When US musician Mariah Carey was diagnosed with bipolar back in 2001, she feared it would end her career. Over the following seventeen years, as she told People magazine in April, she worried that someone would ‘expose’ her secret. ‘It was too heavy a burden to carry and I simply couldn’t do that anymore. I sought and received treatment, I put positive people around me and I got back to doing what I love – writing songs and making music. As hard as this is, I also knew it was time to finally share my story.’
Stigma concerning mental illness is real; the article points out that although Carey’s one of the most successful performers of all time, she was still unable to talk about her diagnosis for years. The responses to Carey’s revelation point out this striking juxtaposition: her sickness and shame against her accomplishments. They conclude that we should accept mental illness because those with diagnoses can be high-performing. As Ellen McGirt writes for Fortune: ‘Mental illness doesn’t have to be a barrier to winning a Grammy, running a country (relax, I’m referring to Abraham Lincoln), or leading a company.’
The problem with anti-stigma efforts emphasising that people with mental illness can be high-functioning is that they leave behind those who don’t perform ‘normal’ versions of themselves, or who actively eschew ‘normal’. It’s also a lost opportunity for us to redefine what ‘normal’ could be.
In care situations, ‘high-functioning’ people are often pitted against the ‘low-functioning’. It’s like having an annoyingly perfect older sibling: why can’t you be more like them? As Sam Dylan Finch explains, people with mental illness diagnoses who ‘pass’ as normal are often granted special privileges and are more likely to be treated with compassion and respect. ‘The people who can’t live up to this ideal are perceived as ‘difficult’ – often written off, misdiagnosed, or pushed off onto other clinicians – and are given less agency, respect, and dignity as they navigate psychiatric care.’ It’s also not ideal for the ‘high-functioning’ person who is pressured to maintain their respectability. When people say ‘you’re not like the other mentally ill people’ they mean it as a compliment, but it erases the fact that, actually, you are like those other people in many ways, you require support, and you aren’t an ‘exception’ as much as you provide one of a diverse array of examples of what mental illness looks like. Plus, it’s very easy to fall off the ‘high-functioning’ pedestal. In this context, anyone who has been diagnosed with a mental illness ought to be weary of identifying with a certain level of functionality – it’s a concept that marginalises us, and introduces difference between us where we could form greater solidarity.
There are many different views of what constitutes ‘functioning’. Under neoliberalism, it’s often conflated with making a net positive contribution to the economy (through having a job and/or providing the free labour of domestic care that is necessary for wealth accumulation). Anti-stigma efforts (for example, this Deakin University report) often highlight the costs of barriers to treatment: mental illness is a leading cause of disability, significant numbers of people with symptoms of mental illness never get treatment, and mental illness costs the economy billions of dollars (mostly in lost productivity). Nudging people to get help is a form of biopower: we collectively spend money on treatments that will get people back to work, so as to make the economy run smoothly.
Aiming for ‘functionality’ is not solely coercive. It’s great to have access to meaningful work, to education, to safe, stable housing. There’s also often very real distress that underlies ‘abnormal’ functioning, and the mental health system grants people access to tools (like medication, or therapy, or other supports) that can genuinely help. In her piece “Sick Woman Theory”, Johanna Hedva points out that the lives of those of us with mental illness, chronic illness, and/or disability require ‘infrastructures of support to endure’. Politics is intimate for us, because without those infrastructures, we will suffer, and some of us will die. We need good access to healthcare, but the terms under which that healthcare exists seem perennially under debate. Will there be an NDIS in the future? Will I have to make co-payments under Medicare? How many subsidised psychology sessions am I allowed? Many of us also need welfare payments. Those in receipt are viewed with suspicion and are constantly assessed and re-assessed as to whether they truly deserve it. As the value of these payments erode, the reminder that the conditions of your existence, your quality of life, are subject to the decisions of populist politicians is viscerally frightening.
The thought that your recovery is ultimately cost-efficient provides some reassurance that there is a neoliberal argument for your continued existence and care. But it is nonetheless still dangerous to define care around ‘function’, because it politicises that care. Psychiatry in particular has a long and ongoing history of oppressing people under the guise of treating the ‘abnormal’. This is a profession that classed homosexuality as a mental illness until 1987. This is also a profession that has used diagnoses and ‘treatments’ to quell anti-colonial resistance as well as the abolition movement. Functioning here is performing your social role, marrying someone of the opposite sex to support the proliferation of the nuclear family, supporting imperialist power, even accepting enslavement. This paternalism is not an historical artefact; these realities are ongoing. People are routinely treated against their will and practices of seclusion and restraint are used throughout the mental health system.
I’ve been lucky enough to encounter psychiatry in more benign ways, most likely because of various privileges I have (having private health cover, being white, and having a tertiary education, I believe, has diffused some of the potential dangers of treatment). But even in more benign interactions within the system, your goals are often defined for you under the functionality rubric.
I have two small examples of how this has happened to me. I remember sitting in a psychiatrist’s office, prepared with some notes to talk about how I’ve been feeling. Before I could say anything, the psychiatrist told me that I was clearly depressed because I wasn’t wearing make-up. It became clear to me that she saw my ‘recovery’ as wrapped up in my ability to cultivate an appearance in line with gendered expectations. The truth was that I was depressed, but as I habitually choose not to wear make-up, to me, that aspect of my appearance is completely irrelevant to my goals and values. I felt squirmy under her gaze. I was reminded that in this interaction I was an object of study. I am not performing to the gender role set out for me as a woman, and thus I am not functioning; I am sick. My interior life is secondary.
In another example, I remember explaining to a psychiatrist that I was having trouble remembering to eat lunch every day. There were a number of reasons: I’d been busy, and one of the medications I’d been taking had the side-effect of appetite suppression. But before I got the chance to even mention these factors, I was hit with a lecture. I was told that it’s very, very important to eat lunch every day as a form of self-care because if I can’t take care of myself, how am I supposed to take care of my children?
I should note that I was twenty-four, and didn’t (and still don’t) have children, I was not pregnant with a child, I had not mentioned any desire to become a mother one day, and had no immediate plans to become one. I was already being shamed for not functioning in a role I hadn’t even stepped into.
I could blame individual service providers for their anti-feminist politics and communicative ineptitude, but the outlooks I’m describing are symptomatic of a system that’s oriented around functioning, whose job it is to smooth over threats to the status quo in the form of ‘mental illness’. Under the current structure of care, the tools we need to manage our distress are part of a Faustian bargain. You can have the tools (if you have enough financial and social capital to even get an appointment), but you must become ‘functional’ or else you will be treated punitively as ‘low-functioning’ or ‘difficult’. It puts me in a weird place where I’m simultaneously calling for better access to care and critiquing that care as hostile to my politics.
As advocates though, we can at least re-frame our efforts to emphasise the importance of unconditional care that doesn’t require that ‘dysfunction’ be corrected but does help people manage difficult experiences. ‘The most anti-capitalist protest is to care for another and to care for yourself,’ Hedva writes. ‘… To take seriously each other’s vulnerability and fragility and precarity, and to support it, honor it, empower it. To protect each other, to enact and practice community. A radical kinship, an interdependent sociality, a politics of care.’
And as advocates wanting to destigmatise mental illness, I’d prefer it if we reframed our efforts away from talking about how those of us with diagnoses can be successful and high-functioning and towards the ways in which we can be supported to live in accordance with our values alongside (or despite, or while honouring, or while being supported for) our limitations and differences. It would show us as agents with interiority rather than people who can pass as normal. The effective difference between the messages ‘look how normal we are’ and ‘look at the fact that we’re agents’ may be big or subtle. It may mean returning to work because you get satisfaction from it, rather than because you have to. It may mean not feeling able to work, but that being okay because you derive a sense of satisfaction and community in different places, and nobody questions your right to exist.
It may mean coming to see your distress as a social protest, rather than a sign there’s something wrong with you. It may mean that my depression has nothing to do with the cosmetics carefully arranged on my face, and that differences can be the result of a choice rather than a lack of capability. It may mean I still find a way to eat lunch every day, but not so I can practise motherhood, but instead so I have more energy to smash the patriarchy. When mental illness treatment and anti-stigma campaigns stop being about restoring ‘normal’, so many new possibilities open up.
It doesn’t matter to me how beautiful Mariah Carey was, or how many albums she sold, or how much money she made. I want to hear about how she was distressed and confused and labelled ill and how she did what she loved. She kept her voice and she sung.
Image: Hands as Portraiture / Raj Lalwani