Note: This was written as an assignment for my course in applied mental healthcare ethics.

The sounds of inpatient mental health wards are haunting.  The screams of inpatients, the sounds of heads banging against walls, and the shuffling feet are the sounds of the anguished and of the socially dead.  After my abusive husband who had emotionally and physically beaten me down to the point I believed I was nothing, told me he was leaving, I attempted suicide and was hospitalized.  First in the pscyh ward of a local hospital, then in a state psychiatric institute.  I was fortunate, in that my total time in these institutions was only two weeks, but it was enough to make an impression and to introduce me to places where people are warehoused and medically chained to keep them from inconveniencing others.  I was fortunate in that I had a college degree, had been in therapy, and my mental health problems were situational.  As a result, I realized that if I wanted to get out, I had to “stow the crazy” and say all the right things to get out of the hospital.  I did and although there are days I still have suicidal ideations, the memory of being warehoused keeps them in check.

My daughter has bipolar and in 2013 she had a psychotic break which resulted in her being hospitalized I the pscyh ward of an inner city Chicago hospital.  Many of the people on the ward were housing vulnerable and due to budget cuts, the dismal state of healthcare in the United States, and a variety of other factors, the unhoused were stabilized and sent back to the streets.  They may have been given prescriptions, but with survival the number one priority, they often did not take these meds and the pscyh ward became a revolving door of people being stabilized, released, and readmitted.  My daughter was fortunate as she had private insurance and an amazing doctor who worked to get her meds stabilized.  She also had a loving and supportive family to go home to.  This meant that she was able to recover and is living a productive life in a loving home.

Social death occurs when someone is not accepted as fully human and as a result lose their social roles and the key components of their identity (Salhi & Osborne, 2021, p. 202).  Key aspects of social death include the loss of one’s social identity, or how you are perceived in the world, the loss of relationships,  the inability to take part in daily activities, the loss of agency, and losses associated with the disintegration of the body (Borgstrom, 2017, p. 5).  The mentally ill face this both within institutions and in society in general.  I know that after my stint in the pscyh ward, I lost social standing people acted as if I was invisible and scary.  And I know that my daughter continues to battle social death to a certain extent, especially by the medical profession.  She is treated as if her physical complaints are not real and are a symptom of her bipolar.  In someone who is not as fierce as she is, this could lead to a loss of agency as she would receive subpar care.  However, she refuses to let her agency be stolen and will switch doctors if she is treated as less than.

Our society as a whole also dehumanizes the mentally ill, especially those unfortunate enough to not have resources.  Walk down any busy city street and if you really pay attention, you will see mentally ill people lying on the sidewalk, talking to themselves, or behaving erratically.  Most people look away or look disgusted by the mentally ill.  Even mentally ill people who are fortunate enough to have resources to treat their mental illness, are in some ways treated as socially dead.  Although Senator John Fetterman received support and praise for being honest after he announced he was seeking treatment for depression (Richard, 2023), others have called him unfit to serve due to his mental health (ECarma, 2023). 

The Clinical Encounter

Clinical encounters between physicians / health care workers and the mentally ill can occur in a variety of situations including in the emergency department, in the psych ward, and in a doctor’s office.  While there are similarities in each of these encounters, there are also differences.

Emergency Department

When my daughter had her psychotic break, she was initially taken by ambulance to a public hospital near her home.  Her brain was trapped on a repetitive loop and she was continually repeating phrases.  Once we got to the hospital, despite my telling the triage nurse that she had bipolar and that we had called her physician, we were repeatedly asked “what she was on.”  She was treated as if she was disposable and as if she didn’t matter because the physicians assumed that she was on drugs.  While in the emergency department, I saw people who  were clearly mentally ill, but who seemed to also have physical complaints.  However, because they could not articulate their pain, they were not treated with respect and it seemed as if the goal of the physicians was to get them out of the ED as soon as possible. 

I took my daughter out of that ED and we went to the hospital where here psychiatrist practiced and she was treated with respect and admitted to the pscyh ward immediately.  However, I don’t believe she would have received this treatment if her doctor had not called ahead and given orders she was to be admitted.

Mental Health Ward

Similar to what occurs with incarcerated inmates, the physical complaints of people on mental health wards are often not taken seriously.  While visiting my daughter, I saw people complaining of physical complaints being ignored or treated as an inconvenience.  This echoes how incarcerated patients are taken to the ED and treated as difficult or inconvenient with their complaints ignored.  Just as inmates are labeled as confrontational when they try to advocate for themselves and demand treatment (Salhi & Osborne, 2021), mental health patients were treated as malingering or as noncompliant when they advocated for themselves.

Doctor’s Office

Some of my daughter’s worst encounters have been with mental health professionals and with other health professionals.  When we first moved from Chicago to Cleveland, she sought care at the Cleveland Clinic.  She was initially enrolled in group medication review sessions against her wishes and when she pushed back and said she would prefer individual sessions, she was labeled noncompliant.  She has also encountered prejudice at other doctor’s offices where as soon as they learn she is bipolar, they start treating her physical complaints as if they are psychosomatic.  She is fortunate that she has learned to advocate for herself, but it is disheartening to have people in the medical profession treat her as less  than human because of her mental health diagnoses.

Restoring Humanity

The remedies for the social death of the mentally ill are similar to those outlined by Bisan and Osborne (2021):

• Clinicians can identify their own biases and look for ways to emphasize and advocate for their mentally ill patients.
• Clinicians should look beyond bad behavior to look for a reason for belligerent or angry behavior. This will require physicians to come from a place of empathy for their patients.
• Organizations can require that clinicians abstain from labeling patients as belligerent or confrontational or other terms that may create stigma.
• Clinicians can stop labeling patients as noncompliant when they ask questions or ask physicians to consider another course of treatment.  A patient may be med non-compliant if they do not take their medications, but questioning a course of treatment is a sign of agency and within a patient’s purview.

My daughter was incredibly fortunate that she had a psychiatrist who believed in her and who treated her as a human being no matter how sick she was.  I remember her sitting in his office insisting that she had had brain surgery and he pointed out how that hadn’t happened as she still had all her hair.  He then went on with the conversation.  He was non-judgmental and compassionate and I firmly believe that if it wasn’t for him, my daughter would have been lost to suicide or would be lost in her mental illness.

References

Borgstrom, E. (2017). Social Death. QJM : monthly journal of the Association of Physicians, 5-7.

ECarma, C. (2023, February 17). FOX NEWS PUNDITS SEEM HELL-BENT ON PUNISHING JOHN FETTERMAN FOR HAVING DEPRESSION. Retrieved from Vanity Fair: https://www.vanityfair.com/news/2023/02/fox-news-john-fetterman-depression

Richard, L. (2023, February 17). Cruz extends support after Fetterman checks into hospital for clinical depression: ‘Mental Illness is real’. Retrieved from Fox News: https://www.foxnews.com/politics/cruz-extends-support-fetterman-checks-hospital-clinical-depression-mental-illness-real

Salhi, B. A., & Osborne, A. D. (2021). Incarceration and Social Death — Restoring Humanity in the Clinical Encounter. The New England Journal of Medicine, 201-203.