of awareness and thinking that is unusual nowadays. Whether or not Demons are real…
Interesting article on the social construction and validation that comes from a dx. The dx may be verifiable by a lab test (malaria) or even false (phrenology) but it does have a social impact
This is so salient to the 4th edition of the book I am editing.
Quoted you "“When patients exhibit a desire for a particular diagnosis during a clinical interaction, clinicians should be sure to make space to explore the role that diagnosis would play for the patient, potentially touching on the mechanisms we lay out here to determine whether they apply to the patient’s interest in diagnosis.” (p.4)".
Thank you again for such an important contribution.
I have to respectfully disagree. Society would be better served by stretching the boundaries of “normal” more generously, and accommodating wider ranges of behavior, rather than coming up with a name for every deviation. “Learning disability” is a way of placing the onus of a disability on a perfectly normal person with a different learning style, rather than expanding methods of education. “Rape trauma syndrome” medicalizes into a syndrome some socially understandable responses to horrific physical attack. “Depression” is sometimes a completely justifiable response to living a life of stress, pressure, and unavoidable obligation ( caretakers of people with Alzheimer’s/ single mothers). And don’t get me started on turning prolonged grief over the loss of a mother or spouse or child into a mental disorder. We were, as a whole, better off when people were described as “odd” or “eccentric” or “grumpy” or “so easily distracted.” None of us are perfect, but I am grateful that my quirks have not yet been pathologized (So far).
I understand that you are approaching this issue from the perspective of a lawyer and advocate for the rights of your clients--not as a clinician. But I must respectfully disagree with the implication that psychiatry has "...turn[ed] prolonged grief over the loss of a mother or spouse or child into a mental disorder." In my view as a mood disorder specialist, this is not the case, though I know there is much controversy surrounding the newly-added (DSM-5-TR) diagnosis of Prolonged Grief Disorder. (The name was unfortunate, in my view, and should have been, "Prolonged Dysfunctional Grief Disorder").
I believe that if you read the criteria for the diagnosis PGD, you will see that PGD differs in important respects from what is sometimes called "ordinary grief" (though arguably, nobody's grief is "ordinary" and is often anguishing after the death of a loved one). As one source explains:
"Grief is a natural response to the loss of someone close. For most survivors, the symptoms of grief dissipate over time. For a small proportion of people, however, intense and distressing symptoms of grief persist, cause problems in daily functioning, and may even pose challenges to simply getting through the day. Prolonged grief disorder is characterized by intense and persistent grief symptoms which are not only distressing in themselves but also associated with problems in functioning. Thus, those who meet criteria for prolonged grief disorder constitute a group of bereaved persons who are significantly disturbed and disabled by their grief." [https://www.psychiatry.org/patients-families/prolonged-grief-disorder]
A relatively small percentage (4-15%) of bereaved adults meet criteria for PGD. Symptoms of prolonged grief disorder (APA, 2022) include:
Identity disruption (such as feeling as though part of oneself has died).
Marked sense of disbelief about the death.
Avoidance of reminders that the person is dead.
Intense emotional pain (such as anger, bitterness, sorrow) related to the death.
Difficulty with reintegration (such as problems engaging with friends, pursuing interests, planning for the future).
Emotional numbness (absence or marked reduction of emotional experience).
Feeling that life is meaningless without the deceased person.
Intense loneliness (feeling alone or detached from others).
In short, it is not so much the "prolonged" quality of PGD that marks it as a clinically significant "disordered" type of grief; rather, it is the degree of suffering and incapacity associated with PGD. I would recommend viewing the video by my colleagues,
Katherine Shear, M.D. and Holly Prigerson, Ph.D, available on the website above.
Best regards,
Ronald W. Pies, MD
P.S. Please excuse me if I have misidentified your professional position. I recall a very good exchange with you on Psychiatric Times some years ago, regarding involuntary hospitalization of suicidal persons:
Dear Dr. Pies: You are kind to remember me, and kind to write so carefully in response. I am an attorney, as you recall, and have always been impressed with the care you put into what you write.
As an attorney, I have represented people with learning disabilities, rape trauma syndrome, and depression, but as you probably could tell, the grief I refer to is my own, from the death of my mother 19 years ago. I still function on a daily basis, but I don't think feeling that a part of myself has died is a symptom of anything. It's just a fact. I don't think life is meaningless without my mother, but it is certainly different, and less--the best analogy is amputation. Life goes on, but it's a different life. I think grief, like suicidality, is "normal," and "normal" in its extremes as well. Certainly people (and sometimes therapists) can be helpful, but they could be helpful without the pathologizing, which I do think is harmful. I will say that I overcame my resistance and went to a grief group, and it actually was very helpful, because it was just a bunch of people who also could not really get over their loss at the pace society expected.
Thank you, Susan (if I may) for your kind comments on my writing, and for sharing your experience with grief, following your mother's death. Let me say that in no way would I have the inclination--or the hubris!--to "pathologize" your experience of grief. I do think we encounter philosophical and practical problems when we focus on the term "normal", which is used in so many ways in medical and psychiatric parlance. For example, a finding that is statistically
"abnormal"--like a "barrel chest"--is by no means necessarily pathological.
As a psychiatrist, I am less concerned with rigorously defining "normal" than I am in identifying and enhancing human flourishing--what the ancient Stoics called eudaimonia. This is sometimes thwarted and even destroyed by certain types of suffering and incapacity--as we see, e.g., in people with schizophrenia or severe bipolar disorder. And, I would add, Prolonged Grief Disorder.
Debating how "normal" or "abnormal" PGD is leads, in my view, down a dead-end. In my view, it is an instantiation of severe suffering and incapacity, and merits professional treatment. I am glad you found that grief group helpful, and professional approaches using specific forms of psychotherapy (not, by the way, medication) may also be helpful In that regard, see: this link:
I believe the idea of "name it to tame it" is powerful. You write:
> "Learning disability” is a way of placing the onus of a disability on a perfectly normal person with a different learning style
--- but what are "learning styles" if not named-to-tamed differences? I see the problem only in calling it a "disability," not in "coming up with a name for every deviation." I know the problem in blaming, calling something "unhealthy."
Also, "normal" has become a loaded word, but it just means "typical". You seem to have attached a value judgment to the word that it does not have. Normal is neither good nor bad. It just states what is common and what is not.
I have to disagree that "normal" has no connotations. If you are told by your doctor that you have an abnormality, that is generally not good news. If you have a baby and you are told it's not normal, that's not 'neither good nor bad.' Our society expects certain behaviors from its members, and the question is always, what are the consequences for deviating. Vance says people should be institutionalized for being homeless and yelling in the street. (Presumably MAGA people who are housed and yell at transgender people are exempt from this). I have represented people who are institutionalized for psychiatric disabilities for forty years, and always marvelled at how society decides which behavioral deviations have to be involuntarily segregated. Certainly when I worked in Montana in the 1980s, many of the people at the State Hospital took second place in the category of mental and emotional disturbance to many of the people who were living in the mountains.
Very interesting piece. But do you see the obvious danger here for valorizing mental illness as identity? Especially for young people? Clinicians incentivized to diagnose to provide a magic elixir? Mental illness as identity has already spiraled out of control on Tik-Tok.
This was such a thoughtful, nuanced, and deeply humanistic piece. Thank you both for the clarity and gentleness with which you approached it.
One thought it stirred for me is about the “sick role” and its unspoken contract. Sociologists outline the benefits of the sick role (support, care, legitimacy), but in practice there are also many obligations woven in. We expect the sick person to minimize their suffering, to comply with treatment (even if it's painful or results in a loss of dignity or autonomy), to “fight,” to contribute when able, to not overburden others, etc. In that light, I sometimes wonder if the relief of receiving a diagnosis isn’t just about gaining benefits, but about being granted permission to set down some of those obligations -- obligations which can, of course, be a heavy and sometimes unbearable burden.
Expanding our view of the sick role as including both benefits and obligations seems to explain why a diagnosis of cancer rarely feels like relief, while in other contexts a label can feel like an immense unburdening. It's the "relief" from those obligations that feels therapeutic. Diagnosis soothes -- even when it does not better explain, change, or treat the underlying condition, or erase any suffering -- because it loosens the burden of expectation.
Of course, humans are hypersensitive to situations where we worry others are accepting our gifts of time, care, and attention without fulfilling our expectations of what they will do in return. So we cannot help but attune to how well this balance between the benefits and obligations of the sick role is negotiated. Certainly, the old paradigm of "diagnosis as stigma or burden", where the sick person suffered all the obligations of the sick role but without the benefits like care, support, and empathy, was certainly a worse way of managing this trade-off. Stigma shows us the cruelty of obligations without benefits, while relief shows us the kindness of being allowed, if only for a moment, to set some obligations down.
And yet, setting down obligations is a tricky dance. Each burden we put down may become one that others must carry. Who decides whose load is heaviest? Perhaps part of our work is simply to recognize that this balance between benefits and obligations is always being negotiated, and to approach that negotiation with humility and care.
Absolutely fascinating and rings true for many people I've observed. And I think it's often NOT about prelude to treatment or accomodations. I've encountered many people who seemed to have gained a lot of relief and peace from the diagnostic label *even if the label was nothing but the concise explanation for their cluster of symptoms*. To use a simplistic example, it seems to go like this: "I'm not shit at maths, I have dyscalculia" --- even though "dyscalculia" is literally a word used to mean being bad at maths. I'm not oversensitive, I have RSD, even tho RSD is *literally* a name give to oversensitivity to rejection. Etc etc etc. I don't understand this at all, on a personal level, but I suspect it might be related to the fact that many people see *mental dysfunction without a medical used label* as a MORAL FAILURE. Which is very sad in itself.
Perhaps for socio-evolutionary reasons and as part of an "agency tracking" module in our mind, we seem to be very interested in tracking "whose fault" something is.
If one particular person is shit at maths, we might suspect that perhaps they had a poor teacher (i.e. it was the teacher's fault). But if all the other students of that teacher turned out fine, or if the student had multiple teachers, we might then move on to suspect that it's that particular student's fault (perhaps they are lazy, or they didn't pay attention in class or whatever). By "finding out" that that person has dyscalculia, this allows us to "realize" that it's "not their fault". Finding out that something is "not your fault" brings a lot of psychological relief.
It's a silly linguistic trick, as you pointed out, but apparently a powerful one.
I think this is spot on! Medicalized label = “nobody's fault” (unless it's a construct such as cptsd, then we get clear “mummy's fault”). It also shows in popularity of “born this way” advocacy for culturally controversial practices or preferences.
This is such an interesting and important topic- the meaning of diagnostic labels, either by patients or doctors. I think I would differentiate this somewhat from placebo or nocebo effect; your ADHD doesn't get better because you name it, your self-esteem does. Or vice-versa, if you get a label you don't want. But maybe I'm wrong.
I think those powerful moments of a clinician-given diagnosis being helpful are correlated with how accurate that diagnosis is perceived to be- how much it accords with the patient's experience- and to what degree something can be done about it. Also in there is whether the patient is actually seeking a descriptive diagnosis, and whether that has eluded them with past treatment. In other words, how much build-up there has been, how much struggle and yearning for an explanation. The relationship and manner of delivery factor in.
Sometimes people come to doctors seeking validation of a diagnosis they believe they have. The power/expiation of a name. It is really interesting that you point out patients do better when doctors come across as certain. This can create a challenge, if a doctor is uncertain as yet, or turns out to be wrong.
As someone who has had unexplained symptoms, I'm very aware of the shame and pain of blank looks on the faces of doctors. We come to doctors for answers, and we learn in medical school to name things. I want certainty, and a name, as a patient, but as a doctor I don't always have those things.
Interesting. Thx for sharing! This piece reminds me a lot of a section in my book "Scale-Smart" where I use the idea of a "Rumpelstiltskin effect" a bit more generally, but essentially with the same overarching theme: name it to tame it!
Here's the book section:
» The first core operation on mental matter is conceptualizing—or, in a phrase, name it to tame it. Much like in the fairy tale Rumpelstiltskin, the moment we give something a name, we begin to gain power over it. Until then, it stays fuzzy, slippery, lurking at the edges of thought. But once named, a concept crystallizes. It becomes a unit you can see, hold, think about—and, crucially, work with. To conceptualize is to give form to the formless. It’s the act of shaping mental mist into a defined object. And the tool we use for that is language. A name—no matter how arbitrary—acts like a handle. Without a handle, an idea might still exist, but it’s hard to pick up, turn over, or connect to anything else. With a handle, everything changes. Now you can grasp the idea. Move it. Share it. Build on it. This isn’t just a poetic metaphor. Research in cognitive science, linguistics, and psychology confirms a simple truth: naming is one of the most powerful acts the mind can perform. When you give something a name—be it an emotion, a challenge, or a recurring pattern—you’re not just labeling it. You’re mapping it into your inner world. You lift it to become a citizen in your personal mental ecology. In that sense, conceptualizing is how our World 2 carves meaning out of the chaos of World 1. Your brain doesn’t just absorb information—it interprets it through concepts. And concepts are made up of categories, distinctions, and—crucially—names.[^wittgenstein] Say you’re concerned about your weight, your back aches, and you’ve caught a cold. When you label this cluster “unhealthy,” you compress a web of sensations into a single idea: health. That unit becomes easier to monitor, talk about, and influence. Psychologists call this a chunk.[^miller] Linguists call it a signifier.[^saussure] Neuroscientists might call it a label that rewires perception by engaging regulatory circuits in the brain.[^lieberman] In every case, the function is the same: to make something handleable. That’s why naming an emotion—“anxiety,” “resentment,” “anticipation”—can reduce its grip. Studies show that labeling feelings calms the amygdala and activates the prefrontal cortex.[^lieberman] It’s like naming the monster in the dark: it doesn’t vanish, but it becomes less terrifying. Once you can name what you’re feeling, you’ve already begun to work with it.
There is definitely power in a name, and I appreciate the meta aspect that there is power in giving a name to the concept of giving something a name.
I saw someone else share the idea of Rumpelstiltskin Effect in another blogpost and it helped me give a name to a related phenomenon I've been thinking about a lot lately. Namely that a diagnosis being sought is often not diagnosis for the person seeking it, but for a child in their care. The parent gets many of these positive Rumpelstiltskin effects from having their child diagnosed, even if the child doesn't necessarily. The parent is relieved of ambiguity, and benefits from being able to reframe a child's behaviour as a medical or psychiatric issue. Indeed, for many people, their first diagnoses were not self sought, but imposed by caregivers. I'm thinking of as Rumpelstiltskin by Proxy.
(I've just written up some of my thoughts on this: https://politicalpelorus.substack.com/p/rumpelstiltskin-by-proxy).
Great article. I recall a client telling me, with great importance, that they had been diagnosed with idiopathic hypersomnia. If you break the name down 'idiopathic' means of unknown cause, 'hyper' means too much, and 'somnia' means sleep. So the medical diagnosis was essentially 'you're sleeping too much and we don't know why' yet those words clearly carried great meaning and significance for this person. It's a great reminder of how much visibility and validation often matters.
Thanks for this interesting summary (and the original article, which this summary prompted me to read).
The *positive* effect of 'naming the thing' is I think undeniable in many cases. As some have suggested (and as you noted in your article) there are also, in some cases, negative effects. I resisted 'schizophrenia' for many years for fear of those negative effects (both public and personal). Agreeing to the label a couple of years ago has led to some of those negative effects. But it cannot really be 'undone' (and I don't wish to undo it anyway, for reasons that aren't relevant here).
In light of both positive and negative effects, I wonder whether it doesn't make sense to pursue a more neutral account of what is going on when a thing gets 'named' (whether that's naming something that previously lacked a name -- Fricker's other famous example along these lines is 'sexual harassment' -- or applying an existing name -- 'schizophrenia', say -- to a particular case)?
I don't have an account to offer, but 'naming the thing' does seem to involve activities such as: 'putting the thing into a category', 'making it possible to talk about the thing', 'making the thing a conceptual reality', 'enabling comparison of the thing with other things', and so on. Naming gives one conceptual, and sometimes also legal, social, etc., control of a thing. It is easy to see how 'naming', understood as involving or enabling these activities (and probably more), can have both positive and negative effects (including both at the same time).
What a fantastic read, as always. Thank you Awais.
I’m reading, ‘Shamanism the timeless religion’ by Manvir Singh and there echoes of your article in his book, and vice versa. A small thing, but it’s exciting for me to see the crossover between an Anthropologist and a Psychiatrists understanding of healing and, I guess, an appeal to authority.
It’s a wonderful phrase too.
People need to know that their struggle isn't their fault (it often isn't). But, that doesn't mean it's not their responsibility (it usually is). Diagnosis is often an alleviator of shame. When you lift shame, healing can begin.
The guest writer's name and profile picture evoke the image of a dead classic author. I mean this in the most complementary sense. I love the sound of that name.
Really great paper and an important phenomenon, which is somewhat surprising hasn't been studied so far, even though it intuitively falls within the well-developed field of placebo science. I guess that, even if non-etiological in themselves, labels can be beneficial to the degree that they allow patients to draw meaningful causal connections, to the point that the possibility of healing gets already implied in the diagnostic framing (a diagnosis of 'medically unexplained symptoms', otoh, completely forecloses that possibility, as do many biogenetic explanations: https://pubmed.ncbi.nlm.nih.gov/30426319/).
It reminded me of this old paper by Brody and Waters, "Diagnosis is treatment": https://pubmed.ncbi.nlm.nih.gov/7354290/
Fascinating and resonant. I thought for no second would you relate this to demonology, and then you immediately did. Shows a breath of awareness and thinking that is unusual nowadays. Whether or not Demons are real…
Interesting article on the social construction and validation that comes from a dx. The dx may be verifiable by a lab test (malaria) or even false (phrenology) but it does have a social impact
This is so salient to the 4th edition of the book I am editing.
Quoted you "“When patients exhibit a desire for a particular diagnosis during a clinical interaction, clinicians should be sure to make space to explore the role that diagnosis would play for the patient, potentially touching on the mechanisms we lay out here to determine whether they apply to the patient’s interest in diagnosis.” (p.4)".
Thank you again for such an important contribution.
I have to respectfully disagree. Society would be better served by stretching the boundaries of “normal” more generously, and accommodating wider ranges of behavior, rather than coming up with a name for every deviation. “Learning disability” is a way of placing the onus of a disability on a perfectly normal person with a different learning style, rather than expanding methods of education. “Rape trauma syndrome” medicalizes into a syndrome some socially understandable responses to horrific physical attack. “Depression” is sometimes a completely justifiable response to living a life of stress, pressure, and unavoidable obligation ( caretakers of people with Alzheimer’s/ single mothers). And don’t get me started on turning prolonged grief over the loss of a mother or spouse or child into a mental disorder. We were, as a whole, better off when people were described as “odd” or “eccentric” or “grumpy” or “so easily distracted.” None of us are perfect, but I am grateful that my quirks have not yet been pathologized (So far).
Hi, Attorney Stefan,
I understand that you are approaching this issue from the perspective of a lawyer and advocate for the rights of your clients--not as a clinician. But I must respectfully disagree with the implication that psychiatry has "...turn[ed] prolonged grief over the loss of a mother or spouse or child into a mental disorder." In my view as a mood disorder specialist, this is not the case, though I know there is much controversy surrounding the newly-added (DSM-5-TR) diagnosis of Prolonged Grief Disorder. (The name was unfortunate, in my view, and should have been, "Prolonged Dysfunctional Grief Disorder").
I believe that if you read the criteria for the diagnosis PGD, you will see that PGD differs in important respects from what is sometimes called "ordinary grief" (though arguably, nobody's grief is "ordinary" and is often anguishing after the death of a loved one). As one source explains:
"Grief is a natural response to the loss of someone close. For most survivors, the symptoms of grief dissipate over time. For a small proportion of people, however, intense and distressing symptoms of grief persist, cause problems in daily functioning, and may even pose challenges to simply getting through the day. Prolonged grief disorder is characterized by intense and persistent grief symptoms which are not only distressing in themselves but also associated with problems in functioning. Thus, those who meet criteria for prolonged grief disorder constitute a group of bereaved persons who are significantly disturbed and disabled by their grief." [https://www.psychiatry.org/patients-families/prolonged-grief-disorder]
A relatively small percentage (4-15%) of bereaved adults meet criteria for PGD. Symptoms of prolonged grief disorder (APA, 2022) include:
Identity disruption (such as feeling as though part of oneself has died).
Marked sense of disbelief about the death.
Avoidance of reminders that the person is dead.
Intense emotional pain (such as anger, bitterness, sorrow) related to the death.
Difficulty with reintegration (such as problems engaging with friends, pursuing interests, planning for the future).
Emotional numbness (absence or marked reduction of emotional experience).
Feeling that life is meaningless without the deceased person.
Intense loneliness (feeling alone or detached from others).
See: https://www.psychiatry.org/patients-families/prolonged-grief-disorder
In short, it is not so much the "prolonged" quality of PGD that marks it as a clinically significant "disordered" type of grief; rather, it is the degree of suffering and incapacity associated with PGD. I would recommend viewing the video by my colleagues,
Katherine Shear, M.D. and Holly Prigerson, Ph.D, available on the website above.
Best regards,
Ronald W. Pies, MD
P.S. Please excuse me if I have misidentified your professional position. I recall a very good exchange with you on Psychiatric Times some years ago, regarding involuntary hospitalization of suicidal persons:
https://www.psychiatrictimes.com/view/two-misleading-myths-regarding-medical-aid-dying
Dear Dr. Pies: You are kind to remember me, and kind to write so carefully in response. I am an attorney, as you recall, and have always been impressed with the care you put into what you write.
As an attorney, I have represented people with learning disabilities, rape trauma syndrome, and depression, but as you probably could tell, the grief I refer to is my own, from the death of my mother 19 years ago. I still function on a daily basis, but I don't think feeling that a part of myself has died is a symptom of anything. It's just a fact. I don't think life is meaningless without my mother, but it is certainly different, and less--the best analogy is amputation. Life goes on, but it's a different life. I think grief, like suicidality, is "normal," and "normal" in its extremes as well. Certainly people (and sometimes therapists) can be helpful, but they could be helpful without the pathologizing, which I do think is harmful. I will say that I overcame my resistance and went to a grief group, and it actually was very helpful, because it was just a bunch of people who also could not really get over their loss at the pace society expected.
Thank you, Susan (if I may) for your kind comments on my writing, and for sharing your experience with grief, following your mother's death. Let me say that in no way would I have the inclination--or the hubris!--to "pathologize" your experience of grief. I do think we encounter philosophical and practical problems when we focus on the term "normal", which is used in so many ways in medical and psychiatric parlance. For example, a finding that is statistically
"abnormal"--like a "barrel chest"--is by no means necessarily pathological.
As a psychiatrist, I am less concerned with rigorously defining "normal" than I am in identifying and enhancing human flourishing--what the ancient Stoics called eudaimonia. This is sometimes thwarted and even destroyed by certain types of suffering and incapacity--as we see, e.g., in people with schizophrenia or severe bipolar disorder. And, I would add, Prolonged Grief Disorder.
Debating how "normal" or "abnormal" PGD is leads, in my view, down a dead-end. In my view, it is an instantiation of severe suffering and incapacity, and merits professional treatment. I am glad you found that grief group helpful, and professional approaches using specific forms of psychotherapy (not, by the way, medication) may also be helpful In that regard, see: this link:
https://pubmed.ncbi.nlm.nih.gov/31622522/
Best regards,
Ron
I believe the idea of "name it to tame it" is powerful. You write:
> "Learning disability” is a way of placing the onus of a disability on a perfectly normal person with a different learning style
--- but what are "learning styles" if not named-to-tamed differences? I see the problem only in calling it a "disability," not in "coming up with a name for every deviation." I know the problem in blaming, calling something "unhealthy."
Also, "normal" has become a loaded word, but it just means "typical". You seem to have attached a value judgment to the word that it does not have. Normal is neither good nor bad. It just states what is common and what is not.
I have to disagree that "normal" has no connotations. If you are told by your doctor that you have an abnormality, that is generally not good news. If you have a baby and you are told it's not normal, that's not 'neither good nor bad.' Our society expects certain behaviors from its members, and the question is always, what are the consequences for deviating. Vance says people should be institutionalized for being homeless and yelling in the street. (Presumably MAGA people who are housed and yell at transgender people are exempt from this). I have represented people who are institutionalized for psychiatric disabilities for forty years, and always marvelled at how society decides which behavioral deviations have to be involuntarily segregated. Certainly when I worked in Montana in the 1980s, many of the people at the State Hospital took second place in the category of mental and emotional disturbance to many of the people who were living in the mountains.
Very interesting piece. But do you see the obvious danger here for valorizing mental illness as identity? Especially for young people? Clinicians incentivized to diagnose to provide a magic elixir? Mental illness as identity has already spiraled out of control on Tik-Tok.