Lincoln is a very large black Labrador retriever, who has bonded to my son-in-law. Bonded does not adequately describe this relationship for it is as if Lincoln is attached to Jim by a very short invisible rope. Recently, during a visit to my daughter’s home I had the opportunity to witness a hilarious demonstration of this attachment. Jim was mowing his yard with Lincoln at his heels, and when he turned to push the mower in the opposite direction Lincoln followed. This continued with Lincoln following back and forth until the job was done. In a similar manner, he is rarely separated by more than a few feet from his master. When Jim leaves he is frantic, constantly watching the door, pacing back and forth, obviously quite agitated. Lincoln would seem to be the poster child (excuse me, poster dog) for the diagnosis of separation anxiety.

According to the ASPCA web site, the condition is not uncommon among dogs, and is most common among those rescued from kennels, and those who have been moved or have lost their major guardian. In other words, it seems that dogs know when they have a good deal and worry that they might lose it. Lincoln fits that category as he had been given up by his family and given to Jim. Watching Lincoln started me wondering if we humans are all that much different from him.

Most of us can recall at least one incident when we experienced “homesickness.” In my own case I remember vividly very intense feelings when left to stay with my Grandparents.   I never have been able to find words to adequately describe those feelings, but have likened it to a kind of psychological amputation in that a part of one’s self is missing. Those who have experienced it will understand how painful it can be.

Leaving for college is a common precipitant for it represents an abrupt breaking of many of the bonds attached to things familiar and to those upon whom we are dependent. My youngest daughter Maggie (currently my editor and the one who bears total responsibility for talking me into writing all this stuff) was the most memorable example of this phenomenon; although, her siblings also experienced it to some degree. Maggie was eager to fly away from the confines of a boring small town to gain freedom from parents who continued to treat her as if she were a child and to subject her to all kinds of stupid rules. As a matter of fact she was so convinced that geography would be the solution to her discontent that she refused to consider any school within her home state.

The vision of that skinny little girl surrounded by huge limestone buildings gently sobbing and feebly waving a goodbye as we pulled out of that parking lot has never left me. Little did she know the effects her mother and I felt from that poignant scene, for we were heading home to an empty nest. Nothing would ever be the same. Maggie was a prime example of the wisdom of the admonition that one should be careful what he/she wishes. She lost nearly 20 pounds during her first two weeks, and was barely able to function according to her roommate who called us to express her concern. Barb and I resisted our impulse to go save her from this horrible fate, and as one would expect she soon had a spontaneous remission, and went on to excel.

Homesickness vs. Separation Anxiety Disorder

What Lincoln and Maggie have in common is that they have both experienced separation anxiety; although in Maggie’s case the condition was temporary but for Lincoln it became chronic, which qualifies him for a diagnosis of separation anxiety disorder. Although they share the same symptoms, Maggie’s reaction would be viewed as homesickness; therefore, benign in its implications while the same problems if persistent are characterized as mental illness.

In like manner, one could make a case that mental illnesses are largely due to quantitative rather than qualitative variations from the norm. Who among us has never experienced an irrational fear, a fleeting suicidal thought, unwarranted suspiciousness, unreasoned feelings of despondency, or a spontaneous episode of anxiety without obvious cause? Such short lived experiences are usually shrugged off, but the realization that these feelings differ from those of a mentally ill person only in their duration can result in self-doubt and feelings of insecurity about one’s mental stability.

The mechanisms we use to deal with these feelings of mental insecurity and self-doubt are all apt to contribute to the isolation and discrimination so often seen in our relationships with people who are mentally ill.

Denial

Denial is a powerful mental mechanism characterized by statements such as: “pull yourself together, stop worrying, quit being so sad, or stop acting so crazy.” Such statements deny illness and suggest he only needs to “buck up,” thus, perpetuating the time honored tradition of blaming the victim for his troubles. Of course kicking a person while they are down is not very therapeutic, but it may help us feel immune. Some naysayers even insist that the whole idea of mental illness is a fable.

Avoidance

Avoidance is another method of dealing with one’s insecurities. It operates under the out of sight out of mind premise. When I was practicing there were some people would not visit friends or relatives in our psychiatric ward. Many others were obviously uncomfortable in that environment, and would avoid eye contact with patients. The usual response to someone exhibiting bizarre behavior is for observers to look away after a furtive glance. Avoidance in its extreme form is to be shunned, which is guaranteed to exacerbate most any mental illness.

Ridicule

Ridicule is a tried and true method to avoid ownership. It is said that those operated Bedlam (which was actually named Bethlem Royal Hospital), the infamous insane asylum in England that charged admission for visits to the facility where one could make fun of and taunt the patients, felt it was quite progressive because the fees collected helped fund the “hospital’s” operation. I imagine the taunters felt safe since most of the patients would have been chained to a wall. We are of course much more sophisticated than the residents of jolly old England, yet when we joke about mental illness, are we not engaged in a similar coping mechanism? For the patients and their families, there is certainly nothing humorous about mental illness.

Words

The way we speak often illuminates thoughts buried so deep that we may lack awareness of them. This appears to be true when we discuss mental illnesses, especially the more serious variety. For example when we say a person is schizophrenic, where schizophrenic is an adjective, we seem to be saying what he is, but when we use the term as a noun as “he is a schizophrenic” we are saying who he is. He is no longer a human with the disease, but he is the disease, and his humanity is diminished.  People with schizophrenia have this in common with those suffering from leprosy, who are usually referred to as “lepers.”

The plight of those who suffer from mental illness

The parallels don’t end there for those afflicted with either diagnosis, leprosy or schizophrenia, have suffered the same punishments including: torture, execution, imprisonment, denigration, ridicule, and shunning. Both have been thought to be caused by demonic possession, curses, divine judgments, witchcraft, etc. They have been with us throughout recorded history and probably longer. You may be thinking, “Yes, but we have become so much more sophisticated, enlightened and compassionate.” Yet, thousands of severely mentally ill people are imprisoned. Only recently has there been a movement to mandate psychiatric care reimbursement by third party payers to be equivalent to that provided for treatment of non-psychiatric illnesses. An estimated 70% of the homeless who live on our streets are mentally ill. Our government has diligently worked to deny benefits to veterans suffering with post-traumatic stress disorder, and the list goes on. Incidentally, the last leper colony in the U.S. was not closed until 1999.

The stigma of mental illness

I contend that ignorance is fertile ground for the development of stigmata. We are often most fearful of those things which are mysterious to us. A diagnosis of separation anxiety does not promote much fear in us. We all have some familiarity with and empathy for that problem, but mention psychosis and there will be a different reaction. There are abundant myths regarding psychotic illnesses, and for many that term belongs in the same category as axe murderer. Since early childhood we have been taught to avoid people who are acting strangely, and what we don’t understand is always strange.

Behavior Health vs. Mental Illness / Patient vs. Client: Renaming and Reframing

Another way of dealing with uncomfortable problems is to reframe them by renaming them as something less threatening. In the mental health field this mechanism is used by mental health advocates in a way that I feel undermines their stated goal of de-stigmatizing mental illnesses. One such term which I find totally repulsive is behavioral health which has found its way into the vocabulary of not only the general public, but those charged with treating the mentally ill. While espousing the need for acceptance, they choose to call the condition by a different and totally inappropriate name. A mental illness is no more a behavior than is cancer, but since there is a type of treatment used for less serious illnesses called behavior therapy, the term has now been co-opted to encompass all psychiatric illnesses.

In their zeal to demedicalize mental illnesses, the powers-that-be have successfully substituted client for the word patient when describing people in treatment. This is an issue which sometimes leaves me wondering if it might be time for some more therapy for myself. I have fought this one unsuccessfully for at least 20 years. The word patient is from the Greek meaning “one who suffers” while the word client has to do with a business relationship. Call me a snob, but I feel a doctor patient relationship is more than a series of business transactions. As I have pointed out repeatedly to all who would listen and even those who would not: Accountants, lawyers, and hookers have clients. Physicians have patients.

Shortly before my retirement, I penned a letter on the subject to all the nurses with whom I worked, expecting them to be a bit more sympathetic since they had been medically trained. When I asked one if she had read my letter, she answered in the affirmative, then said “Your next client is here.”

Sadly, the previously described types of reactions to a diagnosis of mental illness occur at a time in a person’s life when he/she is in most need of support and relatedness. Admittedly there has been some progress in educating us about mental illness, and research is opening doors toward more understanding, but society remains relatively uncommitted to dealing with one of our most pressing problems. Hopefully there will come a time when patients will not fear being seen going into their psychiatrist’s office.

From Eshrink’s Editor: What can you do to help?

Get informed. Volunteer.

(Side note from eshrink’s editor: If you think about it, all of the big issues that face our society are just symptoms of a society that has yet to address mental illness and the plight those who are the caretakers for the mentally ill face. As the election cycle gets in full force, pay attention to how few candidates address mental health and mental illness.)

Below are some resources I found helpful.

http://www.nami.org/Get-Involved/Raise-Awareness/What-You-Can-Do

http://www.nami.org/get-involved/raise-awareness

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