Stigma and Mental Illness

By David Trend

“The more I became immersed in the study of stigmatized mental illness, the more it astonishing to me that any such phenomenon should exist at all,” writes Robert Lundin, a member of the Chicago Consortium for Stigma Research. “I believe that serious and persistent mental illnesses, like the one I live with, are clearly an inexorably no-fault phenomena that fully warrant being treated with the same gentleness and respect as multiple-sclerosis, testicular cancer or sickle-cell anemia.”[i] Here Lundin names a central of problem in the social construction of mental illness: the misunderstanding of conditions affecting the mind as somehow different from other biological illness. The misrecognition renders mental illness prone to the judgmental attributions discussed by Susan Sontag in her 1973 book Illness as Metaphor.  To Sontag, contemporary society reverses ancient views of sickness as a reflection of the inner self.  In this new view, the inner self is seen as actively causing sickness––through smoking, overeating, addictive behavior, and bad habits: “The romantic idea that disease expresses the character is invariably extended to exert that the character causes the disease–because it is not expressed itself. Passion moves inward, striking within the deepest cellular recesses.”[ii] But as before, the sick person is to blame for the illness.

Such sentiments are especially vindictive when a mentally ill person commits a crime. Understandably perhaps, clinical terms like “mental illness” quickly acquire malevolent meanings in the public mind––even though the mentally ill statistically are no more prone to criminality than anyone else. Sometimes this semiotic slippage causes public panic over commonplace disorders. Consider the case of Adam Lanza, the young man who in 2013 shot 26 children and adults at the Sandy Hook Elementary School in Newton, Massachusetts. While mental health analysts speculate that an acute psychotic episode prompted his violence, Lanza never had been diagnosed with a serious mental illness. As reporters scrambled for a story, much was made of Lanza’s childhood symptoms of Asperger’s syndrome, a form of high-functioning autism. The repeated mention of this disorder in news coverage triggered wrong-headed fears nationally of the murderous potential in other autistic kids. According the Centers for Disease Control (CDC), approximately 1 in 50 people (1.5-million) fall somewhere on the autistic spectrum, 80 percent of whom are boys.[iii] This has prompted improved diagnostic measures, which in turn have resulted in an apparent rise in autism cases in recent years––up 78 percent from a decade ago––and made autism a source of acute anxiety for many new parents.

No link between autism and violent behavior has ever been shown. National crime data place autistics at precisely the same rates (1.6 percent) as the general population, with many experts stating that autistic people are, in fact, less likely to commit violence than the average person.[v] Ironically in this context, because of their social difficulties autistic children are far more likely to be the victims of bullying and assault than others. One study found that autistic children are 49% more likely to wander from safe settings due to “social referencing” impairments.[vi] Also, because autistic kids are taught compliance from an early age, they are more often victimized by domestic violence and sexual abuse than the general population.  The Sandy Hook autism story shows how a psychiatric condition––in this case a non-threatening developmental disorder––is vilified in the sensationalizing dynamics of moral panic.[vii] Simple as this process sounds, it raises a host of secondary questions, not the least of which concerns the actual risks of the mentally ill to the rest of us and by what criteria a non-professional makes such an assessment in our current culture of fear.

Here is what statics show: less than five percent of people with serious mental health problems commit violence against others.[viii]  Almost none who do so have developmental disabilities like autism. Violent offenders usually fall within narrower diagnostic categories like schizophrenia, which at best only partially accounts for their anti-social behavior. This is not to deny the legitimate threats posed by delusional psychotics. One’s instincts about the person muttering on the subway are not always unfounded. But often such impressions are based more on perceived unpredictability of behavior rather than on a rational assessment of risk. Statistically speaking, the likelihood of a violent episode is surprisingly low––even as public fear of individuals with mental illness has increased in recent decades.[ix] Also, the interplay of alcohol and drug use with psychiatric conditions is a major factor violence and crime. The National Institutes of Mental Health estimate that 4.6 percent of the population falls under the classification of having a “serious” mental illness––of whom half also have a substance abuse disorder. [x]

In today’s America there are more mentally ill people in prisons than in a hospitals. In fact, the nation’s largest psychiatric ward is the Los Angeles County Jail.[xi] By current Bureau of Justice Statistics (BJS), more than 50 percent of all jail inmates in the US have a psychiatric disorder, with major depression and psychotic conditions topping the list. Over the past two decades, government budget cutbacks have put more formerly institutionalized people with mental illness on the streets, resulting in a 154 percent increase of mentally ill people in the criminal justice system.[xii] According the Patrick W. Corrigan, a well-known advocate for the mentally ill, “Criminalizing mental illness is a way in which the criminal justice system reacts to people with mental illness, contributing to the increasing prevalence of serious mental illness in jail.”  As a result, those with psychiatric diagnose are “more likely than others to be arrested by police” and can be expected “to spend more time incarcerated than persons without mental illness.”[xiii] Women with mental illness are 50 percent more likely than men to land in jail, with many female inmates reporting histories of abuse as children.[xiv] Looking at the mentally ill who commit violent acts, a MacArthur Foundation study pointed to the pivotal role of social context. Typical targets of such violence were family members––87 percent––with most assaults occurring in the home and characterized by “mutual threat, hostility, or financial dependence.” Less than 10 percent of attacks were against strangers.[xv]

Mentally ill people do more violent harm to themselves than they do to others, according the National Institutes of Mental Health. Suicides occur at more than twice the rate of murders nationally, with the mentally ill accounting for the vast majority of self-inflicted deaths.[xvi] Self harm isn’t the only way that mentally ill or developmentally disabled are at risk. Although murders committed by mentally ill are widely reported and studied, less attention has been afforded to murders of them. One study by American and Swedish researchers found that as many as 20 percent of homicides are committed against people with psychiatric diagnoses. The risk of being murdered was highest among the mentally ill who also abused drugs, although its also increased among those with personality disorders, depression, anxiety and schizophrenia. Analytists think that these high rates of murder result in part from common fear that the mentally ill are “unpredictable” or “dangerous.”  This creates “feelings of uneasiness, fear and a desire for social distance and may increase the risk of victimization.”[xvii]  Here again, social context matters––but in a broader sense. Mentally ill people are more likely than the general population to live in risky neighborhoods or to be homeless, which in itself can make them more likely to be victimized. Many of America’s 2-million “long-term mentally ill” in live in inadequate housing and without social support.[xviii] Making matters worse, some psychiatric disorders cause people to be less cognizant of their surroundings and therefore less cautious about personal safety.

Socioeconomic status matters a lot in mental illness.  For people with a psychiatric diagnosis, work can be a key factor in promoting health and social inclusion, as well as financial independence. Most people with mental illness want to work and are among the largest cohort served by the federal Vocational Rehabilitation system. But employment discrimination can make this difficult. When steady jobs can be found, they have proven to be one of the best therapies for reducing the symptoms of mental illness. Nevertheless, unemployment rate for adults with a major psychiatric diagnosis is three to five time higher than the general population. The National Alliance on Mental Illness estimates that 60 to 80 percent of the mentally ill are unemployed, with rates running as high as 90 percent for those with severe impairments.[xix] Half of the latter group lives at the national poverty level of $11,490 for a single person. The costs of such unemployment are huge, with an estimated $25-bilion paid annually in the U.S. in disability payments to the mentally ill.

While the stigma of mental illness directly influences how an individual is treated by others, the effect the label on a person’s self-image creates one of the biggest challenges to the mental health field. As a group, the mentally ill are highly prone to hiding their conditions, avoiding treatment, and deferring support options. A 2007 study conducted by the journal Psychiatric Services found that two-third of patients believed their problems “would get better on their own” and that 71 percent were convinced they could cure themselves without help.[xx]  These tendencies are most pronounced with those in the grips of substance abuse. Often the problem starts at home, as the mentally ill struggle to hide their conditions from family members, or to minimize them. Studies have shown that 30 percent of those with a psychiatric condition try to conceal it from family members.[xxi] In addition to the individual’s belief that he or she can somehow “manage” an illness perceived as a personal failing, there is an additional tragic rationale for this––as the “associated” stigma of having a “disturbed” child or parent can affect the way an entire family is treated. Approximately 25 percent of families with a mentally ill member report instances of avoidance from others. This means that some families will collude in maintaining the illness as a “private” matter, often exacerbating the individual’s reluctance to seek professional care. This can be a deadly move, especially considering that many common conditions like depression and bi-polar disease become progressively worse over time.

In one national study, less than 40 percent of those with serious mental health conditions received stable treatment during the prior year.[xxii] According the Bureau of Labor Statistics, 89.3 million Americans live in federally-designated Professional Mental Health Shortage areas––nearly twice the number in areas with similar shortages for general health care.[xxiii] During the past 20 years, the ways mental illnesses are treated has changed significantly as well, with inpatient care dropping from 42 to 19 percent of expenditures and prescription drugs jumping from 7 percent to 27 percent.[xxiv]  Worries persist among the mentally ill over the consequence of being labeled, channeled into counseling, or obliged to take prescription medications. But resistance to mental health treatment is but part of the problem, since it seems that people with psychiatric diagnoses are less likely to receive health care of all kinds. Until the passage of the Affordable Care Act, a psychiatric diagnosis was the kind of “preexisting condition” that could preclude an individual’s eligibility for health insurance. With new regulation, many in the mental health field say that communication difficulties, resistance to treatment, and subtle biases among health care providers lessen the likelihood of people with psychiatric illness receiving routine health screenings and care.

Some populations resist care more than others. The health risks and reduction in life opportunities related to mental illness are intersectional problems, more heavily affecting the economically disadvantaged and those affected by other forms of social stigma and discrimination. Mental illness among military personnel and veterans is especially problematic in this way. In general terms, public attitudes toward returning members of the military are mixed. While Vietnam-era resentment of returning military is now a relic of history, misperceptions and misunderstandings of the veteran experience persist. For every scene of flag-waving heroic celebration there is a matching image in many people’s minds of violent unpredictability, possibly induced by war trauma. And military culture discourages mental health care. Unlike in civilian life, the privacy firewall between employer and employee medical knowledge is largely missing in the military chain of command, where supervisors often have responsibility for assessing troop readiness. The omniscient character of the military chain-of-command has recently come to public attention in the area of sexual abuse, where supervisors sometimes are both perpetuators and adjudicators of such offenses. The film The Invisible War brought this issue to light in noting that since 2006 over 95,000 such instances had been documented, with less than 14 percent reported and 5 percent brought to prosecution.[xxv] Add to this military social pressures involving toughness, which often persists after service ends, and the stage is set for widespread denial of mental health conditions, the most common of which is Post Traumatic Stress Disorder (PTSD). It is now documented that few service personnel return from active duty without being affected by the stress of war, with as many as 20 percent showing PTSD symptoms.[xxvi]

[i] Robert Lundin, “Foreword,” in Patrick W. Corrigan, ed., On the Stigma of Mental Illness: Practical Strategies for Research and Social Change (Washington, DC: 2005) p. xi

[ii] Susan Sontag, Illness as Metaphor (New York; Vintage, 1977) p. 45.

[iii] Autistic kids often have language delays, obsessive traits, concrete thinking, and difficulty making friends––with diagnoses made by observations of children’s behavior. Early recognition of autism is important to its remediation, since much of the impairment associated with the disorder can be corrected. Many autistics are gifted, including such figures as Albert Einstein, Charles Darwin, Thomas Jefferson, Amadeus Mozart, and Michelangelo.  See, “Autistic Spectrum Disorders,” Centers for Disease Control, (n.d.) (accessed Feb. 3, 2015).

[iv] Miriam Falco, “CDC: U.S. Kids with Autism Up 78% in Past Decade,” CNN News (March 29, 2012) (accessed Jan 12, 2015).

[v] “Are Autistics Natural Born Criminals?” The Autism Crisis (Oct 10, 2010) (accessed Jan 1, 2015).

[vi] April Choulat, “Why Do Autistic Children Wander?” Autism Remediation for Our Children (Aug 11, 2013)  (Accessed Aug. 22, 2014).

[vii] Sociologists have mapped such progressions: from signs (“The person muttering in the subway must be crazy”), to stereotypes (“Crazy people can be dangerous”), to discrimination (“I won’t hire a crazy person”).

[viii] “Violence and Mental Illness,” U.S. National Institute of Medicine from World Psychiatry, June 2003 Vol 2, no. 2 (June 2003) pp. 121-124. (Accessed Jan. 12, 2015).

[ix] Patrick W. Corrigan, in Patrick W. Corrigan, ed, On the Stigma of Mental Illness (Washington, DC: AP 2005) p. 20.

[x] “Prevalence of Serious Mental Health Illnesses among U.S. Adults by Age, Sex, and Age” (2010) (Accessed Oct. 15, 2014).

[xi] Dina Demetrius, “Exclusive: Inside the US’s Largest psychiatric ward, the LA County Jail,” (July 28, 2014) Aljazeera America (accessed May 1, 2015).

[xii] On the Stigma of Mental Illness, p. 20.

[xiii] Ibid.

[xiv] “Study finds that half of all prison and jail inmates have mental health problems,” Bureau of Justice Statistics (2010) (accessed Oct. 10, 2014).

[xv] “Violence and Mental Health: An Overview,” National Institutes of Health  (2003)  (Accessed Jan. 9, 2015).

[xvi] Tom Insel, “Understanding Severe Mental Illness,” (n.d.) (accessed Dec. 15, 2014).

[xvii] Jeremy Laurence, “Mentally ill people nearly five times more likely to be victims of murder than general population,” The Independent, (March 6, 2013) (accessed Feb 4, 2015).

[xviii] On the Stigma of Mental Illness, p. 18.

[xix] “Unemployment,” The High Costs of Mental Health, National Alliance of Mental Illness (Jan. 2010) (Accessed Dec. 20, 2014).

[xx] Sarah Kliff, “Seven Facts about America’s mental-health care system,” Washington Post (Dec 17, 2012) (accessed. Jan. 4, 2015).

[xxi] On the Stigma of Mental Illness, p. 23.

[xxii] The number in treatment for schizophrenia, one of the most problematic conditions, was somewhat higher at 60 percent. See, On The Stigma of Mental Illness, p. 28.

[xxiii]   “Seven Facts about America’s mental-health care system,”  (Dec. 17, 2012) (accessed Oct. 14, 2014).

[xxiv] Ibid.

[xxv] The Invisible War, (accessed Jan. 5, 2015).

[xxvi] Sarah Peters, “Veterans groups encourage returning service members to seek mental health care early” Express Times (July 30, 2013) (accessed Aug. 20, 2014).

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