Finding dignity in mental illness

Mental Health Day next week reminds us of the need to look beyond the patient, to the person beneath
By Chong Siow Ann, Published The Straits Times, 3 Oct 2015

Next Saturday, Oct 10, is World Mental Health Day. As in previous years, there is a particular theme this year - Dignity In Mental Health.

Dignity is one of those words that most people think they know but would struggle to explain. The Shorter Oxford English Dictionary defines it as "the quality of being worthy or honourable" but to grasp what this would mean to someone living with a mental illness, I enlisted the help of one of my patients - a thoughtful lady with a serious mental illness and a wonderfully literary, curious and capacious mind. I asked if she could pen her reflection of what dignity means to her.

After a short interval, she e-mailed me. "Dignity for a patient with mental illness means having equal opportunities to work, or study and to make contributions to society and be shown the means to live a purposeful and meaningful life," she wrote and sadly went on.

"People with mental health issues are being treated with suspicion as to their cognitive and working capabilities. There is no way for this tinted mentality to be lifted in the near future as prejudices and misconceptions run deep. It is akin to certain crimes where the person may be guilty till proven innocent."

Despite the pervasiveness of mental illness in the population - most estimates have it that one in four adults experiences mental illness in any given year - there remains this persistent prejudice that smothers with a pall of silence.

The British author Clare Allan wrote: "There seems to be some sort of agreement, a contract you sign when you first break down, that should you ever emerge from your madness and re-enter the 'normal' world, you promise never to mention what took place. If you break this agreement, at best you'll find people's eyes start to drift away… embarrassment hangs in the air; at worst, you'll be shunned. At the very worst, you will discover you've become an object for general pathology."

The trajectory of a mental illness is often an arc of accretion of losses: a plummeting of self-worth, the dissolution of friendships, and the evaporation of career advancement and employment opportunities. The latter is one of the biggest stumbling blocks for people who had recovered from their mental illness, from picking themselves up and getting on with their life.

To many employers - as with many other people - mental illness is all too often associated with personal weakness, unpredictability, unreliability, unproductivity and violence - even after a person has recovered from an acute episode of such illness. Many make it a point to ask specifically for a history of mental illness and though they may not openly admit it, it is probable that they will eliminate any hopeful applicant who is honest enough to admit to one.

Frightened and desperate, some may lie but those gaps in their resume when they were too seriously ill to work and the subsequent difficulty in getting jobs can be hard to explain away.

In the United States, the Americans with Disabilities Act prohibits discrimination against people with disabilities (including mental illness) in work. In Britain, a law was enacted recently which prevents employers from asking about the mental health of an applicant before making a job offer (except those of "national security").

In Singapore, there is no such legal protection for people with mental illness.

SPEAKING UP

Legislation is obviously important but it won't by itself ameliorate the stigma, discrimination and indignity that are attendant to mental illness.

That might take activism which, among other things, requires individuals to stand up and speak openly about their own experiences of mental health problems. So far, we have precious few individuals who have taken that hard and irrevocable step and no local prominent public figures have done so.

This is perhaps understandable, given that meritocracy has been a cornerstone of our society. Any admission of impairment would be anathema to any aspiration of personal ambition.

Still, when public figures talk about their mental illness, the impact is often tremendous. It debunks the fable that successful people do not become mentally ill; it offers hope when it is seen that they can recover with treatment and assume their successful professional lives.

In August 1998, Mr Kjell Magne Bondevik, who was then the prime minister of Norway, told his astonished nation that he had depression and would be taking leave. He recovered, returned to work, and was subsequently re-elected for a second term.

Following his revelation, he received widespread sympathy and support, and a deluge of letters from people saying: "If the prime minister can talk about his mental health problems, why can't we do it too?" For many, it was the first time that they could talk to somebody else about their illness.

Silence, on the other hand, can be deadly as noted by Kay Redfield Jamison, writer and professor of psychiatry at Johns Hopkins School of Medicine who has bipolar disorder.

"Silence also contributes to the myth that people who are brilliant or 'full of life' cannot possibly become so despairing as to kill themselves.

"They do. Every day. In short, silence helps perpetuate the stigma of mental illness," she said. "Those in the public eye, whether in business, journalism, politics or the professions, have a unique opportunity to lessen this stigma, mobilise research efforts, raise money and educate others who do not have the same financial and educational advantages."

We want and urge people with mental health issues (and their families) to "come out" and speak out - to be the vocal vanguard of social change.

It is a lot to ask for as they would be the ones to face whatever unseen perils might come in the wake of disclosure.

They may feel a redemptive sense of liberation - of not having to hide any more - but may also face oppressive prejudice, pity and condescension of the outside world.

This is an irony that Sharon Synder and David Mitchell, who are scholars in the field of disabilities, have observed - that those who strive to help or treat people with disabilities often "subjugate the very populations they intend to rescue". And this subjugation can also be more subtle.

OBJECT LESSON

I have been seeing my patient (the author of those words on dignity) for more than a decade and in that time and over numerous consults in the outpatient clinic, I had had rather short conversations with her - focusing on her response to medication, her part-time job that I had been most anxious that she should stick to while advising that she monitor her stress level and not engage in anything too demanding, and earnestly urging her to pick up a simple hobby to fill up those empty hours.

Interpreting her reticence solely as a symptom of her illness, I had not tried to engage her more but wondered to myself the extent her illness might have limited her cognitive abilities and drive, and stymied whatever aspirations she had.

During one such consult not too long ago, she told me shyly that she writes, and proffered me an article. That single piece with its lucidity of thought and fluidity of writing upturned all those notions of her that I'd held up to that point. Since then, I have read her writings on a wide range of subjects; her understated intelligence and sensibility evident in clear unadorned prose. These literary outpouring of her feelings and thoughts in poems and prose (some already published) shamed me and were ripostes to my long-held benighted perception of her narrowed and impoverished inner life, and rebukes for subjugating her with my well-intentioned prejudices and not seeing her beyond her illness.

She gave me an object lesson on dignity in mental health: dignity is recognising that kernel of the real person buried under the layers of mental health issues; some of which are imposed by the external world. It is recognising that every one of us has the same desires to be held in regard, to be heard, to be respected, and to be treated as an individual of worth.

The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.