“I can’t write with a dull pencil; I’m really OCD about that.” “God, life sucks; I’m so depressed Game of Thrones is going off the air.” I recently read an article imploring us to watch how we use psychiatric terms, like “OCD” and “depression.” Tossing off psych diagnoses in casual conversation, the article argues, pales their meaning, trivializing real emotional distress and dysfunction. Save terms like “depressed” and “OCD” for those who actually experience real depression and OCD.
I sympathize with the article’s mission. It’s a decent opening into a vexed subject: the problem of how our culture understands and talks about mental illness. But this is a subject deep, important and interesting enough to warrant a closer look than the article has time for. Despite our advancements in psychological neuroscience, and the proliferation of popular, mentally ill characters on television (House, Sherlock), there is still a ton of confusion about what mental illnesses are and what it’s like to live with one. Why do we have such trouble accurately communicating about mental illness? How can we do better?
To get a clearer understanding of why communication is hard, consider my dad.
My dad has OCD.
What does that sentence mean to you?
To some it means my dad looks and acts like Tony Shalhoub from Monk. Don’t get me wrong, Monk’s great! I have a soft spot for Monk, actually. But my dad looks nothing like Monk, and Monk’s OCD is different from my dad’s. Monk romanticizes, plays off OCD as a series of funny quirks (in this this clip, Monk rearranges his boss’s computer keyboard in alphabetical order.) My dad’s OCD also has a (dark and particular) humor for sure. But it also contains toxin. When he doesn’t manage it, dad can lose nights of sleep over bizarre and horrifying conjectures, such as the thought that he’s infected his accountant, Rick Holland, with AIDS because a (non-existent) hypodermic needle may have dropped from his pocket and onto Rick’s desk chair during their morning meeting. I’ve tried in poetry to capture something of dad’s checking ritual, the repetitive stripping of his pants’ pocket, which he performs to forestall his anxiety. From “Indispensable Tools:”
He peels the worn pocket from his pants,
cleansing the cloth of contaminates:
lint, rust, nails, needles, stray strand or particle,
the invisible speckle
of what could be hepatitis,
or AIDS. 
In any case, if we’re having a conversation, and I say, “my dad has OCD”, and you think “oh, like,”
then you haven’t understood what I was trying to say about who my dad is and what he deals with.
This is the problem that the article tries to tackle. It calls for us to safeguard the definitions of our diagnoses, so that when I say “OCD” you know I mean a serious psychological condition and not sharp pencils or a TV character.
Good start. But there’s still a problem.
Being careful with our psych terms tells us what mental illnesses are not. “Being sad because of Game of Thrones ending is not real depression.” But this kind of word-policing doesn’t tell us what mental illnesses are, or what it’s like to live with one . “So then, what is real depression?” In my experience, most people, even some who’ve experienced depression, have trouble saying.
This trouble penetrates deeper into our culture than you might expect. According to the psychiatrist Stephen Rosenman, even mental health professionals struggle with accurately defining our psychological disorders. Psychiatric diagnoses (like “OCD”and “depression”), says Rosenman in his 2008 article “Metaphor, Meaning and Psychiatry,” don’t fully clarify what our mental illnesses are, and may even, he suggests, contribute to public misunderstanding. We should travel with caution when defining and describing ourselves with psych diagnoses, especially when using them to construct our identities. For they have limitations.
Here, in short, is the problem. The science of neurology is budding and incomplete. Some brain diseases have definable neurological causes, such as epilepsy. But the chemical causes of many, classically psychological disorders, like OCD and depression, still elude us . Instead, Rosenman claims, the psychiatric field relies on lists of symptoms to define these mental illnesses, symptoms which are often described with metaphors and are more like “verbal pictures” of literary characters than the hard physiological definitions we are used to in medicine. And as verbal pictures and metaphors go, Rosenman finds our current mental health definitions useful (helpful perhaps for diagnosis), but also incomplete and limiting in the face real life psychological experience . In short, the clinical definition of “depression” can misrepresent people’s real, unique experiences of depression.
Dr. Stephen Rosenman asserts that the DSM’s definition of depression draws “a verbal picture” “of a non-existent (stereotypical) character.”
To see what that means, let’s stay with the example. The 5th Diagnostics and Statistics Manual of Mental Disorders (DSM) defines a severe depression as:
- Depressed mood most of the day, nearly every day…
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day.
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
This checklist draws a “verbal picture,” says Rosenman, not of an unique individual, but “of a non-existent (stereotypical) character.” Many of these bullet points ring true, such as the loss of self-esteem. But, despite its successes, this verbal picture is reductive; it relies too much on “dominant metaphors of depletion:” “diminished ability to think,” “loss of energy,” “diminished interest or pleasure;” it paints depression as mostly “passivity, depletion, and incapacity,” a narrowing description “buttressed…by words such as ‘flat’, [and] ‘down,’” and embodied by the metaphor “depression” itself. This metaphor of depression, Rosenman asserts, is a “withered model.” He recruits the novelist William Styron to back up his indictment of “depression” and offer thoughts for more powerful and accurate descriptions of the illness:
Melancholia would still appear to be a far more apt and evocative word for the blacker forms of the disorder, but it was usurped by a noun [depression] … used to describe an economic decline or a rut in the ground, a true wimp of a word … The word has slithered innocuously through the language like a slug, preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control.
As one who has suffered from the malady … I would lobby for a truly arresting designation. ‘Brainstorm’, for instance, has been unfortunately pre-empted to describe … inspiration. But something along these lines is needed. Told that someone’s mood disorder has evolved into a storm – a veritable howling tempest in the brain which is indeed what a clinical depression resembles like nothing else – even the uninformed layman might display sympathy rather than the standard reaction that ‘depression’ evokes something akin to “So what?”… or “We all have bad days”.
William Blake’s Nebuchadnezzar. (Shredded but miserable.) Rosenman says this depiction expresses a transformation or “mutation,” a quality not often attributed to depressive episodes. What do you transform into when in a depressive episode?
Depression as a “howling tempest in the brain.”
Literature is where Rosenman turns to complicate, expand, and nuance the DSM’s model of depression. He quotes Emily Dickinson,
And then a Plank in Reason, broke,
And I dropped down, and down –
And hit a World, at every plunge,
And Finished knowing –
(I leave it up to you to interpret this verbal picture.)
I also recall lines from Dickinson,
I’ve dropped my Brain — My Soul is numb —
The Veins that used to run
Stop palsied — ’tis Paralysis
Done perfecter on stone,
which characterize a depressive state as a stunning impact, not merely a loss of energy but a “paralysis.”
And, this line from Tony Saprano’s therapist, Dr. Jennifer Melfi: “Depression is rage turned inward.” Anger and self-abuse are elements of (at least my) depression which have largely gone unacknowledged in my therapy or pop-culture.
Literature, Rosenman claims, shows that
Depression is not just passivity, depletion and incapacity. It has various active processes of teeming thoughts, pain, horror, dread, revulsion, mutation…[These qualities] are not captured by the present diagnoses nor by metaphors of darkness, depletion, enervation and slowing.
The science is climbing upward. We’ve already produced an enormous body of knowledge on the neural basis of psychiatric disorders. In the coming years, scientists may deliver definitions of mental illnesses with a precision on par with definitions of diseases of the body, and develop reliable tests to detect them .
But in the meantime, we can’t limit our self-expression and self-understanding to the DSM, popular culture, or pervasive metaphors, such as “depression.” Therapists and psychiatrists are trained and experienced professionals, who can think outside the limits of manuals. They can help us remake our habits and motivations, and gain insight into our behaviors. But they rely on us (their patients), on the quality of our self-expression, to tell them what’s going on inside our heads—as do our colleagues, friends, and families. Our stories and metaphors can be wealthy and powerful sources of data. If we are to understand one another, we need to be attentive storytellers and creative metaphor-makers.
The current science of mental health is an invaluable resource. But our inner-lives are particular, and, ultimately, we are the ones who must describe and define them.
So, I’m calling on my people, distraught of mind and unsettled of soul, to find or invent our best, most truthful, most honest mental-health metaphors. These metaphors can be manifest in art, dance, music, poetry, in combinations. (This is why art exhibitions like “Stories Without Stigma” are important to see and donate to.) Steal them, create them. What these metaphors must be is perceptive.
So, when hunting down and composing these metaphors, no melodrama, agonizing, or pity-mongering.
Rather, critical-awareness, frank curiosity, self-acceptance, attentive honesty, and trust.
And flexibility. Don’t grip any metaphor too tightly. They are, after all, only metaphors.
I can hardly think of harder qualities to practice. But if we practice, I believe we will become wiser, more connected, more informed. Here’s my own attempt at capturing in creative language something of what it was like to grow up with my dad’s OCD.
And when you have a good metaphor, send it to me at firstname.lastname@example.org! #mentalhealthmetaphors. We might publish it.
There is another benefit to creating and reading a personal body of mental health literature.
The poet Jane Hirshfield writes, “one reason to write…is to flush from the deep thickets of the self some thought, feeling, comprehension, question, music, you didn’t know was in you, or in the world.” Poems, she says, “foment revolutions of being. Whatever the old order was, a poem will change it.”
So, I leave you with one piece of advice from Jane. When composing your metaphors, when contemplating your states of mind and searching for the right words to define them, “open the window a few inches more than is comfortable.”
 I think of my dad’s OCD as instinct moving through a medium: the instinct to check for danger moving through the medium of his body. It reminds me of a metaphor found in the Iliad, which characterizes emotions as raw elements (Greek elements remember), fire for example, moving and circulating within our bodies. As a craftsman focuses fire and shapes metal, through skill and knowledge, into implements and artworks, it is the responsibility (and birthright) of humankind to focus and shape our raw emotions, through skill and knowledge, into positive actions. If these raw emotions are not skillfully crafted, they grow wild and burgeon into dysfunction and violence. That takes honest storytelling and attentive listening.  Mental and mood disorders depend, to some extent and incompletely, on culture, genetics, childhood development, interpersonal relationships, religion, media consumption, weather, climate, physical movement, physical environment, diet, etc. Scientists and researchers are working on the problem; they are getting closer; we even have a few working medications and treatments (for some conditions, and for some people). But doctors can’t yet diagnose the precise physiological and chemical cause or provide the targeted medical treatment for, say, OCD, as they can for a condition like heart disease.  That’s without considering the effects of cultural relativity.  By the way, Rosenman makes the point that all science advances by testing, expanding and refining metaphors, or to use another word, by testing, expanding and refining models. “In 1665,” says Rosenman, “when Robert Hooke”
looked at cork through his primitive microscope, he described rows of “monks cells.” His description set up a metaphor that has dominated physiology such that it hard to think scientifically about living tissue in any other way. The recalcitrance of living tissue and the cognitive courage of practitioners and scientists have forced continuing change in cellular metaphors which organize physiological thinking and research. The solidity of the boundaries that the ‘wall’ metaphor implied has been forced to change with the addition of new metaphors – ‘channels’, ‘messengers’, ‘receptors’.
someone feeling anxious about some upcoming news might describe anxiety by saying, “It feels like I’m hanging off the edge of a cliff. Good news and I grab hold of the lifeline, bad news and I fall to my death.” This metaphor not only reflects the person’s inner experience, but also provides insight into the structure of that person’s inner world in the face of potentially life-changing news
A metaphor may capture exactly what one is feeling, but a metaphor might also hold one back or make a situation worse. That is where the process of Symbolic Modeling can be useful. Therapists can help people identify their metaphors and determine whether they are advantageous or constricting.
This post was written by Isaac Weil. Please send any questions or concerns to email@example.com.
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