The Violence of Likeness Stigma
The stigma paradox is a model that describes two types of stigma related to mental health: likeness stigma and unlikeness stigma.
Likeness stigma is the notion that people considered “mentally ill” are “just like everyone else” - i.e. they have agency over their actions and can choose to feel and behave in ways that are considered “mentally healthy” by society. “Everyone feels depressed sometimes,” a person who harbors likeness stigma might say. “But it doesn’t prevent them from getting out of bed, going to work every day, and achieving their dreams. Why should it hinder you?” In other words, snap out of it.
Unlikeness stigma is the notion that people considered “mentally ill” are suffering from a physiological brain difference that prevents them from having agency or choice over their actions. Because “the mentally ill” can’t control their behaviors on their own, they need someone to step in and take over. “Schizophrenics can’t control whether or not they are violent the way you or I can,” a person who harbors unlikeness stigma might say. “They need to be locked up for their own good and for the good of society.”
As psychiatric survivors, it is easy to see just how violent and oppressive unlikeness stigma can be. The notion that we are fundamentally different from everyone else and that our behavior is controlled by a distinct biological entity that needs to be cured or treated for our and others’ safety has been used to justify overt, state-sanctioned acts of violence against us - and to silence us from speaking out about these forms of violence - for decades. Unlikeness stigma is what leads to us being locked up, forcibly drugged, electroshocked, restrained, secluded, etc. A great deal of critical psychiatry work revolves around challenging unlikeness stigma whenever possible, and I wholeheartedly support those efforts.
But too often, I have seen the psychiatric survivors community fall into arguments based on likeness stigma. And that is completely understandable. After hearing that one is “mentally ill” and needs to be “fixed” via drugs or ECT, it is comforting to hear that one can instead alter their behavior without medicalization, by just taking responsibility and thinking differently.
Likeness stigma often goes by the name of “empowerment.” “There’s no such thing as ‘can’t,” I’ve heard fellow activists say. “The mental illness paradigm convinces people they can’t do all the things necessary to live a full life or participate successfully in society - like work full-time, get a college degree, and get married. Too many people are convinced they can’t do these activities because of some illness or brain disease they have. And I want to empower them to do those things, to achieve those goals. Mental illness is not an excuse.”
Quite a few people in psychiatric survivors community have shared a recent article, “No, You Don’t Have a Disorder. You Have Feelings.” In the article, psychoanalyst Lisa Marchiano argues that the notion that our distress and limitations are the result of a mental disorder is a self-limiting and self-reinforcing narrative. “When life problems are addressed only from within the impoverished terms set by a medicalized approach to distress, difficulties become concretized,” she writes. “We become locked in the narrow perspective of the story and cannot escape. Any treatment that takes a too literal approach is likely to strengthen that story, validating our own belief in our sickness and keeping us stuck.” If we just change our narrative, and stop thinking of ourselves as so limited, we can overcome our limitations.
In the article, Marchiano introduces a client who reports having a panic attack during a university exam and as a result wants to increase her dose of anxiety medication. She then questions this client’s narrative, arguing that it is the client’s framing of ordinary distress and discomfort as a panic attack that has led to her continued experience of anxiety and subsequent desire for medication. If her client could just stop thinking of herself as “mentally ill,” she could push through her anxiety without medication and take her exams like any other student.
When you’ve had medications shoved down your throat or injected into your body, when you’ve experienced endless, excruciating pain from drug withdrawal, when you’ve experienced akathisia so horrific you want to die, when you’ve lost years of your life to suffering or the ability to think clearly because of psychiatric drugs - Marchiano’s argument sounds appealing. Finally, a psychoanalyst with power, prestige, respect, and an answer to offer besides, “You have a mental illness and you need to take these drugs, and if you don’t take them I’m going to lock you up.”
But the reality is that likeness stigma can be violent too. It’s a much more subtle, quiet, psychological form of violence, but it can absolutely have a traumatic impact. The very act of defining a person’s internal experience for them - what their brain and body can do or not do, whether their distress is ordinary or extreme, whether they can just “snap out” of their distress if they try hard enough to think differently - is a form of colonization. It is, as Akiko Hart discusses in her last essay for Asylum, the act of imposing one narrative onto people - pursuing a singular, universal truth that applies to everyone, rather than the right for each person to choose what feels most true for them. It is psychological coercion and domination.
Is pressuring someone to do things that makes them uncomfortable, or that are even painful for them, really that different from pressuring them to take drugs or check into a psychiatric ward? If a person is, like in Marchiano’s example, so intensely distressed by exams to the point of having a panic attack, is it really any less coercive than traditional psychiatry to pressure her to push through her anxiety and take the exam? Why not look into alternative ways to measure learning (and while we’re at it, fight for non-hierarchical systems of education to decrease the anxiety of everyone)?
My own violent experience of likeness stigma involves a Large Group Awareness Training, a cult-like self-help seminar designed to instruct participants that they are responsible for everything that happens to them, and any problems they are having result from their own “limiting beliefs” and “victimhood narratives.” When I did not wish to complete the next level of the training, in part due to being autistic and feeling uncomfortable and overwhelmed in large group social settings, I was told that this was a limiting belief - a narrative I had been telling myself. If I just told myself a different story, then I could push through my discomfort and transcend my limitations. I was pressured nonstop by group members, training leaders, and my (now ex) fiancé to attend this training. It didn’t feel so different from the pressure I had experienced within the mental health system to take drugs.
The pressure I experienced to subject myself to discomfort and overwhelm extended to other areas of my life too. At the time of the training, I had a medical condition that made sex painful. My then fiancé, newly armed with the ideas of the training and ready to share them, was convinced that this condition resulted from a limiting belief. If I just stopped thinking of myself as having this condition - as a victim of some medical issue out of my control - and started taking some responsibility, I would stop experiencing pain during sex. (And guess what would be the perfect solution to help me change my narrative around this issue? Why, of course, the next level of the training!) Any protest of mine - any attempt to show evidence that it was a medical issue, not a limiting belief - was seen as a sign of just how hard I was clinging to my “victimhood narrative.”
The pressure to engage in sexual acts that were painful for me lasted for three months. It was during this time that I found myself understanding the pain, anger, and sadness of many who have joined NAMI and other organizations subscribed to the biomedical model of mental illness. I could understand the deep desire, the desperate need, to prove that one’s limitations are real. To avoid and reject coercion to use one’s brain and body in a way that is painful or overwhelming. It was a slap in the face that I needed to feel.
After hearing my story, many people say that I should have not been held responsible for a medical condition, but that what we call “mental illnesses” are different - that because they are not physiologically based, believing that one is limited by a “mental illness” is false. Why is this? Why should it take physiological or biological proof to justify a decision not to engage in an activity that is emotionally or physically painful or uncomfortable? Why can’t we each be the judge of our own experiences and limitations?
The psychiatric survivors movement should be about allowing each person to be the expert on their own brains and bodies, which includes their own limitations and abilities. Defining another person’s experience for them or imposing a particular narrative - whether an “illness” narrative or a “limiting beliefs” narrative - is violent, and it is that act that should be resisted. At the end of the day, likeness stigma and unlikeness stigma are both stigma, and both narratives that are coercively imposed onto people, and we need to challenge both. We need to instead give people a platform to develop their own narratives and understandings of their identities and experiences.
Of course, the stigma paradox is limited. While the experiences of people diagnosed with “mental illness” are often forced into one of the two narratives, these are not the only two narratives that are imposed on the community. A great deal of mental health research and activist efforts revolve around framing one specific issue as the universal cause of “mental illness” or one specific treatment as the solution. Too often, these messages promote a system of coercion - of discrediting people’s stories and experiential expertise on their brains and bodies, as well as pressuring people to think, feel, and act in ways that don’t feel comfortable or natural to them.
I strongly feel that consumers, survivors, and people with lived experience need a place to express our stories and be listened to without being told that we are wrong or in need of fixing. I wonder how different the mental health system and our culture would be if, instead of attempting to find a universal explanation for the causes of “mental illness” or the most effective cure or treatment, researchers and activists focused on what each person’s experiences of the states and behaviors we call “mental illness” mean to them individually and how their experiences of behavioral health treatment have uniquely affected them. Taking each person’s narrative seriously, as truth - and allowing a multitude of truths to co-exist within one community - is the only real way to work toward a mental health system and culture that is free from coercion. It is this goal that I strive to keep in mind as I transition into my role as a researcher and as I continue in my activism.