Ep. 55 - Why Mental Health Still Carries a Stigma

Mental health has come a long way, but many people still hesitate to ask for help because they worry it means they're weak, damaged, or somehow failing. Those beliefs can quietly keep people from getting the care they need.

Dr. Andrew Rosen and Dr. David Gross take a thoughtful look at where the stigma around mental health comes from and why it continues to exist today. They explore the history of mental illness, common misconceptions about anxiety and depression, and why emotional struggles are often judged differently than physical health conditions. Along the way, they explain why thoughts and feelings aren't something people can simply "will away" and how modern neuroscience has transformed our understanding of the brain.

They also discuss how therapy and cognitive behavioral techniques help create lasting change, why education is one of the most effective ways to reduce fear, and how even mental health professionals have faced stigma within the medical community. The conversation closes with a reminder that everyone has strengths, limitations, and areas where they need help—and that seeking support is a sign of growth, not weakness.

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Email: twoshrinksandamic@gmail.com

Transcript

SPEAKER_01 0:08

Hi, I'm Dr. Andrew Rosen. I'm a psychologist.

SPEAKER_00 0:12

And I'm the psychiatrist, Dr. David Gross, and we are two shrinks and a mic. Today we're going to uh continue to talk about some of the uh obstacles to getting adequate mental health care, one of which we've hinted at before is the concept of stigma. Uh stigma's been around for ages, um it goes back hundreds of years because uh it started with uh lack of knowledge. So individuals who behaved in a strange ways and behaves behavior that was out of out of character and different than what the community thought would be viewed as uh sometimes witches and sometimes just uh uh uh not not altogether. And and so it's been a major problem in helping people even now in the 21st century uh come to treatment.

SPEAKER_01 1:00

Yeah, I mean it goes back to sometimes people were thought to be possessed by the devil, other times uh th they mistook m what looked like mental issues or uh brain issues for some other medical illness. Uh uh regardless, it was always viewed as some kind of uh horrible defect. Um and whether it was uh a stigma or you better stay away from that person because you don't know what's wrong with them, or they're capable of doing all kinds of crazy things, uh a sti stigma was associated with uh emotional or mental health problems. And even though we're talking maybe thousands of years later, there's still a stigma. And it it's more subtle, it's not as strong, but people still and all, even smart people who know much, much more about the importance of mental health and mental health treatment, they'll still feel like if they're not getting it together, uh they're weak or they're there's something wrong with them. Just the other day, a person that was seeing me for OCD and they've been making tremendous progress in the middle of everything because they had a rough day. They thought, well, you know, I guess I'm just no good at this, I'm too weak, I should have done better, I should have been stronger. So it's associated with weakness or defect or just some other mistaken notion that makes it harder for people to engage in the whole process to begin with.

SPEAKER_00 2:30

You know, it's amazing how just uh other health problems are accepted without uh second guess, second questions. Uh for example, if you have uh wheezing and and terribly allergic, uh you view yourself as having a legitimate problem and you go to the physician to try to get some help and deal with it. Um if you uh have a finicky stomach, um you decide to get some help. It's not not something that's viewed as a a weakness. Um we're we're modern societies, especially Western societies, are based upon some core belief systems, one of which is that uh we all have this concept we've talked about before of of free will. That uh you can do anything you want if you just put your mind to it. And the reality is none of us are perfect and none of us uh have complete free will. I mean, I I couldn't become a surgeon if I tried to because my visual spatial capabilities are lousy. Uh I get lo I'd get lost in somebody's abdomen if I was asked to operate. And interestingly, when I was in medical school, I kept telling the surgeons that you don't want me in the in the operating theater itself. I'll take care of the person beforehand and I'll take care of the person after surgery. But because of my spatial difficulties, you don't want me operating. And they couldn't understand it. They had this notion that, you know, because it was so easy for them, it's got to be easy for everybody. It's just not the case. Uh thankfully, my uh language skills and other skills are pretty good, which is why it became possible for me to become a psychiatrist. But none of us are perfect. But in our societies, this concept of free will is very, very powerful. Comes from uh, you know, we've talked before about the philosopher of uh a theologian, John Locke, who talked about the concept of free will and that if uh you you can't do something despite trying as hard as you can, there must be something wrong with you. And then we have the concepts of uh if if you're not doing well and you're having problems uh and you're suffering, then you're not a member of the elect, as uh John Calvin used to talk about. And um that was a notion that um if you're not a part of the elect and you're not uh within the accepted class, then you're paying for prices that a price for what was done in the past. Uh uh that was bad. So a lot of this is influencing our belief systems about mental health and mental problems. Um and uh not so long ago that uh there was the ship of fools. Uh in I think it was in England that uh individuals who uh demonstrated uh uh mental difficulties and then in those days they called it insanity were placed on a ship and shipped down the river to the insane asylum. And the the idea was to get them out of sight. That is not don't have them near us because maybe that's catchy, etc. So there are a lot of false beliefs about it to this day. And um uh hopefully that some of the the work that we do and other people do to try to correct the misunderstanding and the and the myths about mental problems will will help.

SPEAKER_01 5:27

You know, there's even these uh terms, slang terms that we have for uh mental health problems that we don't have for other medical problems, you know, cuckoo, uh all kinds of I mean, I can't even think of them all right now, but kind of terms that are looked at with a kind of a sneer or or uh, you know, kind of a funny kind of a response to very serious problems. And it even uh prevails with somebody, it just here's a perfect example. A person who's having all kinds of what we call somatic complaints, physical complaints, whether it be gastrointestinal or cardiac or you name it, headaches. And so this person goes and gets to uh the doctor and they go for specialty exams, and they've been worked up and they can't find any organic illness. So what's left over is whether or not these physical problems are the result of some psychological uh residue and that it's finding its way into the body. And we know that for a fact that stress or psychological problems can find their way into our organs. So if you see somebody and they've been worked up and they can't find anything, everybody assures the doc the patient there is nothing organic. Typically a patient will still be uh uncomfortable with that. They'll feel like, well, maybe you just haven't found it yet. And when you imply that it could be what we call in the old days psychosomatic, meaning the the psychological is converted over into the body, they see it as an insult. They see it as a degrading kind of comment, and that the doctors are just pigeonholing them because the doctor hasn't got done a good enough job in figuring out what the medical problem is. So it's a last resort for most people to think that whatever is going on with them has to do with their their quote-unquote mental issues. And there's shame, there's embarrassment, there's self-punitive statements, there's uh hidden agendas, there's efforts to sweep it under the rug, to not deal with it. And if by chance somebody, a wife or a spouse or somebody says, you know, you really should go see somebody, they might not go, or if they go, they'll go with a lot of hesitation, uh embarrassment, and they'll try to get it done as quickly as possible. So maybe they'll comply and go for one or two appointments and get the hell out of there before it it becomes more obvious that they're in some kind of psychological or psychiatric treatment. So why is that? It's just still in all, even today, people don't like to admit that they may not have control over what their brain does. People think somehow they should be in control of their brain just as much as they're in control of whether they decide to move their foot or their hand. And the truth of the matter is a lot of the brain action is what we call involuntary, so we have no control over it and just happens without any effort on our part. And then there's another part of our brain that does what it does without us knowing it until after the fact. For instance, nobody knows what thought they're going to have in advance, and nobody knows how to control what thoughts they have. It's it's an impossibility. You don't know what you thought until you've already thought it. And so the brain can't be controlled. You can't control what you think, you can control your behavior to in large part, but you can't control what you think, you can't control whether you feel guilty feelings, you can't control whether you feel fearful, you can't control whether you feel sad. It just happens. What we offer are uh techniques to help manage those feelings or to help manage those thoughts. But nobody that I know of is uh capable of controlling their brain to the point where they uh can control it like they might their their muscles or their uh bones or their their a or their body. It's just not the same. So uh it's it's kind of an admission of defeat for many people to acknowledge, you know, I just can't stop thinking what I think, or I can't control how I feel, or I can't control my mood. What we help that person do is to first acknowledge you can control it, but you can manage it and you can make it work very well for you in a healthy way.

SPEAKER_00 10:04

You know, one of the uh of the reasons that it's been hard to get rid of stigma and some of the false beliefs about emotional, behavioral, or or even thinking cognitive difficulties is the fact that um treatment in the field of mental health probably has lagged behind treatment in all other areas of health care. I mean if you think about it, uh a major breakthrough uh uh uh around the time of World War II was the development of uh adequate antibiotics to treat uh infection. Um that just changed the whole world of infections. Uh but in mental health, uh we we had very poor understanding as to what was causing depression, anxiety, uh, abnormal behaviors, uh thinking where there's illusions, which are false beliefs, or people who hallucinated. Um the brain was untouchable. We had we didn't have the technology until recently uh to be able to look at the brain. It's only since the development of the CAT scan and the MRI that we could actually see the anatomy of the brain. And it's only recently since we've developed what's called a functional MRI that we can actually see real-time uh brain activity, uh, which shows us where there are abnormalities in the brain and areas of the brain that are normal. So you can actually uh see improvement in brain function as uh mental health treatment progresses. Uh so the absence of treatment was a problem. Um and it wasn't really until uh we we had a uh uh renaissance of neurobiology in the world, and especially in this country, where we began to understand that there were uh chemicals in the brain called neurotransmitters that were responsible for uh helping to generate the electricity in the brain and manage the flow of electricity across neurons and the circuitry in the brain. Because the reality is that our brain is an electrical organ, somewhat like a computer. It's the flow of uh of electrical transmission across circuitry in the brain that determines the fact that I'm thinking and talking and know that I'm sitting in a chair and looking at the camera, et cetera. Um it's that electricity managed and modulated by the chemistry of the brain that was only discovered in the 50s and 60s, and that's not that long ago, of of the 1950s and 1960s. Um and part of it also is that um without realizing it, we contributed to the stigma. Um I did my training a number of years ago when there was uh half of my training was psychoanalytic and half of my training was neurobiologic, so which I had the best of both worlds, but I still remember the idea that that I was taught that if I opened up a private practice um and I did psychotherapy, talking therapy, that there would have to be uh an entryway to my waiting room, and then there would have to be an exit whereby people could exit without being seen. Of course. Some of that was to protect the confidentiality of the work that was done, but it made it into this mystical, can't talk about it, you know, can't show your face, so to speak, type of uh experience, which I think contributed to the concept of stigma. Um God forbid somebody should see me in the waiting room to see a psychiatrist. Uh yeah, even today that happens. You know, what are you doing here? Exactly. And and and I've uh you know, I've had uh I've had individuals who have been in the waiting room and they s they see somebody from the community and and they say, Oh, you're here too. And I think the more that we can we can um normalize the presence of depression, anxiety, et cetera, especially in our world, I mean the pr the prevalence and incidence of anxiety now is huge. We've seen that in our kids, and it's a real problem. So dealing with this issue is is is difficult. I mean, I I try to explain to individuals the concept of cognitive behavior therapy. Why in the world would that work? You're just trying to you're just giving me techniques, but why would that lead to ongoing change? What's the reason behind that? And I just let people know that, well, think about what when you learned how to ride a bicycle. The first time when you were younger, you got on the bicycle, you were scared stiff, uh, you probably fell a couple of times. Uh hopefully the uh person who was teaching you hung in there with it and you let allowed them to continue to teach you, and eventually you learned how to ride a bicycle. So even if it was 40 years later, I tell people in my office, if I asked you to get on a bicycle now downstairs outside of my building, would you be able to do it and ride away? And they'd say, Yes. How come that's possible? They'd say, Well, I learned how to ride a bicycle. I said, Well, that that what that means is like every other kind of learning, you've reprogrammed your brain. You've created new circuitry. And the good news for all of us, especially uh the two of us, Andy, since we're over the age of 30, um that our brains are constantly changing. It's not like our brains get fixed and they don't change after a certain age. They're always establishing new connections. And and so when cognitive behavior therapy is a technique that allows people with practice to create new circuitry and new connections so that they've learned how to control their panic, they've learned how to control their obsessive thinking, because they've got the circuitry in the brain now that's normal to control of it. The circuitry before that generated the symptoms of panic and generated the symptoms of overthinking and being stuck in one's head were abnormal. And the beauty of cognitive aval therapy is that it can help you reprogram it. So people understanding that suddenly it makes sense. And then when they tell them that if you do a functional MRI of an individual who has obsessed compulsive disorder before treatment, and you see the areas of normality and they see the areas of abnormality that are highlighted, and then they get treated, whether it's with medication or with good cognitive paper therapy, and they improve and they begin to recover, you can see normalization of the brain areas that were abnormal. I mean, that's amazing to be able to say that, but that's because our technology has finally allowed us to do that. But just imagine what it's like in the 1920s and 30s when Freud and his disciples would came up with a lot of notions that turned out to be a little bizarre, and and but they were based upon what they saw. They didn't know any better. But even Freud said at the end of the day, a lot of what he was observing would turn out to be biological. So a lot of what both of us do, as you've said before, Andy, is to educate and help people understand what it's all about so they can get away from this notion that I must be inferior, I must not be as good as other people.

SPEAKER_01 16:26

But you know, it isn't that long ago when the answer to a particular patient's psychological or psychiatric symptoms was something called treffening, where they would actually drill a hole in the skull with the intention that whatever was bad in there in the brain would somehow leave through the hole. That was the effort then, and that was their level of understanding then. Now for us, it seems absolutely bizarre, but that's the level of understanding then. Or the use of leeches to get whatever was bad in the bloodstream that was causing the person to act crazy. The other method was, which is probably still the leeches work. They do.

SPEAKER_00 17:13

If you put leeches around aeches around a uh uh open open wound, it it it's a at least the dead tissue.

SPEAKER_01 17:22

So, or the sanitarium. I mean, you know, that was the other answer is take this person who obviously is not able to cope with the real world and the real world stressors, let's find a nice place out in the countryside in a in a pretty home, pretty mansion, whatever it would be, and let them go there and rest. It's sanitary. Let them rest and let them have no stress and just kind of sit in uh a chair and look out at the beautiful trees in the sky, and maybe after a month or two or six or will or longer, somehow they repair. So even though that is a long time ago, it in some respects it's not a long time ago, and the residue of that is still present. And so but now I think when people do come for treatment, if they can get beyond the stigma part of it and they come for treatment. And we've talked about this, people really don't necessarily know what it is that they're coming to get. What what is treatment? And all too often the the looking for something real like cognitive therapy or or medication or some very specialized technical treatment is met with what like somebody called me the other day, a a new prospective patient. She said, you know, I've been in therapy for about three years, but it's not doing anything for me. It's what we just ch we just chat. We just talk about whatever, you know, how is how was the day and what's going on. But there was never any real serious focus on anything. So this particular person who's having significant levels of anxiety says, I I need to talk to somebody who's gonna do more than my friend could do. So the whole spectrum of treatments that are available sometimes uh do satisfy that person who is uh finally overcoming their their reluctance to get help or their fear of getting help. And very often when they do get into a particular clinician, they fall flat on their face because I could have done this with my friend who needs therapy. This is a waste of time and money because all we did is chit-chat. And I got to learn more about the therapist than they got to learn about me. So in therapy or in treatment situations, there's a a different kind of a stigma that occurs, like I went and it was ridiculously ineffective. So our field still has that notion, uh, still has other notions that you know if we go see somebody uh they may not be any more normal or or healthier than than I am. Uh and so it there's a lot of reasons why people avoid. And what we've done is try to educate people uh a a lot, including through a podcast like this, a lot more about mental health issues and a lot more about what we offer, what really is treatment. And I think it's helped a lot, but still lots of my patients and I know lots of your patients, they still feel like uh uh or have the belief that I wish I was stronger that I didn't need this. I wish I wasn't so weak that I need to come here. I wish I wasn't so in some respects defective that I need help. I wish I was a kind of person who could just go through my whole life on this planet and be in control and not have any issues and not need anybody's help. Now, most people don't feel that way when they need help with their air conditioning system, or they need help with their car, or they need legal help or accounting help or any other help, but when it comes to living life, people still see it as some kind of weakness that they may need some extra intervention or some kind of help.

SPEAKER_00 21:15

You know, sad to say, uh stigma also affects uh uh the mental health providers. I don't know if this is true for psychology, but I know in psychiatry, um I still remember very clearly uh when I was in my last year of medical school, a long time ago, but nevertheless, last year of medical school, uh walking around the wards uh with my white coat on, my stethoscope around my neck, uh, and had already decided that I was going into psychiatry, my classmates would look at me and they'd say, Why you still have that stethoscope? Um, you're not going to be a real doctor. Uh and that that kind of belief system is related to stigma. Uh psychiatry always felt like they were the uh uh stepkids, stepchildren of of of generalized medicine. Um uh it's not it's not real medicine, you're not a real doctor. Um a lot of that influenced by lack of knowledge and stigma. Uh and then the uh the the the general physicians, uh primary care docs or even surgeons who went out into practice realized that forty to fifty percent of their practice turned out to be mental health care without them knowing about it ahead of time. But we were always the uh the stepkids. Um and and that was a problem. Um and and it f for a long time um we felt felt kind of inferior. And I think it also influenced my decision to uh enter into in training a consultation liaison psychiatry, where I spent most of my time on the general hospital wards helping the surgeons and the internists deal with patients of theirs who had emotional difficulties, either coping with the medical problem they had or psychiatric emotional difficulties they had to begin with. And that was a wonderful experience because it was the borderline between borderline between uh organized medicine or surgery and and psychiatry. Um interestingly, that that concept of stigma in mental health, becoming a psychiatrist, uh probably kept back a lot of individuals in medical school from becoming psychiatrists. I mean, in my class of 75 people at uh University of Florida, I think only two or three maybe went into psychiatry. Interestingly now, the numbers of medical students applying to psychiatric residencies is huge. It's just ballooned. I wish I could say it's because of the fact that we're accepted equally among our peers in medicine and surgery. A lot of it, I think, is because of the impact of uh our modern society, the insurance industry, uh, the fact that most uh medicine is becoming corporate. Practices are being bought by hospitals, the venture capital groups, et cetera. So that the experience of being an internist or being a surgeon has is not is not the way it used to be. There's lots of disappointment, lots of burnout, and in many respects, people view psychiatry as a uh better work-life balance, uh more manageable profession. So the that may be one of the major reasons the numbers are going up. I'd like to think it's because uh psychiatry is now viewed on an equal footing with uh endocrinology and dermatology and other specialties in medicine. Um but uh to this day I can tell you that thankfully uh the work we do has been appreciated by our peers in medicine. Um when I started private practice many, many years ago, um, it was my practice with the patient's permission to send out a a letter of consultation to the internist to refer the patient to me. And they would call me up on the phone. That is, the internist would call me off the phone and say, you know, you're the first psychiatrist who ever sent me a letter explaining what was going on, which continued the stigma concept because if the psychiatrist is not going to communicate with the internist who'd made the referral, then it it makes the process this mystical secret, can't talk about it. You know, you know, you must be uh uh need an exorcism or something like that concept. Uh and they were just dumbfounded that I would send out this letter describing what I saw, and then specifically talking about what I thought was wrong and what I recommended for treatment, which at the end of the day helped the uh internist uh in their treatment of the individual. And for me, interestingly, that's the only advertising I ever did. I never at those days we didn't have websites. I never put ads in the paper or anything like that. I just would send out letters, and that's what generated uh uh name recognition and some sense of people knowing what I did. So um our profession has to deal with our own stigma in what we do, and I don't know if it's the same in psychology.

SPEAKER_01 25:45

Uh yeah, to to a large extent. It it it's um we just talk and we don't have uh scalpels and we don't have pills and we don't have x-rays, we talk, and so can't anybody talk? So, you know, to differentiate yourself somehow as uh being able to provide help and treatment that's different than you know a friend could, it it's a real challenge. Um so it's not a stigma exactly, but it is a kind of a uh a problem for the field. Um but you know, the additional thing is I I was thinking, you know that remember that movie uh uh one flew over the cuckoo's nest? Right? Yeah, sadly. And but they never made movies about the one flew over the gastrointestinal unit, you know, or the person who had some kind of uh uh pulmonary problem. Or it's always viewed differently and and in a pejorative way or in uh in a way that uh makes the person look absolutely crazy if they have any issues. So that it it's still there. I mean, I don't know if they're making any movies uh to that degree now, but it's it's still there.

SPEAKER_00 27:01

Well, you know, it it's interesting. Uh psychiatrists had a tendency to kind of make their treatment uh private and you can't talk about it. But psychologists, when I was in private practice or in the early days, had no difficulty getting on the phone with the family doctor who'd referred the patient. And that and that was terrific. And I don't know if it's because of the fact that the psychologists are not MDs and they wanted to communicate with the with the physician to talk about treatment, et cetera. But it made all the difference to the world. And psychiatrists had this, I don't know where it came from. Um I don't know if it came from the Freudian days, but uh they had this notion of keeping it uh quiet and silent. And what made it worse also is the fact that um when I first started to see patients and got referrals from psychologists or mental health professionals who were master's degree in mental health professionals, they would say to me, you know, you're the first psychiatrist who has taken this consultation, seen the patient, communicated with me, and sent the patient back to me. That a lot of the psychiatrists they'd work with uh would hold on to the patient, claiming they could do the psychotherapy just as well as the psychologist uh couldn't. That's not necessarily true, but it's also not the way it should be. If you need to have a team approach, there's nothing wrong with that. In fact, uh my belief is the team approach is even a better way to go than than than uh just taking it on your own. Uh so I hope today's uh discussion has been helpful.

SPEAKER_01 28:22

I just want to add something uh before we finish. You know, you did a little self-disclosure before about, you know, spatial relations and not being good at directionality. So I I I will confess I have the same issue. So much so, you and I years ago, self-disclosure, we were giving a lecture at one of the local hospitals, and we went together and we did a fine job with the lecture. Uh but when we went to find our car and how to get out of the parking lot, it was a disaster. That was one example, and another one was we were just reminiscing about how we were uh sending uh visiting our kids in in sleepaway camp. And uh we did a great job with that because you know we know what we we're good and nice people and we know how to be, you know, warm and all that. But um one of us, which we won't say, uh locked the the keys in the rental car.

SPEAKER_00 29:17

To this day we we we accuse each other of it.

SPEAKER_01 29:19

And so we we uh one of us wore this hat that uh was uh entitled there was a on the cat it said shithead. So we uh we'll just acknowledge that we both deserve to wear that hat.

SPEAKER_00 29:34

And to understand that that none of us are perfect.

SPEAKER_01 29:37

We're not good at that stuff.

SPEAKER_00 29:38

So uh thank you for listening, and uh hopefully hopefully you won't uh hold all that against us. I'm uh uh Dr.

SPEAKER_01 29:45

David Gross, psychiatrist, Dr. Andrew Rosen, psychologist, and this has been Two Shrinks in a Mike. Thank you. Bye bye. The Two Shrinks in a Mike podcast is for informational and entertainment purposes only. The views expressed are those of the hosts and guests and do not constitute medical, legal, or professional advice.