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The Quandary of
Mental Illness as Stigma

Written by Kathi Stringer

August 20, 2003

Can the phrase ‘mental illness’ be de-stigmatized? We have seen the natural progression that “mental illness” equates to “mental sickness,” and sickness when associated with ‘mental’ is instantly stigmatized and can immediately become an insult, “Man, you are one SICK puppy!” Now we see the dilemma, how can the mentally ill distance themselves from “the SICK puppies?” They can’t. Not until they distance themselves from the word “sick.” History offers an import lesson on this futile effort. Before I discuss this further, let us examine the natural flow of the early generational views of language as the decades sailed by.

Idiot. What if people began wearing a button that said, “Stop the stigma of being an Idiot?” And, what if there was a massive organized movement that exposed the film industry and contemporary literature as agents that are stigmatizing the mentally challenged individual with the inappropriate use of “idiot” as a demeaning adjective? Suppose the mission of the organization was to de-stigmatize the idiot, the imbecile and the moron. Do you think a movement like this could be successful? Could ‘idiot’ be clarified and resigned it’s original meaning without insulting the mentally challenged with a renewed association that was lost over time? Further, would be possible that the mentally challenged and their loved ones would embrace such a crusade? Or rather, it would be likely they would try and put distance between the word and its meaning? Before answering these questions, lets examine the formation of stigma.

In 1940 it was proper to refer to the “mental deficient” as the idiot, the imbecile and the moron. A textbook titled “Psychiatry for Nurses” by Karnosh and Gage (1940) carefully instructs the student the correct classifications that have evolved into today’s insult. Below is a direct quote from Psychiatry of Nurses (1940 - p. 237.)

“Types of Mental Deficiency

Idiot
The idiot is one whose mental capacity is below the third-year level; they are clumsy, awkward, untidy and require constant supervision in the performance of the simplest requirement of living. Most idiots learn a few simple words but rarely learn to talk intelligently.

Imbecile
The imbecile may attain a mental level of six or seven years. Imbeciles can generally talk with a very crude vocabulary, can be taught simple manual tasks.

Moron
The moron ranges in mental accomplishment between the eighty-year level and the lower adult normal which is ordinarily reached at about the fifteenth year. Constituting more than 80 percent of all forms of mental defect, the morons are one of the serious problems of modern times. Having no gross physical defects, they present themselves as a shiftless, unstable group which gravitates to the lowest level of manual labor and social activity. Out of this class are the recruited, the petty criminal, the prostitute, and the ne’er-do-well.”

In 1940 the idiot, the imbecile and the moron were terms that were classifications, and were not meant to stigmatize the individual. However, through the generational shift these terms were adapted as an insult to the “normal” public that did not apply themselves, or to basically devalue a person. The terms became so stigmatized that the mentally challenged and their loved ones divorced themselves from these expressions and advocated they are not politically correct. With effort, a new association emerged away from the idiot, imbecile and moron, and mental retardation (mild, moderate and severe) replaced the classification of these stigmatizing terms.

This is an important paradigm to examine when facing the prospect of destigmatizing a word imbued with devaluation. For example, the post idiots, imbeciles and morons did not wear a button stating, “I’m proud to be an idiot” or “Stop the stigma of idiots.” They did not rally in masses at public parks, or stop people on the streets to explain that they are ‘idiots’ and educate the public that they are harmless. Rather, they removed themselves from any association of the words, and quickly. Now shifting from the idiot to mentally ill, how is it possible to reassign a new meaning that is politically correct for the mentally ill? How will the mentally ill divorce themselves from the ‘sick puppies?” I suggest these questions are certainly worth considering since the mentally challenged used considerable intelligence to walk away from heavily stigmatized labels. The question now is, “Can the mentally ill do the same?” How much money and energy will be invested until we look for other less stigmatized terms? Consider the difference: “I am mentally ill” or “I have a chemical imbalance.”

Stigma Soup
The chef that cooked up ‘mentally ill’ managed to make it a concoction that encompassed the reach of every synaptic threat against mankind, financially or dangerously. For example, the severely depressed is in the same stew as the pathological serial killer. We may see on the news wire, “A mentally ill pathological serial killer was found and arrested today in the wake of dozens of roadside murders” and in the same breath “…and in another local city a mentally ill woman perched high on a bridge stalled traffic until a crisis team was able to calm her and talk her down.” The viewer of course, is introduced to the impression that the mentally ill is in the same pot as the poisoned serial killer. And, according to the “Diagnostic and Statistical Manual of Mental Disorders” (DSM), the psychiatrist handbook for assessments, that would be correct.

Physical Illness
Physical illnesses are usually addressed as a ‘medical’ problem and respectfully accepted as scientific in nature. These illnesses include cancer, cardiovascular complications and diabetes. There is much less stigma associated with physical illness. For example, we do not usually hear, “A physically ill serial killer was arrested today…” A physical illness tends to generate empathy and understanding rather than caution and avoidance.

Personality Disorders (not to be confused with deranged)
This is another interesting and confusing label. ‘Disordered’ suggests a defective personality structure at birth, when in fact may be very much ‘ordered’ in direct relation to the environment. I am suggesting the environment was disordered and the personality adapted to survive (effective). For every environmental ZIG, the surviving personality had to adapt and ZAG. The weaker and non-adaptive personalities (disordered) perished.

Authors and theorists, Otto Kernberg M.D. and Vamik Volkan M.D., to their credit realized the stigma of ‘disorder’ and referred to the DSM’s Borderline Personality Disorder (BPD) as Borderline Personality Organization. This rings appropriate since the personality had to ‘organize’ defenses to survive. Those defenses are largely the result of a healthy response based on available and age appropriate resources at the time. The personality that is actually ‘highly ordered’ as a survival defense, is now stigmatized as disordered and lumped in with the serial killers as ‘mental illness.’ This categorical approach appears to put surviving personality as risk for stigma – a failure based approach.

Another interesting contradiction is that “Post-Traumatic Stress Disorder” (PTSD) is NOT viewed as a personality disorder but for the most part as a ‘natural’ and accepted response to a harmful environment, UNLIKE the closely related and stigma tagged survivor diagnosed with Borderline Personality Disorder.

DSM & Mental Illness
It is interesting that ‘mental doctors,’ authors of the 943-page handbook titled “Diagnostic and Statistical Manual of Mental Disorders” were also ambivalent about the book’s title. They anticipated that the word ‘mental’ could have far reaching implications and this dilemma perplexed them as well. Yet, for the lack of more suitable word, ‘mental’ was adapted into the book’s official title.

The adaptation of ‘mental’ is problematic because the brain is an organ (physical), and the mind (mental) is a complex of psych structures that are developed through life experiences. The brain is an organ with tissue as are other organs within the body. A statement that suggests the ‘brain’ is the ‘mind’ muddies the waters. Mental illness invites stigma that arises when the depressed individual (physical brain illness) is lumped into the serial killer psychopath (mental derangement). Is it any wonder the prefix “mental” is alarming?

Until advocates for the chemical imbalanced, i.e. bipolar, depression and schizophrenia (brain diseases) take a hard look at what is getting thrown into the same mixing pot with the (serial killers and child molesters), there is little or no chance to lift the stigma around “mental illness” as a brain disease. This is similar to a metaphor of mixing a few drops of red food coloring (serial killers) into a pot of water. The entire lot is now ‘colored’ as the mentally deranged. For example, it is highly unlikely that most parents would feel comfortable living next to a ‘mental’ person that is identified in the same line-up as the child molester.

Seventy-five years ago it was perfectly acceptable for a straight man to say, “I feel so gay today!” However, not likely nowadays!

Perhaps until there is a hard look at exploitation of ‘mental’ (DSM) that blankets across diseased brains, (dis)organized minds AND deranged minds, the stigma will remain.

Perhaps “mental” people and their advocates could learn a lot from the idiot, the imbecile and the moron. Only time will tell.

References:

Psychiatry for Nurses” by Karnosh and Gage (1940 - p. 237.)

Diagnostic and Statistical Manual of Mental Disorders – DSM-IV-TR

Borderline Conditions and Pathological Narcissism – Otto Kernberg M.D.

Six Steps in the Treatment of Borderline Personality Organization – Vamik Volkan

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