Stigmatization of the mentally ill

At the heart of the stigmatization of the mentally ill and of those who care for them are a number of beliefs ( Table !).


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Table 1 Stigmatizing conceptions of the psychiatrically

The lack of objective, stable, and consistent markers of mental illness is a major contributory factor in the persistence of the belief that in some way mental illnesses are not true or real illnesses compared with so-called organic disorders. Nor is this a prejudice confined to a Western medicine disfigured by a simplistic Cartesian dualism. Raguram et al.{?) have shown that depressive symptoms are construed as much more socially disadvantageous than somatoform symptoms in a South India patient population, while Fabrega, (19 in a extensive review of the literature pertaining to psychiatric illness and its stigma in non-Western society, has concluded that, with the possible exception of Islam, the potential for condemnation and stigmatization of psychiatric illness seems to be present in most of these societies.

Of these various stereotypes, that of the psychiatrically ill as violent is perhaps the most tenacious and in part contributes to the virulence and persistence of other aspects of stigmatization. It is a long-standing perception. A substantial part of the history of psychiatry has been the history of confinement. Our images of madness, derived from that history, powerfully reinforce the notion of mental illness as a state of incipient, latent of actual violence. The very word 'bedlam', defined in the Concise Oxford Dictionary amongst other things as 'a place of uproar', derives from one of the earliest psychiatric institutions, Bethlem Hospital. The growth of the mental hospital, a spectacular phenomenon of the nineteenth century, did little to reduce the fear and the ignorance surrounding the mentally ill. Whatever the precise contribution of enlightenment values to their rise, the mental hospitals retained much of the aura of abuse, neglect, and cruelty which surrounded the madhouses of earlier epochs, so memorably captured in Goya's The Madhouse painted in the early years of the nineteenth century ( Fig, 1). Goya depicts the mentally ill as isolated, locked in an inner world of hallucinations and delusions, 'tragic figures at war with one another and themselves'. (:!1)

Fig. 1 Goya's The Madhouse

Despite the clinical and therapeutic benefits provided by the asylums, the major drawback concerned their size, isolation, and institutional atmosphere. The asylum, referred to disparagingly and revealingly down through the years as 'the bin', helped ensure that the public image of mental illness would continue to include notions of custody, control, chronicity, containment, and fears of contamination and violence. Many such hospitals became overcrowded, poorly staffed, and cut off from the main body of medicine.

With the decline of the mental hospital and the simultaneous development of the acute psychiatric unit in the setting of the general hospital and the rise of what has come to be known as community psychiatry, hopes have risen that the stigmatization of the mentally ill might be reduced and eventually eliminated. Psychiatric illness has become more visible. The mentally ill are no longer locked away out of sight and out of mind. But in countries such as the United States and the United Kingdom, where the rundown of the mental hospital has not always been accompanied by development of sufficient alternative treatment facilities, there has been a rise in concern regarding the association of mental illness and violence(! I3 and 14> and a fear that much of the gain made in terms of the education of the general public and the greater involvement of the mass media in positive portrayal of mental health issues may be offset by a demand for greater custody and control of the mentally ill within the community.(!5>

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