Restoring Clinical Clarity: Why We Shouldn't Be Afraid to Say ‘Mental Illness’
Clinicians have increasingly avoided terms such as 'mental illness', 'mental disorder', and 'mental injury'. This essay examines why this linguistic shift is harmful.
In recent years, the term mental illness has become so stigmatised that counsellors, psychotherapists, and mental health practitioners are now being told to avoid it altogether. While this might seem progressive, it carries unintended and damaging consequences. By softening or abandoning the language of mental illness, we risk eroding the very foundations of the therapeutic process.
When I was a student counsellor, my lecturer taught me to always ask, “What’s going on? Now what’s really going on?” This has always been a key tool for me to understand the clients I work with. Mental health clinicians use diagnostic frameworks not to label or diminish people, but to help them understand and support those in distress. To describe a condition as a mental disorder or a mental injury is not a moral judgment—it is a clinical description that shapes treatment and recovery.
As psychiatrist Allen Frances (2013) observed, a diagnosis is only justified if it benefits the patient by guiding effective treatment and improving outcomes. Recognising the pathological drive toward medical transition provides clinicians and clients with a clear diagnostic framework. When people try to shame mental health practitioners for using this terminology, they impede clinicians’ work.
Without the language offered through the mental illness construct, the therapist is like a carpenter working without their tools. This is why it is essential that therapists protect their right to use precise clinical terms. If therapists dance around these terms, refusing to use them for fear of somehow offending the client, then they are doing their clients a disservice. Colluding with the client that they are fine when in reality they are in deep mental anguish as a consequence of a harrowing mental illness is neither kind nor helpful. It requires a lot of skill and extraordinary attention to the client-therapist relationship to handle this, but it is imperative that clinicians recognise this is part of their work, because to do otherwise leaves the client in isolation with no concept or construct to understand what they’re going through.
“When you want to help people, you tell them the truth. When you want to help yourself, you tell them what they want to hear.”
—Thomas Sowell
There is a key moment in the therapeutic process, typically when the therapeutic alliance is well-established and the client is ready to trust in the process, when the client becomes honest. This moment might not last long – only a few seconds for the more defensive clients – but longer for most. At this crucial juncture the individual’s shoulders might drop, a heavy silence comes into the room, two people are meeting in an intense moment of truth. The defences are down and the client is finally ready to speak about their most secret fears and thoughts.
Most of us know when we have mental demons driving us. We know when we are avoiding reality or using complicated strategies to escape our mental pain. Most of us are also ready to accept the truth – just for a moment - behind these defensive strategies when they are faced with another human – the therapist in this context – who will offer care, insight and compassion.
It is the task of the skilful clinician to help the client reach this moment and meet its gravity without shying away from the truth. The therapist must be able to convey a clear understanding of what may be happening—not didactically, but with understanding and sensitivity.
Empathy is a word that is often overused; however, it is less well known that empathy not only includes the ability to feel what the other person is feeling but also the capacity to communicate that feeling. At that moment of truth, the therapist must ensure that empathy is clearly communicated.
It can be very heartening and healing for the client to realise that their darkest thoughts and most erratic behaviour is not unique and that many others have felt the same. The dawning awareness that their most guarded secrets are shared by many others can be transformative. People often feel more in touch with humanity when they come to realise that their idiosyncratic ways of coping with profound mental pain are also experienced by other people. Through this shared clinical construct, the client realises that they can come to a deeper understanding of themselves and also, importantly, there are other ways forward.
We clinicians need to be able to speak clearly about suffering and mental illness in the right way and at the right time. If we are to provide meaningful therapeutic care we need to be able to speak about the elephant in the room. That is our job.
A recent essay by James Marcus in The New Yorker shows how good people have lost their way through WPATH’s campaign to depathologise medical transition. Marcus describes his love for his adult son and his confusion about the young man’s mental health decline.
He is trying to make sense of his child’s mental health decline in a world where he is told this is not a mental health decline, it is simply a matter of identity and it should be celebrated. Marcus mentions his son’s interest in pornography and inappropriate sexualised language to his father. But he has no ability to follow the dots, because the clinical construct has been removed from the lexicon as a direct consequence of WPATH’s campaign. Of course Marcus doesn’t know this. He only knows that he loves his son and his son requires total surrender to the trans identity. Marcus is experiencing ambiguous loss. He knows something is wrong and his heartfelt essay is an attempt to understand the issue. Yet, stripped of the clinical language needed to make sense of it, Marcus is left analysing his son’s life with only half the pieces of the puzzle.
The new reluctance to use the term mental illness within mental health has contributed to a wider cultural confusion about what constitutes a mental disorder. It also colludes in the stigmatisation of people who experience mental illness. In the case of gender dysphoria, the medical establishment has increasingly framed the desire to medically transition as an unquestionable expression of identity rather than a possible symptom of psychological distress. This reframing makes it almost impossible for clinicians to address the underlying factors that may accompany a person’s wish to alter their body.
The rush to medical transition as a first-line response has led to experimental interventions driven by social contagion and reinforced by medical collusion with pathological belief. Protecting patients from such harms is a moral and professional obligation, not an act of intolerance.
In every other area of psychiatry, structured diagnostic models provide the common language and thresholds needed for consistent assessment and ethical care. The extreme overvalued belief model fulfils this role for pathological fixation on medical transition.[1] It offers clinicians the terminology and clinical guidance required for safe, ethical and effective practice.
Reclaiming the term mental illness is not an act of regression—it is an act of responsibility. When we restore this language, we restore integrity to the way we speak about human suffering. To deny it is to deny reality, and to silence those who work daily to heal minds and protect lives.
[1] An extreme overvalued belief is a rigid, emotionally charged conviction, often reinforced by a group or subculture, that intensifies over time, resists challenge, and drives harmful or dysfunctional behaviour.
When I was an intern in 1973 I worked at the student health service of a major university. I was asked to perform an emergency evaluation of a young man who was under the care of one of the medical doctors at the health service. The patient spoke to me freely but not always understandably, because much of his speech consisted of delusional word salad. I had no doubts about his diagnosis, which was unmistakably schizophrenia, so I recorded it with my chart note. Very soon afterwards the attending physician called and went off on me in a highly unprofessional manner, shrieking about how she "NEVER put(s) a LABEL in a patient's chart."
I consulted with one of the staff psychiatrists about the incident, and he told me that this particular internist had "been a problem" for other members of the psych staff as well. He advised me to "educate her" about the difference between "a LABEL!!" and a diagnosis, using a common physical diagnosis like diabetes for comparison. I was too intimidated at the time to attempt to take on the physician so I didn't, but the incident taught me about the existence of medical professionals who go nuts when they see a diagnosis of mental illness in a patient's chart.
I thought we were over that kind of nonsense by now, at least in the healthcare professions, and have been dismayed by the emergence of the "neurodiversity" movement in recent years. First we had a major amount of concept creep in the areas of neurodevelopmental diagnoses, such that too many kids were being diagnosed with ADHD, autism, or combinations of the two. Then both of those diagnoses were converted into marks of distinction with the presence of impairments being denied. Many of the diagnosed children do not have the impairments associated with autism, and many of the so called ADHD cases are probably cases of anxiety, personality disorders, and other psych issues, so none of them should have been diagnosed with a neurodevelopmental disorder in the first place. A diagnosis of any mental disorder requires that the patient have impaired functioning that fits that diagnosis.
Ms. O'Malley rightly states that the healthcare professionals who engage in suppressing diagnoses of pathology or refuse to acknowledge the dysfunction that accompanies these diagnoses are colluding with stigmatization of mental illness. The professionals themselves are the ones who are judgmental towards people who have mental disorders. They respond by denying the real problems patients have, then project their own judgmental attitudes onto other professionals who speak more frankly about diagnoses, and punish those colleagues for doing their jobs.
Thank you for pointing out the New Yorker article by James Marcus. It was sad for me to read--and it seemed sad for him to write. I'm surprised that a self-described "bookish" person wouldn't research any further than Jan Morris's CONUNDRUM and Rachel E. Gross's VAGINA OBSCURA. He didn't educate himself. But then, the ambivalence in his voice perhaps shows he couldn't bear to.