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Stigma and Mental Illness

Michelle Friedman MD

Michelle Friedman is a psychiatrist and psychoanalyst in private practice, the chair of Pastoral Counseling at Yeshivat Chovevei Torah Rabinnical School (YCT) and Associate Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai Hospital in New York City. A graduate of Barnard College, NYU School of Medicine and The Columbia University Center for Psychoanalytic Study and Research, Dr. Friedman has been involved in bridging religious life and mental health issues for over 30 years. Her recent book, The Art of Jewish Pastoral Counseling: A Guide for All Faiths co-authored with Dr. Rachel Yehuda and published by Routledge, comes out of her teaching experience and her ongoing contact with graduates of YCT and other rabbinical seminaries.

Mindy, age 28, had her first bout of major depression in her late teens. She was hospitalized once for her illness and now attends weekly psychotherapy. Mindy also takes Lithium and Prozac. She is attractive, charming, and enjoys her work as a high school science teacher. Mindy very much wants to get married but when matchmakers mention her psychiatric history, the only dates that come up are men with disabilities. It is as though her depression has marked her as undesirable, stigmatized as belonging to a different category of people.

Chaim, age 45, carries a diagnosis of schizophrenia. He lives with his widowed mother, takes medication and works as a cook’s assistant in a nursing home. Chaim goes to minyan most days. While he is somewhat disheveled and occasionally mumbles to himself, he participates in praying and has a rich spiritual life. Chaim tells his therapist that he would like to be invited to join the guys for an occasional coffee or shiur, but is rarely asked. Chaim feels marginalized, hurt and ashamed.

Any reckoning of mental illness and stigma requires discussion of shame. Shame is the painful internal feeling that arises from the awareness of doing something, or having something done to oneself, that has brought dishonor or disgrace. Shame exists in the context of group culture. It implies a failure to live up to internalized goals that come from parental and societal standards, the ideal of what a person “should be like.” A shamed person experiences his/her failure as a lowering of personal dignity in the eyes of society. He/she fears ridicule, contempt or expulsion.

Stigma, in contrast, comes from the outside, from the surrounding society and culture. It is a mark of lessened value and reduced reputation. The stigma of psychiatric diagnosis outweighs that of virtually every other category of medical illness. Why? What fears does mental illness touch off in us that we shun, however inadvertently, fellow Jews with mental illness?

For many years, a psychiatric advocacy organization maintained a large sign painted on the side of a building near my office, “Depression is a flaw in chemistry, not character.” Whether my patients were dealing with depression, bipolar disorder, schizophrenia, obsessive-compulsive disorder, anorexia, addiction or a host of other struggles, I encouraged them to look at that sign on the way to the subway. I suggested this because they all felt, at one time or another, that their illness was a flaw in their character, that their souls were besmirched, that somehow their disorder was their fault. People do not generally feel this way about medical illness. Even when personal behavior has likely contributed to disease, such as when heavy smokers develop lung cancer or people with obesity become diabetic, those patients rarely feel as ashamed about or responsible for their conditions as people with psychiatric illness. Again, I ask, “Why is this so?”

I’ve thought about this question for years and want to share some of my thoughts. First, mental illness is invisible and pervasive. I remember back in medical school when I rotated on to psychiatry after surgery. My classmates and I felt exhausted, as though we had been hit by an enormous wave. We were puzzled. We didn’t have to get up at dawn to make it to the OR and the work was less physical. After a while, we understood. In surgery it was clear who was sick and who was well. The patients were the people in pajamas, in hospital beds. Their lab values were wildly abnormal, their x-rays and scans showed lesions, their physical exams revealed organs or limbs that were clearly diseased. The medical students and staff walked around in street clothes and did not have bulging hernias or tumors. But on psychiatry, the patients wore regular clothes and their bodies looked OK. Their lab values were mostly within normal limits. Their behavior, however, was radically abnormal– they seemed frozen in depressive wastelands or far away in psychotic realms. Those of us new to this world became desperately tired from trying to make conversation and stay focused in the intense inpatient world of mental illness.

Even scarier, our patients on psychiatry complained of feelings that many, if not all of us, had experienced at various points in our own lives, albeit to lesser degrees. This was my second epiphany. Who of us has not felt, at some time or another, depressed, anxious, or scared? What is the continuum between functional unhappiness and mental illness? How does it get so bad that a person winds up in the inpatient psychiatry ward at Bellevue? Most scary of all, could that person someday be one of us? The stigma of mental illness comes in part from the fear that feelings that we all experience will run wild and take over our lives. Can any of us know at what point sadness will become crippling depression, or when enjoying a drink or two in the evening can slip into alcoholism? When does watchfulness turn into paranoia or carefulness morph into the paralysis of obsessive compulsive disorder?

My third point regarding stigma is the prevalence of misguided, wrong beliefs. Many people fear that people with psychiatric diagnoses can suddenly flip into wild or dangerous states. In fact, only a tiny percentage of people with mental illness commit violent acts, and generally they exhibit warning signs in advance that should alert caregivers who can intervene. Another worry is that mental illness is hereditary and that people with such illness are destined to be flawed spouses or parents. Hence the fear of matches with people bearing psychiatric diagnoses. Here again, research does not support these myths. The fact is that 20% of the population will experience depression, for example, at some point or another across their lifetimes. When we factor in other categories of psychiatric disorders, the statistics become even higher. Some people will have a one-time occurrence of symptoms, while others will need to manage recurrent episodes. It’s also important to note that medication and therapy can help the vast majority of individuals with psychiatric disorders lead full and productive lives as spouses, parents, and productive members of society.

Stigma is one of the main reasons why people with psychiatric illness stop taking the medications that help manage their symptoms. Even though they know that abruptly quitting their medication may induce a relapse, people get caught up in the false belief that the absence of medication means they are not ill. This is especially dangerous when it comes to dating. Not disclosing any significant information about current conditions counts as a major infraction that could tank a shidduch, yet some people are advised to go off their psychiatric drugs prematurely so as to be able to “honestly” say that they are fine. This puts vulnerable people at risk. Dating is stressful enough and it is only exacerbated by not having the support of helpful medication or by the pressure of trying to conceal significant aspects of one’s life story.

Mindfulness of the shame and stigma that accompanies physical and mental illness also greatly influences diagnosis, treatment, and ongoing care. A health worker who is non- judgmental and respectful will not be afraid to ask important questions especially about behaviors and attitudes that may have serious consequences such as unusual thoughts, substance use, or sexual practice. Bringing up such topics in a neutral tone of voice acknowledges the vulnerability of the human condition and gives patients permission to talk about their real lives and feelings. The same is true for rabbis, educators and others who interact with people with psychiatric disorders. This is especially important in traditional Jewish life where social connection factors into religious and community domains. Social isolation and loneliness is a huge burden for people with mental illness. While they yearn for connection and affection like all human beings, many people with psychiatric conditions fear that others will shun them. They may self- isolate to protect themselves from even more pain. This in turn exacerbates their illness.

I want to close with a few words of Torah. The theme of tzara’at, often mistranslated as leprosy but more accurately translated as an illness of unknown origin, occurs many times in the Torah, especially in Vaykira, (Leviticus). Tzara’at is shameful and stigmatizing. Our sages wrestle with this dilemma and suggest that tzara’at represents punishment for lashon hara, slander. According to this view, tzara’at is the physical expression of spiritual impurity and metaphysical distress. Those with it are exiled to live outside the camp so as not to contaminate others. Our sacred texts also contain a profoundly redemptive story of tza’arat. The Haftorah of Metzora, Melachim Bet 7:3-20, describes four men with tzara’at who, due to their condition, were forced to live outside the city walls of Shomrom. In a time of desperate famine due to an Aramean siege, their outsider status coupled with Divine intervention positioned them to raid the abandoned enemy camp and secure food. Despite the pain of stigma and being ostracized, these men demonstrated generosity of spirit. They alerted the king as to the abundant supplies of the enemy camp and saved the people of Shomron.

Today, individuals with psychiatric illness are often isolated and ostracized like those with Tza’arat in Ancient Times.

May we have the merit to lessen the shame and stigma of people with psychiatric conditions and, instead, help them receive proper treatment, support their dignity, and welcome them as full members of our communities.