Mental Illness, Stigma, and Institutionalization

For a long time, when mental illness and mental health were discussed around me, I felt uncomfortable. I judged the mentally ill, was afraid of the mentally ill, and silently stigmatized the mentally ill. I was phobic of what was different, scared that I may be able to relate, and closed to hearing any kind of understanding. I realize now that I was just adding to the problem- the problems those with mental illness face, and the problems I faced as a result of being so judgmental. The truth is, it’s everywhere. People are mentally ill all around us, because life is hard, and our brains are complicated, and we can’t always react and think and feel the way we’d like to. It’s interesting that mental illness has been around just about as long as we can know, with different groups and societies having different interpretations and cures for various ailments. I’ve focused this essay on the history of mental illness globally at first, and then solely in America, and the use of institutionalization and the view of the stigmatized up until now.

Thoughts and beliefs about mental health and mental illness have been around for a long time (1). The early Egyptians thought mental illness was caused by a loss of status or money. The recommended treatment was “to talk”, and turn to religion, with suicide being widely accepted. Homer thought mental illness was caused by God taking someone’s mind away, offering no treatment. Aeschylus claimed mental illness was caused by demon possession, with the cure being exorcism. Socrates thought mental illness was a gift, and that no treatment was required. Hippocrates thought mental illness was due to melancholia and “natural medical causes”, and advised abstinence of various types, a vegetable diet, and exercise (1).

Colonial Americans referred to those suffering from mental illnesses as “lunatics”, derived from the root word lunar meaning “moon” (2). They believed that a full moon at the time of a baby’s birth or a baby sleeping under the light of a full moon could cause insanity. These “lunatics” were believed to be possessed by the devil, and they were removed from society and locked away, or cared for by their families (3). These supposed lunatics were grouped into two categories: melancholy and mania. Colonists believed the only cure involved catharsis, either expel crisis or catalyze crisis from the individual. These procedures involved submerging patients in ice baths until unconscious, or administering massive shocks to the brain. They ‘expelled crisis’ from the patients by inducing vomiting or by draining the ‘bad blood’ from the individual called the ‘bleeding practice’, which often resulted in death (2).

Urbanization in the early 19th century created a societal problem that had previously been left to individual families scattered among rural areas. Isolated asylums were introduced with the European introduction of “Moral Management” (2). This was based on the belief that the environment played an important role in the treatment of those with mental illnesses. Rather than consisting of chain and shackles, the mentally ill were given beds and cleaner surroundings in hope that a more positive environment would aid in recovery. Phrenology was also introduced at this time, in which the shape of the skull was used to help explain illness and render diagnoses.

Wars including the Civil war were a large turning point in the history of mental health. After the Civil War, a large number of those in the military and who had experienced the war closely had significant postwar trauma (2). These servicemen were brought to state mental hospitals and asylums, where the public became interested in their care and treatment (2). Although the public was now watching how ‘their boys’ were being treated, overcrowding brought back restraints to the asylums. New drug treatments, such as opium, had also become available.

This surge of patients in mental hospitals led to an increase of mental hospitals across the country. With federal and state aid from the 1890 State Care Act, institutions were able to regain resources and people and more humane conditions. However, as these institutions grew, the homeless and others seeking food and shelter commonly became ‘patients’ (2). Older relatives were also put in asylums to be cared for there. There were no established criteria for accepting or rejecting patients, and with this, the populations in these asylums skyrocketed. Once again, the asylums were forced to revert back to restraints and old procedures, including ice baths and shock therapy.

In the 1930s, lobotomy was introduced into American medical culture (2). The original lobotomy consisted of a procedure where the neural passages from the front of the brain were surgically separated from those in the back of the brain. The common result of this procedure was the patient forgetting that they were depressed. This initial form of lobotomy was time consuming and extremely delicate, and later, trans-orbital lobotomies were introduced which were performed much more quickly with significantly shorter after-care required for the patient. Because this form of lobotomy appeared so effective and could be performed so quickly, lobotomies became increasingly popular (2). However, these lobotomies were also dangerous, often depriving patients of their social skills and judgments, and due to the number of complications and deaths which resulted, this procedure became referred to as “psychic mercy killing” and “euthanasia of the mind” (2). Along with lobotomies came electro-convulsive shock therapy, with continued overcrowding of patients and understaffing. Rumors of abuse and neglect at these hospitals flooded communities, with reports of patients starving to death, and around the 1950s many patients were reintroduced back to the community in a deinstitutionalization movement.

In the 1950 and 1960s, asylums went through a change, with more treatment drugs available, in addition to new state and federal public policies as a result of the Joint Commission on Mental Illness and Health submitting a report entitled, ‘Action for Mental Health’. This called for increased research, financial support, education for the public, and better training for staff (3). In 1953, the National Mental Health Association cast a bell made from hundreds of metal restraints formally used in mental hospitals, as a sign of hope and change for patients (4). These new procedures in the hospitals resembled those from the previous moral management period. The emphasis shifted to protecting the human rights of mental patients that had previously not been acknowledged. New employees were hired and trained to protect these rights. Treatments were geared towards the individual.

Deinstitutionalization also was taking place during this time, as many in mental institutions were thought to be able to function in society (3). This was beneficial in removing and preventing unnecessarily long-term hospitalization, while harmful to those patients discharged without being shown support or any form of continued assistance. Expectations that those released from these hospitals would often reintegrate back into the community were not met; many remained unemployed and homeless or living in other shelters. In 2000, results from a prospective study revealed that patients released from mental hospitals felt that public stigma and social rejection caused much distress (5). Feeling this ‘stigma’ was associated with being unmotivated to reintegrate back into society, and those discharged from these hospitals were part of widespread homelessness at this time and were at an increased risk rate of going to prison (5).

In the 1960s and 1970s, continuing in the path of deinstitutionalization, the Community Mental Health Centers Act demanded a national system of care to meet the still severely mentally ill (4). This was helpful to those less critical, non-chronic patients, but not enough to serve the needs of psychotic patients who had been released. The implementation of the CMHC Act of 1963 led to an increase in the number of community mental health centers, and a decrease in the number of inpatients in mental hospitals, and therefore was considered a success. However, the CMHC was criticized in providing counseling for problems in daily living, or the ‘walking well’, but was not useful for those suffering more critically and unable to get themselves help (4). Also, in the 1970s, a new group of patients, to be called revolving door patients, emerged. These chronically ill people were often released from hospitals, went off their medications, refused to continue with their treatment, and were often generally noncompliant. Many also had a dual diagnosis of some mental illness and substance abuse, making their cases more difficult and complicated to treat.

In 1977, President Jimmy Carter assisted in the creation of the President’s Commission on Mental Health, which reviewed needs, made recommendations, and held meetings focused around mental health and treatment. The Commission noted that many of the people released from mental hospitals were at a high risk for rehospitalization, partially due to inadequate food, clothing, shelter, and support. In 1980, The Mental Health Systems Act, which outlined what a national system for mental health community care and treatment should entail, was signed. New in office, President Ronald Reagan nullified this quickly, saying that federal funds needed to be cut (3).

Then, with the discovery of selective serotonin re-uptake inhibitors, among other drugs, there was another shift in the viewing of mental illness. This movement involved creating a classification system known as the Diagnostic and Statistical Manual of Mental Disorders. The DSM I was largely based around theoretical bases which were up to various interpretations, whereas the later DSM II was more focused around organizing patterns of distressing symptoms into a diagnosis. The DSM III was significant in that it eliminated homosexuality as a mental illness. This manual created standards for diagnoses, which was a huge step for mental health. While many did not cleanly fit a category or all criteria, it helped organize symptoms into cohesive categories.

Various studies were done to find out what it was about mental illness that created a stigma (4). They found that the public was not afraid of the mental illness itself, but what people with the mental illness might do in terms of violence. The mentally ill, especially the psychotic, were thought of as being more violent than those without a mental illness. They found there was a slightly elevated risk of violence with psychotic patients, but the greater risk was with those with a diagnosis of a mental disorder coupled with substance abuse. However, they also found that the risk of a mentally ill person committing a violent act towards a stranger was substantially less (still very low) than the risk of a mentally ill person committing a violent act towards someone they know, such as a family member (4). Without a great risk of violence, the question was asked as to why the mentally ill remain so stigmatized. Most eyes have focused on media coverage and deinstitutionalization, with the media going as far as to warn people to stay away from the mentally ill at times, and with some who should be receiving help in an institution back on the streets and in the communities (4).

In a movie based on a true story, also in a book, Girl, Interrupted is narrated by Susanna, describing her experience going into a mental institution in the 70s. After being discharged, she says, “Was I ever crazy? Maybe. Or maybe life is… crazy isn’t being broken or swallowing a dark secret. It’s you or me amplified. If you ever told a lie and enjoyed it. If you ever wanted to be a child forever…” (6). Susanna is very relatable. Who has never felt some longing for the past? Should we be locked away in an institution? Whose best interest is an institution for- the patient’s, or the public’s? With a history of institutions under going change with various mental health acts being passed, is there a need for them in society at all?

There are people who are psychotic, with possibly an elevated level of violence. There are people with these dual diagnoses, of mental illness and substance abuse, who are potentially more violent. In my opinion, mental institutions are necessary for immediate and constant treatment. However, this is an idealist view. This assumes that in a mental institution, those who severely need help and receive help can eventually successfully reintegrate into society. This assumes that people aren’t solely given pills to walk around without feeling anything, destined to live their lives in asylums forever. This assumes that time and care are given to each patient, and that funding is readily available for this to happen, which is often not the case. There have been various studies done on how effective various staff ratios are to patients in mental hospitals, and how successful mental hospitals are in treating those with various mental illnesses, such as schizophrenia. In the first study, they found that “staffing decisions should be made on the basis of more precise information about treatment requirements, not just staffing ratios” (7). This is the common result of these studies. While it is still fairly new for these studies to be done on mental institutions, with taboo and stigma low enough to venture into these places, and with many new studies done on various aspects of life and treatment in mental hospitals, the results often turn out to be very individualistic. Even with those of the same disorder, effective treatments often vary, making mental illness often specific to the individual.

When looking for opinions on the necessity of mental hospitals in society, very little came up. Most opinions focus more on admission requirements to mental hospitals, and some to technical, perhaps more touchy things, such as addressing whether mental hospitals should be renamed to something different entirely. A different name may produce initially less stigma, however the purpose is still the same. I think the reason why people, at least not publicly on the internet, are not willing to raise an opinion about the necessity of mental hospitals is the fear of what may result without them. Would the severely mentally ill become our, as a society, responsibility? Or maybe it’s a thought that isn’t even worth debate. Maybe it’s such an innate necessity that no one would think of doing away with them, even and perhaps especially after the many problems from deinstitutionalization.

I’ve always imagined the perfect world, with all people fed and no people suffering. I’ve always thought, or maybe forced myself to believe, that it was a somewhat realistic possibility, if all conditions could be met, and unpredictability didn’t exist- if we could control all that goes on. It’s scary admitting that we can’t fix or control everything ourselves. It’s one thing to have your own problem, understand and feel like you have control over how big a problem can become and know with confidence that it’ll be gone, that you can fix it, or that it’ll go away. It’s another thing to hear about other people having problems that can and do get out of control, something beyond them. Maybe that’s the most frightening thing about mental illness- the lack of control. If someone can’t control what’s going on inside of his/her head, then what else can’t he/she control? And perhaps that’s where the public fear of violence stems from.

People with mental illness were once believed to be possessed by demons. They were then put in shackles, forced to live through terrible conditions, thrown out to the streets, taken back into better institutions, and either back in the communities, or living in these hospitals. It seems to me like there has to be some other factor that accounts for this lack of control with mental illnesses. There are chemical imbalances in the brain, and then environmental factors, and personal temperaments and tendencies, but I want to believe there’s something we haven’t found yet, some other factor, that can account for this lack of control. There’s also the thought that mental illness is what is inside all of us when we lose control- that the conscious, or perhaps, in addition, unconscious control is what keeps us ‘sane’. The other thought is, that maybe it isn’t a lack of control at all. Maybe it’s total control. Maybe they aren’t the same person they once were, but their actions are deliberate and have a purpose, and maybe this is just their control. Our consciousness as humans is what is often said to set us apart from ‘less complex’ beings. Maybe consciousness should be in place of control? Or, perhaps consciousness entails control? We are aware of what we are doing, of who we are, and can predict our own behavior. I wonder if the mentally ill can do the same. I wonder if their illness becomes just as much a part of their identity as their name.

With such an interesting history, understanding mental illness is a topic that will be an open book for a long time. There’s so much we don’t know, and so much we can still find out to help treat those who are suffering. I think that erasing the stigma may end up being just as helpful, or more so, as treatment. When those with mental illnesses can be viewed through a non-judgmental eye, then perhaps they can be free to express themselves, with a past they aren’t ashamed of, and therefore a present and future that may seem even more realistically hopeful. But again, perhaps this is yet another idealistic view. We need to come up with some destigmatizing notion that still acknowledges mental health problems and encourages treatment, without writing a person off for the rest of their lives as ‘crazy’. Where we are now is progression. Little by little, we are becoming more “accepting” of those with mental illnesses, and little by little, through experience, education, and exposure, we’re learning that they’re not solely “the mentally ill”, but those who have encountered illnesses that can be combated.

References:
1. http://www.bipolarworld.net/Bipolar%20Disorder/History/history.html. Accessed on 11/4/08, History of Mental Illness and Early Treatment in a Nutshell.
2. http://www.toddlertime.com/advocacy/hospitals/Asylum/history-asylum.htm. Accessed on 11/4/08, The History of Mental Illness.
3. http://www.mentalhealthworld.org/29ap.html. Accessed on 11/4/08, 20th Century History of the Treatment of Mental Illness: A Review.
4. http://www.surgeongeneral.gov/library/mentalhealth/chapter1/sec1.html. Accessed on 11/4/08, Mental Health: A Report of the Surgeon General.
5. http://en.wikipedia.org/wiki/Deinstitutionalization. Accessed on 11/4/08, Wikipedia: Deinstitutionalization.
6. http://www.imdb.com/title/tt0172493/quotes. Accessed on 11/4/08, Memorable Quotes for Girl, Interrupted.
7. http://psychservices.psychiatryonline.org/cgi/content/full/52/10/1374. Accessed on 11/4/08, Relationship between Staffing Ratios and Effectiveness of Inpatient Psychiatric Units.