It is estimated that in the United States alone, approximately 43.7 million adults (18.6 %) have a diagnosable mental illness, yet only half receive treatment. This could be the collective result of a multitude of socioeconomic factors that limit access to health care (1 – socioeconomic restrictions). But what are the main impediments to seeking treatment among those with the means to do so? It could be that most forms of mental illness by their very nature impair one’s ability to recognize that they have a problem to begin with, such that those afflicted lack sufficient insight into their condition to think that their particular set of problems warrant medical attention (2 – lack of insight). Let’s say we’ve now accounted for about 2/3 of those 21.85 million who don’t seek treatment - and yes I’m making that number up because I don’t have the statistics on this, but humor me for a bit - what about the other approximately 7.283 million? I would venture that shame plays a significant role in the reluctance of some individuals to seek treatment for a mental disorder (3 – shame). And in large enough doses, shame may even evolve into the sort of self-deception that leads to rationalizations for maladaptive and destructive behavior, ultimately culminating in what is commonly referred to as lack of insight. So in fact, shame may account for an even greater share of the untreated population than originally estimated.
But what causes shame? The stigmatization of mental illness can be traced back to the dawn of civilization, and its effect is so sweeping and pervasive that it permeates our culture at almost every level. Whether it be at school, at work or at family gatherings, significant deviations from behavioral norms are treated as serious moral failings, and this form of social control becomes internalized as shame. And this is mostly a good thing – we wouldn’t want it to become socially acceptable for someone to run you off the road or stab you eye with an electric toothbrush. Social deterrents for violent or other seriously harmful behavior are desirable, but where do we draw the line? Why do we feel ashamed for hearing voices or being too depressed to get out of bed in the morning? The answers to those questions are beyond the scope of this blog post, but maybe I’ll get back to them at a later time.
As it turns out, shame and mental illness are inexorably linked. They form an insidious web of reciprocal and mutually reinforcing bonds that effectively subdue and paralyze their victim. And shame arises not only from the stigma of being mentally ill, but often has its roots in childhood trauma, abuse, marginalization, bullying, ostracism, and neglect, the very things that are thought to cause mental illness in the first place. Thus shame causes mental illness, and mental illness, by way of social stigmatization and marginalization, produces shame.
And shame is a definitely one of the main reasons I don’t like to admit to anyone, except in rare circumstances, that I have any form of mental illness. I have never, for instance, called in sick because I was too depressed. Or because I couldn’t bear the thought of being seen or spoken to by another human being. Or that I had just ravaged my face with a pair of tweezers because I noticed some spots forming on my chin. But in fact, I have done all of those things. I typically make up a “legitimate” or organic illness as a cover story for my depression, my social phobia, or my dermatillomania. I can’t go out to dinner because I have food poisoning, or I won’t be able to meet up for drinks because being in the presence of others makes me feel like crawling under a rock. The truth is, I’m tired of having to lie all the time about what’s really bothering me. The shame of it all actually exacerbates the underlying problem, such that I’m afraid to reveal almost anything about myself to others lest they be able to use that information to make inferences about my emotional state or lack of social adjustment. I don’t like people to see where I live, or ride in my car, or even meet my friends, family or significant others. What will this person reveal about me to the people I have to hide my “real self” from? The people close to me know things about me that others can’t know, so by some weird transitive property everyone will know everything and I’ll have no more secrets. My house is full of books and movies about mental illness, suicide and deformity (due to my BDD), so just a cursory glance at my bookshelf will tell a person more about me than I’d ever want them to know. Better to be reclusive and have everyone assume that you’re just an antisocial snob. The freak they know is probably better than the freak they don’t know.
Not only does it keep me at arm’s length from other people, but it has hindered any sort of therapeutic process as well. There are things I simply can’t talk about with a therapist without fear of their judgment and eventual condemnation. Unfortunately therapists are only human beings, and the same rules that govern my interactions with other people apply to them. And censoring myself in therapy just seems too counterproductive to justify the cost and inconvenience. So I don’t go to therapy. I just learn to cope with things in my own maladaptive, self-destructive way, and I suspect a lot of other people do the same.
So why is mental illness so undertreated? Maybe a better question is why do we hold people with mental illness in such low regard? At times it feels like one small step above being a convicted criminal. But mostly I think it reflects the fact that we are still pretty much in the dark ages when it comes to mental illness, both scientifically and politically. From institutionalization, the denial basic human rights and dignities, forced drugging and electroshock treatments, and even gun legislation. From a socio-cultural perspective, we still operate under a lynch mob mentality regarding the mentally ill, the best examples arising in the aftermath of some mass shooting tragedy. Truth be told, people with severe mental illness are more likely to be the victims of violent crime than the perpetrators, so denying them the means of self-defense doesn’t really solve anything (unless your goal is to get them killed off faster, but we’ll save negative eugenics for another post).
