Affirming Psychiatry - Episode 8
What if the psychiatrist’s public face changed from that of a distant prescriber to one of a fellow warrior in the trenches?
The biggest and most deeply destructive myth of mental health is the twisted notion that there is a group of people called the “mentally ill” who are somehow different and separate from the rest of us. “We,” the majority composed of “normal” people, are not like them, the mentally ill. They are different from the rest of us, worthy of pity and curiosity. But since we are good, sympathetic people, we all want to help “those people” who suffer from such illnesses out of the goodness of our hearts.
What is wrong with all of this? The delusional idea that we are separate in any way from the mentally ill. In fact, there is no them because the people who deal with mental illness are us. All of us. Literally all of us deal with mental illness. Every single one of us does. How can this be true? Because massive, carefully performed studies tell us that half of our population experiences some form of mental illness over the course of their lives. Fifty percent of us experience mental illness directly.1 And what about the other 50% of us? The other 50% have the experience of seeing someone we love suffer from mental illness. Whether it is a friend, a family member, or a close coworker, every single one of us loves someone who experiences mental illness. All of us are affected by mental illness, directly or indirectly. There is no them; we are them.
The Myth in Psychiatry
There is no social group that does not include individuals with mental illness. Politicians, attorneys, CEOs, teachers, members of the media, and working individuals everywhere experience mental illness. There is no line we can draw anywhere in society that has individuals with mental illness on one side and individuals without it on the other. This is just as true among doctors and mental health professionals as any other group. Even in a mental health clinic or psychiatric hospital, no such line of division exists. Many of the patients are medical and mental health professionals, while many of the mental health professionals treating them experience mental illness.
How do we know this? In truth, we only have a vague idea of how many psychiatrists and other mental health professionals experience mental illness. But even the limited data we have tell us that mental illness is at least as common among our profession as it is in the rest of the population, and that it is quite likely to be higher.2 Seventy percent of us have experienced mental illness at some point, according to available surveys.3,4 Even more of us have a family member who has experienced mental illness. Why, after all, would most of us want to go into the field if we had no personal stake in it? According to the studies, many of us learned as children to be mediators and junior therapists in our own families who experienced the effects of mental illness.5,6 Why, in the end, do we find our field so fascinating? Because, of course, it applies to us and to those we love. We as medical and mental health professionals deal with mental illness, and it is time for us to openly admit it.
Ending the Myth in the Office
What am I proposing? That all of us who are mental health professionals go on an internet orgy of self-revelation, parading our illnesses and private lives in the most dramatic way possible? Hardly. We have learned the hard way, individually and institutionally, that the mental health treatment we deliver is not about us. Healthy boundaries require us to avoid talking about ourselves with patients. Even if I happen to share the same illness or life trauma, I cannot fall into the trap of equating my experience of, say, anxiety or abuse, with my patient’s experience of anxiety or abuse. We use every bit of our own experience to empathize, but explicitly putting our own experience into the mix of the treatment relationship only serves to confuse both clinician and patient.
On the other hand, I am proposing that all of us become especially vigilant against any subtle implication that our patients are somehow different, separate, or inferior. They are not, and they are certainly not inferior to us. They are fellow human beings who are equally subject to illness, both mental and physical, as us. Personally, I as a clinician seek out every opportunity to dispel the twisted notion that I and other “successful” people do not have the same struggles, problems, and vulnerability to illness as patients.
For instance, consider this bit of dialogue:
Patient: I just wish I was normal and that I did not have to take this medicine.
Psychiatrist: Is that right? Normal people don’t get sick? Normal people don’t take medicines? That’s a pretty high standard you’ve got there. I’m not sure if the rest of us can live up to it.
Patient: I don’t know if you have ever felt overwhelmed by life, but no matter how hard I try, I just cannot keep up.
Psychiatrist (smiling sympathetically): No, I have never in my life felt overwhelmed or overstressed. I have no idea what that is like. Please do explain!
Let me hasten to add, I do not make these sorts of comments flippantly. In these cases, I am talking to patients I have known for years. We have had many discussions about the biological realities of mental illness, about the toxic nature of stigma, and about how common, indeed, universal it is to have some close experience to mental illness. There is a deep context to such comments. Furthermore, we always take pains to return to the shame, anxiety, and grief that the patient is revealing at the beginning of such discussions. But what we do not do in our treatment is accept pernicious and ignorant assumptions about mental health that play into stigma and inferiority.
Myth Outside of the Office
Outside the office, there are bigger changes that I would dearly love to see. What if the psychiatrist’s public face changed from that of a distant prescriber to one of a fellow warrior in the trenches? The trenches, after all, are where most of us find ourselves, both personally and professionally. We fight mental illness. We suffer with our patients, our families, and with our own illnesses. Maybe we can think about new ways of presenting ourselves this way as an organized group, in our national, state, and local associations.
On an individual level, I am not proposing a performative flood of social media revelations. I am proposing quite the opposite: Rather than taking public professions of mental illness as dramatic, we take them as unexceptional. Rather than putting ourselves out there as brave risk takers, we matter-of-factly admit that we too are human and suffer from mental illness. This is not shocking. It is not dramatic. It is as “normal” as having any illness can be.
Like it or not, more of us will have to publicly discuss our mental illness to change the common perception of psychiatrists and to give us a different kind of public platform from which to end stigma. A good bit of experience with advocacy tells me that most individuals have some respect for us as physicians and even psychiatrists. But exclusively presenting ourselves as experts does not have nearly the same impact as referencing our own personal experience with mental illness. Rightly or wrongly, there is no authority today like the authority of lived experience and most of us have that authority, either as a family member or as a person with mental illness. It is time to make use of it. Only when we stand up as individuals who personally deal with mental illness will the public pay attention to us as experts who offer the decisive knowledge they need to deal with it themselves.
The Myth in the General Public
It is critical for mental health professionals to own their personal stake in mental illness as a group. But it is even more important that we use this position to help the general public do the same. Why? Because no matter how altruistic I am, if mental illness is really someone else’s problem and not my problem, then I will never have the same sense of urgency and motivation to do something about it. If mental illness is someone else’s problem, I will turn away from the suffering and eccentricity of those disabled by severe mental illness. I will want to live near someone with severe mental illness, and I will not want to sacrifice to help pay for the care of those with mental illness. The needs of “those people” will never be as pressing as the needs of “us people.”
A vast majority of the general public, according to the polls, thinks that mental illness is real medical illness.7 Everyone supports treatment for mental illness. Everyone says it is important. And yet we have people with mental illness literally lying in the streets because our society does not fund their treatment. We have individuals whose lives would profoundly benefit from inpatient and residential treatment who cannot get it. We have people with serious and even disabling levels of mental illness who cannot access the most effective medications or intensive forms of psychotherapy because of insurance limitations. We have people dying from under-treatment through suicide and the long-term ravages of these illnesses. In such a wealthy nation, how can this be tolerated?
If each of us truly realized and truly believed that mental illness was our own personal problem, we would not stand for this as a nation and a culture. We do not put up with severe cancer sufferers being reduced to poverty and homelessness because of inadequate treatment. If we regarded mental illness in the same way, we would not underfund our mental hospitals to the point of reducing them to near slums. We would not accept the unconscionable manipulations of insurance companies to avoid paying for adequate treatment or the well-meant but inept gestures of our governments in answer to the mental health crisis.
I suffer from mental illness. I have family members and close friends who suffer from mental illness. This does not make me special, and—given that I am a psychiatrist—the fact that I can publicly say so does not make me especially brave. I do not blame many of my colleagues for keeping such information about their own mental health private. Everyone has a right to keep their medical information private.
However, But in the interests of truly ending stigma and undertreatment, more of us are going to have to speak up. Even if we do not publicly identify ourselves as having mental illness, all of us need to shed the last vestiges of stigma from our own minds. And this includes never, ever regarding people with mental illness as “those people” again.
Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is the author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association.
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