NOTE: THIS ARTICLE WAS ORIGINALLY PUBLISHED IN BINAH MAGAZINE

I find lessons in the oddest places.

Just the other day, sitting in a workshop geared for mental health professionals, I learned that if the wrong conjunction lands up in a sentence, a judge could condemn a man to death.

Yep. Death by conjunction***.

A conjunction, for those of you like me, who cut grammar class and have only a vague recollection of the word, is the sum total of eight letters forming the linguistic units of AND, OR, and BUT.

In my personal life, I talk. I have tons to say, opinions to offer, advice to give, stories to share, and jokes to make others laugh. And yes, I gossip too. Not something I am proud of, but something I definitely do. And the older and more mature I get, the lousier I feel about those times.

I wonder why I can't adapt my professional persona to outside my office. As a therapist, I am mostly quiet. I am well aware that nothing I say is as important as what my client tells me. That no advice is more productive than the solutions my clients uncover on their own. That stories may not be shared lightly with a client, that off-the-cuff observations and comments may be deadly to a therapeutic relationship, that a simple negative word can have such far-reaching effects and cause incredible damage.

So, I usually I do not share stories or jokes with my clients, and definitely never gossip.

Never, never gossip.

I am hyper-aware how powerful are my words in the therapy room, their impact on my client, and the great responsibility to weigh and measure each word so that I do no harm.

Never, never harm.

I wish I had that stunning sensitivity in my every day life so that when I come in contact with my children, friends, co-workers, family, and my husband (okay, not my husband; I need to gossip to someone!), I would ascribe to that same commitment of watching my words and do no harm. What seems mostly so effortless in the therapy room seems almost insurmountable outside its parameters.

So let me tell you about this omnipotent conjunction.

But first I need to explain about the DSM-5.

The Diagnostic and Statistical Manual (DSM) is the bible of the mental health field. Every single disorder known to mankind is documented in this gargantuan book. The known disorders like anxiety and depression and bipolar, and the lesser known ones like schizoaffective, body dysmorphic, and factitious disorders. Each one is cataloged by name, by symptoms, by number, by description.

If you go to a psychiatrist, in order for him to prescribe pills, he needs to submit to the insurance a diagnosis based on the DSM. And if you see a therapist who takes your insurance, he can only get reimbursed if he can submit a claim that identifies a diagnosis for which you need therapy. Hypochondriasis is a disorder and dissociative amnesia is a disorder, and even Pica is a disorder, as are Pyromania (setting fires), Trichotillomania (hair plucking), and Circadian Rhythm Sleep Disorder (jet lag!).

Recently, there has been a huge upheaval in the mental health field because a new, revised DSM emerged. First there was the DSM I, then II, then III and IV, and now there is DSM-5.

“Big deal,” you are probably thinking. “Big deal.”

It is a huge deal, because the DSM has far-reaching consequences. The DSM impacts what insurance pays for, and which disorders are funded for research. So because internet addiction is not recognized by the new DSM as a bona-fide addiction, even though it's a reality that therapists cannot fail to see and struggle with, insurances have been let off the hook and do not have to fund therapy or rehab for internet addicts.

Once ADHD (attention deficit disorder), autism, Asperger’s, and Developmental Coordination were identified as a mental disorders, schools were mandated to provide services for children diagnosed with any of them, creating a structure that has helped your nephew, your neighbor, and sometimes your very own child. And when the DSM-5 tightens the definition of autism, limiting the children who can be diagnosed because they fall out of the spectrum as defined by the DSM, it will affect their ability to obtain those special education services they desperately need.

So the DSM is a very powerful book. And the DSM-5, as the most recent one, is most powerful one to date.

As a social worker, I attended a workshop to understand its changes and its ramification on individual functioning, on social work practice, and society as whole.

But when I walked out of that workshop, all I could hold in my head was the disbelief that one little word, one conjunction made up of either two or three letters written into the DSM 5, could determine the fate of a person. The placement of a conjunction could either send him to the electric chair, or give him life.

Scary.

Here is how it works.

Mental Retardation, because of its stigma, will no longer be the identified diagnosis as it has been in previous DSM's; instead, the pareve Intellectual Development Disorder (IDD) will replace it. Nice, no? Yes. Look how important words are that calling someone mentally retarded will now have absolutely no legal status, and thus will slowly be removed from our vocabulary, mitigating stigma of impaired intellectual and societal functioning. Score one for the DSM 5.

Now, a therapist will diagnose IDD in three ways. Firstly, in assessing the person’s intellectual capacity using standardized testing, in what we have come to call IQ (intelligent quotient). Secondly, by how a person demonstrates ability to function in a social setting and in society; meaning to be able to do all the social things we expect kids normally to do at that age, like cross the street, make himself a sandwich, or use money. Thirdly, the onset of these impairments must be noticed during developmental periods of a child's life; meaning, as a child grows his parent notices that he is simply not achieving developmental milestones like learning math, understanding safety rules, or playing appropriately with children his age.

These criteria of determining IDD is similar to its original Mental Retardation, in that IQ level and adaptive social functioning are used for diagnosis although the latter is more crucial according the DSM-5.

If you want to know how important words can be, consider this:

In 2002, the Supreme Court ruled it was unconstitutional, and thus illegal, to execute a person who is intellectually disabled.

It was left to each state to determine criteria to assess for intellectual disability. According to many states, following the DSM guideline, only if a person's IQ is 70 or below do they pass the IQ test for being considered to be IDD, so if the accused's IQ is over 70, they are potentially executable irrespective of the evidence from their social functioning. Actually, as the DSM advises, some states give some leeway when assessing IQ, allowing for standard sources of error up and down in assessment (meaning that a score of 70 can be construed as a possible score of 65 through 75). However, some use a “bright line” in which the number 70 is the actual cut-off number, with no leeway in the testing results.

This bright line is extremely brutal in that some of the testing is the tester’s interpretation of the patient’s responses and therefore leaves no room for some error in subjectivity. So when a potential suspect is being evaluated for his intellectual capabilities, verbal responses to the IQ test, subject to the tester’s interpretations, may sway the results to a 71—in which he may be killed for his actions; or to a 70—which exonerates him from the death penalty (although life in prison or indefinite institutionalization are still possible).

So Mr. Hall, who was sentenced to death for murder, appealed his death sentence on the grounds of this new Supreme Court ruling. But Mr. Hall lost his appeal—and his life— because his IQ score hit 71.

So it seems like a step up that the new DSM-5 pays more attention to assessment of a person’s daily and social functioning more than IQ level to determine a diagnosis of IDD.

But not so fast.

Words. Words. Words.

It is words that carry the awesome responsibility and power to condemn or condone.

Texas, the state with the highest execution rate in the country, has a set of seven criteria to determine intellectual capacity based on social functioning. One of these seven is the ability to lie—to deliberately tell a falsehood; seen as a trait only possible by persons who are NOT mentally retarded (I leave you to make your own judgment of who we label mentally retarded if lying is the skill we attribute only to someone with a high IQ…)

Mr. Wilson, accused of murder, had a clinically assessed IQ of 61, a demonstrably low intellectual functioning. However, he was put on trial, convicted of murder, and sentenced to die. Why? Because, despite his severely impaired IQ level, the Texas courts used these seven criteria of social functioning to ascertain that he was capable of standing trial.

Texas applied the criteria “conjunctively”—you need to be impaired in every one of the seven ways to be considered possibly IDD, so if, for example you lie, showing that in one area you are not fully impaired (no matter how impaired otherwise), you can no longer qualify to be exempt from the death penalty.

“Okay,” you may be thinking. “So Texas used these seven criteria and this guy flunked—or rather he passed the test. Makes sense that he needs to stand trial and die for his actions. I’m sure the beautiful state of Texas knows what it’s doing.”

However, believe it or not, Texas cited evidence of these seven criteria based on a fictitious character in a novel!!!

Lennie, the intellectually disabled main character of John Steinbeck’s classic, Of Mice and Men, became the prototype of how to evaluate mental retardation, forming the basis of Texas’ seven criteria. It would be riotously funny to think that our legal system is founded on fiction, if not for the fact that Mr. Wilson was killed on the basis of this fiction!

When Mr. Wilson’s fate became public, John Steinbeck’s son wrote a scathing editorial expressing his anguish that his father had never intended that the words of his book be used to kill a man.

Maybe so, but words can kill anyway, whether we intend it or not.

So now, with the onset of the DSM-5, it is not only the words of a man being given an IQ test that can kill, or just the words of a novel that can execute; but now a conjunction can deliver a man to the electric chair.

To determine a person’s functioning, to make him either eligible to either die or live, the prosecution and the defense may argue over the conjunction inserted in the DSM-5.

“A conjunction?” you ask in disbelief. “Give me a break. You can’t expect me to believe that!”

But it’s true.

In the DSM-5, the general description of IDD, referred to as the stem, states that IDD is characterized by three types of adaptive functioning, in addition to IQ score. It says, “Intellectual disability is a disorder that includes…adaptive functioning deficits in conceptual, social, and practical domains (emphasis mine).”

Like the Texas criteria, the DSM-5 stem is described conjunctively, so a person has to have deficits in all three areas to qualify as IDD; however, after the stem, the DSM-5 then continues with the diagnostic criteria listed underneath that states that only one deficit in either conceptual, social or practical functioning is necessary to diagnosis a person with IDD!

So, yeah, it is weird that the writers of the DSM made such an error that now these two parts are jarring in their contradictory wording, but it is even crazier that this little unambiguous word has now the potential to create major ambiguity and wreak havoc in courts of law.

The defense will argue that a person can be diagnosed with IDD with simply one criterion, and thus avoid execution; while the prosecution will point gleefully to the conjunctive and written into the stem, creating a strong argument that the accused is not diagnosed with IDD unless he presents with all three.

Major legal ramifications, life and death, hang on a single word.

Chilling, no?

Each day, each and every one of us sits in courts of law. With our careless words, we randomly condemn our friends, family members, children’s teachers, the sheitel macher, the plumber, or neighbor to so many little deaths. Our words kill our children’s confidence, kill our friend’s shidduch, kill a rebbe’s reputation, and kill our neighbor’s livelihood.

And the worst conjunction of all may be found in the sentence protesting our innocence of wrongdoing, “But I didn’t mean it! But I didn’t know!”

And now that you do, will you keep quiet?

I wish I can.

No and or buts.

***Thank you Dr. Jerome C. Wakefield, PhD, DSW, Professor in New York University, and master presenter at the workshop I attended on the DSM 5, for the information found in this article. An special thanks for letting me use your words Death by Conjunction as the title of this essay.

My book, Therapy, Shmerapy, can be found in bookstores or online