Mental Health Stigma and Personal Identity

"The only thing shameful about mental illness is the stigma attached to it." - Lindsay Holmes

A while ago I had a familiar experience. At the Please Touch Museum in Philadelphia, I ran into a South Asian Indian ("desi") family, who had driven down from New Jersey to the museum for their three-year old's birthday. We started talking and our conversation reached the inevitable "so what do you do?" I found out that the husband and wife both worked in IT. When it was my turn to answer, I hesitated.

I am a Clinical Psychologist. I do psychotherapy, psychological assessments, lead therapy groups and conduct evaluations for patients struggling with mental health issues. I work with individuals and families dealing with depression, anxiety, mania, hallucinations, delusions, post-traumatic stress disorder, personality disorders, substance abuse, suicidal thoughts, other self-injurious behaviors, relationship issues, adjustment issues and the task of finding self-knowledge, meaning and purpose in their lives. I work with children, some as young as four years old, to help them successfully overcome present challenges so that these do not build up and result in full-fledged disorders later on. I also teach and do research, mostly related to mental health issues.

I answered that I was a researcher. It was not a thought-through statement. Just the first thing I could come up with in my hesitation. I had a feeling of short-changing myself even as I said it but it had already been said. Later that day, I reflected on why my gut reaction had been to portray myself as a "scientist," which of course, I am, but not a "practitioner," which I am as well. With most Americans, I do not usually hesitate to present the practitioner side of my professional identity. I realized that in this exchange, my South Asian roots had played a significant part. Many a times when I have introduced myself as a psychologist, I have often observed an alarm reaction from South Asian acquaintances. There is a noticeable discomfort, as if a family secret had been revealed, or that the secrets are now threatened by the mere presence of a therapist. The mention of psychology is considered better avoided. Their hesitations are similar to mine, they come from the same place.

Growing up in India, it was not difficult to see the shame of mental illness. The stigma of mental illness casts a net wide and deep. As it is a society driven by family reputation, members of families commonly hide their own symptoms of mental illness or of their family members. Denial is the default coping mechanism. There is a strict demarcation between "normal" and "mental", and nobody in their right mind would allow any identification with the latter. Statements such as "mad or what?", or in Hindi "paagal hai kya?" and derivations thereof are common parlance. And if a little "mad" is a problem, then a lot is a disaster. The treatment of severe mental illness is abysmal and the outcomes for those suffering from it are horrendous, The problem itself is not acknowledged, therefore never solved.

South Asian culture is hardly unique in having stigmatizing attitudes towards mental illness. Western culture tends to have greater individual stigma based on the concepts of independence and self-determination. Other cultures exhibit greater social stigma towards mental illness. However, this is not a litany of any culture, it is a reflection on my experience within these two cultures and the questions that emerge from that. What can we all do to change our default attitudes towards mental illness? It is quite a task to eradicate the stigma of mental illness from a culture but we can all take small steps. For my part, I decided to make the conscious effort to always introduce myself as a clinical psychologist in the future. I hope that people at the other end of that introduction can examine their attitudes towards the "mad," "paagal" or "mental" people, and those who work with them, and respond not with labels and stigma but with tolerance and acceptance.

Love Thy Enemy - Melanie Klein and the 2016 US Presidential Election

“When there is no enemy within, the enemies outside cannot hurt you.” - African proverb

In the weeks before and after the US Presidential patients and colleagues alike have been drawn into the incessant pull of a partisan political climate. The United States has just witnessed a bitterly fought presidential election laying bare the fault lines of divisiveness within this nation. What has been striking has not been the divisiveness per se, but the extreme, one-sidedness of each camp, as exemplified by the notion of living in “bubbles,” impervious to contrarian influences. Witnessing this isolation of viewpoints in Facebook feeds and self-selected news sources, a question arises in my mind about what can the study of psychotherapy provide as a guide to the current predicament of this divisiveness. President Obama in his State of the Union address in January 2016 expressed his regrets about the increased divisiveness of the politics in the country. Things apparently did not improve in the rest of the year as well. As President Obama pondered about the politics of this chasm, we can attempt to understand the psychological underpinnings of it.

This election defied logic. Apparently during the election, there were rule-breakers on both sides but the people who were absolutely shocked at the rule-breaking actions of one party’s nominee were unperturbed by the rule-breaking behavior of their party’s nominee. There was also the strange phenomenon of people being absolutely shocked by the statements and behaviors of a candidate in the primaries but miraculously becoming unperturbed by those statements and behaviors after the candidate became their party’s nominee. The election cycle teemed with rage, disgust, the propensity of seeing the world as black or white. Partisan news organizations and social media accounts repeated portrayed the “other” as the object of the hate and ultimately, destruction. The permeating belief was that MY nominee was a human being of good intentions, but with human flaws, but YOUR nominee was the devil incarnate, needing to be erased from the planet!

As this point, anyone familiar with the history of psychology hears a few familiar notes on a theme. Anyone who took an Intro to Psychology college course might recall mentions of the development of psychoanalytic thought and within it, the development of object relations theory, attributable to the work of Melanie Klein. In the 1930s, Klein formulated important ideas in psychological maturation on the basis of her work with young disturbed children. Klein postulated that infants begin to internalize caregivers as objects. These objects are mental representations of an actual other, primarily a caregiver, whom they perceive as good when the other fulfills their needs, and bad when their needs are not met. Eventually, the child internalizes this split between good and bad, and comes to perceive herself as good or bad at different times. Healthy psychological development occurs when the child is able to integrate the good and bad aspects of self and others (love and reparation) and move from a fragmented, anxiety-driven state of good versus bad (paranoid-schizoid position) to a more nuanced, reality-based appreciation of the good and bad aspects of the same person, including oneself (depressive position). The children who do not successfully make this transition remain trapped in a state where they have a constant need for self-validation, to be seen as a  good object, with a corresponding constant need to expel the bad object from within themselves and locate it in another person or entity. Freud had described a process of painting others with the disowned aspects of the self (projection). Klein went a step further and described a process where a person takes actions to not only project unto others but to engage with others in a manner so as to evoke a confirmatory response of their badness. She called this process projective identification.

We can view the communication between the two parties and their allied media bullhorns, for the most part, as projective identification. If all statements and actions become attacks, and all defenses and counter-attacks are confirmations of the other’s badness, then we start living in a fragmented sense of reality, perpetually winning or losing the sense of self with every news cycle. This is why a question in the second presidential debate regarding an appreciation of the other candidate seemed prima facie ludicrous to so many observers. How is it possible that there is anything redeeming about the other? That is after all the bad object, unidimensional and expendable. How can you ever support THEM?

The media supported this split as it does make for entertaining reality TV. Headline after headline proclaims the newest confirmation of the other’s depravity and disgusting behavior, while validating the self as all-good, suffering, enduring and above all, beyond reproach. The fragmented self looks outside for confirmation of its views of the good self and bad other and the media and the politicians are eager to provide it. The fragmented self makes for reliable votes and higher ratings. It does not matter which side the other represents, as long as there is an other.

It is important to note that integration does not mean a blanket tolerance of the other. When the other treats another as the other, then it should be met with proportionate resistance. The danger lies in the adoption of Klein’s paranoid-schizoid position in the face of either victory or defeat, refusing to accept that the other even exists or the unthinkable, the other now prevails! Not all ideas are created equal but all human beings are, and recognizing the complexity and nuances allow both a child and a populace keep themselves grounded in reality. The antidote, as Klein put it, is love and reparation, the ability to have respect for the separate other, that you can argue with a part without destroying the whole. Voting in an election, as well as living in a democratic society, should be about subjective identification, not projective identification. Ironically, we really are all stronger together.

Pain is pain

"Be kind, for everyone you meet is fighting a hard battle." - Plato

An idea that people in therapy and outside often struggle with and that can help gain perspective on emotional distress is: pain is pain.

In therapy groups that I lead, people are helped to share stories of the pain that they have experienced in their lives. Sharing the burdens we carry is therapeutic, as is providing support to others as they share them. However, as we listen to each others' stories, our analytical parts of the self begin to evaluate and categorize. We find ourselves tuning into the judgmental voices comparing others negatively in relation to our stories. We think of examples such as:

“Is that it? Your mother just shouted a lot at you?”

“You were just bullied in school. Give me a break.”

This perspective is not helpful. Emotional abuse, such as constant  shouting, can be equally traumatizing as physical abuse. In fact, some research has shown that counter-intuitively, emotional abuse alone is more damaging that emotional abuse coupled with physical abuse, presumably due to the relational aspects of physical abuse. Similarly, a person may only be able to verbalize only one set of abusive experiences at this time, such as being bullied. Looking down on others’ pain can give a feeling of superiority, but it is likely to be unproductive in the long term.  

The same experience can occur from the opposite standpoint of viewing our experience as less negative as compared to others. Examples include:

“Oh my God! She was sexually abused as a child AND a victim of domestic violence. I have gone through nothing as compared to that.“
“His father and brother BOTH committed suicide and he is struggling with a drug problem! What right do I have to be sad about my life?“

Looking down on our pain can be just as unskilled. Listening to the traumatic stories of others and consequently minimizing our own, can only provide temporary relief. This only contributes to masking our own struggles and is of no help in the moments when we do encounter our own pain. In the end, both types of comparisons are unhelpful and possibly misleading.

Modern neuroscience tells us that emotional pain is not even different from physical pain. The same regions of the brain appear to be involved in both types of pain. The differences in pain may be considered more due to their frequency, intensity and duration rather than their causes. However, in most cultures, we are taught that somehow physical pain is “real” but emotional pain is “all in your head.” We commit, in clinical psychology terms, what is called a fundamental attribution error in social psychology terms. We attribute external causes to physical pain but internal causes to emotional pain, as if we bring only one of these on ourselves.

It can be concluded that rather than differentiate categories of pain, it would be skillful to focus on the ubiquitous prevalence of pain. Comparing one person’s pain with another, emotional or physical, takes away more than it gives. The Buddha’s first Noble Truth is that “Life is suffering.” Plato exhorted us to be kinder, as he saw everyone fighting a hard battle in life. Nothing much has fundamentally changed on this subject in the millennia since these observations were made. Pain is still built into the human condition. In fact, all pain is pain. Let us respect that, and then we can go about alleviating it.