John Launer: Words I want to ban

Which words or phrases would you like to see disappear from doctors’ vocabulary? I’d nominate three: “lacking insight,” “in denial,” and “manipulative.” For me, they all smack of moral judgment masquerading as diagnosis.

Let’s start with “lacking insight.” Although it carries a vague impression of psychiatric precision, it often means simply that the patient isn’t seeing things the same way as their doctor. It avoids two uncomfortable truths. One is that we all probably lack insight in someone else’s eyes (often the patient’s) but would feel deeply affronted if they said so. The other is that the term is an easy alternative to trying to understand what motivates the other person—for example, that they drink alcohol or take drugs to cope with a state of mind they’d otherwise find hard to bear. It also makes a generalised or global claim about someone, an error that some people call “essentialist”: in other words, a simplistic description that attributes a single characteristic to a person or group in place of any nuance or complexity.1

Saying that someone is “in denial” is open to the same objections. Doctors who use this phrase usually have in their mind an imagined set of emotional responses that everyone is meant to feel in a given situation (anger when thwarted, prescribed stages of grief after loss, and so forth). They’re certain that they’d have these feelings themselves, even though they possibly wouldn’t, and they assume moral superiority as a result. Doctors seem to apply this kind of thinking especially in the context of bereavement. In these and other circumstances, they may ignore any personality quirks or varieties of human psychology that lead some people to react in their own unique way. The lazy use of the term “denial” also appears to exculpate doctors from—God forbid—demonstrating curiosity about exactly how a particular individual is responding and what’s made them do so.

As for “manipulative,” I scarcely know where to begin. We all manipulate others all the time. It’s one of the chief functions of language and human interactions generally—and an entirely legitimate one. We speak to achieve effects, whether it’s ordering a cup of coffee, inviting sympathy, or claiming support for our point of view. Patients come to doctors because they want things that we’re paid to provide. We speak to them as we do because we want them to follow our advice, or we need to get them out of our consulting rooms on time.

When doctors describe someone as “manipulative” what they really mean is that a patient wants something that the doctor, rightly or wrongly, believes they don’t deserve. Whether the patient’s request arises from distress, a misunderstanding, or any other cause, it’s no more or less manipulative than the doctor’s disinclination to say yes. Please can we retire all these expressions and just talk about having different perceptions, expectations, or wishes from some of our patients—and about finding some common ground when we do?