Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 1
Public Attitudes About Mental Illness: 1950s to 1990s
Nationally representative surveys have tracked
public attitudes about mental illness since the 1950s (Star, 1952, 1955; Gurin
et al., 1960; Veroff et al., 1981). To permit comparisons over time, several
surveys of the 1970s and the 1990s phrased questions exactly as they had been
asked in the 1950s (Swindle et al., 1997).
In the 1950s, the public viewed mental illness as a stigmatized condition and
displayed an unscientific understanding of mental illness. Survey respondents
typically were not able to identify individuals as“mentally ill” when presented
with vignettes of individuals who would have been said to be mentally ill
according to the professional standards of the day. The public was not
particularly skilled at distinguishing mental illness from ordinary unhappiness
and worry and tended to see only extreme forms of behavior—namely psychosis—as
mental illness. Mental illness carried great social stigma, especially linked
with fear of unpredictable and violent behavior (Star, 1952, 1955; Gurin et al.,
1960; Veroff et al., 1981).
By 1996, a modern survey revealed that Americans had achieved greater scientific
understanding of mental illness. But the increases in knowledge did not defuse
social stigma (Phelan et al., 1997). The public learned to define mental illness
and to distinguish it from ordinary worry and unhappiness. It expanded its
definition of mental illness to encompass anxiety, depression, and other mental
disorders. The public attributed mental illness to a mix of biological
abnormalities and vulnerabilities to social and psychological stress (Link et
al., in press). Yet, in comparison with the 1950s, the public’s perception of
mental illness more frequently incorporated violent behavior (Phelan et al.,
1997). This was primarily true among those who defined mental illness to include
psychosis (a view held by about one-third of the entire sample). Thirty-one
percent of this group mentioned violence in its descriptions of mental illness,
in comparison with 13 percent in the 1950s. In other words, the perception of
people with psychosis as being dangerous is stronger today than in the past
(Phelan et al., 1997).
The 1996 survey also probed how perceptions of those with mental illness varied
by diagnosis. The public was more likely to consider an individual with
schizophrenia as having mental illness than an individual with depression. All
of them were distinguished reasonably well from a worried and unhappy individual
who did not meet professional criteria for a mental disorder. The desire for
social distance was consistent with this hierarchy (Link et al., in press).
Why is stigma so strong despite better public understanding of mental illness?
The answer appears to be fear of violence: people with mental illness,
especially those with psychosis, are perceived to be more violent than in the
past (Phelan et al., 1997).
This finding begs yet another question: Are people with mental disorders truly
more violent? Research supports some public concerns, but the overall likelihood
of violence is low. The greatest risk of violence is from those who have dual
diagnoses, i.e., individuals who have a mental disorder as well as a substance
abuse disorder (Swanson, 1994; Eronen et al., 1998; Steadman et al., 1998).
There is a small elevation in risk of violence from individuals with severe
mental disorders (e.g., psychosis), especially if they are noncompliant with
their medication (Eronen et al., 1998; Swartz et al., 1998). Yet the risk of
violence is much less for a stranger than for a family member or person who is
known to the person with mental illness (Eronen et al., 1998). In fact, there is
very little risk of violence or harm to a stranger from casual contact with an
individual who has a mental disorder. Because the average person is ill-equipped
to judge whether someone who is behaving erratically has any of these disorders,
alone or in combination, the natural tendency is to be wary. Yet, to put this
all in perspective, the overall contribution of mental disorders to the total
level of violence in society is exceptionally small (Swanson, 1994).
Because most people should have little reason to fear violence from those with
mental illness, even in its most severe forms, why is fear of violence so
entrenched? Most speculations focus on media coverage and deinstitutionalization
(Phelan et al., 1997; Heginbotham, 1998). One series of surveys found that
selective media reporting reinforced the public’s stereotypes linking violence
and mental illness and encouraged people to distance themselves from those with
mental disorders (Angermeyer & Matschinger, 1996). And yet,
deinstitutionalization made this distancing impossible over the 40 years as the
population of state and county mental hospitals was reduced from a high of about
560,000 in 1955 to well below 100,000 by the 1990s (Bachrach, 1996). Some
advocates of deinstitutionalization expected stigma to be reduced with community
care and commonplace exposure. Stigma might have been greater today had not
public education resulted in a more scientific understanding of mental illness.
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