Psychotherapy, neuroscience, and honesty

 Recently, "polyvagal theory" blew up in my social media feed. I think Meta's algorithms have changed lately ... seems like nowadays, you only have to watch through one video from beginning to end to get positively drowned in new videos and texts on the same topic. America's Next Top Model is all over my feed too, after I watched through one video about it ... But this polyvagal thing turned into a real rabbit hole I dived into. I don't have any special relationship to Top Model, but therapy is of personal interest.

Below, I explain why. But if you're not particularly interested in me as a person or my personal life story, you can skip the "personal background" bit and jump straight to section 2, "neuroscience in therapy and polyvagal theory". 

1. Personal background 

Some background for new readers who don't already know this: I was a psychiatric patient, on-off, for over twenty years. And I might be one again, in the future, but for the last eight years, I've managed - sometimes barely, but still managed - without professional mental health services. However, I know several psychiatrists from work, and sometimes ask them for advice, so ... I'm not technically a psychiatric patient anymore, but I'm also not without psychiatrists in my life.
I have always been a psychosis patient, but never precisely diagnosed: the closest I ever got was "probably on the schizo-spectrum, but doesn't tick enough boxes for schizophrenia." 

I've had many pill-prescribing psychiatrists over the years. One of them was also a great listener, even though we didn't have proper psychotherapy sessions or anything (for those of you who have read my novel, Kugghjulssjälar/Cogwheel Souls: Teofil Strand is based on him, even though he gradually departed from the real person and became his own character during the writing process). I could talk to him about everything, and it was really helpful to have that relationship, even though it wasn't actual psychotherapy.
Many psychiatrists over the years, but only three psychologists. I will describe them below.

1. When I first became a patient, I was immediately assigned a psychiatrist for pills and a psychologist for talk. Hard to believe nowadays, but back in the nineties, we still had a proper welfare state, and this was normal public health care! She was psychodynamically trained, and said I would probably improve in the long run from psychodynamic therapy. But first, she said, I would likely get worse, so I would need heavier medication to prevent another psychotic break when therapy stirred things up. This didn't seem appealing to me, so I declined.

2. Many years later, in 2015 or thereabouts, I was a patient at the horribly shitty Capio mental health services in Haninge. 
Psychiatrist sidenote: This was after Sweden completely opened the doors for big-time capitalists to start schools, health services, any sort of welfare services really. They'd be entitled to loads of taxpayer money with almost no oversight on how they spent it, nothing preventing them from running things as cheaply as possible and pocketing the rest. Completely legal to do this. (This is still the welfare system we have.) In Swedish, this place was called "Capio hjärnhälsan" which is a horrible but untranslatable pun on "brain health" and "iron health/great health". I was bounced between different psychiatrists there, I don't know if they had much in the way of permanent staff at all, and when I angrily complained that I wanted to see the same person instead of constantly telling new people about my symptoms, they saddled me with the worst psychiatrist I've ever had. 
By then, I was out of energy and didn't complain anymore, I just kept seeing this guy who called me by the wrong name every single time ("Hello, Matilda", "I'm Sofia, Matilda is just my middle name", "Ah, well, lots of people go by their middle names" every single time). He also had no memory of what meds I was supposed to have, and his patient records seemed to be in a constant state of disarray, so I just told him what to prescribe ... I knew I had a benzo problem (but didn't know what to do about it, since popping benzo was all I could do at the time to keep my nose above water) months before he realized, with a shocked look, that he had been prescribing me quite a lot of the stuff. 
Back to psychologists: At one point, 2015 or thereabouts, I told this bottom-of-the-barrel psychiatrist that perhaps I should have some talk therapy too. He went "oh, you don't? Well, perhaps you should. I'll arrange this for you." And then I got to see some sort of therapist - not sure if she was even a psychologist, but she allegedly (I'm using italics for a reason) was trained in CBT - who immediately told me she didn't know anything about psychosis. Well, off to a good start! She then said we should do mindfulness exercises, because that's good for everything. I'm normally not very attuned to my body (more about this later), but she said I should close my eyes and just focus on my breathing and how the weight of my buttocks and thighs feel against the chair. I complied and pointed my consciousness downwards through my lungs and butt-and-thigh-muscles and I could suddenly feel all the blood vessels in there and all the electricity going up and down nerves that run like threads through the muscles and it was so creepy that I almost screamed and then laughed hysterically and said I don't want to do mindfulness anymore! Psychologist stared at me and said ok, then we'll make daily schedules instead. Daily schedules are good. 
I became near-manic about making daily schedules and following them for a few weeks and thought they helped with everything and then I had a sort of semi-crash and stopped. 
Later, I learnt from a clinical psychologist I know privately that traditional, standardized mindfulness exercises can trigger a new psychotic episode in people who already have psychosis issues, so you should absolutely not do mindfulness with psychosis patients unless you're an expert on this particular topic. But then again, the "therapist" did say she didn't know anything about psychosis, so it's unsurprising she didn't know this either. 

3.  In 2019, I was pretty high functioning and okay-ish but thought, for various reasons, that I needed some talk therapy. Since the horrible so-called therapist described above allegedly was trained in CBT, I absolutely did not want another CBTer. But other types of therapists were hard to find. Seems like almost everyone, nowadays, just offer "CBT and job training". Eventually, I found the Saint Lukas Foundation, emailed them, explained my issues and said that I will not, at this time, go back on meds, and I do not want to do CBT - I want some serious fucking Freud shit! I wanna talk at length about my childhood! 
I got to see a psychodynamic therapist, who was hugely helpful. In the end, we probably didn't do "serious fucking Freud shit" (although I did get to talk about my childhood). Perhaps we didn't do anything that I couldn't have done with a proper CBT therapist as well. Swedish psychologist Tanja Suhinina has written a series of Swedish-language social media posts about how CBT is supposed to be practiced - which differs a lot from how it's usually practiced in today's often shitty public health care system. Anyway. The therapy I got was really helpful, and it was all about psychology and emotions, no neuroscience at all. 

 

After this lengthy personal background, I will return to the topic of therapists who think they need to tell their patients neuroscience stories.  

2. Neuroscience in therapy and polyvagal theory

So, none of my psychologists have talked about polyvagal theory. However, I also teach psychologists and psychiatrists from time to time, in the philosophy of psychiatry, and in these contexts, students sometimes bring up stuff like "the body keeps the score" and polyvagal. So, I felt like I had to learn at least a little bit about this physiology-psychology stuff, but very little knowledge sufficed to set it aside again. In a short course, or a single theme day, on philosophy of psychiatry, you gotta leave out a lot and focus on the most crucial stuff. I already talk about mind/body stuff on a more general level and try to correct important and common misunderstandings; going into specific theories - that I don't even have the expertise to evaluate - would push out philosophy I really want to include. 

Anyway. Recently, polyvagal theory - and, more specifically, therapists saying that it's been debunked now, once and for all, so where do we go from here? - blew up in my social media feed. Others said it's been debunked long ago, it's just suddenly getting more attention. This is a long blog post from 2022, by Alyssa Luck, that several people have recommended to me as a good overview of polyvagal theory and biological claims of the theory that are demonstrably false. Luck isn't a neuroscientist herself, she's a nutritional scientist and science writer, but she conscientiously links to all the science papers she refers to in the post.

Luck also talks about why many therapists get so defensive around polyvagal theory. They've given their patients various exercises that were clearly helpful for them, and polyvagal was supposed to explain why it was helpful. If polyvagal is a bunch of pseudoscience, can we still do the exercises? Or can we prop them up with some other theory instead?

Luck quotes clinician Andrew Cook, from an online discussion of polyvagal theory and psychosomatic researcher Paul Grossman's critique of it. Cook writes: 

"Having applied and adapted PVT for the past 15 years within the context of a bodywork practice and Pat Ogden’s Sensorimotor approach, I must admit that I don’t use most of the scientific core of PVT. Instead, I find that neuroception along with a generic division of human behaviour into three zones (1) fight flight/ sympathetically dominated, (2) normal range, and (3) parasympathetically dominated – is the most useful part. I agree that it’s mythological, and that is a problem. I have actually seen people get a lot of benefit, and then abandon what they found experientially useful because some asshole who read an article they only half understood told them that it wasn’t scientifically valid."

Luck talks a lot in the blog post about how it's natural for humans to want explanations of why something work, we don't like to be told "well, it does work, we're just not sure why". I think this is right. But what if the truth is that we're uncertain why something works? What if the truth is that 
- we have pretty good evidence that this does work for a lot of people
- but we really don't know why?

Shouldn't we just tell it like it is, then? Instead of coming up with "myths"?

This strongly reminds me of depression and SSRIs, and the false explanation according to which people with depression have a serotonin deficit, and SSRIs work by increasing serotonin to normal levels. "Just like diabetics need insulin, depressed people need antidepressants", "if you can't make your own serotonin, store bought is fine", etc., there are a million memes like this one.

 

 Now, depression might, at least in a subset of patients, have something to do with serotonin, but the crude explanation above is almost certainly false. And when this falsity became more widely known, lots of depression patients who had been told this lie by clinicians felt deceived and betrayed. And then some clinicians said that this was obviously not meant to be taken literally, it was just a helpful story, a metaphor or myth. You even saw people victim-blaming their patients, suggesting that they should have understood that the simple neurotransmitter explanation wasn't supposed to be taken literally.

Look. When my very first psychiatrist prescribed me my very first antipsychotic pills (I think it was Fluanxol), I asked my very first psychologist - because she was the one I really talked to, and asked questions of - how antipsychotics work in the brain. The brain is such a big, complicated mess, thoughts and perceptions and emotions and all that stuff is also such a big, complicated mess - how can a pill possibly target the psychotic stuff only? The psychologist said it doesn't. She said treating psychosis with antipsychotics is more like hunting sparrows with a bazooka; you hope to kill some birds without tearing down too much of the forest. 
There are two things to say about the sparrow-bazooka metaphor here: First, it's obviously just a metaphor. Obviously, I don't have a literal forest with literal trees and literal sparrows flying around inside my brain. Second, it's blunt and honest. Did I feel disappointed at not getting a concrete, detailed, and reassuring neuroscience story about how the pills work? Yes, of course I did! Luck is 100% right when she says that people want to know why something works, not just that it often works and thus is worth trying. But at the same time, I truly appreciated my psychologist's blunt honesty.
When I first became a psych patient, I was pretty paranoid. Mostly about demon assassins, but also about clinicians. I suspected that they might still lobotomize people behind closed doors, even though they said it was a thing of the past, and I was scared to seek mental health care. It was only when a friend, who had been a patient there herself, vouched for them that I dared to reach out. I was still all kinds of jittery early on, but my psychologist's blunt honesty helped with that.  
And then, Fluanxol didn't work, so I got to try something else, and I had to go through this long trial and error with different pills before my psychiatrist finally struck gold with Haldol. This trial-and-error process was grueling, of course, but it would have been even worse if my psychologist had tricked me into believing that antipsychotics is a hard science and psychiatrists know exactly what they're doing. Now, I was at least somewhat prepared for how difficult and messy things can be. 

Yes, patients might be frustrated and disappointed if their clinician says they don't really know why something often works - it just does, and is therefore worth trying. They should still be honest! First, honesty is important in its own right. Treating people with respect, as equals, is important in itself, and telling people patronizing comforting lies is wrong in itself. Second, a strict consequentialist should still consider long-term consequences. I know that many clinicians like to believe that psychiatric patients never talk to other people, never read books on their own initiative and never uses the internet; they like to believe that they can fill the patient's head with whatever beliefs they like. But as the Andrew Cook quote above attest (and as everyone with two brain cells to knock together should realize), this isn't true. 
If clinicians lie to their patients, while telling themselves that they're not lying at all, they're just using myths and metaphors, the patients might feel better in the moment, but profoundly betrayed when they later learn they've been lied to. If you initially sold them a story of why something works, and they later learn that the story is false, it's pretty damn hard to switch to "oh, who cares why it works, as long as it does!" But if you're honest from the start - immediately tell them that we don't really know - lots of people might accept this, albeit, perhaps, begrudgingly. 

3. Could Feldman-Barrett's constructed emotions replace polyvagal theory? 

So, to repeat: my social media feed is currently full of therapists who wonder what they should replace polyvagal theory with, now that it's been debunked (or, alternatively, now when the age-old debunking finally gets the attention it deserves). My suggestion: Skip all this fucking neuroscience, which you're not experts on anyway. If a patient spontaneously brings up some neuroscience theory they read about and found helpful, sure, you can roll with that. But don't try to push a certain neuroscience theory on everyone. You can make do with just psychology. 

Therapists will say that patients need neuroscience to feel better. At least in our culture (roughly: modern, western and secular), people don't feel that their psychological problems are worth taking seriously unless they get a neuroscience story to go with them. Okay ... but if that is so, maybe you're job as a psychotherapist is to explain how wrong the premise is? Sure, you might be in the grip of a public health care system or insurance companies that demand a neuroscience story, and if so, you might have to feed them one to protect your patient. But you can still be honest about what you're doing when talking to said patient. 

But this seems really hard to accept for some therapists I've seen posting about the debunking of polyvagal theory. One suggested that they should replace this with Lisa Feldman-Barrett's constructed emotions - that's a much better neuroscience theory to push at patients!

Right. 

So, I read Feldman-Barrett's book "how emotions are made" years ago. I wanna stress that I don't have it fresh in my memory. But I do remember this much:

- She harshly criticizes research according to which there are various universal human emotions and universal facial expressions to go with them; she says these studies are seriously flawed.

- She instead proposes that all we have, pre-culturally and pre-linguistically, are high/low arousal and positive/negative valence. We don't have emotions before language and culture. Meaning that little children, non-verbal disabled people, or non-human animals, don't have emotions either. That's just projection.

I was, immediately, pretty negative when I read it. Then, I didn't really think about it for years ... until it popped up as a suggestion for which neuroscience theory therapists should push on their patients instead of polyvagal. I thought surely Feldman-Barrett must be scientifically controversial as well? I vaguely remember critics accusing her of just doing the strong Sapir-Whorf hypothesis all over again - language doesn't just influence but determine what you can think or feel - even though that has been debunked. 
Of course we're heavily influenced by language and culture, but the claim that there's nothing but high/low arousal and positive/negative valence until language and culture enter the picture is very strong. 

When trying to find the critique I was vaguely remembering, I found this instead , by Karolina Westlund, associate professor of ethology. Westlund freely admits to feeling personally offended by, for instance, Feldman's condescending tone and occasional sweeping, sloppy dismissals of researchers who don't agree with her. Still, Westlund's critique remains factual. 
A lot of it is evolutionary. An antelope who sees an approaching cheetah needs to have more than just high arousal plus negative valence to survive. Antelopes can't experiment with flight, fight, fawning etc. to see what works, they gotta fear cheetahs and flee right away. 

Feldman-Barrett, however, insists that animals don't feel fear, that's just anthropomorphizing. And this is so weird, because she also stresses that a good scientific theory must be able to account for all the data. Well, ethology used to proceed on the assumption that all non-human animals are quite simple. Ascribing emotions to them was a no-no (well, possibly not fear, possibly not everything, but researchers were really scared of anthropomorphizing!) But this was, eventually, a scientific dead end. Now, we have a huge body of research on, for instance, the fairly advanced cognitive and emotional lives of dogs and other non-human species. There's such a huge body of research that F-B must completely explain away if her theory is gonna hold up. It seems really implausible to me that this can be done. And I suspect (though I don't know much of this field) that the same is true for child psychology dealing with very small children - there's gonna be lots and lots of research that F-B must explain away if small children don't have emotions.

Westlund also cites some really weird claims that F-B makes in the book, such as how the Romans never smiled, because smiling with joy was only invented in the middle ages. Of course we don't have any evidence that the Romans never smiled. And although smiling with joy need not be universal, smiling to show benign intent likely is - our closest relatives do it! 

 

As far as I can tell, these are pertinent critiques. Plus, and now I'm getting thoroughly subjective, but the theory just didn't jive with me personally. I really don't recognize the experience of having bodily sensations and spontaneously sensing them as emotions. When I'm experiencing emotions, I tend to either don't experience them as located in any particular place, or, quite often, as being in my head. Note, I'm still talking about emotions, not thoughts, but they're in my head, not my stomach or chest or wherever they're supposed to be. 
I think they end up further down the body when I'm not really in touch with them, when I suppress them. I push them, so to speak, away from me (because I experience me as more in the head than the rest of the body, although the details vary over time). 

Years ago, when I was in a much worse place, I would sometimes get a racing pulse and constricted breathing. It would last for hours; when it finally subsided, I was, of course, exhausted. I told my then-psychiatrist that I had this annoying psychosomatic issue - I was certain all along that it was psychosomatic. 
He said I described an anxiety attack. I said no, that can't be right. I'm sure it's psychosomatic, but it's not anxiety - the only emotion I feel about it is annoyance. It's annoying that this thing keeps happening to me, and that I get so tired afterwards. 
Psych doc insisted it was anxiety and prescribed me betablockers for it (Propanolol), saying I should take 10-20 mg when this happened. They were absolutely ineffectual. I tried higher and higher doses until I took 140 mg at once, and still jack shit. I decided betablockers aren't for me and gave up.

This fall, I had a milder but still unpleasant sensation in my torso. Slightly tightened stomach muscles, slightly elevated pulse, and some hard-to-describe sensation precisely in the middle of the rib-cage. I figured it might be body-anxiety (as I've come to think of it), but if so, I didn't know what caused it. I tried to think of various possible stressors in my life to see if the sensation changed, became more intense, at any point - I thought if the sensation gets amped up when I think about X, then X is likely the cause. This diagnostic method didn't work. I thought about all the possible stressors, but the sensation stayed the same throughout. So I thought; nothing to do about it, then, except waiting for it to pass. Then, I went on a long conference trip, and once I was there, the sensation passed. I concluded it had been anxiety about the conference.

So, this is how I roll. When reading that book, I just felt that I don't fit into this framework at all. It seems to me that a therapist trying to use this theory with everyone would have a hard time fitting me into it. (I would also be pissed off at any therapist saying my dogs lack emotions.) But maybe I'm wrong; maybe Feldman-Barrett's theory is great. Which brings us to the following question:

 4. Should therapists push Feldman-Barrett on patients if we assume, for the sake of argument, that it is a great theory?

So. Let's assume, for the sake of argument, that F-B does have a great theory of emotions, and the theory is wielded by a therapist who's got the expertise to answer every critical question. Should the therapist, in these circumstances, push F-B's constructed emotions on all their patients? I still think they shouldn't. 

Suppose a patient talks about their terrible distress. The therapist says look, these are bodily reactions - high arousal plus negative valence - that you give a certain interpretation. But you could re-interpret them and move forward. We're the architects of our own experiences, like Lisa Feldman-Barrett says! As a matter of fact, emotions don't exist until we think about them and name them. There are no pre-cultural, pre-linguistic emotions.

The patient stares at the therapist in shock. She says: but what keeps me going is the thought of my son; he loves me, he needs me. I sometimes wanna end it all but then I think of my son and keep going. But now you're saying he doesn't love me, because he's got no emotions at all! He's only a year old! (Or, say, autistic and non-verbal.) Of course, he's got physical needs too, but anyone could fill those. If he doesn't have any emotional connection to me, if he doesn't have emotions at all, there's no point in struggling anymore!

Now, I've already stipulated, for the sake of discussion, that this is a great theory and that the therapist is an expert. So, let's say she's got a long answer to give as to why the theory doesn't have this implication (possibly having to do with the meaning of emotion, possibly F-B uses it in a much more narrow way than the patient ... possibly her son can have something which she calls emotion and that's fine). It seems, on the face of it, to have this implication, but actually, everything is fine. 

But even if the therapist is enough of an expert to explain all this, is it gonna be a simple enough explanation for a possibly uneducated patient to follow? In this story, the patient is clearly smart enough to spontaneously add two and two and draw out a (seeming) implication of the theory. But smart isn't the same as highly educated, and to understand more complicated theoretical stuff, you need education too. This is why you need to finish high school before you attend university, and take classes in a certain order while there. You can't just skip to the end of your university education, no matter how smart you are. So the patient might nod and smile (since she's not an ancient Roman, but a modern person, living centuries after the invention of the smile), while silently thinking to herself that her therapist said her son doesn't have any emotions, and now the therapist desperately tries to backpedal through a shitload of psychobabble.  

Now, someone might read this and think: Well, F-B's theory is good for most patients, since it fosters a sense of agency - we're the architects blabla - so I'll just continue to push it on most, while keeping silent about it for clients with strong feelings for a non-verbal child or a pet. But this is once again the fallacy of assuming psych patients don't talk to other people, don't read stuff of their own accord, and don't use the internet. 

Summing up: Stop pushing fucking neuroscience on psych patients because "it makes them feel better". If you're a psychologist, use psychology. You can still say that people can change. You can still talk about looping effects: how we interpret ourselves can affect the way we are going forward, which affects further interpretation, and so on. You can still talk about psychosomatic bodily stuff, even - without very detailed and/or controversial theories about the precise mechanisms. 

If a patient says they came across a neuroscience theory that was helpful to them, you can say good on you. If it's scientifically controversial, or even pseudoscience, you can say well, it's not literally correct, but if it's helpful for you to think this way, why not? (Being honest, not tricking patients into believing "useful myths".) 
If a patient says they came across a neuroscience theory that seems terrible - "I just read Feldman-Barrett to try to understand myself better, but she says my son has no emotions and doesn't love me!" - you could say either you don't have to interpret the theory that way (if that's a reasonable claim), or say it's scientifically controversial, you don't have to believe it. 

Only bring up neuroscientific theories if they're actually relevant. Either because the patient brings it up first, or because you really can't make do with just psychology. Even then, be honest about uncertainties and research gaps.  

Psych drugs, food, and internalized stigma

 I had it bad this past week. Probably a bit overworked towards the end of the semester. Monday morning, when I looked in the bathroom mirror, my face looked completely skewed, like a Picasso painting. My first impulse was that I should paint it into a straighter shape with make-up. Then I thought: no, I should go about this face problem rationally. I should double-check what it looks like in other devices. I turned my phone to mirror mode and looked, and it was normal on the little phone screen. Then I turned on a Zoom meeting for one at the computer, and it was normal on Zoom as well. Only in the mirror did my face look fucked up. So I thought to myself: it's just a mirror illusion. Maybe stress-induced.

And then the week followed. For various reasons, I decided to still go to work even though I didn't do much. I had other bad experiences. I pulled out all the tricks in my bag to handle them (stuff I've written and published about, and then some). It was pretty bad, but now I'm much better. No big breakdown in the end, no disaster, I pulled through.

(I'm pretty active on social media, so maybe someone reading this thinks "huh, I've been following her all along and I had no idea!" Well, I don't like talking publicly about having it bad as it happens - afterwards is a different matter. If I talk about it as it happens I worry that people might feel sorry for me, and their sorry will make me feel sorry for myself and it's all gonna go downhill from there. "You become the way they see you" as Lovisa frequently thinks to herself in my upcoming novel and oh look how smoothly this transitioned into book promotion! Coghweel Souls in March 2025! Ok, back to the blog post topic.)

I pulled through this time, but after a week like this, it's still natural to think about medication. I quit my meds in 2018, but I've always said that if I absolutely need to one day, I'll get back on Haldol. 

People can be weird about Haldol. It's got this reputation of being an extremely strong and dangerous drug. Some people have asked me why on earth I've been given that terrible old drug instead of some of the nice new ones. On the flipside, a woman I met at a party and talked psych experiences with, said "wow, Haldol, that's the heavy stuff! That's the real deal! They only give me these new weak-ass meds, none of which works, how did you get your doc to prescribe Haldol?"
But the whole "Haldol was so bad and extreme and the new drugs are so much nicer" is mostly hype from the companies making the new drugs. At the end of the day, different people have different reactions to different drugs. Haldol worked best for me and that's why I was on it. 

It worked quite well for many years. For several decades, I was on it for much of the time, but not all the time. Occasionally, I would stupid-quit, because I felt good and thought I was cured. Sometimes I'd be alright for a pretty long time after, but then some stressful even would happen and set me off, and I'd be back in the psych system and back on the pills. In hindsight, maybe these stupid-quits had some benefit, though? Maybe they postponed the point at which Haldol just didn't work anymore, giving me only side effects but hardly any desired effect.
I hope that if I really need to get back on it one day, my brain will have rebooted after all the years off meds, and it's gonna work again. I don't think there's any actual science on this. I've asked a few psychiatrists I know through work and their educated guess or professional intuition or whatever you wanna call it is that it's probably gonna work again. 

However, I'd prefer to stay off it. And it's important to me that people understand that this is not because of "internalized stigma". 

"Internalized stigma" is a thing, sure. But I don't think that I have ever suffered from internalized medication stigma. Any stigma I've internalized have been directed at the madness itself, not the medications used to repress it. When I stupid-quit I was highly motivated to think that I wasn't mad, not that I'd be able to manage my madness without meds. These are different things. I definitely had a big chunk of internalized madness stigma, but it was very helpful to talk it out in therapy in 2019. (I went to therapy for my own money. Searched and searched until I found a place where they offered something other than just "CBT" and "job training". I contacted them and said I don't need fucking CBT, I need some serious fucking Freud shit! At the end of the day, I'm not sure if we did any serious fucking Freud shit, but we sure did more than CBT exercises, and it was great for me.)

Stigma against the antipsychotic pills rather than the psychotic condition does exist in antipsychiatry/critical psychiatry spaces. At their most generous, these people will say something like "I don't judge anyone for doing drugs to feel better, regardless of whether they drink, smoke weed, take psych drugs or something else". At their least generous, they will talk of psych drugs as literal poison and people who willingly poison themselves as completely duped. But among regular folks, these views are, in my experience, rare. Regular folks may think that people with common diagnoses like depression and ADHD should just pull themselves together and replace their pills with yoga or something, but psychotics are a different matter, they're bona fide crazy and should absolutely take their meds so they don't become homeless or homicidal axe murderers or both. 

Still, anti-pill views are real, and with common conditions like depression or ADHD, they seem quite common. So unsurprisingly, there's also a counter reaction and people who oppose the stigma. That's good, taking pills shouldn't be stigmatized, but sometimes, the anti-stigma people see stigma and internalized stigma everywhere. And that's what I'm gonna talk about in the rest of the post. People can be reluctant to go on pills for perfectly understandable reasons. It's not all "internalized stigma".

First, there's the obvious case of side effects. Towards the end, Haldol gave me on-off slurred speech because I lost control of my tongue, and visible facial ticks. Especially the tongue thing was really bad. But suppose that my brain really has rebooted, and if I went back on them, it would be like it was before, when they worked. Back then, I had pretty mild side effects. Dry mouth, but I retained good teeth in spite of that issue. I'm more worried about returning to a state of low creativity and being less smart and fast-thinking than I am now. Mind you, I was still able to work full-time as a scholar, I was in no way zombified by the pills. Still, looking back, comparing myself then to the way I am now  - it looks like a pretty high price to pay for peace of mind. It might be tempting to think that psychosis is a mental health matter and therefore intrinsically more important than things like creativity or smarts, which are just little luxury flourishes on top or something. But my mind is one, it's not divided into the health foundation and the capacity flourishes. There may come a time when I think going back on pills is worth it all things considered, but it would take a lot. 

Second, I don't want to depend on pills. And this is where some people really prick their ears and go "did I hear someone voice their internalized stigma?" In particular, I've seen a few different people, as far as I can tell wholly independent of each other, make a comparison with food here. If you don't feel bad about depending on food, but you do feel bad about depending on pills, this goes to show that you're guilty of internalized stigma! You should get over it already and take your pills just like you eat your food. 

First a word of why I would depend on the pills if I went back on them: In theory, it might seem like I'd be maximally protected against any looming psychotic breakdown if I were to combine pills with all my self-invented coping mechanisms that I've talked and published about. In practice, that's unlikely. I could retain all the epistemological frameworks I've developed to prop up this flimsy world of mine and make it feel sturdier, but lots of mental actions I perform - like deliberately dissociating in quite specific ways, or conversing with helpful voices - would likely be rendered hard or impossible when on pills. Moreover, in psych treatment, the pills tend to be framed as your number one crutch and anything else as just a complement. Hard not to fall into that way of thinking, if that's how clinicians constantly frame things.

So, I would depend on the pills if I got back on them. And it's different from depending on food.
I feel fine depending on food because food just works for me. I eat some food, and I get nutrition and energy from it. It works.I also felt fine being on Haldol back when Haldol just worked.
However, when I first became a psych patient, I had to go through a trial-and-error process with a bunch of different pills before we found something that worked (very common experience). That trial-and-error process was extremely frustrating. Doc prescribes a pill. You take the pill. You wait to see if something happens. It doesn't! Too bad. Doc prescribes another pill. You take the pill. Wait to see if something happens. It doesn't, not with this one either! Too bad. Etc. 
Finally, we struck gold with Haldol. As I said above, it worked well for many years. But when it stopped working, that was also frustrating and frightening - will my life just fall apart now? 

One thing that's particularly frustrating is how passive you are in relation to the pills. If you're trying out various mental tricks to help you deal with shit, you're actively doing something, you're performing these mental actions. If something doesn't immediately work, you can try doing it a little differently, try harder at it, and so on. With the pills, the only thing you actually do is swallowing. After that, you have no control over what happens. Stomach acid dissolves the pill, the little chemicals go out in your blood stream, past the blood-brain barrier, attach themselves to little receptors up there - or, at least that's what's supposed to happen. Whether it does, isn't up to you. It works, or it doesn't work. If it works, that's great. If it doesn't, you can only lament this fact, and maybe go back to the trial-and-error process, or adding more pills, and hope that they will do what they're supposed to do, once again just hoping.
And yes, eating food has the same passive, non-controlled element to it. I can't affect what happens with the food once I've swallowed it (at least not in a big way - maybe I'll get better digestion if I take it easy after a meal, but I can't do anything major about it). This is no problem to me because it just works. However, if it didn't just work, then it would be a problem. 

Imagine that I develop Type 1 Diabetes. Extremely unexpected at my age, but imagine it happens. I notice that food doesn't work anymore. My body is supposed to break down the food and extract energy from it, but now it doesn't anymore. I eat and eat, and yet I become increasingly fatigued and emaciated. Let's make the thought experiment even worse! It's not diabetes, so insulin doesn't help. It's similar symptoms, but there's nothing the doctors can do for me. My body is supposed to get energy from food, but the system doesn't work anymore, and it's nothing I can do about that - I can hope that things get back online, but as of now, I can only helplessly watch as all the food I stuff in my mouth goes straight through without doing anything for me.
This would be a serious problem! Not because of "internalized stigma", not because I have an attitude problem around food, but because food doesn't work for me anymore and I'm helpless to do anything about it.
Similarly, it's a real, tangible problem - not just internalized stigma or a bad attitude or whatever - to take pills that just don't work for you. One might argue that feelings of helplessness and despair don't make the situation any better, so you should still try to get over them. Perhaps (though even this can easily veer into problematic toxic positivity territory). But these feelings would nevertheless be caused by quite tangible problems. 

Haldol stopped working for me once. If I went back on it, I would be acutely aware of the fact that it happened once and might happen again. I could only hope that it wouldn't happen again, but there would be nothing I could do to prevent it - when a previously effective medication stops working, it's presumably because of physical, neurological changes in the brain (there's some science published on this, though AFAIK, lots of uncertainties remain), and I have no control over whether my brain will grow extra dopamine receptors or similar. Real problem right there. Not just "internalized stigma".

Third, dependency makes you vulnerable. It makes your situation precarious. And yes, sure, vulnerability is part of the human condition and all that, but I still don't want to take on extra precariousness if it's at all possible to avoid.
Even if the pills work for you, they can only help you if you get them. But access to prescription medication has become far less reliable over the years. This is because of political problems, of course. We should fight for political change. But in the meanwhile, this is a real problem for people on meds, and a rational reason to try and do without if you can do without even if it's hard sometimes. 

I don't worry about being dependent on food because I can reliably access food. Of course, this isn't a privilege that everyone has. Insofar as on-off-starving people (people living with "food insecurity", to use the established euphemism) don't think of themselves as problematically dependent on food, it's probably because everyone needs to eat. One might lament depending on pills that may or may not be available next week, next month, and so on, because one is surrounded by people who don't have to worry about this, but everyone must eat.

However, imagine that breatharianism was a real thing. There are these mumbo-jumbo gurus who claim that they don't need to eat, they can survive on just air and sunshine or what-not. Imagine this was a real skill that some people developed; maybe there were quite a lot of breatharians around. In this hypothetical scenario, I imagine lots of poor and on-off starving people, who tried to go breatharian but couldn't for some reason, would envy those who could. And we don't need to posit an internalized eating stigma to explain why; breatharians' lives would simply be less precarious, they'd have one less serious problem to worry about. Even if the right thing to do is to fight for political change rather than individualize the problem and do breathing exercises for all, someone who could develop the breatharian skill might be rational to do so. If they're gonna get politically active, it will be easier if they're not simultaneously starving. In any case, no need to appeal to internalized stigma over food to explain what's going on here. 

To sum up: Internalized stigma is a thing. It's worth discussing. But in my experience, it gets over-used. Suggesting that there are no real problems associated with being on pills, only attitude problems and internalized stigma, is actually not so different from saying that mental problems aren't real problems, people just need to get their shit together and improve their attitude.

The failed analogy of oppressed AIs in science fiction

 I recently finished Ann Leckie's Ancillary series. This was my verdict on various social media:

"I started reading it years ago. Remembered liking the worldbuilding, but was more ambivalent about the way it was written. I remembered the text feeling too slow and cumbersome overall. 

Now I thought: perhaps that was an unfair judgment due to reading the first two parts fairly heavily medicated? So I got this book and finished the series. 

Well, as with my re-read of Vandermeer’s Area X trilogy a year ago, I percieved the same issues off meds as I did on them, but it's easier to deal with when my brain works faster. In Area X , the problem was a really long slog in book two where nothing much happens for a 150 pages or so, except Control walking around in the office building and thinking to himself that something feels off. (This did not require as many pages as it got!) With the Ancillary books, the issues are low-key but they permeate the series: the dialogues should have been tighter, the on-page tea-drinking should have been cut down, and finally, Brec thinks so many purely expository thoughts! Like this: ”I spottad Sievarden in the hallway - whom I had saved when I met her on the planet Nilt and she was addicted to Kef - talking to the high priest….” Yeah we know you saved her, it was in book one. If I had forgotten your backstory in between books, I’d have looked it up on the internet! 

Sometimes it feels like reading a silver age superhero comic - they were always peppered with exposition for the benefit of new readers who didn’t know the characters.

Also, in the end, the book deals with liberation of and rights for AI persons. Gosh, what a tired old trope! I’m probably gonna do a whole blog post about it later.

I really like the worldbuilding, and I really like Brec, the MC, at least in theory. But overall, it’s hardly my favourite series. I much prefer Leckie’s fantasy novel The Raven Tower."

 

Well, here comes the promised blog post! 

I've heard people claim that oppressed androids and other AI persons in scifi is such a great analogy for many oppressed groups in real life. Typically, these stories feature discussions of whether the AI are sentient or not.
Now, TBF to Ann Leckie, that's actually not the case in Ancillary Mercy. The Radch Empire happily draws a very sharp line between citizens and non-citizens in terms of moral worth, without really tying this to theories of sentience or their mental life. No one says that those features of a person drastically changes when they go from non-citizen to citizen status, and yet, their moral and legal status suddenly shoots up. Thus, the fact that they see their sentient stations and ships as far below their human citizens, need not be because they have any doubts about said sentience.
But in many other scifi stories - like the classic Star Trek Next Generation episode "the measure of a man" where the android Data's moral and legal status is questioned - whether he's truly sentient is absolutely crucial to the matters at hand. And, people have told me, this is such a good parallel for lots of real-life oppression, which is often justified by claims about how this or that group allegedly can't think, or can't think very well.

However, claiming that someone can't think very well is quite different from claiming that they're not sentient. 

There are some fine-grained distinctions here sometimes made in philosophy (and then debated - does this distinction really pick something out? Does it pick something important out?) that won't concern me here. I'm just gonna talk about sentience as synonymous with being truly conscious, rather than just mimicking consciousness, as having experiences and a mental life - in short, when someone is sentient, it makes sense to ask what it is like to be that individual. What is it like to be homeless? What is it like to be a billionaire? What is it like to be a dog? are all questions that make sense to ask, even if we can't give a single answer to any of them because there's too much individual variation, and even though we might never fully answer the dog question because dogs are too different from us in, e.g., their sensory apparatus and cognition. In contrast, it does not make sense to ask what it is like to be a desk. It's not just impossible to answer for us mere mortals, because there are limits to what we can know - there is no answer.

Now, oppression is typically not based on the claim that the oppressed group lacks sentience. Such claims have occasionally been made of some disabled and mad groups, typically those who are either non-verbal or merely speak what seems like complete gibberish to others. However, extreme misogyny, racism, queer oppression, or even ableist oppression of disabled groups that the oppressors remain capable of communicating with, is typically not built on denying that the oppressed groups are sentient.
Sure, they're claimed to be, in various ways, irrational, unthinking, hysterical, animal-like, more brutes than humans, etc etc, and these claims are supposed to justify their oppression. But practices where oppressed people are humiliated or punished for disobedience presuppose their sentience.
If you truly believe that another human being is completely "empty on the inside", more akin to a machine like a car or a lawn mower, attempts to humiliate them, punish them, or put them in their place doesn't even make sense. If you label someone "uppity", if you say they don't show proper respect to their superiors, if you say they're lazy, bitchy, slutty, hostile, or any other negative character evaluation, you're also presupposing that they're sentient - a car, lawn mower or other piece of mere equipment can't be any of the above (see also Kate Manne's "down girl" for a discussion of how misogyny is not built on seeing women as non-human).
This is a huge difference between how oppression typically plays out in the human case, and scifi scenarios with oppressed androids and other AIs.

Moreover, all the humiliation, suspicion and punishment that oppressed people often suffer at the hands of their oppressors, and all those negative character labels that gets glued on them all the time, tend to become self-fulfilling prophecies. If a group of people are labelled aggressive and hostile and the only thing they understand is violence, they tend to become more aggressive and hostile in response. If a group of people are labelled stupid and irrational and therefore there's no need trying to explain things to them, no need to give them an education, they don't understand anything anyway, they tend to become, well, at least ignorant and uneducated, and this is easily mistaken for stupidity and irrationality. If someone is forced to work so hard and such long hours that they never have time to get adequate sleep, their cognitive capacities and things like impulse control and ability to regulate their emotions might deteriorate as a result. And so on. Oppression hurts the oppressed in ways that help the oppressors justify what they do.

Oppressed androids and AIs in scifi rarely suffer from these problems. They are always perfectly articulate, perfectly intelligent, perfectly rational - they're not just as good as, but superior to mere humans! They're faster, stronger, smarter, more logical, better-looking, no flabby fat on their bodies or spots on their skin. (Sidenote: Data is claimed to suffer from the flaw of being emotionless. However, that's not how he actually comes across; he seems to possess emotions, just less vivid ones than regular humans. In practice, being less emotional than the rest of the Enterprise crew comes across as an advantage as often as a flaw - Data keeps his head cold in situations when others would panic, and he's not prone to the same prejudices as mere humans due to his superior logic and lack of exaggerated and biased emotions.) They're just so perfect and superior to us mere mortals in every single way - and yet, they're oppressed, because of pure prejudice on part of the humans. There's no trace of the self-reinforcing mechanisms we see in real-life prejudice, where the oppressors can easily rationalize their oppression by pointing to actual aggressive or irrational or ignorant behaviour on part of the oppressed - nope, it's pure prejudice. 

I think there are several reasons why such stories are so popular. For people who are oppressed in real life, it's a nice wish fulfillment fantasy to imagine that although people say you're inferior, you're actually superior - not just as good as them, but better. Also, all of the audience can feel good about themselves when watching stories that present prejudice as this brute, near-incomprehensible thing; the audience can approve of the message that oppression and prejudice are wrong, while feeling secure in their belief that they would never engage in prejudiced or oppressive practices. They would never look upon a clearly superior being with perfect physique and perfect intellect and then go "you're worse than me and don't deserve any rights". 

Come to think of it, I wonder if lots of these "oppressed AI" stories aren't Jesus-inspired? Maybe not consciously; the creator's conscious intention might have been to write an analogy to oppressed human groups. The creator might be an atheist or agnostic or believe in some other religion than Christianity. Even so, the Gospels and Jesus are a big part of our shared cultural heritage, so they might still be a big unconscious influence. Jesus is, in many ways, portrayed as superior to mere humans; more virtuous and in possession of various divine superpowers. Yet, all these humans hate him and eventually kill him. Presumably, he could have ditched the whole die-on-the-cross-for-our-sins thing, but like an android with Asimov's robot laws installed, he doesn't fight back and allows himself to be killed - that's how virtuous and good he is.

Wow, now I'm way beyond my area of expertise! There are scholars at my department who write about this stuff, like Alana Vincent with religious myths in relation to modern specfic, but I'm not one of them. 

In any case. Androids and AIs generally don't work as an analogy for oppressed human groups.

Finally, the trope of a sentient AI who sees its sentience denied by prejudiced humans feel kinda soured now, by all these ridiculous discussions of whether real-life chatbots and similar might be gaining sentience. I mean, they write so well now! So human-like! Surely there's some emerging sentience there? 

No. Stop it. There's no reason to think so. "This individual seems sentient" might be good evidence that they probably are when it comes to animals - there's no reason why signs of sentience would evolve in the absence of the real thing. But AIs are designed to seem like they can think because the designers know that this will make them more popular. Eric Schwitzgebel has written more about this on his blog here http://schwitzsplinters.blogspot.com/2024/07/how-mimicry-argument-against-robot.html It was more fun to read about or watch such discussions when they remained in the realm of fantasy, where truly sentient androids/AIs have been invented. 
(See also Chris Winkle's post on this at Mythcreants https://mythcreants.com/blog/with-the-advent-of-ai-science-fiction-must-change/ )

 

Disability in speculative fiction

 I'm not at Worldcon in Glasgow. However, I get constant social media updates of what's happening there, courtesy of Sara L. Uckelman (of Ellipsis Imprints, who will publish my debut novel Cogwheel Souls in English! Yay!) For instance, she's been at a panel discussing disability and disability erasure in specfic. This got my mind going - first I wrote some long replies on Facebook, and then I thought enough thoughts about the subject for a whole blog post. 

1. The magical cure and the medical perspective

There's this specfic trope of the magical cure - either a piece of literal magic or amazing technology that can turn the previously disabled character normal again. Off the top of my head, the examples I come to think of are superhero stories - discussions around this in the DC comics when Barbara Gordon was still in her wheelchair, Felicity in the TV show Arrow (a different character but clearly inspired by Barbara in the comics), and some of examples from the MCU movies - the first Doctor Strange movie, Ghost from Antman and the Wasp. So I'll go with these examples since they were the first to pop up in my head, but there are far more out there. 

Now. From a mainstream, medical perspective, it's great if a disabled character can get a medical cure for their tragic impairment. And then, you've got your social justice conscious writers who see how this is problematic. I won't (obvs) try to recap all of the reasons why the medical model is problematic in a blog post, but there's tons written for anyone seriously interested. In extreme brief:

a) Aiming for a thoroughly "healthy" and non-disabled society will be a never-finished Sisyphus job. The bar for what counts as healthy enough constantly rises and you'll always have people deemed "problematic" due to their "defects". Also, when a disability-free society is an outspoken goal, no one is quite free to go against the flow. It might not be illegal to, e.g., not avail yourself of all techniques available for having children as healthy as possible, but expectations from medical professionals, what's default in a medical setting vs an active choice, and social pressure from everyone around you can be strong enough.

b) You will end up with a society in many ways more homogeneous than ours, which isn't a good thing. Some people might wanna say that they only strive to eradicate chronic illnesses and disabilities but not neurodivergencies that provide society with different perspectives and different ways of doing things etc. There are some philosophers who want to place a few conditions, like "high-functioning autism" (an itself problematic term, rejected by many autism advocates) in a the neurodivergence box, while still placing tons of other conditions in the box for disabilities to be eradicated. But because of the dynamics described in a), you'll likely have fewer and fewer conditions in the first box and more and more in the second over time.

c) Finally, the ubiquity of the medical perspective on disability makes it significantly harder for disabled people to fight for equal rights. Here in Sweden, disabled people are legally entitled to getting the assistance they need to live a normal life - with job, studies, their own flat, and so on. For some people, that means they require an assistant constantly by their side, so several employees with a rotating schedule, on public expanses (you'd have to be super rich to pay several employees out of pocket). However, legal entitlements on paper is one thing, what people get granted in practice is, unfortunately, quite another. Right-wing politicians (whether they call themselves "right-wing" or go by "social democrats") who constantly cut down on both taxes and public expenses will order the relevant clerks to make increasingly circumscribed judgments of what their clients actually need, with the wholly predictable result that disabled people are increasingly pushed out of jobs, schools, and overall public life. Adults end up living with their parents, who care for them until said parents die themselves. We're seeing the beginning of a new era of institutionalization.
There's no logical contradiction between embracing a mostly medical model, and yet argue that people should get all the assistance etc they need until we, hopefully, find a cure for their impairments. However, when people think of disability as something inherent and inherently tragic, something inside people's bodies and minds, it's much more difficult in practice to make them realize that withdrawing assistance and similar are political decisions, and to see disabled people as oppressed and discriminated against. The medical model helps, in practice, to cover up political injustices by presenting disabled suffering as a tragic but natural result of inherent impairments. 

Magical cure stories tend to implicitly rely on the audience accepting a largely medical perspective on disability, and therefore cheer for characters who seek a way to erase their tragic condition and become healthy and normal. However, subverting this trope is often easier said than done.

2. The implications of truly magical cures

I'm mad and neurodivergent but able-bodied. No one, whether embracing the medical model or not, thinks my body is inherently tragic. However, imagine that I came across a wizard who gave me the following choice: either you can continue as before, or I can wave my magic wand and make you as fast as Usain Bolt and with the stamina of Kelvin Kiptum. That's it, that's your choice. You can't trade it for something more altruistic, or some different thing that serves your own interests. It's just this offer, which you can take or leave.
I'd probably go yeah sure! Cool! I'd take the offer. 

Thus, the fact that you do not hate your body as is, the fact that you're perfectly fine with it as is, doesn't imply that you wouldn't accept an offer to make it more powerful. However, if I wrote a story about a wheelchair user who was offered "walkability" (is that a real word? Never mind, you all understand what I mean), and accepted the offer, it's probably impossible in practice to give the audience the same impression as when I accepted increased speed and stamina. Because regardless of how non-oppressive the fantasy setting where this takes place is, the audience still live in an ableist world, and this will inevitably inform their reading. Even though accepting the offer of walkability doesn't logically imply that the wheelchair user's life was tragic before it, anymore than accepting increased speed and stamina implies that it's tragic not to be an olympic level athlete, that's how it's gonna be perceived by most. 

Now I was talking about how the audience will perceive things due to them living in an ableist society. However, it's often hard for creators, too, not to insert their own ableism into stories, even if they try to write something social justice informed. Take, for instance, the movie Gattaca. It clearly tries to deal with disability-oppression in a eugenics-obsessed society. Yet, at the end of the movie (spoiler alert), the character who's disabled according to our standards, the audience's standards, brutally commits suicide because he can't stand it anymore, whereas a character who actually seems more oppressed within the universe of the movie but does not come off as disabled to the audience bravely soldiers on. Left a really bad taste in my mouth, that ending. Ok, societal oppression is bad and all that, but still possible to fight, unless you're in a wheelchair like Jude Law's character - he's gotta top himself at the end. Better off dead, that one.
Okay, that was a bit of a tangent, since Gattaca is about a society obsessed with birthing "perfect" babies, not about curing adult disabled people. So back to the magical cure discussion.

In most cases, it's probably better to just stay away from magical cures altogether in your writing. But if you wanna write something with literal and versatile magic or magic-level tech, the best thing is probably to have characters play around with it and change their bodies in a variety of ways (instead of everyone going uniformly "normal"). Like in Michael Moorcock's Dancers at the end of Time trilogy (part of his Eternal Champion series, but much lighter and more whimsical in tone than the others). You've got some people changing sex back and forth, some changing into monsters or looking like non-human animals, you've got this scientist character who's got a hunchback and a club foot and walks with a cane because he thinks it's a cool science look, and so on. I think that works better than specifically having the person who's disabled by real-world standards confronted with a magical cure and then go "no! I won't take it! Because I accept myself as is!" while it's treated as a non-issue for everyone else.

3. Good and bad reasons to reject being cured

In a society with medical treatments that do not exist in the real world, but it's still not on the unlimited, can-do-anything-level we see in Moorcock's Dancers, there are several legit reasons for characters to reject being cured. 

First, they might do so because they don't want to reject an aspect of their identity. This was brought up by ethnologist and crip scholar Christine Bylund when we briefly discussed the matter, and now I've been thinking some more about it ... To some extent, people are simply different with regards to how and what they identify with. People may be more or less prone to see themselves as integrated "bodyminds" vs seeing themselves as minds with bodies, for example. People differ in how much of their mental lives they see as integral parts of their personalities, and what seems a bit more external to them, perhaps simultaneously external and undesirable. I think we'd have differences in identification, and thus differences in how much and what people would be willing to change about themselves, even in an oppressive-free utopia.
However, in an ableist society like ours, disability is a political identity too. This is a big difference between the scenario in which I gladly accept increased speed and stamina, and a wheelchair user accepting an offer of walkability. Increased speed and stamina might get me fame and money that I've never dreamt of before, but I'd remain in the political category of "able-bodied" throughout, whereas a wheelchair user who acquires walkability goes from disabled to normate. For some people, that might be a welcome change, climb the social ladder to a better life, whereas others would reject as grotesque the idea of magicking your way into a politically privileged group. 

In any case, I think a story about a character who lives in an ableist society and gets a chance at a magical cure should deal with how they'll move from one political group to another if they take it. Not pretend like it's a completely isolated, individual choice about either getting cured or "accepting yourself". 

But do it in a better way than DC did with Barbara Gordon! 

Barbara Gordon used to be Batgirl. Then the Joker shot her through the stomach, bullet hurt her spine, and she ended up in a wheelchair. She went on superheroing as the computer wiz Oracle. Occasionally, writers felt the need to address why she remained in the chair despite living in this extremely high-tech superhero world. On the one hand, the DC consensus (if I understand things correctly) was that she provided good disability rep, so better keep the chair, but on the other hand, they should provide some in-universe justification too.
I've got an old nineties comic written by Grant Morrison where the issue comes up in dialogue. Babs says that she'd be happy to have her spine cured if someone invented a way for the nerves to grow back, but she doesn't want a cyborg solution - she just don't wanna be a cyborg, is all. That's a perfectly fine motivation! She'd lived most of her life walking (running, jumping, climbing, she was quite the acrobat), so makes sense that she'd have a preference for getting all that back, but it's also fine for her to just not wanna be a cyborg. 

However, most writers did a different explanation, which I think became the canonical one: Babs thought it would be unfair to all the other wheelchair users out there to accept the cyborg solution. She'd only accept it once it was available to the general public (so probably never in the USA, where she lived). So this is a sort of political motivation, but one that doesn't reject the medical perspective at all, and furthermore, it's ridiculous! Babs regularly used all kinds of amazing tech unavailable to most people - she even used to travel back and forth between Earth and the Justice League space station, in the League's teleportation machine! Apparently, this wasn't unfair to everyone else who could only dream of doing such things, but walking via cyborg gizmo would be.

They should either have stuck with the "I just don't want to be a cyborg" motivation, or given her a political motivation centred around disability activism, rather than some nebulous "fairness considerations" that apparently apply only to walking tech but no other tech. Finally, they should have given her a wider variety of chairs.
I get that she wanted to use a regular, manual wheelchair to get around most of the time. Asking why she'd use her arms to get around rather than drive something electric is like asking why Batman walks with his legs instead of driving everywhere in some vehicle. But she should have other options, like more mech warrior like options, for situations like when she's in the space satellite and it gets attacked by enemies for the umpteenth time. Sometimes, in the old comics I read, she almost came across as a lone luddite among enthusiastic tech bros. It's one thing not to give the disabled character tons of tech that erases their disability. It's quite another to give them less tech than their able-bodied but still non-powered counterparts, like Batman, because the disabled person must be "representative" in what they use.
Anyway. All of this is moot now since, after a few decades, DC cured her anyway and had her return to being Batgirl. 

The easiest version of "disabled character rejects an offered cure" to execute well is probably to abstain from perfect, magical cures, and instead have treatments that come with both pros and cons. They may be fantastical by real-world standards, but nevertheless involve pain, arduous rehabs or some other type of cost. A character can weigh the pros and cons and decide it's not worth it - and maybe do so against the expectations of other people who assume that they'd obviously want to be cured, and that any price should be worth paying. 

This was something Marvel's first Doctor Strange movie did pretty well, I think. The movie has been divisive since Strange starts out absolutely desperate to be cured. Still, we've seen that his entire identity revolves around his job (and the fame and money it's brought), so it's plausible that a career-ending disability would render him desperate. His girlfriend calls him out, too, and says look, you gotta get on with life and find some other job to do! She's proven right in the end, though not quite in the way she thought; she figured he could be a teacher at med school, and instead he became a sorcerer. Still, though. He did find another job, eventually, that he could do with his disability. He chose not to cure himself via magic since this would require constant concentration to uphold, and leave him with less magic for other, more important things. So, it's a thoroughly fantastical movie, but it's a fine and realistic ending in that the main character realizes that
a) contrary to what he thought right after his accident, his disability isn't the end of the world, and
b) now when he knows of a way to cure it, it's actually not worth it, there are better things to use his resources for.
It's only too bad that Marvel completely forgot about his disability in later movies, but I guess this is as good as it gets in the MCU. 

Also, if you're thinking of cures in terms of pros and cons, then there will be cases where it is best to be cured, and it's not ableist to say so. I saw this bizarre discussion about the character Ghost, also from the MCU, where one person insisted that portraying her as desperate for a cure for her condition was ableist. But her fantastical condition, besides giving her superpowers, is extremely painful and actively killing her. She's only in her early twenties, but we're told she'll be dead in a couple of months unless she finds a cure. Her wanting a cure is no more ableist than when a young person dying in cancer tries every treatment the medical profession has to offer because they want to live.

Concluding lines

This is something writers should think about, and put some mental effort into. Not just throw out that old magical cure trope - nor simply reverse it and think you're being progressive because you did it the other way around!

Poor Things is the best feel-good movie ever

I saw Yorgos Lanthimos' "Poor Things" in the theater. I hesitated to do so because although I've really enjoyed the Lobster and the Favourite, I thought - based on some reviews I had read - that Poor Things would make heavy use of the known trope "Born Sexy Yesterday", and another one I like to call "Hot Fair Slut". Unfortunately, I'm not a famous media personality with enough clout to coin new trope names, so "Hot Fair Slut" is as unlikely to catch on as "Grimdark Preach" which I keep pushing in discussions both online and AFK as soon as I get a chance. 

People tend to think that only stories written by authors who see themselves as fighting for good (whether that be leftist social justice values or conservative Christianity or something else) ever get preachy. But there are many dark stories where the author shouts at you through a megaphone "did you think the world was just and filled with honestly good people? You're wrong! And I'm here to tell you how wrong you are!" Cue plotlines about how naïve goody-two-shoes come to see the error of their ways and reform and turn cynical like you ought to.
We need a name for this phenomenon, and my suggestion is Grimdark Preach.

Anyway. Back to Poor Things and the tropes I worried would appear in it! 

Born Sexy Yesterday: A sexy woman is either literally born/created very recently, or she's lived for longer but in a different world (fairyland, different planet, etc.), making her a newcomer among us. Because she doesn't know shit about our world, and have no basis for comparison, she's super impressed by the first dude she comes across and falls for him. Mr. Average gets the woman of his dreams, because she fails to realize that he is average! 

Hot Fair Slut: You know how misogynists rant about "Stacys"? (TBF, they might have come up with a new name by the time I write this blogpost - I don't keep up with their antiques.) A "Stacy" is a hot slut whose greatest crime isn't sleeping around per se, but the fact that she doesn't want to sleep with the men who complain about her. When a woman sleeps around already, it's just not fair that she won't sleep with everyone!
Of course, in real life, it's pretty uncommon to fancy precisely every person you come across, or even every person of a certain gender. Whether you're strictly demisexual or happily promiscuous, it's certainly more common to have some kind of preferences, be sexually attracted to some people and not to others. But since this is unfair in the eyes of misogynistic entitled men, we see plenty of fictional women without these pesky preferences. Hot, slutty women who'll happily sleep with any man they come across. See, for instance, the planet Risa in Star Trek. TBF, they pay lip-service to Risa being a gender-neutral sexy paradise where female crew members can fuck around as much as the men, and where the inhabitants are happily horny and not the least bit exploited. But there's still an overall emphasis of "any man can go there and get a hot babe - no man will be rejected, nor hit on by older or uglier women". Which always makes the place feel kinda iffy. And there are far worse examples than this in fiction.

Some stuff I had read about Poor Things made me worry that it would feature both BSY and HFS. But I was wrong.

On to the actual plot of the movie. Spoilers ahead. And, like, all the trigger warnings for people who need them, I guess.

Godwin "God" Baxter is a mad scientist, like his father before him. He was also his father's guinea pig - his dad used to operate on him, take out organs just to see which are necessary for survival, and overall, God looks more like a traditional movie version of Frankenstein's monster than Frankenstein himself. He's disfigured and castrated and only survives by hooking himself up to various machines of his own invention, but can't bring himself to condemn his father - you see, it was for the good of science! 

He teaches physiology and medicine at a university in a bizarre steampunky version of Victorian London, and hires bullied student (he's noticeably poorer than his classmates) Max McCandles to be his assistant. God explains that he cares for Bella, a young woman recovering after serious brain damage, and he needs Max to observe and make notes of her progress. 

Bella is played by stunning Emma Stone, but immediately deconstructs the whole Born Sexy Yesterday trope for us viewers by not only doing baby stuff traditionally considered sexy in grown women (such as vaguely toddlerish speech and body language, looking at you Leeloo from the Fifth Element - I hate the Fifth Element so much - and tons of other fictional examples), but also throwing food around and pissing on the floor. 

Eventually Max suspects that there's more to Bella than God has told him, and demands to know the truth. Okay, says God, fine! It's actually a real sunshine story.
You see, he stumbled upon this heavily pregnant woman who had committed suicide via drowning. He brought her home and noticed that there remained some electricity in her brain, meaning she was revivable. But he decided against it, because if she wanted to die, he should respect her autonomy. However! The baby's brain was alive and well, so he decided to stick the baby brain in the adult body and make a brand new creature instead.

God is such an interesting character because he does have a conscience and he does try to do the right thing and be ethical. But given his background, he's not (generously put) very good at it. 

This is a fantastical movie in many ways. You gotta accept that biology works differently from real life. (See Bella's entire creation.) Bella's mental development - I guess because of her adult body - goes much faster than that of a real baby. But she remains weird by regular societal standards. It's also a really weird situation, where Max and Bella hardly ever leave the mad scientist's house. God gets the idea that Max and Bella should get married and live with him forever, and they both agree. He draws up a contract that will legally bind them to do that, but then Bella runs away with Duncan the lawyer (a fun and over-the-top-sleazy Mark Ruffalo) who falls for her Born Sexy Yesterday charms (she's stopped throwing food on people and pissing herself at this point). 

They travel around in amazingly bizarre steampunk-versions of European cities. Bella is, initially, thrilled by seeing the world and having lots of sex. However, their relationship soon begins to unravel. Bella isn't some loyal puppy-dog like Leeloo (I hate that movie so much! ). She fucks other people. She tries to punch a screaming baby. She dances and talks in embarrassing ways. She gives away Duncan's gambling money in a fit of compassion after seeing poor people for the first time. Eventually, when they're starving in Paris, she gets a job at a brothel. At this point, it's revealed that Bella does have preferences - she thinks that much (though not all) of the brothel sex sucks. Nevertheless, for various reasons, she decides to stick it out.
Even though Bella, in her typical hyper-rational way, explains to Duncan that her new job is good for their relationship, since she appreciates sex with Duncan more when she's got those crappy sexual experiences to compare it with, Duncan gets super upset and leaves. And then he comes back again and wails beneath her balcony that she's the love of his life and he wants her back. This previously irredeemable fuckboy even wants to marry her! However, at this point, Bella has concluded that (in her words) an unconventional and experimental woman like herself would need an open-minded and forgiving husband, and Duncan is none of that. Goodbye!

So, so much happens in this movie. I'm not gonna recount the entire plot or spoil everything. It's got marvelous visuals, it's frequently laugh-out-funny, but it's also, at heart, a genuine feel-good movie.

Bella, God and Max form a kind dysfunctional family, where God the father figure seems to do his best, but given his own horribly traumatic childhood, he can't help but passing on lots of shit to his "children".
However, he does realize, towards the end of his life, that his own father had been terrible. And Bella calls him out on how he's, well, played God with his creations. And then, after many morbid and bizarre twists and turns, we're finally treated to some sort of reconciliation and a happy ending. (Except for that poor goat! If you've seen the movie, you know what I mean. The goat did not deserve his fate)

I rarely like feelgood stuff. It often feels too soppy, and like serious problems are too easily glossed over. For instance, I enjoyed the over-the-top craziness of "Everything, Everywhere, All at once", but really felt that way about the ending - the mum-daughter relationship seemed terrible, but in the end we kinda gloss over how bad it is.
Poor Things, on the other hand, takes everything up to eleven and beyond, including the relationship problems. There's no shying away from how grotesque God and Bella's "family" is, and yet - at the end of the day, they're still family.

Best feel-good movie ever!

John Z. Sadler's Vice and Psychiatric Diagnosis

 My impression is that people who are neither moral philosophers nor psychiatrists or psychologists tend to think that there's a sharp line between "vice" and "psychiatric disorders" - or, colloquially, between the bad and the mad (note, I don't know of any empirical research that investigates this very matter, this is really just my impression). My impression is also that people are quick to assume that there's a limit to how bad someone can be without also being mad. But perhaps not the other way around. 

Philosophers who work on moral responsibility and moral agency tend to assume this as well. I think all this drawing of lines and placing people in neat boxes is a fundamentally misguided way of looking at moral responsibility, but it's nevertheless the common and traditional way. Neurotypical people are morally responsible agents. Psychiatric and neuropsychiatric diagnoses, on the other hand, frequently undermine moral responsibility, and place people in the "exempted" box. Some philosophers like to divide moral responsibility into different subkinds, and play around with what kind of responsibility you can have with this or that diagnosis, even as you're exempted from the other kinds. 

The moral landscape would certainly be a neater place to navigate if there really were sharp lines between the mad and the bad. Sharp lines out there, so to speak, in nature - but alas, there aren't. And that's the main topic for Sadler's book. 

More than half of the book is taken up by a loooong journey through time, and also, to some extent, through different cultures and different parts of the globe. People have struggled with the mad-bad distinction everywhere and for ages. And they still do! We still don't have a scientifically and philosophically well-grounded theory! This isn't because the mad-bad border is hard to find, and our science and/or philosophy isn't sufficiently well developed yet. It's because there isn't a sharp border. Sure, lots of people may be categorized as purely mad, or as purely bad (though as the reader of the book will see, the latter has, in modern times, been more controversial), but we'll remain stuck with a big grey area.
Sometimes, this grey area has given rise to "vice-laden" DSM diagnoses, like Conduct Disorder, Oppositional Defiant Disorder or Anti-Social Personality Disorder. Sadler calls these "vice-laden", because the diagnostic criteria is moralizing in a way that the criteria for, say, Schizophrenia or Major Depression are not. At other times, after discussions and debates, behaviours remain "just bad" rather than "bad and mad": Intolerant Personality Disorder, Behavioural Addictions (apart from gambling) such as addiction to sex, shopping, or social media, Political Apathy Disorder, and Paraphilic Rapism never made it into any diagnostic manuals. Sadler, only half-jokingly, suggests that White-Collar Antisocial Disorder, or, as we might call it, the Bernie Maddoff syndrome, could be a psychiatric diagnosis - why should only criminals from the lower social classes be pathologized? 

Way too many moral philosophers assume that the business of coming up with psychiatric diagnoses and applying them to individuals is a much harder science than it actually is. If someone has a bona fide diagnosis which includes descriptions of moral vices and vicious behaviour, it goes to show that it's not the person's fault, and they can't be morally responsible. If there's no diagnosis that covers their character traits and behaviour, they are responsible and blameworthy. Or so many philosophers seem to think.
Some people also like to appeal to neurological findings - people with this or that diagnosis have different brains! But every mental difference must have some corresponding brain difference - regardless of which mind-body theory we subscribe to, regardless of whether the mind is identical to the brain or if it supervenes on what happens in the brain or even if we're fancy old-fashioned dualists who think it's just correlation, it follows that every mental difference has some corresponding brain difference. You can't just point to "a brain difference" as evidence of undermined moral responsibility. Nor can you point to "a brain difference" as evidence that people with this or that diagnosis can't help their vices, unlike undiagnosed vicious people.
In our world, you can have Oppositional Defiant Disorder, but not White-Collar Antisocial Disorder. In a nearby possible world, in which human psychology works exactly the same, but psychiatry had a somewhat different development, it's the other way around. 

So, let's admit that psychiatric diagnoses and the mad/bad distinction is a huge bloody quagmire. What are we supposed to do? Sadler ends his hefty brick of a book with no less than forty theses of what ought to be done, society-wise, in light of this realization. He very nicely divides these theses into stuff we could do immediately and more distant, long-term goals.
As I said, it's a huge book, and I can't even begin to do everything justice in a blog post. But an overarching theme of the forty final theses is to ditch the attempt to find a neat mad/bad divide. Psychiatry should admit and discuss more explicitly than has hitherto been the case how value-laden it is, and how value-laden it must be. An open discussion allows for scrutiny and criticism of underlying values, instead of implicit acceptance. Also, we shouldn't divide criminals into the bad who deserve punishment and the mad who should go to forensic psychiatry (though very few perpetrators of serious crimes do so in the USA, the insanity defense is rarely invoked and even more rarely successful). We should rehabilitate as many as possible so they can be released back into society, and permanently dangerous people should be kept in humane confinement. The mad/bad distinction is ultimately irrelevant.

This is obviously extremely controversial. I'm not sure what I ultimately think of this idea. Let's say I'm somewhat sympathetic, because Sadler is so very aware of all the problems and pitfalls that come with this suggestion, and discusses them at length.
Both psychiatry and criminal justice institutions in various countries and time periods have played thought police, and have locked people up under the guise of either punishment or treatment/rehabilitation because they have the "wrong" ideas, dare to challenge old social norms, and so on. This is a serious danger, though it exists even when psychiatry and criminal punishment are kept separate. The goal of any rehabilitative program must be people that aren't dangerous to others, not to turn everyone into "normal" people who think the "right" thoughts. 
Perhaps there is even a greater risk for abuse when the systems are kept separate - it's so easy to justify abuse of prisoners by painting them as evil and thus deserving of everything they get, and simultaneously justify abuse of psychiatric patients by painting them as so irrational and confused and utterly different from normal people that what would count as horrible violations of a normal person is okay, or at least not all that bad, when done to "those people". Also, no need to listen to any complaints they have, since they don't know what they're saying anyway.
Generally, Sadler shows so much more awareness of potential problems with treatment and rehabilitation than many philosophers who write about these matters. Way too many philosophers are acutely aware of how harmful punishment can be, while utterly oblivious to the horrors that often befall people after they have been declared incompetent and exempt from responsibility. 

Regardless of whether one agrees with Sadler's radical conclusions, everyone should agree about the importance of an open discussion about these matters. There's no dividing line between the mad and the bad "out there" for us to discover. And history shows how difficult it is to construct a non-arbitrary line. 

So, this is a positive review. I recommend the book to all philosophers working on these topics, and to everyone else who researches or is simply interested in psychiatry and criminal justice. Or more broadly human nature.

After the recommendation, a reservation: Sadler contrasts common "folk-psychological" explanations of behaviour in terms of beliefs and desires with proper scientific explanations. Then he compares this distinction to the distinction between Newtonian physics and later scientific theories like special relativity and quantum mechanics. Folk psychology and Newton work well in everyday life, but when there's lots at stake and we need to be extra careful, they sometimes need to be replaced with more detailed and complicated theories.
Now I'm in deep water here since I'm not an expert on physics. Nevertheless, all physical explanations seem to me, ultimately, the same kind of explanation. They're all purely causal, tell us what causes what. Now, purely causal explanations may or may not conflict with each other. A biological explanation in terms of cellular events, a biochemical in terms of molecules, and a physical that zooms in on atoms need not conflict, since they take place on different levels of explanation. But causal explanations can conflict with each other. I take it that Newtonian physics actually conflict sometimes with relativity and quantum mechanics. When it does, we may say that Newtonian physics is less detailed but still has its place in everyday contexts where it's sufficiently precise for the purpose at hand, whereas we might need more detailed theories in other contexts.
Reasons explanations, on the other hand, are a different kind of explanation to causal explanations. "Folk psychology" is a loose term, and may involve more than reasons, but insofar as reasons are what we focus on - reasons may justify or not, show that you're action was rational or not, show whether it was moral or not ... Reason explanations are a different kind of explanation. They differ from all causal explanations, whether these causes are understood within a psychological, sociological, neurological, or other framework.
If I explain why I did what I just did by referring to my reasons for doing it, while a bunch of empirical scientists who study me provide causal explanations, the difference isn't that I give a rough and sloppy explanation whereas their explanations are detailed. We're looking at my action from completely different angles.
However, I might over-interpret the point that Sadler wanted to make with his Newton-relativity-quantum comparison. It's possible he agrees with everything I write here, in which case it's more of a comment than a reservation.

Now, I'm gonna nitpick. 

Sadler discusses - and obviously, he's not alone in this, these discussions are common - whether to say, e.g., "I have schizophrenia" or "I'm schizophrenic". The "am" vs "have" debate, "people first" vs "identity" language. He contrasts how people often say "I am" with regards to psychiatric diagnoses, with the "I have" language we use for physical health problems like cancer or a broken bone. Then, he says that this isn't all that weird, considering how intertwined a psychiatric condition may be with one's personality. 
But
a) it's not true that we say "I have" about all physical health problems, it differs from condition to condition, and
b) it's also not true that "I am" language, generally, implies that something is an important part of who I am.
Obviously people don't say "I am cancer" because "cancer" is a noun, you can't say that unless you're the personification of cancer itself, some kind of disease god or other supernatural entity. Similarly, people don't say "I am schizophrenia" or "I am depression". Now, with cancer, people don't usually say "I'm cancerous" either, but there are other physical health problems where "I am" language is common. "I'm diabetic", "I'm HIV-positive", "I'm lactose-intolerant", etc. In English, we say "I have a cold", but in Swedish, we say "jag är förkyld" - roughly, "I'm over-chilled".
Also, if we look at features other than health problems, we habitually use "I am" language about tons of things that aren't important parts of our personalities or who we are. "I'm medium blond", "I'm 169 cm tall", "I'm a Star Trek fan", and so on. In both English and Swedish, people are this or that number of years old and they are hungry if they haven't eaten for some time, whereas in Spanish and French, people have their years and have hunger. Surely these are random language differences that don't matter for how speakers conceive of their ages and states of hunger in relation to their personalities and identities.
And yet, in mental health contexts, people suddenly make a big deal out of "I am" vs "I have", as if these expressions have all these linguistic implications. Well, I guess "I am" vs "I have" have strong linguistic implications in the specific context of mental health now, because so many people have made such a big deal out of it for so long. But why did this come up in the first place? Given that "I am" vs "I have" don't have any interesting implications in language in general?
I can only assume it's because lots of people think it's horrible-horrible-horrible-shameful to have a mental health condition, and therefore they suffer intense second-hand shame every time they hear someone openly say, e.g., "I'm schizophrenic". If you're gonna talk about it, could you at least try to distance yourself from that horrible condition as much as possible?
If this was a peer-reviewed paper rather than a blog post, the imaginary peer reviewer would have this to say:
"That doesn't make any sense. You claim that there's no interesting distinction between 'I am' language vs 'I have', outside of mental health contexts and the special norms that have been created there by people who 'make a big deal out of it'. But if you're right about this, saying 'I have schizophrenia' wouldn't have signaled more detachment than saying 'I'm schizophrenic' until these special mental health language norms were already in place."
Fair enough, imaginary peer reviewer.
Anyway, it's weird. This entire insistence on "have" over "am" in mental health contexts is hella weird, let's just leave it at that.

Finally, philosophers who read this book may find some little annoyances here and there, where Sadler's terminology doesn't align with ours. For instance, at one point, he talks about adherents of retributivism who are  "couching the concept in the context of utilitarian ethics".
This reads as somewhat philosophically confused. Utilitarianism is the view that an action (including the act of punishing a criminal) is right if it maximizes utility (traditionally understood as happiness) and wrong otherwise. "Desert" has no place in utilitarian theory, except, perhaps, as a derived and pragmatically used term. Utilitarians since Jeremy Bentham and onwards have focused on the role that punishment allegedly has in deterring criminals from re-offending and deterring potential criminals from offending in the first place (something Sadler also recounts in his book). Retributivism is a different theory, according to which criminals should be punished because they deserve it.
Now, it's possible to hold a mixed theory, according to which we have several different reasons for punishing criminals; they deserve to be punished, and it's great if we can deter people from crime. Stephen Morse and others have pointed out that real-life politicians often freely mix appeals to an alleged deterrence effect and appeals to desert when they argue for harsher punishments. Nevertheless, claiming that we have both deterrence reasons and retributivist reasons to punish criminals is very different from saying that deterrence is a reason for retributivism.

Still, this was a very minor nitpick. Overall, I recommend this book. Agree with Sadler or not, he does raise some really important questions.