Beyond Labels

by Mac Gander

A recent article in the New York Times argued that it’s OK to throw around DSM-V labels as markers of ordinary human behavior, and I largely agree with Maia Szalavitz’s point in “I Don’t Mind If You Say You Have ‘a Little OCD.’” The language of mental health has permeated ordinary discourse in a way that we take for granted now. While this can be seen as trivializing psychological challenges that are real and sometimes disabling, it also demonstrates an acknowledgement that human psyches exist on a spectrum and we all are flawed in some fashion.

But the article leaves something unexplored that I think is worth unpacking: labels carry harm as well as good. The good is undeniable, and to see it I only need to look at how disorders of the mind like bi-polar disorder and schizophrenia were treated during the time I was growing up and what treatment can be like now at its best. Likewise, in my own field of education for those who have struggled in school, the distance traveled in the span of my professional career from the language of deficit and disability to that of difference and neurodiversity has been a hard-won victory, and a good one.

But there are also two real harms involved. One harm is obvious: labels often carry stigma, and they substitute for true, nuanced understanding of difference. To say that someone has ADHD is to consign them to a category of disorder, and since very few people have a rich and nuanced understanding of ADHD, it also risks stereotyping and two-dimensional thinking. How much worse are diagnoses like bi-polar disorder, substance use disorder, or borderline personality disorder?

Beyond stereotyping and stigma, labels assigned to the mind also connote a sort of fixed state of being, an identity, in a way that physical disorders do not. We don't think of someone who has is treated for colitis or cancer as having an identity formed by those physical conditions, but to say that one is in treatment for bi-polar disorder or is on the Autism Spectrum immediately tends to reduce one to one's psychiatric label. That's a real problem, because it is false and marginalizing.

The passage that I fixed on in Szalavitz’s piece was this one: "This is another reason it’s important to recognize a spectrum that spans both‌‌ typical and ‌extreme behavior is helpful. A spectrum isn’t set in stone: People can often move along it over time, and the line between what is typical and what reflects a diagnosis is a ‌‌gray one."This seems obvious to me, but once a label has been assigned we tend to forget the point. In reality, diagnosis of mental processing is subjective, based on reports, interviews, and observed behavior, including performance on standardized psychometric tests. There are no physical tests for conditions like ADHD or OCD. Different psychological challenges may have physical effects, most obviously in the physiological dependence associated with substance use disorder, but these are sequelae to the underlying condition.My own life has had ups and downs over the decades, and during some of the down times I have been assigned various labels, mostly for insurance purposes. I can proudly count five labels--clinical depression, general anxiety disorder, post-traumatic stress disorder, substance use disorder, and attention-deficit hyperactivity disorder.

Obviously, the emotional, psychological, and behavioral elements of my being that sanctioned these findings at various times were real and part of who I am, along with a lot of other traits, all mixed together to form an identity that can't be reduced to any of its parts.

If fear and anxiety caused my low self-esteem, shyness, and social isolation and caused me to use alcohol and other drugs to overcome these things, it also drove me to excel academically and propelled me through two successful careers. If sadness and depression often watered my backyard and caused me the pain and suffering of isolation and addiction to alcohol, they also bore fruit in my writing and in my compassion for others. If my mind sometimes works in disorganized, scattered, and inattentive ways and motivation fails me when a task is dull, it also is capable of making useful, unexpected connections and in pursuing worthy projects with relentless energy and will until completion.

The question of labels is complicated, perhaps made even more so by the control that the insurance industry has over what doctors can do and still be paid. Without a diagnostic code, insurance won’t pay for treatment, which is why I carry five different labels for what is actually just one complex of psychological strengths and vulnerabilities. Labels are also useful, because it is useful to think in categories and draw distinctions. The depression and anxiety of someone who is also on the autism spectrum may be different than the same traits in someone who has ADD, and benefit from different approaches to support and treatment.

Still, it is possible to overstate the value of distinctions when it comes to providing help. In a lot of cases, the question of etiology is not a necessary guide. The case of delayed acquisition of reading skills is a good example: for a long time, children with reading problems were differentiated on the basis of whether they had dyslexia, second-language barriers, or the barriers that come from socioeconomic disadvantage. It turns out that the same basic approach to fostering reading development works well in most cases. It seems likely that this may be true in the case of other brain-based challenges.The value of labels seems limited to me—useful for insurance purposes, less so for treatment, and positively harmful in the way in which they carry stigma and substitute stereotypes and caricatures easily substitute for understanding and empathy.

If diagnosis is a gray area, and the distinction between clinical and sub-clinical manifestation of a trait are based on subjective decision process, why use them at all? Perhaps the real problem is the myth that there is anything like normality in a culture as toxic as ours has become. But the worst thing of all, to my mind, is that these labels rule out any consideration of the strengths and gifts that come with the challenges. Much of the greatest creative work of the last century —in business and science as well as the arts--was produced by individuals who had traits that are consistent with diagnoses of ADD, substance abuse disorder, depression, dyslexia, autism spectrum, or the like. To say that their work was great despite their challenges is simply a lie. Individual identity is a whole, not a set of fragments.

Downplaying strengths and gifts is a way to assert a hegemony of normalcy, one that was never useful and now has no legitimate justification at all. It is not possible to discard diagnosis altogether, especially for severe conditions, such as bi-polar disorder or schizophrenia, where effective medication may be essential. The question of whether the most common medications—like stimulants for attention disorders or SSRI’s for depression—should be subscribed as widely as they are now is an open question, but having a way to distinguish between psychological conditions that share common symptoms is certainly useful. In the end, having some way to form categories and draw distinctions is inevitable. But we need some fundamental changes in how we think about defining cognitive and emotional differences. Until we do, strengths and potential will continue to be disregarded, and individuals with their bright spectrum of human traits and abilities will keep being reduced to caricatures.