Tetrahedron Letters 46 (2005) 5559–5562Muneo Shoji,a Kaoru Shiohara,a Masato Oikawa,a Ryuichi Sakaib and Makoto Sasakia,*aGraduate School of Life Sciences, Tohoku University, Tsutsumidori-amamiya, Aoba-ku, Sendai 981-8555, JapanbSchool of Fisheries Science, Kitasato University, Sanriku-cho, Iwate 022-0100, JapanReceived 4 April 2005; revised 6 June 2005; accepted 8 June 2005Abstract—Syn
Psr.jku.atPapers on Social Representations
Textes sur les représentations sociales
Volume 10, pages 3.1-3.18 (2001)
Peer Reviewed Online Journal
2001 The Authors
Unification and differentiation: a study of the
social representations of mental illness
Using the theory of social representations, this small-scale, qualitativestudy considers whether mental illness is differentiated by a laypopulation. Three focus groups (total n=17), using students were conductedand content analysed, along with a random sample of articles from twoBritish newspapers, ‘The Mirror’ and ‘The Daily Telegraph’. A strongsocial representation of unified ‘mental illness’ was found, with the centralaspects of unpredictability, permanency, violence and Otherness. However,differentiation of mental illness in social representation was also found,both along biomedical lines, and through the idea of a set of continuabetween the more normal and the more mentally ill. It will be suggestedthat differentiation occurs in today’s society due to efforts to maintain bothexisting ideology and a positive identity, but that any condition that can belabelled ‘mental illness’ will also be inevitably associated with the unifiedrepresentation of mental illness, limiting the effect of this differentiation.
It will be concluded that differentiation of mental illness has been somewhatoverlooked in social representations studies, and merits further attentionfrom a theoretical perspective.
1 This paper draws on work undertaken during an MSc degree at the London School of Economics, funded by the Economic and Social Research Council. The author is now working on the social representations ofmental illness held by people who use mental health services, and would like to thank Dr SandraJovchelovitch, Dr Gerard Duveen and two anonymous reviewers for their input to this paper.
J. Foster, Unification and Differentiation Introduction
This paper discusses the results of a small-scale study investigating differentiation in social representations of mental illness in a student population.
Public understanding of mental illness has been considered from a variety of perspectives, including attitude/public opinion work (Johannsen 1969; Maclean 1969; Rabkin 1972;Crocetti, Spiro et al. 1974; Rabkin 1974; MORI 1979), ‘lay beliefs’ (Rippere 1977; Rippere1981; Furnham 1984; Furnham and Rees 1988), geneology (Foucault 1961/1995), and socialrepresentations theory (De Rosa 1987; Räty 1990; Jodelet 1991; Rose 1996). The majority ofthese studies conclude that mental illness is viewed extremely negatively, and the mentally illseen as violent, unpredictable and irrevocably"Other” (Nunnally 1961; Maclean 1969; Miles1987; Gilman 1988; Jodelet 1991; Rose 1996). These negative attitudes appear both strong,and historically tenacious (Sarbin and Mancuso 1970; Rabkin 1974; Hall, Brockington et al.
One question, however, that has been somewhat overlooked is that of differentiation in understandings of mental illness amongst the general public: is mental illness regarded as onegeneric category, or is it divided into different conditions? Secondly, if there isdifferentiation, does this parallel medical thinking, or other lines of lay knowledge? Several factors point to the existence of differentiation in public understanding of mental Firstly, previous research in different areas has found evidence of differentiation. Nunnally (1961) found that neurotics were seen as weaker, and psychotics were liked less; Jodelet's(1991) villagers divided their lodgers from a local mental hospital into five types, from thechild-like ‘innocent’, born with mental illness, to the ‘crackpot’, a more recent criminalphenomenon; using multi-dimensional scaling, Stockdale and Purkhardt (1993) found thatmental illness was divided into four distinct groups in public representation – anxiety,depression and paranoia were significantly separated from Multiple Personality Disorder(MPD), schizophrenia and psychopathy, for example. Some theorists seem to presuppose theexistence of differentiation from the outset, and pre-divide mental illness themselves in theirresearch, usually into its medical categories: such studies have found that the public appear tohave more negative attitudes if asked about schizophrenia (Appleby and Wessley 1988;Furnham and Rees 1988) than about depression (Rippere 1977; Rippere 1981).
Secondly, professional understanding of mental illness is highly differentiated, as shown by diagnostic manuals (World Health Organisation 1993; American Psychiatric Association1994) and textbooks on psychiatry (Gelder 1983) and psychology (Davison and Neale 1994).
Research into professional social representations supports this: Morant (1995; 1996) foundthat mental health professionals divide mental illness into more understandable neurosis andmore incomprehensible psychosis.
Lastly, other areas of health are differentiated in public understanding, as both studies using social representations theory (e.g. Joffe 1995; 1996 on HIV), and other studies (Sontag1978, on cancer and TB) show. If health can be differentiated in public understanding, canmental health? Using the theory of social representations
Social representations theory was employed in this study for several reasons: firstly, there is a strong tradition of work using the theory in the area of mental illness, as shown by thestudies cited above. There have, of course, also been substantial contributions from other J. Foster, Unification and Differentiation areas, such as attitude theory, but such a perspective is too static (Moscovici 1963), and failsto give sufficient access to meaning.
Access to meaning is particularly important in the current study: as the brief review of the literature above indicates, it appears that people might differentiate on some level in theirrepresentations of mental illness, but it is much less clear how this differentiation mightmanifest itself, or why it might exist. Social representations theory, with its emphasis onprocess and content, allows closer consideration of this topic from an interpretivistperspective, in a way in which other theories of knowledge or attitudes might not.
Similarly, social representations theory provides a useful forum for examining the development of everyday knowledge of mental illness: Moscovici (1984) describes howscientific knowledge enters the everyday domain: might the differentiation found inpsychiatric professionals’ representations of mental illness have influenced publicrepresentations? If so, how has it been transformed from professional to publicrepresentation? Individuals and groups do not passively encode and mirror therepresentations held by other groups, but actively work through them, changing them as theydo (Jovchelovitch 1997). Unlike many other theories of lay knowledge, socialrepresentations theory refuses to privilege one representation over another, or to seedifferences as the results of error or bias. This is crucial when examining issues such asmental illness, where a significant power differential exists between groups holdingrepresentations: psychiatric knowledge occupies a position of considerable power, in thatpsychiatrists are granted the power to define the normal and the abnormal (Morant 1998). Atheory of knowledge which allows for the existence of other forms of knowledge, and doesnot judge these against one another is essential: participants must feel free to express ideasother than ‘accepted’ medical versions. In parallel, however, social representations theoryallows acknowledgement of the ontological aspects of representation: historical analyses ofbeliefs about mental illness (for example, Foucault (1961/1995), demonstrate the weight ofenduring and negative images of mental illness on individuals and groups through the ages.
Lastly, it has been argued (Rose 1996; Rose 1998) that mental illness represents a failure to familiarise the unfamiliar in representation: mental illness remains feared, and may thereforebe familiarised as unfamiliar (Morant 1996). Considering whether mental illness isdifferentiated in representation might begin to add to this debate. Do we fail to familiarisemental illness in our representation, or is it possible that some aspects of mental illness mightbe familiarised more than others? Methodology
Two methods were employed in this study, focus group interviewing and media content analysis, in an attempt to triangulate the data through accessing different perspectives (Flick1992), and to access representations operating at the microgenetic level through conversationand at the sociogenetic level through the media (Duveen and Lloyd 1990).
Focus groups were chosen over individual interviews in that, as a social situation, they are often more appropriate for studying the social phenomenon of social representations (Farr1993; Livingstone and Lunt 1996). Three focus groups (n=17) were held with different typesof undergraduate student. The first focus group comprised students from a London dramacollege, none of whom had any background in psychology; the second was held at an EastAnglian University, and comprised students taking an introductory course in psychology; the J. Foster, Unification and Differentiation final group was held at a London University, and was made up of students taking their FinalExams in Psychology. All students were contacted through posters advertising the project, orthrough word-of-mouth. These groups were chosen to examine the possibility of the diffusionof professional representations into public representations. Zani (1993) suggests thatpsychology students maintain less social distance between themselves and the mentally illthan other students: could psychology students be considered akin to amateur scientists,diffusing aspects of professional knowledge into the public? At each group I employed a flexible question guide that moved from the general to the specific (see appendix1): I was concerned not to explicitly ask about differentiation, as I feltthat this would influence the results. Questions were asked about ‘mental illness’ in general,as in other studies in this area (Jodelet 1991; Morant 1996), after which a series of cards wereintroduced (see appendix2). Vignettes have been employed very successfully in muchresearch into mental health (Cumming and Cumming 1957; Brockington, Hall et al. 1993),including some that employs social representations theory (Wagner et al 1999). The cardsfeatured pieces of information that one might find in a volume such as DSM-IV (AmericanPsychiatric Association 1994), but each was contestable, and non-gender specific.
Participants were invited to discuss their reactions to the cards, such as whether they mightdescribe someone with mental illness.
Two British newspapers were chosen for content analysis purposes: one tabloid, ‘The Mirror’, and one broadsheet, ‘The Daily Telegraph’. ‘The Mirror’ is traditionally a moreworking-class, left-wing newspaper, which drew a readership of 6 million in 1996-1997(Matheson and Pullinger, 1999), while ‘The Daily Telegraph’ was the best-selling broadsheetin 1996-1997, with a readership of 2 million (Matheson and Pullinger, 1999), and traditionallyattracts a higher class, more right-wing reader.
For the period 28.1.96 - 28.1.98, an FTProfile search for articles referring to mental illness yielded 61 items for ‘The Mirror’ and 160 items for ‘The Daily Telegraph’2. Arandom number generator selected a sample of 25% of the articles from each newspaper,leaving 16 articles from ‘The Mirror’ and 40 articles from ‘The Daily Telegraph’.
The focus groups were transcribed, and read many times along with the sample of articles.
All data was entered into the NUD*IST computer-aided qualitative data analysis program,and coded into themes: the ‘tree structure’ that NUD*IST allows the researcher to developwas useful here, as data was coded into the conditions mentioned, including generic ‘mentalillness’ (the root), and the causes, effects, consequences and miscellaneous details (branches)referred to for each condition. This coding frame broadly follows the categories of Leventhaland Benyamini's (1997) individualistic illness representations theory (identity of illness,causes, consequences, timeline and curability), but was employed flexibly. Text that did notfit these categories was also coded into more data-driven coding units, such as humour,thereby allowing unexpected elements to emerge from the data. A sample of the data wasrecoded at a later date to ensure that coding had been performed consistently. The results 2 It should be noted that this difference in volume of articles on mental illness between the tabloid and the broadsheet does not seem typical: ‘The Daily Mail’, another tabloid, for example, contained 177 articles onmental illness within the same time frame J. Foster, Unification and Differentiation were then compared across focus groups and newspapers, and the similarities and differencesnoted.
Although there were some interesting differences, it was the similarities across groups and between newspapers that were more striking, and it is on this aspect that the remainder of thispaper will focus.
Mental illness and mental illnesses
The data indicated the existence of a strong social representation of ‘mental illness’, featuring violence, unpredictability and Otherness. However, differentiated representations of‘mental illnesses’ also exist, both along medical lines and along other lines of understanding.
Despite this differentiation, however, anything that can be linked to mental illness (e.g.
depression, anxiety, autism), however much discussion or argument this linkage may entail,will also be connected with the general social representation of mental illness. All mentalillnesses are therefore seen as having the potential to lead to unpredictable, incomprehensibleviolence.
"A53:‘But even though these people are not a danger to anyone but themselves,because we don't know exactly what's going on in their brain, we don't knowexactly what's going to happen. They might flip out and do something bizarre,because you can't quantify what's going on in their heads’.” This sub-text of unpredictability, violence and Otherness is frequently reiterated, in focus groups and newspaper articles alike.
"B2: ‘But people are so afraid of reactions with people with mental illness, it's justthe unpredictability of it. And abnormal behaviour in social situations, and itworries people and makes them feel like, well, quite, scared, in some ways, Iguess. Just pre-empting reactions.’” "A recent report found that one murder is committed about every two weeks bymental patients and about 1,000 commit suicide each year” ‘The DailyTelegraph’ 17.1.98 In these cases, no specific mental illness is mentioned: the message is clear - all those linked to mental illness have the same threatening potential.
Aspects of the social representation of ‘mental illness’
I will now briefly examine some of the elements of this representation of generic ‘mental illness’, before considering further differentiation.
In focus groups and newspaper articles, mental illness was located squarely in the brain. It is therefore encased in a highly sensitive, visually inaccessible and impenetrable matter,making it somewhat mysterious.
“A4: ‘They all come from here [taps head] whether you deem it an illness,something which is negative, or .’ A8: ‘It comes from the brain and it's a disorder, illness.’" 3 A=non-psychology students; B=first year psychology students; C=psychology finalists.
J. Foster, Unification and Differentiation This parallels Jodelet’s (1991) findings, in which participants saw mental illness as stemming from a failure of the brain, which stops developing when the misfortune occurs.
Interestingly, the mystery surrounding the brain is expressed through focus group participants’ frequent avoidance of saying the words ‘brain’ or ‘mind’, here generally equatedwith one another, and their reliance on body language to convey implied meaning, as shownabove. The brain itself seems to be held in considerable awe.
Despite frequent discussion of the ‘nature/nurture’ debate, mental illness is commonly referred to as the result of a ‘chemical imbalance’ in the brain: mental illness is represented asthe result of usually harmonious chemicals or hormones becoming unsettled, affecting thebrain, and therefore the person whose brain it is.
"A3:‘Another word for mental then. Brain condition?’ A5:‘Cranial chemical imbalance.’ [Laughter]” [discussing possible different names for mental illness] However, assigning the cause of mental illness to a chemical imbalance does not necessarily imply that the cause is something wholly internal; this was especially apparentamongst the students with some familiarity with psychology. A chemical imbalance in thebody (and almost exclusively in the brain) could either be caused purely internally, throughgenes or hormones, or brought about through external, social factors, such as traumatic lifeevents.
"B5:‘But trauma doesn't mean it's not chemical, trauma can surely createchemicals.’” The modern day representation of mental illness as the result of an imbalance of chemicals seems to parallel the representation of the Eighteenth/Nineteenth centuries which inspired the‘moral management’ approach to madness. Rose (1985) states that during this time madnesswas associated with the ducts of the body, and the blood and humours carried within them.
Representations of the way in which medication works might be the modern-day equivalent ofrepresentations of the way in which cold baths worked on the humours in older societies, re-balancing the unbalanced and realigning the mis-aligned. However, social factors were also seen as playing an important role in causing mental illness: the interaction between physical and social factors is represented as a kind of‘tendency + trigger’ idea: mental illness is represented as being triggered by an event, oftensomething more social, such as bereavement, that activates a previously dormant tendencytoward mental illness. This can be used to explain why some people become mentally ill aftera traumatic event, and some do not. I believe that this is further evidence that mental illness issocially represented as ultimately biological in cause. Individuals are represented aspossessing some organic tendency, again, maybe hormonal or genetic, that predisposes themto particular reactions to certain social events, and consequently to becoming mentally ill.
"B5:‘But at the same time there are people who exhibit symptoms of a mentalillness after a painful life event, but, you know, another person could have thathappen to them the same, and the same illness wouldn't ensue, so I think there area lot of background factors and sort of chemistry.’ J. Foster, Unification and Differentiation B1:‘Not. that predetermine you, but that combined with the right kind of triggersmight affect you in that kind of way.’” "C3:‘I'd have to argue that there'd be physical underpinnings and physical effectsand causes at all stages, erm and obviously there are triggers in one's life.’” This parallels Morant’s (1996) findings of professional representations of the role of ‘resources for life’ in the causation of mental illness.
Contrary to De Rosa’s (1987) finding that children move from criminalised to medicalised representations of mental illness as they grow older, the adult participants in this studymaintained a strong sense that mental illness may be, to some extent, the choice orresponsibility of the person involved, something which co-exists in potential contradictionwith biological models of causation.
"B3:‘I mean, I've come across people who say that mental illness is an excuse, ordepression is an excuse, you know, just for being lazy or whatever.’” "A6:‘You know, like one day my mind just goes [clicks fingers], right, that's whatI'm doing because I can't handle reality. Is that genetic, or is it, you know, just likea way of dealing with things that society doesn't accept?’” What, then, are the consequences of the fact that mental illness is still, to some extent, and however implicitly, represented as the fault of the person concerned? Having a mental illnesscan entail guilt. An individual must have behaved in a certain way, or possessed certaintendencies that led to their particular predicament. Mental illness must therefore be hidden,and is viewed as potentially shaming. Mental illness must be concealed, as Goffman (1968)describes the concealment of potentially discrediting information, if stigma is to be avoided.
“B1:‘It can be very hard to get somebody to, kind of, explicitly confess to it.’” “B2:‘And there's also a feeling of shame associated with it as well. In some wayit's their fault that they're not normal.’” However, paradoxically, there is also a sense that being mentally ill absolves you from responsibility for yourself, your illness and your actions. This is particularly the case innewspaper reports of legal proceedings: crimes can be explained, even justified, if a diagnosisof mental illness is given. We need the explanation that mental illness provides in order tounderstand a variety of crimes, from rape and murder to corporate fraud, and for other formsof socially deviant behaviour.
"Israeli reports said he took a bus to Hebron yesterday morning and wanderedthrough the Jewish quarters before deciding to open fire on the Arab market.
Israel's Channel 2 television said he had a history of mental illness.” ‘The DailyTelegraph’ 2.1.97 "Muraglia, of Camden, who has a mental illness, and once bared her bum in court,was in cells yesterday after leaping the dock.” ‘The Mirror’ 31.7.97 "B3: ‘[T]here's people who will say at the slightest exhibition of any strangebehaviour, 'Oh, there must be some problem here.’’” Reports of criminal proceedings even routinely refer to the defendant’s mental health status when they are not diagnosed with any mental illness. This serves to link the idea of crime,especially violent crime, to mental illness even in cases where no link exists.
J. Foster, Unification and Differentiation If mental illness is caused by the combination of tendency and trigger, and is generally explainable by a chemical imbalance in the brain, how does the onset of mental illnessmanifest itself? How do people make familiar the highly unfamiliar concept of ‘going mad’?Some metaphors were used to describe this process, such as ‘flipping out’, ‘snapping’,flipping a coin, ‘switching off’, and the brain ‘overheating’, all of which imply that going madis a rapid, even violent event. However, I believe that here language begins to fail us in oursocial representations, and we become more reliant on other means of expression. De Rosa(1987) argues that the figurative element of social representations may be more social, andmore enduring, than the linguistic element: in this study focus group participants consistentlyemployed the same actions to denote the process of developing mental illness.
"B1:‘And a fear that she's always going to [clicks fingers] switch off, I mean thatwould always be my great fear, like you'd just never, you wouldn't feel totally incontrol.’” "A4:‘I mean, a schizophrenic cannot tell when that attack's going to come’ [clapshands]” "C1:‘But with manic depression you have to be like, .kerchow. you know.’” This reliance on non-verbal portrayals of ‘going mad’ might support those who argue that familiarising mental illness is difficult, certainly in terms of naming it.
However, mental illness is not represented as entirely negative: it is seen as occasionally leading to ‘extra’ qualities. Indeed, there was some discussion as to whether being ‘extra’talented might lead to a person developing mental illness in the first place. This idea, and themystery surrounding the brain, is illustrated in the following focus group extract.
"A5:‘Well, they say that we only tap into a certain percentage of our brains, of thebrain. Are these people born with a kind of mechanism that enables them to tapinto other areas of their brain? Because there isn't any scientific back-up to helpthese people in childhood, all this brain energy goes un-harnessed - where it kindof shoots off in all directions and because they don't know, there's no one elsearound them who has a similar sort of intellect, who can harness that type of brainpower.’” The media plays a significant role in propagating this representation of the genius of madness. Participants referred to cases they had seen on television of gifted artists etcetera.
Also during the data collection, the film ‘Shine’, the story of a gifted musician and his mentalhealth problems, was released, prompting much discussion of the link between genius andmadness in the press.
"The film has invested heavily in the 1960s' idea that the mentally ill may reallybe more sane than the rest of us. David Helfgott is portrayed as a 'Holy Fool',whose dormant genius survives the tyranny of his father and is revived by thelove of a good woman.” ‘The Daily Telegraph’ 11.2.97 This representation of the genius of madness is, again, something that can be found throughout history (Foucault 1961/1995; Porter 1987).
The above results all seem to provide support for the existing literature on representations of ‘mental illness’, but what of representations of ‘mental illnesses’? What evidence ofdifferentiation can be found in the data? J. Foster, Unification and Differentiation Differentiation
There was considerable evidence that mental illness is also differentiated, into mental illnesses in social representation. In this study, differentiated representations exist both alongmedical lines, and along other lines, specifically based around the idea of sets of continua.
It appears from the data collected in this study that a ‘hierarchy’ of mental illnesses has arisen within social representations (see figure 1). Morant (1996) found clear differentiation inprofessional social representations between psychosis and neurosis. In the present study, theseparation is not as explicit, probably because fewer lay people share the scientific definitionsof psychotic and neurotic, although they have passed into everyday language. In this project,participants made the distinction between what they termed ‘lower level’ and ‘higher level’mental illnesses FIGURE 1A hierarchy of mental illness.
Please note: too much differentiation was apparent to comprehensively present adiagram in two dimensional form. However, mental illnesses have been groupedtogether according to some similarities that emerged from the content analysis of focusgroups and media. The top right hand corner contains mental illnesses that are bothhigh level, and involve social deviance, whereas the top left hand corner involves lessdeviance. This deviance distinction is not made in the lower level mental illnesses.
J. Foster, Unification and Differentiation These two different types of mental illness were seen as having different characteristics Medical differentiation, therefore promotes significant differences between representations of lower and higher level mental illnesses in terms of their causation, effect, curability andtreatability, and location.
Characteristics of types of mental illness Violence, mainly to othersSocial deviance.
Often obvious in appearance.
NOT drugs (could just suppressissues).
Continua: lines of differentiation
However, medical knowledge does not exclusively account for differentiation of mental illness in representation. I believe that in representation mental illness is objectified using theimage of a continuum. People make sense of mental illness by imagining sets of variouscontinua, within which, I would argue, differentiation is implicit.
The most important continuum is that which relates to whether a person can be categorised as mentally ill or not. Any symptom, behaviour or lifestyle can be placed along thiscontinuum.
normality________________________________________mental illness Individuals, then, may exhibit certain symptoms, and not be mentally ill themselves, as they exhibit a more ‘diluted’, and therefore more normal form. This is especially the case forthose with ‘lower-level’ mental illnesses, but may also be relevant for elements associatedwith ‘higher-level’ mental illnesses.
"B4:‘I mean with all of them it's all, I mean, if it was a major degree ofunhappiness and then elation then its a kind of illness, but then if you just have asmall amount of it then it's kind of normal, so I suppose this means you have ascale, and then it becomes at one point it becomes too much for you, and then its amental illness.’” “A5:‘But what you do when you have a mental illness is that you're just takingsomething that we all normally do to an extreme.’” J. Foster, Unification and Differentiation “C1:‘Sometimes hears voices is a weird one, because don't you sometimes do thatwhen you think someone's called your name and they haven't?’” This makes some mental illnesses less irredeemably Other per se, and more a possibility The severity of a condition can be established according to its position on the following not harmful________________________________________harmful Some mental illnesses are not considered harmful.
“C3:‘I've got a friend who talks about good numbers and bad numbers,. there arecertain letters and certain things that were good and bad. I don't believe she'sever been diagnosed with any kind of illness or whatever, but I think, like, six wasa good number, and eight was a bad number. And the thing is, that is obviouslymental illness, but it's not, you don't have a problem with anything.’” It is therefore more difficult to classify what constitutes a mental illness at the ‘not harmful’ end of the continuum, as this blurs with what might be considered normal. As wereach the other end of the continuum, however, we are faced with a binary distinction,between mental illnesses that make people a danger to themselves, and those that make them adanger to society. A person may occupy both these positions: for example, a person withschizophrenia may be seen as both self-harming and violent towards others. A person withdepression, however, may be deemed ‘harmful to self’, a paedophile ‘harmful to society’.
“A6:‘Some of these people, they're a danger to themselves, they're not a danger tous.’” However, as discussed above, although some people seen as mentally ill are not considered an overt danger to others, the fact that they are still classed as mentally ill, and thereforeassociated with those who have the potential to be violent towards others, through theunification of mental illness in social representation, makes them too seem potentially violent.
Another set of continua relates to temporal aspects within mental illness. Firstly, what proportion of time does the individual feel symptoms associated with mental illness.
Some of the time_______________________________________All of the time Secondly, how long have they felt this way? For a short time______________________________________For a long time These continua seem to be particularly important in the differentiation of different types of "B4:‘And it's also what we were talking about, if it starts running your life in away, if, you know, you have this, not just all the time, but .’” "A2:‘But I'm not sure. A lot of people feel unhappy, but I think it's when it's allthe time…’” Similarly, the person can either have felt/behaved differently for a long or short time. The longer the condition continues, the more serious it is seen to be, just as the more of a person’slife a condition takes up, the more serious it is.
J. Foster, Unification and Differentiation "C3:‘Believes there is no point in continuing with life - has done for some timeand is thinking about doing something about it. There seems to be a temporalaspect to all of these.’” [discussing what would make each vignette seem moreuncontroversially ‘mental illness’] A continuum also exists regarding treatment.
Doesn’t have treatment___________________________Has treatment Mental illnesses that require, or are given, some form of treatment inspire more fear, especially if that treatment is drug-based.
"C1:‘But the fact that you know, if you know your friend's going through a badtime and you're worried about them, then you will look after them and that doesn'tscare you, but it's when it's labelled , and it's medicalised, when your problem istreated in that way, then it becomes a stigma. I mean, there's a massive differencebetween, it could be the same symptoms, it could be exactly the same thing, but ifsomebody doesn't go to the doctor it's not actually segregated as being a certainthing. And that's fine, your friend's down, you're worried about them, you lookafter them.’” This echoes Jodelet’s (1991) findings that foster parents were more afraid of lodgers who took medication than those who did not. Miles (1987) also found that acceptance ofindividuals with various diagnoses declined rapidly if it was indicated that an individual hadspent time in a mental hospital. The mentally ill are seen as less mentally ill if they avoiddrugs and hospitals.
There can therefore be differentiation within the same condition. Different social representations held by the public appear to exist of things that might be identically labelledby the medical profession.
Why do we differentiate?
Why is there differentiation in social representations of mental illness? Differentiation might be a historical phenomenon: Rose (1985) states that ‘neurosis’ arose in the community,not in the asylum, which could explain why it is represented as less Other: it has always beenamong us, and not confined away from society.
However, we may differentiate in order to maintain both existing ideology and our own identity. I believe that two powerful Western ideologies are implicated in the representationof mental illness, that of the individual and that of success and failure.
In Western society today, the individual is seen as the measure of all things (Markova, Moodie et al. 1998), and the mind has become analogous to the very core of the individual(Lukes,1973). An illness that threatens the mind therefore threatens our very essence ofbeing: to become mentally ill is to lose one’s mind, and to lose one’s mind it to lose one’sself. Mental illness is therefore a terrifying prospect.
Similarly, great store is laid by success and failure (Ichheisser,1949). Individuals are praised for their successes and blamed for their failures. Mental illness is often seen as afailure: a failure to cope with life, a failure in the family, and so on. In order to succeed, wemust therefore not succumb to mental illness, or we risk blame from our fellow members ofsociety.
J. Foster, Unification and Differentiation Thompson (1990) states that unification is an important mode of operation of ideology.
The unification of mental illness in social representation provides a safe strategy formaintaining existing ideologies, especially those of individualism and success and failure.
Within these ideologies, mental illness, and those with mental illness are discredited: thementally ill are denied the rights accorded to others, including freedom, and voice. We needto maintain a sense of control and power over the mentally ill if we are to maintain our beliefin our own rationality and rights (Porter,1987). Rose (1985) has discussed how, historically,societies have felt that degeneracy is a burden on the entire society: the ‘feeble-minded’represent a weight that civilised societies find both embarrassing and irritating.
It was rare in my data to find the voice of someone who accepted the label ‘mentally ill’, although I did not set out to recruit participants with experience of mental illness. In order tobe allowed a voice, then, the speaker must first reject the identity ‘mentally ill person’4,maybe explaining why they may be erroneously thought to be.
"B3:‘But I'm not saying that I sit down and explicitly think about things. I'm justusing that as an example. I'm not saying that I'm mentally ill, either, you know.’[Laughter]” This is particularly the case in the newspaper articles I examined, which generally offered no voice to the mentally ill: some, however, were sympathetic and spoke for the mentally ill, alegitimate voice showing compassion for the afflicted.
"PROZAC is a name that is too often taken in vain. This wonderful drug, whichhas eased the despair of millions of the mentally ill, is now usually spoken of asan unnecessary self-indulgence.” ‘The Daily Telegraph’ 30.11.97 Similarly, the families of those referred to as mentally ill rarely speak: instead it is the ‘friend’, the charity worker, somebody not tainted by hereditary implication.
The occasions when voice was accorded to those connected with mental illness were usually when the person in question had now successfully rejected the label of mental illness -interviews with former sufferers, for example.
"A view from the asylum: Anna Reynolds spent six months in a mental hospitalafter killing her mother. She was adjudged sane, and released. But the fate ofthose left behind, she says, should make us all feel ashamed” The SundayTelegraph 12.5.96 Those who currently accepted the label of mental illness and/or were considered mentally ill by others, were largely silent (or silenced). As Hall (1991) has said, you must bepositioned somewhere in order to speak: the mentally ill are accorded no such position.
Interestingly, ‘The Daily Telegraph’ consistently identified mental illness with ethnic minorities and young people, while ‘The Mirror’ associated it with young people and women.
The message appears to be that an average male/white/middle-aged reader can rest safe in theknowledge that he is less at risk than ‘inferior’ others. Gilman (1985) maintains that insanityhas long been linked with blackness or Judaism; women, as ‘the weaker sex’ have similarlybeen portrayed as more susceptible to madness (Ussher,1991).
How, then, do we reconcile all of this with the fact that mental illness is not unusual? Many focus group participants had personal experience of what could be labelled mental 4 This has not always been the case. Porter (1987) and Feder (1980) show how the madman has, in some historical contexts, sometimes been the only one accorded a voice. Certainly, we see in Shakespearean dramahow the fool dares to speak the truth in a way others do not, and is allowed to do so by virtue of his or herinsanity.
J. Foster, Unification and Differentiation illness, in themselves or in family and friends. Newspaper articles noted how ‘common’mental illness is. However to be mentally ill is clearly to be both feared and silenced. In orderto speak, and to maintain a positive identity, we must therefore reject the identity of ‘mentallyill person’.
Focus group participants were keen to reject the identity that could be assigned to them on the basis of information that they gave about themselves, and nervous laughter often followedcertain ‘admissions’.
"B3:‘Periods of unhappiness and elation, that one's interesting. gosh, everyonecould be called mentally ill. God, it makes you, it makes me worry.’ [Laughter]” “A5:‘Well, I was going to say I've suffered from every single one of these cardsat some point in my life, and I'm not mentally ill.’” Additionally, we live in a society where therapy and counselling are increasingly a part of life. Many people attend counselling, which might threaten their identity unless what they seethe counsellor for can be differentiated from what a madman would see a psychiatrist for.
"C3: ‘You know, I was sitting down in the bar with some people, and we were all,there was only one of us who hadn’t been to counselling, and it was like ‘Wellwhy haven’t you been?’ [Laughter] ‘Go on, go’ [Laughter].’” "C1:‘It's almost like you've got this perception of mental illness as being reallyscary, and bad and a bit strange and we don't know anything about it, but on theother hand we've got this, it's perfectly acceptable to go to counselling and havetherapy, about phobias and all this like really low-level stuff.’” Conclusions
Differentiation: a way of maintaining ideology and identity
If we believe that some mental illnesses are less severe, that some forms of a mental illness are less severe than others, or that some experiences and conditions should not be classified asmental illness, then we maintain a safe identity, whilst not challenging the existing ideology.
We can continue to project our fears onto the Other in the way in which Gilman (1988) and(Joffe 1999) describe. Crawford (1994) claims that health is increasingly a key area for self-expression: we need to be seen as healthy to maintain a positive identity, and thereforeconstruct the Unhealthy Other as the risky, immoral alternative to the Healthy Self.
In differentiating, then, we can explain our own experiences, whilst maintaining the identity of the mentally ill Other as unpredictable, violent and somebody to be feared, withoutaccepting that others may also view us in similar terms.
"A5: ‘Because when you say someone's mentally ill the first thing that comes intoyour head is raving spaccos dribbling in a corner defacing themselves in someway.’” In order to avoid thus being identified with the ‘raving spaccos’, we must differentiate in our representations of mental illness, making some less unfamiliar than others. We do thisbecause we cannot alter the overall ideology that presents mental illness as highlystigmatising. Differentiation, then, attempts to maintain our identity whilst not challengingthis ideology.
J. Foster, Unification and Differentiation The Problems of differentiation
Ultimately, however, this strategy of differentiation fails because it does not overcome the strength of the social representation of general, unified ‘mental illness’ with its centralelements of violence, unpredictability and Otherness. Whilst depression, anxiety, anorexia andso forth may well be seen as more Same than Other, thereby partially convincing us that ourown identity is not threatened and that existing ideology is not challenged, the fact that theycan all be labelled ‘mental illness’ means that they will be associated with the central aspectsof the general social representation, that is, violence, unpredictability and Otherness.
Mental illness and mental illnesses: cognitive polyphasia in action?
Differentiation in representations of mental illness is therefore clearly a topic that merits closer attention, and more sustained work than this small-scale preliminary study provides. Italso has some interesting implications for the wider theory of social representations.
Differentiation appears to be an example of cognitive polyphasia (Moscovici 1961): in asimilar way to that in which participants in Wagner et al's (1999; 2000) study in Patna, India,draw on ideas from Western psychiatric thinking and more traditional forms of knowledge intheir representation, participants in this study draw on aspects from the generic representationof mental illness, with its enduring and negative elements, and from more medical lines ofknowledge, and in doing so, create, modify and sustain representations of mental illness andmental illnesses that interact with one another. One possibility is that the more genericrepresentation of mental illness as unpredictable, violent, fearful and Other, has more incommon with older representations of ‘madness’, whereas differentiated representations ofmental illnesses owe more to newer ideas drawn from psychiatry and psychology, amongother areas. Moscovici (1993) discusses how the theme of contagion in madness is anexample of a canonic themata, an enduring element, drawn from the collective memory of asociety. Perhaps this representation of generic mental illness, or madness, owes more to suchnotions, which continue to shape and constrain today’s representations of mental illnesses.
Considering the differentiation of mental illness in representation, then, and studying its change over time, might lead to a more comprehensive understanding of the generation anddevelopment of systems of everyday knowledge and representation, and the crucial rolewithin these processes of a dynamic polyphasic cognitive system, constantly in development(Moscovici 1961), and working against a background of historically constrained socialknowledge (Rose et al, 1995).
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Appendix 1: Topic Guide
• What is the first thing that comes into your mind when I mention mental illness? • What is mental illness? Are there any other names for it? What do you think is the best • What do you think are the causes of mental illness? • What are the effects of mental illness? (On the person suffering and on those around them; social/ physical/ psychological).
- Which, if any of these people do you think might be mentally ill?- What do you think might have caused them to be like this?- What do you think they are like? What might it be like talking to them? Howmight they behave? How might you feel about being with them?- What do you think might happen to them • Does anybody else have anything that they would like to add about any of these Appendix 2: Vignettes used in focus groups
Feels very unhappy and hopeless.
Sometimes hears voices.
Very underweight. Eats very little.
Believes there is no point in continuing with life.
Has periods of unhappiness and periods of elation.
Performs protective rituals.
Believes that people are talking about them behind their back.
Sometimes has strong feeling that can’t breathe and is dying.
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