In medicine, mental health has traditionally been “displaced” from physical health, cordoned off into its own, often devalued, category. Working as an internist in a mental health clinic, however, I often sense the reverse—the physical health displaced from the mental. Patients are there primarily for their psychiatric issues, and other medical concerns seem secondary.
Of course, displacement is almost always a defining feature of the patients here. Many have lost their jobs because of their illnesses and are now unemployed or on disability. Others have needed to move away from their families—or been kicked out—and live alone. Many of the medications used to treat the psychiatric disorders have major side effects that change how patients’ bodies feel—adding weight, depleting energy, causing tremors. In other instances, the displacement is more subtle. Even those with good jobs and housing may feel out of sorts socially, struggling with friendships, dating and going to the gym.
In one sense, my job with psychiatric patients is little different from the “regular” patients I take care of in the medical clinic: I treat their asthma, hypertension and diabetes; try to get them to stop smoking and drinking; and push for screening tests like mammograms and colonoscopies.
But there are times when displacement renders screening almost ridiculous. How important is a Pap test for someone who is actively hallucinating? Who can think about their cholesterol level when they’ve just lost their housing? And sometimes the pain of mental illness is just too much to bear. When I talked to one patient about stopping his two-pack-per-day smoking, he told me, “It’s the only pleasure I have.” On these days, I ignore the recommendations from the U.S. Preventive Services Task Force in favor of just sitting and listening.
But I also know that psychiatric patients have historically been shortchanged when it comes to their non-psychiatric medical issues, so I need to be careful that a sympathetic ear does not replace appropriate medical care. Even if patients live in shelters or have trouble leaving their homes due to depression or agoraphobia, they should not miss out on tests, such as colonoscopies, that are proven to save lives. True, it can be challenging to arrange for such tests for some psychiatric patients, but that is not a reason not to try.
In fact, some of my most incisive discussions about screening and treatment have taken place in the psychiatric clinic. Perhaps because these patients have so much experience with the health care system, they push me especially hard to justify what I am recommending. In such instances, there seems to be little displacement at all—just two people having a complicated chat about how best to proceed.
While the sense of displacement is a dominant theme for many patients with mental illness, we—both medical staff and the general public—should be careful not overemphasize it. To do so is to potentially reify such individuals as “the other,” further isolating and marginalizing individuals who already carry an unfair burden of pain. Psychiatric illness is not walled off from the rest of illness; symptoms such as anxiety and depression weave through much of the population.
To be ill is to be displaced—displaced from health, displaced from one’s former self, displaced from the community of the well. (Virginia Woolf wryly described those who are ill as “deserters” from “the army of the upright.”) Mental illness can exert an especially potent displacement, as it can evict elements of personality and sense of self. Health professionals need to pay close attention to how our patients’ medical and social conditions potentially alienate them from the daily rhythms of life.
But displacement cuts both ways. We must be careful not to further displace patients by overemphasizing the challenges they confront. It is a precarious balance. For patients—and their caregivers—it is a constant negotiation of the unsettling penumbra between health and illness.