Studies in labeling and stigmatization of mental illness are mostly quantitative in examining public attitudes towards mental illness. There were only a few of them focus on the views of persons of mental illness (Corrigan and Watson, 2002; Corrigan, & Lundin, 2001). The views and experiences of persons with mental illness was neglected in the research and related literature. All these are crucial in generating effective measures for intervention and service. Thus, in this study, the empirical phenomenological approach was involved in data, hoping that experiences and views persons of mental illness can be fully respected and revealed.
The Phenomenological Approach
Van Kaam (1966) described this approach as follows:
`The empirical phenomenological approach involves a return to experience in order to obtain comprehensive descriptions that provide the basis for a reflective structural analysis that portrays the essences of the experience. The approach seeks to disclose and elucidate the phenomena of behavior as they manifest themselves in their perceived immediacy (van Kaam, 1966:15)
Giorgi (1985) outlines two descriptive levels of this approach: the original data from open-ended questions and dialogue and reflective analysis and interpretation respondents’ account or story (Giorgi, 1985 & Moustakas, 1994). In this study, during the interview process, the writer tried to start with descriptive narrative provided by the respondent who is viewed as co-researchers. The writer and the respondent were engaged in smooth dialogue. Questions concerned were aturally flowed out from the dialogue. In the whole process, the writer avoided any interpretation or evaluation of the respondent (von Eckartsberg, 1986)
Phenomenological Data Analysis
Melearu-Ponty mentioned three criteria for phenomenological analysis, genuine descriptive account by respondents; researcher’s interpretation reduce to minimum and search for essence (Melearu-Ponty, 1962 and Giorgi, 1985). In this study, once collected, the data were read and scrutinized so as to reveal their structure, meaning configuration, coherence and the circumstances of their occurrence and clustering (von Eckartsberg, 1986). The writer focuses on the how respondents’ personal experiences in daily interaction with members of community. In what way the construction, process, consequences and coping of label and stigma of mental illness were naturally flowed out from respondents’ own narration.
Findings
What Contributes to the Stigma and Label of Mental Illness
The Views of Persons with Mental Illness
In this study, respondents with mental illness expressed the following views towards the stigma and label of mental illness.
Respondent D:
`There is no such thing as mental illness. I am not a mental patient. We are being labeled as mentally ill simply because my family, my friend, my doctor and my boss perceive that I am mentally ill. Mental illness is an excuse used by them to isolate, to blame and to oppress us and deprive our rights to enjoy normal daily life.’
Respondent A:
`I am mentally ill. My doctor and my parents told me that depression is a serious mental illness. I have to depend on medication to counteract my symptoms. I felt dreadful, I am hopeless and worthlessness as I am a mental patient. The medication make me better, I have to follow the instruction of my doctor and my parent so as to suppress my depressive mood.’
Respondent F
`Mental illness is a terrible stigma. People look down upon you simply because you have a record of mental illness or showing any sign of mental illness. For those who know your record of mental illness, including your friends, your colleagues, they may labell any thing you have done. Even you do a good job, they do not believe in that. If you have some minor strange behaviors, or impulsive emotion, they would quickly label them as symptoms of mental illness. For those who do not know your record of mental illness, if you appears normal, no one beware that you are a person with mental illness.
The Views of Family Caregivers
C’s Sister
`C can be easily labeled by others as a person with mental illness. His symptoms are so obvious. He always deludes that he is the famous movie star “ Bruce Lee” (a former Chinese marital art master who is an international movie star). He tries to dress and perform like `Bruce Lee’. Our neighbors, relatives and friends all know that he is `insane’ and some even tries to make fun of him. Others try to avoid him fearing that he may suddenly broke into violence and aggression.’
E’s mother
`Ever since the leaving of her girlfriend, E was so depressed. He refused to go to work. He refused to clean himself. His personal hygiene was poor that his odd smell clearly showed that he was `. Many neighbors gossiped behind us saying that he was schizophrenic and with potential violence. In fact, he was too depressed to care about his personal hygiene. He was only a young man with a broken heart.’
B’ s mother
`When B is in good mood, she appears gentle and kind. She was able to work and interact with others normally. However, whenever she feels stressful, she cried bitterly and deluded that she was deserved by her boyfriend. She might delude that the richest man in Hong Kong had fallen in love with her. ’
Stigma and Labels are both Objectively and Subjectively Constructed
From the above narration by respondents and their family members, it is interesting to note that stigma and label and mental illness can both be objectively and subjectively constructed. Objective facts are odd and bizarre behaviors (C’s odd behaviors and delusion to be Bruce Lee), poor personal hygiene or outlook (E’s poor personal hygiene and bad body smell). All these are easily misinterpreted by others as signs for `violent’, `myths’, `troubles’ and `craziness’. (Phelan & Link, 1998; Ng, 1997: Torrey, 1994). However, it can also be subjectively constructed. D asserted that the label was only subjectively interpreted by others if even she did not exercise any symptoms and bizarre behaviors only because of previous record of mental illness. This seems to concur with the studies done by Link (et.al. 1999). In this study, persons with mental illness seemed to be more sensitive to others’ subjective construction of label of mental illness. Their family members tended to be more sensitive to objective construction of mental illness as they faced symptoms and odd and bizarre behaviors daily. Furthermore, mental state and symptoms might affect the receptivity of the label of mental illness. For example, as C was indulged in his active delusion of the marital art movie star, he ignored others’ stigmatization. A’s depressive mood might intensify her internalization of the stigma of mental illness. Her psychiatrist might intensify this stigma so that to increase A’s drug compliance. Nevertheless, as F’s mental state was stable, she was highly sensitive to others’ labeling. Finally, though family members were empathic to their relatives with mental illness. They understood that their relatives’ conditions changed overtime. Sometimes they were better and sometimes they were worse. They also understood their relatives’ feelings behind symptoms and odd and bizarre behaviors.
The Interactive Process in Public Stigmatization and Labeling
Nearly all respondents and their family members had unpleasant experiences in being labeled and stigmatized by others in the community.
Respondent B and her mother had the following experience in a supermarket.
`My mother and me shopped in a supermarket. I wore a patient uniform and was a bit dirty. When I entered the supermarket, everyone looked at me. Some gossiped behind me. No one approached me. Suddenly, the manager of the supermarket approached me and asked my mother what sort of things I wanted to buy. I said I preferred to look around and buy a box of drink. She pointed out where the drinks placed and left us alone. However, she still kept an eye on us. Other customers avoid coming close to us but they stayed at a distance. I could hear what they said. Some said I was crazy and was a mental patient. Some said it was a pity that a pretty young woman became insane. Some even said my mental illness was a consequence of some bad deeds done by my mother. Other questioned about my potential dangerousness. When I came near the drink and snack corner. Some were afraid that I would pick out some glass bottles and threw at them. They were very alert when I picked up some bottles of drinks from the shelf and put them down rudely. When I came close to the shelf placing kitchen utensils, they were very nervous. They even approached the manager and warned her that I might pick up some kitchen knives. I passed along this corner quickly. They became more relaxed than before.’
C’s sister and C had the following unpleasant experience.
`One day my brother walked aimlessly and played marital art in the middle of a street in a busy commercial area in Hong Kong. Because of the fear of being stigmatized, I tried to stay a bit away from him. People stared at him. They tried to keep at a safe distance away from him while he was playing marital art. Finally, he slowed down and went to a Chinese restaurant. He sat down quietly and ordered for some food to eat. His untidy hair and strange body postures symbolized that he was a mental patient. People in the restaurants sat at their seats and kept looking at him. When he stood up and went to the toilet, they moved away so as to keep a `safe’ distance away from him. Most of the time, he dared to look at them. However, if my brother looked back, they would appear nervous.’
D described the following experiences in an arcade.
` I sat on the corner of the ground of an arcade. They surrounded me. I sat on the ground saying that I was sacked by my bad employer. I was sent by the King of Heaven to punish any bad employer in this world. People laughed at me. Some even invited me to punish their bad bosses. Some were pity about me. Some took a glance and walked away..’
E said that she was frustrated by the following experiences in a children playground.
` Once I walked in a children playground within a public park. Nearly, all parents there stared at me and watched me closely. They were highly anxious with my behaviors fearing that I might harm their children. At first I kept sitting at the corner of the playground. I felt very sad and cried. They tended to pull their children back. After a short while, I started to shout that I was deceived by someone. I hated every young woman who always deceived men. At that moment, everybody in the playground looked at me. They were very tense. Some parents immediately stood in front of their children. Some even embraced their small kids and started to go away. Some moved along to search for guards in this park. A young father even nervously picked up a stick and ready to defend him and his child.’
F had the following unpleasant experience in a shop.
`People around me watched me closely in the shoe shop, especially the shopkeeper. She simply walked very close to me and tried to ensure that I would not frighten other customers. I appeared normal except my body posture was rigid and tense because of the side effect of the medication. I picked up some shoes and tried to wear them. She could not tolerate any further. She persuaded me that no shoe in her shoe shop was suitable for me and advised me to went out and find another shop.’
The following unhappy experience was described by G’s mother.
` I and my daughter, G shopped in a large department store. Because of her delusion as a modern dancer, she taped foot or danced slowly. No sooner, it caught the attention of two sale girls. They tried to predict what my daughter was going to do in the next movement. Finally, to prevent further troubles, they called upon guards in the department store. With the help of a guard, these two sale girls escorted us to leave the department store.’
H had the following unhappy encounter in a Chinese restaurant.
` I was advised to leave the Chinese restaurant simply because of my depressive mood. In fact, I had done nothing to disturb them. I only cried bitterly for my misfortunes and yelled out my inner anger towards life. However, the manager together with other waiters and customers all agreed that I was irrational and insane. When I walked out of the Chinese restaurant, many customers appreciated the prompt action of the manager saying that he was determined to stop my disturbance. What I needed was institution and detention rather than fooling around in the community.’
The Socially Constructed Process in Public Stigmatization and Labeling: Interactive Action and Response
The experiences of respondents and their family members showed that stigmatization and labeling of mental illness was a socially constructed process by members in the public areas. The construction process involved several elements: public areas, symbols or icons representing mental illness, action and response among persons with mental illness and the public. These public areas could be; supermarket (in B’s experience); arcade (in D’s experience); children playground (in E’s experience); shoes’ shop (in F’s experience); department store (in G’s experience) and Chinese restaurant (in H’s experience). In all these public areas, people come and go and engaged in well defined activities such as shopping in shops and departmental stores, sitting in public transport, dining in restaurants. According to respondents’ experience, stigmatization and labeling started with certain behaviors, symptoms and signs that symbolized mental illness. It might be depressive mood and crying (in D’s, E’s and H’s experiences). It could also be odd and bizarre behaviors (C’s marital art; E’s ventilation of her anger towards men and F’s dancing). It might be some signs (F’s rigid and tense body posture due to side effect of medication or B’s patient uniform). All these signs created disturbances to the well defined norms within these public areas. People there interpreted them as possible `outburst’ of unpredictable and mythical danger, violence and danger’. Following such construction of label of mental illness was the arousal of fear and immediate need of self protection. That might be the reason why people in public places tried to watch closely but keep a safe physical distance to respondents in this study. For instance, B and her mother was watched and gossiped by others in the supermarket. C was watched by others in the street and in the Chinese restaurants; D, E and F was watched by others in arcade, shops and department store. Instead of immediate rejection and exclusion, respondents in this study were watched by others for a certain period of time. Thus, B was able to look for some good in the supermarket. C was able to play marital art in the middle of the street in a commercial area. D was able to cry bitterly in the arcade. E was able to stay quite a while in the children playground; F was able to try some new pairs of shoe in a shoe store. G was able to dance in the department store. They might be afraid that immediate exclusion would provoke sudden outburst of the violent and crazy behaviors.
Within this period of time, people around or responsible persons in public areas spontaneously gossiped, discussed, assessed and prepared for suitable actions. For example, in B’s experiences, customers in the supermarket spontaneously gossiped behind her. In G’s case, her bizarre dancing in the department store was watched by two sale girls. They assessed, discussed and planned for appropriate actions. In E’s experience, parents in the children playground were so anxious about every action of E. They were well prepared to defend for their children if E broke into violence and aggression.
Rejection, exclusion and defense finally evolved if these signs of mental illness far exceeded the tolerance limits and threats clearly manifested. Respondents F, G and H were finally being excluded from the shoe store, Chinese restaurant and department store. However, it was interesting to discover that, this sort of tolerance limit was in fact, subjectively constructed by the public, especially by those who were responsible to maintain order and safety in public areas. For instance, F was excluded from the shoe store by the sale girl only because of her rigid and tense body posture. G was escorted by a guard and two sale girls to leave the department store.
In fact, not all people in public areas labeled persons with mental illness. People with religious beliefs or similar situations may be empathic to persons with mental illness. In this study, A had the following pleasant experience in a bus.
` I got on a bus and sat on a seat on the upper deck. I cried bitterly, saying that I was so frustrated by my failure in courtship, public examination and employment. Later, a middle aged woman in nice dress approached me. She hold my hands tightly and comforted me. She said that she had similar experiences when she was young. She had very poor results in public examination and her boy friend left her suddenly. But she worked through all these because of her religious belief. She was a devoted Christian. She even prayed for me and comforted me. Later she gave a business card to me and told me to ring her anytime I needed help. I looked at the card. Oh, she was a minister of a Christian Church.’
Consequences of Labeling: Social Exclusion and Coping
The findings in this study showed that social exclusion and discrimination were common among persons with mental illness because of the results of stigmatization and labeling. Different coping strategies were used by various respondents. Some were healthy ones and some were unhealthy ones.
A tried to be patient hoping she could be recovered in the future.
` I am still troubled by my failure in courtship, public examination, and employment. I am still deeply frustrated by others’ labeling and stigmatization. I need to depend on medication to ease my depressive mood. But with my support from my sister, I know that sooner or later I can be better. In fact, the worst situation has gone. My psychiatrist told me to wait patiently.’
B’s mother was so angry and shameful towards the labeling and discrimination.
B’s mother said: ` I had taken care of B for 12 years after her onset of schizophrenia. I do not mind the never ending burden of caring B’s daily life, reminding her to take medication and comforting her when she felt upset. However, the reaction of the public, especially our neighbors make us felt angry and shameful. A few of them are helpful but most of them gossiped behind us. They always think that the occurrence of my daughter’s mental illness is due to my bad deeds done in my previous life (in Buddhism, one’s life fortune is pre-determined by what s/he had done in his or her previous life). Whenever we walked by, they stared at us strangely. I felt shameful in facing their eye contacts. We have done nothing harmful to the neighborhood. Why should they discriminate us. I am seventy three years old now. I worried one day when I died, who can take care of B? Facing the labeling by our neighbors, B always quarrels with them. It makes the discrimination even worse.’ (B’s mother cried bitterly in the interview)
Facing the labeling and stigmatization, C’s sister avoided going out with C.
`My brother was so confused in his residual psychiatric symptoms. He always deluded he was the famous marital art movie star, Bruce Lee. Members in our community all knew that he was the `crazy dragon’. Some even address him simply as `Silly Bruce’. Guards in nearby shopping arcade tried to stop him going inside. People around gossiped and excluded him. I was caught in a dilemma. On the one hand, I dared not to go out with him fearing of others’ labeling. On the other hand, I was afraid he was being caught by the police because of potential dangerousness towards other by practicing marital art in the open area. He also feared of others’ labeling. He said that there were too many ones being jealous of her excellent marital art skills and reputation. Thus, we rarely went out, instead, we locked ourselves in our home. He tried to practice in his room by punching sand bags and watching movie of Bruce Lee. Apart from reminding him to have regular medication, we could do nothing.’
D felt humiliated and inferior towards the public labeling.
D said: `I feel humiliated by others. I am constantly labeled by others as an `insane and crazy person. It is nothing wrong to feel frustrated. Every one wants some supernatural forces to ride off those bad guys. However, others’ labeling makes me felt deeply inferior and humiliated. I dare not to look into others’ eyes. I get a feeling that their eye contact judging me as a patient that I have to lock up in hospital. By the way, I am only an insane mental patient. No one wants to employ me nor no one dares to make friend with me. I feel lonely, helpless and inferior. My social worker helped me to have a job in a sheltered workshop, but it was really boring there. I preferred to work as a guard in an arcade. I hoped one day, I can find such a job.’
E described that public labeling intensified his depressive symptoms.
E said: ` I dare not look into others’ eyes. I am a patient with depression. People know that I have mental illness. They look down upon me. I am sad, useless and hopeless. Every body looks down upon. To be abandoned by my girl means that I am worthless. Others’ exclusion further proves that I am worthless and hopeless. I think I am the most worthless male in Hong Kong. Everyday, apart from sleeping, eating and idling in the park near the psychiatric half-way house, I could do nothing. I deeply hoped that one day my girlfriend can come back to me ’
F firmly asserted that labeling and stigmatization was a burden for her recovery. Nevertheless, she tried her best to live a normal life.
F said: ` I struggled very hard in these years to get ride of the label of an insane person. Others’ discrimination made me fear that it was nearly impossible to be recovered or live a normal life again. I dared not to go out, I dared not to find employment or even dared not to go to church thinking that all of them may tease at my symptoms. Fortunately, my church members and my sister were very supportive. They accompanied me to go out. They tried to persuade with other church members that I had a lot of strengths and ability. They encouraged me to show concern to others. I hope all members in the community try not to discriminate, or to exclude clients with mental illness. Their normal respect is crucial and vital for our recovery. In fact, the most important thing for recovery is to try my best to live a normal life including a normal job, a normal daily life pattern, normal social activities and normal family. .’
G’s mother described her worry with G.
`I was so worry about G. She was my own daughter. She became a schizophrenic patient when she was only 15 years old. My husband died five years ago. I am the only one to take of her. I am 55 years old now. I was so worry about G’s future. I hope one day she can marry a good guy and take care of her. However, her mental symptoms still prevails. Everywhere she went, she was labeled by others as a `crazy dancer. Her social worker in the halfway house encouraged her to work in a sheltered workshop, but she always slept there. She was only suitable to be a dancer. Now I can take care of her. But one day I die who can take of her.’
H tried to live independently after her divorce.
`Being divorced by my husband was dreadful. But to be a depressive patient was even dreadful. Within these five years, my life was ruined by depression. Everyone looked down upon saying that I became crazy after the divorce. I could not take care of my son. I could not go to work. But now with the help of my mother, my social worker and my psychiatrist, I am much better. I begin to recognize that I have to stand on my own and be independent. I have to construct my own future by reminding myself and training myself to live a healthy life. My social worker helped me to found a good job as a cleaner in a arcade. My mental state is stable. I hope sooner or later I can discharged from this halfway house, return home and live together with my beloved mother and my beloved son.’
Healthy or Unhealthy Coping
Public stigmatization and labeling brought along social exclusion of persons with mental illness. In this study, respondents were excluded from public areas like Chinese restaurants, department stores, children playground and arcade. All respondents and their family members felt angry, being looked down by others, and deeply humiliated. Different respondents and their family members constructed various ways in coping social exclusion. Some of them were unhealthy ways and some were healthy ones. Unhealthy coping implied that respondents and their family members internalized others’ stigmatization and labeling in form of self stigmatization. For example, B’s mother felt shameful and dared not to look at others’ eyes as her neighbors gossiped that her daughter’s mental illness was a punishment of her misdeeds in her previous life (in Buddhism, everyone’s fate is a result of one’s behavior, in previous life and this life). Similarly, D felt lonely, helpless and inferior because of being looked down by others. E also dared not to look into other’s eyes thinking others might judge that she was mentally ill. Together with self stigmatization might be self exclusion. For instance, C’s sister dared not to go out with C fearing that he might be caught by the police because of odd and bizarre behaviors. B always quarreled with those who labeled her. To avoid that, B’s mother tried to keep B at home. As a result, one’s competence for recovery was greatly hindered. D always felt that he was only a mental patient and no one wanted to employ him and no one wanted to make friend with him. E also felt that he was useless and hopeless. He was the most worthless male in Hong Kong. Apart from sleeping, eating and idling, he could do nothing. G’s mother and D’s sister also felt helpless and hopeless towards their relatives’ mental illness. Healthy coping meant building up a positive attitude so that one could be positive and constructive in recovery and living a normal life. All these positive attitudes and coping strategies were needed to be supported by empathic social workers, church members, family members and neighbors. For instance, with the full support from her sister, A tried to be patient with a hope that one day she could recover from her depression. By means of the help of his social worker, D also hoped that one day, he could find a good job. With the spontaneous and full support from her church members, F tried to live a normal life including a normal job, normal daily pattern, normal daily activities and normal family.
Conclusion: Constructing A Supportive Community
As a conclusion, this paper describes the personal experiences of clients with mental illness about in facing the labeling by members of communities in Hong Kong. It seems that public stigmatization and labeling of persons with mental illness in the community of Hong Kong is a spontaneous social construction process between the members in the community and persons with mental illness. As a result, social exclusion and self stigmatization may occur that hinder recovery and community integration of persons of mental illness. All these have important implications to psychiatric rehabilitation intervention and services. Related professionals, policy makers should try their best to build up a caring and supporting community for persons with mental illness. First, facing spontaneous labeling by members in the community, persons with mental illness should be empowered to counteract labeling and public stigmatization (Krauger, 2000; Stormwell, 2002). Anti-oppressive psychiatric rehabilitation and community program may include the following:
1. Helping clients with mental illness to express and communicate their unpleasant feelings of being discriminated properly to members of community. Assertive training of feeling expression sentences like: `I feel uneasy about your staring. I hope you regards me as a normal person’ may be a good start for such anti-oppressive assertion’.
2. Encouraging family members of clients to interact with their neighbors and members in the community to share their burdens and difficulties in family caregiving so that they can solicit their respect and concern in accepting clients with mental illness to interact normally in the community.
3. Exploring and identifying neighbors, friends and members in the community who are empathic with clients with mental illness and allying them to support a normal interaction of clients of mental illness in the community.
Secondly, it is important to nurture constructive and gradual interaction among persons with mental illness and members in the community. It may first start with interaction with acceptable members in the community and fully recovered persons with good social functioning. Once such interaction is facilitated and encouraged, those members in the community who are neutral to mental illness may be more willing to interact with persons with mental illness. With their support, the community may gradually move one step forward to accept persons with some mild odd and bizarre behaviors and residual mental symptoms. Finally, a supportive community for persons with mental illness should be also protected by related legislation like anti-discrimination ordinance and appropriated mental health education so that members in the community can nurture their respect to concern to persons with mental illness.
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Psychological Associates,
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All Rights Reserved. A Private Non-Profit Agency for the good of all, published in the UK & Honduras
All Rights Reserved. A Private Non-Profit Agency for the good of all, published in the UK & Honduras