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This time-honoured propensity has probably served mankind and its
ancestors well in protecting the species and ensuring 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, diseases such as leprosy, cancer, 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, infection. Many factors influence the
natural history of such stigmatizations; for instance, changing
familiarity, better general control over the perceived threat,
assertiveness of the minority group concerned, changing societal
and personal value judgements.
Throughout this time, the stigmatization of people with mental
illnesses has prevailed, with rare exceptions. Western man has
brought his 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, their personality and their 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
stigmatized groups, (e.g. the physically disabled, with their
ramps, rumble strips, Olympic Games and back-up legislation) the
mentally ill rarely fight their corner. The nature of their
illnesses, whether characterized for instance, by inertia,
egosyntonicity or cognitive breakdown, militates against it.
Meanwhile, one of the features of the recent 'Changing Minds'
campaign survey (Crisp et al. 2000, Gelder 2000) has been its
attempt to secure public opinion concerning six or seven mental
illnesses. Sufficient of the public clearly recognises 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 (DoH 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
Recently, Haghighat (2001) has presented a 'self-interest' theory
as providing the basis for our proneness to stigmatize.
'Self-interest' could be advanced as a reason for much human
behaviour. So far as stigmatization of people with mental
illnesses is concerned, 'self-interest' in its broadest sense is a
useful unifying proposition serving a range of purposes from
protection of self-esteem, reinforcement of mental defence
mechanisms, through to protection of socio-economic status and
potential for economic exploitation. Haghighat attaches most
importance to the licence it provides for socio-economic
exploitation. He reviews literature which 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 which 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. Thereafter he proposes that stigmatizations, 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,
the severely and chronically mentally ill 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 stigmatization 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 man's present self-interest when confronted by
those with mental illnesses in his midst. For instance, the recent
'Changing Minds' campaign national survey shows that people with
schizophrenia and the addictions in particular, are perceived by
the majority of the public 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
co-morbidity are some of the factors that have led people to
perceive those with schizophrenia as much more dangerous than they
are. Sontag (1988) writing within the context of having cancer
herself, 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 and Hoffmann-Richter
(1999) suggest that schizophrenia, in recent years, has taken on
this mantle to an ever greater extent, from cancer and AIDS which
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 campaign survey 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 (DoH 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 corner stone 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". In psychiatry we constantly
seek determining explanations both for form and content of mental
illnesses. At the same time, we usually operate as if our patients
have choice though we may also know that sometimes, their
decisions, e.g. whether to engage in the prospects of change, will
depend upon the context (such as experience of stigmatization,
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, though he stops
short of examining their relationship to the stigmatizer's own
personality and its robustness or otherwise in respect of defences
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 sociopolitical perspectives.
Interventions
Haghighat concludes with an inventory of interventions which he
hopes might collectively provide opportunities to mute the
self-interest that drives our stigmatization of, distancing from
and otherwise our exploitation of the mentally ill. Several of
these fit comfortably with the campaign's survey finding 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 though 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, providing it is accompanied by the necessary social
skills. He applauds, though he is also sceptical of, the work of
Wolff and his colleagues (Wolff, Pathare, Craig 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 appears to be that mankind will grow up
and adopt a more fraternal caring society, throwing off his
biologically driven competitive nature and evolving along correct
ideological lines. However, he describes also the chaos into which
we are thrust these days 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. Mankind 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 prerogative of
the State. Such morality can also have other springs. Toleration
of the mentally ill has occasionally been more evident in ancient
civilizations. Theologians (Lewis 1943) have sometimes equated
social and scientific evolution with moral decline, i.e. cognitive
development without the corresponding affective maturation and
related increase in self-awareness that Haghighat reminds us is
the key to personal growth. Befriending the mentally ill today is
importantly a voluntary activity, doubtless with origins as
diverse as those fuelling social exclusion of the mentally ill.
There is agreement that, above all, we need more than ever to
search for and respect the uniqueness of the individual apart from
his/her illness; yet also recognise the contributions to
civilization that have sprung from such associations. Also to
remember the value of hybrid vigour and the awful sterile dangers
of genetic standardisation.
As a campaign such as 'Changing Minds: Every family in the land'
strives to achieve this goal by opening up this inescapable agenda
for public attention we shall still need to try to empower the
mentally ill to test out the relevance, to their own potential
self-interests, of the current Disability Discrimination Act (DDA)
and the soon to emerge U.K. human rights legislation. We may also
need both to acknowledge our biologically driven behaviours before
we can more effectively shape and curb them, and to become more
knowledgeable about 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 to and mute
this unattractive and tenacious human trait of unfairly labelling
and seriously disadvantaging others.
References
Alison-Bolger YY (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 MG, 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. Prepared for Central Office of Information CO1
Ref: RS4206.
Gelder M (2000) The Royal College of Psychiatry's survey of public
opinion about mentally ill people. In: Crisp AH (ed) Every Family
in the Land. www.stigma.org.
Gilbert P & McGuire M (1998) Shame; Social roles and status; the
psychobiological continuum from monkey to human. In: Gilbert P &
Andrews B (eds) Shame; Interpersonal Behaviour, Psychopathology
and Culture. New York: Oxford University Press Pp. 99-125.
Haghighat R (2001) A unitary theory of stigmatization. British
Journal of Psychiatry 178: 207-215.
Hughes P (2000) Stigmatisation as a survival strategy:
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Land. 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: stigmatization
of people with schizophrenia. In: Crisp AH (ed) Every Family in
the Land. www.stigma.org.
Lewis CS ( 1943) The Abolition of Man. Oxford: Oxford University
Press.
Littlewood R (1998) Cultural variation in the stigmatisation of
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Sontag S (1988) AIDS and its Metaphors. London: Penguin Books.
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Acknowledgement
Copyright 2001 Royal College of Psychiatrists. Reproduced with the
kind permission of the Editor and the College from the British
Journal of Psychiatry, 178: 197-199, |
