Stigma and Prejudice in Psychiatry
Carl S. Burak, M.D., J.D.
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After my 1968 graduation from medical school, I spent thirteen years practicing primary care medicine. I worked on the Navaho and Hopi Indian reservations, was an emergency physician in Pennsylvania and California, and had a private family practice in Bennington, Vermont. Despite completing my residency in psychiatry in 1978, I did not limit my clinical practice to psychiatry until almost four years later. With my "medical" background I am often frustrated by the stigma and misunderstanding which surrounds my specialty. Psychiatry treats problems which are primarily medical, not primarily psychological. Sure, psychological stress and experience at times exacerbates affective and thought disorders, but stress also exacerbates ulcers, arthritis, asthma, and most other "medical" problems. In an effort to clear the air I have written a new book, When I Became A Psychiatrist People Stopped Waving On The Street. I hope you find the excerpts which follow interesting. PrefaceMany of you who are reading this will intuitively understand Lisa Brady. Attractive, happily married, devoted mother, successful attorney- it would seem unlikely that she would see a psychiatrist; yet her story and her feelings are really not unusual. I am appreciative that she has allowed me to share our conversations. I am equally indebted to Ben Brady. First embarrassed, his willingness to disclose his part of the story provides a poignant opportunity to underscore the misunderstanding and stigma which tenaciously clings to psychiatry and mental health. Chapter Two- Tears For No Reason... We were both silent for a few seconds and I continued. "It was about the time I finished my training that our Eli was born. As a father I found myself thinking more about family and East Coast roots. Then out of the blue a physician friend in Vermont called to tell me about an opportunity in family practice. "Didn't he know you had gone into Psychiatry?" "I think he did, and that's what is strange. I remember laughing, saying `What a crazy idea—move from San Francisco to Vermont and go back to family medicine?'. A year later we were in Bennington, Vermont. "You closed your psychiatry practice in San Francisco and returned to family practice in Vermont?" "Strange, but true. In the Spring of 1980 we moved. It seemed like an ideal situation for me and ideal for Ronnie as well because she would become the on-site psychologist." "But you would actually be a family doctor?" "Yes. But so much of family medicine is psychiatry anyway that I thought my training would serve me well." "So how is it that you returned to psychiatry?" "Well, what happened was probably predictable. When I arrived in town, Bennington had only two psychiatrists. There was really a need for more, and my medical colleagues began to make requests for my psychiatric services. `Would you see this patient in the hospital?' `Couldn't you see this young woman, she really needs help.' Eventually I found myself practicing psychiatry in the morning and family medicine in the afternoon. Inevitably medical emergencies would occur in the morning while I was counseling and psychiatric emergencies would occur in the afternoon while I was seeing general medical patients. Talk about stress..." "So what happened?" "It dawned on me that I had been enjoying psychiatry. I had given up some of the formality that was the legacy of my training." I smiled. "If I hadn't I probably wouldn't be telling you this story." Lisa was nodding. "I'm glad you are." "Anyway, I had begun to work more from the heart and it felt better. Also, Ronnie and I really enjoyed working together and especially counseling other couples. So, after a lot of soul searching and with much discussion we decided to open our own office; Ronnie would continue doing what she was doing and I would return to full-time psychiatry. Life would be simpler. I could focus." "What about your family practice patients?" "In early September 1981 I sent a letter to all of my family practice patients and as much as possible I spoke to everyone. I tried to help everyone find a new doctor." "How did they feel?" "Most understood, but it wasn't easy." Lisa nodded. "But what I didn't realize was that in making this switch I had inadvertently created a social experiment in community attitude." "How?" "Because I already had completed my training in psychiatry, I was literally able to change my specialty over a weekend. On Friday, October 23, 1981, I was a family doctor in a small town. On Monday, October 26, 1981, I was a psychiatrist in the same small town and what happened hovered somewhere between sad and humorous." "What happened?" "In the weeks before the changeover, when I would walk down Main Street as a family doctor, I was constantly greeted with, `Hi, Doc, how ya' doing?' Sometimes people would even wave or shout a greeting from across the street; there was a very friendly feeling. But, as soon as I officially became a 'psychiatrist', the difference was dramatic; I would walk down Main Street and no one waved. I mean no one waved. If I was greeted verbally, it was only when someone passed at a close distance and said hello with a quiet voice. I used to smile thinking the whole town had learned ventriloquism. Even lips seemed not to move. No one ever shouted `Hey Doc' any more." Lisa looked directly into my eyes, shaking her head almost imperceptibly. "Very interesting." She grew quiet and contemplative. We sat in silence for a few moments. Finally I asked softly, "So, how can I help?" Chapter Six- Emotional BandwidthAfter our moment of levity I asked, "Lisa, why do you think most people come to see me?" "Because they're depressed?" "Absolutely right. With the more moderate depression like yours you can still smile. When the depression is more intense that's pretty difficult." "If my depression had been more intense, I think I would have been here sooner." "I agree. So what is it that you inherited that ultimately led you to see me?" "I'm not sure what you're driving at." "I believe that the major factor that ultimately defines who comes to see me is their inherited ability to become depressed." "So if I had inherited the ability to have an ulcer, I might be seeing the gastroenterologist?" "Exactly." "Okay." "So—with mood and emotion, although the ability to be depressed is key, there's a more comprehensive perspective." "Which is?" "With the possible exception of someone who may be in the midst of a manic or near manic episode, no one comes to me and says, 'Doc, I'm feeling wonderful and I just don't think I can go on'." Lisa smiled. "The inherited characteristic which ultimately defines which individuals are more likely to seek the help of a psychiatrist is not just one sided, not just about the downside that we call depression; it has to do with emotional Bandwidth or range. Feeling great—not manic—just fine, wonderful, productive, happy, creative, energetic, gregarious, all of those things— is what I affectionately call `affectively enriched'. That's the upside of your emotional Bandwidth." "I'm not sure I understand." "Well, you came to see me because in some way you were feeling a little down." "That's right." "And with varying intensity that's probably the main complaint with almost everyone I see." "Okay." From time to time you experience a moderate problem with mood that has been an intermittent part of the background noise of your life." "I think that's right." "Yet you weren't comfortable enough to see someone had it not been for our chance meeting on the beach." "Actually it wasn't chance; I was exercising and saw you leave to go out for your run that morning— and I had been thinking about talking to you. But your point is well taken... Anyway, what is Bandwidth?" "I would call it your inherited emotional range. My guess is you probably have a wider emotional range, or Bandwidth, than someone who we'll describe as even tempered, someone whose mood range always stays in that middle or equilibrium area.—But I could be wrong because you and I haven't even talked about your up moods if you have them." "Now I see what you're driving at and I do have enriched times." "Well that's not unusual as I have found through these past years, but for the moment let's continue to focus on the way you've been feeling recently— this downside of the emotional range." "Okay." "You are not suffering from a paralyzing depression. I doubt you ever have, although you may tell me I'm wrong about that." "No, I think that's accurate." "So right now you're running on half a tank." "Uh hmm." "You're dissonant, but not devastated; still able to smile and laugh." "Dissonant really fits." I continued, "You managed to take care of business, but without your usual enthusiasm. You have less passion and little of the joie de vivre than you have at other times, but you're certainly not suicidal." Lisa nodded. "You're able to get out of bed and do the things you have to do, and you're not entirely without hope- but you're blah." "So you're suggesting that I have a more moderate depression." "Yes." "Do most people like me usually seek help?" "I don't think so. I believe that a very large number of people who have the more moderate type of moodiness have no thought of seeking help, either because their dissonance is camouflaged by the background noise of day to day comings and goings, and it is accepted as the way it is— or if they do wonder about their moods they don't come in because they are uncomfortable with the notion of seeking professional help. Or, some people might feel that they would somehow be different or lose the essence of themselves if they got treatment. They feel as though there is some hard to define personal value embedded in the angst. It's sort of what you suggested before." "All of that fits me. I think my moods were sort of camouflage for a while and obviously I did feel uncomfortable with the notion of professional help. But I also was... No, I am still a little afraid of losing myself." "By the time you leave I hope you understand that I don't believe that happens. But you must feel truly comfortable about whatever you decide to do, and no matter what that decision is, I will respect it." "I appreciate that." "Good." I paused for a moment, but there was no further comment from Lisa. "Getting back to what I said before, the greatest misunderstanding I've had through the early years of my practice was my lack of appreciation of this notion of emotional Bandwidth. I would focus only on the down side, everybody's complaint, and generally ignore the up side unless it was extreme. Psychiatry has taken relatively little notice of modest affective enrichment until it reaches a level that is troublesome, and then the descriptive terms tend to have a pejorative cast like hypomanic or manic or high." "That's interesting." "You're aunt, the one who was manic depressive, undoubtedly has a more extreme Bandwidth." "I guess that's right." "And your grandfather, the toy maker— sounds as if he sort of lived enriched most of the time." "Hmm. Maybe. Interesting." "Having said that, it's important to also understand that emotional inheritance is not passed from one family member to another in exact form. There may be obvious similarities between parent and child, or between various family members, but no two people are exactly alike." "You've got that right." I smiled. "So, for the sake of discussion I believe that about fifty percent of the world's population is even-tempered. That's not a precise figure, just an estimate, but I think it's in the `ball park'." "Okay." "So the other fifty percent or so have inherited an emotional Bandwidth that extends beyond the area of equilibrium." "Does everybody with the wider Bandwidth have both the up side and down side?" "Good question. I don't think so. Some people unfortunately are lopsided down. A few lucky people are lopsided enriched; as I said, maybe that was your grandfather." "I sort of remember him that way, but I was really so young..." "Well, whether or not that was him, it's my impression that most people who have inherited the broader Bandwidth do experience both sides, the depression and the enrichment.—Think of it this way, I think I mentioned this before— When you're in the middle even-tempered zone it's as if you're swimming comfortably in the ocean. When you've been a bit down like you have been recently you're not swimming, you more of less treading water. Someone who is more intensely depressed than you may in fact be drowning. And when you are affectively enriched, it's more like you are surfing or dancing on the waves." "I like those images." "Okay. So imagine what it might be like if most of your time was spent dancing on the waves— happy, raring to go, filled with energy, thoughts clear, wanting to be with people, attracting people, and going through problems like a hot knife through butter." "It would be terrific." "And you've been there at times?" "Not in the extreme, but I've definitely been there." "Good point. You've probably never experienced the intensity that occurs with your aunt; but you've certainly experienced that joie de vivre which has been lacking lately." "Right." She became very thoughtful and still then after a few moments emerged from her trance and glanced at her watch. "I'm sorry, I didn't realize that it was so late." "I thought Ben was at home with David and you were okay with time." "He is and I'm fine, but I don't want to impose on you." "I appreciate that, but there's no problem. It's important to me that you know where I'm coming from when you think about your options." "One of which is taking medications?" "Yes." "There's no requirement that you take medication. I'm certain that you would continue to carry on if you don't take an antidepressant." "But what do you really think I should do?" "It's possible that medication might lead to an improvement in the quality of your life; to greater the consistency of those times when you're feeling well rather than just okay or blah." "Hmm." "It's your call, and there's no pressure to decide right now." "Okay." "But you're hesitant." "Right." "So tell me your concerns." "Two things— The first is that fear you mentioned that something will control me or change me in some way." "Okay." "And I'm almost embarrassed to tell you this, but I'm a little afraid that if I take medication Ben will regard me as weak or he'll somehow look at me differently." She paused, "I know that probably doesn't make sense because he's encouraged me to see you- maybe it's just my own fear that I'm dealing with." "Well, maybe Ben will feel as though this is somehow a reflection of weakness- but I doubt it." I hesitated, "If you would like, even before you decide what to do I would be happy to have Ben come in with you so we can all talk." "I'd like to think about that." "That's fine, let me know." "I will." "Now about your first concern, whether you'd be changed or controlled in some way?" "Yes." "Once someone takes a medication which they believe is helpful I always ask two questions." "Which are?" "First, `Do you feel normal?' As far as I'm concerned your response to that question needs to be yes. You should feel comfortable, not altered or drugged in any way. If you feel drugged or altered or have any significant side effects with any medication I prescribe, I would want you to try something else." "I have a friend who takes an antidepressant, I forgot what it is, and she tells me that it helps because she is less upset about things— but she feels emotionally numb. I don't want to feel that way." "That's exactly what I mean. Feeling numb is not normal. I'd probably want to find some other medication that fits her individual chemistry better." "So how do you know when you have chosen the best medication?" "A million dollar question. You don't know. It's not what the book says should happen, it's what you say does happen that counts. It comes down to your gut feeling, observation, and clear communication between the two of us." "So if I say I'm feeling better, what will that tell you?" "If you say you're feeling better that's good, but it may still not be clear whether the medicine you're taking is a bull's-eye or an 80 percent solution. The difference that occurs when you're taking medication is not that you have an unusual or foreign emotional experience, it's that you run closer to your optimum and there is more emotional consistency." "So how do you figure out when to keep a medication or try something else?" "We talk. Sometimes it's not clear whether we have the best fit possible between the medication and your system, but the more we talk the more we're likely to get things right." "So I could feel somewhat better and relatively normal and still not have the best possible results?" "Unfortunately that's true." "Hmm." She was quiet for a moment and then said, "You mentioned the second question." "Yes. If you think a medication is working very well, I always ask whether there have been moments in your life when you've felt good like this, without any medication. Perhaps these moments lasted only a few hours or a few days, perhaps it was a long time ago, but no matter when it was or how brief it was you felt good, exactly like you have been feeling since you've begun the medication." "And most people say they have felt that way before?" "Yes. I'd say more than ninety-five percent of the
time when we're on the right track almost everyone says they
feel just the same way they have at those times in the past
when they've been at their best. That's the key point.
The difference with taking medication is not one of
unusual emotional experience, it's one of improved emotional
consistency. Without some nutritional blending which
allows our mood machinery to maintain it's efficiency, some of
us "Not a false high." "Right. Like I said, it doesn't make you high, at least not in the way I think you mean. I believe you're thinking of that situation in which the way a substance makes you feel distorts the perceptions you have normally in your day to day life. I think that's getting high. In other words it's like drinking seven margaritas, or smoking marijuana; it's not a consciousness you can routinely achieve with the natural mood states we're talking about. When you get high I believe there is distortion occurring. My experience has been that medications or nutraceuticals do not create distortions when they are appropriate for your system. If you somehow feel unnatural when you're taking a particular medication or supplement, I would advise you to stop. That may be arbitrary, but I think it's reasonable." "Sounds reasonable to me." "Think of running. No matter how hard you might train, no matter how refined your exercise, nutrition and attitude, each of us can only run as fast as the machine we were born with will allow. At our best some of us run faster, some slower. Our running talent is passed on to us by parents who don't have any particular control over the process themselves. I think that our mood talent is passed on to us in the same way; therefore, things that help us reach our own mood potential— things such as therapy, exercise, nutritional supplements, a change in diet, acupuncture, meditation, medication— all have the potential to impact our chemistry and move us towards optimal mood performance. And just like running talent, I believe the optimal which is achieved by efforts to be at our best, is largely defined by that inherited mood talent." Jacksonville Medicine / March / April, 2002What's New
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