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TOOLS FOR TRANSFORMING LANGUAGE

April 01, 2006

Many of us undoubtedly have thumbed through thousands of medical records and charts. In our more existential moments, we might have asked ourselves, “What is all of this? Does it really mean anything? Is it really necessary?” If we really are committed to service transformation, the way we work needs to be questioned and probably changed.

A few months ago we visited a person involuntarily brought into a crisis program. Unclear about why she was being held against her will, she asked what had been written in her chart. The first notation was “clt is 32yo, cauc F, schiz.” We thumbed through pages of progress notes, social histories, and assessments, and as we read some of the less judgmental comments to her, she began to sob:

This is so upsetting because they have it all mixed up. This is not the way things happened. Also, the way they describe me is not who I am at all. How could they know me this long and never even know who I am?

When we write about people, are we focusing on their potential for recovery, or are we bogged down in describing their problems, using shortcut code language that only means something to us and others like us? Do we describe who the person is and what she needs from us to begin, or continue, her recovery process? Or is this just a glorified record-keeping/billing process that satisfies auditors and insurance payers?

“Person-first language” is a concept that emerged from the disability-rights movement, and it affirms that individuals are first and foremost people, not diagnoses, or clients (“clt”) or patients (“pt”). Person-first language is more than just being politically correct. It frames the way we experience the people we are serving, because our use of language strongly influences our thoughts. To quote George Orwell, “If thought corrupts language, language can also corrupt thought.”

Language is a core element in developing recovery- oriented services. The same worn-out language will not help us move toward better recovery outcomes and might even hold us in old work patterns. Questioning and changing the seemingly inconsequential elements, such as language, will free us up to move ahead with our service transformation efforts.

What does transformed language look like? Let's examine how we can transform “clt is 32yo, cauc F, schiz.” When we use “clt” or “pt” to refer to a person, we distance ourselves from acknowledging her as a real person—a person just like us, but with extra life challenges. Staff have told us that when they begin to refer to people by name in charts, they immediately feel more connected to them as persons and see them as partners in recovery.

The next part (“32yo, cauc F”) tells us nothing about a person's strengths and abilities or potential for recovery, yet such terms usually appear first, implying that these are the most important factors about the person. Of course, demographic information needs to be captured. But what's more important in records is information related to recovery (all too often omitted), such as “Richard wants to find a job” or “Jane hopes to go back to school, and is asking for help in managing symptoms and issues related to her diagnosis so she can move ahead with her plans.”


TABLE. Person-centered alternatives to commonly used words and phrases

Worn-out language

Language that promotes acceptance, respect, and uniqueness

you're just

you are more than

decompensating

not him/herself today; he/she is experiencing symptoms

manipulative

resourceful; really trying to get help

crazy

unique

compliant

might not be confident about personal choices or decisions; afraid

noncompliant

beginning to think for him/herself; taking personal responsibility

entitled

aware of rights

resistant

not open to; chooses not to; has own ideas

frequent flyer

gives us many opportunities to intervene and support

baseline

what a person looks like when doing well

unmotivated

has other interests; bored; doesn't know how to begin

helpless

unaware of capabilities

hopeless

unaware of opportunities

grandiose

has high hope and expectations of self

user of the system

resourceful; good self-advocate

druggie; crackhead; junkie

person with an addiction or diagnosis of substance abuse

high-functioning, low-functioning, dangerous, danger to others/danger to self (DTO/DTS)

person is showing these issues and characteristics



The last part in our example (“schiz”) is the most disparaging. Someone might be assigned a diagnosis, but that is not who she is. A friend of ours once said, “Once I became my diagnosis, there was no one left to recover.” A transformed statement would read like this: “Jane is hoping to get a job, and is asking for help with managing her symptoms since they are making it difficult for her to stay connected to what's going on around her.” Of course, her mental health diagnosis will need to be recorded. But also important is to record recovery language. Now we know that Jane has hopes and dreams and is motivated to accomplish them. We know that she's experiencing symptoms that are making this more difficult, and we know she is hoping to make improvements. We begin to see ways our training and experience can help. We have grounds to be motivated and have hope. A record entry of “schiz” hardly conveys all of this.

Recording different information and using different language can change the way we think and feel about a person. Sure, it takes more time. But it can elevate our level of hope for her and call forward a more creative response from us and the many other staff who will read the medical record (Remember, this information follows a person around for a long time).

The table lists alternatives to some of the more commonly used words and phrases. We hope this will help you begin to come up with more recovery-oriented ways of describing people, which ultimately will lead to better recovery language and outcomes. The language guidelines developed by the United States Psychiatric Rehabilitation Association are another source on the respectful use of language (see http://uspra.org/files/public/langGuidelines.pdf).

In closing, let's rise to the challenge of considering the way we label our services, as well. Why do we persist in calling a service “case management” when people aren't cases and they don't want to be managed? Why do we provide “crisis services” when we know that people have come to us to get out of a crisis situation?

Lori Ashcraft, PhD, directs the Recovery Education Center at META Services, Inc., in Phoenix.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.

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IN THIS DEPARTMENT Behavioral Healthcare provides guidance on operational transformation to meet the increasing call for recovery-based systems.

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