Chronic, Acute, and Situational Mental Illnesses: Hierarchy and Oppression

Despite the fact that I spend a lot of my life trying to improve awareness and acceptance for people with mental illness, I know that I still screw up. I know that I carry around internalized ableism, and that I make mistakes in how I view myself and the mental illnesses I live with. One of these has been swirling around in my head as I try to make sense of it and challenge it for quite some time now, and I think it’s time to start talking about a form of ableism that is most common in communities of people with mental illness.

It’s not unknown that we treat different kinds of mental illness as more or less important. Depression and anxiety are often considered “not really sick” whereas schizophrenia or personality disorders get lumped into “super crazy*, bad people”. But one of the ways that we distinguish different kinds of mental illness is something that I haven’t heard people talk about much. That’s the difference between acute, chronic, clinical, and situational mental illnesses. One of the times that I have heard this expressed is in the debates over deleting the grief exception for a depression diagnosis. Many people said that this was “medicalizing sadness” or making the normal into illness. The idea behind that is that if your emotions are in response to something, aren’t chronic, or are “normal” (emotions that make sense for the situation, even if they are extreme or debilitating), then you can’t be mentally ill.

There’s a lot to unpack in those distinctions. I think in many ways words like acute, chronic, and situational function in much the same way as functioning labels: they are used to dismiss the opinions and abilities of those who are really struggling and to withhold treatment from those who can appear “normal.”

Similarly, I see hierarchies existing within mental illness communities about what constitutes actual sickness, what is serious illness, and who deserves attention. Some people use those same words to demean others as crazy or out of touch with reality, or to focus on visible elements of mental illness over chronic ones.

Chronic mental illness is just what it sounds like: ongoing mental illness. It can stick around for years. Often people will use it to mean lower intensity, but it doesn’t have to be. Situational mental illnesses are those that arise in response to something. You might become depressed when you’re working a really awful job or after a nasty breakup, or anxious after living with an abusive partner.

Clinical or acute mental illness is typically what we call mental illness that has a large impact on an individual’s life. It’s mental illness that seriously impairs someone’s ability to go through their daily life. Sometimes it’s seen as synonymous with “serious”.

Sometimes we use it to refer to specific incidents that are more extreme. In this case, I’m going to use acute to refer to discrete incidents that are extreme, visible, and intense. This could include things like a PTSD flashback, self-harm, hallucination, or being triggered. This parallels the way that acute and chronic are used to refer to pain.

Unsurprisingly, these incidents tend to get the most attention of all mental illnesses, whether that attention is positive or negative. These are the types of incidents that are used to either prove how “crazy” and “other” mentally ill people are, or as evidence that the lives of mentally ill people are actually really, much more difficult than you think. these are the incidents that scare the pants off of family and friends and typically get some kind of immediate response. I personally have experienced these types of symptoms being prioritized over my chronic emotional problems that were leading to these symptoms. If I self harm, people view it as something that needs to be solved immediately. If I continue to feel all of the awful feelings that led me to self harm, other people don’t seem overly concerned. In my mind, that’s backwards since it’s treating the symptom instead of the problem.

Another example of this prioritization comes in discussions of trigger warnings and ways to help protect people who are susceptible to mental illness. We focus on trigger warnings or content notices because being triggered is immediate, visible, intense. Things like racism, or negative self-talk may not trigger an immediate reaction, but over time can build up into just as serious chronic conditions. For some reason we often ignore those. I have even noticed in myself that I tend to use “content notice” instead of trigger warning when I’m talking about racism or sexism, because in my mind they do not link immediately to a “triggered” reaction (questions of the utility and place of trigger warnings are not relevant here). But racism, sexism, transphobia, and other oppressions can lead to long term, chronic mental illnesses that are just as debilitating and often deadly.

It’s important to recognize that even low level, chronic conditions deserve compassion and treatment, not just the big, acute incidents that are scary and in your face. Interestingly, I’ve also seen chronic, acute, or clinical labels used to discount the competency of the people who get them. So while those people’s problems are taken seriously and considered important or deserving of treatment, they as people are often dismissed or discounted because they are “too sick” or “not thinking clearly” or just different.

People have actually said to my face that my brain is scarier or harder than theirs because they have only experienced situational depression, not clinical depression. Some people who have difficulties accepting mental illness will use the phrase “situational” to imply that they aren’tĀ really mentally ill. It’s a way to acknowledge that you struggle without accepting the full label. To me, that belies internalized ableism. There is nothing wrong with being mentally ill. Why would you need to specify or qualify your depression or mental illness unless you felt uncomfortable accepting it? It’s easier to maintain that your opinions and experiences are normal or valid when you have a label that says you only get really down when it makes sense, when you’re reacting to life, when it’s situational. The problem is that when you say that you imply that people with clinical depression aren’t normal or valid. You’re implying that if an emotion is irrational, then there’s something wrong with it or the person who’s having it. Amazingly, I believe that even when I have irrational feelings I’m still capable of behaving with empathy and kindness, and that I am still a decent person.

While these labels are helpful in many ways when they’re used as simple descriptors, it’s easy to use them to imply that some types of mental illness are more important than others or that some people are more or less mentally ill than other people. Those kinds of divides are generally quite unhelpful. Comparing suffering generally does very little to help anyone and does a lot to invalidate people’s experiences. I worry that within mental illness communities we are dismissing people if they can’t prove their mental illness credentials, and that in the vast world where stigma still reigns, labels are used to keep mentally ill people othered.

I think it makes the most sense to think of mental health as a spectrum, from people who are really struggling to those who are living a life that they find satisfying. We can all move up and down the spectrum at different times and in different situations, and everyone deserves help and support to reach a life that feels good to them. Sometimes people have emotions that are overwhelming and debilitating to them in situations where those emotions make sense. They still deserve help. Sometimes people have emotions that don’t make sense. They still deserve respect. I think it’s important to recognize that even among people who have mental illnesses or are working hard to eradicate ableism, there are sneaky ways it can enter into our thinking. I for one am going to make an effort to validate and support everyone, even when it’s easy to assume that my mental illness is more important. I see no benefit in creating an hierarchy in my activism.



*I don’t much like calling people crazy, but these are the folks that commonly get called crazy as a way of othering. I use it here to illustrate the ways people talk about about mental illness.

Note: My friend Will over at Skepchick was the first person who pointed this out to me, so huge thanks to him forĀ getting this started.

Image from Antidepressant Skills Workbook.