The Enigma of Stigma: The Continued Stigmatization of Mental Illnesses Today

BY PAIGE GLOWACKI*

Arising out of a lack of awareness and fear, stigmas surrounding mental health have become ingrained in most cultures. In colonial times in America, the mentally ill were treated like criminals and regarded as “sub-human beings.” For 300 years, treatment of mental illness was primitive and static, often brutal and inhumane, like being chained in kennels and cages like wild beasts. In the 1800s, a period of institutionalization began, housing the mentally ill away from society. By the 1930s, electroconvulsive therapy and surgery were introduced as revolutionary ideas in treating mental illness with limited effectiveness. Pharmacotherapy, in particular, the discovery of antipsychotic medications, accelerated successful therapy into the 21st century. These medications offered the promise of curing mental illness and thus resulted in deinstitutionalization and outpatient therapy. Eventually, several antidiscrimination laws in the United States were enacted to protect the rights of the mentally ill and combat stigmas. However, these laws only target the discrimination component of stigma; cues, stereotypes, and prejudice are beyond the reach of legislation. Besides social stigma, or the biased attitudes others have, many individuals suffering from mental illness experience self-perceived, or internalized, stigma. Both social and self-perceived stigma have negative consequences that impair self-esteem and character, obstruct access to treatment, and result in poorer outcomes. Despite advancements in treatment, awareness and education, and federal policies addressing mental illness in the United States, stigmas of mental illness remain exceedingly prevalent in society.

Stigma is comprised of stereotypes, prejudice, and discrimination. Stereotypes, though occasionally positive, become a problem when applied to all members of a broad group. Stereotypes not only fail to accurately represent the group as a whole but also are assumed to be true regardless of individual characteristics. As a result, stereotypes often elicit prejudice, which consists of prejudgment and automatic negative thoughts. Prejudiced attitudes can lead to discriminatory behaviors that restrict the rights of the target group and the opportunities available to them. Exploitation and domination, enforcement of social norms, and avoidance of disease and contagion are the main reasons that societies stigmatize.

The inhumane treatment of mental illness throughout history promoted the social acceptance of stigma. During the Middle Ages, the mentally ill were made outcasts in society. Many doctors viewed mental illness as either a result of demonic possession, physical illness, or a punishment from God. In the American colonies, treatment of the mentally ill involved emotional torment, social isolation, and physical pain. These treatments were designed to minimize the trouble caused to the community by the mentally ill and worked at a socioeconomic level to exclude mentally ill people from society. Incarceration in response to atypical behaviors became another tactic to isolate this population. As a result, many people with mental illness found themselves in jail and could never receive proper treatment living as convicted criminals. The first public mental health hospital in North America was the Public Hospital for Persons of Insane and Disordered Minds in Williamsburg, Virginia, established in 1773. Treatment in this hospital included solitary confinement, conditioned fear of the doctor, powerful but ineffective drugs, bleeding, shackles, and plunge baths. In 1843, Dorothea Dix, an influential advocate of the mental health movement, saw the mentally ill placed in jails along with criminals. In her Memorial to the Legislature of Massachusetts, she writes, “I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience!” By drawing attention to these inhumane conditions, Dix paved the way for state hospitals nationwide.

State hospitals were underfunded, understaffed, and so overcrowded that they resulted in extremely poor living conditions. The priority of the hospitals became custodial care instead of therapeutic care, with the role of medical professionals shifting from treatment to caretaking. In 1887, Nellie Bly, a journalist for the New York World newspaper, feigned insanity to be admitted covertly to the Women’s Lunatic Asylum on Blackwell’s Island, New York. Her writing prompted an investigation of the asylum and resulted in New York City increasing funding for mental health care and making regulatory changes. Thus, an effort for deinstitutionalization and outpatient treatment began.

As a result, in the late 1800s and early 1900s, psychiatrists began to work towards cures and preventative techniques. Eugenics, or the attempt to improve the human species through “breeding out” undesirable characteristics, and forced sterilization were introduced. Forced sterilization delayed the advancement of mental illness treatment and promoted stigmas.

As the 20th century dawned, new treatment methods flourished, including electroshock therapy, the lobotomy, and antipsychotic drugs. Yet, many of these treatment methods only came about as a way to adjust the perception of mental illness in society rather than actually helping the mentally ill

Introduced to the United States in 1954 as the first antipsychotic, chlorpromazine, brand-name Thorazine, proved effective at alleviating certain symptoms of mental illness to the point that patients could lead relatively normal lives and not be confined to institutions. The Community Mental Health Act in 1963 was designed to encourage individuals with mental illness to live in their communities and was a turning point in society’s outlook towards mental illness.

In theory, deinstitutionalization was designed to improve the lives of many patients, but in reality, it was poorly implemented. The mentally ill failed to receive appropriate care after mass deinstitutionalization, with a lack of support from the community. Many became homeless or were taken into the correctional system. The results of this approach, though not as inhumane as containment in asylums, created a massive homeless population. People on the streets were not only severely impaired by their illness, but they also served as clear proof of the general public’s reinforcement of stereotypes. Structural discrimination of the mentally ill, a form of institutional discrimination against individuals that restricts their opportunities, is still pervasive, both in rehabilitation efforts and in legislation.

Federal policies expanded the legal protection of individuals with mental illness by directly addressing discriminatory behavior by others. The laws that target this discrimination share three common features: expanded protections over time for people with mental illness, differential protections for subgroups with mental illness, and implementation challenges that stem from label avoidance that impair the capability and effectiveness of these laws. The Americans with Disabilities Act (ADA) of 1990 addresses workplace discrimination against those with disabilities, including the protection of those with psychiatric disabilities.

The Education for All Handicapped Children Act of 1975 addresses discrimination against those with disabilities in school settings and also offers protections to students with mental health related disabilities. It granted federal funding for states to provide an appropriate education for disabled students. Renamed the Individuals with Disabilities in Education Act in 1990, the law has been amended several times to increase protections for children with mental health related disabilities.

Over the past few decades, increased education and awareness of mental illness have led to the recognition and acceptance of mental health, joining physical health, as an essential part of one’s well-being. There is evidence that public stigma toward major depressive disorder has significantly decreased over the last twenty years. However, stigmas of schizophrenia and alcohol dependence remain unchanged. The perception of threat associated with schizophrenia has actually increased over the past 30 years.

A recent example of stigma surrounding depression has been on display in the media. Yale University has been faced with a federal lawsuit. Yale has been accused of pressuring suicidal students to withdraw from the school during their crisis. Furthermore, the students must go through a stressful readmittance process. Rachel Shaw-Rosenbaum, a freshman at Yale, committed suicide on campus in 2021 after contemplating the consequences of withdrawing from the school. Her death exposed the punitive way Yale treated suicidal students and the university’s reinstatement policies. Yale renamed the process “reinstatement” instead of “readmission.” Nevertheless, students had to write an essay, secure letters of recommendation, have an interview with Yale officials, and take two courses at another four-year university to return. One student who was struggling with panic attacks and feelings of worthlessness had heard about other students being forced to leave because of depression and the lengthy reapplication process. She feared Yale’s response if she were to open up about her thoughts. Thus, she did not seek help. When it became unbearable to continue suppressing her depression, she attempted suicide. With the university perpetuating harmful stigmas, this student felt unable to open up about her struggles, leading her to attempt to solve the problem the only way she knew how. The university is now being sued over “systemic discrimination” against students with mental health disabilities, claiming that the Ivy League institution unfairly treats students struggling with mental health and fails to modify policies to accommodate them. Another student, Hannah Neves, was encouraged by Yale psychiatrist Heather Paxton and mental health and counseling director Paul Hoffman to withdraw from the school. These officials added that it would “look bad” for her if she was withdrawn involuntarily. They had not discussed alternative accommodations with her that would have allowed her to remain at Yale while receiving mental health treatment. Instead, these oppressive and stringent policies would result in the loss of housing, community, health insurance, and removal from campus. The resulting trauma from involuntary withdrawal exacerbates the external and internal stigma experienced by the student. These policies only serve to amplify barriers to effective care and resolution. This evidence supports the fact that the stigma of mental illness flourishes in the intellectual elite of current society.

While federal laws provide a foundation of protection against discrimination, legislation has fallen short. There must be a creative engagement of society to find alternative approaches that directly target other components of stigma. These challenges should involve ethical enlightenment and moral responsibility. Moving forward in this battle against stigmatization requires increasing interpersonal contact with individuals with mental illness and educating people on how stigma is a moral injustice. How much longer will the mentally ill have to grapple with debilitating stigmas in addition to their illnesses?

Endnotes

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Paige Glowacki is a senior at the Hockaday school in Dallas, Texas.

She is planning to major in cognitive science, economics, and statistics.

She is interested in applying behavioral economics to create models of effective delivery of mental healthcare.

NOTE: While the author might be stated difrerently in the heading, it is Paige Glowacki