Challenging Stigma: Should Psychiatrists Disclose Their Own Mental Illness?

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Dr Hinshaw notes that there has been progress in discussing mental illness more openly, dispelling older myths and misconceptions, and diffusing some of the stigma.
Dr Hinshaw notes that there has been progress in discussing mental illness more openly, dispelling older myths and misconceptions, and diffusing some of the stigma.

Burnout has become an increasing problem among physicians. A recent Medscape survey found high rates of burnout among medical practitioners, including 42% of psychiatrists and mental health professionals.1 Depression is also extremely common in physicians, who have a suicide rate higher than that of the general population, and even higher than that of other academics.2 There is also a high suicide rate in psychologists, with some studies suggesting that close to 30% have felt suicidal and nearly 4% have made a suicide attempt.3 One study of more than 1000 randomly sampled counseling psychologists found that 62% of respondents self-identified as depressed, and of those with depressive symptoms, 42% reported experiencing some form of suicidal ideation or behavior.4

Beyond the stresses of being a psychiatrist, psychologist, or other mental health professional, there are several reasons some practitioners of these disciplines may be vulnerable to mental health disorders.

"Many people choose to enter the mental health professions, at least in part, because they want to examine their own, or their family's, psychological issues, vulnerabilities, or pain," according to Stephen Hinshaw, PhD, professor of psychology, University of California, Berkeley, and professor of psychiatry and vice-chair for child and adolescent psychology, University of California, San Francisco. 

Dr Hinshaw, who is the author of Breaking the Silence; Mental Health Professionals Disclose Their Personal and Family Experiences of Mental illness,5 told Psychiatry Advisor that all too little attention has been paid to the mental health issues of clinicians. Instead, the topic "seems to be out of bounds, with silence remaining the order of the day."

A 2015 survey of Canadian psychiatrists found that of 487 psychiatrists who responded to a questionnaire, nearly one third (31.6%) said they had experienced mental illness, but only about 42% said they would disclose this to their family or friends.6

Stigma, Silence, and Shame

Mental illness has historically been associated with a stigma, Dr Hinshaw observed, noting that other illnesses were also once stigmatized.

“Cancer was once considered a shameful disease—for example, back in the 1930s, 1940s, and 1950s, one would never put ‘cancer' in an obituary as a cause of death because it was perceived as an illness a person brought upon him or herself as a result of weak moral fiber,” he said.

Today, this is no longer the case. “Look at how far we've come with cancer—for example, in the case of breast cancer, many women have told their stories, and everyone has joined in the fight against this disease,” he said.

By contrast, "we are not anywhere near there with mental health, although there is more openness and more revelation than there once was," he said.

Dr Hinshaw is the author of Another Kind of Madness: A Journey Through the Stigma and Hope of Mental illness,7 which describes his family history of mental illness.

"As a boy growing up in Ohio, I had a wonderful family, except that my father would disappear as though into thin air for months at a time. My mother never told me where he was and I did not know if he was alive or dead," he recounted.

"There was no announcement of when he would return and no explanation, so I got used to the idea that you do not talk about 'bad' stuff."

Dr Hinshaw's father revealed his history of mental illness during spring break of Dr Hinshaw's first semester at college. Initially diagnosed as having schizophrenia, which was ultimately rediagnosed as bipolar disorder, Dr Hinshaw's father was warned that this information was so toxic and destructive that the and his wife were "forbidden" from ever mentioning the topic to their children because the children's "lives could be destroyed if they ever found out."

Dr Hinshaw decided to become a psychologist in part because he had a "mission" to accurately diagnose his father. As a result of his efforts, his father eventually received the correct diagnosis and appropriate treatment.

However, Dr Hinshaw reported, he was ashamed to tell his roommates or girlfriends about his father's lifelong struggle with mental illness because it was "too shameful" and would make him "unfit to be a clinical psychologist."

"It took me years to be able to talk about my family legacy with people I trusted, and several years later, I saw a therapist and finally talked about it."

After being in therapy, Dr Hinshaw decided that, in addition to his clinically oriented research on child and adolescent mental illness, "I needed to engage a narrative and talk about our family's experiences, and my own mental health struggles coming to terms with them, to try to break the silence and break the stigma."

Dr Hinshaw considers himself "fortunate" to have been mentored by Kay Redfield Jamison, PhD, a renowned psychologist and author of An Unquiet Mind: A Memoir of Mood and Madness,8 a memoir of her life with bipolar disorder. "Jamison was a ‘trailblazer' in self-revelation, challenging prior notions of the need for concealment, Dr Hinshaw said.

"Us and Them"

One of the challenges of self-revelation is the judgmentalism of colleagues and fellow mental health professionals, Dr Hinshaw stated.

"When I give presentations about my and my family's story, there are often some embarrassed silences among colleagues, and a sense that you should not really write or talk about this," he recounted.

This reaction "may come from the notion of 'us' vs 'them.' We are the healthy ones, the healers, while they are the patients who are ill and need to be healed. And if you are ill, you are not one of 'us,' you are one of 'them,' and not fit to be a practicing psychologist or psychiatrist."

Dr Jamison described her own experience of self-disclosure similarly, characterizing some of the responses to her book as "quite psychotic and frightening,"9 with several colleagues making it "abundantly clear that it would have been best to keep my illness private," while "others were obviously embarrassed by my disclosure and appeared to have no idea of what they should say or do when in my presence."9

However, she also received hundreds of letters from physicians and mental health professionals expressing appreciation for her publication and describing their own experiences with depression, bipolar disorder, the lack of support from their mentors or colleagues, and too often, their dismissals from medical school or residency programs.9

Moreover, she noted that she was "unusually fortunate" because the chairmen of her departments at the University of California, Los Angeles, and Johns Hopkins in Baltimore regarded her disorder as a medical illness, and were "deeply compassionate and supportive." The harsh letters she received were outweighed by supportiveness, kindness, and understanding.9

"Fitness to Practice"

In her Lancet article,9 Dr Jamison indicated that several individuals suggested "that I had no business writing, teaching, or seeing patients, despite the fact that my illness was well controlled."

Elyn Saks, JD, PhD, associate dean and Orrin B. Evans Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences at the University of Southern California Gould Law School in Los Angeles, spoke to Psychiatry Advisor about her decision to enter the mental health profession.

“I have schizophrenia and benefited greatly from classic psychoanalysis,” recalled Dr Saks, who is the author of The Center Cannot Hold: My Journey Through Madness.10

“Although psychoanalysis is commonly thought to be ineffective in people with schizophrenia, it had been extremely helpful to me during my psychosis and I was interested in being trained as a psychoanalyst and seeing patients myself.”

Dr Saks, who is also an Adjunct Professor of Psychiatry, University of California, San Diego School of Medicine, asked her colleagues and mentors whether her illness might impede her ability to be an effective psychoanalyst. “To my analyst, the real question was if I developed psychosis, would I recognize when I was slipping and have the integrity to stop seeing patients?"

Her advisors expressed confidence that she had sufficient self-insight to recognize incipient psychosis and the integrity not to see patients when impaired.

"I was fortunate," she acknowledged, adding that an article she coauthored described several other medical and mental health professionals who disclosed their diagnosis of schizophrenia and continued to treat patients successfully.11

Dr Hinshaw noted that there is "obviously a middle ground between saying that anyone can practice medicine, psychiatry, or psychology no matter what their mental state or, on the other hand, saying that you are automatically unfit to be a medical or mental health professional if you have a psychiatric disorder.”

Licensure Concerns

Many physicians with mental health problems, including psychiatrists, do not self-disclose because they are afraid of being sanctioned by licensing bodies. A study of 2106 female physicians found that only 6% with formal diagnosis or treatment of mental illness had disclosed their condition to their state.12 A review of medical licensing examinations in all 50 states plus the District of Columbia found that 43 states asked questions about mental health conditions, 43 about physical health conditions, and 47 about substance use.13 There was a greater likelihood of being asked for history of treatment and prior hospitalization for mental health and substance use vs physical health disorders. Moreover, in states asking about mental health, only 23 limited all questions to disorders causing functional impairment, and just 6 were limited to current problems.13

Another study of 5829 physicians found that nearly 40% reported that they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure.14 However, these questions may be in violation of the Americans with Disabilities Act. 15 Court decisions and the US Department of Justice have begun to establish that such questions do indeed violate the Americans with Disabilities Act.16

The concerns of physicians reluctant to disclose are unfortunately well-founded. Steven Miles, MD, an internist, described his own 3-year battle with state licensing officials seeking his private psychiatric records after he self-disclosed a diagnosis of bipolar disorder on a routine relicensing questionnaire, despite no evidence of impairment or interruption in executing his clinical duties.17 The experience inspired him to coauthor a consensus statement on discrimination in medical boards against physicians with mental health disorders.18

The American Medical Association's House of Delegates unanimously approved a Section Council on Psychiatry Resolution, requesting that medical licensing boards refrain from asking questions about a history of mental illness—largely because these questions may deter medical students and trainees from seeking mental health treatment.19

Psychiatrist Kernan Manion, MD, a psychiatrist who lost his license under similar circumstances,17 founded an organization, the Center for Physician Rights, spurred by his own experience to "pursue necessary changes in the administrative legal arena to ensure fairness, prevent abuse of power and, where indicated, promote ethical and compassionate treatment."18 The organization offers peer support and other resources for physicians facing these and other issues with their state medical boards.

A detailed December 2018 article by Jones et al16 reviews current medical licensure questions for each state and their validity under ADA standards and sheds further light on judicial and Department of Justice developments in addressing these concerns.

Disruption of Therapeutic Boundaries?

One reason many psychiatrists and other mental health professionals do not disclose their mental illness is out of concern that this type of self-disclosure is inappropriate and impedes the therapeutic process.

Dr Saks reported that she decided to discontinue her psychoanalytic practice when her book was published.

"When I wrote my book, my analytic institute was divided. As an analyst, one is supposed to be a blank screen, and I did not want patients to be speculating on what was on my mind when the purpose of therapy was their own mental processes. On the other hand, many colleagues felt that disclosure could be beneficial to patients, who might feel more understood,” said Dr Saks, who is a faculty member at the New Center for Psychoanalysis in Los Angeles.

She acknowledged that discontinuing seeking patients was a personal decision on her part, and that both sides of the dilemma are valid.

Dr Hinshaw stated that there has been a great deal of evolution in psychotherapy since the classic "blank screen" model of psychoanalysis or psychodynamic therapy, in which "it would be countertherapeutic for the psychiatrist to disclose anything about him- or herself, much less a mental illness."

Now, however, "we are in a different era of an array of therapies, and I think it is an open question as to how much a therapist should disclose."

The question, he suggested, is "whether the disclosure will help or interfere with ongoing treatment." On the one hand, it may be inappropriate to disclose mental illness because it may place the client in a role of wanting to offer support to the therapist or speculate about the therapist's personal life or illness. On the other hand, "thoughtful and timely disclosures might let the patient know he or she is not alone, mental illness is not infrequent, and even therapists can struggle with their own mental illness." It also directly models that mental illness should not be shrouded in silence and stigma.

John Draper, PhD, executive director of the National Suicide Prevention Lifeline and Executive Vice President of National Networks for Vibrant Emotional Health, told Psychiatry Advisor that the network of national and local crisis hotlines associated with Vibrant originally had a rule prohibiting hotline counselors from self-disclosure.

However, an evaluation of telephone conversations revealed high levels of self-disclosure on the part of these crisis workers, “which was effective in building understanding and rapport, and deterring callers from suicidal activity," he recounted.

The Lifeline's Standards, Training, and Practices Committee therefore revisited the issue of self-disclosure and arrived at 3 parameters.

“The first parameter is that the purpose [of self-disclosure] must be to help the caller feel understood and to build rapport. The second is to foster a spirit of collaboration, so that there is no ‘us' vs ‘them' but a ‘we' who are facing a common problem,” Dr Draper said.

The third parameter is that self-disclosure must “always focus on the needs of the patient or client, and be in the service of the caller rather than the counselor.”

Dr Hinshaw emphasized that the timing and context of self-disclosure are "critical" and advised therapists to "use a lot of self-scrutiny and bring up the issue in supervision" before making the decision.

A Human Face

There have been "real signs of progress" in discussing mental illness more openly, dispelling older myths and misconceptions, and diffusing some of the stigma, Dr Hinshaw pointed out.

However, there is a long way still to go, he warned. "Silence and shame on the part of clinicians, teachers, and researchers perpetuates stigma," he said. "If we cannot even acknowledge our own sources of interest and inspiration to enter this field or our own vulnerabilities, how can we accept corresponding experiences in our patients and encourage them to challenge stigma in their lives?"

Dr Saks agreed. "The best way to reduce stigma is putting a human face on mental illness, not just showing that it is a biochemical disorder. When clinicians come forward with their stories, it goes a long way toward helping people chip away at the stigma."

References

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  2. Anderson P. Physicians experience the highest suicide rate of any profession. Medscape Medical News. Available at:  https://www.medscape.com/viewarticle/896257#vp_1. Accessed; December 12, 2018.
  3. Kleespies PM, Van Orden KA, Bongar B, et al. Psychologist suicide: Incidence, impact, and suggestions for prevention, intervention, and postventionProf Psychol Res Pr. 2011;42(3):244-251.
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  7. Hinshaw SP. Another Kind of Madness: A Journey Through the Stigma and Hope of Mental Illness. New York, NY: St. Martin's Press, 2017.
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  10. Saks E. The Center Cannot Hold: My Journey Through Madness. New York, NY: Hachette Books, 2008.
  11. Frese FJ 3rd, Knight EL, Saks E. Recovery from schizophrenia: with views of psychiatrists, psychologists, and others diagnosed with this disorder. Schizophr Bull. 2009;35(2):370-380.
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  13. Gold KJ, Shih ER, Goldman EB, Schwenk TL. Do US Medical Licensing Applications Treat Mental and Physical Illness Equivalently? Fam Med. 2017;49(6):464-467.
  14. Dyrbye LN, West CP, Sinsky CA, Goeders LE, Satele DV, Shanafelt TD. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017;92(10):1486-1493.
  15. Schroeder R, Brazeau CM, Zackin F, Rovi S, Dickey J, Johnson MS, Keller SE. Do state medical board applications violate the Americans with disabilities act? Acad Med. 2009;84(6):776-781.
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  17. iles SH. A piece of my mind. A challenge to licensing boards: the stigma of mental illness. JAMA. 1998;280(10):865.
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