Stigma

Stigma

 
“Why did you become a psychiatrist?”. This question is asked by even the best of friends who feel vaguely uneasy in the presence of a “shrink”. (I tell them I don’t shrink, rather I expand people’s life options but they still are wary of my medical specialty.) All medical doctors who elect to specialize in psychiatry (instead of surgery, cardiology or other specialties) are warned by well‑intended professors that psychiatrists are the step‑children, the untouchables and the outsiders of medicine. But no one explains why.  When I reminisce back over 12 years of medical school and post‑graduate training and scan the national income statistics for medical specialists (psychiatry is right there at the bottom along with pediatrics), I wonder myself.

 

We all have pivotal life‑defining experiences and mine, vis a vis a career in mental health, came in July 1974. I was sitting in a dusty diner in eastern Oregon with a good friend, David. We had driven his jeep across the country to go surfing in California but had swung north to climb Mt. Rainier. Now, heading south to the beaches of Santa Barbara, we pulled into the non‑descript east Oregon diner and were sitting in a four person booth awaiting our meal. That is when I noticed a faded sign tacked on the wall that read: “One out of every four Americans is mentally disturbed. Check your friends. If they look OK, you’re it!”

Well, that was 1974. Twenty years ago. Today, life in America appears quite a bit more crazy. 60% of marriages now end in divorce. 80% of primary care patients meet the criteria for major depression. Escape modalities (passive entertainment) thrive and continue to be big business. We can zone out by choosing from the perennially popular alcohol, a bewildering variety of recreational drugs (pot, coke, and now heroin making a comeback among high schoolers), prescription drugs (valium, sedatives), TV (the average kid watches 10 hours a day!), an infinitely seductive computer world (games, E‑mail) and on the horizon, Virtual Reality – a computer driven fantasy world of 3‑D simulation and illusion.

 
Unfortunately, more and more kids don’t want to just be entertained. They want meaningful lives and not passive entertainment. So they suffer, act out (more than 10 millions American school kids are on Ritalin or similar behavior‑ controlling medicines) and increasingly, they quit. Suicide is the second largest cause of death in adolescent boys. In 1960, 3.6 kids per 100,000 killed themselves. In 1990, that number rose to 11.3 kids per 100,000. That is more than a 300‑fold increase. A national trend is described in New Hampshire where 26% (more than 1 out of 4) of high school students reported seriously considering suicide in the last 12  months. 21 % had a plan and 10% made an attempt. In the USA, a teenager kills him or herself every 6 hours with a gun. (It’s 10 PM. Do you know what your child is feeling?)

 
If suicide is second, what is the primary cause of death in adolescents? Murder. Between 1979 and 1991, 50,000 US children (under 21) were killed by guns. This number equals the number of casualties the US suffered during in the entire Vietnam war. Kids aren’t the only “crazy” ones. Adults participate also. In 1990, there were 10 deaths by guns in Australia, 13 in Sweden, 22 in England, 68 in Canada, 87 in Japan and 10,567 in America. (Yes. 10,567). Crazy or what?

In a future column, I’ll discuss effective tools for addressing these problems, but for now, I just wanted to make the (irritating and unpleasant but very important) point that if more people aren’t crazy, at least more are acting crazy. Approaching three out of four. That is quite a change from 1974. Today one could have quite a “diner dinner party”.

Society is diseased (ill at ease, uncertain) in so far as it stigmatizes the mentally ill. The consequences involve inadequate services made available and the tragic statistics noted above regarding suicide and violence. But, rather than judge, let’s try and understand why we all shun the mentally ill. Why the health care plans fail to prioritize services for this disenfranchised patient population. The reason the stigma exists is that, more so than in any other health field, a perceived dichotomy exists between “we” and “them”.

 
Furthermore, society reinforces the chasm because “we” are terrified of becoming like “them”. And for good reason. Imagine what “they” go through. Granted, it is tragic to have one’s leg be amputated or lose one’s vision. It is terrible to have to adjust to dependency upon insulin (diabetes), cortisol (failure of adrenal capacity), blood pressure medication or anti‑ cholesterol agents. But all of these allow for the sufferer to perceive the illness as a “parts failure” problem. I’m OK but my circulation failed. I’m just fine but my eyes or heart or pancreas failed. As such, these “parts failures” pale in severity compared to losing control of one’s mind. That is the nature of “their” suffering. For many of us, it is unimaginable.

 
This illness, mental illness (read “soul illness”) is so terrifying because it hits us where we live. That is to say it hits us and not just our body parts. The disease is of the individual not his leg, pancreas or blood pressure. We as a society fear that invasion of our very core and so we can’t tolerate relationships with those already under siege. We lock them up (the state hospital legacy). Out of sight out of mind.    But these “crazy” people suffer greatly and need our understanding and companionship. It is a tremendously rewarding profession.

 
How about you? Perhaps you need a psychiatrist. (Note your immediate feelings of indignancy and horror!) But, bear with me a bit. How would you know if you needed good psychiatric care or just “parts work”? Try asking yourself this simple question. When you get sick or hurt, do you say: “I am sick.” or do you phrase it: “I feel sick.” Do you say: “I am a cancer patient.” or “I have cancer.” The latter in each case indicates your core is under siege and that your’s is no longer simply a “body parts” problem.

As a psychiatrist, I wonder with people about their painful realities and try to accompany them on their frequently tempestuous life course. I face their Sphinixes with them and consult with them on their life riddles. Some are unfathomable like the 45 year old mother of four whose entire family was erased in the span of one minute by a drunken driver. Now, depressed and grief‑struck, she asked me for one good reason why she should not join them immediately. Or the ancient woman whose terminal cancer landed upon a frail body long since crippled and wheel‑chair bound because of rheumatoid arthritis. Her faith and trust in God rivaled Job’s but now, stuck with a stubbornly vital physical body, she asked me “Why won’t my God whom I love and who loves me relieve me from this suffering?”

 

These are the tough questions. Others are relatively easy. I recall “Eva”, the multiple personality disordered person who asked me whether I thought she (with just one body but 12 separate personalities) had a valid medical excuse for driving “alone” in the carpool lane. She had read about the pregnant woman who, with her viable fetus was challenging a moving violation ticket for driving “alone” in the carpool lane). I told her not to get her hopes up.

 

We stigmatize the mentally ill. The irony is ponderous: those who suffer greatest and are in the most need of compassion (from the Latin “com” = with and “passio”= suffer or, to actually suffer with another) are stigmatized because their illness is too terrifying. Instead of understanding them (standing under and supporting them), we avoid them, look the other way or most horrid of all, moralize down to them.

 

And yet we all suffer. And we all (at times) are “psychiatric” patients. The young woman with metastatic breast cancer, the veteran whose amputated leg stump gives his chronic intractable pain, the mother who miscarried, executives who drink to treat stress ‑ to the degree that these people suffer, they are psychiatric patients. That is because suffering is a soul or psychiatric symptom. All of us, at times, need some “help”.

         

At those times we need tools (medicines) or resources or short‑term counseling to help us through the dis‑ease part of our illness. (Frequently if one soothes the dis‑ease, the illness remedies itself). There is a burgeoning subspeciality field of psychiatrists covering specific issues related to various illnesses: AIDS, addiction disorders, multiple sclerosis, chronic pain etc. These psychiatrists treat the suffering people whose ill bodies need medical treatment.

 

1974 to 1994. « La plus ca change »   … Maybe it has ever been thus.

Over 100 years ago, Thoreau wrote: “The majority of men lead lives of quiet desperation.” 

 

By the way, remember my friend David, who sat with me in that Oregon diner years ago? Well, he became a psychiatrist too.  Crazy world, eh?

 

To your Health,

 

Bradford S. Weeks, M.D.  ©  1994

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