Understanding mental illness: Internalised stigma is real — and psychiatry must change its approach

Editor's note: What does it mean to be ‘mentally ill’? In this weekly column, Sneha Rajaram writes about navigating through a ‘mentally ill’ life — encompassing aspects that are both everyday (medications, rights) and contemplative (the universality of suffering)

I sometimes joke that I “arrived on the scene” too late to be diagnosed with schizophrenia and too early to be diagnosed with borderline personality disorder (BPD) – consequently, in the 2000s, I ended up with a bipolar tag. I don’t know if there is any kernel of truth in this silly sally about trending diagnoses. But over the years, as I’ve wondered whether or not I should’ve been diagnosed with BPD and whom to approach about it, I’ve realised that a BPD diagnosis is even more of a double-edged sword than most psychiatric diagnoses. It is a highly stigmatised condition, not just among lay people but also among psychiatrists/psychologists themselves. BPD patients – many of whom are dealing with the aftermath of severe emotional trauma – are seen as attention-seeking, manipulative, disingenuous. American psychiatrist Judson Brewer, for instance, writes how he was taught to approach BPD patients at the beginning of his career:

I was handed down clinical wisdom from my mentors with a knowing wink of “Good luck, soldier!” as if I was going into battle and they were seasoned generals. Their advice included the following admonitions: “make sure you keep the same appointment time every week with them,” “keep everything in your office the same,” “if they call, begging for an extra appointment, be polite, but above all don’t give it to them.” “They will keep pushing and pushing your boundaries,” I was warned. “Don’t let them!” After working with a few patients with BPD, I started to see what my mentors were talking about. If I took a call from a frantic patient, I would get more (and more) calls. If I let a session run long, at the end of my next session there would be an angling for more time. My BPD patients took a disproportionate amount of my time and energy. I felt as if I were dodging bullets with each interaction. This was a battle. And one that I felt as though I was losing. I tried my best to hunker down and hold the line—no extra time, no extra appointments. Hold the line!

Is there any way, then, for a patient diagnosed with BPD to escape internalised stigma?

Illustration by Satwick Gade

Illustration by Satwick Gade

BPD seems to exemplify, in a magnified way, how any kind of psychiatric diagnosis itself creates internalised stigma. None of us are born diagnosed. Not all of us grew up with a mental illness. One day, we reached a point where we decided we needed help, or we felt forced to seek help, and we went to a psychologist or a psychiatrist. Some of us did it because we cared about ourselves. Many of us only did it because the alternative was dysfunction or death. But most of us dragged our feet to our first consultation, because stigma is so acute that there was no way we could not apply it to ourselves.

As I said the last time, there currently seems to be no way to pry diagnosis and stigma apart. Earlier we were “us”, and now, just by sitting in the shrink’s waiting room, we’ve fallen down the rabbit hole and become “them”. We wonder what the receptionist is thinking, even though we tried to appear as sane as possible to her. We wonder what the pharmacist thinks when we show him a prescription for antipsychotics. Only antipsychotics, we think, could get us through the process of showing that prescription to the pharmacist. We cringe as he digs through our file and our psychiatrist’s notes.

The psychiatrist doesn’t tell us it’s okay to be depressed and okay to take medication, and that this is well within the range of human experience. The therapist doesn’t either.

As a result, even as diagnosis relieves us by naming our pain, our self-esteem plummets when we hear that name. We’re relieved that we’re not alone in facing this. But we are different now. There is something wrong with us. Everyone who’s close to us will have to be told. And from now on, everyone new we meet, whom we become close to, will have to be told. It is now a thing.

Now, I’ve heard kind people who would be described as mentally healthy express shock when they hear about someone who’s depressed and resisting treatment, who doesn’t want to go to a psychiatrist or therapist, who doesn’t want to take meds or be labelled. To them, it seems like such a logical choice: if you’ve got diabetes, you go to a physician and take insulin, don’t you? To me, their reaction shows a failure of the imagination – a failure to imagine themselves in a clinic, being prescribed psychiatric medication and agreeing to take it indefinitely. If it were as simple as physical disease, why would so many of us – even in the most supportive and informed environments – keep resisting medication and try our best not to take it unless really necessary? Even those of us who know from experience that medication makes our lives easier? Diabetics don’t usually do that with insulin, as far as I know.

For a moment let us ignore side effects as a reason why people resist meds – one, they are gradually decreasing as pharmaceutical technology advances and two, we seem to accept them better from “physical” medication. But there is also an inherent shame in taking psychiatric medication for many of us, no matter how well-informed we are, how scientifically we view the topic, or how much compassion we have for ourselves. Popping an antidepressant seems tantamount, for many of our subconscious selves, to an admission of defeat, of being less than ourselves, of needing a pill to complete us, to be ourselves again. This feeling is practically impossible to understand without taking psychiatric meds yourself. It is also, unsurprisingly, no tonic for self-esteem.

Diagnosis and medication both seem to target not our bodies, but our selves, our personhood, our personalities (note the word “personality” in BPD and other “personality disorders”). And if we’re not advanced spiritual practitioners, we tend to identify with our sense of self. No amount of serotonin-based explanations of mental illness seems to be able to stop us taking a psychiatric diagnosis personally. And if diagnosis is that hard to separate from internalised stigma, then psychiatry needs to rethink its approach to many, many things.

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Updated Date: Nov 23, 2018 18:50 PM

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