The other day, a colleague of mine called me to consult on a case. The client was a young adult who had been diagnosed with autism. At one point she said, “His black and white thinking is caused by his autism…” My heart rate instantly quickened and before the apoplexy could do too much brain damage I interrupted her and curtly said, “No. His black and white thinking isn’t caused by his autism, his black and white thinking causes his autism.” She seemed confused, so I did my best to explain the damage that can be done by reifying labels. I probably did a lousy job, because her mystification lingered. I don’t know if I can do it better now, but I have the advantage of being able to cut and paste, so here we go.
I told my colleague that the more you rely on a label (a diagnosis) the less you are likely to know your client. Although it’s helpful, indeed necessary, when starting out in any field to learn the jargon, and thus have a convenient shorthand for describing a phenomenon and reducing the morass of information into manageable wholes, it can also lead us down wrong paths. It is no accident that the more experienced a clinician the less jargon you will hear.
Humans are simply far more different from each other than we are alike. The self-proclaimed “autistic” psychology professor Stephen Shore is credited with the cute saying that “If you’ve met one person with autism, you’ve met one person with autism.”
Diagnostic labels obfuscate more than they clarify. Reducing someone’s personality to a group of symptoms does serve to focus on what some have concluded are the most meaningful bits and pieces, but by doing so we too easily fail to see the richness and contradictions of those behaviors that lie outside what we expect to see, and that makes us prone to errors. If the label we give to the jar with the white powder in it is “flour” then that is what we expect will be in the jar, not the sugar that you put in the wrong jar when you were preoccupied with getting the internet upgraded. It is not necessarily that it becomes a self-fulfilling prophecy (although it could, if a therapist subtly steers his or her client toward the expected set of symptoms through explanations or interpretations that elicit those symptoms), but rather that the therapist actually “misses” the deeper truths of who is sitting opposite.
Diagnoses are, essentially, metaphors, in the same way Susan Sontag brilliantly described cancer as a metaphor in her seminal essay “Illness as Metaphor.” Metaphors can be compelling ways to describe things, but they are not the same as the things we are describing. You can’t meaningfully say that John is schizophrenic any more than you can put a blanket of air on your bed, shoot an idea, buy a moral compass from the nautical supply shop, or really give me a piece of your mind. That is not to say that—like John the Baptist, I cannot be a good shepherd even though I have no sheep. What I do mean to say is that I may indeed be a good shepherd, but I am much more than that, and by the way, I have goats (well, I used to). As the semanticist Alfred Korzybski famously said, “The map is not the territory.”
Another Hungarian hero of mine– Thomas Szasz, made a career out of professing that psychiatric diagnoses were essentially a form of social manipulation. A psychiatrist himself, Szasz insisted that he was not anti-psychiatry, but anti-coercive psychiatry. He saw psychiatric diagnoses as socially constructed with little to no medical evidence to support them, to be used, perhaps, to remove someone’s freedom (as in the case of hospitalizing a schizophrenic), cast someone aside from society (such as calling homosexuality a disease, which although eventually abandoned was done for decades), or sell drugs that don’t work or cause more harm than good.
Too many wrong roads are driven when we begin to think that the metaphor is the real thing. The depth of personhood, the miraculous complexity and uniqueness of each individual, is transmogrified into the label we put on the package. Korsybski once dramatically demonstrated this when he took a break from a lecture to eat some biscuits that had been wrapped in white paper. After commenting how much he enjoyed them, he offered some to students in the front row, who enjoyed their taste until Korsybski removed the white paper to reveal that they were dog biscuits. The students became nauseated, and Korsybski said something to the effect that we not only eat food, but we also eat words.
The problem with my colleague stating that her client’s “black and white thinking was caused by his autism” is that “autism,” as are most psychiatric diagnoses, is merely the label on the dog biscuit package. It may or may not have anything to do with what is inside the package, but instead may have everything to do with what we think is in the package. The truth is that, to this day, as is so with many things, we scientists know a lot about what the collection of symptoms we call autism looks like, but we don’t know much at all about how it comes about, or what goes on physiologically to cause those symptoms.
When we reify something, we also give it a static quality. We take something that should be a verb and turn it into a noun that just sits around on a shelf waiting for someone to pull it off. And in doing so, we begin to think that there is little we can do with it. If we only referred to John as a noun, as proper as that would be, we would imagine him standing somewhere. But if we said he was “Johnning,” we would imagine all that he does that makes him tick. Saying someone has autism, or depression, or even a virus, leaves us little to do with it, freeze-drying it as it were, and even creates a bit more distance between us and them. If autism, or any diagnosis, was a verb rather than a noun we would be more interested in what it does and how it works, thereby bringing it to life and moving us to engage with it.
Another problem with my well-intended colleague’s comment is the direction of causality. We need to know the territory before we can draw a map, but drawing the map will not create the territory. We could say with some certainty that the more it rains the more umbrellas will be sold, but no matter how many umbrellas we buy we can’t make it rain. Does giving someone the label of autism make that person lose the ability to perceive life’s grays, or does the inability to perceive gray cause us to give someone the label of autism? And if, as I would insist, it is the latter, then what useful information does that give us? And if we make the mistake of reversing causality, thinking that this thing we call autism causes black and white thinking, it could freeze us in our tracks. We would have succeeded only in thinking we know something that we don’t, becoming autistic-like in our thinking and missing the grays, the subtleties that might lead us down different and potentially fruitful paths.
My colleague fell into a dangerous trap, but although the landscape of our language and everyday thinking is littered with those traps, no experienced clinician or practitioner of life should fall into them. Confusing the map with the territory is something that ultimately can hurt our clients when the label is a psychiatric diagnosis, and when the labels we serve up are liberals, conservatives, Palestinians, Moslems, Jews, Christians, or maybe even Hungarians, we may succeed only in creating obstacles to understanding each other.