|Year : 2015 | Volume
| Issue : 2 | Page : 181-183
Mental illness and stigma: Has psychiatry done more harm than good?
Department of English, Lakshmibai College, University of Delhi, Delhi, India
|Date of Web Publication||22-Apr-2015|
Prof. Ashima Kanwar
Department of English, Lakshmibai College, University of Delhi, F-83 Kalkaji, New Delhi - 110 019
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Stigma against people with mental illness is a very complex public health problem. There could be diverse reasons for this ranging from:
- Lack of awareness;
- Fear of a dimly-comprehended and much-misunderstood illness;
- Illogical generalizations; and
- Disrespect for the heterogeneity of life.
The result-for the mentally ill-could well be diminished access to social determinants of healthcare, employment, and housing. In addition, people with mental illnesses are exposed to numerous health risks such as malnutrition, drug abuse, violence and homelessness. Maybe this explains nondisclosure of illness in an increasingly degenerate civil society.
Keywords: Stigma, erosion of a sense of self-worth, sense of shame, psychiatry and its discontents
|How to cite this article:|
Kanwar A. Mental illness and stigma: Has psychiatry done more harm than good?. Indian J Psychol Med 2015;37:181-3
I would like to begin with a few lines excerpted from Shakespeare's King Lear:
Pray do not mock me
I am a very foolish old man,
and I fear I'm not in my perfect mind. 
These lines are uttered by the eponymous protagonist of the play. The king-rendered homeless by his treacherous daughters-utters these lines as he steps out into the pouring rain with a crown of wild flowers upon his ruined head.
The king, despite his illness, has the insight to know that society, at large, has had nothing but derision, contempt and ridicule for the mentally ill. Perhaps it is for this reason that he says:
O let me not be mad, not mad, sweet heaven
I would not be mad
Keep me in temper, I would not be mad. 
The king has a premonition of the imminence of madness. He understands the perilous condition of his state of mind. He has an inordinate fear of madness, understandably so.
One cannot help but be reminded of the Royal Bethlem Hospital or Bedlam, as it was later called. The hospital had begun the deplorable practice of charging a visitors' entrance fee. People would come to see the mad confined here. Many of the visitors - who had not come to meet relatives - ended up provoking the "inmates" for their amusement and entertainment. People would flock to the hospital with the sole intention of watching the antics of the insane. All the visitors were charged a penny for the privilege. This was stopped in 1770 because it tended to disturb the tranquility of the patients by "making sport and diversion of the miserable inhabitants." Entrance was then by ticket only, designed to stop indiscriminate visiting. 
Custodial institutions today disallow this kind of prurient voyeurism, not out of humanitarian concern, but because the appalling conditions, lack of sanitation and the plight of the institutionalized have all the makings of a public scandal.
Michel  talks at length about the Ships of Fools, which he insists actually existed. Boats - carrying a cargo of the insane (including wandering lunatics, vagabonds and the homeless poor) - were a commonplace sight in the Medieval Ages. Madmen were placed on unpiloted boats - that had no destination or disembarkation point - and were left to drift downstream in search of their lost reason.
There is no documentary evidence for the actual existence of these ships of fools. Therefore, there is no reason to believe in the veracity of Foucault's claims, his insistence in the matter notwithstanding. This is not to say that Foucault was deliberately trying to sensationalize the unfortunate plight of the insane because he was writing from a specifically anti-psychiatric, anti-establishment point of view. Nor is this an attempt to discredit Foucault's work or, in any way, belittle its profound historical and philosophical significance.
Probably, Foucault was presenting as I understand it, an allegorical re-reading of history. He was speaking of the exclusionary ethos that society has always had toward the mentally ill. He was seeking to make a point about the extradition of the insane. I am reminded of the Erwadi fire tragedy (6 August 2001, India) in which 28 mentally ill patients - manacled to their bedposts - were charred to death when a fire accidentally broke out. Responses have been ambivalent to say the least. Although it is true that there was much outcry by human rights groups, it is also true that there were several who heaved a huge sigh of relief at what had happened. After all, the incurably insane had been a huge drain on public resources; were not serving a useful or productive role in society; would never be amenable to treatment; and were no good to anyone on the face of earth. They would never be useful, tax-paying "docile bodies" who could be "subjected, used, transformed and improved through a strict regimen of disciplinary acts. " Schizophrenia eludes the micro-physics of discipline.
One reason for such stigmatizing attitudes could be ignorance, but this only begs the question further. Stigmatizing views about mental illness are not limited to uninformed members of the general public. Well-trained professionals, from mental health disciplines, very much subscribe to stereotypes about mental illness. I am reminded of the open talk by a clinical psychologist at a mental health nongovernmental organization (NGO) in Delhi.  The lady − thinking she was addressing the uninitiated − began talking of "these schizophrenics" who "do not ever brush their teeth; never shower; have no personal hygiene; and seldom ever step outdoors."
To cite another example, I can well imagine the distress of a woman - diagnosed with bipolar disorder - when her consulting psychiatrist asked her if she was inclined to promiscuity. The clinician  was of the view that hyper-sexuality was a typical trait of bipolar disorder. The woman, dumbstruck at the crudity of the allegation, never sought psychiatric help again.  I do not think any definitive causal link has been established, beyond scope of doubt, between hyper-sexuality and bipolar disorder. Conventional approaches to mainstream psychiatry have proved to be highly prejudical to the interests of marginal groups.
Girma et al. have pointed out "stigma is not only a consequence of mental illness, but also a factor that interferes with help-seeking behavior. It may delay treatment-seeking in patients with mental illness and as a consequence, the cure and rehabilitation process." 
It's easy enough to impute narrow-mindedness and bigotry to mental health professionals. The problem doesn't end there. Psychiatry has done itself a great disservice by placing every nuance of "aberrant" or idiosyncratic behavior on a homogenous, trans-historical, trans-cultural continuum. Therefore, because the Diagnostic and Statistical Manual of Mental Disorders, Fourth to Fifth Edition (DSM IV-V) is essentially a classificatory manual, all people with schizophrenia (in countries, cultures and regions across the world) are necessarily required to be violently inclined and all people with depression are likewise necessarily expected to be suicidal. 
It is from the unchallenged centrality of the DSM IV-V that a consensus - about the essentially monolithic and unchanging discourse of mental illness - emerges. Hence, Ben-Zeev et al. speak of the need to re-structure and replace stereotypical classifications of mental illness with "a range of dimensional probabilities" that would respect the heterogeneity and diversity of life in all its myriad forms. 
Stigma has diverse ramifications. Any attempt to view stigma as a nefarious plot - on the part of a ruling psychiatric elite - to hold down or subjugate the mentally ill would necessarily entail a misreading of the issues at hand. Blaming society at large - by attributing stigmatized perceptions of mental illness to ignorance and misinformation - will not help either. I have no wish to present my readers with a seamlessly integrated reading - of the psychiatric fraternity's complicity with the uninformed general public and an insensitive media-of the manner in which the mentally ill are perceived. This article admittedly seems to hint at a convergence of opinion. However, I have no wish to duplicate what I have set out to debunk by trying to present stigma as a homogenous construct.
I am sure that people are perfectly capable of less discriminatory attitudes of sensitivity, tolerance and empathy in varying degrees of intensity. Human rights organizations, NGOs working in the field of mental health, stakeholders involved with disability, better-trained mental health professionals, writers, sociologists, historians and even members of the general public have held very dissenting and unconventional views. That apart, I don't think that it is within the scope of this article's claim to ambition to understand the complexity of the issue in its entirety. However, I have tried to offer a working discussion of the devastating impact of (i) public; and (ii) self-stigma on target groups:
This is a widely endorsed public perception of fear, derision and avoidance of the mentally ill. The result is limited access to employment, housing, healthcare. One reason could be lack of awareness, but other reasons abound. To take an example, popular films seem to suggest that people with mental illnesses:
- Are mass-murdering, homicidally inclined violence junkies;
- Have themselves to blame for not being "strong enough" to battle illness;
- Have been visited by the divine wrath of an unforgiving god. Hence, the mental affliction is retribution for bad karma.
In this case, stigma works insidiously - when internalized - to erode the sense of self-worth or social relevance. It works at various levels to instill a deep level of insecurity. To take an example, childless women experience self-stigma. Single people fare no better in terms of social acceptance. Erving  points out how a "questionable" person proves his claim to normalcy by citing his acquisition of a spouse and children, and oddly, by åttesting to his spending Christmas and thanksgiving with them."
The existent situation would improve with better economic and employment opportunities.
| Conclusion|| |
I can well say that I have no answers on easy offer. The menace of madness will remain an unresolved and indeterminate set of problems. People's perceptions are not going to change overnight that is not to imply that everyone thinks alike. A community's attitude - toward the mentally ill - plays a paramount role in treatment-seeking, drug compliance and rehabilitation. I hope that this article will help raise greater levels of awareness and help combat stigma against the mentally ill.
Given the complexity of issues, the debate will always remain an inconclusive one. I do not claim to offer a resolution.
| References|| |
Shakespeare W, Foakes RA, editors. King Lear. The Arden Shakespeare (Third Series). Methuen Drama; 1997.
Michel F. Madness and Civilization: A History of Insanity in the Age of Reason. Trans. Richard H. Vintage Books. New York: Random House; 1965.
Michel F. Discipline and Punish: The Birth of the Prison. Trans. Sheridan A. Penguin Books. London: 1977.
I do not wish to name the organization. Badmouthing people will not de-stigmatize serious illnesses or ever make this an equal opportunities world.
I do not wish to divulge the psychiatrist′s name or identity. Likewise, I would not want to make mention of the hospital he is allied with.
Written consent was taken from this woman patient before excerpting the interview in this article. I do not wish to disclose the identity of the patient.
Girma E, Tesfaye M, Froeschl G, Möller-Leimkühler AM, Müller N, Dehning S. Public stigma against people with mental illness in the Gilgel Gibe Field Research Center (GGFRC) in Southwest Ethiopia. PLoS One 2013;8:e82116.
Ben-Zeev D, Young MA, Corrigan PW. DSM-V and the stigma of mental illness. J Ment Health 2010;19:318-27.
Erving G. Stigma. London: Penguin Books; 1963.