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Our Sick Society: Curing the Stigma attached to Mental Illness through Public Awareness and Education

AIH399 MAKING HISTORY
DEAKIN UNIVERSITY

by Shelise Robertson

 

Executive Summary

  • This article argues for the creation of well-defined social and institutional guidelines encouraging diversity and equality to accompany Australia’s current Mental Health Reform.
  • Terminology used will be appropriate to the historical context and ‘mental illnesses’ will be used as a broad umbrella term.
  • No progressions made throughout the history of mental illness thus far have efficiently removed stigma, despite innumerable studies contending that stigma contributes to poor mental health and, often, prevents individuals from seeking help.
  • Current prejudices toward individuals with mental illnesses evolve from a long history of mythmaking and misunderstanding surrounding difference. This must be recognised first before it can be lessened.
  • Historically, stigma and discrimination have hindered positive progressions in reforming mental health services, with social attitudes shaping oppressive policies and encouraging abuse.
  • Positive progressions that have been made historically have been achieved through challenging ingrained prejudices.
  • This discussion uses two vital periods, including ‘confinement’ and ‘incarceration’, to substantiate claims made. As these have been transnational experiences without clear borders, the article looks broadly at the American and English experiences that helped to establish stigma evident today in Australia.
  • · For help or information contact Lifeline on 131 114, beyondblue.org.au, or Suicide Helpline Victoria on 1300 651 251.

Clifford Whittingham Beers, having leapt from his fourth-story bedroom on a seemingly perfect New Haven day in 1900, soon discovered himself heavily guarded behind sanatorium walls. Every evening, before his personal attendant went to sleep, Beers’ doctor would come by candlelight and sit beside him. That doctor would take his hands and, despite Beers’ resistance, bind them within a canvas ‘muff’ saying: ‘You won’t try again to do what you did in New Haven, will you?’ Well, like anyone, Beers had done many things in his hometown and struggled to figure out just what action had deserved this routine torture. When he suddenly understood what was implied — that they referred to his suicide attempt — Beers said that having the muff secured became ‘the most humiliating incident of my life…for the first time since my mental collapse I wept. And I remember distinctly why.’ Locking the muff seemed to unleash his imagination. It unlocked all the illusory shame his suicide attempt and bipolar had earned him, he believed, in ‘disgracing’ his family, friends, and university. Ultimately, Beers thought it signified that he no longer deserved social inclusion; indeed, that he deserved to be locked away and forgotten.

Physical restraints are no longer used as enthusiastically as they were when Beers described this experience. Needless and avoidable feelings of shame and rejection, however, still endure — creating barriers between individuals, social inclusion, and mental wellbeing. These feelings primarily persevere because, when constructing what constitutes the ‘normal’, western societies simultaneously construct the ‘abnormal’ and wrongfully stigmatise it as shamefully undesirable. Stigmatisation gradually naturalises and, subsequently, is regularly internalised by individuals positioned within the stigmatised ‘group’. Various ‘minorities’ have undergone this process, yet hardly any other ‘group’ throughout history has been stigmatised as protractedly, suffered as many legalised experiments, or been dehumanised as thoroughly as individuals diagnosed as ‘mentally ill.’ Professor Pat McGorry observes that this intolerance continues today, shamefully, allowing individuals to be and to feel socially isolated whilst preventing them from getting help and from getting well. Indeed, the Mental Health Foundation of Australia has discovered that stigma is currently intensifying rather than diminishing in western communities. The present Australian Mental Health Reform, alongside its admirable yet long overdue aims to improve mental health services, thus must be accompanied with informed and prolonged public awareness and education. History indicates that this alone will counteract growing stigma and, subsequently, encourage social inclusion thereby alleviating psychological distress.

Stigma is an irrational attitude that, unable to be cured with obviously perceivable facts or reason, amplifies when left unchallenged. It therefore must be, as social psychologist John Kremer and his colleagues suggest, persuasively confronted through enforcing informed societal policies or guidelines that advocate diversity and encourage full social inclusion. These, Kremer et al. argue, should be publicly imparted through frequent unbiased media representation and through educational institutions. Although change will not be immediate, such developments frequently relocate stigmatised ‘groups’ back within prejudiced individuals’ moral frameworks and, thereby, persuades them to interact appropriately with stigmatised individuals. Concurrently, and especially if the education is aimed towards younger individuals whose prejudices are not as thoroughly indoctrinated, it also actively denaturalises stigma and brands it as a socially unacceptable attitude. An indispensable component for producing these social policies is to recognise currently circulated myths regarding mental illnesses as precisely that — ‘myths’ — formed  within specific historical and ideological contexts. For, before it can be efficiently combated through the dissemination of informed knowledge, stigma’s roots first must be understood as mythical and without any essential foundations in ‘reality’. When this information is understood and circulated it will help construct educational knowledge and hinder stigma’s cumulative nature. The Mental Health Foundation of Australia recognises several damaging myths encouraging exclusion and discrimination that these methods can combat including the belief that mental illness means an individual is permanently ‘abnormal’.

Associating mental illness with an immutable ‘abnormality’ requiring exclusion evolved from a protracted history of ‘othering’ beginning in earnest during the confinement period. Prior to confinement, whose dates essentially complement European Enlightenment, the ‘mad’ had held a unique social space. Indeed, as Michel Foucault suggests, social inversion festivals like the ‘Feast of Fools’ flourished and heroic protagonists like Shakespeare’s melancholic Hamlet dominated the Renaissance imagination. The Enlightenment’s rationalisation and standardisation, however, began shattering this space through restrengthening and heightening veneration for the socially created ‘norm’ and the established ‘reality’. Consequently, negative value judgments were placed upon deviation from these. Subjective rulings placed on these neutral circumstances, sociologist Robert Brooks suggests, thereby formed psychological difference as naturally synonymous with irrationality, the substandard and social deviance. Deviance was largely defined in relation to an individual’s labour efficiency, with low productivity resulting from illness signifying low social usefulness. Low social usefulness located the ‘mad’ beyond social inclusion and, as a ‘rationally’ deducible ‘fact’, thus closer to ‘irrational’ and ‘immoral’ animals. Foucault notes that the Lord Mayor of Cromwell’s England — and, by extension, English officials — considered the ‘mad’ as less than animals. They were ‘vermin’ and dehumanised pests whose existence upset civil society and whose ‘abnormality’ was thus naturally irreversible and threatening. This irrational association, despite the centuries passed since it formed and despite today’s increased knowledge base surrounding mental illness, currently remains a firmly entrenched ideological perspective within western culture.

Ideological entrenchment occurs primarily as stigma grows when left unopposed. Accordingly, despite the period’s medical advancements, social attitudes towards mental illness during the incarceration period built upon confinement’s essentially unchallenged ideological foundations further naturalising mental illnesses’ status based on ‘otherness’. Indeed, with this period occurring form the early nineteenth century up to the world wars, mental illness gradually evolved to signify individuals’ supposed ‘natural’ inferiority or vulnerability. For, although ‘lunatics’ were now human individuals and no longer ‘vermin’, they remained largely conceived within a framework dichotomising between the venerated ‘normal’ and the degraded ‘abnormal’. Lunacy ‘abnormalities’, however, were newly conceived as potentially curable or incurable moral and intellectual problems largely affecting ‘weaklings’. This concept was formed — similar to the period’s racism and sexism — through the discourse and language of patriarchal paternalism. Its dialogue suggested that lunatics required secular guardianship and ‘care’ by ‘capable’ individuals, preferably beyond the sight of civil society and within a controlled setting. Unsurprisingly, according to the UK Science Museum, capable individuals were always male and always positioned as authoritative father figures. Patients, by inference, were unruly children. Predictably, as these now weak and  ‘childlike’ individuals were accordingly excluded into asylums, historian Klaus Doerner argues society reinforced its ‘norms’ and progressively became even more intolerant to ‘difference’. The associations between ‘weakness’ and ‘mental illness’ consequently became ingrained, and they persist today. Such uninformed prejudices, since the period’s racism or sexism are highly acceptable, thus need to be combated with education now before they become further entrenched.

History additionally indicates that strong societal policies endorsing difference are required because, not only is stigma cumulative, it also allows oppression and human rights violations to grow and to thrive. Indeed, historian Stephen Garton argues that, when stigma towards mental illness is ignored and allowed to ferment within broader society (as it always has been), official policies have formed matching these social biases. Consequently, they have frequently been inhumane — from lashings to today’s unhelpful silence surrounding suicide — and have sanctioned human rights violations tolerated against hardly any other social ‘group’. In turn, as communities habitually harmonise prejudices with social guidelines, this predictably strengthens the already prevalent practices of exclusion, discrimination, and stereotyping. Those diagnosed or believed mentally ill thus are dually stripped of their freedoms and rights by official law and by informal social sanction. Under  several articles of the Universal Declaration of Human Rights, this simply is an unacceptable and shameful practice — whether the freedom removed is primarily physical, intellectual, spiritual, or an amalgam — that benefits neither the individual nor society. Creating social guidelines thus is essential to prevent further transgressions against individuals’ freedom such as those seen during the confinement period.

Policies and informal social sanctions during the confinement period were shaped to the prevailing belief that mental illness was an immutable form of social deviance. Accordingly, it became both legal and desirable to exclude ‘madmen’ in ‘madhouses’ and, thereby, to strip physical freedom from individual humans. Thus, at the beginning of English confinement, pauper lunatics were separated from other ‘undesirables’ under the Vagrancy Act of 1714. Pauper lunatics, although newly exempt from whippings and whilst their communities ‘kindly’ funded their ‘sojourn’, were presently to be involuntarily confined for as long as ‘such Lunacy or Madness shall continue’. This confinement — or, essentially, ‘this exclusion of difference’ — largely took place in prisons, London’s Bethlem Hospital (soon known as ‘Bedlam’), and within other emerging lunatic houses. Negligence and oppression behind these walls was not uncommon. It ranged from physical torture to psychological abuse with many individuals chained inside small enclosures for years or even decades. Other abuses were more subtle yet just as damaging and dehumanising. Bethlem, for example, increasingly gained a reputation as a tourist attraction. Individuals, like peculiar animals at a circus, were ‘on show’ for the commoner through to royalty to view at their leisure. Foreigners could even come and witness — and stare at and deride and scorn — the city’s ‘rarities’ whilst touring London’s other ‘fascinating’ sights. Physical freedom and dignity was, thereby, ‘lawfully’ taken from individuals reflecting and enhancing the social environment of stigma and exclusion.

The official and informal policies generated throughout the incarceration period similarly reflected the social environment whose prejudices had been entrenched during confinement. Incarceration’s central ideological milieu surrounding mental illness, it should be remembered, was largely paternalistic and dichotomised between the insane individual as vulnerable ‘child’ and masculine society as powerful ‘guardian’. Accordingly, exclusion from mainstream society remained and greater intellectual and physical oppression — like the binding of Beers’ hands through to dreadful experimental ‘cures’ — flourished across the West. Inmates in Australia’s overcrowded asylums, for example, often were openly humiliated, physically or sexually abused, and spiritually degraded. Indeed, headed by influential mental health practitioner Dr John Fishbourne, an August 1890 inquiry into Melbourne’s ‘Yarra Bend Lunatic Asylum’ even found patients gravely neglected with many covered with and suffering from undressed bed sores. Some immobile patients were forced to lie in filthy conditions. Others were attended to with the basest medical appliances. Dr Fishbourne, quoted in The Argus, said that these degradations had been allowed under Victoria’s ‘Lunacy Statute’ as:

…the very vulgarest kind of prejudices appeared to have influenced our legislators in dealing with the question, so that the difficulties of placing persons suffering from incipient brain disease under competent treatment has been added to instead of lessened.

The same ‘vulgar’ prejudices had allowed abuses and ignored their seriousness when reported. Thus, again, it is clear that official and informal policies toward mental illness shape themselves to social preconceptions and, in a vicious circle, reinforce these preconceptions. It is, consequently, vital to create informed public awareness and social guidelines to hinder similar oppressive practices from developing today.

Education and awareness will not only dissuade violations from coming into existence, but also instigate positive change within the social environment. For, when prejudice has been recognised as prejudice and combated accordingly, there always has been improvement in the way mental illness is perceived. This allows greater social inclusion that, in turn, allows greater collaboration in the treatment of mental illness. McGorry suggests it also ensures individuals are more inclined to seek help and to visualise help as desirable. Such a supportive environment, SANE Australia argues, is vitally important for individuals living with mental illness — as it is with physical illness, too — for research clearly reveals this is essential for managing illness, for encouraging participation in social activities, and for helping individuals to return to work. For Australia, whose employment rate of individuals with a mental illness according to The Australian is one of the lowest in the western world, this is a pertinent objective. Moreover, in a recent SANE Australia survey almost all respondents contended that reducing stigma would improve their self-image, reduce self-stigmatisation, and reduce social isolation. This, again, is a vital goal, for as McGorry notes suicide is the biggest killer of young Australians and currently less than half of Australians with a mental illness seek help. Creating this improved social environment is not impossible and, in the past, it has been achieved through confronting stigma with informed knowledge and understanding.

The confinement period witnessed minimal change in dominant attitudes towards the ‘insane’ until asylum reformers began challenging these ignorant perspectives with informed knowledge. The Reform Movement transpired virtually simultaneously across the West and included numerous influential individuals from ‘moral treatment’ founders Jean-Baptiste Poussin and ex-patient Philippe Pinel to American humanitarian Dorothea Dix. Publicly, these reformers declared that the insane were not animalistic as generally believed, and that their ‘difference’ therefore deserved to be treated with compassion not punishment. Hence, in her 1843 Memorial, to the Legislature of Massachusetts, Dix persuasively challenged stereotypes through graphically describing the atrocious conditions the insane were secluded within; through her efforts Dix succeeded in humanising them. It was important, she asserted, to acknowledge her inspections had discovered individuals ‘beaten with rods, and lashed into obedience’ and even a man confined in ‘a close stall for 17 years’. In acknowledging it, Dix continued, we could ‘place ourselves in the situation of some of these poor wretches’ and then ‘hasten to the relief of the victims of legalized barbarity’ we could barely imagine having conducted upon ourselves. Dix, through this argumentative technique, succeeded in relocating the insane back within American legislatures as well as the media’s and the public’s normative moral frameworks. Gradually, her pioneering work facilitated the establishment of six public asylums, an officially funded Massachusetts state asylum, improved treatment within Scottish and American asylums, and changed public attitudes. Confronting prejudices publicly with knowledge thus produced a reduction in prejudicial attitudes and positive changes within the medical and social spheres.

The incarceration period concluded similarly with reformers across the West generating informed awareness regarding mental illness and, thereby, opposing stigma and prejudicial attitudes. A key American reformer was Clifford Beers who, upon his release from three years’ of incarceration and abuse, hoped to challenge negative public attitudes towards mental illness and to humanise the insane. This, he believed, was essential for individuals’ mental health, for creating lasting reform, and for countering the inhumane practices he had both witnessed and experienced. Indeed, in his autobiography titled A Mind That Found Itself (1908) Beers claimed:

More fundamental…than any technical reform, cure, or prevention — indeed, a condition precedent to all these — is a changed spiritual attitude toward the insane. They are still human: they love and hate, and have a sense of humour…Is it not, then, an atrocious anomaly that the treatment often meted out to the insane persons is the very treatment which would deprive some sane persons of their reason?

This book, with its graphic depictions of maltreatment within and beyond asylum walls, achieved Beers’ aim of altering ‘spiritual attitudes’ on a national and international scale. Curator Parry Manon suggests it even helped initiate the United States reform movement. By 1909, Beers also had co-founded the ‘National Committee for Mental Hygiene’ (still in existence and today known as Mental Health America), whose client-advocate goals included developing desirable mental health services and amending social attitudes towards mental illness. These goals still are being realised today yet Beers proved that, like Dix before him, positive change in social attitudes could be attained through confronting them with informed awareness. Unfortunately, as no official policies backed these remarkable reformers in their endeavours, it should be remembered that their changes had a lasting but not overly pervasive impact. Today, however, this pervasive impact can be achieved in Australia by creating awareness and reinforcing it with policy.

The ‘demoniacal dread’ that Beers said had filled him for six years and caused him to jump from his bedroom window left the moment he hit the earth outside his family dining room. From that very moment, as his family rushed out to him, he never experienced the desire to suicide again. It was, he thought, important to explain:

That the very delusion which drove me to a death-loving desperation should so suddenly vanish would seem to indicate that many a suicide might be averted if the person contemplating it could find the proper assistance when such a crisis impends.

Today, over one hundred years later, this statement remains crucial. Australia has and is helping to develop the ‘proper assistance’ for any mental illness when needed. The ‘proper assistance’ nonetheless now needs to be complemented with ‘proper’ social attitudes so that assistance seems desirable and has a lasting impact. Proper social attitudes cannot be forced into creation yet they can be cultivated through societal guidelines, education, and awareness that will alter the currently entrenched framework through which broader Australian society conceives mental illness. Through generating this alteration, the positive advances the Mental Health Reform promises to accomplish will be secured for the long-term whilst, simultaneously, helping to produce long overdue improvements within our social environment.

For help or information visit beyondblue.org.au or contact Lifeline on 131 114 or Suicide Helpline Victoria on 1300 651 251.

Selected further reading:

Act of Parliament, 1714, ‘First Legislation for Pauper Lunatics,’ in R Hunter & I Macalpine (eds.), Three Hundred Years of Psychiatry 1535 – 1860: A History Presented in Selected English Texts, Oxford University Press, New York, 1963, pp. 299 – 301.

Beers, C, A Mind That Found Itself, Andrews UK Limited, United Kingdom, 1908.

Beyond Blue, Get Information, Beyond Blue, 2011, retrieved 1 October 2012 http://www.beyondblue.org.au/index.aspx?link_id=7.897

Brooks, R, ‘Official Madness: A Cross-Cultural Study of Involuntary Civil Confinement Based on ‘Mental Illness’,’ in J Hubert (eds), Madness, Disability and Social Exclusion: The Archaeology and Anthropology of Difference, Routledge, London, 2000, pp. 9 – 29.

Coleborne, C, Mental Health, The University of Melbourne, 2008, retrieved 1 October 2012, http://www.emelbourne.net.au/biogs/EM00960b.htm

Dix, Dorothea, Memorial to the Legislature of Massachusetts [1843], American Journal of Public Health, 2006, retrieved 1 October 2012, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470564/

Doerner, K, Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry, trans. J Neugroschel & J Steinberg, Basil Blackwell Publisher, Oxford, 1981.

Dunlevy, S, ‘Jobs the Measure of Mental Health Reform,’ The Australian, 1 August 2012, http://www.theaustralian.com.au/national-affairs/jobs-the-measure-of-mental-illness-reform-says-allan-fels/story-fn59niix-1226440436685

Foucault, M, History of Madness, Routledge, Oxon, 2006.

Foucault, M, Madness and Civilisation, Tavistock Publications, London, 1967.

Gardiner, L, Fishbourne, John William Yorke (1843 – 1911), Australian Dictionary of Biography, National Centre of Biography, Australian National University, 2012,  retrieved 1 October 2012, http://adb.anu.edu.au/biography/fishbourne-john-william-yorke-6175/text10611

Garton, S, Medicine and Madness: A Social History of Insanity in New South Wales 1880 – 1940, New South Wales University Press, Kensington, 1988.

Grob, GN, The Mad Among Us: A History of the Care of America’s Mentally Ill, The Free Press, New York, 1994.

Hatfield, A, Family Education in Mental Illness, The Guilford Press, New York, 1990.

Kremer, J, N Sheehy, J Reilly, K Trew & O Muldoon, Applying Social Psychology, Palgrave Macmillan, New York, 2003.

MacDonald, M, Mystical Bedlam: Madness, Anxiety, and Healing in Seventeenth-Century England, Cambridge University Press, New York, 1981.

MacDonald, M & T Murphy, Sleepless Souls: Suicide in Early Modern England, Clarendon Press, New York, 1990.

Manon, P, ‘From a Patient’s Perspective: Clifford Whittingham Beers’ Work to Reform Mental Health Services,’ American Journal of Public Health, vol. 100, no. 12, 2010, pp. 2356 – 2357.

McGorry, P, ‘A Deadly Silence that has to End,’ The Age, 10 September 2012, retrieved 1 October 2012, http://www.theage.com.au/opinion/society-and-culture/a-deadly-silence-that-has-to-end-20120909-25m58.html

McGorry, P, Open Minds. Improve Services. Transform Australia, Pat McGorry, 2012, retrieved 1 October 2012, http://www.patmcgorry.com.au/

Mental Health America, Our History by Decade, Mental Health America, 2008, retrieved 1 October 2012, http://www.nmha.org/centennial/history.html

Mental Health Foundation of Australia (Victoria), Fight Stigma: Stamping out the Stigma of Mental Illness, Mental Health Foundation of Australia, 2009, retrieved 1 October 2012, http://www.mentalhealthvic.org.au/index.php?id=112

Miller, M & F Torrey, The Invisible Plague: the Rise of Mental Illness from 1750 to the Present, Rutgers University Press, New Brunswick, 2001.

Mindframe, A Resource for on the Portrayal of Suicide and Mental Illness, Mindframe National Media Initiative, 2012, retrieved 1 October 2012, http://www.mindframe-media.info/

SANE Australia, Stigma and Mental Illness, SANE Australia, retrieved 1 October 2012, http://www.sane.org/images/stories/information/research/0701_info_rb4.pdf

Science Museum, Dorothea Dix (1802 – 1887), Welcome Trust, retrieved 1 October 2012, http://www.sciencemuseum.org.uk/broughttolife/people/dorotheadix.aspx

Universal Declaration of Human Rights, United Nations, retrieved 1 October 2012, http://www.un.org/en/documents/udhr/index.shtml#a19

© APH Network and contributors 2012. All rights reserved.

 

Citation: Shelise Robertson, Our Sick Society: Curing the Stigma attached to Mental Illness through Public Awareness and Education. Australian Policy and History. October 2012.

URL: http://www.aph.org.au/our-sick-society

Permanent link to this article: http://aph.org.au/our-sick-society