The Public's Ideas about Mental Illness


1 / mE IDEAS AEOUT ENTU ILLNESS PUBLIC'S Paper Presented A by Star, Shirley Director Senior A. Study Opinion National Chicago Center, University Research of of Health National Association for Ffental Meeting to the the Annual Sheraton-Lincof IndTana Indianapolis, n Hotel-- November 5, 1955 has (As more tactfully suggested, I: have become the some- our chairman rather background, say me let By way of of study.) unique a perennial what representative that is a pioneering attempt by the National Opinion Research this research Center, Chicago, subject to thorough analysis the nature of popular think- University of to thirty-five study is based on The hundred intensive in- mental about ing illness. about an 5our and a half's duration--with a representative terviews--interviews of the and publlc Anerlcan is, so far as we know, the only such study of cross-sectlon the national scale. The goals of attempted research are, first, to describe a on sone detail the in ideas about mental illness current in our society characteristic second, explain--so far as we to reasons why popular conceptions of can--the and, of their firm can.~iction t5at Eeczase illness they do. assume form mental the - ion needed for effective in£ omat is progrzmming, the this of order understandln,~ cosponsored by the Nattonal Association for research Health and the is Nenral - the advlce and It has had help benefit of Institute Health. Pyental of National. both of these groups and fron a large number from psychiatrists including both of And, finally, I should add, an Public Information. the and the APA ComLttees GAP support study 'the Generocs and patient: financial had of a number of foun- the has dations. much Sackground. So for am still faced with the embarrassing task of I mentioning, however, that for study been in the has some five years now. progress We have discovered an alnost inexhaustible anoznt of information in the study and have not Seen a33.e to bring ourselves to stop exploring and publish what \re yet I mention this for two though early next year. [.re swear we will 3y have; currently first, because I and we feel about the over delay: Ion: the guilt reasons a5ove results, talk only the s~allest fraction of our today and, second, I'm will about at all not that the aspects I've singled out will zctuaizy be those that inter- sure est you most. either czse; hope that in the discussion perlod yot! will not I In will feel content of my remarks, but to raiseSany and all questions that lirnitpd the tr occur 'you. So, get down to the data, let me start with the marerials which to most bear directly the present outlook Ear on intensified attack on the problems presented an by hospitalized mental illnesg, for, this, I assuxe, is one of the most inmediate - and probfens concerning this Association. In the first place, 71 per cent pressing of the feel that a person who "goes out pu5lic his mindfi can generally of Anerican better again. get addrtional nine' per cent think same can, but aren't sure (An the majority; about get per the a-rerage case cannot thhk better again; nine li cent cent per no opinion.) have Even more decidedly, 91 per cent Selieve recovery from "nervous condftior?stt short of psychosis is generally possible. (Another five per thick gener- is at least sometimes possible; two per cent feel recovery is cent it don't not and two per cent just possible, kaow.) Moreover, in talking about ally recovery from mental illness, 56 per cent reconmend either a nental hospital or a the psychiatrist not always in exactly those terns, of course--£or (FiH-?t5)--th~ilgh treaemect of psychosis. Similarly, 52 per cent recornend professional psychiatric

2 < 4 - - - 2- When people are asked what they would do '!ner~ous treatment conditions" for {la-5). put as we it, "was not started peculiarly--or, acting family their in if somaone to It cent say they would turn Fer psychiatric facilities 63 himself, like acting ; more often, after the help obtainable from (18) immediately (NH-9)--somet:mes, If we put all friends general practitioners proves ineffecrive fasily, or (45). - - per time or another 85 at cent of the one these together, differing questions gave this American of positive support to psychiatric treatment (144 people kind only=12). shifted from asklng people we the treatment of rn=nral about And, when asking fllness to the per- and severity of problem that a ro then kind characterize a psychiatrist, the same general impression before consulting son should have far the largest group in the emerges: per cent--feels that treat- 5y population--46 be without delay, before problems sought a chance to become ser- have should ment .) (Next highest=I1due course1'=18 sjmptons. first the occurrence of at ious, on the basis of facts like these I think it is the to say that fair So, American average adult knows illness can treated and knows that its mental that 5e facilities--psychiatr

3 -3- Quite the con- findin~s like these. Now certainly don't want to dismiss I . I just because they are important. them They cell us chat on started with trary, vital mental front--the task of mobilizing community facilities for one very health good treatmelt illness--there is already a mental measure of the more of effective say don't it 1 further be still probably can which public acceptance increased. but see I don't how we can deny say enthusiastic, don't it I is whole-hearted; is majority of the public now recognizes the need for treatment facilities that the however will, go along with expanded public programs in this area. and reluctantly, - it me that the mental health to aims at accomplishing a But, seems rnovement more than simply managing to do better what we now do good any case--to deal in a rate sufficient to cope with the ever-increasing case-load facilities increase at of to substantially the percentage increase recoveries among hospitalized or even And, when it cones to these more amtitious and long-run goals, the doing of cases. as a minimum, earlier case-finding and that done now--say, are routinely things not and detection, or, as a maximum, actual pre- earlier earlier referral treatnent health--the mental posicive praxotion of mental and data I've of vention illness are not: only irrelevant, but they are ~ost likely misleading. There a as cited is, "First, a famous old recipe for rabbit stew which begins, know, sure all I'm you rabbit." catch your when people say Now'the catch, a wirlia mental that person illness needs professional psychiatric care and ideally, treatment should be that, the same thing: they know some- is much soon as the first symptoms occur, sought as of thing cook a rabbit, if they ever encounter one, to they are not pre- how hut to recoznize one pared it bit thexi, much less to catch one. if ~'m tallcing loosely for a sober research report on a serlous problem, pretty our this but ,ne to the heart of does study, For, .even though 1've jusr given Erin$ you some results bearing on the ql~estion of whether people knows to do once they . know they have a case of mental illness to contend with, our primary focus of that has Seen that logically-prior questlon represented by the qualification, interest on In other words, have illness to a case with." deal of mental they they know Itonce been concerned with hoe people define for themselves we mental illness is, have what it from other fom,s 04 human Lehavior, how differs develops and how it is to how it recognized when it occurs. This is an area where be are dealing less with what we and it is here, in my judgment, to, facts know than what: belrefs t5ey adhere people from health as distiact, perhaps, education mental health action en- that mental its thorniest problers. counters stu2y let revlew for you briefly tte So results of this part of our me main and problems they highii~hc. Actaallp, each the bepn by aslcins the per- intervce:~ hear you "When asked, IJe what 2 mental illness. us for deecri5e to son meaat by that say soneone is 'mentally-ill, ' what does that nean to you?" Most person a tile Great ver5alizing at all ajout difficulty concept, but, with the people have of additionai questions like, "What f s a mentally-ill person like'?'' or "Eow he:p do a act?" or '?.lhar does a aerson person that tells you that he mentally-ill does mentally-Lll?t', almost everyone can, is af ulthately,be talk in terms led to and behaviors 3y which such per- traits characteristics of the mentally-ill or tile sons might recognized. 3e their it appears that just about half From descriptions, publLc equates mental illness with psychosis, although, of course, the people most they-speak being this term. But, generally, as of the mentally-ill never use would "insane, If "crazy , 'I "nuc L~, I' "out of their minds," and attribute to them such char- . irration- acteristics iinpulsi~eness, loss of control, extreme un?redictability, ss or such syaptoms as violent behavior, incomprehsible legal inco~petence; ality and talk, delusions or hallucinations.

4 initial reactions to the meanin% of For than half the public, slightly less illness include to the area of neuroses or to emotional and per- mental reference But disturbances, generally. sonality less extreme manifestations the of omission of the from mental concept illness of sewent pgblic cannot be larger the by the face value, however, for liken we ask, taken specifically, whether entirely at very whc everyone is "insane" or "out of mentall>-: mind, I' the majority answer is ill his The key term in this nonpsychotic mental illness syndrome "ne~ousness," is "No." is one in anothez, about two-thirds of the publ5c recognize the kind of way and, or -- of of self, and of relations conceptions with others that of disturbances mood, characterize personality disorders. sight, At it appears that a najority of the American public does first then, hand, Seti~een " on the one "insanity, 2nd "nervous conditions, " distinguish, roughly, meaning the If this conclusion were correct, public of of knowledge ocher. on the illness and of this term to human bel~avfor could be regarded as mental application that fact is, however, The though people professLonal approximating roughly usage. pinned down to this more inclusive definition of mental illness by explicit can be to encouraged That is, whenever people are they seldom it. stand by questioning, mental illness, without being talk for their definitions of the term, about pressed te&toO slip i:roPPa usage which they to their original spontaneous corresponds ---+ for ex~~mple, people will say that a of Thus, it identification wi'-,Fsy2hCFis-;- illness, Sreakdown" regarded as a nental be because a person can "nervous canzot a nervous breakdown withour being "out of have mind," even though he has just his people there are other nent21 ilinesses in addition to "insanity." said chat non-psychotic in mental illness, distin~uished the defining forms as those who, which, in contrast to the psychoses, are temporary and easily recosered from, c3n also assert a !'nervous breakdownn or some othgr-!llustrative form of behavior that cannot be mental illness because it is temporary and will be recovered regarded as from. 2 way, a similar sort of paradox different when people are asked In a emerEes their concepts of nental illness to to series of descrrptions of six per- apply a descriptions help of psychiatrists, we developed the of a paranoid, a With sons. schizophrenic, an anxiety neurotic, an alcoholic, a campulsive-phobic per- simple To give you some idea of and an instance of childhood behavior dlsorder. sonality quality of descriptions, let me read one of then: the these of to a certain kind describe person and aslc Now I'd like a few questions about him.. .I you thinking of a mzn--let 's call 'm hi=? Jones--1-rho Frank very he doesn't trust any3ody, suspicious; is be's sure and everybody Is agacnst him. Sometimes he thinks that that people he sees on the street are taliiing a2out hLm or follow- ing hi^ around. he has beaten up men who couple of now, A tLmes that he t5ou~ht they-were plotting even know because didn't him, him. against curse he bqan to The his wife terribly; nizht, at5er he then her and threatened to kill her, because, he said, she was hit workin~ him, too, just like everyone else. a~ainst described, were people asked to indicate whether anything each For of persons the whether ~ironi, what was wronz, that could have caused whatever was wrong, and was or should not ke regarded as mentally-ill. the psrson should Well, when stop people talking the abstract, in whom come to individuals, in and they can often per- down ceive tendencies thzt they see In themselves and others, there is a remarlcable in-- ability--or recoznize nental illness, Of the six persons des- un~~illl~gness--to cri5ed, only the most extreme one--the paranoid--is diagnosed as mentally ill by -1

5 here may interest 70u. The exact figures anything public. like of the the rnalority They are: Par 5% 2no: 7 d schizophrenic Simple 34 29 Alcoholic Anxiety 18 neurotic child Disturbed 14 Compulsive-phobFc 7 person we described corresponded rgther closely Even the images when the with illness people had given us, the tendencjr that: for these same people mental of was out for reasons why that hypothetical person should not be classified to reach rather to mentally-ill, accept the implications of their original defini- as than "nervous"--tense, instance, the anxiety neurotcc as described amicus, For we tlons. irritable and this was, of course, the exact characterlzatioo of a 2nd insecure, when Well, illness mental non-psycb~tfc ~r7hiclz eiven us. many pecple hzd previously anxiety only take who described this kind of the syndrome as mental ill- we people -. we still find only 20 per cenc of them sayin2 that our particular instance of ness, is mentally (vs, 15). anxiety neurosis ill people then, a situation in which have genzra1I.y started by effect, In we there are all kinds and deerees of mental iXLness and ended by denying saying r5at failir~g to that anythfng short of the most extreme manifestations is or reco@.ze an illness. we iook at our data for mental explanation of why this should a W:~en be to not is it that we firmly believe that parenthetically, be let (and say, me explailed as stupidity or any mass drsmissing epithet), human capriciousness, such that there are we number of principles people --. rely on in trying to decide find a Their not a pakticular person's behavior represenrs mental illness. whether or self-control nature centers around t5e point of rationality, at this discussion normalcy, generally, with some side excursions into such questtons as the dif- and Since tine is short, 1 will hew to between the physical sad the mental. ference , the line in t3is presentation. main practice, people it clear that they do not generally regard behavior fn mske First of obtain. three interrelated conditions iilness, of ualess proof as nental look for a Lreakdown of inrellecr, all, they complete of cognirive loss an almost so, in a loss or, reason. And short, in explaining why a particu- function in^ of exanpie is not mentally ill, they frequently say things lar "A lot of people Like, who nervous, their minds are as good as :bey ever was1' or "She lcnows what she are doing, as her @.i. c2n1t be affected.': Second, people expect, almost is a nec- so cansequence rationality, this loss of essary that the behavior called xental of self-co3tro1, must a serious loss of represent usually to the point of iilcess respon- Sein~ not of and certainly to the point dangerous violence others against for one's sible acts. say example is' mentally-ill because 'Ye isn't peo~le ar- Here of himself" in hecause ''~ie's getring danzerous for the people who lfve control or him," QT someone with is not mentally-ill because "He isn't doing things he else shouldn't: doing" or because "Be isn't really out of be could stop acting control--he that way if he wanted to.'' Finally, people feel that, to qualify as mental Illness, behavior should be inappropriate--that is, reasonable nor expected under the par~icular cir- neither this in long person finds himself. What which amounts to Is that as the cuxstances as a person's behavtor can be viewed as logical, mottvated or determined, people fegl can they understand it, especially if it is an expected, predictable way of this behaving a particular sitrration. And in is so largely the-dornizant vies~ of

6 assume, rational, find tend to and look for that people the hman behavior, roots of Perhaps a few examples of understandable causes behavior. even deviant extrenely to help 1 mean. Talce, for instance, the paranoid whom we des- clarify will what cribed violently quite hostilely and acting. toward distrustful as suspicious, and way of accounting for sach a person is to at that assume frequent others: the most of life has genuinely been some.time victim he injustice, persecution or his in a which his reaction was, at that tine, at Least, a logical, under- to mistreatment Or response. girl, who is described as withdratm and the standable schizophrenic Either to as not conditioned perceived sociability. always is apathetic, almost did not teach her to Like people, failed her -L'prrs'nll this rather Lacliward parents to activities to coxnteract her withdrarjin~ tendency, or for one child into social else another, Limited her socizl contacts; or or it must 5e that reason severely about her--her appearance, talents or personality--ied to rejections and something Or, take the girl G~O in to avoid them. taught relations, which rebuffs her social described as cbeclcin~ her gas and door and phobically avoiding ele- is compulsLvely vators: almost by only be explained beha-~ior referring to exper- always, can her involved these elements--she has learned this behavior from experiences iences which fires, elevator in accidents. - thefts, thin^ kinds all these eqlanatfons, as i~eL1 as-other significant The about or attribute to willful miscond~ct behavior to physical illness, which problexatic in- that they represent people's usual attempts to make rhe behavior of others is - to thenselves. And, es Lone telligible the.behavior can be made intelligible, as .J not illness. re~ard it as mental to So, people frequently say is tendency the else anything of think that csn't I because mentally-ill, F.US be like, "IZe thin~s make hi3 ac,t like that" or "it doesn't have to would mental illness--it might be just be his parenrs didn't raise him right." - Now, all 05 this, 1 am sure, has a most famrliar sound to all of you, and not It of is, giving this kind have talk I of been just because now. for years several man the of rcoral norms and premises about set and his nature that course, about same of our legal codes, governLng who shall be held responsible and pun- all underlies ished acts a2d who shall be exempt for his by of insaniry. punishment reason from other words, it Or, an expression of an internally-consistent, rather well- in is hurzan view of deeply nature and of human conzuct t5at is norally-grolmded organized, in en~rained {Jestern civilization. Accordiz~ to man, rationality and the of to exercise self- this view ability control are it basically qualities. Prom this, human follows that the cent~al, the he is rational, person to control himself and is responsible for his able and acts, his are reasonable--appropriate to the circui;?srances In which he acts Given the intelligible to others in and light of those circursstances. finds hinselE this view of normalcy, it follows quite consistently tl-,at: if nental illness repre- sents the of noxalcy or its opposite, it must necessarily turn out to be a loss extreme form psychosis. rather of orientation, this Given Follows that mental ft is a very threat- also illaess fearful thing and not an idea to be entertained lizhtly about anyone. Emo- ening, it tionally, to people loss of what they consider to be the distinctively rspresents a is free will, and there and kind of horror in de- rationality qualities human of humanization. As both our data and other studies make clear, mental illness is somethins that want to keep as far from themselves as possible. 1 would par- peo~le John done attention to a study being your under the direction of Dr. ticularly call A. CZausen of Nil31 which, as one of its phases, examines the process by which the wives to mental patients actually came hospitalized define their husbands as of ill. mentally Much more than our stories about hypothetical people can, his results

7 . * .-. t .,. -7- the to conclude that the hus5andts behavkr must extrene underscore reluctance the mental ex~lanations which these wives clusg signify many illness, alternative denial they at as tenable, and the way this were can, in extrene in- long as to all throughout the perfod stances, hospitaiLzatios. perslst even of our the very fact: that so many people recognize the need for As data, for cited care psychotics--a fact which I for earlfer in a to professional facilities contest--is at the sarr.e time an expression more thFs desire to disassoci- positive of themselves ate illness. mental to say, the typical psychotic patient That from is the (69+6?) of American public and, nore by than tiio-thirds dangerous as viewed is treatment, for considerations of for about the same proportion more reason than this feel that interesting thing is that The institutionalized. should be psychotics nake psychotlcs what it is they ne2n when they say people are dan~erous, when clear exclusively thinking out thsy are not primarily or that in terms of physical it turns more expressions are, frequently, people there what through Running violence. say, the kfnd ansiety generated in people when they are forced to deal with persons of of lost rheir hurnan qualities, persons who have crucially neither can be'r-avior whose controlled by the means be are applied in every-day interperson- understood or which al relationships. over "danger" the element of and is described in Over again, the responsible person's being unpredictable, irrational, and not of terns psychotic acts. his 'for dangerous, not so much because Ee his overt acts, but because-- is of quote some typical responses--"You to know they never are going to do" or "They what do anything," this very uncertainty constitutes the real threat. mip,ht an2 very sense, a In real too, view a people illness as irre~ediable, psychotic despite the that, as I indicated earl:er, most people say psychotics get becter fact again. Gut, look at it: more closely, the most frequent position is that, when,we only In fact, Setter again, they cari never tbaugh be the sane. they gst can again a of the kmerlcan people believe third psychotics can generally recover again that per a point where they will show no sips of their former illness, whereas 37 to cent that most will always sSoa signs of the illness. believe last group, (This is course, the 11 per cent who do not beleeve any degree of recovery ~XCLUS~V~ of of who, possible definitLon, would also feel is by and to show continued that they signs of illness. 19 per cent of the public are in varying stages of The rernai~ing or, about is usually possible at all r5coverp doubt whether so, to what extent.) if failed to ask e:

8 Again, in own words, "The very thought of their havin~ been insane would people's be with I'd always be thinlcinz about it and feel I had to TJe cautious always me, not might IZ~'d be careful Or, to say anything that I or do." anything rnieht in say her." irritate disturb or 38 per cent of the public deny that a1:hough some And, respond 15 this, oaly would per cent: believe that freedom from lllce they personally be typical of the general public. would reactions such thinc of sort the suppose, I is, toward attitudes of complex This psychosis Certainly, the when they talk about a kind of atavistic fear. people have in mind Take, for can rational considerations we set uncover. beyond of go attitudes any who said that most psychotics can recover completely with no signs instance, people former and their that most psychotics aren't dan~erous in any sense, even of illless ill. when this it be tSat two-fifths of Then group still feel the saae should why hesitancy, and disconfort at the idea of associating with a3 ex-patient that 1 fear have just described? is true this fisure is a good deal loner than that for It that is extreme population--people who Selieve recovery the generally impos- the other of and that psychotics are usa~lly dangerous--where the &istrust of the ex-patient sible --. be as a reasonable outcome of beliefs that he is not really or ~ikolly viewed might still Bgt there remains the question of what wken ill (79). cured dan~erous is and the people who say nothing about psychosis that mizht explain their fears of bothers the ex-patient. is just evidence of such paradoxes as these which lead us to It the a to ints the totality of the many different feel of data we have all po~ that Icinds very basic and widespread fear, however btlried-it nay be--a fear ?b each individual in that too may be oversvl~elmrd by irrationality--and a consequent withdrawal fron he avoidance any thin^ that activates that fear. and of '~~ *** - -. this leaves us today 5s Where like this: on the one hand, there so~ething is an old, socially-sanctloned, well-established of views which suppcrts the set of rnestal only with violent, e:ctrer,e psychosis and, within illness identification conzzxt of this ideas, more catastro- less as the ultimate emerges nen:al or illness befall a hwan beins. can phe that the orienration people are using when ThLs Is with they think abo~ct other individaals or human behav5or senerally and deal or On they to the term ~en~al illness. einotionally the other hand; ours when respond a literate, educated population, and they have encountered in tke various channels fs inforraation rather of diffezent polnt of view. dccordtng to this doctrine, and a of is as a fact rather than as a pofnr of view, all manner presented it usually emotional within the eeneral category beLong mental illness. disturbances of So, we ask peopla to cocsider abstractly acd when the question of just i~tellectually, what illness is supposed to cover, it is this modern definition that they mental give us. of are, other words, in a We in transition in which the modern period anythine of mental. illness has been rather widely dLsseminated without deftnition like equal acceptance of c5e point of view about the nature of mental illness an back about of human personality and hehzvior which lies roots of this usage and the the term. of is a definition which people simpljt cannot work wirh in It practice within con2e:rt of their fundar.enta1 beliefs about: >-ma behavior. Most people the definition simply to; once having stated the try in answer to our questioning, don't who people The to their more fami'LFar way of thinking. revert thereafter they olm try dilerxnas reconcile the two usually end up with some do and ardc~~ard compro- to mises; for instance, mental. -most_-comon is --to assume ttie reconciliation illness that --.__- _- -- - is also a tern referring to a variety ofcharacter defects--that is, to disapproved ncrally behavior the indivtdual is held which responsible. People who arrive fur at this posiCion say rhings like, "1 wouldn't say he is mentally-ill because maybe that" the fellow can't help being liZce poor or "He could overcome those feelines if

9 -. .,+ " v* , ' .I' . c, * 19- * lets nust be wanted illness when he so them get hi= down," This, he to it a mental room for the neuroses and other 'emotional disorders within the course, of makes mental 'Jut it in no way illness, the essentially =oral approach of chaqes category then which activates most people's inability to assimilate them fully to the :' to mental of illness. ',category >-- program lateness of the hour view the of that still is to follow, In the and take the tine to expand that rather cursory reference to the public's image I won't non-psychotic disorders, imzge exists whether q~ not people agree that which of Nsither anything am I goin2 to try to say be called mental illness. shoilld they that about status of psychiatry, another topic popular our study attempts all the at I do want to take a last minute to to two final points, however. cover. make . all, I dcnrt want to leave you of ?he iqression that a solid and First with wnll of opiniso exlsts. 0';viously we are suffering from an embarrass- unbreec5nble as evcdenced by our difficulties in orzanizing the of study, ment this riches in prese~tatian p;blication, in a relarively brief and, like this, I've materials for had to be stringently selective. But, if, in place of the topic of "IJhat, the Public - instead on ''IJho Thinks What," there would have I had been asked to commeat Thinics," been a different picture placed before you. Ours is a complicared, hetero- somewhat society--groups differ--etc. in emphasizing as I have the dominant geneous So, thoqht, lost optnions, main tendencies, I hope you have not of . majorlty modes It is In the deviant, from were far the unanimous. of ,sight that all of these fact usuaL1y that the bezinnlngs of change are signs seen, and these ',minority thinicing report cl?_ange if I hzd time to there, of are then. - ...-& \ must we brings me to n17 final all 1 think that point, this an3 Nevertheless, the that when we talk soberly recognize loni-iun aims of mental health edu- about cation, we are talking ahout bringing aEout a veritabie revolution in people's ideas and This kind of change can occur, I am cer- questions. about fundmental some very only would I defeat. or dgubt of councils offer to toda;? here not despair, tainly that f-~ndamenral chznges sre slovly and painfully achieved; usually far too suggest ' Perhaps by facing the people who are laEorinz to kin2 them about. slowly to satisfy be squarely of rhe task, we will all enorniry izare proud of, or, at the very the least, less disappointed and disillusioned by the relatively small changes that can or be in any one year achieved even five. (Thank you. )

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