Mental illness stigma is harmful and pervasive. Depression, for example, is still seen by many as a character defect. Stigma can increase distress and prevent people from getting the help they need during a mental health crisis. While mindfulness may help manage the subjective experience of stigma, social perceptions of stigma nevertheless increase the likelihood of discrimination and socioeconomic disadvantage for persons with mental health diagnoses and can lead to inaction even from practicing clinical psychologists.

Jenny Logan, “Viewing Mental Differences on a Continuum Reduces Stigma,” Mad in America

Today I read this article quoted above and it made me want to talk about my own experiences with stigma and challenging concepts of mental health/illness in academia.

By far the worst part of being diagnosed at a young age was the way that people suddenly changed their behaviour around me. Friends, family, teachers, doctors – everyone who I thought I could depend on began treating me like an “other” – a different category of person that no longer inhabited the “normal” range of experience. I was no longer a human being, I was a mental illness.

Stigma, the discrimination directed at people based on perceived social differences, can come from anywhere – public institutions, private relationships, and even from within. It was bad enough being a child who was pathologized by clinicians for having distressing emotions, but it is even worse as an adult to see that I have internalized these mainstream narratives about mental illness. I struggle to stop seeing myself as broken, sick, irredeemably disabled and unfit for public society. A big part of my recovery process right now is simply unlearning the harmful self-concept that was imposed on me by a medical model that looked at my identity as a set of symptoms and chemical imbalances, rather than a human being living through a difficult experience.

When I was near the end of my undergraduate career, and making a plan to move up into doctoral studies, I really wanted to research critical approaches to psychiatry and mental health. So I was fortunate to be able to recruit a professor who specialized in the philosophy of psychiatry for a private seminar course. The goal was to familiarize myself with the field, write a paper that held some value in the fields of philosophy and/or critical psychiatry, and hopefully impress the admissions committee at my future PhD program.

The course was disappointing. Although I barely scratched the surface of available research, I found that the philosophy of psychiatry was really out of touch with modern concerns surrounding mental health. Philosophers described mental illness as a defect in the mechanical structure of a person’s brain; individuals were reduced to their extreme states, and discussion of the social determinants of madness, or criticisms of the psychiatric enterprise, were largely absent in my readings. I wanted to enter this rather snobby and out-of-touch arena and speak its language, but also encourage it to take a principled stand against the moral and material harms of psychiatry and social stigma. The paper I ended up writing pointed this out in the very first lines:

Philosophers of psychiatry and mental illness tend to follow the lead of medical science in concerning themselves almost exclusively with clinical forms of cognitive impairment— mental disorders in their most extreme instances. However, we recognize that there are both common and clinical forms of the associated mental states. Grief is common whereas depression is clinical, and fear of death is common whereas generalized anxiety is clinical. Here I argue for the moral imperative of understanding sub-clinical symptoms of mental disorder – or more colloquially, experiences of ordinary madness.

G.J. O’Farrell, “Ordinary Madness: Sub-Clinical Symptoms and the Moral Dilemma for Diagnosis and Treatment of Mental Disorder“, Unpublished Manuscript

The Mad in America article that I quoted at the top refers to a study which argues the same thing that I did in my paper: mental illnesses should be viewed on a spectrum or continuum. Apparently this is not a new idea, but it appears new to many people, including academics and clinicians. According to the article, this recent study gives us evidence for the claim that viewing mental illness as existing on a spectrum that includes normal, healthy experiences on one end and severe, extreme experiences on the other, helps people to let go of their fears and prejudices, and treat people with experiences of madness/mental illness as equals. One implication here is that a binary view of mental illness is not just incorrect, it’s harmful.

But the implications of a continuum model of mental illness, as I argued in my paper, go beyond merely challenging discriminatory attitudes and reducing the stigma that mad people experience. It also challenges the way that we diagnose and treat mental distress, because it admits that not every experience of extreme or distressing mental states falls neatly into the category of a disorder or illness. It seems obvious and utterly non-controversial, but apparently it needs to be stated and re-stated that difficult emotional states, psychological distress, and even total breakdowns or other experiences of crisis, can all be part of a healthy and rational mind experiencing the normal challenges of life.

Yet in the over-developed world that I live in, this simple truth is being aggressively erased by a dogmatic view that mental health involves an absence of distress. We live in a culture of toxic positivity, and this culture is harmful.

In my paper I argued that philosophers have a unique and valuable role to play in improving mental health care, because we can parse out the nuanced ethical problems that psychiatrists and other clinicians face when being approached by a person in mental distress. If we accept a continuum model of mental illness, then it is likely that some people who seek mental health care are experiencing normal, sub-clinical symptoms of mental illness – what I like to call experiences of ordinary madness.

There is a moral and material risk to diagnosing and treating ordinary experiences of mental distress as if they are pathological. It can cause harm to the patient who is trying to understand what is a very normal and healthy experience, if suddenly they are described by a clinician as ill, imbalanced, and abnormal. Initiating treatment can make the patient feel as if their problems are much bigger than they really are, so big that they are beyond their own individual means to cope with them. Serife Tekin’s paper, which I cite in my own work, is a fantastic analysis of the way diagnosis can harm a patient’s self-concept, and in fact be detrimental to effective treatment. This is to say nothing about the real risks involved in invasive forms of treatment for mental disorder.

Sometimes symptoms of anxiety and depression are signs of clinical illness – I’m not going to try to argue that these are not real conditions that deserve clinical attention. But perhaps just as often, if not more often, these symptoms and other states of mental distress are indicators of a rational and healthy process that is unfairly shunned by mainstream society. We are too often judged as weak if we feel sad or afraid or angry, but how else are we supposed to feel when, for example, living through a global pandemic, inundated daily by the news of incompetent politicians and protests against public health measures led by conspiracy theorists? Or when trying to appreciate the gravity of a global and existential threat like climate change? There are very real and rational reasons to be mad.

How is someone supposed to feel when they live in an abusive household, or experience emotional neglect, or are sexually assaulted, or socially isolated by their peers? For some people who are really struggling and can’t find any reasonable explanation of their own distressing experiences, a diagnosis can be a relief and a revelation. But sometimes the isolation of diagnosis, the sense of powerlessness that comes with it, and the stigma that immediately appears in every part of life is more like a punishment and a prison sentence.

Experiencing difficult mental states is also an unavoidable part of becoming a better person. None of us are born perfect moral agents, and it is almost inevitable that at some point we will recognize in ourselves an unethical impulse. In this excellent paper, C. Chapman argues that to be ethical people, we must be willing to “cultivate a troubled consciousness”, because it is only through recognizing our own involvement in oppression, and wrestling with the very difficult emotions that arise as a result, that we navigate our way to a more ethical life.

When I, as a privileged white Canadian, cisgendered, heterosexual man realize my complicity in both systemic and active forms of racism, sexism, ableism, homo/trans-phobia, colonialism, ecocide, etc., it feels awful. And it should. Being with those feelings and listening to what they have to tell me is how I begin the process of learning to be an anti-racist, a feminist, de-colonialist, and so on. These moments of a “troubled consciousness” tell me where and how I need to work on myself in order to become a better moral agent.

All of this is to say that symptoms of mental illness are not inherently pathological. We all experience madness to some degree in our day-to-day lives. Viewing others who experience madness to a greater or lesser degree as equals, as “one of us”, simply experiencing their humanity in a different but still familiar way, allows us to cultivate compassion and understanding for one another.

Ordinary Madness: Sub-clinical Symptoms and the Moral Dilemma for Diagnosis and Treatment of Mental Disorder (An Anecdote)

Some of these ideas are explained in some detail (and with an unbearably academic voice) in this paper that I wrote in my final year of undergraduate study and later presented at a conference in Montreal. Sure, it wasn’t my best paper, but I thought it had some pretty good ideas inside. It was limited by the fact that it was a term paper for a course, and so I had less time than I would have liked to do research and finish writing it, and the word count limitation created an arbitrary barrier to what I could explore.

But the paper itself provided an interesting anecdote about stigma. The conference I presented the paper at was hosted by Concordia’s Interdisciplinary Humanities program – an innovative and intersectional academic space that includes arts and social activism as readily as humanities and STEM academics. I was nervous that I would be torn apart for my amateur-level understanding of a broad and complex field of study, but I was happily surprised. My work was embraced there, many wonderfully inspiring conversations followed my presentation, and I was validated both in my research and my individual experiences by scholars, artists and even a fellow philosopher, who all shared my concerns about the moral harms of mental health care. For a short time, I felt like there was a small corner of academia where I belonged.

It went so well I thought I would try to have my paper published in a journal of philosophy. I knew that the paper was far from perfect and would need some work, but the response I got from my peer reviewer was so over-the-top in its dismissal of anything I had to say, I was a little shocked. Since the argument of my paper could essentially be summarized as “Philosophers have a moral duty to help clinicians better understand and respond to symptoms of mental illness,” surely, I thought, it would be of some appeal to other philosophers. Yet the feedback said that my ideas were “unoriginal”, “empty”, mere “opinion”, and claimed that whatever I was doing, “this is certainly not philosophy.”

It’s true, I wasn’t doing philosophy in the sense that academics would expect – and while I contend that academic philosophy is a pale and misleading imitation of what philosophy in its grandeur can be, that’s a story for another day.

But it’s true, I didn’t engage with enough secondary literature, I wasn’t familiar with mad studies or the history of philosophical analyses of psychopathology. I was trying to do something comparatively dull and simple: combine my own lived experience with the bits and pieces of “credible” information that academia had made available to me in my role as an undergraduate student. I had never heard of mad studies, and my professor was largely unaware of critical approaches to psychiatry, so I took what I was given and strung together a narrative that was basically saying: people are harmed by reductive and ignorant views of mental illness, and a continuum view of mental states may help us alleviate that harm.

Looking back at the reviewer’s comments, I don’t think I was the recipient of mental illness stigma, but rather the stigma of being a non-expert, a non-academic, and therefore an outsider who was not qualified to generate knowledge. I hadn’t climbed the class ladder far enough, my position in the ivory tower was insecure and fragile, and so I wasn’t regarded as a credible knower on the subject. Rather than being directed towards relevant research I may have missed, I was essentially ridiculed for having missed it in the first place. This is what I wrote back to the journal after receiving the peer review:

Thank you for reviewing my paper. After some consideration I have decided not to resubmit my work. It is not clear to me what would be required to make my paper, described in the feedback as mere opinion and certainly not philosophy, adequate to the reviewer, and frankly given the tone and content of the feedback it seems strange that I should be invited to resubmit my work in the first place. Nonetheless I appreciate the opportunity to have my work scrutinized and I will take this criticism into consideration as I continue my work on the subject. 

How obvious was my disdain? I can’t tell. But it was an experience that put me off submitting to academia any time soon. Maybe I should re-write that article as a blog post, in a more conversational and casual tone, that doesn’t try to appeal to the authority of the academy in order to earn its claim to credibility. Some day, perhaps with more reading under my belt, I may try to re-write and re-submit my article to an academic journal.

But it is validating to know that despite one cranky philosopher’s comments on my paper, my ideas were not naïve, and that other academics still see value in doing research that challenges stigmatizing views of madness. Despite the fact that I didn’t construct my argument in a way that effectively demonstrated those ideas to a niche and demanding audience, I know that symptoms of mental illness exist on a continuum, and that not every experience of mental suffering is caused by illness. I know that ordinary madness is a part of healthy everyday life. I know that I was misdiagnosed, that I am not neurologically broken or sick, and I know that there is a space for philosophers and ethicists (among others) to criticize and improve upon our current ideas about what constitutes illness, and what mental health really looks like. I know that I have a moral duty to call out the harms of psychiatric care, and help others avoid the harms of being turned from a human being into a mental illness. I know I’m not ill. I’m just mad.