Two kinds of mental health stigma

Real Social Skills

Content note: This post contains both criticism of and respect for the mental health system. If you find one or the other upsetting, this post will likely bother you.

There are two basic kinds of mental health stigma: dismissiveness, and dehumanization. Mental health conversations tend to have trouble acknowledging both at the same time — usually it’s at most one.

Dismissiveness stigma is when people deny the reality of mental illnesses. This plays out in a number of ways. One classic example of dismissiveness is “antidepressants are just a tool of capitalism to stop people from noticing that things are wrong”, or “Stop complaining. There are people with real problems”. There are many other examples.

Dehumanization stigma is when people deny the humanity of people with mental illnesses. A classic example of this is people who believe that the purpose of mental health treatment is to reveal the real person underneath — and that therefore, any objections they might make to the treatment “aren’t the real them talking”. There are many other examples of this as well.

Dismissiveness and dehumanization are both major problems. They’re both real, and they both do a lot of damage, even up to the point of costing people their lives.

People tend to perceive the mental health system very differently based on which kind of stigma looms largest for them. For a lot of people, it’s much easier to see one type than the other.

People who mostly experience dismissiveness often see the psych system this way:

  • No one took my problem seriously
  • I was scared to turn anywhere for help
  • Once I finally took the leap and went to therapy, things got so much better
  • Or, once I finally stared medication, things got so much better
  • (Or even: medication and therapy saved my life).
  • (Or even: I’m so glad people finally pushed me to get treatment; they were right.)
  • I wish people wouldn’t be so afraid. I wish everyone had access to this.
  • We need to fight stigma so that people can get the help they need.
  • (And to reform laws so that everyone has access).

People who mostly experience dehumanization often see it more like this:

  • When I entered the psych system, people treated me like I wasn’t a person
  • They forced me to take medication I didn’t want to take
  • The drugs didn’t work, and had harmful side effects
  • When I complained, they treated it as a symptom and raised the dose
  • They forced me to be in therapy I didn’t want to be in, and that made me worse
  • When I tried to advocate for myself, people treated it as a symptom, and no one took me seriously
  • Things only got better for me when I stopped therapy and/or medication and started a different approach
  • (Or even: stopping therapy and/or medication saved my life)
  • I wish people wouldn’t be so uncritical of a system that hurt me
  • I wish “unmedicated” wasn’t used as a slur implying that people who make the choices I make are all terrible people
  • We need to warn people, and reform the laws and systems that allow people to be treated this way

Some people’s experiences in the mental health system are positive in ways that nothing else is; some people’s experiences are horrifying. (And for a lot of people, things are more mixed). Neither type of experience is universally representative; both are real and common. Both matter, and need to be part of the conversation.

When most of someone’s experiences are with dehumanization, it can be hard to understand that dismissiveness is also a problem. Or why anyone would regard mental health care as positive, or lack of access to it as a problem. They may also find the terminology of “mental illness” repugnant, and have a strong preference for “crazy”. But it really is the case that for some people, mental healthcare including therapy and medication is a really good thing. And that for some people, the biggest problem with the system is difficulty accessing it (either because others discourage it, or because it’s too expensive.)

When most of someone’s experiences are with dismissiveness, it can be hard to understand that the dehumanization experiences are also real. (Particularly for people who were really afraid of mental health care and then had a transformative good experience with it.) It can be hard to understand why someone would prefer an apparently pejorative term like “crazy” over an apparently-netural term like “mental illness”. It can seem like people must be exaggerating, or that these things only happened in the past, or something like that. But dehumanization is still a problem now, and fighting treatment stigma will not address that problem.

Both dehumanization and dismissiveness are important barriers to people being treated as they ought to be. Because of both types of stigma, people lack access to help they vitally need. For some people, that help is treatment. For others, it’s access to resources like housing, respite, and assistance with food. For a lot of people, it’s both. People’s very real mental health struggles should not be dismissed; neither should the humanity and human rights of people with mental illnesses be denied.

Short version: There are two types of mental health stigma: dismissiveness, and dehumanization. Dismissiveness is when people deny the reality of your condition; dehumanization is when people think that your condition makes you less than human. Dismissiveness is often made better by the mental health system; dehumanization is often made worse. People whose experience is primarily in one category often don’t understand that the other category exists. Both matter, and both need to be part of the conversation.

Drugs, crutches, and other tools

Real Social Skills

Psychiatric medication is highly stigmatized, and so is physical disability. One way that this comes out is that people say pejoratively, “medication is a crutch.”

Why is “crutch” an insult? What do people think is so terrible about using crutches?

I think that it’s a kind of ableism where people don’t understand that disability actually exists. They believe that anyone can do anything, if they put their mind to it and work hard. When people with disabilities can’t do something others can, they assume that we are just being lazy. They assume that about moving, they assume that about moving, and they assume that about thinking.

They believe that if they push us to try harder, then we will learn to stop being disabled. They think that if we stay disabled; it’s because someone’s giving us permission to be lazy. They’re constantly on guard against the possibility of a disabled person getting away with something.

They are aggressively hostile towards any visible adaptive strategy. When they see crutches or medications or whatever, they are terrified that we are getting permission to be lazy.

Sometimes, they think it’s ok for us to use these things, but only if we fall into a very narrow category of people think think have real disabilities. For instance, they might think wheelchairs are ok for paralyzed people, but have no respect for wheelchair users who can walk. Or they might think it’s ok to use medication if you’re trying to stop, but have contempt for people who need medication long-term and have no plans to stop taking it. Or whatever other combination of things. People have a lot of really weird ideas about disability, and just about any prejudice you can imagine exists.

Crutches are a tool. There are other mobility tools. Medications are several different tools. There are other mental health tools. They all have advantages and disadvantages, and everyone has to figure out what works best for them. Every strategy is stigmatized, because ableists expect us to think our way out of being disabled. But crutches aren’t actually bad things, whether they’re literal or figurative. We all find the ones we need.

Short version: People with disabilities need adaptive strategies to work around disability-related limitations. Ableists think that we’re just being lazy when we use adaptations such as mobility aids or psychiatric medication. They often pejoratively say “you’re just using that as a crutch,” as though using adaptive equipment is the worst thing you could possibly do. But actually, there’s nothing wrong with crutches. We all find the ones we need, and that’s a good thing.

Disability does not end where values begin

Real Social Skills

One of the most painful aspects of disability is that it can interfere with treating people the way we’d like to treat them, and doing what we’d like to do for them.

Disability makes some things hard, and other things impossible. Often, we have values that say it’s important to do the thing anyway. This does not actually make it possible to do the thing. Caring about others doesn’t make disability go away. Accepting and accommodating our limitations works a lot better. We can only do things that are possible, with the brains and bodies we actually have.

For instance, body language:

  • People communicate a lot of important things through body language
  • Some people can’t see well enough to understand body language
  • Others have insurmountable cognitive barriers to understanding body language
  • It’s important to listen to what people are saying. That doesn’t make it possible for everyone to understand body language.

Understanding speech:

  • Most people communicate a lot of important things through speech
  • Some people can’t understand speech
  • (Either because they can’t hear well enough, or for cognitive reasons)
  • It’s important to listen to people. That doesn’t make it possible for everyone to understand speech

Text communication:

  • There are often competing access needs in text communication
  • Some people can’t read walls of text, and need whitepsace
  • Some people aren’t capable of putting in line breaks (or aren’t reliably capable of doing so)
  • Some people need simple language to understand things
  • Others are incapable of changing their language use, and have to use big words in order to communicate
  • The importance of listening doesn’t make it possible for people to understand every kind of writing.
  • The importance of communicating in a way people can understand doesn’t make it possible for everyone to communicate in every way people need
  • Sometimes there needs to be an interpreter

Inaccessible buildings:

  • Some important meetings take place in inaccessible buildings
  • Some people can’t climb stairs (or can’t do so reliably)
  • The importance of the meeting doesn’t make it possible to climb the stairs
  • Even if someone you care about really, really needs your help with what’s going on at that meeting

Outdoor events:

  • Some people can’t be outside for extended periods safely
  • (For any number of reasons)
  • This is just as true when there’s an important protest. Caring about the issue doesn’t make being outside any safer.
  • Or when there’s a wedding or something. Caring about friends and family doesn’t make it any safer to be outside

Recognizing people:

  • Most people want people they know to recognize their face and remember their name
  • When people aren’t recognized, they often feel like no one cares about them
  • Some people can’t recognize faces
  • Some people can’t remember names
  • Understanding the importance of recognizing names/faces does not make it possible for everyone

Intermittent abilities:

  • Some people can do certain things only some of the time
  • They may be able to push really hard and do it in an emergency
  • Or it might fluctuate in ways they have no control over
  • That doesn’t mean they could do it reliably.
  • Caring about something doesn’t make it possible to do it all of the time.
  • Disability is real even when it’s intermittent.

There are any number of other examples. When something is physically or cognitively impossible, it’s still impossible when it’s important. When it’s dangerous, it’s still dangerous when it’s important. Caring about other people doesn’t make disability go away.

Whatever we do, we have to do as who we are.

Short version: Disability makes some things hard, and other things impossible. Often, we have values that say it’s important to do the thing anyway. This does not actually make it possible to do the thing. Caring about others doesn’t make disability go away. Accepting and accommodating our limitations works a lot better. We can only do things that are possible, with the brains and bodies we actually have.

An opinion is still an opinion if you put a question mark at the end

Real Social Skills

Therapists usually see themselves as facilitators rather than advice-givers or problem-solvers. They generally believe things like:

  • “We never tell people what to do”
  • “We create space to support them through figuring it out.”
  • “We raise questions.”
  • “We don’t give advice, we let them come up with solutions.”

Thing is: “raising questions” in practice amounts to expressing a lot of opinions. An opinion is still an opinion when it is phrased as a question. It’s *especially* still an opinion when it is phrased as a series of leading questions and pregnant pauses.

It matters what therapists of any kind believe about their clients; they can’t help very much without understanding what’s going on. That’s a reason why psychologists and other types of therapists spend years in school learning psychological theories and practical methods. One of the major ways in which therapists are sometimes able to help people is by having well-informed opinions and understanding things that others don’t.

It’s ok for therapists to have opinions — but they need to be well-informed, and they need to be able to modify them in response to new information. (Eg: Sometimes the patient knows something you don’t, sometimes there’s social or cultural context that changes the meaning, etc.)

I think that it is much easier to have a worthwhile opinion if you can admit to yourself and others that you have opinions and that your opinions affect other people.

Short version: Therapists tend to express their opinions to clients phrased as a series of questions. They think that this means they’re not expressing an opinion, but rather just asking and creating space for the client to think. It matters that this is not true. Therapists have opinions (and should have opinions), and being honest about that makes it much easier to learn new things and make your opinions needed. An opinion is still an opinion if you put a question mark at the end.

Acknowledging the unfixable

Real Social Skills

Many people face awful things.

Sometimes, those things aren’t fixable.

Sometimes you can’t make it better. Sometimes all you can do is try to find a way to live with it.

Living and enjoying your life doesn’t make the bad things irrelevant.

Often, people who don’t face the awful things want to pretend that everything is either fixable or already ok.

This leads to pressuring people experiencing awful things to smile and pretend everything is ok.

That doesn’t help. It doesn’t make anything ok. It just means that people are forced to face things alone. This isn’t right.

People shouldn’t force you to pretend that you’re ok when you’re not. People shouldn’t force you to pretend that the world is better than it is. If you’re facing that, I’m sorry that’s happening to you.

Sometimes we can’t fix the bad things. But there are problems we can fix. We can stop silencing people and we can stop isolating people. We can respect people, and stop expecting them to protect us from reality.

We can’t fix everything, but we can stop being jerks to people facing unfixable problems.

Finding what you can fix; living with what you can’t

Real Social Skills

Activism and advocacy are emotionally difficult on a number of levels.

One reason is that the problems that need solving are enormous.

No one has the capacity to solve all of them. Everyone has some degree of power to act; nobody has the power to fix everything or address every injustice.

Making the world better is largely a matter of seeking out opportunities to act. Caring about the problems isn’t enough. Being willing to fight for what you believe in isn’t enough either.

It’s important to look for circumstances in which you have power to make something change. If you look, you will find some — and not others.

The opportunities you have to create change are not always the opportunities you care about most. Caring deeply doesn’t always create power.

And there are always tradeoffs. There will often be situations in which there are many things you could do — and only the resources to do one of them.

There are usually compromises. Victories are usually partial. And they often involve complicity in things you’d rather not be complicit in.

And in order to find the opportunities to change things, you have to keep looking — even though this means you’ll see things you can’t fix.

This can be very hard to live with. It can be tempting to believe that if you just tried harder, you’d be able to fix everything. Or that if you cared more, you’d be able to do everything. Or that if you were a better person, you’d be able to avoid making compromises (or working with people who do bad things).

I think it helps to remember that it’s like this for everyone. No one can fix everything; everyone has to make choices and compromises.

I think it also helps to remember that the problems exist whether or not you’re looking at them. Looking at the problems hurts; it also gives you the chance to do something about some of them.

It’s also important to remember that you matter, and that there are things in the world that are good. Not everything is horrible (even though sometimes it feels that way); a lot of things are good. And people matter and are worth loving now, as things are. Activism isn’t about hating everything; it’s about making things better. And recognizing already-good things and valuing people both actually help with that.

Short version: Activism involves caring about more things than you can fix. It involves a lot of tradeoffs and difficult choices. It’s not your fault; it’s like this for everyone. You can’t fix everything; you can do work that matters and make some things better. Remember that the world contains good things too.

Your role is not permision

Real Social Skills

Being a disability expert of some kind doesn’t give you the right to violate boundaries. People with disabilities are people. Being an expert of some kind doesn’t mean you have a relationship to them. It doesn’t mean you have any authority over them, either.

Being a parent of a disabled kid isn’t permission to take on a parental role with every disabled person you encounter.

Being a nurse doesn’t make it ok to ask people with disabilities invasive medical questions.

Being disabled doesn’t make it ok to tell other disabled people how to live their lives.

Being a special educator doesn’t give you the right to tell disabled people how their minds work. Or what they can and can’t do. Or to force them to make eye contact.

Being a therapist doesn’t make it ok to take on a therapeutic role with every disabled person you encounter. Treatment requires consent; being a therapist doesn’t make you an authority on anyone else’s life.

Being a researcher doesn’t give you the right to tell people with disabilities what they can or can’t do, or how they should live their lives.

Being disability staff doesn’t mean that random disabled people you encounter in public places need your help, or that you know how to help them, or that you have the right to tell them what to do (actually, that applies even when you *are* someone’s staff).

People with disabilities have the same rights to privacy and autonomy as anyone else. No matter what kind of expertise you have or think you have.

Facing other people’s pain

Real Social Skills

Sometimes, it’s very hard for people to acknowledge other people’s suffering.

It sometimes follows this kind of pattern (I picked arbitrary names to make it easier to read):

  • Sam is suffering in some major way
  • Otto finds this incredibly painful to witness
  • Otto can’t fix the problem that is causing Sam pain
  • Otto pressures Sam into reassuring him by pretending that he’s feeling ok and it’s not so bad
  • This allows Otto to ignore what’s going on, and to not have to be upset about Sam’s pain anymore
  • Sam’s situation gets worse, but Otto gets to feel better

It’s easy to fall into treating someone this way without realizing it, especially if you’re in a helping profession. If your identity is centered around being helpful to others, it can be very painful to acknowledge important things you can’t fix. It’s still really important to acknowledge them, because otherwise you end up hurting people. It’s really important to develop emotional coping skills to be able to acknowledge pain that you can’t fix.

If other people are doing this to you, it can sometimes be disorienting, especially when the people who do it are otherwise genuinely helpful. It’s really degrading when others pressure you to pretend to be ok so that they can feel better. Sometimes, this is hard to detect clearly. Sometimes, people are making it much better than it’s ever been — and you’re genuinely grateful for that — but at the same time, it’s still pretty awful, and they want you to convince them that everything is wonderful.

Most people experience both sides of this dynamic at some point in their life. Whichever side of it you’re on, it helps to remember that it’s a thing, and that it’s not ok. People shouldn’t pressure others to pretend they’re ok when they’re not.

Detecting imperius curses

Real Social Skills

There are patterns of psychological manipulation that have very similar effects as the imperius curse described in Harry Potter. When you’re on the receiving end, it can be very hard to figure out what’s going on and resist.

One way to tell is watching how you change when you’re around someone, especially if you’re not comfortable with the changes. Double especially if they emphatically say that they are not trying to influence you and would never try to influence you.

For instance, if your views change dramatically around someone else in this kind of pattern:

  • You normally think one thing
  • When you’re with this person, your views dramatically change
  • When you’re not with them, you can’t understand why your views changed
  • Or you might even find the views you adopted in their presence repulsive
  • But it keeps happening over and over when you interact with them

Especially if this happens when you try to contradict them:

  • You: I don’t agree with you about x. I don’t see myself that way. I don’t believe that.
  • Them: Why are you telling me that? What makes you think I ever told you what to think?
  • (And then, somehow, you still end up thinking the thing while you’re with them. And not thinking it when you’ve been away from them for a while.)

This can also happen with actions. Sometimes imperius curses mean that being around someone affects what you do. It can mean you do a lot of things you don’t think that you want to do. It can mean being really confused about why you did the things.

Particularly if this happens when you try to avoid doing the things:

  • You: I don’t want to do x.
  • Them: Did I ever say you should? All I did was ask.
  • (Then you somehow still end up doing the thing. And when you’re not with them, you don’t think you want to do the thing and aren’t quite sure how it happened.)

Another pattern:

  • They say they’re not trying to influence you.
  • You try to express a different opinion or desire or choice
  • If you’re trying to express a thought or desire, you don’t get to complete the thought or process why you think it
  • Instead, the conversation drifts into their opinion
  • You end up feeling like you agree, and complying with it
  • It’s not really agreement, because you weren’t really able to think about what they are saying and what you think about it, and why you think what you think
  • It’s being prompted into an emotional state in which disagreeing with their position feels impossible or petty, and in which surrendering is a relief

When you try to express a choice:

  • They pretend that you didn’t express a choice
  • And keep talking about it as though a decision has not been made
  • (And maybe say some things that might be reasonable if you hadn’t already made a choice and expressed your choice)
  • (Or some things that would make sense if you’d asked for their advice)
  • They also say some things that are just prompting you in the direction they want you to go in
  • And somehow, the conversation never stops until you give in to what they wanted
  • (And, often, not until you feel like it was your idea and reassure them that you agree with them, or maybe even thank them for their help)

Another pattern:

  • They say something awful about you in a tone that sounds loving and compassionate
  • The way they speak to you makes it hard to realize that any other opinion is possible.
  • You might end up thanking them
  • (And then possibly getting angry hours or weeks later when the effect wears off)
  • (And being really confused about what happened).

These are a few examples. There are many other ways this can play out.

Changing your opinion in response to someone else’s ideas is not bad in itself. Neither is changing your mind about what you want to do. Those are both important things to do in a lot of situations. The reason that imperius curse effects are bad isn’t that people subjected to them change their opinions or desires. Changing can be good; it’s the *kinds* of changes that imperius curse effects cause that’s the problem.

Imperius curse effects are bad because they short-circuit persuasion and induce compliance. They create emotional prompts that feel like believing something, even if you haven’t actually been persuaded of it. Or prompts that feel similar to wanting to do something, even if you don’t actually want to do it. It makes it hard to tell that the other person ends somewhere, and that your thoughts and feelings matter and might be different from theirs. It’s an intense violation, and it can be hard to detect and resist. I think knowing about the patterns helps some.

Short version: The effects of the Imperius Curse described in Harry Potter are very similar to a form of non-magical emotional manipulation that happens in the real world. They trick people into feeling like they want things they don’t want, or like they agree with things they don’t agree with. There are some patterns they tend to happen in. Knowing about the patterns can make them easier to detect.

Mean people who aren’t mean all the time

Real Social Skills

Mean people aren’t necessarily mean all the time. Mean people aren’t necessarily mean to everyone.

I think most people who are mean are nice to at least some people at least some of the time. It can be hard to understand that they’re mean to other people in ways that matter if you don’t see it.

One example of this is that many men who are awful to women treat other men well. Some men don’t know this. They often assume that a man who treats them and their male friend group well is basically well-intentioned — and may have a lot of trouble understanding why their female friends think he’s dangerously creepy.

That happens in a lot of contexts. Some of which have to do with socially marginalized groups like gender or race or trans status or disability or religion or any number of other things. Some of them aren’t like that.

Sometimes it’s about in groups and outgroups in ways that aren’t otherwise connected to privilege.

For instance:

  • Jesse is mean, but not mean to everyone.
  • Jesse is nice to people who they like
  • Mostly, Jesse likes people who admire them and don’t contradict them about anything important
  • Jesse is mean to people outside their circle
  • People who are in Jesse’s circle and really admire Jesse might have trouble believing that they’re ever mean to anyone else
  • On the logic that “Jesse has never said anything like that to me; I can’t believe Jesse would say that”. Or something else like that.

It’s not unreasonable to base some of your opinions on what’s probably going on in a conflict on your personal experiences with someone. To an extent, it’s *necessary* to do it that way, because you can’t find out what’s going on by disregarding what you know. But it’s also important to remember that the way someone treats you might not be representative.

For instance:

  • If you’ve never contradicted someone, you might not know how they handle being contradicted
  • If someone’s never been mad at you or someone you respect, you might not know much about how they treat people when they are angry
  • Everyone gets into conflicts.
  • Everyone gets contradicted.
  • Everyone is wrong sometimes.
  • Nobody handles this perfectly. Some people handle this more-or-less reasonably; some people handle it horribly.
  • If you haven’t seen what someone does in those situations, it’s hard to know whether their reactions are reasonable

Short version: It’s easy to misunderstand conflicts by assuming that people who have always been nice to you are always reasonable with everyone. It’s important to consider what you know about someone *and* to consider the possibility that your experiences with someone may not be representative.