Plain Talk about the Stigma of Mental Illness

Among people who have been treated for mental illness, what is the biggest problem they face when trying to resume life in the community?

Most will say it is simply their inability to be accepted by other people. They have difficulty finding friends, housing, and work. They feel the sting of discrimination in almost everything they attempt. Many times they feel old friends are uncomfortable in their presence. They feel cut off from society.

They are the victims of the stigma that still surrounds mental illness. Numerous scientific studies have shown that stigma, often overt, is directed toward former mental patients by society. It becomes their most debilitating handicap.

Since 1980, the National Institute of Mental Health has been a leader in a nationwide attempt to remove the stigma associated with mental illness through an effort to encourage employers to hire people who have come through such illness and who are now able and eager to work. It has been proven that the dignity of work provides stability and meaning to these people as much as to those who have never experienced mental illness.

By forming a partnership with the private sector, the Institute has inaugurated an information program for employers that is paying dividends. Employers have learned that former mental patients, including the chronically mentally ill, comprise a valuable labor pool for American business.

But, employer knowledge and acceptance are not enough. The problems of stigma are everywhere. They affect all of us. We have found, also, that as the general public learns more about the devastating problems caused by stigma, even greater understanding and help will follow.

One in five families in the United States knows the devastating impact of mental illness. But its effects are far-reaching as family friends, and co-workers suffer by changes inflicted on them by another’s mental illness.

Thirty percent of the population will suffer from cancer during their lifetimes, while 15 percent will be touched by mental illness. However, victims who have suffered both mental illness and cancer report that the mental illness caused them the greater pain.

In truth---the obstacles faced by recovering mental patients following treatment for their illness are often as difficult to overcome as was the illness.

Here, the question must be asked, “What is mental illness?” To begin with, mental illness is not a homogeneous entity which a general discussion of mental illness seems to imply. However, included under the rubric of mental illness are symptoms and problems that affect many persons but which may not be evident in others. These symptoms may not seriously---or even markedly---impair personal or social functioning. On the other hand, there are persons who may suffer from more serious, obvious, and incapacitating degrees of illness. These latter persons may well require hospitalization and intensive care and treatment.

Since the passage of the National Mental Health Act by Congress in 1946, care and treatment of mentally ill people has improved dramatically, assisted immeasurably by improvement in the use of psychoactive drugs (such as tranquilizers) and the development and use of other new therapies.

Improving Treatment

Today, research has unraveled many of the mysteries about the origins of mental illness. It has revealed that many mental illnesses are actually caused by biochemical imbalances, as is the case with many physical illnesses.

The mentally ill should not be blamed for their condition any more than diabetics should be blamed for having diabetes. Uncovering many of the biochemical imbalances has led to treatments restoring the needed chemical balances, just as insulin controls the balances for diabetes. As long as a diabetic person takes the proper dosage of insulin, that person can live a normal life. It is much the same with mental illness. As long as the victim follows prescribed treatments, that person, too, can lead as normal a life as possible.

As care has been upgraded, so, too, have the settings in which treatment is given. For many decades, the usual responses to the mentally ill were to hide them away at home or to relegate them to asylums. As the number of admissions increased, care in the asylum became mostly custodial.

Problems of Deinstitutionalization

The populations of public mental hospitals grew until, about 30 years ago, more than 550,000 were housed in State and county facilities. Since then, deinstitutionalization---the process of releasing mental patients to communities---has lowered the number to fewer than 150,000.

At first, deinstitutionalization was hailed as a momentous advance by those who advocated treatment and services in community-based facilities---community mental health centers, halfway houses, psychosocial rehabilitation programs, and the like.

However, practice out paced practicality; where the mentally ill were once caged as animals, chained to walls, mistreated, and even beaten, new understanding of metal illness has given many of them freedom. But the price of that freedom has often been aimless wandering through the streets, without homes or jobs. And, in too many instances, Americans who have had the misfortune to suffer mental illness---even those who approach a societal definition of normal---daily face an unsympathetic, unfair, and hostile society.

Historical physical abuse or neglect has been replaced by a less visible but no less damaging psychic cruelty.

Generally, in these enlightened days, we do not physically remove from our midst those we do not wish to have around; and we no longer send them to a far-away asylum. Instead, we isolate them socially, a much more artful though equally debilitating form of ostracism. A paradox now exists. In a time of vastly increased medical sophistication, which virtually guarantees greater numbers of restored mental patients, discrimination against them continues. Although we as a society have come far in the way we respond to those with mental illness, there is still a great distance to go.

For example, research studies have found that most Americans think the two worst things that can happen to a person are leprosy and insanity. In American society, ex-convicts stand higher on the ladder of acceptance than former mental patients. Asked to rank 21 categories of disability, from the least offensive to the most, respondents placed mental illness at the bottom of the list.

Attitude Changes

Public attitudes toward the mentally ill have changed in the past few decades, but the changes appear to be minimal. A 1979 study updating an earlier attitudes survey found “no noteworthy changes in attitudes toward the mentally ill 23 years later.”

People continue to discriminate against the mentally ill, although it may be less socially acceptable to admit it openly. Discrimination crosses all boundaries of society and exists among people of all ages, socioeconomic levels, intelligence, education, and places. Nearly everyone, it seems, regards victims of mental disorders as “fundamentally tainted and degraded.”

Even more astounding, mental patients sometimes face rejection from professionals who are paid to treat and help them. A key finding of a 1980 forum on stigma was that many health-care professionals harbor unconscious, unstated negative feelings about their mental patients. A 1980 survey found some psychiatric nurses showed prejudice toward their patients. Other studies have shown that it is not unusual for some staff members in psychiatric facilities to abuse their patients physically.

What is behind the stigma directed at mental patients? Some researchers think the term stigma is itself the problem. Too strong a word to be useful in describing the full range of reactions toward the mentally ill, they believe, it discourages objective thinking about the problem it encompasses. That is, they believe simply talking about stigma may cause it.

Other investigators suggest that behavior, not a label, is what evokes negative response. For example, relatively well-adjusted and well-educated people who develop a psychiatric disorder but recover are unlikely, in this view, to suffer extensively from the problems of the stigma. It is the more or less permanently disabled persons who tend to be the objects of fear and avoidance.

Fears of Dangerousness

One of the reasons for this view, perhaps, is that people fear the mentally ill because they are thought to be unpredictable. But the truth is that the behavior of former mental patients is, on nearly every occasion, no different from the rest of society.

Thus, it should be said clearly: The vast majority of mentally ill persons are not dangerous. Here as elsewhere it is unfair to stigmatize the many for the acts of the few. The unfairness is apparent when danger from former mental patients is compared with the danger from drunk drivers. Some of the most predictably and demonstrably dangerous persons in our society are drunk drivers who account for about half of all fatal automobile accidents (about the same number as all criminal homicides each year), but Americans demonstrate a truly astonishing tolerance for this group of dangerous persons.

Then compare this to the record of former mental patients. Fewer than 2 percent of them pose any kind of danger to society. The reality is that persons who have been through emotional disturbances are typically anxious, passive, and fearful.

But the myth of dangerousness is perpetuated through a lack of knowledge by most members of the public. The belief that mentally ill persons are to be feared has been described in the research literature as a “core belief of the American public.” Further, a recent California survey found only 17 percent of respondents agreed with the statement that mental patients are not dangerous.

The facts belie these beliefs. There has been an increase in the arrest rates of former mental patients over the past 29 years, but this increase pertains to former patients who had arrest records prior to being hospitalized.

Though there have also been a few studies showing higher rates of violent crimes by mentally ill persons, those who do not have prior arrest records have post-discharge arrest rates equal to or lower than those of the general population.

Why then the continuing public perception of them as dangerous individuals to be feared and shunned?

Role of the Media

Many observers fix a large share of the blame on the communications media. Newspapers in particular stress a history of mental disorder when they find it in the backgrounds of people who commit crimes of violence. Television news programs also sustain this view with their sensationalization of crimes where former mental patients are involved.

In television dramas, mentally ill persons are often portrayed as violent or victims of violence. Such stereotyping illustrates one of the many uses of mental illness by television producers or directors---to excite fear in the audience. One critic has pointed out that, on television, mental illness is synonymous with danger. Although that idea cannot be supported by known facts, it lends authenticity to the myth.

In this respect, the media--in the interests of fairness and in recognition of their power to influence public opinion---have a responsibility to provide a broader perspective on the mentally ill. A leading scientific investigator in this area has commented, “That the mass media can condition a subtle set of attitudes which influences the behavior of society toward those who have been hospitalized for mental disorder is unequivocal.”

The media usually reflect the beliefs of the public. Thus, it follows that when a majority of Americans are convinced that there are benefits in helping to change beliefs about mental illness, these beliefs will be positively altered. And the media must be convinced that at least some of the credit for helping change beliefs would accrue to them.

Possibility of Change

A summary of several studies indicates important areas where change is likely: in increased positive images of mental patients, in decreased fear ratings of them, in decreased fear of becoming insane, and (by patients themselves) in increased self-confidence. This likelihood is borne out by university-based studies which show that negative and stigmatizing images of mental patients can be altered.

For example, a Minnesota mental health education program informs the public in a straight-forward way of the struggles of real people with emotional problems. Early indication are that awareness of such people’s experiences and perceptions results in increased resistance to negative mass media images of current and former mental patients.

There are other encouraging signs of greater public understanding and acceptance of mental illness. Women, for example, have been found to be far more accepting of mental patients than are men. Recent Canadian and U.S. studies have shown positive acceptance of community mental health residential facilities, even in situations where residents have been labeled “mentally disordered offenders.”

A survey by the National Restaurant Association, the first ever to investigate employment of the mentally restored in a single industry, produced solid evidence of the value of former mental patients to employers. The most outstanding result of the survey concerned work performance. More than 75 percent of employers who had hired mentally restored people rated them “as good as or better” than their co-workers in motivation, quality of work, attendance, job punctuality, and job tenure.

Fellow employees were described as cooperative and helpful toward their mentally restored co-workers, supporting the findings of another study of a shift toward understanding and acceptance when mental patients are given a chance to fill normal roles in work and other activities.

Thus, as impressive as the gains in treatment of mental illness have been over the past few decades, they are not enough. It is also necessary to alter society’s perceptions of mental illnesses and the mentally ill. People must understand that mental illnesses are real, that they are common, and that no one is beyond help. It is important to spread the message that, thanks to research, effective treatments are now available to help most mentally ill people lead satisfying and productive lives at home, at work, and in the community. These treatments are continually being improved through ongoing research. There is now more hope than ever for people who are mentally ill, and there should be more acceptance of these individuals by society at large. Only when they can take their place among us as valued employees, tenants, and friends will their struggle against mental illness be won.

For more information, contact:

The Alliance for the Mentally Ill

NAMI of Greater Chicago

1536 West Chicago Avenue

Chicago, IL 60622

(312) 563-0445.