I have grappled with dual thinking about physical and mental illness for years, both professionally and personally. I had dared to hope that things were improving slowly, that mental illness was better accepted, if not understood, by the general population in the UK, even if not by the medical profession.
Unfortunately I feel forced to re-evaluate after some recent events. It is clear that long term opiate use, initiated by doctors for chronic pain, and inevitably leading to dependence, is not regarded as illness, but a matter of lifestyle choice. There is no recognition that the person may still have the pain for which the opiate was prescribed; they are viewed in the same highly judgemental light as the street drug user (who of course also has a mental health problem). Alcoholism, despite the increasing publicity about the risks of heavy drinking, is also seen as a matter of choice, with the associated implication that the sufferer is somehow weak, lacks morals, selfish, and other negative attributes.
Medically prescribed opiates can lead to the same physiological and psychological outcomes as street-obtained opiates, with the difference that the user can obtain their drugs legitimately and know that their drugs are pure and reliable in effect.
When acute physical illness supervenes for the opiate dependent patient it seems that there are broadly speaking two responses. Either the medical staff completely ignore the opiate use and fail to understand that there may be significant implications for management of the physical illness, or there is a judgemental response (from nursing staff, relatives, and sadly sometimes medical staff. It is the latter that has particularly dismayed me as I have witnessed a range of negative views, varying from “if they are serious about getting better they will stop the opiates now” to “the (serious and unrelated) physical illness isn’t really the problem, it is all down to lifestyle.” The most negative response is “s/he shouldn’t be wasting NHS money when s/he has brought all this on her/himself”.
This takes us back to the still pervasive idea that mental illness isn’t ‘real’ – certainly not in the way that physical illness is. Those suffering with mental illness should be able to ‘snap out of it’, ‘get their act together’, ‘get busy so there isn’t time to navel gaze’. Many still deny that addiction disorders are illnesses – some of these same people think that anorexics should ‘just stop messing around and start eating properly.’ I have seen an adult child disown their parent (with a life-threatening illness) because that parent has substance dependence as well. The reality of the life threatening illness is denied by the adult child despite irrefutable medical evidence, and the belief that the dependence is a matter of choice is unshakeable.
Doctors in acute hospital medicine remain woefully ill-informed about mental illness of all types, their scanty information dredged up from their medical student days. For some this predates the closure of the asylums. Prejudice against psychiatry stems from ignorance and, still, fear. Fear that mental illness, still ill-understood and uncontrolled, could affect any one of us. It is not surprising that doctors with mental illness still try to hide this from colleagues, seeing it as a stigmatising diagnosis in a way that a chronic physical illness would not be.
Failure of doctors to recognise mental illness as equally important and relevant as physical illness is detrimental to patient care. There is no point in performing batteries of tests, prescribing exotic and expensive drugs, and possibly carrying out intricate surgery, if the patient’s mental illness goes unrecognised. If doctors fail to ask the right questions – about lifestyle, drug consumption (prescribed or otherwise), mood etc, then they will fail to gather all information available. Of course, patients may lie, deliberately or otherwise (I certainly have), and it may be appropriate to seek further information from friends or relatives (with the patient’s permission). All of this requires time and trust – neither of which seem to be readily available in 2016. Time is in short supply for us all, our lives become busier and busier despite (or because of) modern technology.
Trust is another matter. Trust is built up over time. Trust comes with continuity of relationship, both personal and professional. Trust means knowing that you can admit your mental illness to yourself and to others without shame or fear. Trust means knowing that you can proclaim that mental illness has equal validity and standing with physical illness, and that both you and others will really believe this.
I have been fighting for this parity of esteem for mental illness for nearly twenty years. I feel sad and despairing when confronted with evidence that people that I know well still don’t accept it. I will continue to trust optimistically.