But handles aren’t doors.

It’s my job to label people.

That’s not how I like to think about it, but that’s how patients sometimes see the diagnoses doctors give them: like we’ve slapped a sticker on them that says, “Dangerous! Don’t touch!” And I get that. There’s been great progress in the public perception of mental illness, but there’s still a lot of negativity compared to physical health problems. Depression still gets taken less seriously than diabetes. And it’s worse with a diagnosis like schizophrenia, which people sometimes react to like they’ve been cursed.

Not everyone experiences a diagnosis so negatively, though, even in psychiatry. For some, a diagnosis is liberating: the realisation that a combination of symptoms that felt random and disconnected and strange actually has a name, is actually known, and there’s something that can be done about it. For people like that, the diagnosis is still a label, but in this case, it’s a label for something they were afraid didn’t have one.

Labels are not the issue. The issue is us, and how we use labels.

Which brings us to Procrustes and his bed.

A gruesome Greek legend

You may have heard of him, but just in case you haven’t, here’s the lowdown. Procrustes was a figure of Greek legend who had an inn on the way out of the city of Athens. He would invite passers-by to spend the night in a bed that he promised them would be a perfect fit. Those who took him up at his offer would find themselves waking up in the middle of the night to find Procrustes at the end of the bed. If they were shorter than the bed, he would be stretching them to fit, and if they were taller, he would be amputating their legs to size. And here’s the kicker: nobody ever fit the bed exactly.

It’s a gruesome story, but like many myths, it speaks to a sober truth: the unfortunate human tendency to fit people to things, rather than things to people.

You’ve probably thought by now of a few examples from your experience. The thing to remember, though, is that the problem in the story of Procrustes isn’t the bed—it’s Procrustes himself.

But not everyone thinks that.

To label or not to label?

You might have noticed that one way people respond to Procrustean situations is to focus on the beds.

At one extreme, there are those who actually argue that mental health diagnoses are bad and should be discouraged. Fortunately, that’s a minority view—imagine all the people who actually find diagnoses liberating who would lose out. But we must remember that extremes of a problem can sometimes distract us from its more insidious forms. An example of such an insidious form is the way people sometimes deal with sensitive subjects like mental disorder by simply not acknowledging it.

The danger with that, though, is that losing our ability to talk about things doesn’t stop us thinking about them. It does, however, mean that we will think about them less clearly. And worse, it means that when people act based on labels they’re not even articulating, we can’t even talk about it, because they’re not conscious of the labels they’re working with. The things we don’t name don’t disappear, they simply continue to influence us from a deeper level, while being inaccessible to us.

That’s why a key aspect of therapy is simply naming things: because you have to name things to do anything meaningful with them.

In the Bible creation story, one of the first tasks given to the first man was to name the animals. And again that story highlights a key idea: that the act of naming things—of labelling—is key to what it means to be human.

If that’s true, though, it’s no surprise that the act of naming carries both great potential and great risk.

You know what else carries both great potential and risk?

Fire.

Labels as fire—and other labels…

Heads up, we’re going to look at several metaphors here.

Let’s begin with fire.

Fire is one of humanity’s greatest hacks. Through fire, we’ve been able through history to increase our sources of food, to keep ourselves warm, to manipulate even metal. Fire is so important that another Greek myth depicts it as something stolen from the gods. And yet fire is dangerous, a force that can damage individual people, and if it really gets going, even destroy whole communities and cities. And yet, we don’t eliminate it. We learn to manipulate it, to work safely with it and continue to use it even now when electrical heat is so much more widely available.

Fire is powerful, but it’s how we use that power—or let it act—that’s good or bad.

Same with labels and naming things.

How then do we contain labels like we do fire? Time to switch metaphors. Because there’s a bunch of, well, labels, that we can use to think about labels.

  • Labels are like boxes. They’re containers for putting things in. The problem then isn’t using a box, it’s misusing them. Just as you box things when you move houses, you also store information daily in mental boxes, but the box doesn’t define the contents, it’s just a container to make it easier to find stuff: you would rather not search every box when you need the power drill you got for your birthday. Occasionally, you put stuff in the wrong box—you’re human, that happens. But you don’t insist that because the drill ended up with the kitchen stuff, it has to be used in the kitchen. At that point, the box has become a cage.
  • Labels are like maps. They’re a way to find our way around things. You’ve probably heard the expression, “the map is not the territory.” It’s true, but you do need a map if you intend on not getting lost in the territory. And as I’ve written elsewhere, the value of maps lies entirely in their having less detail than actually exists: by cutting out a lot of what is actually there, a map makes it easier to focus on the paths. Similarly, the often-highlighted critique of labels, that they don’t say everything about a person, is actually the point. A diagnosis provides a quick shortcut to broadly understanding the path forward for a patient, and labels for people allow a broad sense of how to relate to them. It’s what allows us to interact with people without having to be intimate with every single person every time. That said, for those we want to connect deeply with, you’re going to have to go beyond the map.
  • Labels are like handles. A handle opens a door, but it’s not the door. Similarly, labels offer a way into people’s hearts and lives, as long as we remember that they are only handles, and not the rooms themselves, or even the door. And the thing with a handle is you want to use it carefully: pull too hard, and you might break it and find yourself stuck on the wrong side of the door. But pulling too lightly wouldn’t do either: you have to pull enough to actually open the door and go in. Most of all, though, before pulling at any handles, it matters whether you’ve been invited in—you certainly don’t want to be forcing your way.

Which brings us back to Procrustes. If a bed doesn’t fit, there’s something to be said for making the best of it. A poorly fitting bed is probably better than none, and those who need a bed might be happy to make do with it pending a better fitting one. But it simply wouldn’t do to insist the bed is perfect and the person who must be made to fit. And here, Procrustes’ fate offers a final lesson: he ended up lying on his bed when the hero Theseus “fitted” him as he had so many before.

If beds—or labels—don’t fit, it’s probably worth having another look at not beds in general, but the bed in question.


Image courtesy Olga Safronova

Published by Doc Ayomide

I’m a medical doctor with specialty training in psychiatry, and I love thinking and writing about what it means to be human.

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21 Comments

  1. Very good read, Ayomide. The metaphors are on point!

    In your clinical perspective, are physicians overdoing psychiatric labeling, or there’s still significant diagnostic room to itemize other human mental health problems?

    1. Thanks, Ned! To your question, I think the issue is less over-labelling than rightly labelling, which of course can be tricky. But at our best we try to make up for that by being slow to label and open to changing our minds in the face of new information that suggests the label we’ve settled on is wrong or inadequate.

  2. I see. Being slow to label, and ensuring the label is the right one. That sounds practical and wise. Thanks for that insight!

    Historically, clinicians are trained to be conservative, (except maybe in high stakes emergency situations). So one can see how the slow methodical approach comes naturally to us physicians.

    Now there’s the little complication of psychiatry having possibly been invaded by the general public including activists. And being all the rave on social media.

    With the public as stakeholders now firmly in the mental health care picture, and perhaps without the practical wisdom of conservatism necessary to negotiate these knotty issues, one wonders to what degree this trend might have unwittingly impacted the practice of psychiatry.

    Not sure if you have any perspective on that line of inquiry.

  3. Well written argument. Although, in my opinion, labels do more damage than good. When you label a person, that’s all you see – the disease and not the person. Labels work more to satisfy the person doing the labelling, not the person being labelled. Mental health is subjective, but labels allow the professionals to put a bunch of people in one single box, because they have certain presentations in common.
    I hear your argument, but it isn’t reality in practice.

    1. Thanks for your kind words! Labels can be—and often are—used reductively. Yet we must name a disease if there is to be any hope of providing good care for the person. Is there a risk that in naming the disease the person will be seen as nothing more? Certainly. But there’s also the risk, in not naming the disease, that we will be unable to even know what to do about it. Similarly, professionals using labels to group common presentations together is a feature rather than a bug. Imagine if every time a person went to hospital the doctors had to start from scratch understanding how to help them, without being able to bring their experience to bear? That would be a worse state of things than healthcare pre-modern medicine. So again, the problem isn’t that categorising, it’s if we were so bound to our categories that we missed the differences. Indeed, by allowing us to group similar things, labels in fact help us appreciate differences, wouldn’t you agree?

  4. Another good way to look at it, Anonymous.

    You’re right. Everything has pros and cons. While not being completely harmless, it is very very doubtful labels do more damage than good.

    For example, one could follow your line of argument and say labeling mental health physicians ‘psychiatrists’ does more harm than good because it disembodies them. But if we jettisoned the term psychiatrist in this instance, it’s unlikely to help in any way but rather would cause confusion.

    We know psychiatrists are people. We don’t need to unlabel them to get to that rather simple conclusion.

  5. I used to disregard labels, now I don’t.

    I have learnt (painfully) from my experience with frenemies that accurately identifying people and putting them in correct boxes ie labels can save us from experiencing betrayals and heartbreaks down the line. Right-labeling will help you understand where the people in your life fall in the character and trustworthiness spectrum.

    As pointed out in previous comments, labeling has its cons. If you do not take the time to correctly analyze a person or situation before coming to a conclusion, you will inevitably add to the problem or create new ones. Also when trying to see which ‘box’ people fit, as much as possible we should put ego and personal bias aside so that we can see the situation for what it is and not according to our biases. I have experienced this as a patient, true story.

    I was having intense chest pain that lasted over 24hours so I rushed to a nearby pharmacist. She asks some questions and concludes it is acid reflux so she gave me meds and said to see the doctor immediately. I got to the doctor’s and she disregarded the pharmacist’s assessment and gave her own diagnosis: functional dyspepsia and maybe a heart issue. A quick search of both illnesses and I thought I fall on the acid reflux category, so I insisted on seeing another doctor.

    After ECG and a couple tests, the second doctor (older and more experienced) apologized and said it is in fact simply acid reflux and that I shouldn’t worry. I found out later that the first doctor just wanted to disregard the pharmacist’s assessment. I could have saved time, money and emotional distress had she put her ego aside. I never saw that doctor again.

    1. Beautifully said! And great point about the way ego can get in the way of using labels right—so much of what we get wrong as humans comes down to ego, doesn’t it? Thank you for such a considered comment!

  6. Glad you’re back Doc – thoughtful content as always. I particularly resonate with Labels as boxes and maps – nice imagery of labels as helpful tools in navigating and parsing complex situations.

    And as you say, people will always label – that’s what it means to be human. It’s more helpful in my mind to ask “how can we use labels more effectively” than “should we label or not” because humans operate based on heuristics – it is not realistic or IMO healthy to believe that we can ever treat every single situation we find ourselves in a perfectly customized manner without being overwhelmed.

    What you so eloquently highlight is being intentional and proactively aware about understanding when labels don’t fit and realising that what to do then is to focus on the particulars of that situation in their own right and make the best decision you can, as well as periodically review labels to discard those that are more harmful than helpful on average.

    1. Thank you for the kind words! I’m glad you found the metaphors resonant. And you’re right: it’s unhelpful to think about this in a binary way of “Yes or no”, rather than the more useful “how”. Thanks for your thoughtful comment!

  7. I see the point you’re trying to make, Ned. However, the example you’ve chosen doesn’t work. Being a ‘Psychiatrist’ is a profession, so it’s a job title not a label in this sense. Just like psychologist, lawyer, accountant….you get the gist. As a psychologist, I see the damage attaching a label to a person can do but I also agree with Ayomide, there are few people that finds label helpful when they have been ignored or dismissed for so long. In this case, I believe it’s the previous experience that makes getting the label an aha moment rather than the perceived good.

  8. The metaphors certainly resonate with me and I love them.

    I think of labels as the start of a journey with flexibility to make a turn as the journey progresses.

    In using labels, I often ask how this can be communicated in the most helpful way. From experience, I have seen how labels can liberate and also how it creates a box. And perception is a key component.

  9. Been a while Ayomide. I like the metaphors. The labels should guide us to better understanding.

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