Darkness Visible

People with mental illness often seek professional help. But what happens when professionals also have psychological problems? How do they overcome the stigma and the stress? And can mental illness actually make them better therapists?

"During an attack it was easiest for me to be with religiously observant patients," laughs S., a clinical psychologist of 45 who has been coping with bipolar disorder (manic depression ) for more than 20 years. "They thought the messiah is the Lubavitcher Rebbe and I thought the messiah was me. There's not such a big difference!"

S. was 17 when she began to have psychological problems. After a few bewildering weeks her condition improved, and she and her family labeled the event as an unclear but passing phenomenon. After high school she did her army service without any special problems and went on to study psychology; as an undergraduate she did volunteer work at Enosh, the Israel Mental Health Association. To the young student, the mental patients whom Enosh helped rehabilitate seemed to come from a different world.

Mental illness
Alex Zhitomirsky

As a master's student, however, S. fell into depression. This time she sought treatment, in the course of which she entered a manic period and received a professional diagnosis.

"I am not traditionalist or from a religious home," she says, "but my attacks of mania tend to have a messianic, religious and national content. I feel I have special powers; suddenly the world is filled with hints that are aimed at me - everything connects and interrelates, and is charged with meaning. It's extremely tiring."

S. tried to conceal her inner mental chaos from her colleagues, but it wasn't easy. "After all," she relates, "I was surrounded by professionals who are experts in identifying such cases."

It was not until a few years ago, when she completed her residency at a state mental health institution that she felt sufficiently confident to dare to reveal her situation. "I felt that it was a part of me that should not be hidden," she explains.

S.'s case might seem exceptional. Yet, surprisingly, in a profession which is supposed to be open and supportive of people who are coping with mental illness, and to treat them - most therapists in such a situation apparently prefer to keep quiet about it.

The Ministry of Health did not provide data about the number of therapists who suffer from mental illness. However, according to Dr. Naomi Hadas-Lior, former head of the National Council for the Rehabilitation of the Mentally Disabled in the Community, the incidence of mental illness among therapists is similar to what it is among the rest of the population: between 1 and 3 percent. Some therapists entered the profession after being diagnosed, and their disability perhaps played a part in that. Others developed problems after already working in the profession.

Therapists who are coping with mental problems of their own are supposed to report their condition to the authorities and to their employers during their studies and also afterward, when being hired and in periodic health declarations. Such professionals come under the supervision of a special Health Ministry committee which assesses their ability to function. The committee has the power to suspend or even ban the therapists from working in the profession.

In the view of Hadas-Lior and others in the field who are aware of the phenomenon, most therapists prefer to hide their illness because of the stigma attached to it - the fear that they may be seen as dangerous. Indeed, many of the medical forms of the Health Ministry and educational institutions categorize mental illness as "hazardous."

"Because of the serious stigma, therapists do not want the establishment to intervene in their personal struggle. To keep the secret, they avail themselves exclusively of private therapy," Hadas-Lior says, adding that she personally knows therapists who go abroad when they need hospitalization, rather than face exposure in Israel.

Occupational hazards

The university empathized with S. when her illness surfaced during her studies. It was agreed that she would continue to attend classes, but would stop her residency and undergo psychiatric treatment. S. decided instead to take a two-year break, during which she worked at a boarding school and traveled to India. She then resumed her studies.

"I felt I was coming from a whole different place then," she recalls. "I was in psychological and psychiatric treatment, I processed what had happened to me. I was able to keep going."

After graduating, she married and started to specialize in child and youth psychology. During her residency, she thought - mistakenly, like many others in the same situation - that she had recovered completely, and stopped her medicinal treatment.

S.: "I felt fine for a few years and thought I didn't need medicines and that nothing would happen." In fact, nothing happened for some time. However, after giving birth to her second daughter, S. became depressed again and also entered a period of mania. She resumed treatment.

"The big difficulty was how to continue the residency without anyone knowing," she explains. "Some of my patients had problems that were related to my problem, and because I did not want to expose my condition to other residents, I received private instruction."

Like several other "coping therapists" she met, one of them a psychiatrist, S. kept her secret for years. Most of the therapists she knows have never been exposed. However, she decided to tell her employers about her illness after her residency.

What reactions did you get?

S.: "I revealed my condition after I was already a specialist and was held in sufficiently high regard to get support. My superior had suspected it beforehand, but as long as the situation was under control she did nothing. She also supported me when I decided to stop taking the pills again, during my third pregnancy. I now get treatment at my place of work, and it all seems so simple and so right."

As far as S. knows, neither the mental health clinic where she works nor the university department in which she was a student passed on the information about her illness, for fear that the system would not accept her. There have been cases of therapists who were exposed and suffered as a result. S. knows a psychologist who was compelled to find a different place of work, because his professional milieu was unwilling to accept the fact that he has a mental disorder. Like others in his situation, he declined to be interviewed for this article.

Bizchut, an organization that promotes the rights of people with disabilities, has waged several successful struggles on behalf of therapists whose jobs were jeopardized after their illness was exposed. In one case, the organization helped a hospital nurse who had completed her studies cum laude and gone on to work for a year. After she informed her employer that she had undergone psychiatric hospitalization in the past, the Health Ministry committee granted her only a temporary permit to engage in nursing and placed her under various restrictions. She appealed the decision successfully with the help of Bizchut. In a less fortunate case, a student in a therapeutic field who declared that she had an illness lost half her scholarship; her references and her rich experience were of no avail.

Speaking last year at a conference of the Enosh association, an official from the mental health services unit of the Ministry of Health, Yechiel Shereshevsky, referred to the "conceptions of stigma that prevail in the health system ... If someone wants to be a doctor, a nurse or even a dental technician - he is obliged to inform the authorities of any past mental illness. One could say this is an archaic regulation, but regrettably we have only recently been informed that the situation is also identical in new legislation regarding occupational therapy and physiotherapy."

The legal adviser of Bizchut, Sharon Primor, explains that when it comes to obtaining a license to work in the health professions, "only people with disabilities, including mental ones, must undergo a checkup. This is a stereotypical and paternalistic approach. The Health Ministry must exercise its authority with caution and deal with facts, not speculation or prejudice," she emphasizes. "Studies prove that the incidence of violence among people with mental illness is no higher than among the general population."

A spokesperson for the Health Ministry noted that the professional suitability of mental health therapists who suffer from a mental disorder is considered with great sensitivity, to reduce any damage to the therapist and clients. The committee monitors their condition "and determines whether they can continue to practice the profession, and if so under what conditions - whether by medicinal treatment, psychiatric monitoring, additional review by the medical committee or supervision on the job. In some cases it is decided that they are not permitted to work in the profession for a certain period or permanently."

The spokesperson added, "It can be assumed that there are medical professionals who suffer from mental illness without the knowledge of the Health Ministry."

Double life

Many of those who deal with the phenomenon might agree with the ministry: Perhaps the problem lies not with the monitoring committee, which is described as acting fairly and with openness, but actually stems from the stigma and opposition that the so-called coping therapists arouse within the profession. Illill Tzin, director of the social unit in Enosh, also suffered from the revelation of her mental history. She has a master's degree in social work, but became ill after completing her undergraduate degree. "My condition was categorized in all kinds of ways, ranging from post-trauma to schizophrenia," she says, adding that only seven years later did she return to her field of study. She also switched jobs a number of times.

"In one case," she relates, "I had a director who thought that someone with a mental disorder could not be a therapist, that it was inappropriate. She didn't fire me, but I was treated so badly that I left. In another case, the director told the staff about me in a twisted way and people spoke harshly to me, including making comments like, 'It's not clear whether a mentally ill person is trustworthy.' After that, I decided to keep quiet, until I came to Enosh. The association ensures that a substantial percentage of its staff are people who have coped, or are still coping, with mental illness."

Among those in the therapeutic professions, explains Dr. Hadas-Lior, there are a range of typical viewpoints and also some "under the table" opinions. In private, many professionals say they are unwilling to work alongside therapists with mental disabilities. Studies have found that in certain types of these professions, the stigma against the mentally ill is far more severe than it is among the public.

The question of whether to reveal the illness is a very personal one," says the psychiatrist Prof. Yigal Ginat, the chairman of the Reut association for community mental health. "As in the general population, there are therapists and physicians who committed suicide in the wake of mental illness, there are some who lost their professional license - and some whom no one knows about."

Ginat treats several professionals who have not made their illness known to their employers. "Many of them fear - regrettably, with good reason - that revealing their mental disability will adversely affect their career and their promotion, as well as the chances that people will come to them for treatment. There is still a stigma which associates mental illness with lack of good judgment, and that's a label they don't want."

But there is a price to be paid for keeping the secret: ongoing fears, the pressure caused by a dual life, the need to lie.

"It's not easy living with the secret," S. says. "I wanted to tell people, but the fear stopped me. The whole situation leaves you with difficult feelings. After all, you are hiding something bad, something you are ashamed of - but I did not do anything bad. All told, I have an illness, like any illness. The need to conceal it is painful and infuriating. When you are in a state of depression, in which your self-image is already low, and you have to hide something so basic from your milieu, it's not helpful. As it is, you feel less worthy and less equal.

"There were times when the patients actually shared my secret. In fact, it is not always responsible to be in a position like that with patients. That is problematic. For example, in a manic state I could buy a patient presents, and that is not conducive to work. A therapist with an illness has to safeguard himself at all times."

'Ethical question'

Even as concealment of their condition from the professional milieu causes therapists hardship, some maintain that their unique situation is actually very helpful to them in their work.

"At the end of the day, what makes a therapist is his life experience, and above all his experience with suffering. That is the advantage of the wounded therapist," S. says. "My experience also taught me a great deal about what the patient opposite me is undergoing. I know firsthand how meaningful a therapeutic relationship is, how total it can be and how painful it is if there is no empathy. I know how much it hurts to have labels attached to you."

Hadas-Lior agrees: "These people have very distinctive knowledge that they bring with them." She cites as an example the case of good friends whose 21-year-old son fell ill. "One night, he was in a very bad way and needed to be hospitalized, but he refused. With all my experience I tried to persuade him, but to no avail. I called in a friend, a professional who is coping with his own mental illness, and within an hour the young man packed a bag. That is the power of personal experience."

According to Dr. Max Lachman, from the Department of Community Mental Health at the University of Haifa, "Practitioners in the therapeutic professions who have mental illness have knowledge 'from experience' which is of vast importance for setting policy, for the development of a practice and for research. Their angle of looking at things enriches the field and imbues special qualities to knowledge about the illness and about the ability to recover from it. Quite a few therapeutic interventions and models for therapeutic services have been designed with their help."

Still, isn't it problematic that therapists keep the secret to themselves and continue to treat patients without supervision?

Lachman: "There is an apparatus that is supposed to protect the public, namely the Health Ministry's monitoring committee. It's true that it is convened only if a person decides to inform the authorities or if the illness is otherwise discovered. But in general, these are people who function well most of the time. Their knowledge in this field helps them safeguard themselves in a situation of not being exposed."

If a therapist suffers from a mental illness, "it could pose certain dangers to the treatment he gives,' says Dr. Yochi Ben-Nun, chairwoman of the Israel Psychological Association. "Depression, for example, can dull the senses, affect concentration, patience and good judgment, and also be projected onto the patient. There are situations in which the danger arises of a loss of boundaries and incorrect responses."

At the same time, Ben-Nun thinks that the key to maintaining the right balance lies with the therapist himself.

"If it is not an extreme situation of unsuitability, the therapist has to be the one who decides whether to suspend himself from work until he recovers or to tell his patients," she says. "The question is whether the therapist has doubts about providing optimal treatment. It is important for him to get guidance and treatment, but the responsibility rests with him and he has to consult therapists and colleagues about how to behave. It's an ethical question."

According to the director of the Geha Mental Health Center, Dr. Zvi Zemishlany, the dangers posed by a therapist who suffers from a mental disorder are no greater than those in any other profession.

"There are people who hold very senior positions and have bipolar disorder. So maybe there's a week in which they talk fast and are in high spirits. That's not terrible," he says. "And maybe a psychologist with manic depression is preferable to a prime minister who has it. I don't think a therapist's mental illness should be exposed, just as there is no need to know whether he suffers from hemorrhoids or has sexual problems."

Hadas-Lior: "Every illness can be dangerous, in every profession. Every illness can put others at risk if the person who is ill does not take medicine. But when it comes to mental illness, people think straight off that the person is unstable or lacks judgment. That is fallacious. Generally, people are hospitalized due to a mental problem for a very short period of their lives, recover and go back to the routine, like after an asthma attack. There is no reason in the world to treat it differently from any other illness."

Sense of mission

Barak Har-Lev, 41, a social worker from Haifa, did not reveal his illness - bipolar disorder - during his undergraduate studies, 15 years ago. "Exposure is part of a process of identity building, which takes time," he says, adding that he made his illness known during his master's degree studies in the community mental health department of the University of Haifa. The department, which also focuses on the subject of rehabilitating people with psychiatric disabilities in the community, applies its policy in practice by accepting with open arms students who have a mental illness and meet the admission requirements.

"Along with the advantages, a therapist who comes from the world of mental illness also has great difficulties," says Har-Lev. "We have valuable experience, but it can also be very heavy baggage. I am constantly dealing with what I went through. Like a moth drawn to a flame. Sometimes there is a problem maintaining boundaries, not getting too emotionally involved, and you get worn down. A therapist who is coping himself needs special support and guidance, and it seems that what is available is insufficient."

Prof. Ginat agrees: "The fact that someone has experienced mental illness affords greater understanding, but also removes him from the objective stance of therapist, and that is liable to produce excessive involvement and identification."

In one case he was involved in, Har-Lev reacted very sharply when a patient was hospitalized and did not receive money for a phone card and other expenses.

"That situation, in which she was cut off, had no rights and was dependent on others for basic things infuriated me from a personal place," he says. "I behaved like Robin Hood, and it was wrong." In some cases, he notes, it might be a good idea for the therapist to cease treatment.

"It's hard when one wound touches another," S. adds. "When I see a patient going crazy, it can be very painful for me. But with treatment over the years, my wound is less painful and I can be more empathetic in my treatment and more understanding of patients who are undergoing experience similar to mine."

Har-Lev explains that he himself was treated by a psychiatrist who had a mental disorder: "He did not introduce himself as a coping therapist, but at a certain stage of the treatment, when it was appropriate, he offered an example from his life. I think his coping made him a better therapist. He was more understanding. A psychiatrist who gives a patient a pill does not always consider side effects such as decreased sexual functioning, for example. I definitely believe these things should be talked about."

Many of the therapists who overcome the stigma and reveal their illness are driven by a sense of mission, a desire to change things. Illill Tzin from Enosh has been on both sides of the fence: As a patient, she was treated by social workers who were her fellow students, and as a social worker she treated patients she had met when she was hospitalized. "Most of the time I was a threat to my fellow students. They saw me and perhaps understood that they too were not immune from going off the deep end," Tzin explained in a lecture she gave on stigmas in mental health at the University of Haifa two years ago. She talked about harsh experiences she had undergone when hospitalized in a psychiatric institution, including being tied down, and the attitude of superciliousness and contempt that she felt on the part of the medical staff: "I turned into a potted plant that needs to be watered and placed in the sun. I was a person in minimal maintenance. Not a meaningful person. Not someone who has to be listened to."

Those feelings generated anger, and the anger led her to change her life and return to the "normal" world and try to change the approach of people she came into contact with. "I was able to progress," says Tzin, who is 35, has two children and lives on a moshav, a cooperative farming village, in the south of the country. "I know it is terribly easy to say I am a special case, but the truth is that I was in the roughest, lowest states of being. Ten years ago, all my aspirations in life boiled down to the desire to get through a few months without hospitalization."

Tzin believes that there are many people with mental disorders who can succeed, and that professionals like her should infuse them with hope and belief in their ability. "I know that when people see me it gives them strength: If she could do it, so can I. And that is very different from the feeling of lack of trust that I got from professionals in the field."

Two worlds

Miriam Goldberg is the administrator of the Hebrew Internet forum "Speaking from Experience" on the Abiliko portal, which serves the disabled community. She is trying to lead what she calls a "journey of recognition" by people with mental difficulties who are hoping to be therapists. "We have to recognize that there are people who exist in both worlds," she says.

Goldberg, 24, is a social worker and is in her first year of the master's program in community mental health at the University of Haifa. As a girl she suffered from eating disorders and depression, and during her undergraduate years she secretly underwent psychiatric hospitalization. She did not like the attitude toward mental health that she encountered during her studies.

"They did not see the person behind the illness," she explains. "They would talk about 'the schizophrenic' and I would tell them that the correct term is 'a person with schizophrenia.'"

After revealing her condition to her colleagues, she discovered that she had been plunged into a very difficult situation: "Once you get labeled, everything gets connected to the illness," Goldberg notes.

In the past seven years, however, students in her condition have been able to get assistance thanks to a special "academic support" project, as it is called, which is organized under the auspices of the Health Ministry, the National Insurance Institute and the Reut association. Withing the framework of the project, operating on the campuses of the Hebrew University of Jerusalem, the University of Haifa, Tel Aviv University and Ben-Gurion University in Be'er Sheva, students with mental disabilities receive discreet academic, emotional and social assistance.

"At the outset, a few universities told us that they had no need for the program, 'because we do not have mentally ill students,'" recalls Dr. Naomi Hadas-Lior, who serves as a consultant for the project. "Those reactions showed mainly that the illnesses were being concealed."

Currently about 70 students are taking part in the program in the country - about 10 percent of them pursuing therapeutic studies. Each student is assigned another student as a tutor, and help is also provided by lecturers and teaching assistants.

Burst of recovery

In the 1980s and '90s, a different approach to coping with mental illness began to emerge in the United States. Instead of relying on medical models applied by others, this approach stresses the patient's ability to get to know himself and his own strengths. The Recovery Movement, as it is known, has begun to make inroads in Israel in recent years, and some of the comments made here by coping therapists reflect its spirit. The movement claims that the passivity and lack of will that characterize mental patients are not symptoms of the illness, but the result of depression and despair that stem from society's attitude toward them.

The movement was spearheaded by leading U.S. therapists who had coped with mental illness themselves, such as the psychiatrist Daniel Fisher, who was hospitalized as a young man with schizophrenia and is now an adviser on mental health to the Obama administration. Proponents of the movement, among them Dr. Patricia Deegan and Prof. Kay Redfield Jamison, argue that patients can recover and lead a full life in the community. Deegan, for example, said in an interview that after she was diagnosed as a young person as having schizophrenia, the psychiatrist told her that there is no chance of recovery. In response, she became determined to help change the system from within.

"'I'll become Dr. Deegan, and then I will change the mental health system so no one ever gets hurt in it again.' That became my survivor's mission. That became the project around which I organized my recovery," Deegan has said of her decision. Humorously, she related that it was clear to her that she should not share her newfound mission idea with her psychiatrists, who would treat it as yet another hallucination. Nevertheless, her secret undertaking became the mainstay of her recovery.

For his part, Prof. Fisher emphasizes the importance of hope and belief in the ability to recover. The greatest hope, he says, can come from those who have been there; if recovery is impossible, there is nothing to aspire to, there is no future.