On stigma, the people it silences, and the ones who pay the price alongside them
When people ask what inspired me to become a therapist, I usually say it runs in the family. That tends to prompt a follow-up: were your parents psychologists? And I say no. I say I simply grew up with a very intimate understanding of what happens to people, and to the people around them, when the help that is needed is not there.
My mother was diagnosed with bipolar disorder 40 years ago. For many years after that, she was under the care of a psychiatrist. She took her medication (most of the time). She managed, in the ways that medication allows a person to manage. But she would point blank refuse to see a therapist.
Her reason, stated plainly and without apology, was this: “Therapy is for crazy people.”
She did not consider herself crazy. She considered herself someone with a medical condition, a chemical imbalance, a matter for doctors and prescriptions and clinical appointments. The idea that she might also benefit from sitting with another human being and talking about her life was, to her, not just unnecessary. It was an insult.
I had no choice but to accept her position. And we all, her family, the people who loved her, lived inside the consequences of that refusal for a very long time.
What the word “crazy” has cost us
My mother’s words were not unusual. Some version of that sentence lives in more families than most of us would care to admit. But before we can understand why that word carries such power, it helps to understand what it has historically meant to be on the wrong side of it.
For much of the nineteenth and twentieth centuries, a psychiatric label was not simply a diagnosis. It was a social verdict. Once applied, it could strip a person of civil rights, remove them from their family, and confine them to institutions where the conditions were, by modern standards, unconscionable.⁴ Families routinely concealed mentally unwell relatives rather than seek help, not out of cruelty, but out of a rational understanding that the label itself could cause more damage than the condition.
The psychiatric profession was not always a reliable arbiter of who belonged inside that category. In 1973, psychologist David Rosenhan published his now-famous study On Being Sane in Insane Places, in which healthy individuals gained admission to psychiatric hospitals by faking a single symptom, then behaved entirely normally thereafter. None were identified as well. The study concluded, starkly, that we cannot reliably distinguish the sane from the insane in psychiatric institutions, and that once a label is applied, everything a person does is interpreted through it.¹
That same year, the American Psychiatric Association voted to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders, having classified it as a mental illness since 1952. It did not disappear from the manual entirely until 1987.² These are not ancient history. They fall within the lifetime of many people reading this article, including my mother’s. They are the sediment beneath my mother’s words, and beneath the words of every person who has ever said, with a mixture of pride and fear, that they are not crazy enough to need help.
Her fear was not irrational. It was inherited, passed down through a culture that had given people very good reasons, across generations, to keep their distance from anything that might attract that label. Research confirms that this inheritance is still with us: a landmark review by King’s College London, examining 144 studies involving over 90,000 participants worldwide, concluded that stigma exerts what the authors called a “toxic effect”, actively preventing people from seeking help for mental health problems.⁶ The barrier is not always practical. Often it is this: the simple, deeply human fear of being seen as less than whole.
What strikes me now, sitting with clients who carry their own versions of that sentence, is how much work that one little word is doing. Crazy is a perimeter. It marks out a category of people who are different from us, more damaged, less in control, fundamentally other. As long as we can keep ourselves on the right side of it, we do not have to consider that we might need something.
But the perimeter is imaginary. There is no meaningful line between the people who need therapy and the people who do not. There are only people, all of them carrying something, all of them shaped by experiences they did not choose, all of them capable of living with more understanding and more freedom than they currently have access to. A 2025 study from the University of British Columbia and Harvard Medical School, analysing data from nearly 57,000 participants across 21 countries, found that globally only 6.9% of people with mental health conditions receive effective treatment, and that the single greatest barrier at every stage of that journey is not cost or availability, but a person not recognising, or not permitting themselves to recognise, that they need help.⁵
The question is never whether you are crazy enough to deserve the room. The question is whether you are curious enough, or tired enough, or brave enough, to walk into it.
What medication cannot do
I want to be precise here, because this is not a piece about the limitations of psychiatry, and it is not a criticism of my mother. Medication gave her stability that she would not otherwise have had. And I am personally grateful for that. That matters enormously, and I do not want to minimise it.
But lithium is not a life story.
Underneath my mother’s diagnosis was a whole architecture of experience, trauma, loss, relational patterns that had formed long before any psychiatrist entered the picture. This is not simply my clinical intuition. Research now consistently shows that people with bipolar disorder are 2.6 times more likely to have experienced childhood trauma than the general population,⁷ and that a history of trauma is associated with earlier onset of the condition, more severe episodes, and significantly worse long-term outcomes.⁸ The trauma underneath was not incidental. For many people, it is part of what drives the illness, and medication, however necessary, cannot reach it.
What could reach it is the very thing my mother refused: a conversation. Not about her diagnosis, but about her life. About what had shaped her before the diagnosis existed. That work, the work of understanding rather than simply managing, requires a different kind of space. And that space was the one thing she would not enter.
The people in the waiting room of someone else’s refusal
Here is something that does not get talked about enough.
When someone refuses therapy, they do not absorb the full cost of that refusal alone. And just as tragic, neither do the people for whom therapy was never a realistic option at all. Whether through cost, geography, cultural invisibility, or simple lack of access, the absence of that support does not stay contained. The people who love them absorb it too.
This is not merely an observation. Sociologist Erving Goffman identified it formally as early as 1963, describing what he called courtesy stigma, the process by which the stigma attached to one person spreads outward to those closest to them.³ Family members of people with mental illness do not only live with the practical consequences of that illness. They live with its social weight too. The society induced shame. The unspoken instruction to keep things quiet. The chronic alertness. The years of learning to read a room.
They become, without choosing to, the container for everything that therapy might otherwise have held. They develop their own patterns in response, ways of managing, of tiptoeing, of bracing. They learn to read rooms and moods and silences with an accuracy that no child, no partner, no sibling should ever have to develop out of necessity.
And then, sometimes, they carry those patterns quietly into their adult lives, not always knowing where they came from or why certain things affect them the way that they do.
There is a particular kind of wound that comes not from your own refusal to seek help, but from living inside someone else’s, or someone else’s inability to access it. It is not less real for being indirect. It is not less worthy of attention for being hard to name.
If you grew up alongside someone who needed more support than they were willing or able to accept, and if that experience left its mark on you, that is a completely valid reason to walk into a therapist’s room. Not because you are crazy. Because you were human enough to love someone, and love, when it exists alongside unaddressed pain, is never without cost.
What therapy actually is
In my experience, the people who are most resistant to therapy share a common misunderstanding of what it involves. They imagine confession, or judgment, or being told that everything they have done is wrong and that their childhood is to blame for all of it.
What therapy actually is, at its best, in the right room, with the right person, is a conversation in which you are finally permitted to be entirely honest. About what you find hard. About what you have never said out loud. About the version of yourself that you have never quite managed to show anyone, because you were not sure it would be acceptable or safe.
That conversation does not require you to be crazy. It requires you to be human.
And if somewhere in your life there has been someone whose unaddressed pain shaped you in ways you are still untangling, a parent, a partner, a sibling, then you already know more than most people about why that conversation matters. You learned it the hard way. You do not have to keep carrying it the same way.
At the other end of the spectrum
And then there is a different person entirely. Someone who had, by most measures, a healthy childhood. A stable home. Parents who were present and loving. No diagnosis in the background, no crisis they can point to, no justifiable struggle.
This person also sometimes finds their way into my room. And they arrive with a particular kind of apology already prepared: “I don’t really know why I’m here. I had a perfect childhood. I shouldn’t have to be here.”
That sentence moves me every time I hear it. Because what it reveals is that the stigma around therapy does not only operate at the extreme end, the crazy end. It operates just as quietly at the other end of the spectrum too. The message this person has absorbed is not that therapy is for crazy people. It is that therapy is for people with justifiable triggers. And they have decided, before they have even sat down, that theirs do not qualify.
But here is what I have learned from sitting with these clients: sometimes, the very healthy childhood that you had robbed you of the opportunity to develop the skills to manage everyday life struggles. Adversity, navigated with support, builds something. When that exposure is absent, never experienced, its consequence only becomes visible when ordinary adult life begins to demand it. In fact, the importance of exposure to manageable adversity in childhood for healthy emotional development has been thoroughly evidenced in the scientific literature.⁹˒¹⁰˒¹¹˒¹²˒¹³
That is not a failure. It is simply an unmet need. And therapy is one of the places where it can finally be met. What lies at the other end of that work is the same thing it offers everyone who walks through the door: a clearer view of yourself. Patterns noticed before they become problems. Relationships understood more fully. A version of yourself that is not just coping, but genuinely, consciously, alive to its own experience.
You do not have to be crazy to want that. You just have to be human.
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References
- Rosenhan DL. On being sane in insane places. Science. 1973;179(4070):250–8.
- Drescher J. Out of DSM: Depathologizing homosexuality. Behavioral sciences. 2015 Dec 4;5(4):565-75.
- Goffman E. Stigma: Notes on the management of spoiled identity. Simon and schuster; 2009 Nov 24.
- Byrne P. Stigma of mental illness and ways of diminishing it. Advances in Psychiatric treatment. 2000 Jan;6(1):65-72.
- Vigo DV, Stein DJ, Harris MG, Kazdin AE, Viana MC, Munthali R, et al. Effective treatment for mental and substance use disorders in 21 countries. JAMA Psychiatry. 2025;82(4):347–57. doi:10.1001/jamapsychiatry.2024.4378.
- Thornicroft G, Mehta N, Clement S, Evans-Lacko S, Doherty M, Rose D, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet. 2016;387(10023):1123–32.
- Palmier-Claus JE, Berry K, Bucci S, Mansell W, Tai S. Relationship between childhood adversity and bipolar affective disorder: systematic review and meta-analysis. Br J Psychiatry. 2016;209(6):454–9.
- Etain B, Aas M, Andreassen OA, Lorentzen S, Dieset I, Gard S, et al. Childhood trauma is associated with severe clinical characteristics of bipolar disorders. J Clin Psychiatry. 2013;74(4):397–405.
- Center on the Developing Child, Harvard University. A Guide to Raising Resilient Children [Internet]. Cambridge, MA: Harvard University; 2025 [cited 2026 Jun 17].
- Ballash N, Leyfer O, Buckley AF, Woodruff-Borden J. Parental control in the etiology of anxiety. Clinical child and family psychology review. 2006 Jun;9(2):113-33.
- Pandey AL, Sarkar SA. Overprotective parenting and its impact on young adults’ sense of individuality and independence. International Journal of Applied Social Science. 2025;12(5-6):352-7
- Greco LA, Morris TL. Treating childhood shyness and related behavior: empirically evaluated approaches to promote positive social interactions. Clin Child Fam Psychol Rev. 2001;4(4):299–318.
- Masten AS, Best KM, Garmezy N. Resilience and development: Contributions from the study of children who overcome adversity. Development and psychopathology. 1990 Oct;2(4):425-44.