Mental illnesses are organised around a set of diagnostic labels that can be ascribed to people with common mental experiences who behave in similar ways. This is rooted in the ‘medical model’ which assumes mental health problems are the result of physiological abnormalities, generally involving brain systems. A disorder is considered as an illness and is therefore treated with physical treatments, usually medication, that modify the underlying biological disorder. The type of treatment given is determined by the presence or absence of various signs or symptoms. This assumes that people with mental health problems are experiencing a state divorced from that of ‘normal’ individuals: a mental illness.
Who diagnoses and how?
Kraepelin first began describing syndromes which had a common set of symptoms differing from those of other syndromes, in a classification system which later formed the basis of the World Health Organisation’s (WHO) International Classification of Diseases (ICD:WHO, 1992). Being in its tenth edition highlights the difficulty to accurately identify and classify mental health conditions. The American Psychiatric Association (APA) devised its own classification system, known as the Diagnostic and Statistical Manual (DSM) , which although having much in common with the ICD system, differs in a number of details. This has also changed over the years since its first publication in 1952 and is now in it’s fifth revision (DSM-IV-TR:APA 2000). The classification system is multi-axial which allows the individuals mental state to be evaluated on five different axes. This provides a dichotomous diagnosis of either mentally ill or not.
Diagnostic consistency – p 10 ab and clin psych.
Psychiatrists have developed systems to classify mental disorders that describe the kinds of symptoms and behaviour commonly seen among those considered to be mentally disordered. These fall into three main groups; personality disorders, psychoses and neuroses. While some forms of psychosis, such as schizophrenia, may make a small, independent contribution to the risk of offending, it is much more likely that other forms will be concomitant with, but not necessarily contributory to, offending behaviour.
In debating the classifications of mental disorder under three main groups, a word of caution is in order. Mental disorders can vary greatly in their symptoms, severity, course, outcome and amenability to treatment. Each of these disorders has subcategories, and the presenting features can vary in their severity. They can adversely and to differing degrees affect any and every aspect of a person’s life. There also remains tension in the medical disciplines not only with regard to the exact diagnosis in the individual cases but also as to whether some disorders actually exist as independent categories.
What is the public perception? Labels
Many people gather what they know about mental illness either from personal contact with people with such conditions or from the media. 4,5. Very little is formally taught on mental disorders within the education system. 6. In 2003 it was found that 77% of people knew someone with a mental illness. A person’s knowledge attitudes and behaviour towards people with a mental illness will affect things. The media can influence knowledge, attitudes and behaviour by being the main source of information. 8.
Several classic studies in social psychiatry have illuminated the important role that cultural beliefs play in shaping societal responses to people with mental illnesses. Hollingshead and Redlich 1 introduced the concept of “lay appraisal” to indicate that, long before mental health professionals may become involved, people such as family, friends, coworkers, police, and, of course, the person himself or herself appraise the early signs of mental disorders and make decisions about what (if anything) should be done. Others have provided vivid evidence regarding cultural stereotypes. In Nunnally’s 2(P51) semantic differential study, for example, respondents typified a mentally ill man as “dangerous, dirty, unpredictable, and worthless.”
Recent research suggests that stereotypes of dangerousness are actually on the increase8 and that the stigma ofmental illness remains a powerfully detrimental feature of the lives of people with such conditions.9-13
Where does this come from? – Media
In a study from New Zealand it was found that more than 50% of all news items depicted the mentally ill as dangerous. 10. With key themes being danger to others (61%) criminality (47%), unpredictability (24%) and a danger to themselves (20%). This study concluded that ‘print media portrayals are negative, exaggerated and do not reflect the reality of most people with mental illness. 10,12.
Fewer than 5% of the stories were from the person’s own viewpoint and only 1% quoted the person in their own words. Own voices largely absent from media depictions of mental illness. 13.
A Canadian study found similar results. A selection of articles from 8 major Canadian newspapers were compared with 2 specialist mental health publications. 14. The news papers portrayed mental illness as ‘essentially pejorative’.
A UK study compared mental health and physical health items published in 9 national papers. 64% of mental were negative compared to 46% of physical, general medical. Negative medical articles suggested bad doctors whereas mental tended to describe bad patients.15. Another study found that nearly ? of all tabloid stories used pejorative terms such as ‘looney’ or ‘nutter’. 16.
In the US 3000 newspaper stories about mental illnesses were categorised and it was found that most stories focussed on dangerousness and violence. Many were front page stories (39%) but less often treatment was mentioned (14%) and recovery (4%). This tendency to highlight violence above all other aspects of mental health was described as ‘structural discrimination’ 17. They concluded there was a lack of accurate information about mental illnesses within the public domain.
Newspaper coverage of mental illness tends to be short of accurate and detailed content, emphasises violence over all other aspects of mental illness and reinforces prejudices against people with mental illness. There is ‘ample evidence for a distorted presentation of mentally ill people in newspapers’ 26.
As the media are the public’s primary source of information about mental illnesses [1-3], depictions of those suffering from these disorders contribute significantly to the stigma associated with mental illness. This contribution makes the negativity of media depictions [1,4-8] a matter of great concern, and it has been argued [9-12] that these depictions would be more favourable if psychiatrists and other mental health professionals were more closely involved. Two of the psychiatrists presented mental illnesses in less negative ways than in the other items. These more positive depictions were undermined by the devices that the journalists used to give authority to the portrayals of mental illness and by the need to create ‘newsworthy’ items.
Published studies of newspaper stories dealing with mental illness [5,21,22] do not report accounts
or explanations provided by those with a mental disorder. This means that readers are informed about mental illnesses through stories from lay persons or professionals who have interacted with a sufferer.
The media have a powerful influence on attitudes towards mental illness and it is therefore not surprising that they should feature so prominently in anti-stigma programmes. Although the intense media interest in psychiatric topics offers a tantalising opportunity to convey an ‘anti-stigma’ message, the outcomes of media intervention are often disappointing.
While short-term interventions using films and literature may change self-reported attitudes, the evidence for longer-term behavioural change is very weak. This may be because adverse stories are the result not simply of media sensationalism, but of a more subtle collaboration between the assumptions of both journalist and reader (Allen & Nairn, 1997).
Journalism depends on narrative and this often involves selection of facts, interpretation and exaggeration. The media, of course, has an instinctive bias towards reporting the strident or the extreme. While marked bias may lead to distortion, most journalism is not dishonest or manipulative per se. Reporting a story in a way that failed to start from, or work with, existing attitudes is likely to be perceived as propaganda. It would be naA?ve to expect the media to act as ‘educators’, unless this represented a story in itself.
This is not to excuse stigmatising material in the media, but rather to seek to understand how it comes to be published. These adverse stories, and there are plenty of examples, involve stereotypes and misunderstandings that closely reflect the ignorance and prejudices of the audience. Journalists and broadcasters are generally not cynical propagandists and modifying adverse media stories will depend ultimately on influencing broader population attitudes and beliefs about mental illness.
Does perception/media portrayals reflect reality?
This research is complex and we need to tread with care. 11. It is more accurate to record actual violent events rather than officially registered crimes, which tend to underestimate violence. Research should consider all the characteristics of those who are violent (for example their age, alcohol and drug use) and not simply attribute all offences to mental illness alone. There is a need to distinguish carefully between having a history of mental illness, as against experiencing psychiatric symptoms at the time of a violent act. Research needs to consider whether wider social changes, such as unemployment rates, or changes in the patterns of mental healthcare have any bearing on the rates of violence. We need to distinguish relative risks (how much more often people with a particular condition may commit violent acts than those without this condition), from absolute risks (the actual number of such incidents or events).
Violence and mental illness
Studies of Public Perception
A high percentage of the general public associates psychotic disorders with violence
How dangerous are persons with mental illness?
The best studies find an increased risk of violence among persons with mental illness
(e.g., oneaˆ?year incidence of about 25% vs. 2% among nonaˆ?mentally ill)
Also, increased risk of being the victims of violence
The risk is on par with other socialaˆ?demographic variables (age, SES, race)
Higher incidence of violence/arrest attributed to certain untreated psychotic symptoms ,
stress, externalized depression, “conflicted” social relationships
The risk is elevated when there is also substance abuse and persons are living in “socially
disorganized” neighborhoods (low income, residential instability, fragmented families)
Also, much of the violence occurs among persons who know each other
No -So what affect can this have? – Stigma, labelling, treatments
Despite an apparent improvement in public understanding the nature and causes ofmental illness, mental disorders (especially psychosis) are linked with perceptions ofviolence. As such, public’s perceptions are not entirely out of line with objectiveassessments of risk.
Unfortunately, perceptions of violence are a significant component to the stigma
associated with mental illness which likely adds to the devaluation and discrimination
that many persons who are diagnosedaˆ?aˆ?yet are not violentaˆ?aˆ?experience.
Stigma and social rejection, in turn, limits social opportunities, such as jobs, housing,
and social networks for persons with mental illness, that to some extent, serve as
protective factors in reducing stress, and thereby reducing the risk of violence.
While the proportion of persons with mental illness who are at risk of violence/criminal
behavior is modest, in the aggregate, the risk translates into appreciable increases in
the numbers of persons with mental illness who end up in the criminal justice system- a system that was not intended for therapeutic purposes, but has been forced to adapt
by becoming the nations largest residential facility for the mentally ill. High quality, wellaˆ?coordinated community mental health services that focus on both symptom reduction and socialaˆ?economic wellaˆ?being (e.g., housing, employment) may reduce the number of mentally ill persons who end up in jails and prisons. Such efforts require tremendous initiative on the part of policy makers and local
agencies, and are likely to be limited in their effectiveness relative to the scale of the
Prejudice against those with mental illness increases social isolation and is a source of harassment and discrimination in employment, housing and insurance (Byrne, 1999; Corrigan et al, 1999). Having a mental illness adversely affects situations as diverse as prisoners being granted parole (Miller & Metzner, 1994) and patients being offered suitable organs for transplant (Corley et al, 1998). Stigma means that people are reluctant to present with psychiatric problems to primary care and often default from specialist services (Van, 1996; White, 1998). This might partly be a response to negative attitudes expressed by general practitioners (Lawrie et al, 1996, 1998) and hospital medical and nursing staff (Fleming & Szmukler, 1992). Not surprisingly, this discrimination adversely affects social behaviour and damages self-confidence (Gilbert, 2000). Such findings prompt two obvious questions: is it possible to act against stigma? And if so, what is the best way to go about it?
What can be done in the future?
To have a mental disorder does not in the vast majority of individuals increase the risk of a violent offence. Those most at risk are the mentally disordered themselves, from laws, prejudice, sentencing etc. There is also an elevate risk of self harm and suicide. The climate of fear associated with mental disorder, typified by the label of mad, which has become synonymous with bad and dangerous, exacerbates the problem. Knowledge and understanding can help to reduce fear and by understanding the ways in which vulnerable members of society can be supported then we can also identify the rare few that may cause harm to others.