Monday, September 6, 2010

Stigma of Mental Illnesses and Excessive concern with privacy

One occasionally comes across a patient who places a great premium upon privacy. He does not want your secretary to call his house to remind him of his appointment. He is especially disturbed if your secretary leaves the message about his appointment with a family member or on the answering machine. In the office, he reverts to hushed tones when he is criticizing others or talking about sexual matters as if the subject of his criticism or sexual desires can overhear him, even if they are hundreds of miles away. He periodically wonders if your secretary or other patients in the lobby can overhear what he is telling you. When you are writing a letter to his work for something like medical leave he does not want you to let them know that you are more than a MD and a psychiatrist, and certainly does not want you to mention that he is on psychiatric medications. One such patients refused to go for sleep study in the hospital which is across my office, preferring to go across the city, on grounds that the neighborhood will overhear his snoring if he sleeps in the hospital here instead of the hospital yonder. In short he is ashamed about having a mental illness and wants to hide that fact from the world.
Now the public relations department of the American Psychiatric Association will tell you that all this is result of that nefarious "stigma" - a word which has reached the status of a battle cry among the rank and file of that association and something they all feel noble fighting about - attached to mental illnesses. The official position of the APA is that this stigma has no psychological basis and if we all pretend and assure each other that mental illnesses are no different than other medical illnesses the problem will just go away.
A man is not ashamed to declare that he has been stricken with a serious heart attack or cancer; illnesses that leave him far more handicapped, and debilitated, and which should make him far more cautious about admitting to their existence in himself than something like obsessions or anxiety which at least in their initial stages cause hardly any limitations.
Yet it is only mental illnesses that a man is terribly ashamed of and feels as if some great secret will be exposed, and he will be humiliated in public, if he admits to having them.
In a few patients who showed this excessive concern with privacy I was able to establish that this sense of shame was intimately connected to masturbatory activities. It is not necessary that the patient is actively indulging in it. He may be just tempted towards it or vigorously struggling against it or just practicing it in his thoughts. Mental symptoms, at least those which are not due to gross injury to the brain, are substitutes for frustrated sexuality. Since frustrated sexuality finds satisfaction either in perversions or in neurotic formations, and often finds discharge in auto-erotic activities, a person is ashamed of these formations (mental symptoms).
Stigma of mental illnesses is at bottom mankind's shame with sexuality and masturbation.
An interesting fact about these patients of mine who show the greatest concern about privacy, they all have shown themselves to be primarily Obsessional Neurotics.
Now we know that obsessional neurotics show the greatest predilection for discharging their sexual tensions through masturbation. Much of their compulsions and other rituals are displaced and elliptical imitation of touching their genitals and vigorously fighting against it. Behind this struggle lies their fear that by touching they will cause harm to the person touched. These obsessive patients of mine with great concern for privacy as a rule refuse my offering them coffee at the beginning of session to avoid any touching and to avoid getting poisoned by me. They show equal concern in giving me anything lest they poison or kill me.
Now this paranoid/compulsive behavior throws some light upon their concern for privacy. In their masturbatory thoughts sadistic destructive thoughts predominate. They are full of thoughts of causing harm, especially death, to others. It is this that they are really ashamed of.
Also they do not want the world to know as to how much death wishes they have towards everybody in general.
Now in their conscious thoughts they have hardly a clue as to how much destructiveness towards others they possess. In fact in their conscious mind they see themselves as very kind, conscientious fellows who will give the shirt off their back to help others. And this is generally true of their actual behavior or at least most of it. A lady, not a patient of mine, was the greatest do-gooder in her community, and who was excessively concerned about all kinds of privacy regarding people knowing her business in the region where she practiced her philanthropy. Behind the philanthropy there were lot of anger and rage against the elected officials of that region, against whom she was discharging her obsessional destructiveness, but which she wanted no one to get a whiff of.
Now these privacy lovers are most concerned about their family knowing that they are seeking treatment.
Because these patients communication in the session is invariably about their obsessions and compulsions. [ On examining they overwhelmingly show themselves to be destructive/erotic thoughts towards their family members.] No wonder they do not want the family to have any clue that that they are talking such evil stuff about them in therapy.
In this context it is worthwhile to mention how privacy has become such a great issue with the banks/investment firms, the medical industry and the American government. Now we know how banks took the whole world for a financial ride, in secrecy, causing so much destruction and misery. No wonder they make so much fetish out of privacy and to assure you as to how conscientious they are about guarding your money from unscrupulous folks, while in reality they have been the biggest looter of your money.
Doctors and insurance companies show similar fetish about informed consent and transparency about side effects of drugs, and research trials and medical procedures, trying to convince you that everything is being done according to rules and ethics, while in reality most of their rules and show of ethics are how to secretly milk their patients to bare bones in name of practicing high class medicine.
The government's increasing fetish with privacy is to deflect our attention from its ever widening intrusion in to our lives, including now the right to spy upon us 24/7.
Just one last point about stigma of mental illnesses. Is there a justification for the world to attach stigma to mental illnesses? The psychiatric profession will consider it sacrilegious for any of its member to question such a sacrosanct war cry for the patients, but the truth remains that the world will always consider mental illnesses as something on which a derogatory value judgement should be attached.
And they are to some extent right.
People instinctively know that mental problems are not entirely chemical imbalance or genetic problems or something in which the sufferer is totally innocent.
They sense behind those mental symptoms there are aggressive designs and desire to harm society or at least not be a part of it [a neurosis is finally nothing but a withdrawal from the world and to find satisfaction in one's private world.
It is for this reason the world holds mentally ill with contempt.

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