Stigma and the Ailing Physician. Part 3

I want to continue and conclude this series of blog entries by describing two types of stigma, enacted and felt. Although these terms were originally used to describe stigma associated with epilepsy (1), they can be extended to mental illness. Enacted stigma is exterior and refers to discrimination against people with a psychiatric illness because of their perceived unacceptability or inferiority. Felt stigma is interior and refers to both the fear of enacted stigma and a feeling of shame associated with having a mental illness. I believe that both types of stigma can be at play when a symptomatic physician decides to seek treatment.

Examples of enacted stigma tend to be more systemic (lack of parity in health insurance coverage and reimbursement, exclusion clauses in disability insurance contracts, contested dismissal of residents from training programs) than specific to the doctor-patient relationship. But this does happen, albeit uncommonly. A psychiatrist friend of mine who has zero felt stigma about his recurrent major depression had a very uncomfortable experience with a new psychiatrist he consulted in his home city. The psychiatrist was quite belittling and critical of him for not disclosing his “precondition” during interviews for psychiatry residency. Although my friend was asymptomatic all through training and completely adherent to treatment over that span of time, he was made to feel fraudulent and diminished by this doctor. Needless to say, he went elsewhere for treatment.

Felt stigma can manifest itself in many ways in the treatment relationship. First, physicians who feel ashamed of having a mental illness will be inhibited and less forthcoming. They may be embarrassed to disclose key pieces of their personal and family history or to talk about certain symptoms like symptomatic drinking, abortive suicide attempts, homosexual cruising, compulsive viewing of pornography, and so forth. The treating psychiatrist may not get a true picture of the illness complexity and severity.

Second, even well-intentioned physician-patients may be less treatment adherent. They miss or cancel appointments. They ‘forget’ to take their medications or take them haphazardly. They assume a passive attitude to treatment rather than a collaborative and participatory one. They resist engaging in psychotherapy, especially explorative or insight-oriented modalities.

Third, they bolt from treatment at the first signs of symptom amelioration because each visit with the psychiatrist or each pill is a reminder that they are undergoing psychiatric treatment. A variant of this are physician-patients who seduce the psychiatrist into believing that they are far more improved than they really are, so visits are spaced out prematurely or treatment is suspended. And fourth, because of felt stigma, these same patients are reluctant to return for treatment when or if they relapse because they feel they’ve failed and they are ashamed of their “acting out” regarding the previously prescribed treatment.

What’s the bottom line? Be patient and empathic with doctor patients. It takes time to accept a stigmatized illness. Our compassion conveys a message of acceptance and understanding, something they are still struggling to internalize. 

References 

1. Scambler G, Hopkins A. Being epileptic: coming to terms with stigma. Sociology of Health and Illness.1986;8(1): 26-43.

Dr. Myers is Professor of Clinical Psychiatry and immediate past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, NY. He is the author of seven books the most recent of which are “Touched by Suicide: Hope and Healing After Loss” (with Carla Fine) and “The Physician as Patient: A Clinical Handbook for Mental Health Professionals” (with Glen Gabbard, MD). He is a specialist in physician health and has written extensively on that subject. Currently, Dr Myers serves on the Advisory Board to the Committee for Physician Health of the Medical Society of the State of New York. He is a recent past president (and emeritus board member) of the New York City Chapter of the American Foundation for Suicide Prevention.  

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.