Language of health care

I have to say that my interest in words is elemental. I study words, enjoy them, and gaze at them as one would a sculpture. Indeed for me, a word is a sculpture. Imagine the word ‘obfuscate’, the ‘fus’ in it has all the attraction for me, of carrion for ravens, it is a basic even primordial attraction. Much like eyes has for a splendid curve. So, it is true it is not language itself, not sentences, not prose but words that delay me, that keep me awake at night, that I dream about and imagine and feast upon. As J-P Sartre said

‘poetry is on the side of painting, sculpture, and music…It does not use [words] in the same way [as prose], and it does not even use them at all. I should rather say that it serves them. Poets are men who refuse to utilize language’.

Sartre went on

‘it seems at first he has a silent contact with them [words], since, turning towards that other species of thing which for him is the word, touching them, testing them, fingering them, he discovers in them a slight luminosity of their own and particular affinities with the earth, the sky, the water, and all created things’.

I might add that for me words can be beautiful, ugly, tactile, euphonic, slender, robust, rotund, emaciated, empty, dense and so on. Some of the trends in the use of language within the NHS are irksome and distressing, some comical and incomprehensible. Think of the little boy in the tub out in the South China Sea. It is a surprise to see him paddling in the ocean that one imagines that one’s mistaken. Actually he is a grown up in a yacht! That is how language in healthcare sometimes operates. It can be deceptive. My aim is to talk about this kind of language. I shall examine the titles of government green and white papers, I shall examine some of the changes in use of language in clinical psychiatry for example, and finally I will ask what is it that motivates these changes. Are these language uses driven by the same factors that linguists believe drive language in general? Or is there some other hitherto unrecognised malevolent impulse at play?

Governmental language of health

Since the new coalition government in May 2010, there’s been a subtle shift in the language of healthcare. The old language is out and the new language is in. This is exemplified by shifts in emphasis such as

Bottom-up rather than top-down
Local rather than regional/national
Society rather than state
Social responsibility rather than stakeholder
Principles-based rather than evidence-based.

The Labour government ushered in and entrenched its own language in 1997. The most memorable were partnership, stakeholder, clinical governance, excellence as in (NICE) & clinical excellence awards, world class commissioning, and choice agenda. It also consolidated the use of commercial language within the NHS so that instead of financial audit there was now clinical audit, instead of managers, there were CEOs, executives and non-executives of boards, and business plans and audit trails became the order of the day.

Here are some of the titles of green and white papers from 1998 onwards:

The new NHS: modern and dependable.
Our healthier nation: a contract for health.
Our health, our care, our say
Shaping the future together
Liberating the NHS

These titles suggest an aspiration for government to work with the wider population towards something desirable and good. It starts off with ‘the new NHS’ and continues with ‘our healthier nation’ and so on. Of course, M&S have since discovered that the tagline ‘your M&S’ is more user friendly! So I suppose we might in due course see titles that say ‘your NHS’, ‘your health, your care’, etc. What is obvious is that government recognises the importance of language as a tool in shaping the response of its audience and also recognises that there is scepticism, even cynicism in its audience, therefore there is a need for language that declares a common, shared interest, and that is collaborative in intent, hence the use of ‘our’. On occasion, the language can be mystifying: very few people had realised that the NHS was in need of liberation from a colonising force by the joint efforts of Comrades Cameron and Lansley before the publication of Liberating the NHS! In truth, whatever the intentions of government, the titles of these papers belie the unilateral thrust of much of government action and direction of travel.

The language of mental health

For much of my career in psychiatry, language use and modifications of the conventions exemplified by language change have been central to the practise of psychiatry. I will not delay by exploring changes of terms such as ‘dementia praecox’ to ‘schizophrenia’, of ‘manic-depressive psychosis’ to ‘bipolar affective disorder’, or of terms such as ‘idiot’, ‘imbecile’ to terms such as ‘mild and moderate mental handicap’. These changes are interesting and some of the determining motives in these changes are important and interesting in their own right and I might return later to talk about them.

My concern is to examine terms such as “community care” as opposed to “hospital care”, “home treatment”, “early intervention”, “mental health problems” as opposed to “mental illness” or indeed “mental health” coming to stand as a synonym for “mental illness” as in “he has mental health”. Finally in this list is the term ‘recovery’ which is used to mean ‘lack of recovery’ but in a positive manner, that is to give hope. For example a recent article wrote as follows:

‘Recovery’ is usually taken as broadly equivalent to ‘getting back to normal’ or ‘cure’, and by these

standards few people with severe mental illness recover. At the heart of the growing interest in

recovery is a radical redefinition of what recovery means to those with severe mental health problems.

Redefinition of recovery as a process of personal discovery, of how to live (and to live well) with

enduring symptoms and vulnerabilities opens the possibility of recovery to all. The ‘recovery

movement’ argues that this reconceptualisation is personally empowering, raising realistic hope for

a better life alongside whatever remains of illness and vulnerability. This paper explores the background

and defining features of the international recovery movement, its influence and impact on

contemporary psychiatric practice, and steps towards developing recovery-based practice and services’.

These uses of words and language in psychiatry mimic some of the use of language by the government; they are conscious attempts to alter the meaning and emotional value of words for a defined purpose. This is a good place to ask what are the factors that determine change in language use?

I am no linguist and must therefore rely on Thomas Pinker and Guy Deutscher to guide me. In talking about ‘spoon’ Deutscher wrote

‘Initially, it seems odd that the meaning of ‘spoon’ has managed to change so much over a relatively short period of time. What is more, such somersaults in meaning may appear alien to the very purpose of language, namely providing a stable system of conventions that allow coherent communication. For how can speakers reliably convey their thoughts to one another if the sense of the words they use can suddenly change?’

Deutscher argues that the motives for change are economy, expressiveness and analogy. Economy refers to the tendency to save effort, expressiveness to the speakers’ attempts to achieve greater effect for their utterances and to extend their range of meaning, and analogy is the mind’s requirement to establish order.

Let’s concentrate on ‘expressiveness’. We need to keep in mind here, that these motives refer to the inner restlessness in language for change and not to the positive actions of those who Pinker refers to as ‘language mavens’ whose desire is usually to crystallize language in a state of statuette elegance, close to some purported past glorious age.

A good example of how expressiveness works in our time is the change of meaning of the word “wicked”. The word “good” has lost much of its immediacy and power so that in response to the question ‘what was the gig like?’ “good” seems hardly an adequate response compared to “wicked” which captures the thrill and danger of the new music and its exquisite vibrancy! Such words as ‘resent’ that, originally meant ‘appreciate’, have radically changed meaning, much as ‘wicked’ is doing now. Excessive intensifiers also do the same sort of work: extra-, super-, and hyper-, as in extra-strong, superhuman, and hyperactive. These new words appear to be responding to the debasement of the ordinary words.

However in the NHS and in psychiatry, language change is conscious and deliberate rather than fuelled and driven by the inner restlessness of language itself. This is where George Orwell comes in.

1984 & Borges

In the Appendix to 1984, ‘The Principles of Newspeak’, Orwell wrote

‘Newspeak was the official language of Oceania and has been devised to meet the ideological needs of Ingsoc, or English Socialism…The purpose of Newspeak was not only to provide a medium of expression for the world-view and mental habits proper to the devotees of Ingsoc, but to make all other modes of thought impossible. It was intended that when Newspeak had been adopted once and for all and Oldspeak forgotten, a heretical thought – that is, a thought diverging from the principles of Ingsoc – should be literally unthinkable, at least so far as thought is dependent on words’.

Here Orwell makes plain the drive behind Newspeak, which is to control thought:

‘Its vocabulary was so constructed as to give exact and often very subtle expression to every meaning that a Party member could properly wish to express, while excluding all other meanings and also the possibility of arriving at them by indirect methods…Newspeak was designed not to extend but to diminish the range of thought, and this purpose was indirectly assisted by cutting the choice of words down to a minimum’.

At least this way, it could be guaranteed that Ingsoc members would be ‘on message’, no need then for pagers that minute by minute tell members what to think or say in response to queries from the Press. Newspeak was a political programme that limited how the word ‘free’ could be used. ‘This dog is free from lice’ and ‘this field is free from weeds’ were possible constructions but not ‘free’ as in ‘free to think’ or ‘free to do as you please’. As Syme said to Winston ‘Do you know that Newspeak is the only language in the world whose vocabulary gets smaller every year?’

What is frightening even terrifying about the language of government and of some of the language deployment in psychiatry is the combination of Orwellian ‘doublethink’ and ‘newspeak’! Doublethink is characterised by knowing and not knowing, of being conscious of complete truthfulness while telling carefully constructed lies, of holding simultaneously two opinions which contradict one another, repudiating morality whilst laying claim to it. ‘Even to understand doublethink involves the process of doublethink’. In the new language, it can both be true that one does not fully recover but that one does recover! It can both be true that we can make choices of where to be treated but have an even more restricted choice than ever before. The NHS can be ‘modern and dependable’ yet ‘old and unreliable’. We can have ‘world class commissioning’ that fails any test of commissioning for its local, very parochial community’. Or we can have ‘a contract’ that is only a word that suggests a legal document which isn’t legally binding.

I want to end by way of reference to my favorite writer, Jorge Luis Borges. It is said that Borges once claimed that the basic devices of all fantastic literature are only four in number: the work within the work, the contamination of reality by dream, the voyage in time and the double. For Borges, the problem of illusion and reality is at the heart of literature. And we are all of us fabricators, making up our world anew everyday, trying but often failing to decipher the symbols around us. In this quest we are endlessly immersed in language, continuously grasping and grappling with words to say what we feel and think, trying to tie down that which is indefinable and amorphous, that which is vague, subtle, evanescent, formless. And the world like Borges’ Tlön is mere chaos, an irresponsible license of the imagination and it is language that orders and preserves it for us. Not the language devised for politics, not the language that aims to restrict imagination even for good reason but the language in which great writing is done because there is so much more to write and say for ‘the certitude that everything has been written [or said] negates us or turns us into phantoms’.