Think of the last time you had a terrible conversation about a contentious issue. There probably came a point when you and the other person were speaking past each other.

Conflict is part of communication. To accept difference is to also accept an amount of agonism: working through conflict to come to solutions that all parties find acceptable. In rhetorical studies, an academic field devoted to researching how persuasion in its many forms creates knowledge and the bonds that hold us together, we attempt to teach and practice awareness and analysis of why and how conflicts have emerged so that deliberation can proceed, rather than become obstructed.

In my research on communication, I’m struck again and again by how differently people conceptualize the phenomena most people in the United States call “mental illness.” While one person may theorize mental illness as a medical disease like diabetes that may be mitigated with pharmaceutical interventions, another may interpret the same phenomena as a spiritual becoming, and another as a psychodynamic avoidance. Indeed, I am still often surprised by how differently even close friends approach these issues.

Often unstated beliefs underpin what seems like “common sense” policy moves. Often blockages emerge because of an unexamined impasse over facts, definitions, values, or policy. Considered together, our sets of beliefs on facts, definitions, values, and policy constitute our orientations toward topics. This frame for analyzing conflict is called stasis theory. 

This blog post offers a stasis theory frame tailored to deliberations about mental health and mental illness that you can use as a tool for identifying when and why a discussion has stalled. Before serious deliberation, it’s better to ask than assume. Once you understand the site of conflict, the conversation can hopefully return to a productive exchange.

I’ve outlined below one rhetorical studies approach to understanding discourse around mental health. I hope to illuminate the different orientations people bring to the phenomena often labeled mental illness, and why we should not take these differences for granted. I hope this piece and the accompanying questionnaire can help activists, practitioners, and advocates better understand one another and find actionable consensus in policy goals. The primary goal is to spur complex conversation without prescribing a correct answer at the outset. 

Conflicts at the level of fact

For the purposes of this blog post, let’s provisionally define “facts” as accurate descriptions about the state of the world. Although the presentation of facts is often – arguably always – laden with values, we will accept that there are descriptions of the material world that we should understand as facts. For example, the number of people materially living without housing in a particular area at a given moment is worth knowing. Granted, to provide such a fact, we would have to come up with a specific definition of what living without housing means. We must come to terms with a tension in the definition of facts.

It is simultaneously true that the definitions and methods of research are under continuous deliberation among researchers, and that ignoring information created through rigorous and sound research techniques is unwise. Often facts are actually estimates, but they still offer actionable information about the world.

People arrive at deliberations with a map of the facts in their mind. It’s worth asking all parties in a conversation to describe how they understand the state of the world, and then check those views against sound sociological work. The rest of the conversation may proceed differently once the parties have a more accurate understanding of the state of affairs.

Conflicts of facts in mental health deliberations often center on topics such as:

• The practical ease of accessing consensual psych-services and materials for survival. How many people diagnosed with mental illnesses are experiencing poverty? If someone desires consensual psych-services, what material resources are required to obtain them?

• The efficacy of psych-services when provided. How many, and to what degree, do people diagnosed with mental illnesses find the outcomes of medications sustainable and satisfactory? How many, and to what degree, do people diagnosed with mental illnesses align culturally with their care providers?

• The association of violence with mental health diagnoses. Is a mental health diagnosis actually associated with a different rate of violent encounters when other factors like receiving violence are controlled for? At what rate do people diagnosed with mental illnesses experience violence at the hands of police, care providers, family, and/or strangers?

Conflicts at the level of definition

Conflicts of definition can both be at the level of individual words, and at a more abstract level of the nature of the issue. Indeed, there is abundant cultural debate about what a “mental illness” even is.

Conflicts of definition in mental health deliberations often center on topics such as:

• Defining the nature of mental illness. Is mental illness a biological brain disease, a socially delineated category, or some other phenomena that may trouble the binary between material and social? Is this largely a public health issue or something else, like a poverty issue? Can public health and economic inequality even be separated from one another? It is also important not to underestimate the number of people who still see behaviors categorized as mental illness as a sign of demons or a moral failing. Communities may also have their own terms and cultural orientations that view the differences associated with diagnosis as positive or neutral traits of that person’s being.

• Defining the roles of communities and public institutions. Is the suffering of people diagnosed with mental illnesses a policy issue that warrants the use of public resources, or an interpersonal conflict best left to the private sphere? If suffering is a health issue, what are our public institutions’ duties to public health? When and to what degree should the non-governmental communities around mentally ill people take responsibility for their wellbeing?

Conflicts at the level of values

Conflicts of values center largely around whether there is a problem, and the costs and benefits of intervening. They also assess who is impacted and how they will be impacted. Some rhetoricians also describe these as conflicts of quality.

Conflicts of value in mental health deliberations often center on topics such as:

• The amount of suffering tolerable in a society. You may be surprised by the range of suffering people will describe. Some people find a large portion of their community members living in misery acceptable, particularly if they believe in a meritocracy it is the lot of some to suffer. It is worth knowing this about someone you are conversing with, so you may move onto a different value that you may find alignment in.

• The distribution of care work. If public institutions will not support community members, who does this work fall onto? Oftentimes, care work will fall on women and femmes within the family and/or community. These carers may be paid professionals or taking on care unpaid for a person they love. They may become exhausted or disabled themselves providing care without broader support. Because care work does require time, energy, and material resources, caregivers are stakeholders in these deliberations.

• The autonomy of those labeled mentally ill. If someone believes that a person with a mental health diagnosis is not quite a legal person, they often tacitly believe harm inflicted on the path to “cure” does not count because there is no person present to injure until reason is restored. The implications of this view may be disturbing, but it is worth knowing if someone espouses this idea. I encounter it frequently amongst psych-professionals, police, and family members of those diagnosed with mental illness in the United States. There is a range of beliefs among those diagnosed themselves about the degree of intervention tolerable in an extreme state of consciousness like “psychosis,” as evidenced by some people’s willingness to sign psychiatric advance directives. The kind and degree of intervention acceptable can lead to enriching discussions of trust, autonomy, and mutual vulnerability.

• The cost of doing nothing. It will certainly take resources to improve the quality of life for people diagnosed with mental illnesses. However, even people who are indifferent to the suffering of those diagnosed may care about reverberating impacts on the surrounding community. Conversely, in certain contexts there may be diagnosed people who are fine as they are and would prefer to be left alone.

Conflicts at the level of policy

Conflicts of policy focus on what exactly should be done about mental health-related issues. Let’s hypothetically say that everyone in the conversation agrees that a person experiencing non-consensus reality should not be without shelter. They still have to come to some agreement about what policy tool is best suited to address the issue.

Conflicts of policy in mental health deliberations often center on topics such as:

• Modes of psych-services. These are often discourses on the efficacy of consensual and non-consensual interventions. Questions about psych-service policy may also include funding for said services and the roles of out-patient versus in-patient services. If psych-services are on the table, how will they reach populations with different levels of access to transportation, internet services, and monetary resources? In addition, this comes with conversation on the legal right to refuse psychiatric services.

• Modes of peer and community support. These are issues of infrastructure that will make participation in a community sustainable. Is there infrastructure for those diagnosed to find each other and support one another if they desire those connections? Is there a way to recover key pieces of paperwork like a social security card if this person has lost those items? Is there a viable onramp for people to reenter work or education if that is a desired outcome? If the policy involves investing resources in the communities around the diagnosed person, do the people, cultures, and discourses around the diagnosed person support their thriving and the intervention posed?

• Modes of poverty relief. If someone is going to be provided housing, will there be strings attached that may make that option unfeasible or undesirable such as an invasive degree of supervision, or demands to take medication or get sober before entering housing? Is direct cash transfer on the table? What organizations and government agencies will be involved? To what degree should resources go to community and family members alongside the diagnosed person?

This long set of questions is just the beginning. This resource is designed to help orient you to frequent and potential sites of conflict in discussions about mental health so you may tease out what is obstructing a conversation. I’ve also developed an accompanying questionnaire (below) that can help you and the people you communicate with assess your own views. 

Stasis theory does not guarantee a future consensus, but it almost certainly helps the communicators understand one another. In the process, you may also find that you have never considered some of the topics on this questionnaire. If this happens, I hope you take it as an opportunity to discuss and consider how that question interlocks with the others. Evaluating the gap may have rippling effects on how you think through other topics. 

When thinking about issues we care about, it can be easy to fall into what we in rhetorical studies call “common places” – pithy pre-packaged world views that are frequently circulated in discourse. For example, “Mentally ill people have a right to treatment” is a common talking point in mental health discourse in the United States and other parts of the world. Commonplaces are almost always unraveled into something more complicated when walked through full rhetorical diligence. The goal of a successful rhetorical deliberation is not to win a debate, but come to nuanced understandings of issues and discover where we can reach consensus. With this in mind, I hope you find these tools helpful. 

Resources and References

• Care Work: Dreaming Disability Justice by Leah Lakshmi Piepzna-Samarasinha

• Freedom Is an Endless Meeting: Democracy in American Social Movements by Francesca Polletta

• The Caring Self : The Work Experiences of Home Care Aide by Clare L. Stacey

• The Effect of Informal Care on Work and Wages by Courtney Harold Van Houtven, Norma B. Coe, and Meghan M. Skira

Supplemental Questionnaire:
Getting Oriented to World Views About Mental Health

We often take for granted just how differently we see the world from others. These unstated differences can lead to baffling conflicts when people try to work together. With this questionnaire, you and your fellow communicators can hopefully get acquainted with each other’s beliefs about what is called “mental illness” in the context of the United States. The goal of this tool is to spur discussion that opens room for complexity and curiosity.

What are your assumptions about the facts?

We develop a sense of how the world looks based on our direct experiences, what we witness, and what we hear secondhand from the people around us. Oftentimes these views are not necessarily wrong, but they are such a small slice of the world that they are unhelpful when generalized.

Questions to ask to illuminate assumptions about the facts include:

1. How many people in your community do you think are seeking support for mental health-related issues?

2. Describe the process for obtaining desired mental health services. What obstacles do you think a person encounters? How does their social position and identity inform those obstacles? What resources do you think a person needs before they can schedule an appointment?

3. How effective do you think psych-services such as pharmaceutical interventions (medication), therapy, hospitalization, and/or poverty relief (e.g. supportive housing, funds for food) are at relieving distress and trauma?

4. Do you believe there is a connection between violence/crime and psychiatric diagnosis? If so, why do you think this association exists?

How do you define “mental illness”?

Beliefs about what a mental illness is, and how issues of mental illness function, are informed by culture, popular narratives, and personal experience. 

Questions to ask to illuminate assumptions about definitions include:

1. To what extent do you think mental illness is a medical condition? 

2. To what degree do you think cultural and social understandings of what is considered “normal” influences who is diagnosed with a mental illness? To what degree do you think that social categories like race, queerness, disability, and gender impact psychiatric diagnosis? 

3. To what degree do you think poverty and stress contribute to mental health challenges?

4. To what degree do you think that religious or spiritual factors contribute to mental health challenges?

5. To what extent do you think mental health challenges are caused by a person running away from other problems in their life?

6. To what degree do you think someone diagnosed with a mental illness is responsible for their actions and their own care? 

What values do you bring to discussions of mental illness? 

Concepts of care, accountability, and social responsibility vary across cultures and values systems.

Questions to ask to illuminate assumptions about values include:

1. In what ways are those in a person’s social sphere (e.g. family, friends, communities, governments, etc.) responsible for their well being? Who is responsible for what? Who isn’t responsible?

2. Are there circumstances where someone may justifiably retreat from a relationship with a person diagnosed with a mental illness?

3. Are there circumstances where a person experiencing mental health challenges may be held accountable for harm they may have caused others? If so, how? (e.g. apologies, restorative actions like compensation or repairs to damaged property, etc.)

4. To what extent and in what circumstances may a community ignore someone’s suffering? To what extent and in what circumstances is poverty an acceptable outcome in a society?

5. If someone is diagnosed with a mental illness, are there circumstances where the people around that person may pressure or force that person into treatment? What treatments and what degree of force is ethically acceptable?

6. If someone is diagnosed with a mental illness, do they have a moral duty to the people around them to try to “recover” or “cure” themselves?

7. If someone is diagnosed with a mental illness, what can they reasonably ask of others in regards to care and accommodation? What can be asked of family, friends, employers, communities, and governments?

What do you see as actionable and ethical policy?

Sometimes people are quite closely aligned in believing an issue needs to be addressed and have a similar vision for a good outcome, but they diverge in discussions about the best way to get there.

Questions to ask to illuminate assumptions about policy include:

1. If you had a million dollars to address problems faced by those diagnosed with mental illnesses, how would you spend that million dollars?

2. Do you think that poverty relief has a place in reducing the distress of those diagnosed? In what form?

3. Do you believe forced hospitalization or medication is helpful or ethical? If so, in what circumstances do you think it should be applied? Who do you believe is fit to make that decision? How would someone contest a decision made in error?

4. Do you think that access to services paid for by the government should have conditions attached? For example, do you think someone should have to get sober or prove they are actively seeking employment before having access to supportive housing?

5. To what extent do you think those diagnosed with mental illness should be financially responsible for psych-services? For example, should the government pay for therapy sessions or prescription drug costs?

6. Do you think it's appropriate for people with mental health challenges to form communities amongst each other? If so, do you think these efforts should be supported with public resources?

Paige Welsh is a PhD student studying rhetoric and writing at the University of Texas at Austin. Her research interests include medicine, law, and the philosophy of consciousness. She has published her work in venues such as the LA Review of Books and Narrative Magazine. You can see her full portfolio here: https://www.clippings.me/phwelsh1993 

IDHA’s blog is home to diversity of perspectives and opinions about mental health and healing. These posts seek to magnify a wide range of perspectives on different topics. The opinions expressed are the writers’ own.