To the Heart of the Matter, Part III: The Critical Nature of Authenticity and Virtue in Combatting Stigma


So doctor, here is the question we are struggling with.  We just want to know whether this behavior is part of his condition or just part of being a kid.  We don’t want to punish him for something that he can’t control.  

One of the most frequent questions that I get from parents sounds much like this.  Spurn of good intent, they often want to know whether or not a specific action, usually a disruptive or harmful one, is something that they should just accept (or at least learn to manage) or a behavior that they should work and aspire to improve.

As a parent myself, I very much empathize with the question.  I want to be a responsive, empathetic father to my kids. I also want to make sure that my expectations are appropriate based on a variety of factors, especially developmental ones. But as the years have progressed, I have found myself coming to a juncture where I feel that this time-honored question often ends up leading us in the wrong direction.  For starters, as I often say to parents, we are dealing with one mind and one body.  Although certainly situations may occur where both are not functioning in the way that we (or others desire), the idea of a division between the “condition” and “the person” is often artificial.  Certainly lesions on the brain can cause seizures.  A lack of activity and poor diet can increase the likelihood of anxiety.  But when we ask to define what is attributed to the “condition” or the “kid”, we can get into some muddy waters that go beyond how brain structures are operating, which never function in isolation.  Each of us is a dynamic composite of our imperfections as much as we are one of the qualities for which we excel.

But to understand how we as parents (or people) respond to differences we perceive, we must first ask what defines appropriate?  Certainly this includes many things—developmental capacity, family expectations/values, societal norms, school/legal expectations, religious values, and the like.  Certain standards seem relatively easy to agree on.  Few people would argue that randomly stealing a car or destroying another’s possession is acceptable.  But other standards do not always evoke such a consensus, especially when we are talking about behaviors of youth and adults who have been identified with psychological or developmental concerns.

In fleshing out these areas, though, all of us must acknowledge that a few, critical determinations play a huge factor in deciding what is acceptable and what is not.  One is simply whether or not we feel an individual is meeting the situational demands that are expected of them.  The other is the values of those who are around or responsible for them.  The third (and certainly connected to the other two) is how well (or not) a person’s actions preserve the integrity of other people who come in contact with them.  In response to the question posed at the beginning of the article, it seems the question should be reframed to say, “What do you feel like is important to teach them about how to act?” and/or “What behaviors do you feel should simply not be allowed no matter what condition they have?”  By no means am I saying that we should ignore what is reasonable to expect given what we know about them.  But in shifting to these areas of focus, what I am hoping to do is to both better understand the values and beliefs of the parents, and determining where energy is best allocated.  For example, it may be true that a 10-year-old child diagnosed with an autism spectrum disorder who is nonverbal and still can’t recognize letters has difficulty refraining from physical aggression.  But does that change the fact that this is simply an action that should not be accepted or allowed, but instead something we continue to work in changing?

A little ways back, a teenage girl came to me to talk about her brother, who is diagnosed with a genetic condition associated with various developmental/psychological challenges.  One of her questions was, “How should I treat him?” Reflexively, I responded with “Like your brother.”  As I went on to explain, I encouraged her to love him unconditionally, but to not simply sidestep and allow behaviors that were not only detrimental to others, but also him and his development.  I encouraged her to tell him (in an honest, supportive way) when he did things that others clearly perceived as alienating or frustrating as well as encouraging and praising him when he acted positively.  Like any sibling, if your older sister isn’t going to tell you that you have corn in your teeth or you were acting goofy, no one will.

In regards to the issue of stigma, it seems that one of the mistakes made, often with good intention, is that we are often taught to give others allowances for behaviors if their circumstance or condition predisposes them to act in a certain way.  For example, if a person is depressed, we are often taught to ignore them when they are rude.  Certainly I am not advocating that we walk down the sidewalk handing out free advice to everyone that we feel stands out for any reason.  But what I am saying is that we must start treating others like they are our brother—whose worth is equal to all even while uniquely their own—not someone who is different than I.  Stigma is at its worse when we separate “we” from “them” as if the diagnosis or label they have been given warrants a division that does not exist.  But when we see the fleshy, imperfect, human person for who we are, we are summoned to be authentic.  If we feel bothered or wronged by someone else, or feel that someone is harming themselves (with or without even being aware that it is occurring), then we must work through layers of fear and uncertainty and treat them how we desire to be treated.  Simply sidestepping the obvious, and then categorizing and dehumanizing them (now or later) only intensifies the separation that both people will feel.

As I speak of this, I am sure that flashes of all kind are arriving at your cortex.  Beyond the obvious obstacles that may rise to the surface, one of the challenges to this mode of thought might start with two simple thoughts:  “Who are we to judge others?” and “Why should I impose my values on others?”  In response to this, I begin with a simple premise:  “If I do not give of myself authentically to others, through whatever means this may occur, then what do I have to give?”  Certainly, many of us may think differently about circumstances as they appear.  But in our daily life, we are not first asked to render legislative or medical decisions; we are asked to deliver honest, compassionate ones.  If my response begins with anything less than this, it is a contrived one—not an authentic one derived from millennia of living and loving and dying together.  Whether a person is depressed or autistic or has an IQ of 40, it does not change this.  You are one of me, and I am one of you.  So, if I let you know that I wished you wouldn’t scream in public or act rudely to one of my friends, I want you to know that it is not because I am judging you.  It is because I am attempting to love you, like I would my brother.

What emerges from authenticity is something even better, and sets the stage for the gift of courage.  While we all may seem to be very different in mind and body, there is a force that has remained remarkably consistent throughout the ages even as much has changed.  As I noted in my newest book, it is the value of virtue.  Regardless of race, creed, practice, or experience, people consistently report that virtue remains virtue.  Six universal virtues exist.  They are wisdom and knowledge, courage, humanity, justice, temperance, and transcendence. Within these six virtues are 24 character strengths, also endorsed across the world.  For example, courage is composed of authenticity, bravery, persistence, and zest while temperance is composed of forgiveness, modesty, and prudence.  Available to all, exclusive to none, these virtues and strengths run like an undercurrent through our world, and into another.

Still, people will argue that although all (most) believe in virtues such as justice and humanity, “the devil is in the details.” Similar virtues may look different in practice.  To some extent, I acknowledge this assertion.  But I also believe that in our politically, dramatically inclined landscape, so much time is spent demonstrating how we are different that it underscores just how much we are not.  I put forth a contention that most people agree on whether most actions are virtuous or not, regardless of circumstances or condition.  Instead of being so worried about the outcomes (and reported conflicts of our beliefs and behaviors), we would be better spent focusing on our process and intent.  While we can never fully control what will happen when we act, we can always control why we act.  If we started focusing much more on the latter than the former, I believe that what we will find is a society built on compassion and honesty instead of one marred by division and distrust.

Like most issues, the struggle of stigma stems from a much deeper place than the labels and the alienation might suggest.  It stems from a notion that somewhere along the line, we began to diverge from each other, as authenticity moved away from our responding.  We began to compile reasons why value was equated with status, and brotherhood with membership.  We began to lose sight of each other and started to see descriptors that clouded where we began.  In some ways, it is not a new problem.  Two thousand years ago, the lepers were left to die because of fear and derision.  I understand.  I don’t want to get sick, or hurt, or even be uncomfortable simply because of another person.  Of course, that person could be me.  If we are going to really make a difference in the world of mental health stigma, we must get to the heart of the matter.  All people deserve compassionate, honest care.  All people, stigmatized and stigmatizers, deserve to be heard, understood, and valued, no matter what worth that society may place on them.  I am my brother’s keeper.  You are mine.

A few months ago, I attended a silent retreat on the banks of the Mississippi River  south of St. Louis.  Lead by a remarkable Jesuit priest who had lost his father to suicide at a young age, it was a much needed few days spent largely in the silence of my own mind.  As I sit here reflecting on one particular talk he gave, emotion wells up in me.  Father recalled his days in hospice care, and how one morning he entered into a somber place that had long dealt with the saddest circumstances people could bring.  The nurses informed him that they had received an infant the night before.  Disfigured worse than they had ever seen, the baby boy had one eye, barely a nose, and a face that looked inhuman.  Everyone seemed uncomfortable.  But as Father spoke, he recalled this sudden, deep desire to go to this child’s room to hold him, and rock him like his own.  When he did, he was astounded at the beauty and majesty that he saw in this little boy.  Others came to see the same thing; they repeatedly sought to hold him throughout the days.  He died a few weeks later.  When he did, all mourned.  It was clear that this beautiful child had evangelized love.  Those that knew him would not be the same.  Neither would I.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


  1. Looks like I’m first. Let me simply proffer the observation that so-called stigma is inherent to the act of labeling, which sets the preconditions for further “other”-ization of those on the receiving end of such pseudo-“diagnoses.” Leprosy is a real disease btw (though I hear it’s not virulently contagious).

  2. “You are one of me, and I am one of you. So, if I let you know that I wished you wouldn’t scream in public or act rudely to one of my friends, I want you to know that it is not because I am judging you. It is because I am attempting to love you, like I would my brother.”

    I think it says in the Christian Bible something like ‘let he who is without sin cast the first stone’?

    Isn’t this precisely what psychiatrists do? Cast the first stone in the form of a stigma? And then the community, armed with a rock pile, join in until….. Still, if it is not a judgement they are passing, but an expression of their love for a person who is their brother, and they are treating them as they would like to be treated, then their should be no problem when their turn comes.

    These ‘first stones’ seem to be cast on many occasions as a result of the projections of those who believe themselves to be virtuous. Perhaps an understanding that it is better to forgive may be the best advice they are ever given.

    I love your work James, though it is difficult for me to reconcile what you write with what I have personally observed in a locked ward. Have you been reading about the treatment of Garth Daniels in the articles by John Read on MiA?

    Kind regards

  3. When dualistic ‘othering’ stigma is aggressively and chronically thrust upon the marginalized, second-classed citizens of society, then it is purely about prejudice, fear, discrimination, and class division. That’s where it can be life-compromising at best, and deadly at its worst..

  4. “But I also witnessed a number of individuals who really did work hard to do the right thing by the patient and themselves. These are the stories that almost never get told as certainly they do not draw the attention that stories such as you mentioned. But I think it is important they are recognized, whether it is a mental health technician or a psychiatrist. Otherwise, it makes it appear that simply by working in these facilities (prisons or psychiatric units), you are an uncaring person. And this mentality only serves to further divide people, and not provide discussion about how we improve care in an albeit flawed system.”

    James, the system is not simply ‘flawed,’ it is ill-making and corrupt, so working for it is divisive, in and of itself. I don’t feel that survivors’ well-founded and vividly illustrated grievances against the way the system impacts the clients so negatively are necessarily about accusing people of being uncaring or unfeeling (although as we all know the system is filled to the brim with cold and calculating individuals who wouldn’t know the needs of a client from a hole in the ground), but more so about the false beliefs and inherently demeaning and disregarding attitude that drive the system on the whole.

    Many people who work in the system will agree with this, perhaps, out of their own compassion, but still, the situation does not change despite being constantly challenged for its crimes against humanity (and I do mean that literally), and the system only digs in its heels, as per the system being closed to grievance, despite there usually being some kind of grievance protocol. It does not work. Clients have no credibility, the system will find something to pin on the griever to which they will alert the entire community, like spreading viscoius gossip in the guise of ‘case notes.’

    This is how stigma is used as a tool for oppression. It happens repeatedly, I saw this a lot when I worked in the system. They will make up a reason why the client is not credible in their grievance against staff. It’s not that hard to stonewall a client–they will be described as manipulative, controlling, divisive, angry, etc., even when there is no foundation for this, blatant lies. From what I witnessed, I am not exaggerating.

    It’s really hard for me to not say something here when the system just continues to hurt and drain a lot of people while paid professionals are having discussion after discussion, complaining of not being recognized for being one of the ‘good ones’ and above the fray.

    in all honesty, I think these are issues of personal ego, which can never trump what those that are marginalized feel as the result of stigma. When a client complains or gives negative feedback, t’s not about ‘what do you think about me?’ but more like, “Will you please listen to what my needs are so that you can do your job properly?” I don’t know how else to say it. For those marginalized by the system, it is a matter of survival, and that is immediate.

    Mental health professionals should have a much stronger sense of self than caring what other people think about them, otherwise they will not be good examples to clients, and in fact, they will project all their own issues onto them, which is what happens when lack a grounded sense of self. If we care about what others think, rather than to simply live our truth, then we lack sense of self, I can’t see it any other way.

    • Exactly, that’s what I’m trying to say. The important thing is bad stuff is aloud to happen. The whole I greater than the sum of it’s parts. We can’t possibly not call out a corrupted system, at the chance certain individuals may be misrepresented. There is so much more at stake for letting the problems remain not talked about. People have to realize this.

      • People who work in “the system” who are truly our allies (Richard Lewis comes to mind but there are others) are not personally threatened or defensive when we rip the system, and don’t need to constantly be reassured that we have no personal animosity towards them. But it’s important to realize that they are the exceptions that prove the rule, not proof that it’s just a question of “good” vs. “bad’ practitioners.