Each May, during Mental Health Awareness Month, we traditionally reflect upon access to care, stigma, workforce stress, and treatment modalities. Although these are all critical, I believe there is another question of greater and more practical importance: How do we, as physicians, approach human suffering?
One legendary psychiatrist who cared deeply about that question was Karl Menninger (1893–1990). A titan of twentieth-century American psychiatry and co-founder of the Menninger Clinic in Topeka, Kansas, Menninger wrote extensively not only about mental illness, but also about responsibility, conscience, and the role of society in shaping thought and behavior.
What emerges from his books, from The Human Mind to Man Against Himself, and from The Crime of Punishment to The Vital Balance, is a specific professional stance. He consistently and faithfully returned to the idea that understanding should come before judgment. That idea sounds simple in principle, but in practice, it is rather hard.
Menninger argued that mental illness exists on a continuum with so-called normal behavior, rejecting the notion that they are distinct. The difference between stability and breakdown is often a matter of degree, a function of stress, conflict, or a lack of support, rather than a clean divide.
For physicians, that idea has immediate practical implications. It reminds us that vulnerability is not remote territory; it is part of the same reality in which we all live. Menninger felt that the labels of psychiatric diagnoses often interfered with the process of understanding the actual, lived experiences of his patients.
In Man Against Himself, Menninger examined suicide and self-destructive behavior as attempts to manage intolerable internal conflict. He extended this reasoning to aggression and antisocial behavior. For him, understanding was distinct from excusing. Responsibility did not disappear; however, assigning responsibility without attempting understanding was, in his view, incomplete.
He did not argue that accountability should vanish. He worried, instead, that we would oscillate between blame and avoidance, effectively condemning what we have not first sought to comprehend. Medicine cannot function without judgment; we make decisions every day that carry heavy consequences. The question, however, is not whether we judge, but whether we first seek to understand.
Long before the concept of the "therapeutic alliance" became standard, Menninger treated relationship as central to the process of healing. Technique mattered, but for Menninger, it was never enough. Healing begins in the space between two people.
In all specialties, this can have meaning and application. Patients remember how we speak to them; colleagues remember how we respond under pressure. In a healthcare environment increasingly defined by metrics, relational presence can feel secondary. On the contrary, it is likely the most essential thing we offer.
So, what is mental health? In The Vital Balance, Menninger did not define it as the absence of symptoms, but as the capacity to live, to work, to love, to tolerate frustration, and to participate meaningfully in society. That definition is both broad-reaching and practical. It acknowledges imperfection and shifts the focus from symptom resolution to mindful interaction.
Mental Health Awareness Month rightly emphasizes resources and recognition, and as such, we pause to reflect. In daily practice, we often move quickly out of necessity. Unfortunately, speed can negate curiosity. Therein lies the risk: curious understanding should inform judgment, not follow it. Mental health is not a destination we arrive at, nor a perfect state of mind that we maintain. It is a living, breathing practice to bravely engage with life as it is, and to choose connection over withdrawal. I believe Menninger held an optimistic view of mental health because he perceived that, in some form, we all essentially have a basic desire to know one another. From that understanding comes genuine relationship, and from there, the health and healing that sustains us all.
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The Weight of the Secret: Reflections on Professional Transparency
For those of us who have spent any significant time in practice, the professional mask is practically a second skin. From the earliest days of residency, we are conditioned to project a quiet and unwavering presence. Every May, during Mental Health Awareness Month, we speak to our patients about the importance of removing their own masks. Yet, reading a recent article on KevinMD by Dr. Jessi Gold forced me to stop and consider a different perspective: what happens when the mask we wear for our patients becomes a cage for ourselves?
Dr. Gold is not a fringe voice. She serves as the Chief Wellness Officer for the University of Tennessee System and an Associate Professor of Psychiatry at the University of Tennessee Health Science Center. Her entire career is built on the intersection of clinical excellence and physician well-being. And yet, Dr. Gold recently disclosed a truth she guarded for thirteen years: she has been on a stable dose of Wellbutrin since her training.
To a layman, this is probably just a footnote. To a physician, especially one advocating for wellness it is a revelation that highlights a third rail in our culture: the fear that being a patient somehow compromises one’s standing as a healer.
We have made progress in destigmatizing therapy. It is now culturally acceptable for a physician to mention they are seeing someone to navigate the wreckage of a difficult code or the grind of a high-volume surgical schedule, and we respect it as proactive maintenance.
But as Dr. Gold’s experience shows, a silent, rigid threshold remains between talk therapy and pharmacotherapy. Dr. Gold admitted she believed in medication for her patients, yet she privately viewed it as a sign of worsened illness for herself. She feared that if colleagues, here in Allegheny County or elsewhere, knew she required a prescription to maintain her equilibrium, they would view her as clinically lesser. This is the internalized stigma that quietly haunts us. It is the irrational belief that a medical degree should somehow immunize our neurotransmitters against the same biological laws that govern our patients.
There are, of course, dignified reasons for our reticence. The forensic and analytic traditions emphasize the blank slate of the provider. There is also a legitimate, ethical concern that lived experience can become self-serving if handled poorly. Dr. Gold wrestled with this herself, wondering if her openness would be dismissed as an ego boost. But what is the actual cost of this blank slate when it is maintained through isolation? When a system-wide Wellness Officer feels she must hide a successful, life-stabilizing treatment for over a decade, it suggests that our professional survival depends upon a performance of perfection that we know in our hearts is a veneer.
As I look at the medical students and residents at our local Pittsburgh institutions, I wonder what they see when they look at us. If we only show them the version of ourselves that never requires help, we are teaching them that their own health is a secret to be guarded. We are setting them up for a profound and lonely sense of failure the moment they encounter their human limits. Dr. Gold’s disclosure is a gift for us all. She is proof that one can be an associate professor, a prolific writer, and a system leader while also being a patient who takes a daily pill. The takeaway from Dr. Gold’s story is that professional dignity does not require professional perfection. Whether that involves therapy, medication, or both, it is a clinical reality that deserves understanding and respect.
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“Labor to keep alive within you that little spark of celestial fire called conscience.”
— George Washington
May is recognized as Mental Health Month, a time set aside to reflect on psychological suffering, stigma, and the conditions that make healing possible. Those conditions are not created by awareness campaigns alone. They are shaped quietly, daily, in the conduct of ordinary encounters. If emotional safety depends upon how power is carried in vulnerable spaces, then character becomes a clinical instrument.
As a young man, George Washington carefully copied by hand a set of 110 Rules of Civility in Conversation and Behavior. They were not originally his. The maxims traced back to a sixteenth-century Jesuit manual on decorum, translated and circulated through English schools before arriving in colonial Virginia. Washington transcribed them as an exercise in discipline. He did not compose them; he practiced them.
They were not written to enforce obedience. They were intended to shape character; to cultivate restraint, humility, and attentiveness in one’s dealings with others. Long before Washington was entrusted with power, he was learning how power ought to be carried, and how easily it can become careless when left unexamined.
Medicine unfolds in a similar moral landscape. Each clinical encounter is more than an exchange of information; it is a meeting shaped by asymmetry, of knowledge, authority, and vulnerability. Illness disrupts not only physiology but identity, time, and agency. The clinician enters that unsettled as one whose words and decisions carry consequence. How that presence is enacted matters, and is often remembered long after the diagnosis is forgotten.
Civility, in this sense, is an ethical posture, a disciplined way of inhabiting authority in the presence of vulnerability. Like Washington’s copybook, it is a practice that is repeated, imperfect, and formative. The following rules are not techniques to be executed, but orientations to be renewed, sometimes in the smallest gestures.
Listen before speaking.
Listening acknowledges that the patient’s experience cannot be reduced to a category. Symptoms may fit patterns, but lives do not. To listen before speaking is to suspend premature certainty and allow the meaning of the illness and not only its mechanism to emerge. It also means tolerating the extra thirty seconds that do not fit neatly into the schedule.
Apologize when appropriate.
An apology acknowledges harm at the level of experience, not merely at the level of outcome. In moments of error or misunderstanding, apology restores equilibrium. It affirms that authority does not confer exemption from accountability. A quiet “I’m sorry this happened” can steady a room more than a paragraph of explanation.
Receive every question with seriousness.
Questions often arise from fear or confusion rather than curiosity alone. To take a question seriously is to treat it as an expression of agency. Respect requires patience with uncertainty, even when the answer feels obvious to the one giving it.
Attend to what is worthy of affirmation.
Illness can narrow a person’s identity to symptoms and deficits. Recognition restores dignity where illness erodes it. To affirm perseverance, humor, clarity, or resolve is to refuse reduction. Many patients will remember that acknowledgment as clearly as they remember the prescription.
Speak ill of no one.
Contempt is corrosive. When speech becomes dismissive the moral climate of care shifts. To speak ill of a colleague or a patient in the presence of others is to grant them permission to do the same. Restraint is a form of environmental protection, though it often feels, in the moment, like swallowed impatience.
Extend equal concern to all.
Distress does not present uniformly. It may appear as gratitude, hostility, compliance, or resistance. Equal concern requires steadiness toward all forms. Justice in the clinic begins with the disciplined refusal to divide persons into categories of worth. It is not always easy, which is why it is discipline.
Guard privacy in word and manner.
Privacy is not a matter of regulation, but of reverence. Vulnerability is entrusted, not surrendered. The lowered voice, the careful chart, the discreet gesture — these signal that what has been shared will not be handled casually. A chart left open on a screen can undo what trust required years to build.
Be present, however briefly.
Presence depends on attention, not time. Even under constraint, attention can be whole. A patient who feels seen is more than reassured; they are recognized. Anyone who has sat at a bedside late in the evening knows how unmistakable the difference is between being looked at and being looked through.
Exercise humility with humor.
Humor, when directed at the absurdity of the situation or the clinician’s own limitations, narrows hierarchy. When directed at the patient, even in jest, it becomes a tool of exclusion. Without humility, levity risks dismissal. The line is thinner than we like to admit.
Allow the patient to release the encounter.
Illness often strips control from daily life. Allowing the patient to release the encounter restores a measure of agency. A hand on the door handle before the patient has finished speaking is an assertion of exit, not an act of care. Civility requires the final pause to be theirs, even when the hallway is already calling.
Civility serves not only the patient. It also becomes a means of preserving the clinician’s own moral integrity. When the pressures of daily practice threaten to reduce the work to a series of technical tasks, these rules serve as anchor points. They are felt most sharply when we resist the urge to hurry through what is essential.
Mental Health Month asks us to consider suffering that is often unseen, and vulnerability that does not always announce itself clearly. In such encounters, diagnosis may follow, but conduct comes first. Psychological safety is shaped in tone, in restraint, in whether a patient feels hurried or heard.
Washington copied his rules in adolescence. He did not yet command armies or govern a nation. Character preceded authority. In medicine, too, authority is entrusted daily, often in rooms where stigma, shame, or quiet despair accompany the patient inside. Where power exists, discipline of conduct is required.
Character is not formed in moments of ease, but in repeated acts of restraint. Civility does not promise perfection. It makes something more modest, and more vital; that those who enter our care, especially in matters of mental health, encounter steadiness and dignity.