Joseph Rauch's Blog

Note: This article first appeared on Medium.com. The title of my second novel, “The Last of the Mentally Ill,” releasing in January 2022, is a reference to one of the issues I explore in this article.

For more than 14 years Natasha Tracy has been writing about her experience living with bipolar disorder. Early on in her career, a reader criticized the tone and language of one of her pieces about the condition.

“The commenter felt that because I had a large platform on which to speak, it was my duty to speak in a way that was politically correct,” Tracy said. “Because this was so early on my in writing career, I was actually hurt by this comment because the commenter didn’t appreciate my desire to express myself and my experiences in the most honest and authentic way possible.”

Over time these responses became common. Tracy was too accustomed to such feedback to feel hurt. Nonetheless, she did speak out against language policing and those who wanted to stifle her voice. Tracy wrote several pieces that addressed the growing presence of political correctness in the expression of mental health, including “Why It Doesn’t Matter If I Call Myself Crazy.”

More recently mental health advocates have pestered her about writing that people “suffer with mental illness.”

“Their logic seems to be that imposing the idea of ‘suffering’ on others doesn’t indicate that you can successfully live with mental illness,” Tracy said.

In response Tracy has argued that an illness, by definition, is a source of suffering. Writers should not sacrifice “accurate wording,” she said, only to appease a minority of critics.

Even the term, “mental illness,” has come under fire. In 2014 Tracy spoke to a group of teachers about mental illness, including her experience with bipolar disorder. One of the audience members was perturbed and asked why Tracy did not instead refer to the condition as a “brain disorder.” The participant believed the alternative wording was less stigmatizing.

Echoed by other bloggers and writers in the space, there were several points Tracy emphasized across many op-eds and blog posts. One was that she had a right to use whatever language she pleased to describe herself and her experience with mental illness. She agreed to consider more sensitive language when referring to others. But, to her, the intention of messages regarding mental illness was far more important than semantics.

Tracy worried that an obsession with restricting language might encroach upon free speech and diminish the impact of writing about mental illness. The scope of acceptable topics might become limited as well. To be powerful and compelling, she believed some stories needed to be raw and take the risk of offending people.

“Following all the rules, all the time, waters down writing and makes it toothless,” Tracy wrote in a 2012 op-ed for Healthy Place. “One could get permanent writer’s block worrying about ticking off some group of people who care about some specific word.”

Another recurring theme in her work was that the stigma of mental illness transcended diction. The underlying attitudes behind certain phrases was the problem, Tracy said, not the words themselves.

During the last decade or so there have been both tidal and subtle changes in sentiments and terms regarding mental health. Inclusive language has played a role in increasing the number of people who are comfortable joining the discussion of mental illness.

On the other hand, lawyering over language has excluded people who feel like they cannot genuinely express themselves without drawing the wrath of angry commenters. Rather than existing purely as a synonym for sensitivity and mindfulness, being “politically correct” has developed a connotation that is primarily pejorative, often followed by sighs and eyerolls. Many people believe inclusive language and political correctness are the same, that the former is, ironically, the politically correct term for the latter.

Psychologist Mike Walker, author of “The Social Construction of Mental Illness and Its Implications for Neuroplasticity,” analogized political correctness to “training wheels” for people who still need to evolve their attitudes and practices. It is at least useful for facilitating superficial changes in the discussion of mental health.

As the conversation has expanded to be sensitive to more people, the list of non-controversial words and phrases has shrunk. It is difficult to decide whether this pattern has had a net positive effect on reducing stigma and encouraging people to become educated on mental health issues.

In 2016 Ohio State University released the results of a study that proved there can be stigmatizing consequences to using certain terms and phrases related to mental illness. When reviewing stories with moral themes, participants were more likely to negatively evaluate characters described as “the mentally ill” as opposed to “people with mental illness.”

“The findings suggest that language choice should not be viewed just as an issue of ‘political correctness’,” said Darcy Haag Granello, a co-author of the study. “This isn’t just about saying the right thing for appearances. The language we use has real effects on our levels of tolerance for people with mental illness.”

The push for “person-first language” has been gaining momentum for twenty years, Granello said, and is a consistent theme in the modification to phrasing regarding mental illness. Researchers have yet to thoroughly study the many other words, terms and phrases related to mental health.

Nonetheless, it is clear the majority of thought leaders in the mental health space have embraced the logic of person-first language. Any writer or speaker who has basic familiarity with mental health terms knows to avoid using a disorder as an adjective for another person. Calling someone with borderline personality disorder “borderline,” for example (“She is borderline.”), is no longer widely accepted.

Some diagnostic terms have evolved alongside media usage. People who work with a therapist are more often called “clients,” not “patients.” In part because of the stigma of “manic” and “mania,” “manic depression” became bipolar disorder.

Now that many organizations, including the National Institute of Drug Abuse [NIDA], consider drug addiction a disorder, some believe it is insensitive to call someone an “addict.” The word has a stigma as well and is often pejorative. During one of its more recent updates, the Diagnostic and Statistical Manual of Mental Disorders began using the term, “drug use disorder.”

People who live with mental illness have introduced alternative terms as well, some of which mental health professionals have adopted. Unlike the efforts of organizations such as the NIDA, these initiatives often introduce labels that sound less clinical. The phrase, “crippling depression,” has become a popular synonym for severe forms of major depressive disorder. Adding the wording, “high-functioning,” in front of various mental illnesses has become a common linguistic pattern as well. Some career-driven millennial women with clinical depression, for example, tend to be more comfortable with “high-functioning depression.” They feel like the phrase more accurately describes their experiences.

In line with the pattern of reducing judgmental tone, some of the diction around suicide has changed. Those affected by suicide often use the inclusive language, “died by suicide,” rather than “committed suicide.” The latter risks implying suicide is a crime. This rhetoric can be alienating and upsetting to those who have attempted or been affected by suicide.

Unfortunately a few of the linguistic transformations related to person-first language and negative connotations have been inconvenient and disruptive for mental health professionals and their clients. While preparing for a presentation for social work professionals, one of the organizers told therapist Laura MacLeod she needed to remove the word, “clean,” when referring to helping clients become “clean and sober.” The concern was that such language implied people with addictions were dirty. MacLeod did not believe the edit would be helpful.

“This strikes me as wildly indirect and not at all beneficial to the population we serve,” MacLeod said.

While studying to receive her Master of Social Work degree, MacLeod led a support group called “Mentally Ill Chemical Abusers.” When she mentioned the group in a paper, her editor suggested she change the name to something less “harsh.”

The response frustrated MacLeod. None of her fellow members had voiced any issues with the name or a desire to change it. She struggled to understand why people felt the edit was necessary.

Sometimes conflicts around mental health language unfold in much more public forums. On August 31, 2016, a Twitter user started the hashtag, “#IGetDepressedWhen.” Initially most participants only acknowledged the hashtag as an opportunity to be funny and clever online.

“#IGetDepressedWhen I open my paycheck,” one person Tweeted.

Hundreds of others joked about trivial inconveniences, everything from running out of Kool-Aid to school starting up again.

Then people began criticizing the thread, claiming it was making light of clinical depression, a serious mental illness. More users jumped in, defending the language in the hashtag by citing the dictionary definition of “depressed.” These people argued the word was primarily an adjective and that those offended were being too sensitive and politically correct. The conversation quickly escalated into a virtual battle royale between people with various views on inclusive language and political correctness in the context of mental illness.

The thread still stands as a microcosm of aspects of the ongoing conflict. There are usually positive intentions behind the push for sensitive language that reduces the risk of upsetting anyone. Unfortunately some of these efforts come across as aggressive, pretentious, humorless, oppressive and counter to the principles of free speech. Mental health advocates can be overzealous and judgmental, even when pushing for diction they believe is nonjudgmental.

This behavior makes the recipients of criticism feel beleaguered rather than enlightened. Many service providers, writers and influencers in the mental health space feel as if an army of trolls are trying to rob them of their words, to downsize the vocabulary they depend on for income or creative expression. Some members of the community react by doubling down on attitudes that might be stigmatizing.

The manner in which people engage with one another during the discussion of mental health is as important as the actual issues. People are often open to being politely educated, not lectured or lampooned. Writer s.e. smith, who has frequently reported on mental illness, has been grateful when readers have respectfully informed her of concerns with language.

“I’ve definitely had readers challenge me on terms or attitudes in my work and it’s made me a better, more thoughtful journalist,” smith said. “Sometimes it’s something as simple as ‘hey, we don’t use that term anymore’ and sometimes it’s more complicated — ‘hey, have you considered that this framing is harmful for people with mental health conditions?’”

Even-tempered discourse can be beneficial in a clinical environment as well. Therapist Tina B. Tessina, Ph.D., has been practicing for more than 35 years and has seen a myriad of changes to the mental health lexicon. It has been easier for her to evolve when the dialogue is civil.

“I always appreciate when someone with a particular life experience educates me without judgment, and it’s easier to hear the information if I am not made defensive about the delivery,” Tessina said.

No matter what words we think are appropriate, all of us can benefit from being more tolerant and empathetic. Mental health advocates need to manage their emotional reactions to language they do not perceive to be inclusive. Taking a deep breath or walking away from the keyboard can make the difference between a helpful or hurtful response.

It is important to educate people on the potential impact of their diction. The study on the stigmatizing effect of referring to people as “the mentally ill” in certain contexts proved mental health language can have tangible consequences. It is likely that many other words and phrases are similarly detrimental. Until researchers completely analyze the language of mental illness, we can benefit from encouraging each other to be careful with words.

The approach, however, should be sensitive. Inclusive language represents the idea that is it wrong to exclude people. Those we disagree with should not be an exception.

Respectful discourse can accelerate the process of hashing out language. Maybe then we can significantly change the attitudes and beliefs behind the words.

If you've read "Teach Me How To Die,"Teach Me How to Die I hope it's gotten you thinking about a lot of different subjects.

This discussion guide is for anyone looking for a more formalized way to think and talk about the book, and for book clubs. I'd love to hear your answers to these questions and prompts. Thanks!

<spoiler>

READING GROUP GUIDE for
TEACH ME HOW TO DIE by Joseph Rauch

1. What is your impression of Walter as the book opens? As the book continues? Once you know the history of his childhood and dramatic experiences with and separation from his mother?

2. Why do you think the author chose to begin Teach Me How To Die with such a gruesome scene? Did you like the book’s slightly non-linear structure?

3. What did you think of the man Walter encounters in his bedroom when he first dies, the one who urges him toward violence? What did you think of the process Walter undergoes where he is allowed to experience performing horrible acts to purge himself of repressed desires?

4. Share your own conception of the afterlife.

5. How do your spiritual and religious views affect your interpretation of The Truth, the being who oversees the book’s version of the afterlife? How do David (the sex-addict/adulterer soul) and Yolanda (the nun soul) process the afterlife as a place that is far from a Christian vision of heaven?

6. Do you agree with Walter’s guide, Vincent, that “both ‘good’ and ‘bad’ men…have the same potential for horrific action” (page 35)?

7. Vincent calls The Truth “an asshole.” Explore Vincent’s negative views of humans and spiritual beings alike, and his frustrations over being a guide that he voices near the book’s conclusion. Are they well-founded?

8. What are your thoughts about Teach Me How To Die’s version of justice and judgment, as witnessed in the courtroom setting? What about the trials being viewed as entertainment for the spiritual beings; does this remind you of any historical precedents or recent/current events? Share your experiences if you have ever been on a jury or witnessed a trial from start to finish.

9. Walter muses: “What would happen in the physical realm if technology existed that could dole out rewards and punishments in the way The Truth did?” (page 79). How would you envision that possibility?

10. What lessons can be gleaned from the life, experiences, and attitudes of Hilda, Walter’s mother?

11. If you had the Right of Choice granted to you, where you could select nothingness or a fantasy, what would you choose? What do you think of Walter’s choice of “‘Nothingness is perfect for me’” (page 149), especially as he explains his decision to Vincent?

</spoiler>

I’m on the E train and a child who isn’t mine is leaning her head on my left shoulder. She is sleeping and I don’t quite know what to do yet. Her mother is to her left daydreaming, completely unaware that her daughter’s head has shifted onto a stranger. I decide to let her rest. She looks so peaceful and happy and I don’t want to wake her. The eavesdroppers and onlookers understand my decision and their judgments register on their faces. The consensus is clear: what I’m doing is strange and perhaps in violation of some unspoken social code. They don’t care enough to say anything though since talking to a stranger on a subway might violate another part of that same code. That is, most of them don’t care enough to say anything.

“That’s mad creepy, bro.”

I take my eyes off the subway floor and look up to see a pimply-faced Latino teenager with a grey hoodie that must be at least three sizes too big for him.

“Relax, man. I just don’t want to wake her up.” I say it softly but with a bit of hostility. Maybe I’m also annoyed that someone is violating the code.

“I’m just saying that’s not your kid, bro.”

His voice rises and the mother finally looks over and realizes what’s going on. She reacts as if she has just received an electrical shock and viciously yanks her daughter’s sleeve, causing her to drift away from me. Our eyes meet for a moment and the mother smiles at me weakly in a mixture of appreciation and embarrassment. She ignores the teenager entirely, shifts her head back over, and resumes daydreaming. She doesn’t utter a word.

I look back to the teenager and see him glaring at me, upset that I haven’t been punished for breaking the code. The brakes on the train screech and the teenager looks at the electronic display.

“Whatever, man,” he hisses as we near the 14th Street stop.

He turns his back to me so he can exit the train. The mother shakes her daughter awake, again without saying a word. The child opens her eyes, still in a daze. Seeing her daughter is in no condition to walk right away, the mother hoists her up and allows her to fall asleep again. The train gives a final jolt as we arrive at 14 Street and the mother nearly loses her balance since her arms are occupied. No one tries to catch her. In fact, they dodge her as if she were trying to delay them. She regains her footing in time and exits the train along with the teenager.

The next stop is West 4th, my stop. I do my usual reflection upon how “West 4th Street Station” is a misnomer since one can’t actually enter the station from West 4th Street. Then that same subway jolt tells me it’s time to get up.

When I begin making for the doors, most of the people who were within the radius of my argument with the teenager look at me. Some avert their eyes when I look back, others pretend they were looking at something else. I wonder which ones and how many of them think I was in the right and it suddenly starts to matter to me. The only spectator who maintains eye contact with me is a mother with her newborn son strapped to her chest. Her smile is almost blinding and she gives me a nod of approval. It fills me up.

I exit the car and now I’m smiling too. I’m believing that if it were to happen again, I would do the exact same thing.