Opinion: Physicians, mental illness, and the problem with ‘passing’

My patient sits with her back hunched, eyes fixed on the taupe industrial carpet as though she is fervently avoiding Medusa’s gaze. She tells me about the depression that has dogged her life, subverted her career, infiltrated her relationships. She tells me about the medications she’s tried and “failed,” as if patients fail medicines and not the other way around. She tells me about lovers and friends who have become burnt out and fallen by the wayside. In short, she tells me about loss, and shame, and the desperation that accompanies a life lived on the edge in an experiential war zone.

And as she speaks, she does not know that all of this is terribly, uncannily familiar to me.

I have spent the last two decades living a double life. Outwardly, I am a psychiatrist — I have worked in hospitals, clinics, and in private practice. Internally, I have often struggled with hopelessness and depression. During my residency, I spent many days wondering who was more depressed, my patient or myself. On rounds and at staff meetings, I spoke about patients with mental illness in a professional manner, as though the experiences of despair, isolation, shame, and regret did not reverberate within me.

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Most of my 20-year battle with depression, which was littered with lost jobs and relationships and peppered with unsavory experiences like hospitalizations and electroconvulsive therapy (ECT), is in the past. I no longer go to the grocery store to buy one banana and one container of yogurt because the future seems uncertain. Yet each time I talk with a patient about ECT or ketamine or any of the numerous medications I’ve tried personally, each time I sit with someone who is profoundly depressed, my lived experience feels very near.

Erving Goffman, a sociologist who studied patterns of hierarchy and relatedness between groups of people, would have described my experience as “passing.” In “Stigma,” his seminal 1963 book, Goffman identified the ways in which those with “undesirable attributes” experience interactions with individuals lacking those attributes. Goffman’s subjects varied widely, from those with physical differences, character defects (people who had been incarcerated, people with mental illness, and the like), and those of a different race or religion from the cultural norm. The genius of Goffman was that his work was completely impassive: It comprised an indictment of the effects of discrimination without ever using the language of social justice. As Goffman wrote: “By definition, of course, we believe the person with a stigma is not quite human.”

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Goffman made an important distinction between those whose difference was visible or discernible and those for whom it was hidden; the “discredited” vs. the “discreditable.” To some extent, the issues faced by these groups diverge. The person with an unseen stigmatizing attribute is constantly afraid of being exposed. The individual acquires, as I have, a double life: There are those who know about the person’s undesirable condition, and those who do not.

It becomes essential to the afflicted individual to keep these groups separate, and to protect her or his secret in general society. Goffman defined such a precarious, fraught existence as “passing.” As he noted, the effort to constantly pass induces a measure of strain.

Mental health professionals often tell people that there is no shame in being mentally ill. The illness is a disease, or the product of traumatic experiences, or both, depending on your particular camp — in any case, it isn’t the patient’s fault. And yet clinicians fervently guard their own histories of mental illness. A physician patient of mine drives to a different town to fill prescriptions so he is not recognized as a doctor by the pharmacist. Another asks me to provide her with drug samples so her insurance company won’t be informed of her psychiatric medications.

Like me, my patients are passing.

If doctors cower at the prospect of revealing a diagnosis of a mental illness, how can we expect patients to hold up their heads?

During the pandemic, I decided to begin attending a peer supervision group with other psychiatrists in my region. The group meets monthly to discuss both clinical and administrative issues in private practice. One person Zooming, I’ll call him Dr. A., had been working at a private psychiatric hospital where I was hospitalized 15 years ago. I had trained with him in residency years before; in fact, since I was a year ahead, I had supervised him on the inpatient unit.

If doctors cower at the prospect of revealing a diagnosis of a mental illness, how can we expect patients to hold up their heads?

I had consulted a second doctor on the call, Dr. B., when I was looking for a new therapist several years ago. Though we had decided not to work together, he knew a fair amount about my psychiatric history.

As I faced Drs. A. and B. on screen, I felt my heart race and perspiration accumulate on my neck. I was self-conscious about speaking and my appearance. The two of them gazed at me, over the safety of the internet, with huge smiles pasted on their faces. My daughter, who knows about Paul Ekman’s work on micro-expressions from the family-friendly television series “Brain Games,” would have called these fake smiles.

In the course of the meeting, we spoke about our practices, who specialized in what, who was accepting patients and who was not. In other words, clinical discussion. Neither Dr. A. nor Dr. B asked me how I was or acknowledged in any way the fact that they knew “my secret.”

Of course, it would have been inappropriate for one of them to say, “So, Susan, how’s the depression?” or “Have you been hospitalized lately?” Yet I also felt prohibited from acknowledging my prior encounters with them.

After the meeting ended, I felt first relief, and then shame, and then anger. I felt ashamed to be reminded of my past history, and I felt angry that I had to feel ashamed, that I was not allowed to be seen fully, as a psychiatrist who has also been a patient. I had the sense that if I had acknowledged my history, those fake smiles would have gotten even wider and more feigned. Because physicians are not supposed to cross that line: We are not supposed to become patients.

My first course in med school, like that of so many students, was human anatomy. When the course ended, I published an essay about the implications of anatomy as the first introduction to medical training. In it, I argued that through the dissection of the cadaver, through the objectification of a human body, medical students are inducted into the society of doctors and that the lesson of anatomy is essentially one of hubris.

I added, though, that a second lesson is, in fact, the opposite: humility. Holding the cadaver’s hand, I mused that it must have held a trowel, a child’s hand, or a pen thousands of times. The body we were dissecting had belonged to an elderly woman. It was studded with cancer and yet there were still the remnants of pink nail polish on her fingernails. Although she was dying, she still cared to paint her nails. It is impossible not to be humbled by the complexity of the human body and the strength and perseverance of the human spirit.

I want to differentiate compassion from humility. There has been much discussion of a lack of compassion in medicine, all of it entirely warranted. But compassion entails recognizing another’s distress and wishing to alleviate it. Humility is the recognition that there but for the grace of God or neurotransmitters go you. Compassion engenders solicitousness; humility also engenders respect.

It seems to me that, somewhere in medical training, during the grueling hours of internship and residency, or later during years of practice, many doctors lose sight of the principle of humility. We speak in code and refer to patients by their illness identity, like “Mrs. X. Is a 56-year-old diabetic with peripheral neuropathy,” instead of by their actual identities as a teacher, musician, or homemaker. In fact, the ability to be succinct and use as many doctorly words as possible, instead of normal words, is drilled into young doctors on rounds.

We lose sight of, or deny, our own frailty and susceptibility to illness. Our patients see us as intact and invulnerable, and this illusion becomes part of our own consciousness. As I wrote in my anatomy essay, physicians draw a metaphorical line in the sand and expect death — or illness, or infirmity — to respect it.

Physicians are notoriously bad at seeking care for physical and mental health problems. In a 2016 study of more than 2,000 female doctors, nearly half said they thought they had experienced a mental illness and had not sought help for it. The usual reasons physicians cite for not seeking care involve fears about licensure, concerns about professional advancement, and stigma among their peers. To belabor a point, these physicians are passing.

I believe the fault is not with licensing boards or hospital administrators, but with the culture of medicine. I suspect the people attracted to medicine as a career are exactly those who have the greatest fear of death, weakness, or vulnerability. How better to ward these off than by stuffing yourself to overflowing with knowledge about the body, and defining yourself as a caregiver?

Goffman’s book predated the Civil Rights Act, the women’s movement, the Americans with Disabilities Act, and the removal of homosexuality as mental disorder in the Diagnostic and Statistical Manual of Mental Disorders. We have come into awareness of some stigmas more than others, which is not to say that we have eliminated any of them. It seems to me that stigmas die hard, and perhaps among the most abiding is the stigma against those with mental illness.

I hope that in my lifetime, it will become no longer necessary to pass in order to be a member of a professional group, as I did in the peer supervision group. I hope that physicians who have suffered mental illness will be able to seek help and share their insights without fear of judgment or ostracism. I hope that physicians can embrace our frailty and humility as well as our knowledge and power.

I believe it is necessary that we do this, not only because we owe it to ourselves and our peers, but because we owe it to our patients not to view them as of a different class than ourselves. Until then, we are essentially treating those with mental illness as “others” — in Goffman’s vocabulary, as “not quite human” — and give them fake smiles instead of real ones.

Susan T. Mahler is a psychiatrist in private practice and mother of two tweens.

Source: STAT