By Cmdr. Russell Carr, MC, chief, Psychiatry Department, Walter Reed National Military Medical Center
Senior officers sometimes come to our mental health clinic on back elevators and wait in hallways for their appointments. There are medical staff who refuse to be seen officially in the clinic. Some people who are being seen in our clinic refer to themselves as “crazy” and separate from normal people. There is still stigma.
Service members say it will ruin their military career if they acknowledge they need help and get an appointment. Doctors say they will not be allowed to practice medicine any more if they get help. People fear it will always be used against them if they acknowledge weakness. This is rarely true, and not nearly as often as most people think it is. Only for those who suffer catastrophic mental illness is this true, and they are usually so ill that they rarely even understand how much their illness has changed their lives. For the overwhelming majority, there is no consequence for seeking help, except feeling and functioning better. But fear and stigma remain. I feel it speaks more to the meaning of mental illness for people than the actual repercussions.
Most people fear being labeled “crazy.” To many people, those with mental illness are dehumanized. They are “other;” no longer part of humanity. The stigma they experience about mental illness speaks to the fear of being labeled as other. In the military, other often means weak, putting self before mission or unit, or unable to cut it. One’s identity becomes that of someone who does not belong, who is a burden. These self-images are all incompatible with the sense of camaraderie, self-sacrifice, and putting team and mission above self that are part of military service. A broken self-image can leave a service member feeling alienated, alone. Fundamentally, it comes down to connection to others, and the fear of losing connections by acknowledging problems often keeps many service members from getting the help they need.
But I think that stigma is also a manifestation of a much deeper, personal fear. Outside of military settings, there are psychoanalysts who talk about the hope and dread of seeking treatment. In fact, there is a book by a very well known contemporary psychoanalyst, Stephen Mitchell, by the title Hope and Dread in Psychoanalysis. Basically, people hope for improvement when they seek treatment, but they also fear repetition of their past. They fear that the provider will reinforce a self-image of being broken. They fear they will not find empathy and acceptance, but a relationship in which once again they are a failure, or not good enough. Their fears will then seem true and unchangeable. They also fear that the person they seek help from will not understand them. They fear they will be alone, lost in their failings forever.
A very wise mentor of mine, Dr. George Atwood, once told me that there is nothing more powerful than being understood by another human being. We all seek that. We also all dread not being understood. Many suffering from depression, PTSD, and anxiety disorders have a shattered sense of themselves. They do not feel understood. Others tell them, or maybe they have told themselves, that their reactions to situations are not acceptable, maybe not even human. They feel that they cannot share their perspectives with others and are left feeling overwhelmed and alone. Feeling understood and accepted by another person is the antidote to isolation and stigma.
Patients often do not know it, but they are seeking understanding from us as mental health providers, or other care providers they seek. They arrive via back elevators or worry about their medical licenses out of fear of not being understood, or dread that prior rejections will be repeated. But there is also hope in seeking treatment. Often, once people feel understood, they loose this stigma and fear.
I have had patients change from hiding to sitting in our waiting room. They might say they see it as part of leadership. But they also say with their actions, “I have been understood. I have found someone who is willing to wade into and dwell in the horrors I have experienced. This person does not look away from me. So I will sit in public and wait to speak with this person again.” This is often all they want and need to right their lives. They need help overcoming the danger they see in shame, stigma, or weakness so they can accept themselves. Living in one’s skin is the one way we can thrive as human beings. If we can give that to each other by not looking away from suffering, then maybe much of my business will disappear.