(Image by Xavier Sotomayor. Sourced from Unsplash)

As many as one in four of us experience mental ill health (McManus et al., 2009). It is often difficult to see, even to those closest to the person experiencing it. What feels so pressing and imposing to one person can be completely unseen to another. And there is a host of physical illnesses that can’t be seen, but greatly impact daily life.

Depression and Anxiety
Often going hand in hand, depression and anxiety don’t show on the skin. Underneath our drives to ‘put on our best face’ and ‘get through the day’, there is a struggle to cope with thoughts and emotions that feel like they could consume everything.

On the outside, however, we so often put on a smile, say we’re fine, and do our best to push through to the end of the day.

It’s common to feel the need to ‘pull yourself together’ or ‘get on with it’. The difficulty with these adages is that they leave out the crucial information of how to do either of those things. And so we punish ourselves for not being able to live up to them.

A sense of shame and embarrassment can often come with mental ill health – whilst we at BCTC firmly believe that mental ill health is nothing to be ashamed of, and are glad to see cultural attitudes slowly changing, many people remain concerned about the stigma of revealing that they’re struggling to cope.

Responsibilities for others can also lead us to keeping the problem invisible – we may try to ‘protect’ others from worrying about us, not wishing to ‘burden’ them with our own problems.

People who have experienced trauma can face many of the same blocks as those above. In trauma, there can be an additional difficulty – many people with post-traumatic stress disorder have reported feeling their trauma was not ‘valid’ because they did not sustain a visible injury.

This can also contribute to survivor’s guilt, in which we cannot understand why we survived whilst others did not. To have been able to survive without externally visible injury, but still suffer the internal psychological consequences, can be deeply confusing, and a source of shame, guilt and anger.

Traumatic events have long been understood to leave physiological impacts on the body, but many of these are unseen. In the presence of trauma cues (things that remind us of the trauma itself), the body can experience the same physiological responses it did at the time the trauma occurred – it remembers the event and acts as if it is happening again. In the words of Bessel van der Kolk, a world-renowned expert in trauma: ‘the body keeps the score.’

Reactions include palpitations, muscular tension, muscular pain, freezing, shaking, difficulties with sexual responses, agitation, nausea/vomiting… the list goes on.

Chronic Pain, Fibromyalgia and Multiple Sclerosis
People who have experienced severe and enduring mental health difficulties, or experienced trauma, are more likely to develop a chronic health condition such as chronic pain or fibromyalgia (Bondesson et al., 2018). In trauma, chronic pain may be the result of injuries sustained at the time that continue to impact on physical functioning, or may result from other causes. However, these conditions can affect anyone.

These chronic conditions are unseen from the surface – the pain, fatigue, migraines and other symptoms are experienced internally. They profoundly impact both day to day functioning and mental health, without any obvious outward sign that they are ever present for the person experiencing them.

It is important to be aware that these conditions often fluctuate in their intensity. We often have the notion that someone using a wheelchair must be confined to it always – in reality, many people require wheelchairs to assist their mobility because they are unable to travel longer distances, but can walk short distances. This does not mean they have any less right or need to use a wheelchair.

‘But You Were Fine The Other Day’
As therapists, we often hear that people are reticent to disclose difficulties such as those above because their intensity may vary week by week, or day by day. On some days, functioning may improve because physical symptoms or emotional distress are somewhat less, whilst on other days, when these increase, tasks become harder once again.

And, of course, many people are fighting to not let these invisible conditions rule their lives, or hold them back. They make great efforts to engage with life, to not mesh their identity with an illness or condition, to bring meaning into their day. On the outside, it may appear as though everything was ‘fine’ on such days, when on the inside, it was a monumental effort.

This variability can be difficult to understand or to anticipate even from the inside. When people face the prospect of trying to explain these shifting barriers to other people, it can be a very daunting proposition. Fears of being misunderstood or dismissed are common. Others don’t want to have to ‘lecture’ or ‘educate’ people about the full extent of their condition, and so avoid the topic altogether.

Finding ways to communicate about our needs, in a way that feels appropriate to us, is often an important step in helping these conditions become less invisible.

We Don’t Know What Others Are Going Through
It is vital to remember that when we look at someone, we know nothing about them from the surface. We don’t know the history of their life, their thoughts, feelings or physical health. We don’t know the variability of their symptoms, which one month may be debilitating, whilst in another, they can go out and spend time with family or friends for a time.

We must take care to not make assumptions about the lives of others, and be open to hearing their experience, without judgement. If we don’t understand something, we must reach out to ask questions, or seek information from reputable sources.

There are many illnesses and conditions that cannot be seen, but they are no less valid.

Bondesson, E., Larrosa Pardo, F., Stigmar, K., Ringqvist, A., Petersson, I.F., Joud, A., & Schelin, M.E.C. (2018). Comorbidity Between Pain and Mental Illness – Evidence of a Bidirectional Relationship. European Journal of Pain.

McManus, S., Meltzer, H., Brugha, T.S., Bebbington, P.E. & Jenkins, R. (2009). Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. The NHS Information Centre for Health and Social Care.

Van der Kolk. (2015). The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. Penguin Random House: USA.