How Are You? The Medical Price of Societal Norms

by Nevin Sastry

How are you doing today?

It's a harmless question with any number of answers. But most people would have to be speaking with an immediate friend to answer, ”sad.” I will be the first to admit that I answer, “good,” or some variation, as a response when I am, in fact, feeling sad, upset, or anxious. “I'm good” is the go-to answer when it comes to those acquaintances whose names I can’t remember—I would almost certainly be ostracized if I complained to everyone about my problems. Still, with friends, there is some societal expectation to be honest about one’s emotional state, at least to a point. Would anyone still answer this question honestly if the true answer was “psychotic” or “suicidal?”

The public intuitively avoids discussing these touchy situations because of their inherent awkwardness, but this frame of mind is the culprit of one of the greatest medical problems in the world. Our culture resents dialogue on psychiatric illness. We know people are depressed and that suicide, homicide, and self-inflicted injuries are significant problems, but we struggle to acknowledge how close these tragedies can affect us personally. The result of this ignorance can be catastrophic.

I witness this problem with relatively high frequency as a Nurses’ Aide in Western Psychiatric Institute and Clinic (WPIC.) Patients come and go frequently from WPIC, as it is an institution intended only for a seven to 10 day turnover rate. Incidentally, the frequency of suicidal ideation as a diagnosis is stunning, to say the least. I’ve had the privilege of experiencing extremely in-depth interactions with suicidal patients. One was a mother of three whose daughter had a stroke and died; the mother blamed herself. She believed if she could end her life by a forged accident, her life insurance policy would help her family out of debt. When I asked her about her other children, she insisted that they would “get over it.“ Another patient had just undergone a divorce—if it weren’t for a quiet little suicide note he sent to his friend, he would have almost certainly died. He was found with the drugs he intended to overdose with and was sent to the hospital.

I sometimes lament the fact my job exists, because in the end a psychiatric hospital exists as a last resort: a place to prevent individuals from hurting themselves or others at the cost of some basic freedoms. A WPIC patient cannot leave the building, cannot go to the bathroom without assistance, and has to be observed by a staff member on the unit at all times. Such extreme conditions are often mandated for people who have gotten as far as tying the noose or swallowing the whole pill bottle. These individuals are then placed in this hospital until they have received what is systemically considered ”acceptable treatment.” This handling is not necessarily the most desirable treatment—someone with plans to have died on Tuesday is probably less pleased than most to be stripped of his freedoms on Wednesday.

Most people who reach this point have never had a real dialogue about mental illness. This lack of conversation is the outcome of society's fear of discussing psychiatric disorders. I might go so far as to say it is the outcome of our general desire for everyone as individuals to be ”sane.” That mental illness (and those who suffer from it) has amassed a negative connotation in the public eye is not mere speculation: a 1977 study conducted by Steward Page of Lakeshore Psychiatric Hospital (Toronto) and published in the Canada Journal of Behavioral Science gave definitive results that indicated a strong public bias against psychiatric patients. The study consisted of 180 phone calls from a recruited female to a landlord, asking about an advertised room for rent. In the main test cases, the caller would say she was a patient at a mental hospital that was being released soon and was looking for a place for rent. In addition, there was a condition in which the caller claimed to be inquiring about a room on behalf of her brother who would be released from a mental institution in two days. In control cases, the caller would simply ask about the room for rent, not mentioning anything about psychiatric hospitalization. Responses to the caller were recorded and scored as being either positive, negative, or unsure.

The results indicated that there was blatant discrimination against those callers identified with mental illness. Furthermore, not only were the callers with apparent mental illness stigmatized in comparison to those who presented without it, but also the reaction to the mentally ill was on par with the reaction against someone who was a “criminal.” Analysis confirmed that significantly more positive responses were obtained in control conditions than either of the other cases, and it was found that a caller was more than three times as likely to be refused the accommodations when the “mental illness” label was used.

It may seem reasonable that landlords find people with mental health problems less-than-ideal tenants. However, the idea itself is the result of an assumption that the mentally ill are deficient citizens. Many mentally ill people are extremely adept at their careers. Kay Redfield Jamison, Ph.D., is a professor of psychiatry at Johns Hopkins, who suffers from bipolar disorder herself. Her work is dedicated to breaking down the stigma of psychiatric illness:

“The problem with mental illness is that so many who have it—especially those in a position to change public attitudes—such as doctors, lawyers, politicians, and military officers—are reluctant to risk talking about mental illness or seeking help for it. They are understandably frightened about professional and personal reprisals.”

This idea of “us vs. them” in the context of the psychologically ill is dangerous; it keeps us distanced from each other and encourages a continued silence between the “sick” and the “sane.” The alienation of people with mental illness and the subsequent social stigma brings in tow a kind of misunderstanding of psychiatric phenomena.

It may seem as though there is no way to eliminate the fear of discussion surrounding this topic, but there is hope. While part of the blame for this unfortunate phenomenon may lie in those who suffer from suicidal ideation and their unwillingness to talk, there are distinct problems stemming from the public side that nurse the continuation of this phenomenon.

One significant hurdle is the expectation for a depressed person to “feel better” after they’re given advice by a listening party. Unlike the antibiotics for bacteria, combating depression is an internal mental wrestling match. Therapeutic intervention is not designed to be easy, but rather extremely taxing for the patient undergoing it. As such, the listener who expects, whether consciously or unconsciously, a depressed person to jump into happiness may actually contribute to the guilt a depressed person has for being in this state to begin with.

Our strongest power in this fight is that of empathy. As Pitt students, we see efforts every year to raise awareness for this unfortunate problem. Upperclassmen present for the bomb threat terrorism two years ago remember the trauma and stress of being repeatedly kicked out of their dorms in the middle of the night. They may also remember the shooting that occurred at WPIC. And, according to the National Institute of Mental Health, a staggering 26.2 percent of people over age 18 suffer from a diagnosable mental disorder. If mental illness is so close to home, then we should stop treating it as something alien. Maybe we don’t need to answer “how are you?” truthfully every time, but taking the courage to tell someone when you are not doing as well as you could be is a step in the right direction. Furthermore, if someone has the courage to talk about their mental afflictions to you, having the patience to listen, without the blind need to instantly heal, can help the fight against stigmatization of mental illness day by day.