people talking past each other – Real Social Skills

Content note: This post contains both criticism of and respect for the mental health system. If you find either upsetting, it’s likely that this post will bother you.

I wrote recently about two distinct kinds of mental illness stigma. There’s dismissiveness, where people aggressively deny that someone’s mental illness is real. There’s dehumanization, where people believe that someone’s mental illness is real, and treat them as though their condition makes them less than fully human. Both are common, and people who have experienced one more than the other tend to have very different perceptions of the mental health system.

One example of difference in perception: Mental health advocates often say things like “Medication for mental illness is just like insulin for a diabetic”. People who have mostly faced dismissiveness often see this as validation; people who have mostly faced dehumanization often see it as a threat.

From the perspective of someone who has mostly experienced dismissiveness, it might sound like this:

I’m really glad that someone understands how serious my medical condition is
People have told me over and over that I don’t have a real problem
Or that medication is just a crutch I’m using to avoid dealing with things
Or that it’s whiny to want medication
Or they might say things like “You’re not sick. People with cancer are sick.”
My medication is really, really necessary
Or even: my medication saved my life, and I think I’d die if I stopped taking it.
I’ve had to fight my doctor, my family, or my insurance company to get access to the medication I need.
It messes up my life when people don’t take my need for medication seriously.
I’m glad someone gets it about how real my medical condition is, and how important it is for me to have access to medication.

For someone who has mostly faced dehumanization, a statement like that might sound more like this:

People have treated me like I’m not a person, and use analogies to physical conditions to justify it.
People have made me take medication I didn’t want to take, that did things to my brain and body that I didn’t like.
They’ve done this to me in order to change how I felt, thought, or behaved.
They’ve told me that what they were doing to me was just like giving insulin to a diabetic.
And that this meant I could not possibly have any valid reason to object to the treatment they wanted me to have.
But diabetes and mental illness aren’t actually all that similar.
Insulin-dependent diabetics who refuse treatment die. When I refused treatment, I didn’t die. It’s not the same. I’m not sick in that way.
The way I am is not the same as having a life-threatening physical condition with an obvious straightforward life-sustaining treatment.
It’s important that people understand the difference.
When they don’t understand the difference, they treat me as though I’m not a real person unless I am on the medication they want me to be on.
People say “unmedicated” like it means violent, dangerous, or incapable of understanding something. It doesn’t. It just means that someone isn’t taking medication. That doesn’t tell you anything in itself.
I need people to respect me as a person, and respect my right to make treatment decisions. When they don’t, things can get really bad really fast.

There are numerous other examples of things like this. Most things people say about mental health look very different to people who have primarily experienced dismissiveness than they do to people who have primarily experienced dehumanization. Neither perspective is right or wrong exactly; both are important and incomplete.

Access to psychiatric medication is important; respect for the humanity and human rights of people who have been diagnosed with mental health conditions is also important. Things aren’t great for anyone, and they could be a lot better for everyone.

Short version: Mental health discourse often looks very different depending on perspective. People who have mostly faced dismissiveness tend to see things one way; people who have mostly faced dehumanization tend to see things a different way. Scroll up for a concrete example.

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.