Language and mental health

international | miscellaneous | opinion/analysis Saturday April 02, 2005 01:02 by Mark - N/A ellerby1 at aol dot com 22 Briar Avenue Brandon Durham DH7 8AL 01913783202

cultural forms and origins of stigma

What really causes the stigma of mental health?

In order to gauge the problem of the stigma of mental illness it is necessary to see how many words and phrases, heavily used by the media, which stigmatise those with the illness. The results are quite surprising: there are at least fifty two such words and phrases. These are:

Loony, loopy, round-the-bend, round-the-twist, crazy, crackers, off your rocker, off your trolley, nuts, not a full shilling, not a full pound, not all there, daft, screw loose, mad-as-a-hatter, mad-as-a- march-hare, not a full deck, zany, mental, cranky, deranged, raving, loco, out of your mind, off your head, dotty, potty, batty, cuckoo, one sandwich short of a picnic, balmy, bonkers, bananas, screwy, insane, disturbed, unhinged, barking, fruit cake, nut case, head case, flipped, snapped, wacko, lost it, not right, loosing your marbles, mental, funny, abnormal, mad and non compus mentus.

These words are not the only labels but they also further infect other every day notions and as such form a separate group of terms. Examples of this include the phrases sick joke, insane laughter, ranting and raving, insanely jealous, screwed up, hoping mad, cracked up, madly in love, method to your madness, mad axe man, mad scientist, frayed ends of sanity, mad driver, it’s a crazy world, the lunatics are running the asylum, acting like a maniac, daft as a brush and tipped over the edge. Fifteen such further phrases in all. Madness etc here is an example of what Hayek called a weasel word – in that it has the ability to attach itself in an unwarranted manner to all sorts of every day language

These words and phrases are reinforced by a number of other terminological considerations: doctors are referred to as ‘shrinks’ and hospitals as the ‘loony bin’, ‘nut house’, ‘funny farm’, ‘bedlam’ or ‘mad house’, being run by the infamous ‘men in white coats.’ Such people are ‘committed’ rather than ‘admitted’ and ‘certified’ rather ‘diagnosed.’ This latter aspect is also exemplified in the 1960`s song “There coming to take me away ha ha!” People also talk about ‘maniacs’ instead of ‘manias’ and of ‘psychos’ instead of ‘psychoses’. All this when the existence of medical terminology was meant to dispel the stigma. We shall examine all these groups of terms and their origins later.

Edmund Burke said that prejudices are non rational but were responsible for holding society together. Mental health however is one area where reform is needed along the lines of enlightenment reason which Burke opposed.

In relation to the popular definition of mental illness and the stigma of being mentally ill a number of further considerations seem also to be worth noting here. These relate to the common misuse of the following words and phrases referring to mental illness: dual or split personality for schizophrenia, madness or insanity for mental illness, and psychopathic for psychotic. These words seem to be at the root of much of the stigma experienced by people with mental illness.

In the case of the first instance - the notion that schizophrenia is a dual personality - the origin of this example appears to be the story of Jeckyll and Hyde. Notwithstanding the fact that there does exist something else called multiple personality disorder, the prefix “schizo” signifies to most people a “divide”, “split”, or “schism” within the self and hence suggests the common misperception of schizophrenia noted here. Phrenesis is the Greek word to divide.

The Jeckyll and Hyde story connects well with those cases, heavily reported in the media, where schizophrenics have been violent towards themselves or other people. This connection has also been used in a number of well known films including Alfred Hitchcock`s ‘Psycho’, and ‘The Shining’ starring Jack Nicholson. Here the central character is a knife-weilding maniac, or mad axeman respectively. The protagonist is ‘insane’ or ‘mad’ rather than ill, and is ‘psychopathic’ rather than ‘psychotic.’

Michel Foucault in his work , Madness and Civilisation, has written a history of insanity in which he argues madness is feared as a form of ‘otherness’ alien to and outside of the experience of self proclaimed ‘normal people’. This perception of madness as otherness seems to be reinforced by the atitudes outlined above to the point that it infects the unconscious misuse of everyday language.

Origins.

The origins of much of the present stigma of having a mental illness appear to lie in the Victorian period. To illustrate this it is useful to explore some of the connotations of some of the words used to describe the mentally ill – in particular the word ‘lunatic’ and the phrase ‘cracked up.’

The first derives from the days of padded cells and straight jackets. The second is a disparaging term for a nervous breakdown deriving from the Victorian ethic of self help and self reliance. The word ‘lunatic’ conjures up images of mad people out of control, needing restraint, and confinement in an asylum. Underlying this social exclusion and physical confinement is the fear that mad people may turn violent. This is a premise heavily influenced by continual reports in the media of acts of violence by schizophrenics towards themselves or others – all of which helps conjure up the Hannibal Lecter image of the mentally ill. Such films and reports reinforce the negative connotations of the word ‘lunatic.’

The other image of mental illness is that such people have ‘cracked up’ under pressure. Such individuals are said to have ‘lost it’ (it referring to their sanity) and are seen as weak compared to those who can cope with life. To ‘crack up’ is not a socially acceptable reaction and such people ‘ought to pull themselves together’ and ‘grin and bear it.’ The nineteenth century also associated these attitudes with what became known as Social Darwinism – the doctrine of survival of the fittest. Neitsche thought “that which does not kill me makes me stronger.”

Is it also ‘cowardly’ to commit suicide? People seem to think this is the ‘easy’ way out and that such people can’t ‘face up’ to their problems. People have much the same attitude to alcoholism. For Catholics suicide is also a sin – does this add a further aspect of stigma to the mentally ill? Some would perhaps argue that suicide is not easy but actually the opposite. However we never see the hero or heroine in films or the media cast as courageous and heroic for surviving schizophrenia etc or commended on the suicide.

It is worth noting that these Victorian values reappeared in the 1980`s and 1990`s with Thatcherism. These values have reinforced the stigma of having to ask for help in the new society which stresses self-help and self-reliance since they have reinforced the prejudice that mentally ill people ought to be able to ‘cope’ outlined above.

It is these notions - of the existence of ‘lunatics’ and that some people ‘loose it ‘ and ‘crack up’ - which gives seems to have contributed to what Foucault calls ‘the great confinement’ (in asylums) which occurred during modern times and is thus at the root of the stigma experienced by people who have schizophrenia or manic depression.

Meanings.

It is interesting (not only in point of fact) to note the origin and meaning of those stigmatising words and phrases which label schizophrenia and manic depression. The origins of these words fall into four basic categories. First is the technical source, second are those words and phrases coined in popular parlance, third are words and phrases which are literary in origin and finally are words and phrases which are slang in origin. We shall briefly examine each in turn but constraints of space prevent an exhaustive enquiry.

The first group includes word such ‘lunatic’, ‘manic’, ‘madness’, ‘non compus mentis’ and ‘insane’. Lunatic for example is Roman/Latin in origin – the Romans believed (in the way modern Astrologers do) that the phases of the moon influenced behaviour including behavioural abnormalities. It is curious that the word has survived so long given it’s meaning. ‘Insane’ is equally curious as it merely signifies the absence of something and does not denote any positive characteristics. ‘Non compus mentis’ seems to imply that there is some kind of deficiency which in popular parlance carries a stigma – because it implies non competence.

The second group are not technical words but are still used in standard English. These include ‘zany’, ‘raving’, ‘crazy’, ‘mental’ and ‘deranged’. Some of these words can be used in a non-derogatory way but only the word mental directly relates to the problems experienced by psychiatric patients (a point to which I shall return). The word ‘bedlam’, derived from the Victorian asylum Bethlem, is still used in common language to mean a state of uproar and confusion despite the fact most modern hospitals are quiet and restful. ‘Deranged’ and ‘raving’ are very derogatory terms.

The third group are words which have acquired authority through their appearance in great works of Literature. Lewis Carrol’s Alice in Wonderland is a good example – as it contains the mad hatters tea party. The phrases appearing therein of Mad-as-a-hatter and mad-as-a-March-Hare have passed into language. The first is curious since the Victorians believed that the Mercury used in the rim of a top hat which helped weigh it down was responsible for driving people mad! The second phrase refers to the way Hares gad about in the rutting season in March. This does look quite manic.

The final group – slang words – is the largest and falls into two sub categories: ones with contain some insight or and ones which don’t. Being ‘nuts’ relates directly to mental problems since your ‘nut’ is a slang word for the head it refers to some problem with it. Other slang terms are more oblique but contain the same kernel of meaning: having a ‘screw loose’ for example implies there is something wrong and in need of fixing. Other slang terms (ones which fall into the secondary category above) are in contrast are devoid of meaning: these include potty, dotty, batty, balmy, bonkers etc etc.

It may be objected that in normal parlance these words can also be used in a jocular way. Even the word ‘shrink’ can be harmlessly used to refer to psychiatrists in the way people refer to medical doctors as quacks. Nevertheless there is a social stigma relating to mental illness – sometimes through the corruption of technical terms – and this is how it is expressed. It is instructive to consider an example.

Many of the words used in popular and curiously also in technical parlance lend themselves to meanings which are stigmatising. Consider for example the derogatory form of ‘manic’ which becomes ‘maniac’ and the transmutation of the phrase ‘lunatic asylum’ into ‘loony bin.’ In the end it would be helpful is we stopped employing even such quasi-technical terms as insane - and referred instead only to the more medical sounding referents such as ‘mental illness’ or ‘psychiatric problem’ and of “lunatic asylums’ as “psychiatric hospitals.”.

The use of politically ‘correct language’ has been instrumental in combating other types of prejudice such as racism (blacks as ‘wogs’), homophobias (gays as ‘benders’ and lesbians as ‘dykes’) and also gender neutral language and would therefore also be of key importance in the area of mental health promotion. The employment of such terms in the media – as has been done in other areas of social life – is vital in raising awareness. Curiously however the terminology of mental health stigma is the one major of social life which has yet to be reformed in the media. Some meanings perpetuate ignorance other contain insight – we shall examine these problems later.


Engagement with Madness

The layman has historically had a five fold engagement with madness; there has been both the fascination and the fear of madness, comedy and ridicule, and finally hostility. It is worth exploring both attitudes to the extent they might shed some light on (some of) the historical origins of the stigma.

Part of the fascination with madness lies in the popular myth referring to mental illness that genius is touched by madness. In many ways this seems to be how society has coped with those in it`s midst capable of turning what everyone thinks upside down. Thus madness is a category imposed on some by others as a means of social control. Take for example the philosopher Friedrich Nietzsche who was imprisoned in a late nineteenth century asylum or the abuses of psychiatry by the former Soviet Union in the twentieth century of it’s dissident rebels like the physicist Anatolie Sheransky.

The second aspect of the fascination with madness also lies in the notion that the mad person has some how escaped the strain of the responsibilities and pressures of modern life. Foucault to this end seems to romance his notion of madness by associating a freedom with it. Likewise the psychiatrist R. D. Laing argued that children who are batted like a ping pong between their arguing parents react by escaping off to the fantasy realm of schizophrenia.

The fear of madness begins with it’s misrepresentation by the media and in literature such as Jeckyll and Hyde.What is so terrifying about these tales and there modern day equivalents such as Hannibal Lecter is that they try and get inside the mind of the mentally ill as something abnormal. The patient is therefore exploited for the shock value with little of the appropriate medical context involved. This also creates a further aspect of fascination.

Thus fascination and fear (shock value) have historically resulted in an insatiable curiosity about madness. Thus in Victorian times people were drawn to visit lunatic asylums (like Bethlem) to see for themselves what madness is. Although it was never hospital policy to promote this, patients were put on show to the general public, laughed at and mocked for their ‘unusual’ behaviour and ‘absurd’ delusional ideas. This I think is one origin of the stigma of mental illness resulting in the view that madness is comical and / or ridiculous.

Other more recent examples of the (mis-) perception that madness is comical can be found in the Inspector Cleauceau comdies were the madman Dreyfuss is incarcerated in a padded cell babbling about the former with a nervous twitch! In the second case above of the perception of madness as ridiculuous we can find a more recent example in Bram Stoker’s Dracula were the character Renfield is likewise incarcerated in an asylum whose governer mockingly ask him “oh so you think you are God I suppose?”

More recent examples of this kind of comedy and ridicule can be found in the 1960’s song: “there coming to take me away ha! ha!” Another may be found in the character of Doctor Silverman in Terminator 2 who laughs at the notional delusions of the principle protagonist Sarah Conner – that a robot from the future is trying to kill her and at the fact that it looks human so that there is no evidence to the contrary. The same character in the first Terminator movie also declares mockingly that the character Reece is “in technical terms he’s a loon!”

The establishment of asylums had an unintended consequence – it led to the perception that there was ‘something wrong’ with the inhabitants. They became known as the ‘funny farm’ or ‘loony bin’ and the word ‘Bedlam’ passed into language. Doctors instead of transforming the understanding of ‘madness’ into ‘mental illness’ became known as the infamous ‘men in white coats.’ The underlying mis-perception here is that there is something ‘abnormal’ about the mental ill which has resulted in both hostility and stigma towards madness.

The story does not end here however. It is thus left to ask: why does this aspect of the stigma exist? One reason is that, simply, people have something to gain by affirming their ‘normality’ in this respect: it allows people to demonstrate their ‘soundness’ by being able to say “well I’m not like that.” This infers a mark of superiority while the mentally ill are implied to be deficient, abnormal or even unnatural and hence some of the origins of the stigma. These attitudes and reactions have created myths and ignorance about mental illness – we shall examine this problems later.

The language of mental health stigma and social exclusion.

This article follows on from an earlier article on language and stigma but focuses on one aspect of this language – that of exclusion and confinement. This I think is the possibly the most important and dangerous aspect of the stigma and should therefore be outlined in more detail than in my earlier account.

The language of the spatial segregation of the mentally ill in asylums can reinforce the social exclusion of schizophrenics in particular as it gives rise to the popular myth that lunatics need separating and locking up. This is reinforced by the popular notion such places are like bedlam requiring restraints, padded cells and straight jackets. There seem to be two elements here: the aspect which is derived from the popular social beliefs and mis-perceptions and secondly the aspect which derives authority from academic accounts of psychiatric hospitals.

Socially to the mentally ill exclusion from ‘normal’ society in such places may seem like a social or even a moral prison. These fears on the part of the mentally ill about others attitudes towards them (hostility) and the fear, on the part of the community, of the mentally ill (who may be violent) mean that the occasional walls around hospitals function as a psychological security barrier for people on both sides. Such walls become a physical symbol and the incarnation of this divide else the occasional remoteness of hospital buildings help to institutionalise the spatial separation of the mentally ill by creating a self enclosed little world with little ‘outside contact.’

The lack of contact with such places and the outside world has created a number of myths and notions about such places. They became known as the ‘funny farm’, ‘loony bin’, ‘bedlam’ or ‘lunatic asylum.’ Doctors became known as the ‘men in white coats’ and as one writer in breakthrough pointed out that in the popular perception is that people would disappear into such places and never be heard of again. The most abiding media image is that such places are one’s of confinement.

This can be found in the asylums in popular films such as Hannibal Lecter and Terminator 2 and as the sun newspaper recent headlined also put it in the case of a famous boxer ‘Bonkers Bruno Locked up!’ The reason for this abiding image is not just the sensationalism of Hollywood films but is continually reinforced by reports in the media of cases where schizophrenics have been violent towards themselves or other people. The most famous case of this which received massive media coverage is perhaps that of the Yorkshire Ripper Peter Sutcliff who has been detained in Broadmoor high security hospital. Sometimes the way this is presented the impression created would seem to be that there is little difference between a schizophrenic and a psychopath – a connection first made in R. L. Stevenson’s Jeckyll and Hyde.

The spatial divide infects the language we use to describe this state of affairs: we speak of people being ‘out there’ in a hostile community (and of hospital as ‘in here’). The allusion to the spatial confinement of the mentally ill is also evident from a number of other unconsciously used phases such as when people are referred to as being ‘taken away’ or ‘carted off’ to the loony bin – and of people being ‘committed’ instead of ‘admitted’ . People even talk of people ‘escaping’ from hospital and there are the repeated headlines such as ‘nutters on the loose.”.Take for example the song “they are coming to take me away ha ha!” The popular image of being locked up is not helped by the notion of compulsory confinement implicit in the legal power of a section and ultimately by the existence of locked wards and secure hospitals.

An example of this sort of thinking can even be found to a small extent in the official government policy strategy of care ‘in’ the community. This creates the impression that care was previously somehow outside of the ‘wider society’ an allusion which recurs in the so named government ‘social exclusion unit’ who area of competence includes mental health. Even the current existence of housing associations providing ‘sheltered accommodation’ for mentally ill people has tended to reinforce the related and older (but still popular) notion that hospitals are still a ‘refuge’ or ‘asylum’ from the society which in another sense implies that such places are elsewhere.

Academically, Foucault in his work Madness and Civilisation argues that there are a series of ‘dividing practices’ in modern society and that madness is an example of this. In his further work The birth of the Clinic another example of such a practice is analysed between the ill and well which has further implications for mental health. In these works Foucault refers to the development of mental hospitals as ‘the great confinement’ and of the populace as the ‘carcereal society’. The origin of this development, according to Foucault, was the labelling of psychiatric patients as ‘others’ and as not the same as ordinary people as well as the notion of the ‘dangerous individual’ to which our account makes contemporary reference above.

This much depends on awareness of the language we use to describe such places. We now talk of being ‘sectioned’ instead of ‘committed.’ The trouble here is that the word implies an element of compulsion which could give the wrong impression. ‘Admitted’ is by far and away the best term possible. Another difficultly is our propensity to talk of the mentally ill as ‘those people’, ‘we’ and ‘they’, ‘them’ and ‘us’ or as Foucault has it ‘same’ and ‘other’ etc etc. The notions of confinement serve to further create and reinforce the social divide which this language expresses.

In sum the notions of psychiatric hospitals as places where we lock up lunatics and various terms which create this impression outlined above are best avoided since where we have separate groups without social interaction the various myths and stigma surrounding mental illness can only be reinforced in the ways outlined above. Politically correct language - particularly in terms of notions of confinement outlined above - as with it’s deployment in other areas is also of key importance here. Care in the community on this account should go along way to undoing the stigma of mental illness in this respect – as the isolation of psychiatric hospitals has been one source of ignorance about mental health ( a notion very closely connected to mental health stigma which we shall examine shortly).

Obviously the reality of being admitted is very much the reverse to the Hollywood and media image. Many admissions are voluntary and in my own experience I have seen very few examples where some kind of force or compulsion has been necessary. I think that this aspect of stigma is so out of touch with hospital that this last point does not even need underlining.

Statistics and Quotes on Stigma

Thank you for an interesting reply to my follow up article on mental health stigma which made reference to the positive views of authorities on the enlightened nature of the society. It would seem that much depends on where we look for information about the stigma – what little material is available on the subject. Just as there are cases of enlightened and positive attitudes to mental illness there are also many cases of the opposite experience.

In America for example, according to the National Mental Health Information Centre ()
the fear of stigma discourages half of those with a mental illness from seeking treatment – a total of almost twenty two million people each year. This is all the more astonishing in a country where seeing a psychologist or psychiatrist is popularly to be believed part of the culture – so much for being enlightened in this respect.

The centre also provides some qualitative statements which show the extreme nature of this ‘fear.’ Two particular examples jump out of the list. The first is that “stigma can cause families and friends to turn their backs on people with mental illness.” The second is that “many people would rather tell employers they committed a petty crime and served time in jail than admit to being in a psychiatric hospital.” This last point is also a good instance in respect of the enlightened views of employers to which Edward made reference in his first reply.

So what about Britain? Every year in this country there is a Mad Pride march and the web site of this organisation (www.ctono.freeserve.co.uk) is full of interesting facts about the stigma. The title of one of their web page perhaps sums the aims of the organisation up very well – ‘Out of the bin and Glad to be Mad.’ The picture painted of mental illness is broadly similar to that in the USA but perhaps even more graphic.

Both sites note that and make reference to the fact that the mentally ill are “mocked in harsh ugly language” or the American site put it “stigma is about disrespect and using negative labels to identify a person living with mental illness.” As the mad pride site further argues “We no longer tolerate headlines about “yids” or “niggers” yet “psycho” is still acceptable.” The use of language was an important theme of my original article.

However where I think the mad pride site differs is it’s qualitative examples since these reveal how bad the stigma can get. As the site argues:

“The diagnosis becomes a mark of Cain, a bar to personal relationships and employment. The user often ends up destitute and alone with little or no hope for the future. Depression sets in, with suicide the frequent result – as many as 1000 a year. What might have been an understandable problem …[becomes] then diagnosis and ultimately a death sentence.”

What hope is there from such cases from employers when, as in the American example above, there own family members turn their backs on the mentally ill?

The underlying reason here is that as the mad pride site points out and as my article also made clear is the fear that the patient may turn violent. They quote a pertinent example. The decision by former Health Secretary Frank Dobson to detain schizophrenic with a violent history in hospital indefinitely. The key point is that this creates the wrong image. Langauge is again important to mad pride’s case here and they give the example of headlines about “crazed killers” and “nutters on the loose.”

In fact what happens in America in respect of mental illness has much impact in Britain through the influence of Hollywood – to which the original article gave many well known examples like that of Hannibal Lecter. We even let our children watch American cartoons called “loony tunes.” If there are examples of enlightened people and employers we have also great cause for pessimism about mental health stigma.

Mind is perhaps the most authoritative source of information on the subject. They too concur with the idea in my original article that language and the media are of central importance. In reference to their web site (www,eastsurreyhealth.nhs.uk / healthy / mentalhealth / stigma) it has been quoted that:

“Mind published the results of a survey which found that negative stories in the media, which refer to psychos, nutters, maniacs and madmen have a bad effect on people mental health problems and cause people additional stress.”

According to Edward there are employment opportunities for the mentally ill which exist side by side with the stigma. According to Mind however a different picture emerges:

“47% of people with mental health problems have experienced discrimination in the work place. Many loose their jobs or become unemployed.”

As my follow up article indicated the underlying cause of the stigma is ignorance and prejudice. Edward had focused much argument about this however this is also something that has been researched by Mind. As far as ignorance and prejudice are concerned Mind report that:

“40% of the public associate mental health problems with violence … about one third don’t know the difference between a learning disability and a mental illness.”

My original article and the follow up made both these points – but the most telling fact about the impact of the media – which Edward argued had little influence on social attitudes about mental health is that, according to Mind

“66% of people with mental health problems feel that the discrimination they face is directly linked to media coverage. 66% said it made their mental health problems worse. 37% felt their family and friends have reacted differently to them as a result of media.”

It might be thought that mental health is so common that everybody has encountered it and thus through experience have become enlightened. If this were the case the media would make no impact. However as the research suggests this has mostly not been the case.

Ignorance.

Any attempt at reform of attitudes towards mental health – namely the stigma – to many seems like deceptively simple task. All that needs to be done is to combat people’s ignorance so that, as the reasoning suggests, is to talk about and educate. Ignorance which I think is the key concept in this view and is unconsciously used by people and as with the notion of prejudice is quite a difficult notion to employ.

If at one level it seems intuitively correct to call the stigma of mental health a ‘prejudice’ at another level it could be and often is called ‘ignorance’. Ignorance is conventionally defined as a lack of knowledge and in so far as we think of it this way education seems the appropriate response. Reform of language such as calling it ‘mental illness’ instead of ‘madness’ for example could change attitudes and make people more aware. It also fits in with the optimistic enlightenment view that people are rational about such things and that social criticism is the vehicle of progress.

At another level ignorance could be defined and interpreted differently. It implies that something is ignored. Ironically to ignore something in this way – once it is pointed out to us - could also be called even more ignorant (ie we can also ignore the fact that we are ignorant) but this use of the word is also subject to the same definition (that we are ignoring something) so the original problem remains. Thus if we point out that someone is ignorant they would probably say well I don't care. The question then becomes why do people ignore such things? This is because they already have an attitude which conflicts with the issue about which there is (to others) a question. So perhaps the issue is not about ignorance at whatever level but the underlying attitude. Here then is the word unimportant?

The answer I believe, which may seem surprising and even counter-intuitive, is no - as the underlying attitude is also partly determined and reinforced by the degree of ignorance which it in fact embodies and so becomes an object of criticism. Any attitude is reinforced by the ignorance it creates. Here politics is of direct relevance. As George Orwell said in his famous work 1984 any totalitarian ideology has as it maxim - or in political language it’s slogan - the phrase ‘ignorance is strength’. How does this account of such ignorance relate to mental health?

The equation of mental health and ideology here is that mental health prejudice serves to advantage some in society at the expense of others. It allows some people to gain a sense of superiority through their self-proclaimed and normatively charged ‘normality.’ So ignorance appears not so much as a deficit of knowledge but rather as a social attitude which like Orwell’s notion of politics and ideology serve to perpetuate the priviledge of some at the expense of and repression of others (in this respect prejudice and ignorance go together). Here then ignorance is both a more subtle and complex notion than would appear from it’s popular usage and is in certain senses of the word an important notion.

A number of famous quotes are of direct relevance here as the words ignorance and reason crop up again and again;

The prejudices of ignorance are more easily removed than the prejudices of interest; the first are blindly adopted, the second willfully preferred.
-George Bancroft

Prejudice is never easy unless it can pass itself off for reason.
-William Hazlitt

A prejudiced person will almost certainly claim that he has sufficient warrant for his views.
-Gordon W. Allport

To relate this back to the popular and common sense usage of the notion we have to be aware of the ill considered context in which the word is used. People in the know such as nurses and social workers will refer to the stigma of mental health dis-missively and say ‘oh that’s just ignorance.’ In fact this is in some ways a very problematic and difficult thing to say in the ways outlined above. The ‘ignorance’ here is wilful and contrary to being unaware of their actions they know what they are doing in creating a stigma. Society seems to need a ‘whipping boy’ and to pick on the vulnerable. Here further quotes are very relevant:

Opinions founded on prejudice are always sustained with the greatest violence.
-Francis Jeffrey

Nothing in the world is more dangerous than a sincere ignorance and conscientious stupidity.
Author: Martin Luther King, Jr.

Nothing is more terrible than ignorance in action.
Author: Johann Wolfgang von Goethe

The stigma of mental illness can be compared in this respect to the other areas of social life such as racism, homophobia and the sub-ordination of women. Racists and the like are not ignorant to the hurt and fear they cause to other people – like everybody else they have a moral sensibility – it’s just that they ‘ignore’ it. Such people are to some extent choosing to behave in this way and so can be held responsible. The law for example makes it illegal to discriminate against people on the grounds of race, gender, sexuality and psychiatric history in terms of employment and any other form of social activity. Ignorantia legis haut non excusat. -ignorance of the law is no excuse in court!

The aspect of ignorance seem apparent from the nature of the stigma and the language. Most people cannot distinguish between a psychologist and a psychiatrist, between mental health and mentally handicapped and between schizophrenia and a split personality. This does not bode well for the medical semantic emphasis on the notions of mental illness and mental health which have been coined instead of madness, and of hospitals instead of asylums.

Prejudice.

As we have argued combating the stigma the stigma of mental health on the surface may seem straightforward. After all one might think that all that is required is that we have only to appeal to people’s sense of injustice at the cruelty of the stigma of mental illness to change things. Unfortunately things are not quite so simple as the issue raises some difficult and contested social questions. Constraints of space prevent an in depth look at this issue but the basics can readily be outlined and assessed.

'Prejudice' is a technical word and has been used in theoretical writing. In popular parlance it means bias but in technical terms it means beleif An example is the argument that any reform of social attitudes is a difficult business since, as Edmund Burke revealed, it is such non rational prejudices are difficult to eradicate through criticism (he famously claimed they are the cement 'which hold society together).' Think for instance of the problems of eradicating attitudes and beleifs about race. Burke however wrote before prejudices like race, gender and mental illness were considered to be social issues. How does this relate to mental health?

Criticism of attitudes towards mental illness however strike at the heart of the cultural beleifs which Burke argued are pervasive features of social life – namely at the rough tough ‘stiff upper lip’ required to face life’s difficulties and over come them. This is the Victorian work ethic of self help and self reliance (mentioned in a previous article) but is ultimately part of the British character and national identity. Perhaps then attitudes like these are so deeply rooted in our culture that the task of reform seems almost impossible?

More optimistic however is the enlightenment belief in the role of education to transform attitudes and this appears to be were the key battle ground must be located for mental health. This leads directly to consideration of a related notion as William Hazlitt famously said “prejudice is the child of ignorance.” Perhaps we should be given the option of studying some Psychiatry at school. Even amongst educated professional people today however there is still a thing about seeing a ‘shrink’. The media must also play a lead educational role here in changing the image of madness and films such as A Beautiful Mind are exemplary.

Racism, gender issues and the like have already attracted much academic (and educational) attention. Some of this however does not give cause for optimism about mental health stigma. Take for instance the current charge of ‘institutional racism’ levelled by the Steven Lawrence enquiry, the recent electoral successes by the British National Party in Oldham and the sociological scepticism about the idea of the ‘new man’ which has been called a modern myth – given that many working women also have the sole burden of house work, child care etc etc. Prejudice is ‘endemic’ in many areas of social life and seems to support the conservative view of it.

Where such beliefs – or ‘prejudices’ as Burke defiantly called them - are meant to unite us they in fact divide and alienate the significant portions of the population who experience madness and the other social stigmas. This is implicit in the language used by society which refers to it’s others as ‘them’ whilst referring to itself as ‘us.’ Reform here, contrary to Burke’s general view above, would thus have beneficial social consequences and would ironically further the social unity he sought to defend. Thus Foucault has sought to blame capitalism for the stigma of mental health.

Finally it is worth noting that the issue is not so divided as might appear from this brief account. Even Burke was not concerned to reject all attempts of change and reform - as might also be implied by the label ‘conservatism’ which as the label suggests implies that we should keep things as they are. Speaking on the political context, which was Burke’s major focus, he said that a state without the means of some change was without the means of it’s own preservation. This perhaps bodes well for the social issue of mental health despite the impact it would have on the national and cultural self concepts outlined above.

Positive versus Negative.

This article focuses on the fact that when people label others as schizophrenic they do not know what they are talking about. Hence so many of the labels are negatively defined. They just mean that ‘those people’ are not the same as me. They signify that they do not know what they are talking about and hence they are all used (and defined) in a negative manner. This is also true of some of the positive definitions of madness. Only words like mental health or illness should be used because although they just mean not well they specify a positive characteristic like the patient has some kind of desease.

The word ‘insanity’ is purely a negative concept without positive content, signifying only a moral lack, it does not specify any concrete characteristics in particular, and it is thus a wholly empty category. Yet the concept is widely used along with its synonym ‘madness’ which is itself a word which no one, on closer inspection, is able to define – except by reference to further negatives: ‘not rational’, non-sensical, non-compus mentis.

Where a positive picture of ‘madness’ is presented it is in connection with another old word: that of ‘bedlam’. But even here this notion trades on a negative understanding of madness. Here those who have ‘lost their minds’ or ‘lost their reason’ or ‘loosing their marbles’ (three further negative definitions) are commonly thought to be half crazy, uncontrollable, clamorous, distressed, fearful, and intense – full of raving loonies and maniacs. The generalised anarchy of this notion of ‘bedlam’ reinforces the negative connotations of its synonym: ‘lunatic asylum.’ No explanation of why this behaviour obtains is forthcoming other than a circularity: it is the behaviour of lunatics..

Consequently then hospitals are thought of as the ‘loony bin’ while the illness is thought of it negative terms – those of, in Foucault’s words, ‘unreason.’ There appears to be little real idea of what hospitals are like, or when defined negatively, what goes through the minds of the mentally ill. The negative definitional aspect of madness is also to be found in a number of popularly used expressions such as ‘not all there’, ‘not right’, ‘not a full shilling’, ‘not a full deck’, ‘one sandwich short of a picnic’ etc.

The existence of medical terms like hospital or illness, although they signify something else positive, do not easily remedy the situation. Amongst those who do not know anything about psychiatry (including the great mass of people) these terms arose suspicion since they can be taken to imply that there is something biologically or medically abnormal or unnatural about the ‘insane.’ Consequently doctors are referred to as the infamous ‘men in white coats’, hospitals as the ‘funny farm’ and ‘loony bin.’

Part of the shock value in literature and film is that we are left to imagine the nameless horrors of what madness is. In the Silence of the Lambs the madman Hannibal Lecter is referred to as “they don’t have a name for what it is .” This absence is typical of madness which is a wholly empty category.

“Madness” here is an empty Portmanteau word, in Lewis Carrolls phrase, into which we might throw any such behaviour which is deemed by society as “unusual” and which it does not understand: manias, melancholia, delusions, paranoia, hallucinations, schizophrenia, catatonia etc. Lewis Carroll thought such words were devoid of meaning.

In sum the reason is that such words are defined in a purely negative way. These are worth listing altogether: it is unusual, abnormal, insane, non-compus mentis, deficient, deranged and not rational, non-sensical, un-real and Unreason Such words are defined solely by their opposites: normal, rational, sane - rather than by any positive characteristics they might intrinsically possess themselves. Crucially Foucault puts this contrast as ‘same’ and ‘other’.

Strictly speaking then there is no such thing as “madness” there is only mental illness but use of that word appears in every day speech and media coverage and despite the above connotations the word has. It is thus greatly in need of reform and political correctness on the part of society which labels certain psychiatric behaviours derogatorily as “deranged”, “mad”, “maniac”, “insane”, “abnormal” or “lunatic.”

It is thus left to ask: why does the stigma exist? One reason is that, simply, people have something to gain by affirming their ‘normality’ in this respect: it allows people to demonstrate their ‘soundness’ by being able to say “well I’m not like that.” This infers a mark of superiority while the mentally ill are implied to be abnormal or even (or like prejudice over sexuality) unnatural. All three of these notions here are further negative definitions as outlined at the start of these notes, Thus a little reflection should be sufficient to reassure the mentally ill that in all of the above ways in which they are referred to by others the notions are devoid of meaning.

Postive and negative definitions of mental illness contain little or no insight into the nature of the problems of mental health. IN this way they help sustain the ignorance about mental illness and the attitudes which stigmatise and prejudice it. These latter aspects will be examined later.
Combating the language of stigma.

Reform of mental health stigma has mainly opposed, on the basis of scientific understanding, the notions of ‘mental health’ and ‘mental illness’ to ‘madness’. Despite some positive media images to the contrary the language of being ‘off your rocker’ and ‘round the twist’ prevails in the media and in everyday speech at a subconscious level. Much more needs to be done however through an examination of the language of the stigma.

‘Madness’ in point of fact is an example of what Lewis Carroll called a Portmanteau Word - in that it tries to put some very different things into the same box. I suspect that this is because society has had a tendency to simply label any behaviour which is does not understand in the same way. Thus manias, melancholia, delusions, paranoia, hallucinations, simple schizophrenia, hebephrenia, catatonia, schizo-affective disorder, bi-polar, hypo-manic, hyper-manic, hearing voices etc..’ have been so grouped together. But what does this ‘madness’ mean other than the loss of reason. It signifies nothing at all about being ill.

Thus similar such words tend to be defined in a purely negative way: it is abnormal, insane, unusual, non-sensical, non-compus mentis, deficient, deranged and not rational - Foucault in his work Madness and Civilisation adds a further negative term : Unreason: people are thought to have ‘lost their minds’. The negative definitional aspect of madness is also to be found in a number of popularly used slang expressions such as ‘not all there’, ‘not right’, ‘not a full shilling’, ‘not a full deck’, ‘one sandwich short of a picnic’ etc. But where is the understanding of having a health problem in all this negative talk?

This to me suggests a strategy to combat mental health stigma on an everyday level. All words are defined by reference to other words. But if we press someone further to explain what is meant by “balmy” or “bonkers” etc often we find that in the popular mind no further definition is available beyond referring back to another such word in the slang vocabulary eg “deranged”, “cranky”, “crackers” etc. I think underlying the use of such labels is the intuition that people do not really know what they are talking about. This can be readily exposed.

Often too in every day terms madness can be seen as a coping mechanism for acute stresses in life that can find no other outlet. Consider for example how often the phrase “you’ll drive me mad!” is said on an every day level. Deployment of this notion should also attempt at removing some of the social stigma of the illness. R.D.Laing thought that a mad world was responsible for driving people mad.. It also coincides with the current psychological theory that stress can cause psychoses. Other such phrases here include being “tipped over the edge”, “the frayed ends of sanity” and “driven round the bend.”

Other words linked to the stigma have different connotations. In particular the notions of being ‘locked up’, ‘taken away’, ‘carted off.’ Foucault famously picked up on this and called the birth of the asylum “the great confinement.” Most people have probably heard of care in the community and so reference to this in reply to such statements might help combat the image of mental illness in this respect. I also believe it is necessary to also stop talking of being ” ‘sectioned’ here because it sounds too much like the old word ‘committed.’

Words can then be weapons and a careful consideration of the language of the stigma and the elements and degree of insight such usage involves could provide a useful armoury in the battle to transform attitudes to mental health. Thus the word ‘mental’ has some insight as it refers to the mind, having a ‘screw loose’ implies that there is something in need of fixing, and can be compared to the word batty or potty contains little idea of what is being talked about. The most direct approach in such a war of words and political correctness is perhaps to turn the language of the stigma against it users so as to question what he or she thinks he or she knows about it and expose the ignorance of his notions. Political correctness is the key.

Social Science and Mental Health.

The stigma of mental health has a psychological dimension. We have noted that the stigma of not being able to cope with depression - to pull oneself together and grin and bear it – is cultural – having a stiff upper lip - but this can also be reduced to psychology. This attitude could be derived from our notion of masculinity – men are not suppose to show their feelings and worst of all break down and cry. Such behaviour is conversely the province of femininity – though there seems to be potential improvement in this aspect of the stigma associated with the ‘new man’.

Some radical feminist like Germaine Greer think that this attitude is characteristically male and which has also historically glorified strength, persecuted cowardice and being warlike, violent and aggressive. Women are viewed as weaker and thus are to be ruled. Men according to Greer are the problem. The question then is – is this characteristic human nature or can it change? Pessimists think no, optimists disagree. The enlightenment advocated education to create progress through rational criticism, conservatives are sceptical and see this as inaccurate and utopian.

Some psychologists like the behaviourist school founded by Skinner and Watson thought that the socialisation process could be manipulated to create or ‘engineer’ change. The vehicle of this process is that of ‘positive and negative reinforcement’. We should criticise injustice and praise good behaviour to create social progress. The problem is that this theory is deterministic and seems to think that people can be controlled and fashioned rather than regarding individuals as choosers of there own behaviour, authors of their own attitudes. People choose to maintain the stigma. How does this work?

When we argue about the role of education and media images of madness we are tacitly assuming that they have some kind of influence over people’s beliefs, attitudes and perceptions in the way that behaviourists have tried to argue (this has also been the main thrust of liberal feminism in the area of attitudes to gender). This is often through what is called ‘auto-suggestion.’ We assume that they are basically rational and have an innate sense of injustice to which we can appeal (such as the injustice of mental health stigma). However many experiments in social engineering designed to improve or perfect or change human beings – such as those in the former Soviet Union - have failed. Let us explore this comparison further.

To conservatives such ideas about social planning have been an economic disaster and result from ignorance about the selfish competitive and acquisitive aspects of human nature – this is also often the ‘pub talk’ on the issue. The USSR failed to compete with western economies, created a famine through the collectivisation of agriculture and finally ended up in a revolution against the system which tried to impose things from the top down etc etc. Changing any form of behaviour in such ways is in the conservative extremely difficult however good the intentions.

The analogy with mental health here is that people have a comparable self interest in upholding the stigma of madness in that it allows them to proclaim their ‘normality’. Self interest can be a very powerful social force – as the failure of USSR economy, the rise of Thatcherism and market socialism show. Some people think these development are so important that we have arrived at “the end of history”, that capitalism is “the final form” and that the selfish capitalist individual is “the last man (as Frances Fukuyama argues).” Appealing to social justice has failed, thus appealing to the injustice of the stigma of mental illness might also fail in a similar way. Furthermore labelling capitalism as greedy and selfish has done little to change attitudes, thus labelling madness as mental illness may also fail in a comparable way.

Oppression in all it’s form is the subject matter of politics and the rationalisation of oppression is the subject matter of ideology. This also runs throughout the comparable areas of stigma: the power of men over women, normal over deviant, white over black. This has often been called the tyranny of the majority and as John Stuart Mill wrote in the last centuary society is now the greatest threat is liberty. Power creates oppression and thus politics is an apt metaphor – as Lenin said politics is about power.

This is not as straightforward as it seems such ‘power’ as Foucault has shown is not imposed top down like an ideology but exists at the micro rather than the macro level. It is internal to the society and operates on an interpersonal basis. Nevertheless what Foucault locates as the form of the operation of power is the makings of the modern subjectivity. This is the ideology of liberalism. What Foucault calls ‘the great confinement’ occurred during the primacy of the Victorian code of self-reliance what he refers to as the stifling ‘anguish of responsibility’.

Foucault talks little about the origins of the stigma stating only that reason is imposed on madness. Politics is of no help here. In fact the macro level theories of power –decision making, agenda setting and ideology all lie behind the making of modern subjectivity and Victorian moral code. The ideology of freedom created confinement. He sees the moral offence caused to the society as ‘madness was perceived for the first time through the condemnation of idleness’. In fact society has a vested interest in such a determination all of which could ground a macro theory of madness: society has the power to decide its view of ‘madness’ and sets the agenda so as to limit and control how we should talk about it, and also defends its view with its ideological self-interested values. This crucial aspect will be examined last.

Foucault has a category of resistance to power but it is a very undeveloped notion. He thinks it difficult to resist since his notion of power lacks a focus or a centre. Sometimes he talks about capitalism as the source of opposition – but how far would changing the system cure the problem. Foucault attempts to understand this problem in examining what he calls the ‘mechanisms of power.’ He believes in ‘local struggles’ instead of a general theory. All the time however he makes reference to the impact of moral values and capitalism as the form of the stigma. Underlying these features are self-interest and other mechanism of power which receive their fullest exposition by Steven Lukes.

Political philosophies like conservatism here have been called “philosophies of human imperfection.” Conservatives are sceptical about our innate capacities for goodness, our potential to change and our “malleability” in the face of social engineering. This position is disputed by liberals ands socialists in the ways outlined above – both ideologies are products of the enlightenment in this respect. In psychological terms conservatives think there is a disposition against social change, where the behaviourists tried to engineer it. This is a massively contested issue and goes to the heart of the debate between ‘left’ and ‘right’.

Conservatives then defend keeping things as they are and think change should be gradual. They think that people are ‘immersed’ (as Roger Scruton the official philosopher of the conservative party put it) in social life and that rational criticism is not internal to this and indeed cannot be influential in changing things because of it’s external nature. Ironically enough the sort of account conservatives give of the role of prejudice is just such a rationalisation and as even Scruton himself admits this problem is insoluble.

Gramsci on the left argues that all ideologies seek to transform themselves out of the context of theory and argument and into the realm of common sense. They become unconscious and are guides to action and practice. This is exactly what has happened to the values and ideas about mental health and particularly the notion of a stiff upper lip and the ideas of mental health as comical, absurd, dangerous, weak and abnormal. Ideology is a particularly good parallel in this respect. Gramsci famously called this state of affairs ideological “hegemony.”

This is not it must be noted an equation of conservatism with racism or sexism etc and indeed some contemporary conservatives, like John Gray, think that in some of these areas the pace of ‘social change’ will quicken – as William Hague and others famously suggested conservatives we must ‘embrace’ gays and lesbians and avoid been seen as ‘the nasty party’. Not every aspect of what have been traditional social views is to be conserved – mental health is an area to be included here.



Why is there a stigma?

The stigma of mental illness arises from the belief or prejudice that men are suppose to be tough and able to overcome life’s difficulties and whatever life throws at them. The general attitude is expressed by popular sayings that “life is hard” and “life is not a bowl of cherries.” The tough minded attitude seems to be the origin of the stigma of mental illness. It opens the way for derision of those who cannot cope as weak and incapable, it stigmatises those in need of help. If you are depressed you “just have to get on with it” and “pull yourself together.” Ultimately “you should not need help” since in the end “it is up to you to help yourself.” There is little understanding or sympathy, in some peoples view, of mental health and especially depression as an illness. Indeed it challenges the whole concept of a more humane approach to mental illness.

If the opinion is handed down that this is a medical problem and is refused by scepticism in the society because of its historic cultural inheritance then the result is ignorance and prejudice. If on the other hand the reaction is that this diagnosis is to some extent persuasive and makes some kind of sense then people are going to think that if this is a legitimate medical problem. This may be especially true if for example medication prevents a persons suicide many people may be sympathetic to the need for medical help. The danger is that it might also create the impression that they are just weak and “taking the easy way out” and even that “they don’t deserve any help.” Most people will be torn between both extremes. This opens up social scientific questions about people having an interest in promoting stigma in this sense and the possibility of changing attitudes based on self interest.

We may call the view we are examining “enlightened.” Prejudice in contrast is often “dark” and clouds our understanding. It is to be criticised in the area of mental health through coming to know what the object of the prejudice is. That is if we work with people with a mental illness then we will become sympathetic and try to help them. From this perspective prejudice is not only “blind” and insensitive but is cruel and “victimises” the social group involved. At the limit we cannot really “know” the problems of depression and schizophrenia unless we have had it ourselves but we cannot fail to see some one “going through” this and not react to it. We want to help but don’t know how. Mediciation is the most direct approach possible when faced with this dilemma.

But there is a problem. As we have said people will be torn between sympathy and blame even in the case of suicide. It is thought to be both selfish and stupid though if we know the person involved we may be sympathetic and perhaps blame ourselves that we did not do enough to prevent it. We talk of people being “pushed to the limit.” The problem is that others go through the same experience and do not “resort to killing them selves.” The consensus for some is that “this is a matter of private judgement” and perhaps not of public concern. Others think that we must do everything possible to “prevent this sort of thing.” Nowadays this includes medical treatment.

It may be that some people with the same amount of stress or who have gone through the same experiences did not kill themselves. They are seen as stronger and so the prejudice arises. It is difficult to say anything conclusive and often the subject is never discussed. I think most people would say it is wrong but not with absolute certainty. It is seen as the extreme example. The whole issue is “difficult” though some brave people have fixed negative views on the subject. Thus if others want to ask for medical help it would be denied them. Those who do are stigmatised and not considered as behaving acceptably. At this point they are labelled as “weak” and “immoral” and the stigma begins. They can be used as examples to show how “tough” the others are. This is the right attitude to life and is reflected in the culture and human society which presents all kinds of like challenges which must be “faced up to.” Those who don’t are cowards for not “confronting” the “way the world is.” If they kill themselves then “that is up to them” but they “will get no sympathy from me.”

Castigating the whole idea of mental health in this way leads to the view that people with depression are not facing up to their problems. Others survive experiences like divorce, domestic violence, unemployment or warfare so they must be weak or incapable. Here we get the view that I am better than them because I am stronger. This is to be admired and moralised into a virtue and principle. It is something to which we aspire. It serves a world view in which people who do cope have an esteemed position, those who do not are derided as having in some sense “failed“. Those who succeed in “overcoming their problems” have a social status. The strong label themselves so in accordance with their reasoning but to confront a perceived disputing problem with respect to their values. To acquire this status in the eyes of other people and allay feelings of guilt they must conform and perhaps are afraid not to. This prevents seeking help and makes us “keep our feelings quiet“.

It is in the interests of people in society that they attain this self esteem. We conform because of how other people might see us and the pressures of praise and blame. But where we deal with an interest in promoting these beliefs say for the perceived good of the society and the individual we run up against the problem that where an interest is involved the prejudice is more difficult to eradicate. How far can we change such a view of the social interest.

The stigma of mental health thus has a psychological dimension. We have noted that the stigma of not being able to cope with depression - to pull oneself together and grin and bear it – is cultural – having a stiff upper lip - but this can also be reduced to psychology. This attitude could be derived from our notion of masculinity – men are not suppose to show their feelings and worst of all break down and cry. Such behaviour is conversely the province of femininity – though there seems to be potential improvement in this aspect of the stigm