The Stigma of Mental Hospitalization

The An

Stigma of Mental Hospitalization

Attempt

Walter R. Gove,

to Evaluate Its

PhD,

and

Consequences

Terry Fain, MA, Nashville,

Tenn

According to societal reaction theory, if a person has been labeled mentally ill, his ability to function in normal societal roles will be seriously impaired due to the reactions of others and he will be channeled into a deviant role. To test this explanation, the experiences of 429 persons who had been treated in a state mental hospital were investigated. A year after their hospitalization these patients showed a as

decided improvement in their relationships with their coinhabitants and modest improvements in their instrumental performance and community activities. Each patient generally had a positive evaluation of his hospital experience and perceived both his situation and his ability to deal with problems as improved. Furthermore, only a small minority of the patients appeared to see the stigma of hospitalization as having posed a serious problem.

According

to the traditional psychiatric perspecperson enters a mental hospital because he is suffering from a serious mental disorder. It is presumed that once in the hospital he is treated for this disorder, and that when the goals of treatment have been achieved

-la.

ti ve,

a

the patient is discharged. Because resources are limited and the staff and facilities overburdened, actual treat¬ ment goals are usually modest. In general, the aim is to return the patient to the level of functioning that existed prior to the episode that precipitated hospitalization. In fact, patients are frequently discharged even when this limited goal has not been attained if it is believed that the patient will not benefit from further treatment and that he is not a danger to either himself or others.1 According to the traditional psychiatric perspective, if a former pa¬ tient has a reoccurrence of a mental disorder upon return¬ ing to the community, it is generally assumed that it is related to the problems that initially precipitated hospi¬ talization. In recent years the core assumptions of the traditional psychiatric perspective have been challenged by a school generally known as the societal reaction perspective (sometimes as labeling theory). This approach views stabi¬ lized deviant behavior on the part of the individual as being primarily due to the actions of others. Relatively little importance is attached to the behavior, called pri¬ mary deviance, that is initially reacted to. Such behavior is assumed to arise from a wide variety of social, cultural, and psychological contexts, and to have at most only mar¬ ginal implications for the psychic structure of the individ¬ ual, having little or no effect on either the individual's self-image or the social roles he occupies.2,p171 According to the societal reaction perspective, the most crucial step Accepted for publication Nov 20, 1972. From the Department of Sociology and Anthropology, Vanderbilt University, Nashville, Tenn. Reprint requests to Box 8, Sta. B, Vanderbilt University, Nashville, Tenn 37235 (Dr.

Gove).

in the

development

of stable deviant behavior is the

ex¬

perience of being caught and publicly labeled a deviant. Whether or not this happens to an individual is believed to be largely dependent on his position in the social struc¬

ture. The societal reaction theorists argue that persons who have passed through such a ceremony and have been forced to become members of a deviant group (eg, by

being placed in an institution) have undergone a profound and generally irreversible process. It is argued that they are likely to accept the ascribed deviant role, developing a deviant self-image and world view. Perhaps more impor¬ tant, it is believed that their deviance, having been pub¬ licly established, will act as a master status which will override other social attributes and they will no longer have the opportunity to behave normally. With regard to mental illness, the evidence indicates '

that the societal reaction theorists are wrong in min¬ imizing the importance of primary deviance, for the bulk of the evidence indicates that persons who are hospi¬ talized are seriously disturbed and that hospitalization is initiated as a last resort after the situation has become untenable in the community.14-5 Furthermore, the evi¬ dence, at least tentatively, suggests that the societal reac¬ tion theorists have greatly overstated the degree to which patients will shed their former identity, undergo a process of self-mortification, and acquire the deviant identi¬ ty-presumed characteristic of the mentally ill.57 The evi¬ dence is more limited regarding the degree to which being labeled mentally ill seriously impairs the expatient's abil¬ ity to function in social and instrumental roles and chan¬ nels him into a marginal position in society. This is the is¬ sue with which the present paper will be concerned. A number of studies81" have been made of the public's image of mental illness. These studies indicate that the public lacks accurate knowledge about mental illness, dis¬ torting and exaggerating the amount and type of distur¬ bance, and that the mentally ill are regarded with fear, distrust, and dislike. For example, the mentally ill are not only thought to be unpredictable and potentially dan¬ gerous but also to be "dirty, unintelligent, insincere and worthless.'""p2331 Phillips,11 using case materials, has shown that rejection of the mentally ill is related not only to their behavior but also to their being labeled as mentally ill by being in treatment, particularly a mental hospital. In short, there is evidence that the public stereotype of the mentally ill is highly negative. Evidence on the patient's path to the mental hospital in¬ dicates that the patient and others tend to deny mental illness and to maintain a belief in the person's normality, even in the face of seriously disturbed behavior.1215 The reasons for the denial of mental illness are undoubtedly

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complex, but they probably, at least in part, reflect a de¬ sire to avoid stigma.18 Reports of former mental patients and their relatives indicate that at least some of them at¬ tempt to hide the fact of hospitalization.17 Furthermore, former mental patients and their relatives very fre¬ quently deny that they were ever mentally ¡11.5.12,15,18,19 Cumming and Cumming19 suggest that such denial facil¬ itates the destigmatization of the mentally ill. It should be noted that the ease and reasonableness of such a denial is probably greatly facilitated by the fact that the ster¬ eotype of mental illness is grossly exaggerated and in¬ accurate and the behavior of most persons who are men¬ tally ill generally does not correspond to the stereotype. It is probably also the case that the inaccuracy of the ster¬ eotype is one of the reasons persons initially deny they are mentally ill. Although it is clear that the public has a negative ster¬ eotype of mental illness and that some patients and their relatives are concerned about the views of others, it is not at all clear that the stigma of mental hospitalization has a major effect on the social situation of most former mental patients. Olshansky,20 for example, found that although people expressed negative attitudes toward the mentally ill, they were fair and generous in the way they dealt with the mentally ill. Farina and Ring21 in a lab experiment found that the belief that someone was mentally ill did not affect how comfortable the respondents were with the subject, the degree they liked him or their willingness to associate with him, although it did affect their perception of his instrumental behavior. Three studies2224 of patients in mental hospitals suggest that the majority of such patients are not seriously concerned with questions of stigma. Furthermore, the data presented by Swanson and Spitzer25 indicate that the person whom patients name as the individual whose opinion is the most important to them shows relatively little tendency to reject the men¬ tally ill. We have been able to locate only two articles that sys¬ tematically report on the feeling of stigmatization among ex-mental patients. A major study by Freeman and Sim¬ mons26 found that only 24% of the relatives of former mental patients reported feelings of stigma. Further¬ more, as such feelings were strongly related to the per¬ sistence of "abnormal" behavior on the part of the expatient, the proportion of relatives who feel stigmatized simply because a member of the household had been in a mental hospital is probably considerably smaller. In two relatively small studies reported on by Cumming and Cumming,19 roughly half of the former mental patients re¬ ported feelings of stigma, with stigma being defined as either a sense of shame or a generalized expectation of discrimination. From their article it is not clear how im¬ portant these feelings are, for we do not know what pro¬ duced these feelings nor their consequences. Their data do suggest that feeling stigmatized is transitory, for they found that it tended to disappear with time and with occu¬ pancy of normal societal roles. For former patients probably the most important in¬ dicator of continued occupancy of the mentally ill role is rehospitalization. According to the societal reaction for¬ mulation, as the former mental patient has already been

seriously stigmatized and channeled into a marginal posi¬ tion, it would seem that rehospitalization would be highly dependent upon the expectations and tolerance of others and would be readily initiated if difficulties arose. How¬ ever, Angrist et al4 found "that relatives viewed read-

mission as a last resort for behavior which cannot be han¬ dled without medical help" (p 100) and further, that the intrinsic features of illness are more important than the expectations and tolerance of others (p 170). These results appear to be essentially similar to those of Freeman and Simmons.27 In summary, the data indicate that the public ster¬ eotype of the mentally ill is negative and is suggestive of serious discrimination. However, the data on the conse¬ quences of having been in a mental hospital are much less definitive, but tend to suggest a more benign picture. It appears that when persons actually deal with expatients, they are relatively open and fair and that they do not maintain the social distance that the general stereotype would suggest. Furthermore, stigma appears to be transi¬ tory and it may be that when it does persist it is primarily due to a continuation of psychiatric difficulties and not a history of having been hospitalized. However, with the ex¬ ception of the data on rehospitalization (where the evi¬ dence is essentially negative), past studies have not fo¬ cused on our core question, namely, does the stigma of having been in a mental hospital adversely affect the per¬ sons' position in the community. We will now turn to this

question.

For our evaluation we will look at the experiences of a group of 429 patients treated at Northern State Hospital in the state of Washington. One set of these patients (N 258) was treated in an experimental or pilot program =

and was comprised of all the psychiatric patients who had entered the "hospital from a particular county over an 18month period. The second set of patients (N=171) was comprised of all psychiatric patients who had entered the hospital from the same county during the year prior to the establishment of the pilot program. The pilot patients re¬ ceived very intensive care. During the first few days of treatment, high dosages of medications were adminis¬ tered in a highly structured medical setting, the patients were then transferred to a readjustment area where they and their families were involved in developing concrete plans aimed at improving the patients' situation in the community. The control patients went through the normal hospital program, which although less intensive and struc¬ tured than the pilot program, was very good for a state mental hospital. The control patients had, by most stan¬ dards, a short hospitalization (their median length of stay was 54 days) but it was considerably longer than that of the pilot patients whose hospitalization was very brief (their median length of stay was 21 days). A detailed de¬ scription of the pilot program and an evaluation of the ef¬ fectiveness of the treatment of both the pilot and control patients is presented in Gove and Lubach.28 No follow-up information was obtained on ten (2.3%) of the patients and in addition, ten (2.3%) of the patients had died in the year following hospitalization. For the remainder of the patients information was obtained regarding their situ¬ ation a year after entering the hospital. At this time, 51


patients were in an institution (mental hospital, prison, nursing home) and 358 were in the community. Of those in the community all but nine had also been in the community prior to hospitalization, while among those in an institution a year after hospitalization, 15 had resided in an institution just prior to hospitalization. In 81.6% of of the

the cases, the information was obtained from an inter¬ view with the expatient. In the remaining cases, someone other than the patient was interviewed, typically a parent or spouse. Interviewing someone other than the patient tended to occur when the patient was residing in an insti¬ tution. As would be expected when someone else was in¬ terviewed, those data, of necessity, were less complete and such cases account for most of the nonresponses in our analysis. We would note that in no instance is the pattern of the data changed when person interviewed is used as a

control. The evaluation of the two sets of patients showed two major differences. First, patients from the control group were more likely to be chronically institutionalized. For example, an analysis of the net increase in persons resid¬ ing in an institutional setting (mental hospital, nursing home, prison) a year following hospitalization showed an increase of 11.7% among the control patients and 1.9% among the pilot program patients. Second, the control pa¬ tients were somewhat more likely to have lost some of their roles in the community than were the pilot-program patients. This was probably due partly to the fact that the staff of the pilot program made every effort to assure that the patients' roles were held open for them and partly to the longer hospitalization of the control patients. On most of the other variables, such as role performances, the dif¬ ferences between the groups were not statistically signifi¬ cant although in general the performance of the pilot pro¬ gram patients was slightly better. Because stigma should affect both groups in a similar fashion, and because on most of the variables analyzed in this paper the patients in the two groups had similar expe¬ riences, we will combine the two groups in our presenta¬ tion. In attempting to evaluate the consequences of being stigmatized by having been in a mental hospital, we will compare the patients' situation prior to hospitalization with that of a year after hospitalization, looking partic¬ ularly at involvement in instrumental and social roles. There are two major ways in which stigma may create se¬ rious problems for the expatient. First, others may treat the individual as a deviant and channel him into a mar¬ ginal position in society. Alternatively, the expatient may be so concerned that others will discriminate against him that he withdraws from interacting with others and con¬ sequently drifts into a marginal position. Although we are concerned primarily with the issue of stigma, stigma is only one of a number of factors that may impair an expatient's performance. Of key impor¬ tance from the psychiatric perspective would be the possi¬ bility that the expatient will continue to experience seri¬ ous psychiatric difficulties. This could occur either because the patient's disorder was not completely controlled (as was noted above, the goals of state hospitals tend to be limited in scope) and/or because the expatient has re¬ turned to a stressful situation. Another possibility is that

by simply being absent from the community the roles the patient formerly occupied will no longer be available. For example, even aside from the question of stigma, employ¬ ers may be unwilling to hold a job open for an indefinite period. A third possible source of difficulty is that the pa¬

tients may have been socialized into the institution of the hospital and that their problems are due to the adoption of the mentally ill role. Because of the shortness of their hos¬ pitalization, these last two factors (loss of roles due to length of absence and socialization into a total institution) would appear to have a minimal impact on the patients in this study. This is particularly true of the pilot-program patients. This leaves two factors that are likely to seri¬ ously impair the situation of these expatients—a serious psychiatric condition and stigmatization. If these patients are more marginally situated after hospitalization than before, we will not know the relative importance of these two variables, but such a finding would indicate that stigma may be important and should be taken seriously— particularly if the expatients report discrimination. In contrast, if we find that most of the expatients are doing as well as they were prior to hospitalization, this would strongly suggest that stigmatization has not been a seri¬ ous

problem.

Before turning to an analysis of the data, we would note that the major problem with this study is that the data on the patients' situation prior to hospitalization are retrospective, a problem that seems endemic in studies of treated mental illness. Thus, in looking at changes over time we are generally looking at changes the patient per¬ ceives, and not necessarily at actual changes. It is possible that the patients may use the hospital as a scapegoat, blaming all their troubles on it. (Edgerton29 found that this occurred among formerly institutionalized mental re¬ tardates who were living in the community.) Alterna¬ tively, it is conceivable that, to reduce dissonance, expatients may tend to overemphasize the beneficial con¬ sequences of hospitalization. Evaluation In

our

evaluation

we

will look at the

following general

(1) instrumental performance and economic posi¬ tion, (2) social relationships in the home, (3) relationships and activities outside the home, (4) the expatient's eval¬ uation of his hospitalization and general situation. areas:

Instrumental Performance and Economic Position.—While the data on employment indicate that many of the pa¬ tients had occupied a marginal position in the community for a long time (for example, prior to hospitalization 81 men indicated they were in the labor force but unem¬ ployed), there was a slight increase in the number of men employed and a substantial increase in the number of women employed following hospitalization. Before hospi¬ talization 61 men and 17 women reported being employed, whereas 65 men and 39 women were employed one year after hospitalization. This suggests that in most cases hos¬ pitalization did not seriously affect the employment status of the majority of expatients. This inference is supported by the fact that when the unemployed patients were asked the open-ended question "what type of problems do you have in trying to get a job?" only one respondent


Table 1.—Performance of Housework Before and One Year After Hospitalization (Percent) A.

Rating of Housework for All Women in Housework Role Housework Rated Good 52.3 70.4

Poor NR Before hospitalization 47.7 175 3 After hospitalization 0~ 29.6 159 B. Reported Changes in Quality of Housework Among Women in Housework Role Before and After Hospitalization

Better_No Change_Worse_ _NR 7 24.5

4J5

55

Ö~~

mentioned that having been in a mental hospital made it difficult to get a job. Women who were living with a spouse or young children or both before hospitalization and/or at the time of the in¬ terview were asked about their instrumental performance as a housewife at these two time periods. After a number of questions dealing with specific tasks (eg, shopping, cleaning house, preparing meals) the housewives were asked about assistance they received in caring for the household and were then asked to evaluate their overall performance. The interviewer then gave a rating on a 4point scale as to the adequacy of their household care. Data on these ratings are presented in Table 1, part B. There are fewer women in a housewife role a year after hospitalization than prior to hospitalization because some women had left their family while others were in an insti¬ tution. However, in spite of this decline, there was a no¬ ticeable increase in the number of women doing a "good" job as housewives. Similarly, an analysis of women who had household responsibilities both before and after hospi¬ talization showed a noticeable trend towards improve¬ ment. It should be noted that the housework of women no longer with their families had generally been of poorer quality prior to hospitalization than the housework of women who remained with their families. A third indicator of the patient's instrumental behavior is his financial situation. To a large degree one's financial position is determined by one's employment, but it also re¬ flects budgeting skills and use of community resources such as public assistance. We would note that, when ap¬ propriate, members of the hospital staff would refer the patient to community agencies and thus, in some cases, the hospital may have played a direct role in helping the patient economically. Two items of information were col¬ lected that bear on changes in the patient's economic situ¬ ation. The patient was asked if he was experiencing seri¬ ous financial problems either before hospitalization or at the time of the interview, and he was also asked about general changes that had taken place in his financial situ¬ ation. The data on these items, for those expatients who were living in the community both before hospitalization and a year following hospitalization are presented in Table 2. Both items indicate a tendency towards an im¬ proved economic situation. As is consistent with the fact that many of the women are supported by their spouses, the data indicate female patients are less likely to have fi¬ nancial problems and their financial situation is less likely to

Table 2.—Financial Situation of Patients Living in the Community Both Prior to Hospitalization and a Year After Hospitalization (Percent)

change.

Patients Who Had Serious Financial Problems Neither Before Before and Before After Nor After After Only Only 1.8 Men 31.5 10.5 56.1 114 Women 20.4 0.4 11.5 67.7 226 B. Reported Changes in Overall Financial Situation Worse No Change Improved Men 26.5 60.7 12.8 117 15.7 Women 76.2 8.1 223

Table 3.—Patient's A.

NR

NR

Relationship With His Cohabitants (Percent)

Relationships For All

Patients

Living in the Community

at Either Point in Time

Good or

Excel¬ lent

Fair

Poor

NR

Spouse

28.3 35.4 237 13 Before Hospitalization 36.3 68.0 11.1 206 After Hospitalization 20.9 Children 9.5 198 20 Before Hospitalization 73.8 16.6 After Hospitalization 85.9 12.0 2.2 184 Others Before Hospitalization 29.3 27.6 44.0 75 8 After Hospitalization 56.8 25.9 17.3 81 B. Changes in Relationship Among Persons Living in the Same Situation Before and After Hospitalization NR Improved No Change Worse 32.5 66.5 194 1.0 Spouse Children 12.4 87.6 169 0.0 Other 25.0 69.2 5.8 52

In summary, the data on jobs, housework, and finances do not indicate that the patient's position in the commu¬ nity has deteriorated. In fact, a slight tendency for im¬ provement is shown. Social Relationships With Cohabitants.—In looking at the patient's relationships with those he is living with, we will separate such persons into three categories: spouse, chil¬ dren, and others. Patients who were living with a spouse before hospitalization and/or a year after hospitalization were asked a number of questions about their relationship at these times (eg, who made decisions, how the spouse felt about the patient's housework or job, the frequency and severity of arguments). They were then asked to rate how well they got along with their spouses on a 5-point scale. In spite of the fact that fewer persons were living with their spouses following hospitalization, there was a marked increase in the number of patients who reported a "good" or "excellent" relationship with their spouses (Table 3). As these data suggest, when we look only at pa¬ tients who were living with their spouses both before hos¬ pitalization and a year after hospitalization, a substantial number indicated that their relationship had improved. It is interesting to note that among those who had left their spouse following hospitalization, 72.5% reported that they


"poor" relationship with their spouse prior to hospitalization as compared to 27.9% among those patients had had

a

who remained with their spouses, which suggests that those who left their spouse generally had long-term mari¬ tal problems that preceded hospitalization. A similar procedure was used for patients who were liv¬ ing with (1) young children and (2) others (generally par¬ ents, siblings, and friends). As can be seen in Table 3, pa¬ tients generally reported better relationships with their children than with their spouses and fewer changes in their relationship; however, the pattern of changes was exactly the same as the pattern noted previously. Many persons living with "others" before hospitalization were not after and vice versa. However, the pattern of change is again the same. Persons who had ceased living with oth¬ ers, and to some extent those who had ceased living with their children, were more likely to report a poor relation¬ ship prior to hospitalization than those who retained their

living arrangements.

In short, the data on relationships with coinhabitants show a strong tendency for improvement following hospi¬ talization and the data provide no support for the belief that the stigma of institutionalization frequently has an adverse effect on such relations. Relationships and Activities Outside the House.—In an at¬ tempt to assess changes in the patient relationships and activities outside the home we will look at changes in (1) amount of visiting, (2) involvement in conflicts with oth¬ ers, (3) time devoted to recreational activities, and (4) par¬ ticipation in formal organizations. Our analysis will be based primarily on the 349 expatients who were living in the community both prior to hospitalization, and a year after their entrance to the hospital. The patients were asked how frequently they visited their parents, siblings, children, other relatives, in-laws, friends, and neighbors. They were then asked if there had been any change in the frequency they visited others fol¬ lowing their hospitalization. This information on visiting was obtained on all but 11 of the patients residing in the community at both points in time. The majority of the pa¬ tients (56.8%) reported no change in the amount of vis¬ iting over the two time periods. However, there were more patients (25.1%) reporting an increase in visiting than pa¬ tients (18.1%) reporting a decrease. The patients were also asked if they had been having any serious conflicts with friends or relatives before and/or after hospitalization. Information on conflicts was obtained on all but ten of the 349 patients residing in the community at both points in time. Most patients (67.6%) reported an absence of such conflicts both before and af¬ ter hospitalization. Next in frequency were the patients (20.9%) who reported having such conflicts at both points in time. However, when change did occur it tended to be positive, there being more patients (10.0%) reporting con¬ flicts before but not after hospitalization than there were patients (1.5%) who reported conflicts after, but not before

hospitalization. Turning to activities, the patients were asked what they

did for recreation outside the home and how much time they spent on these activities. They were then asked if these recreational activities had changed in any way fol-

lowing their hospitalization. This information was ob¬ tained on all but 13 of the patients residing in the commu¬ nity at both points in time. Most of the patients (72.9%) indicated that there had been no change in the time de¬

voted to such recreational activities. However, there were again more persons (16.1%) indicating an increase in time devoted to recreational activities outside the home than persons (11.0%) indicating a decrease. The patients in the pilot program were also asked the frequency with which they attended meetings of volun¬ tary organization both before and after their hospitaliza¬ tion. Of the 215 pilot-program patients residing in the community at both points in time, this information was obtained for all but nine patients. As with the other vari¬ ables, most patients (78.6%) indicated there was no change in the frequency with which they attended such meetings. This figure is primarily a product of the fact that two thirds of the patients indicated that they simply had never attended such meetings. Again, however, there were more patients (12.6%) indicating an increase in at¬ tendance than there were patients (8.7%) indicating a de¬ crease in attendance. For two of the above variables, recreational activities and changes in visiting, the information collected dealt only with changes in these behaviors and such data has meaning only for persons residing in the community both prior to hospitalization and at the time of the interview. For the other two variables, conflicts with others and at¬ tending meetings, information was collected separately for each point in time. A comparison of all persons living in the community at each point in time indicated that af¬ ter hospitalization fewer persons were involved in con¬ flicts and that slightly more persons were attending meet¬ ings than prior to hospitalization. In summary, the data on activities outside the home show only modest changes following hospitalization, but the changes that do occur are positive. We will now turn to the respondents' overall evaluation of the consequences of hospitalization and of changes in the patient's general sit¬ uation and his ability to handle problems. As such eval¬ uations are quite subjective and are apt to reflect the van¬ tage point of the respondent, in presenting the data we will control for the person interviewed. As with all questions such as these, when the respon¬ dent was someone other than the patient, the patient's name was substituted for the word "you." General Evaluation.—In an attempt to evaluate the per¬ ceived effects of hospitalization the patients were asked two questions. First, "Do you think your stay in the hospi¬ tal did you any good?" and second, "Do you think your stay in the hospital harmed you in any wayl" As is indi¬ cated in Table 4, most persons viewed hospitalization as having been beneficial and only a few viewed it as having had detrimental effects. Interestingly, there was not an inverse relationship between these effects; most persons who saw hospitalization as having no positive effects also saw it as having no negative effects, while 72% of those who saw hospitalization as having negative effects also saw it as having positive effects. Because of our interest in stigma, a qualitative analysis was made of the 19 pa¬ tients from the pilot program who indicated they had


Table 4.—Overall Evaluation of Patient Residence One Year After Hospitalization

Hospital Experience

Helped by Hospitalization

Percent

Helped

Person Interviewed Patient

Open community

Other Patient Other

Institution*

Totals Patient Harmed by

Residence One Year After Hospitalization

Harmed 13.5 8.3 16.0 0.0 12.7

Patient Other Patient Other

Totals

hospital, prison,

10 36

Percent

Institution*

A mental

18

Hospitalization

Person Interviewed

Open community

1

NR 298 35 27 13 373

84.2 71.4 74.1 92.3 82.6

or

nursing

NR 304 36 25 14 379

17

30

home.

Table 5.—Perceived Changes: Patient's Ability to Handle Problems No

Residence One Year After Hospitalization

Person Interviewed Patient Other Patient Other

Open community Institution* Totals

Patient Other Patient Other

Open community Institution* Totals *

A mental

hospital, prison,

or

nursing

Improved

27.0 50.0 36.0 60.0 30.8

Worse 4.3 0.0 8.0 6.7 4.3

300 30 25 15 370

36.6 39.4 60.0 46.7 38.8

4.0 3.0 20.0 33.3 6.2

298 33 25 15 371

Change

68.7 50.0 56.0 33.3 64.9 Patient's Overall Situation 59.4 57.6 20.0 20.0 55.0

NR 23

39

20

38

home.

been harmed in some way by hospitalization. The replies of seven of these suggested a concern about the stigma of having been in a mental hospital. To evaluate perceived changes in the patient's general situation the patient was asked "Do you think the situ¬ ation you are in is any better or worse than what it was before you went to the hospital?" The response for those persons in the community a year after hospitalization in¬ dicated that the majority saw the situation as having im¬ proved and only a very small minority saw the situation as worse. For the patients in an institution the tendency was to see the situation as neither better nor worse than what it was prior to hospitalization (Table 5, upper portion). Overall, these results indicate a clear tendency to perceive the situation as having improved. These results should not be interpreted as indicating that the patients perceive themselves as being without problems, but only that they perceive some improvement. In another part of the interview the patients were asked "since returning from the hospital do you think you have, in any way, presented a problem at home?" Among the patients living with someone in the community, 29.2% in¬ dicated they had been a problem. These patients were asked to describe how they had been a problem. Seventynine percent of the patients indicated that it was the way they behaved which had created problems for others and most of the remaining patients indicated they had re-

quired either nursing care or financial assistance. A care¬ ful rereading of the answers by the pilot program patients found only one response that might be indicative of a con¬ cern with stigma (ie, the patient reported that "my hus¬

band has become very nervous and self-conscious" since my hospitalization). To evaluate perceived changes in the patient's ability to function effectively the patients were asked "Do you think you are better able or less able to handle problems that come up than you were before you went to the hospital?" As is indicated in Table 5, lower portion, the majority of the patients in the community perceived themselves as better able to handle problems and only a very small mi¬ nority as being less able. Among patients in a institution, the responses were fairly evenly balanced between the perception that the patient's ability had improved and the perception that it had not changed. In summary, as a group the patients tended to view their hospitalization as having been beneficial and to feel that both their situation and their ability to handle prob¬ lems had improved. Comment

According ness

acts

to the societal reaction theorists, mental ill¬ master status overriding the other statuses

as a

of the individual. They hold that if a person has been la¬ beled mentally ill, his ability to function effectively in nor-


mal societal roles will be seriously impaired and that he will be channeled into a deviant role. However, the mental patients studied showed, following their hospitalization, marked improvements in their relationships with the per¬ sons with whom they were living and modest improve¬ ments in their instrumental performance and community activities. Most patients also had a positive evaluation of their hospital experience and perceived their situation and their ability to handle problems as improved. Further¬ more, probes on a number of questions indicated that only a very small minority felt that the stigma of having been in a mental hospital had posed a serious problem. In short, these data suggest that the societal reaction explanation grossly exaggerates the negative consequences of being labeled mentally ill. Furthermore, the fact that most of the expatients are not only functioning in the community but feel that their situation there is improved suggests that other processes, which have been ignored by the societal reaction theorists, are present and important. The data are thus consistent with other evidence5-30 which indi¬ cates that the societal reaction perspective does not pro¬ vide an adequate general theory of mental illness. This is not to say that the processes pointed to by the societal re¬ action theorists do not exist but only that there are other processes which in most cases are more important. It is worth mentioning at this point that by focusing on the be¬ havioral consequences of hospitalization, the data pre¬ sented may not reflect the proportion of expatients who had been concerned, at least some degree, with the issue of stigma. It is the impression of one of us (W.R.G.), who conducted virtually all of the interviews, that a substan¬ tial minority of the expatients were initially somewhat

embarrassed and uncomfortable about having been in a mental hospital, but that they did not perceive the stigma of hospitalization as having had any serious or long-run consequences. These data also bear on two more general issues. First, as discussed in the introduction, the public stereotype of the mentally ill is highly negative and when the public is presented with abstract cases, the responses indicate that they will seriously discriminate against persons labeled as mentally ill. However, this study suggests, as have oth¬ ers,20·21 that when persons actually confront someone who has been labeled mentally ill they in fact do not seriously discriminate against them. This inconsistency points up the difficulty of trying to extrapolate to behavior from an¬ swers to abstract questions in surveys. What is partic¬ ularly striking about this finding is that people say they will act in a socially undesirable (inhumane) fashion, but apparently act in a socially desirable (humane) fashion (which is the reverse of the way social desirability is as¬ sumed to interact with verbal responses and actual behav¬ ior). Also, the societal reaction perspective is a general per¬ spective which provides an explanation for a wide variety of deviant behaviors. The conclusion that it does not pro¬ vide an adequate explanation of mental illness certainly does not prove that the societal reaction perspective is inadequate as an explanation of other forms of deviant behavior, but it raises that possibility and points to the need for a systematic evaluation of the explanatory adequacy of societal reaction theory with regard to other types of deviance. This investigation was supported in part by Public Health Service re¬ search grant 5-RI-MH00898.

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Wiley

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