The language that describes mental illness is constantly evolving. Caution is advised.
Greta Thunberg, the 16-year-old climate-change activist from Sweden, attracted the attention of America’s 45th president this week. “She seems like a very happy young girl looking forward to a bright and wonderful future. So nice to see!” Trump tweeted. This comment upset many progressives, but what really tipped them over the edge were the remarks made by the Daily Wire’s Michael Knowles.
While debating the progressive pundit Christopher Hahn on Fox News, Knowles described Greta Thunberg (who, as is well known, has Asperger syndrome) as a “mentally ill Swedish child who is being exploited by her parents and by the international Left.” Hahn immediately interjected, “Shame on you.” The network later admonished Knowles, dubbing his remarks “disgraceful” and releasing a statement that apologized to Thunberg and viewers.
But were the comments awful?
Is it accurate and appropriate to describe Greta Thunberg as being “mentally ill”?
And if not, why not?
In analyzing what is an incredibly complex question related to the evolution of psychiatry and language, it’s helpful to zoom out from both politics and Thunberg. First, a quick note: Michael Knowles is a great guy (and a friend), and whether or not you decide that the words he used were the best available, know that his meaning has been mendaciously twisted in extremely bad faith.
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The American Psychiatric Association added Asperger’s disorder to its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in 1994 as a distinct form of autism, with the following diagnostic criteria:
Severe and sustained impairment in social interaction, and the development of restricted, repetitive patterns of behavior, interests and activities that must cause clinically significant impairment in social, occupational or other important areas of functioning.
In 2013, the current DSM-5 incorporated this into a broader category of pervasive developmental disorders called “autism spectrum disorder.” Behavioral symptoms are categorized by severity. See here:
Table: Severity levels for autism spectrum disorder
| Severity level | Social communication | Restricted, repetitive behaviors |
| Level 3 “Requiring very substantial support” |
Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches | Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action. |
| Level 2 “Requiring substantial support” |
Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and how has markedly odd nonverbal communication. | Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action. |
| Level 1 “Requiring support” |
Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to-and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful. | Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence. |
The helpfulness of psychiatric categories is, of course, limited. This has been observed from within the field, for instance by the late Hungarian psychiatrist Thomas Szasz. Szasz published provocatively titled books such as The Myth of Mental Illness (1961) and The Manufacture of Madness (1970), and though he did not deny the existence of suffering, distress, or mental conditions themselves, he believed that their status as diseases were flat-out wrong.
Rather, “psychiatrists are not concerned with mental illnesses and their treatments,” he argued. “In actual practice they deal with personal, social, and ethical problems in living.” He also considered psychiatry inherently political. Szasz wrote that diseases — much like Virchow’s concept of cellular pathology — were necessarily physical. And he therefore argued that “mental illness” is merely a metaphor: “Minds can be ‘sick’ only in the sense that jokes are ‘sick’ or economies are ‘sick.’”
Though this view has never been accepted in mainstream psychiatry, it has elsewhere. For instance, in Illness as Metaphor (1978), Susan Sontag similarly argued that the language we use to describe illness is figurative and morally loaded. Though Sontag — who had breast cancer when she wrote Illness – was primarily discussing physical diseases, her point may be even more applicable to mental illness. She wrote:
The romantic idea that the disease expresses the character is invariably extended to assert that the character causes the disease — because it has not expressed itself. Passion moves inward, striking and blighting the deepest cellular recesses.
Coincidentally, this is the precise reason that the term “mental health” was invented. Indeed, at the turn of the 20th century, medical professionals and those championing institutional reform of asylums hoped to reduce the stigma of “mental illness” by softening the language and its connotations. However, for obvious reasons (one being efficiency), the effort to describe depressed or psychotic individuals as having “poor mental health” (as opposed to being “mentally ill”) did not easily catch on. Accordingly, there has been inconsistent usage ever since, so that describing the homeless schizophrenic as “mentally ill” may be tactful, while describing the autistic teenager this way — for example — comes across as an insult.
This is odd, certainly. And not least because “the risk architecture of autism may not be profoundly different from schizophrenia” and since “new findings in schizophrenia and autism place these disorders squarely in the field of complex genetic disorders,” according to Thomas Insel, a neuroscientist and psychiatrist and the director of the National Institute of Mental Health. Of course, Insel is — as scientists ought to be — extremely careful not to overstate the genetic component of these disorders. “Recent progress is indeed a giant step forward for the field, but it is one step on a long journey,” he says. “Complex genetic disorders, by definition, will not yield a simple genetic test for diagnosis.” Nevertheless, he also makes an interesting point about the language that lay people use to discuss mental disorders:
What I’ve been talking about so far is mental disorders, diseases of the mind. That’s actually becoming a rather unpopular term these days. . . . For whatever reason, it’s politically better to use the term “behavioral disorders” and to talk about these as “disorders of behavior.” Fair enough, they are disorders of behavior, and they are disorders of the mind. But what I want to suggest to you is that both of those terms, which have been in play for a century or more, are actually now impediments to progress, that what we need conceptually to make progress here is to rethink these disorders as brain disorders. [Emphasis added.]
The reason Insel seeks to shift the focus from behavior to brains is that behaviors, he says, are the symptoms. In focusing purely on symptoms, we neglect our duty for early detection and intervention, which — in the case of physical ailments — can be life-saving. Of course, not all mental disorders listed in DSM-5 have equal claim to being “brain disorders.” Attention Deficit/Hyperactivity Disorder (ADHD), for instance, is widely overdiagnosed, while other disorders, such as gender dysphoria (formerly gender-identity disorder), can be significantly influenced by social contagion.
Indeed, one of the greatest challenges in the field of psychiatry has been that research into the genetics of psychiatry has been — until very recently — largely unfruitful. Nevertheless, of late, there have been some promising (if minor) developments. For instance, in a study entitled “Patches of Disorganization in the Neocortex of Children with Autism,” in the New England Journal of Medicine, medical researchers compared — brace yourself, it’s science — “fresh-frozen” brain tissue from dead autistic children with tissue from a control group of dead children without autism. They found some striking brain abnormalities in the autistic cohort and noted that these abnormalities seem to have begun in utero. So we might say with relative confidence (relative only to the complete dearth of research that came before) that even by Szasz’s definition, autism is, indeed, an illness.
But does that mean we should describe people with autism as “mentally ill”? Possibly not. It is, of course, tempting to dismiss all such evolutions in modern language as “political correctness.” In my view, this is mistaken. Words that help or hinder the mentally vulnerable matter. For instance, the word “retard,” once commonplace, is now considered offensive. And good riddance. As we move toward a kinder, gentler world, psychiatric terminology will inevitably keep pace — Szasz was right that psychiatry has an unavoidable political dimension. But psychiatry must, must, must remain wary of malign political and ideological influence (please see gender dysphoria).
Moreover, common sense and decency require that we respond in good faith when we do think that someone has used the “wrong” word. Because this stuff is tricky, folks. And each of us is flawed.