December 3, 2023

Content warning: This post mentions suicide.

“We all have mental health, but not everyone has mental illness.”

The clinical language of “mental health” is not a new phenomenon. The National Institute of Mental Health was established way back in 1949. But the rise of mental health as an object of discourse in the public sphere is a relatively recent phenomenon. For example, the top four national newspapers by readership – The New York Times, The Wall Street Journal, The Washington Post, and USA Today – published a total of 43 articles referencing the term “mental health” in 1990, compared to 575 articles on mental illness. By 2022, there were 577 articles about “mental health” among those same publications (an increase of 1242%), while the number of articles covering mental illness was 668 (an increase of only 16%). (See Figure 1 below.) A dramatic increase in the number of articles about mental health occurred after the emergence of COVID in 2020 although there was already a steady increase during the decades prior.

Figure 1. Rise in the number of news articles referencing mental health. The straight red line represents the line of best fit for the average number of articles published per year among four newspapers (The New York Times, The Wall Street Journal, The Washington Post, and USA Today) that contained the phrases “mental illness” or “mentally ill” between 1990 and 2022. The straight blue line represents the line of best fit for the average number of articles per year containing the phrases “mental health issue,” “mental health issues,” “mental health problem,” “mental health problems,” or “mental health crisis” between 1990 and 2022. To see the trends for each newspaper, click here.

According to the Harvard McLean Hospital website, mental health is a measure of our well-being, and while a person’s wellness is very individualized and subjective, any drastic changes in our relationships, behaviors, and decision-making could indicate that something’s amiss. Mental illness (or having a mental health disorder) is one possible state of mental health, and though these terms are often used interchangeably, there is some benefit to talking about mental health as differentiated from mental illness. In particular, in our treatment of mental health as a public health issue, society more widely acknowledges the role of external factors that contribute to poor mental health. In recent years, for example, there has been much research and discussion about the impacts of social media, climate change, and COVID on people’s mental health. On the other hand, phrases like “someone is having a mental health problem” and “someone is experiencing mental health issues” can serve a similar function to psychiatric labels by reducing people’s distress to inner states that ignore the role of life experiences and environment, including abuse, trauma, and discrimination, in creating and shaping the presentation of mental illness.

When a person thus says they are “having mental health issues,” it can mean anything from having a psychiatric diagnosis to struggling with multiple life stressors. This vagueness can be valuable as it allows people to talk about their well-being (or lack thereof) without necessarily having to disclose or receive a diagnosis. There is a double standard here, however. The safety in talking about our mental health openly not only relies on its lack of specificity, but also on the ableist assumptions we believe people will make about us based on race, social status, and perceived achievement. When a world class athlete or celebrity talks about their mental health, they will generally be assumed to be struggling with acute depression or anxiety, unless they’ve said or done something that jeopardizes their career, in which case they will come out as living with bipolar disorder. In contrast, when we talk about the mental health of someone who is unhoused, unemployed, or has committed a violent crime, we will probably assume that there is something inherently “wrong” about them, or that they are experiencing “severe mental illness.” In my own case, as someone who writes about mental illness, neurodiversity, and autism, and someone with a circular rather than linear life trajectory, I often have to gird myself for people’s wild assumptions about me, from the assumption that I must have psychosis (which is heavily stigmatized and therefore not a benign assumption) to the more troubling accusation that I “must have done something bad” (someone’s actual words).

It’s also worth asking, if “mental health” is truly destigmatizing, why do we rely on its ambiguity in order to be able to talk about it? The truth is that mental health campaigns that address serious issues like burnout among physicians and high rates of stress and anxiety among college students are positive and important developments, and they will hopefully save lives. The other truth, however, is that most anti-stigma advocacy around mental health does nothing for people with mental illness, let alone people labeled with “severe mental illness.” Indeed, the anti-stigma aspect of most mental health advocacy rests entirely on the passive inclusion of mental illness under the umbrella of mental health, while the normative beliefs about mental health are often ableist and reinforce a delineation between those striving for or practicing “good mental health” versus those who have “bad mental health,” e.g. mental illness. How can we claim that mental health as a phenomenon distinct but inclusive of mental illness is becoming destigmatized, when conversations and attitudes about mental illness remain much the same as they’ve always been?

Who do anti-stigma campaigns actually serve?

There’s much to be learned in the similarities between current mental health advocacy, which centers mostly white, abled, neurotypical people, and the anti-homophobia campaigns of the ’90s and ’00s, which centered mostly white cisgender males, and for the most part pushed marginalized sexualities and gender identities further to the margins. For example, through the 2000s, gay representation in the media largely focused on presenting the “respectable queer,” a gay, white, cisgender, middle class person who was allowed to appear on screen only as long as they weren’t too openly gay, or were such a caricature of gayness that their sexuality was rendered a part of the joke.

Like the earlier politics of gay marriage equality, current anti-stigma campaigns seek not liberation but inclusion within “a system of hierarchy and domination grounded on distinctions between the respectable and the degenerate,” with respectability conferred mostly upon the subset of abled, neurotypical people. As the legal scholar, Yuvraj Joshi, observes, there is a difference between respect, which “connotes acceptance of difference,” and respectability, which “connotes acceptance of the norm.” Just as early gay activism sought respectability over respect, mental health advocacy actually entrenches ableist, neurotypical values and beliefs while placing the onus on neurodivergent people to “cease to be unacceptably different.” Indeed, most criticism of neurodiversity advocacy stems from parents of autistic children who fear losing supports and interventions whose primary goals are to encourage approximations of abled, neurotypical standards of behavior, i.e. respectability, rather than to support disabled people as they are.

Of course, there is a legitimate question of centering that must be grappled with in the neurodiversity “movement,” and to be fair, neurodiversity has been largely a white-centered affair with mostly white, autistic people in leadership. But I would also argue that for all its current faults, the neurodiversity movement is a true disability-centered movement that advocates for liberation, including for those with the highest support needs. Just as we reject labels of “profound autism,” we reject the label of “severe mental illness,” which draws an arbitrary line between people with anxiety, depression, or subclinical symptoms and people with mental health disorders. In contrast to neurodiversity advocacy, mental health advocacy is not a true disability-centered movement as it routinely ignores the voices of those with certain psychosocial disabilities, routinely espouses the medical model and pathologizing language, and rarely advocates for people’s self-determination.

Mental health anti-stigma campaigns are very much interlocked with the medical model of disability, in that it’s ok to talk about not being ok, but it’s not ok to talk about people for whom medication has not helped; it’s not ok to talk about suicide; it’s not ok to talk about people living with psychosis, dissociation, or personality disorders; and it’s definitely not ok for people to live with “untreated mental illness.” Much like early anti-homophobia campaigns made gay inclusion conditional on the degree to which gay white men could perform straightness, mental health campaigns continue to stigmatize people who cannot perform good mental health, especially if they are actively experiencing psychosis or otherwise behaving in ways that people find disturbing or upsetting. Because inclusion is conditional on “acquiring a respectable social identity,” this ends up widening the divide between respectable (those who can) and non-respectable (those who cannot).

The poster children of mental health campaigns are, without exception, people who can claim to have managed or overcome mental illness with medication and other treatment. As we normalize talking about mental health but exclude the complexities of people with “severe mental illness” from these conversations, we end up further stigmatizing and marginalizing people who most need to be part of the conversation.

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