Thoughts on Mental Health

Therapeutic politics, mental health as high status, the gentrification of disability

Housekeeping: We launched an experiment around back-channel references as a service, specifically a back-channel bounty marketplace (upvote us on Product Hunt!).

I’m curious to test the following: 1/ Will people want to pay to get references? 2/ Will people want to get paid to give references — will it expand the pool of people who want to give references? 3/ Will money taint the reference in somehow, will people be less happy with it? 4/ Could this back-channel method work in other categories, like for getting warm intros to buyers in target companies?

As a reminder I’m hiring for Turpentine and my other projects (more roles than the ones listed here). I also spoke about the vision for Turpentine in an interview here.

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A couple years ago I wrote about the rise of therapy culture. Mental health framing has recently made me skeptical for a number of reasons.

Mental Health as High Status

One reason is that, in under a decade, it’s become high status among elites. I heard a comedian say he started seeing a therapist and he got a standing ovation. Prince Harry and Oprah have started a new Apple TV series called “The Me You Don't See” about famous people telling us about how they've suffered these enormously terrible, terrible personal events.

Celebrities increasingly come out with their mental struggles. Demi Lovato has discussed her addiction challenges, bipolar diagnosis, sexual assault, eating disorder, her coming out as nonbinary — and it’s helped her sell out her new album and become the face of an online therapy platform that once SPAC’ed for $1.4 billion dollars.

Of course, it’s not just celebrities who are going public with their struggles. Everywhere we look people are sharing their struggles and earning compliments for being so brave. Indeed, disability has even become identity. In our therapy culture piece, we discussed the global status marketplace and how there is pressure for 8 billion people to fill 8 billion niches since they’re no longer competing with their town for status, they’re competing with the whole world. Of course, 8 billion niches are hard to find, so people look for identities in weird places, including disability. So you find people slicing the onion thinner and thinner and thinner to find new identities. 

Daniel Bergner published a story in the New York Times about a paradigm shift that's underway, in which people suffering from severe psychosis like schizophrenia should not be seen as people suffering from a disease but as people merely with a different identity. People are trying to redefine disability as not just something that you have, but something that you are.

Instead of trying to treat it, we’re trying to make it acceptable, which is a noble intention. But in doing so, we make it desirable, which causes what Freddie Deboer calls “the gentrification of disability”:

When I talk about the gentrification of disability, I'm talking about the fact that due to the very nature of disabilities that are related to cognition or behavior, the people who are in the best position to talk about having those disabilities and who guide the conversations are usually going to be the people who are the least debilitated by those conditions.

And it seems they're doing it for status and attention, which seems crazy on the surface but makes sense in a culture where people are rewarded for having different kinds of claims to victimhood. The other thing that I'm seeing happen is that people who are suffering from dangerous psychotic disorders are being recast, not as sick, not as needing help, but as different.

In fact, there are people who’ve come down very harshly saying, “No, it's not a disorder. And it's, in fact, eugenics to look for a cure.”

Instead of focusing on curing the disability, we’re shaming people for implying that a disability is something to be cured in the first place. Of course, the very concept of disability depends on the notion that disabilities are inherently negative.

It's very much a customer service mentality of mental health treatment, the idea that the way you treat a mentally ill patient is to never question they’re feeling, because if the feeling is “natural”, it must be legitimate.

Freddie continues:

Something is truly lost when the public face of mental illness ceases to be a schizophrenic person struggling to maintain their grasp on self-control and becomes instead a member of the professional class who tells jokes about their Ritalin consumption online and labels themselves #neuroatypical on Tinder

Mental illness will become in time just another status marker for those who have never worked anywhere but behind a laptop--a vector for competition in the great post-collegiate race, something people put down to juice their chances of getting accepted at Cornell. People hate when I talk as though there are personal benefits to identifying with these disorders, but there plainly are, or diagnoses would not decorate so many Instagram bios, would not make it onto so many scholarship applications, would not appear in so many gauzy celebrity profiles.

The challenge to them remains the same: how do you proceed with your quest to turn mental illness into a positive thing, an honored thing, a “valid” thing, without inevitably privileging the narratives and interests of those whose mental illness is least malign? How do you imply to generations of young strivers that having a mental illness is cool and unique, without alienating those who feel neither cool nor unique, but only afflicted? How do you normalize mental illness without further marginalizing those who are least normal? How long do you keep insulting people who have suffered by claiming that their suffering is good, actually?”

Therapeutic Politics

Another concern is that mental health is increasingly used for political ends.

John Stuart Mill’s harm principle states that “your right to swing your fist ends where my nose begins”, or where harm begins. In recent years, the concept of harm has expanded significantly, which has led to what Paul Goffried calls “therapeutic state”, which basically means that anything that isn’t progressive can be called “harm”—if you aren’t sufficiently deferential to the progressive shibboleth, you are causing harm. There is a very high overlap between people with a therapeutic worldview and the idea that there is systemic injustice in the world.

People aren’t merely prejudiced towards immigrants; they are xenophobes. The bigot is not only mentally ill, but any space he enters becomes an “unsafe space” where people get “triggered” for his “harmful opinions”. This explains why people were encouraged to march during George Floyd protests but not to leave their house for weddings or funerals. Because racism was a public health crisis, even bigger than COVID. 

A bigger concern is that the mental health regime doesn’t seem to be working. 

From 2009 to 2019, the proportion of high school students reporting persistent feelings of sadness or hopelessness increased by 40%. It’s only gotten worse since the pandemic. Hospitalization for suicide attempts by girls in particular rose 51% from 2019 to 2021.

In one study, conducted last September, more than half of eleven-to-seventeen-year-olds in a screening of 1.5 million said that they’d thought about suicide or self-harm “nearly every day” for the past two weeks. Some people say this is due to social media, but they have to explain the fact that the rise is concentrated among liberals, not conservatives, who have the same use of social media but not of therapy.

Why are mental health issues higher in liberals than among conservatives? Hard to say. I’ve gathered a few possible reasons:

• It’s a selection effect. Liberals care more about helping people with mental illness than conservative do, and so people with mental illness are more likely to be liberal to receive that empathy and support. Being liberal doesn’t cause mental health issues, mental health issues cause one to be a liberal.

• Conservatives have more of a self-responsibility ethos (“pull yourself up by your bootstraps”) which means they are more likely to believe they can change their circumstances, which can reduce mental health issues.

• Conservatives are more likely to embrace the traditional societal structures that have net reduced mental health issues: Religion, Nationalism, Family.

• Showing that you openly embrace dealing with depression in some circles is a signal that you are more in touch with yourself (ie, went to college), and also, if your state of depression is influenced by e.g. Trump, climate change, it shows that you care more.

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I think it’s great that we’ve destigmatized mental health. In 2016 I was vocal on the topic in the tech community. But just like with any pendulum, I wonder if there’s a chance it has swung too far.  

Destigmatize too much and you start to raise the status of what was previously stigmatized. When you make victimhood the new heroism, everyone aspires to be a Super(wo)man of suffering.

I think it’s great that people don’t feel ashamed going to therapy now, or facing their traumas. But I wonder if we made it so cool to go to therapy that people feel like it’s in their status incentive to have mental illness — that it’s not okay to be happy-go-lucky, or that that’s somehow basic.

Indeed: If you go to a doctor in OBGYN, or gastroenterology or endocrinology, that that doctor will examine you, and there may come a point at which he would say, from the point of view of an endocrinologist, there's nothing wrong with you. 

But that rarely happens in the mental health professions. People rarely go to a psychologist and the psychologist says to them, you know, there's really nothing wrong with you. You’re OK. Feeling sad is just a part of life.

It’s a shame we convinced people that anxiety is a medical disorder rather than a natural part of life. There are far too many people who grew up thinking anxiety is somehow unnatural, and thus not building coping mechanisms and essentially developing clinical problems because resilience wasn’t taught. Katherine Boyle’s piece on Suffering nails this.

Thomas Szaz used to say that having a mental illness and going to a doctor to cure it is like disliking the program on television and calling up a television repairman to fix it. The TV's working fine; it's just broadcasting stuff you don't like. And similarly, to say that someone who drinks too much or neglects his family or is abusive is diseased, rather than just fucking up, is a way to shirk responsibility. 

Life can be brutally hard, and you're allowed to find it all very overwhelming and tragic. A really basic modern instinct is to look at what is simply human tragedy, and instead of accepting the tragedy as such, to decide it's insufficient for this to be a tragedy. This needs to be a crime against me and identity.

How did it get this way? 

There was a fork in the road in psychology where the profession went with Freud instead of Adler. It should have gone the other direction, but Adler was less lucrative. The school that ought to be dominant is Adler/Frankl/CBT/stoicism.

This is well documented in Vienna because it’s now widely known that Freud was doing dubious experiments on women. But now these experiments are basically commonplace psychiatry. We should be very afraid that a freakshow practice by weirdos in Vienna is now the mainstream way of understanding the mind across the western world. Freud is universally discredited, and yet is still core of so much in the modern era. It’s nuts. 

Malcolm Collins in a podcast once compared psychiatry to scientology, noting that both try to incept you with trauma and recharacterize your past experiences to fit some trauma, which tends to heighten the PTSD instead of mitigate it. Of course not all psychiatry does that, but it does make sense that a psychiatry which incepted trauma would outcompete other forms of psychiatry because it makes the patient more dependent on the psychiatrist. 

The rise of psychiatry is also when the "Death of God" really kicked in. Therapy replaced the Protestant personal relationship to God. Psychiatry substituted for church.

I’m generally skeptical of turning normal human activities— introspection, prayer, community, conversing with family—into clinical practices that can be bankrolled by the state. Therapy is indeed a replacement for many of these things.

The optimal level of introspection is probably not zero, but if you navelgaze hard enough you will almost certainly find some pathology to be troubled or fascinated by. And a culture that obsesses over this is sabotaging itself. The more introspection a person who is unhappy or lacking purpose becomes, the sadder they get in parallel — with all the language and tools of someone who feels empowered.

People seem to me to be extremely self-alienated, and a lot of their behavior (*including* loud "i go to therapy! i work on myself! i integrate my traumas!" performativeness and signaling) is just a big cope for this.

The path that “self esteem” took from its origination under Rand to where it ended up is illustrative of this. “Self esteem” from Branden and Rand was supposed to be the result of human accomplishment and creative expression, man standing up against nature and collectivist society and achieving great things. Then after Branden broke with Rand and dove headlong into the 1970’s, it turned into what it means today, the lie that you should have a high opinion of yourself before you’ve actually done anything.

Ideally, the therapist would help you distinguish what can be changed in your life vs. not. Stoicism's whole thing is having you accept the things you can't change (like I'm never going to be a world-class musician or whatever). Where you should embrace or abandon agency is the rub.

Quantitative people in the profession seem to get that Cognitive Behavioral Therapy (CBT) is the only method of therapy that actually works. CBT is mostly about changing your systematic misperception of your reality. Although it’s also worth noting that in many ways, some of the sanest people enjoy the most bizarre delusions ('God has a plan for me', 'my life has real impact in the world', etc.). Choose your delusions wisely.

Modern therapeutic language is totally inverse to the Stoic-derived principles considered best practice by modern Cognitive Behavioral Therapy. As Jonathan Haidt chronicled in “The Coddling of The American Mind”, these unhealthy beliefs included: always trusting your feelings, assuming disagreement is always a personal attack, and believing hurtful words lead to real harm, including permanent trauma. 

So get therapy if you need it (I’ve been seeing a somatic therapist for the last six months, it’s been helpful for me ;)), but be mindful of its limitations, don’t make it your identity, and don’t use it as a replacement for friends or family or rituals.

Richard Hanania has a good critique of the mental health framing that I’ll close with.

If we told people that fear of flying was something everyone struggles with, that it was the result of what others have done to them, or structural racism or whatever, I’m sure we’d get more of it. Imagine further if TV, music, and movies taught kids that fear of flying made them deep and interesting, and schools and universities had fear of flying awareness weeks. This is pretty much the modern approach to mental illness. 

A series of data points converge on the idea that navel-gazing and the medicalization of things like anxiety and depression are themselves major causes of the conditions they are meant to fight.

Even the phrase “mental health” is part of the problem. Think about how we speak about health in other contexts. Whether someone has a healthy heart or spine has nothing directly to do with their ideological, moral, and spiritual commitments. The individual is an observer of a mechanistic process. Maybe you eat less to take better care of your heart, but there isn’t an intimate relationship between how you perceive the organ at any particular moment and its overall functioning.

Another misguided metaphor, one that’s always particularly bothered me, is when we say “drug addiction is a disease.” What an insult to people with real diseases! The difference here is that if you put a gun to a cancer patient’s head they don’t stop having cancer. But drug addicts clearly respond to incentives, which is why Mao’s method could work only on this “disease” and no other. Their pathological behavior is therefore more analogous to the everyday choices we make about our lives than it is to a person being overcome with a physical illness.

The mental health module could be excused if it led to positive outcomes. But I don’t think it does. I believe that it crowds out superior frames through which to understand the human psyche, ones that form the basis of myth, ritual, and religion and have withstood the test of time. The language of medicalization – bureaucratic, self-pitying, distant, and sterile – crowds out the language of virtue, which has the power to move people.

Think about a friend who is acting pathologically risk averse by being too afraid to do something you know that they should do. You can tell them “stop being a wimp,” and that gives them agency. The framing is judgmental – there is a right and wrong way to behave, and you are incentivizing them to make the correct choice. In contrast, a medicalized way of understanding the problem relegates your friend to the status of helpless observer, provides no immediate psychic penalty for doing the wrong thing, and prioritizes one’s current emotional state and immediate comfort over the action ultimately taken, when simply taking the action itself has the potential to change one’s inner condition for the better.

This is why the concept of "mental health" is counterproductive. It removes locus of control, based on faulty analogy between mental and physical health. Views and attitudes about your psyche are part of the thing itself, it's not a mechanistic process to be observed. Avoid the mental health framing.