Doctors, mental illness and the problem with “passing”
M.The patient sits with her back bent, her gaze fixed on the taupe-colored industrial carpet as if fervently avoiding Medusa’s gaze. She tells me about the depression that has haunted her life, undermined her career, and infiltrated her relationships. She tells me about the drugs that she tried that “failed” as if patients were failing and not the other way around. She tells me about lovers and friends who burned out and fell by the wayside. In short, she tells me about the loss, shame and despair that accompanies life on the edge in an experience-rich war zone.
And while she is speaking, she does not know that all of this is terribly, incredibly familiar to me.
I’ve spent the past two decades leading a double life. Outwardly, I’m a psychiatrist – I’ve worked in hospitals, clinics, and private practices. Internally, I often struggle with hopelessness and depression. During my assistantship I spent many days wondering who was more depressed, my patient or me. On ward rounds and at staff meetings, I spoke professionally about patients with mental illness, as if the experiences of despair, isolation, shame, and regret were not reverberating within me.
Most of my 20 year struggle with depression, littered with lost jobs and relationships and riddled with unsavory experiences such as hospitalization and electroconvulsive therapy (ECT), is in the past. I no longer go to the supermarket to buy a banana and a can of yogurt because the future seems uncertain. Yet every time I talk to a patient about ECT or ketamine or one of the numerous drugs I have personally tried, every time I sit with someone who is deeply depressed, my lived experience feels very close.
Erving Goffman, a sociologist who studied hierarchical and relational patterns between groups of people, would have called my experience “temporary”. in the “Stigma,” In his seminal 1963 book, Goffman identified the ways in which people with “undesirable traits” experience interactions with those who lack these traits. Goffman’s subjects varied widely, from those with physical differences, character defects (people who were incarcerated, people with mental illness, and the like) and those of a race or religion other than the cultural norm. Goffman’s genius was that his work was utterly indifferent: it involved indicting the effects of discrimination without ever using the language of social justice. As Goffman wrote, “By definition, of course, we believe that the person with a stigma is not entirely human.”
Goffman made an important distinction between those whose difference was visible or discernible and those to whom it was hidden; the “discredited” vs. the “discredited”. To some extent the problems of these groups diverge. The person with an invisible stigmatizing attribute is constantly afraid of being exposed. The individual, like me, acquires a double life: there are those who know about the person’s undesirable state and those who do not.
It becomes essential for the individual concerned to keep these groups separate and to protect their secret in society in general. Goffman defined such a precarious, tense existence as “temporary”. As he noted, the effort to persist creates an effort.
Psychiatrists often tell people that there is no shame in being mentally ill. The illness is an illness or the product of traumatic experiences or both, depending on the camp – in any case, the patient is not to blame. Yet clinicians eagerly guard their own history of mental illness. A doctor patient of mine goes to another city to fill out prescriptions so that the pharmacist does not recognize him as a doctor. Another asked me to provide her with drug samples so that her insurance company would not be informed of her psychiatric medication.
My patients go by like me.
When doctors shy away from diagnosing mental illness, how can we expect patients to hold their heads?
During the pandemic, I decided to join a peer supervision group with other psychiatrists in my area. The group meets monthly to discuss both clinical and administrative issues in private practice. Zooming a person, I call her Dr. A., worked in a private mental hospital that I was admitted to 15 years ago. Years ago I had trained with him as a specialist; In fact, I had been looking after him as an inpatient since I was a year ahead.
When doctors shy away from diagnosing mental illness, how can we expect patients to hold their heads?
When looking for a new therapist, a few years ago I had a second doctor, Dr. B., consulted. Although we decided not to work together, he knew quite a bit about my psychiatric history.
When I saw Drs. A. and B. on the screen, I felt my heart racing and sweat collecting on my neck. I was confident about how I spoke and how I looked. The two stared at me over the security of the internet with huge smiles on their faces. My daughter who knows about Paul Ekman work on micro-expressions from the family-friendly television series “Memory games,” would have called this fake smile.
During the meeting, we talked about our practices, who specializes in what, who accepts patients and who doesn’t. In other words, clinical discussion. Neither Dr. A. nor Dr. B. asked me how I was doing or admitted in some way that they knew “my secret”.
Of course, it would have been inappropriate for either of them to say, “So, Susan, what’s the depression like?” Or “Have you been in the hospital lately?” But I also felt forbidden to acknowledge my previous encounters with them.
After the meeting ended, I felt first relief, then shame, and then anger. I was ashamed to be reminded of my history and I was angry that I had to be ashamed that, as a psychiatrist who was also a patient, I was not allowed to be fully seen. I felt that if I had acknowledged my history, that fake smile would have grown even wider and more fake. Because doctors are not allowed to exceed this limit: We shouldn’t become patients.
My first medical school class, like so many other students, was human anatomy. When the course was over I’ve published an essay on the implications of anatomy as a first introduction to medical education. In it, I argued that by dissecting the corpse, by objectifying a human body, medical students are accepted into the society of doctors and that anatomy is essentially a lesson of hubris.
However, I added that a second lesson is actually the opposite: humility. I held the corpse’s hand and thought that it must have held a trowel, a child’s hand, or a pencil a thousand times. The body we dissected belonged to an elderly woman. She was covered with cancer, and yet there was still some residue of pink nail polish on her fingernails. Even though she was dying, she still loved painting her nails. It is impossible not to be humiliated by the complexity of the human body and the strength and endurance of the human mind.
I want to distinguish compassion from humility. There has been a lot of discussion about lack of compassion in medicine and all of this is perfectly justified. But compassion is recognizing another’s plight and wishing to alleviate it. Humility is the realization that they are all about the grace of God or neurotransmitters. Compassion creates care; Humility also creates respect.
It seems to me that many doctors lose sight of the principle of humility somewhere in their medical training, during the strenuous internship and assistantship or later during the years of practice. We speak encrypted and refer to patients based on their illness identity, such as “Mrs. X. is a 56 year old diabetic with peripheral neuropathy “instead of her actual identity as a teacher, musician or housewife. In fact, young doctors are practiced on rounds to be concise and to use as many doctoral words as possible instead of normal words.
We lose sight of or deny our own weakness and susceptibility to disease. Our patients see us as intact and invulnerable, and this illusion becomes part of our own consciousness. As I wrote in my anatomy paper, doctors draw a metaphorical line in the sand and expect death – or illness or ailment – to respect it.
Doctors are notoriously bad at treating themselves for physical and mental health problems. In one Study 2016 of more than 2,000 female doctors, almost half said they had a mental illness and had not sought help. The common reasons doctors cite for not seeking treatment are fears of admission, concerns about career advancement, and stigma among peers. To make one point, these doctors are over.
I think the fault is not with the regulatory authorities or hospital administrations, but with the culture of medicine. I suspect the people who are interested in the medical profession are precisely those who have the greatest fear of death, weakness, or vulnerability. What better way to fend off these than to stuff yourself to excess with knowledge about the body and define yourself as a caregiver?
Goffman’s book was from before the Civil Rights Act, the Women’s Movement, the Americans with Disabilities Act, and the Eliminating homosexuality as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders. We have become more aware of some stigmata than others, which is not to say that we have removed them. It seems to me that stigmas die hard, and perhaps the stigma of people with mental illness is most persistent.
I hope that in my lifetime it will no longer be necessary to pass to be a member of a professional group, as I did in the peer supervision group. I hope doctors with mental illness will be able to seek help and share their findings without fear of condemnation or ostracism. I hope that the doctors can accept our weakness and humility as well as our knowledge and our power.
I believe we need to do this, not just because we owe it to ourselves and our colleagues, but because we owe it to our patients not to see them as a different class from ourselves. Treating them until then we people with mental illness are essentially “others” – in Goffman’s vocabulary as “not entirely human” – and give them a fake smile instead of a real one.
Susan T. Mahler is a psychiatrist in her own practice and the mother of two children.