Chapter 7 examines interventions that can be implemented to address mental illness stigma. These include individual actions that the person who is stigmatized can engage in to help them cope with or resist stigma and actions that other people are obligated to perform in order to decrease stigma they may endorse or perpetuate unwittingly. These also include structural changes that social institutions and systems must undergo to make social structures less stigmatizing and more supportive of people with mental illness, and social and cultural interventions that increase the belongingness and acceptance of people with mental illness into the community as well as transform social norms to be more supportive of people with mental illness. In addition to using philosophical argumentation, this chapter draws on empirical literature in social psychology that examines what works to reduce and resist stigma.

Chapter 3 analyzes some of the ways that stereotypes harm people’s sense of self and identity. One way is through expressive harm, which is the harm that results from the unwitting and inevitable perpetuation of stereotypes. Stereotypes have a pervasive cultural power that enables them to control people’s thoughts, feelings, behavior, and social interactions even when people actively disavow the stereotype. Other ways that stereotypes harm people’s sense of self and identity are through the internalization of oppressive social scripts, which ascribe motivations and expectations for behavior, and through stereotype threat, in which people inadvertently and paradoxically act in ways that correspond to stereotypes even as they are trying hard to avoid fitting stereotypes. When people with mental illness internalize oppressive social scripts and experience stereotype threat, they incorporate negative stereotypes into aspects of their experience and identity, which damages their identity and sense of self and also diminishes their autonomy.

Chapter 5 assesses harms that people with mental illness experience that are related to how their self is constituted. These include harms of de-individuation and mis-identification, but also, as this chapter focuses on, harms of social exclusion and dehumanization that result from status loss and moral distancing. Dehumanization occurs through both being reduced to a stereotyped trait and being viewed as lesser compared to others. Having a sense of belonging and being accepted as an equal member of a moral/epistemic/social community are important parts of being viewed as and viewing oneself as a full human being; these are also critical for developing and exercising autonomous agency as well as for well-being and flourishing. People with mental illness are often excluded from these communities as a result of public stigma, diminishing their autonomy and well-being. This chapter shows how dehumanization, social exclusion, and belonging uncertainty threaten belongingness and autonomy.

Chapter 1 examines what mental illness stigma is and analyzes the components of mental illness stigma to show how people with mental illness experience stigma in their daily lives. These components include labeling, stereotyping, prejudice, moral distancing, social exclusion, status loss, dehumanization, microaggressions, discrimination, and epistemic injustice. In each case, I use empirical evidence from the social psychology literature on stigma to show ways in which people with mental illness experience these forms of stigma. Next, I look at factors that affect the kind, degree, and scope of stigma associated with mental illness, including beliefs, political values, cultural values, socioeconomic status, education, and gender. Finally, I examine how many people experience compounding stigmas that come from multiple sources.

Chapter 6 examines what makes discrimination and microaggressions (as a form of discrimination) wrongful. Discrimination involves differential treatment where some people are treated in different, unequal, and worse ways compared to others, and where that differential treatment is based on possessing a socially undesirable trait that marks a person as bad and inferior. Discrimination is wrongful because it harms people in a variety of ways, impacting their circumstances, resources and opportunities, options, agency, autonomy, and well-being. It causes material disadvantage and distributive injustice that denies people access to resources and opportunities and prevents them from having the basic goods necessary to participation in society. It also demeans people and leads to unfair subordination, loss of deliberative freedom, and decreased autonomy. This chapter reviews the philosophical literature on discrimination to provide a pluralistic account of the many harms discrimination and microaggressions cause to people with mental illness, which altogether make discrimination wrongful.

Chapter 2 assesses what stereotypes are and explains what makes them both wrongful and harmful. The chapter begins by defining stereotypes, explaining their relationship to prejudice and implicit bias, and showing how they are maintained due to cognitive biases. I examine factors that go into making the judgments involved with stereotyping. Then I analyze what makes stereotypes wrongful, including their rigidity, their falsity, and the way they overgeneralize about a person’s experience so as to erase its nuance and complexity. I look at descriptive and normative components of stereotypes and show that negative stereotypes always make a normative judgment about the badness and inferiority of a person who fits the stereotype.

Chapter 4 shows how internalized stigma often results in adaptive preferences that harm a person. When people incorporate aspects of negative stereotypes into their identity, they sometimes develop adaptive preferences by internalizing harmful social norms and beliefs embedded within these stereotypes. I show how people with mental illness often develop goals and desires that are shaped by these beliefs and social norms, which limits what they believe they are capable of, thus reducing their options for action and truncating their agency and autonomy. While adapting desires to one’s circumstances can be positive, as in positive adaptation, it is negative when it is harmful to a person. The adaptive preferences that result from this can be seen as rationality deficits that are oppressive and nonautonomous and that damage well-being and flourishing.

The introduction motivates the book’s arguments by showing how mental illness stigma remains pervasive despite greater awareness of mental health issues and more resources directed at mental health treatment and destigmatization. The forms of mental illness stigma most commonly expressed are stigma against people with severe mental illness who are perceived as homeless, and internalized stigma that people with mental illness project onto themselves. Mental illness stigma arises as a reaction to the violation of social norms of what a human being should be in the Western world in the twenty-first century. I give an account of stigma as the devaluing and discrediting of a person based on possessing a social trait that is seen as violating social norms, constituting a relationship of power. Components of stigma include labeling, stereotyping, prejudice, moral distancing, social exclusion, status loss, dehumanization, microaggressions, discrimination, and epistemic injustice. The chapter ends with a description of the book’s scope, methodology, and chapter outline.

We explore the unique considerations surrounding menopause, periods and contraception for people with intellectual disability (ID), the barriers they face and how to achieve ‘equal outcomes of care’. A complex interplay of communication differences, societal assumptions and stigma, diagnostic overshadowing, physical accessibility challenges, and gaps in healthcare providers’ understanding of ID, create these barriers. Aspiring to achieve equal outcomes of care requires early and adapted communication about menopause, periods and sexual health. Clinicians need to adapt clinical care to embed enquiry about menstruation and menopause and use systematic tracking tools to understand a woman’s periods and associated psychological and behavioural changes and then offer the whole range of treatment options. The responsibility lies with professionals to be aware of the barriers, provide reasonable adjustments to overcome them, and to advocate for equal outcomes around menopause, periods and contraceptive health for people with ID. The chapter includes insight from ‘experts by experience’, and each section provides practical suggestions for professionals working with people with ID.

This introduces the key themes of Spirituality in Mind, including the concept of entanglement and the importance of attentiveness as both a spiritual practice and a clinical skill. Whereas many books on psychiatry by psychiatrists emphasise controversies and fears, the intention here is to focus on spirituality as casting light on what patients most desire. This book is different from other books on spirituality and psychiatry by virtue of engagement with the humanities (especially theology and religious studies), its concern with the ‘ordinary theology’ of patients and its attention to the invisible assumptions of pragmatic atheism. This does not mean that atheists or agnostics are less likely to be spiritually attentive than those who are spiritual/religious (not infrequently the reverse may be true) and the situated perspective of the author, and of all psychiatrists, is highlighted. An outline of the book as a whole is provided, some clarifications are given in regard to vocabulary (notably in respect of ‘patients’ and ‘theology’) and general remarks are made concerning the clinical case studies.

This explores the phenomenon of auditory verbal hallucinations (AVHs) as an example of entanglements of spirituality and psychopathology, and looks at ‘spiritually significant voices’ (identified by those who hear them as having spiritual/religious significance). Some have proposed making a differential diagnosis between ‘genuine’ spiritual experiences and mental illness, but the criteria for making such distinctions can be controversial and misleading, based on a false presupposition that the two are mutually exclusive. Research shows that patients identify some experiences as both part of an illness and spiritually significant. Patients with a psychiatric diagnosis are often subjected to epistemic injustice, wherein their claim to know things (e.g. spiritually) is discredited owing to prejudice associated with their diagnosis. A case study explores entanglement of spirituality with AVHs and considers implications for assessment/treatment. Voices of this kind may be meaningful for those who hear them, whether or not associated with a diagnosis, and affirmation of this and patients’ positive spiritual coping, where possible, can be a positive factor in promoting recovery.

The perimenopause is an individual experience, influenced by life circumstances, cultural context, family history and narrative. The perimenopause can last many years and women, as well as health professionals, can be poorly prepared for this potentially challenging period. Most people know to expect hot flushes, and maybe genitourinary symptoms. However, if the emotional symptoms, such as, reduced ability to cope, irritability and sudden anger, arise first, years before the expected hot flushes, it can be difficult to understand and have a detrimental effect on a woman’s life. We explore widespread physical symptoms of perimenopause and highlight symptoms that are regulated in the brain: hot flushes, body temperature regulation, sleep disturbances, libido. We focus on emotional symptoms, such as mood changes, depression, anxiety, agitation, irritability, a sense of overwhelm and losing the ability to cope, and explore their impact on suicidality. We briefly look at cognitive symptoms and explore the influence of trauma and the differences in experience by ethnicity and cultural influence. Finally, we look at the experience of premature ovarian insufficiency.