Facing Change
In addition to serving as a professor of psychiatry at Duke University School of Medicine and staff physician at the Durham Veteran Affairs Health System, Damon Tweedy, M.D. is the acclaimed author of two books, Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine and Facing the Unseen: The Struggle to Center Mental Health in Medicine.
CaringBridge recently sat down with Dr. Tweedy for a wide-ranging and thought-provoking conversation on race, medicine, mental health, and caregiving. We explore how we can confront systemic gaps head-on and create solutions like CaringBridge that offer meaningful emotional and practical support during life’s most challenging health journeys.
What inspired you to write Facing the Unseen, and how does it build upon the themes of your previous book Black Man in a White Coat?
During medical school, I was thinking my specialty would be cardiology or orthopedic surgery. My psychiatry experience in medical school wasn’t very good. We were in a state hospital setting, and it felt like a different world, an institutionalized world. It felt almost non-clinical.
As I got further into my training, I began to see that many medical problems were worsened by mental health issues. And in some cases, were caused by them. Going through medical school and my internship year, it didn’t feel like people really talked about it much. People avoided it, but it was definitely impacting our patients.
During the first year or so after the initial COVID-19 pandemic struck, a group of medical students spoke to me about how mental health issues were frequently being ignored and unaddressed in medical wards and in clinics, and that this was making things worse for their patients. That sounded very similar to my own experience when I was at their stage of training. It made me take a step back and think about this continued separation between physical health and mental health. The questions Facing the Unseen tries to explore are, ‘How did we get here? What have we done wrong? And what can we do better?’
That was the reflection point for me to begin to think about writing this book. It was looking at my own journey; about how we neglect mental health issues within the general medical world, how we treat the mind and body as separate things, and often to the detriment of not just patients, but also doctors. I wanted to explore all those themes in the book.
The parallels between Facing the Unseen and Black Man in a White Coat are there. In my first book, the focus is about how African American people in particular in this country have been marginalized, in the healthcare world.
Many years in the past, hospitals were segregated. If the facility couldn’t take a Black person, they had to send them somewhere else. Sometimes to a lesser facility, sometimes far away. Sometimes both. I think there’s some similar parallels in the mental health world today. For example, if a person comes to the ER with a mental health concern, people often must be transferred elsewhere for treatment. That typically isn’t the case for physical health problems. Certainly not as often. There are some echoes of being marginalized and outcast.
How do you feel mental health impacts physical health and healing?
I learned in medical school that if someone has a mental health issue– they’re depressed, anxious, manic, or psychotic– you’re always supposed to rule out substances, medications, and medical conditions. In knowing that information, it’s obvious that the mind and body are interconnected. The brain is certainly part of the rest of the body.
Yet, despite this obvious awareness, there’s still this tremendous disconnect in how we approach it. We have separate systems of care, separate insurance systems. A person can see their primary care doctor relatively easily in most cases, but for that person to then get a mental health referral can be tremendously difficult.
There are all these factors that we’re working with. There’s system stigma, societal stigma, and then there’s also the internal stigma that people themselves face.
In Black Man in a White Coat, you talk about a patient named Chester who had racial prejudices, and how you formed prejudices of your own of him and his family. These prejudices and stigmas are all around us and inside of us. How do we work to overcome them?
That story was about race and perceptions, and a long history goes into that. So how do we not let that always get the best of us? In a setting where your goal is to provide the best care possible, how do you not let history get in the way of that? The fact that people have clear faults or problems doesn’t mean that they’re necessarily irredeemable.
Even if you bring it back to mental health, there’s a lot of parallels. For example, you take an illness like schizophrenia, which is clearly a very serious illness. We see the worst of it when we see people who are homeless or in acute distress. It conditions us to think of that illness only in one way, rather than thinking about it as a spectrum.
I talk about this in both books. If you have labels on charts, people get pre-conditioned to say, ‘okay, this label means that this person is basically hopeless.’ It took me many years to begin to see people who had schizophrenia who were actually functioning pretty well.
So, how do we broaden our image when we see a label and we only think the worst? There’s a spectrum of illness, and our goal as healthcare providers and doctors is to get them on that better journey, even if they can’t see it at that moment in time. It’s important to get beyond those labels, to think about what type of baggage we’re bringing into interactions with people who are different from us or who are struggling. How can we connect with them? How can we help them?
What would you say is the biggest issue in terms of reducing racial disparities in healthcare today?
We’re still dealing with the effects of 400-plus years of history. I think there’s a tendency for all of us– particularly younger people– to feel like the world starts when you show up. But the world is built on everything that came before us, the people that came before us. It’s a long journey, and change doesn’t go as fast as many of us would like it to.
The disparities are built on history– political, social, and economic. It’s almost as if we’re taught, at least during my training in the 1990s/early 2000s, that medicine is separate from the rest of society, like we’re above the fray. And that’s a mistake, because of course we entered into medical school as people formed by society. There’s no way to pretend we didn’t grow up in certain places and have certain attitudes based on how we experience life and that we wouldn’t bring that into how we practice medicine.
The younger people who come to medical school now are much more engaged with these issues. They’re much more knowledgeable about social issues, but it’s going to take time.
The health system has to increasingly and more effectively interact with other parts of society – education, housing, food access, social services - that can then influence health, because health outcomes are a combination of all sorts of factors.
In your work, how have you seen both physical and mental well-being impacted by a strong support network?
It’s extremely important. There are studies that have looked at women with breast cancer, and the women who had better psychological support fared better. On the surface, it seems like breast cancer is just a biological disease. But clearly, the social support is important.
One of the worst things about illness is that it can be isolating. People don’t want to be a burden to other people, so they withdraw and isolate. When that happens, it’s hard to find meaning. So much of life is about purpose and meaning. It’s really important to have people around you who recognize and validate how important you are to them, because that gives you a reason to keep going.
A support network can really give people a sense of purpose.
At CaringBridge, we’ve seen how that support network impacts not only the person on a health journey, but also their loved ones who are caring for them throughout it. What kind of support do you think a family caregiver needs to take care of themselves and their loved one?
The person who has the illness is the center of attention. But for the family caregiver, the whole context of their relationship to that person has been upended. There’s a certain rhythm you’ve had for so many years, and it’s totally changed with an illness, whether it’s a sudden illness like a stroke or a more gradual one like dementia.
There’s a lot of strain and so many emotions for the caregiver. There can be a sense of guilt, like if you ask for too much help, then you couldn’t do it yourself. There have been so many times I’ve been in a room with a patient, and they’re not fully cognizant, so you instead talk with their wife or husband. And they’re so tired.
About 10 years ago, I led a class where a student gave a presentation on caregiver stress. She brought in all these statistics about higher rates of depression and other health issues with caregivers. In medicine, we focus on the patient in front of us, but that session on caregivers was eye-opening for me. I went back into my own clinical practice and thought about how I can do more to help caregivers. Sometimes, just acknowledging the stress they’re under is really important.
Now, I’m more knowledgeable about connecting people with resources and support groups.
How do you feel a platform like CaringBridge can help bridge the gap to get family caregivers the support they need?
I think it’s wonderful. Sometimes, it’s just about being overwhelmed. You have all these family members and friends asking questions. Also, there’s practical things like coordinating treatment, appointments, and insurance. All of this is hitting them at the time they’re dealing with the emotions of their loved one being diagnosed with a serious illness.
The world is so complicated. Our healthcare system is so complicated. How is one supposed to navigate that and take care of themselves in the midst of it all?
Just like physical and mental health are intertwined, these things are intertwined. If you can’t deal with your emotions, it’s hard to deal with the practical things that need to be done. And vice versa. A platform that can facilitate community while at the same time helping with the practical things is immensely important.
Years ago, I was taking care of a guy who had dementia. I saw him and his wife quite frequently. I remember one day she was experiencing some physical symptoms. She ended up having some heart rhythm abnormality and had to be hospitalized. She had neglected her health, putting it aside to care for her husband. That really struck me as an example of how someone needs to care for the caregiver.
Anything more you would like to add?
There are clearly parallels between the books that I wrote in terms of how the issues with race and bias connect to the mental health challenges of today in real ways. The separation of medicine, physical health, and mental health is detrimental across the board. There’s this tendency in medicine to see people as body parts and not the whole person.
The issues with family caregivers are huge and only beginning to be explored. It’s been my students who’ve helped me expand my own sense of that.
I’m optimistic despite the challenges we face in our world. I think future clinicians are going to bring forward a more holistic healthcare system where they think about issues in a much more intentional way.
There’s a quote from James Baldwin: "Not everything that is faced can be changed. But nothing can be changed until it is faced.”
You can’t change everything that’s come before you. But in order to affect any change, you have to face the things that are causing our problems in the world, whether it’s stigma, mental health, or racial bias. Whether it’s confronting caregiving distress or mental health stigma, it’s all driven by the same idea of, ‘how do we face these problems head on and begin to devise solutions that actually make it better?’
In Closing
We couldn’t agree more. A heartfelt thank you to Dr. Tweedy for taking the time to talk with CaringBridge. We recognize the importance of having these conversations and facing the issues together to help ensure that no one goes through a health journey alone.
You can purchase Dr. Tweedy’s books here: