The tendency to stigmatise
ARTHUR
CRISP, FRCPsych (Hon.), Chairman
Royal
College of
Psychiatrists' anti-stigma campaign ‘Changing Minds: Every Family in
the Land’. Psychiatric Research Unit, Atkinson Morley's Hospital, 31
Copse Hill,
London
SW20 ONE
This time-honoured propensity has
probably served humankind and its ancestors well in the
service of species and related personal survival. Such
biological mechanisms as those subserving immediate
survival, the quest for food, reproduction and related
territorial needs are presumably its foundation. Moreover,
the crudity of categorisation and labelling of related
perceived possible threats needs, constitutionally, to be
safely over-inclusive, before juggling the consequent
options of relating to, coming to dominate, fleeing from
or ignoring the source.
In recent social history such core
matters as race and political persuasion, such diseases
as leprosy, cancer and AIDS and various physical
handicaps have all triggered this process. One can see
with just these few examples how idiosyncratic are the
concerns evoked (e.g. perceived immediate physical
danger, excessive demands for change, death, infectivity). Many
factors influence the natural history of such stigmatisations:
changing familiarity, better general control over the
perceived threat, assertiveness of the minority group
concerned and changing societal and personal value
judgements.
Throughout such time, the
stigmatisation of people with mental illnesses has
prevailed, with rare exceptions. Western humankind have
brought their particular perception to bear. Mental illnesses
have some unique properties. They express themselves primarily
through cognitive, affective and behavioural symptoms and
signs — those very dimensions that make us what we are
as individuals. The afflicted person may be perceived as
identified with, and not separate from, the illness
(Alison-Bolger, 1999). Psychiatry itself adopts this
perspective with many mental illnesses as it attempts to
explain links between the illness and the individual's
development, personality and relationships. This
biopsychosocial model may be widely applicable but it is
often restricted, in the public's mind, to mental
illness. Perceived negative aspects of the illness then readily
attach themselves to the afflicted person, as also happens,
for instance, with physical illnesses regarded as
self-inflicted. Secondly, unlike many other stigmatised
groups (e.g. the physically disabled, with their ramps,
rumble strips, Olympic Games and back-up legislation),
those with mental illnesses rarely fight their corner.
The nature of their illnesses, whether characterised, for
instance, by inertia, egosyntonicity or cognitive breakdown,
militates against it. Meanwhile, one of the features of the
recent College Campaign Survey (Crisp et al, 2000) has
been its attempt to secure public opinion concerning six
or seven mental illnesses. Sufficient numbers of the
public clearly recognise differences between these
illnesses and this is reflected in the differing negative
opinions expressed concerning each of them.
The literature on this subject is
patchy. It has tended to focus on schizophrenia and
depression and much of the best has recently emanated
from Australia, where related and well-organised
anti-stigma campaigns have run through much of the last decade.
A recent Department of Health commissioned literature review
on public attitudes to mental health/illness (Department of
Health, 1999) concluded that the experience "does not
bring a strong sense of understanding, but rather of
acknowledgment — that we do think of those with mental
health problems in this discriminatory way". The authors
suggested that "the origins of fear and dislike of those
with mental health problems may well from a deeper spring
in society". The report implies that greater
understanding at this level may be a necessary next step
if change is to occur. The ways in which we have come to
apply our natural capacities and instincts to the tasks
of relating or not relating to those of us with mental
illnesses in our given and changing cultures and with our
existential concerns would seem to provide the arena for
this quest.
THE
SELF-INTEREST HYPOTHESIS
In this month's Journal,
Haghighat (2001) attempts to present a credible unitary
theory to account for all these interactions. He reviews
literature that reflects the breadth of vision he wishes
to bring to bear. Within ‘Constitutional origins’, which
oddly he distances from genetic influences, he cites the
work of experimental psychologists that supports notions
of the need, safely but broadly, to categorise potential threats
and thereafter, if confirmed, to load them with other negative
attributes. He considers ‘Psychological origins’,
and the chosen literature consolidates the notion that, defensively,
we need to identify scapegoats and thereafter to condemn and
avoid them. He then proposes that stigmatisations, whether
they be of another race, fellow competitors or people with
mental illnesses, are weapons in socio-economic competition.
He seemingly sees no biological substrate to this theme, but
pauses briefly to present possible independent evolutionary
influences, serving species rather than personal
self-interests. Could our present-day attitude partly be
fuelled by our ancient need to distance ourselves from
"poor reproductive bets" and those who are "sexually
unattractive" (Gilbert & McGuire, 1998)? More certainly,
people with severe and chronic mental illnesses may be
perceived as "poor economic bets" when it comes to
considerations of reproduction and its more immediate
social consequences. He concludes by advancing the plausible
proposition that "the fundamental basis of all stigmatisation
is pursuit of self-interest", which society naturally comes
to enshrine.
If we propose that our repertoire
of responses has evolutionary biological origins, we can
then consider how they have been harnessed to serve
humankind's present self-interest when confronted by
those in their midst with mental illnesses. For instance,
the College Campaign Survey (Crisp et al, 2000)
shows that people with schizophrenia and the addictions in
particular are perceived by the majority of people as
dangerous and therefore are likely, directly, to evoke
ancient considerations of control or flight. That
perception is, of course, generally exaggerated and its
fuelling is another matter for consideration. Adverse and
selective media attention, lack of diagnostic clarity and
comorbidity are some of the factors that have led people
to perceive those with schizophrenia as being much more
dangerous than they are. Sontag (1988), writing within
the context of herself having cancer, stated "... diseases
acquire meaning (by coming to stand for the deepest fears)....
It seems that societies need to have one illness, which
becomes identified with evil, and attaches blame to its
‘victims’... Any disease that is treated as a mystery and
acutely enough feared will [also] be felt to be morally
if not literally, contagious". Finzen & Hoffmann-Richter
(1999) suggest that schizophrenia, in recent years, has
taken on this mantle to an ever greater extent, from the
cancer and AIDS that Sontag was writing about.
Haghighat's emphasis on self-interest expressing itself
importantly in terms of economic exploitation can apply
to all mental illnesses, although he does not identify any
particular ones and may mainly have had schizophrenia in mind
throughout much of his discourse.
In contrast, the College Campaign
Survey (Crisp et al, 2000) reveals the theme of
perceived self-infliction, especially in respect of the
addictions but also in those afflicted with eating
disorders, who, however, are not also seen as dangerous.
Similar literature over the years has revealed this same association
in the public's mind (Department of Health, 1999). It raises
the problems of ‘free-will’ and ‘choice’, which
Haghighat does not address. Perhaps we can only cope with
this dilemma by not discussing it. Belief in it is often
the cornerstone of our self-image, at least in the Western
world; it is also the basis of law and order in society. Max
Hamilton used to comment: "Free-will is something we believe
we have, but we equally believe that we can predict how others
will behave" (M. Hamilton, personal communication, 1970).
In psychiatry we constantly seek determining explanations
both for the form and the content of mental illnesses. At
the same time, we usually operate as if our patients have
choice, although we may also know that sometimes
decisions such as whether to engage in the prospects of
change will depend upon the context (experience of
stigmatisation, legal constraints, transferences within
therapy). Meanwhile, this dilemma may be at the heart of
people's tendency to blame such groups of patients in
particular. Haghighat considers that psychological
mechanisms may be at work here, although he stops short of
examining their relationship to the stigmatiser's own
personality and its robustness or otherwise in respect of
defenses against personal dysphoria (Hughes, 2000). Yet,
as with responses to dangerousness, it accords with his
self-interest hypothesis.
Two of Haghighat's main thrusts
have to do with the view (e.g. Littlewood, 1998) that we
may be prone to take advantage of the mentally ill by
exploiting them economically. This could be linked
closely to our ancestral origins and those commonplace natural
behaviours of attempted territorial domination and its
purposes. Haghighat himself examines causation categorically.
Although ultimately he extols a monistic philosophy, he does
not, for instance, seriously attempt to explore interactions
between psychological and socio-political perspectives.
INTERVENTIONS
Haghighat concludes with an
inventory of interventions that he hopes might
collectively provide opportunities to mute the
self-interest that drives our stigmatisation of, and distancing
from, and our exploitation of those with mental illnesses.
Several of these fit comfortably with the finding of the
College Campaign's survey that the public overwhelmingly
perceives people with all mental illnesses as difficult
to communicate and empathise with. Such perceptions and
expectations promote distancing, social exclusion and
ignorance. An association between prejudice and ignorance
has long been demonstrated, although the nature of that
relationship is unclear. Haghighat commends educational
programmes and is aware of their limitations in reaching
out to people's deep fears. He sees the potential value
of familiarity with people with mental illnesses, provided
that it is accompanied by the necessary social skills. He
applauds, although he is also sceptical of, the work of Wolff
et al (1996) and Leff (2000),
who have begun to develop and evaluate neighbourhood
induction programmes. In this connection, a recent
community psychiatric nursing initiative in Glasgow is
also noteworthy (Kaminski & Harty, 1999).
But Haghighat's main hope comes
through as being that humankind will grow up and adopt a
more fraternal caring society, throwing off their
biologically driven competitive nature and evolving along
correct ideological lines. However, he describes also the
chaos into which we are these days thrust through endless
bombardment with information and our increasing geographical
mobility, and acknowledges that under such circumstances we
may become defensively prone to ever coarser negative
compartmentalising and labelling processes. Humankind has
always had the capacity to be more cruel than nature
requires. Along with his belief that fraternal ideologies
will triumph over the law of the jungle, Haghighat
identifies the need to curb undue competition and freedom
to exploit others in the interests of the entire
community. Much law and custom are designed to do just that,
but justice and compassion in particular are not the
prerogatives of the State. Such morality can also have
other springs. Toleration of mental illness has
occasionally been more evident in ancient civilisations.
Theologians (Lewis, 1943) have sometimes equated social
and scientific evolution with moral decline — cognitive
development without the corresponding affective maturation
and related increase in self-awareness that Haghighat reminds
us is the key to personal growth. Befriending of people with
mental illnesses today is importantly a voluntary activity,
doubtless with origins as diverse as those fuelling social
exclusion of those with mental illnesses. There is agreement
that, above all, we need more than ever to search for and
respect the uniqueness of the individual apart from his or
her illness, yet also recognise the contributions to
civilisation that have sprung from such associations. We
should also remember the value of hybrid vigour and the
awful sterile dangers of genetic standardisation.
The campaign ‘Changing Minds: Every
Family in the Land’ strives to achieve this goal by
opening up this inescapable agenda for public attention
but we shall still need to try to empower people with
mental illnesses to test out the relevance to their own
potential self-interests of the current Disability
Discrimination Act (DDA) and the soon-to-emerge UK human rights
legislation. We may also need to acknowledge our biologically
driven behaviours before we can more effectively shape and
curb them, and also become more knowledgeable and comfortable
about ourselves, before we become more at ease with mental
illness in others. Apart from good protective legislation,
greater public self-awareness is probably now essential for
significant and enduring change. Meanwhile, Haghighat's
contribution deserves recognition as an early building
block and social prompt in our efforts to penetrate and
mute this unattractive and tenacious human trait of
unfairly labelling and seriously disadvantaging others.
REFERENCES
Alison-Bolger, Y. Y. (1999)
The original sin of madness — or how psychiatrists can stigmatise
their patients. International Journal of Clinical Practice,
53, 627 -630.
Crisp, A. H., Gelder, M. G., Rix,
S., et al (2000)
Stigmatisation of people with mental illnesses. British Journal
of Psychiatry, 177, 4-7.
Department of Health (1999)
General public attitudes to mental health/illness. COI Ref: RS4206.
London: Central Office of Information.
Finzen, A. & Hoffmann-Richter,
U. (1999) Mental illness
as a metaphor. In The Image of Madness (eds J. Guimón, W.
Fischer & N. Sartorius), pp. 13-19. Basel: Karger.
Gilbert, P. & McGuire, M. (1998)
Shame, social roles and status; the psychobiological continuum from
monkey to human. In Shame: Interpersonal Behaviour,
Psychopathology and Culture (eds P. Gilbert & B. Andrews), pp.
99 -125. New York: Oxford University Press.
Haghighat, R. (2001)
A unitary theory of stigmatisation. British Journal of Psychiatry,
178, 207 -215.
Hughes, P. (2000)
Stigmatisation as a survival strategy: intrapsychic mechanisms. In
Every Family in the Land (ed. A. H. Crisp). www.stigma.org.
Kaminski, P. & Harty, C. (1999)
From stigma to strategy. Nursing Standard, 13, 36-40.
Leff, J. (2000)
Contemporary images and the future: stigmatisation of people with
schizophrenia. In Every Family in the Land (ed. A. H. Crisp).
www.stigma.org.
Lewis, C. S. (1943)
The Abolition of Man. Oxford: Oxford University Press.
Littlewood, R. (1998)
Cultural variation in the stigmatisation of mental illness.
Lancet, 352, 1056 -1057.
Sontag, S. (1988)
Aids and its Metaphors. London: Penguin Books.
Wolff, G., Pathare, S., Craig,
T., et al (1996)
Public education for community care: a new approach. British
Journal of Psychiatry, 168, 441 -447.
Received for publication August 9,
2000. Accepted for publication August 15, 2000.
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