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’t 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 for getting this started.

Image from Antidepressant Skills Workbook.

Hierarchies of Eating Disorders: A Spiritual Perspective

If you’re someone who reads lots about eating disorders, you’ve probably already seen this article by Maree Burns floating around recently. For those who aren’t enmeshed in the world of post-structuralist and feminist critiques of eating disorders, you may want to try to read it anyway. It’s a little long and at times jargon-y, but it’s also fascinating and makes important points about the hierarchies we set up around eating disorders. Similar to Burns, I will not be using this post to posit anything about the actual nature of eating disorders, but rather about how they’re constructed in the common conscience of Western society.

There are many points in Burns’ article that I’ve spent time grappling with: the fact that anorexia is both held up as perfect control and derided as sickness and disgusting, the way anorexia and bulimia can be mapped onto the virgin/whore dichotomy, and the tendency to view anorexia as the ideal eating disorder. There is an hierarchy of eating disorders, one that is held up by nearly everyone. Anorexia is considered cleaner, more respectable. Many people even view many of its characteristics as positive, but simply taken too far. On the other hand, bulimia is considered disgusting, animalistic, and out of control.

Burns looks at this hierarchy from the perspective of post-structuralism. I’d like to take a different perspective that I think can illuminate some other elements of the hierarchy and the ways that eating disorders make a certain kind of sense. Spirituality is something that Burns does not touch on at all in her article, despite the fact that moral language runs rampant in descriptions of eating disorders, and in the past eating disorders often happened in religious contexts.

Throughout her article, Burns draws on the Western concepts of dualism. She looks at it particularly from a feminist lens, in which female is associate with body/disorder/evil/animal, and male is associated with mind/rationality/control/order. However there is a slightly different version of this dualism that may actually shed more light on eating disorders, which is the body/soul split. Burns points out that society (including pop culture, psychological professionals, and those who actually have eating disorders) makes negative judgments of only certain elements of eating disorders. This includes the behaviors of bulimia (especially purging) and the skeletal body of someone with anorexia.

She posits that these are different types of judgment: the judgment of bulimia is about actions that don’t fit into the appropriate feminine mold, while the judgment of anorexia is about a body that makes a mockery of the thin ideal.  She looks to how each of these “negatives” deviates from acceptable feminine roles and how that deviation results in judgment. In contrast, the behaviors that make up anorexia (self-denial and self-control) are often viewed positively as movements from feminine (bodily) to masculine (rational).

However there is another way to interpret the negative judgments we cast on those with eating disorders and the ambiguous position of anorexia in society. We can find a clue in the religious language used by starving saints in past centuries and co-opted by some people with anorexia today (including myself). Oftentimes this language circulates around dismissing the body completely and moving into a fully spiritual realm. The prioritizing of the next world over this one still holds sway in Western culture (despite frequent cries about our society falling into horrible materialism).

These criticisms of eating disorders reveal that bodies, particularly bodies that remind us that we are animal, mortal, and fallible, are what receives criticism. Negative judgments of bulimia often center around the corruptness of the body and through the body, the individual. The body is seen as the ruler in this situation, but the focus on the body is often given a moral meaning. People with bulimia binge, however the binging on food is often extended into other realms: they’re posited to be kleptomaniacs, sex addicts, or out of control. Most of these assumptions focus on impurity and the fact that binging and purging “taints” the individual. I’ve often heard them referred to as “failed anorexics”. This means that they have failed at the purity that those with anorexia achieve because they allow their body and its needs to overtake them. The obsession with “how much did you eat” and “how did you throw it up” reveal society’s dark obsession with the animalistic elements of bulimia and how it affects the body, rather than an interest in the inner lives of those with bulimia.

Burns suggests that the negative judgments of bulimia are made in contrast to the self-control (often interpreted as rationality) of anorexia. She says: “Self-starving is also paradoxically privileged as a signifier of those qualities that have historically been associated with ‘masculinity’, such as self-control, persistence, transcendence of the (labile feminine) body, and strength” However I would argue that this type of self-control is often associated with spirituality rather than any kind of rationality, as she suggests. People recognize the irrationality of anorexia in the context of the material world. However starvation, asceticism, and self-denial have a long history in the religious tradition of transcending this whole plane of existence.

Something that I’ve posited for quite some time is that the end goal of anorexia is to become pure spirit, to no longer be held up by worldly, finite things.This is why anorexia is often held above bulimia. However the reality is that people with anorexia do have bodies and their actions do impact their bodies. When their bodies begin to appear abnormal, we’re reminded again that they are human, finite, and mortal and that their bodies are falling apart. We are reminded of death (see: focus on the “skeletal” nature of the anorexic figure). And especially as Western societies move closer to secularism, this reminder of death is viewed as disgusting and disturbing, garnering criticism. The combination of heavenly motivation with dying body creates the mixed reaction of most individuals.

This additionally explains the feminine coding of anorexia. It falls in line with the tradition of women who fade away into martyrdom and make their femininity acceptable by rejecting their bodies unequivocally. It is part of the “pure” woman, the history of women as keepers of the spiritual well-being of their families, of women as more moral and in touch with religion than men. Part of the push/pull response to anorexia is the fact that the very deadliness and extremity of it is considered admirable by some. Not everyone can do it: it refuses to accept human limitations and so in some ways appears almost supernatural. The extreme refusal of finitude almost appears to be a martyrdom, especially for those who are trapped within the eating disorder. There’s even a kind of cultish interest in the fact that many people with anorexia suffer from ammenorrhea. Their bodies no longer even produce blood, one of the most obvious markers of human finitude.

On the flip side, bulimia reminds us of our more animal side. We think of the behaviors not as outstanding or amazing, but as mundane and slightly disgusting. We associate overeating with animals, with bodies, and we view vomit as wholly animal (because bodily fluids are gross ya know?). It’s very easy to view the dichotomy between bulimia and anorexia as a struggle between our lower natures and our higher spiritual calling.

And of course if we are considering female morality and spirituality, sex must be play a role. The connections between food and sexuality have already been identified, particularly in Burns’ article. Abstinence is a largely spiritually driven quest. Few secular people feel the need to be abstinent for moral reasons (of course there are some, but it’s not nearly as common as within religious circles). The drift of the spiritual meaning of sexuality into food also colors our conceptions of eating disorders. Just as the body is dirtied and corrupted by inappropriate or out of context sex, so it is by inappropriate or out of context food: a binge. An important part of this connection is the way that sexuality is used to dehumanize, animalize, and objectify women. When we use phrases like “orgies of eating” to describe a binge, we sexualize not only the food, but also the individual participating, and through that sexualization we objectify. It portrays people with bulimia as less human, as more animal. The objectification of women through hypersexualization plays directly into the ways that anorexia (anti-sexual) is viewed as humanizing, pure, and spiritual while bulimia is viewed as animalistic: those who engage in it are objectified just as others who are hypersexualized are.

While the role of male/female dichotomies plays an important role in eating disorders, we should also consider the dichotomy of worldly/heavenly and how that can explain some of the behaviors and attitudes we have towards eating disorders. The history of eating disorders (particularly the long history of female saints starving themselves to death) is a good place to start in this perspective.