Critics of deinstitutionalisation have argued that it was a ‘most stunning public policy failure’106
and ‘[i]t is now an axiom that deinstitutionalization caused the contemporary epidemic of homelessness for the mentally ill’.107
Rothman suggests that while it was hardly debateable that deinstitutionalisation ‘failed to deliver appropriate services to ex-mental patients or other persons in need of them’, it is inappropriate to suggest that a process that reached its peak in the 1970s is the root cause of current homelessness. As has been shown in 2.1 and 2.2, people
experiencing mental illness have historically been highly representative within the
102
Richard Lamb, ‘Deinstitutionalization and the homeless mentally ill’ (1984) 35 Hospital & Community Psychiatry 899.
103 Robert Sommer and Humphry Osmond, ‘The Mentally Ill in the Eighties’ (1981) 10 Journal of
Orthomolecular Psychiatry 193, 199.
104 Koyanagi and Bazelon, above n 100, 1. 105
Jeffrey Draine et al., ‘Role of Social Disadvantage in Crime, Joblessness, and Homelessness Among Persons With Serious Mental Illness’ (2002) 53 Psychiatry Services 565.
106
David Mechanic and David A Rochefort, ‘Deinstitutionalization: An Appraisal of Reform’ (1990) 16 Annual Review of Sociology 301, 302.
107
Robert Weisberg, ‘Restorative Justice and the Danger of “Community”’ (2003) 42 Utah Law Review 343, 364.
homeless population.108 Newly created problems such as the ‘revolving door’ phenomenon where patients are discharged from psychiatric hospitals only to be readmitted again within a short period are also blamed on deinstitutionalisation instead of insufficient community resources.109
However, the social issues associated with deinstitutionalisation and the
implementation of community-based mental health care has succeeded in propelling the issue of mental illness into public view. What had once been a private, ‘out of sight, out of mind’ topic became a visible community problem confronting an unprepared and concerned public that was reminiscent of the social movement of the pauper lunatics in the 17th and 18th centuries. The newly deinstitutionalised had become the newly homeless, the newly unemployed and the newly poor on urban landscapes world-wide.110 They also became the newly criminalised. ‘This resulted, in part, from the after-effects of deinstitutionalization, but more
importantly from stigma, fear, anger and the misuse of the dangerousness concept’.
111
This unexpected, swift and largely unplanned process of deinstitutionalisation triggered an explosion of quantitative and qualitative research beginning in the early 1950s.112
Initially, mental health professionals wanted to measure the level of public acceptance toward recently discharged patients in need of accommodation, employment and community health care but for many other commentators, deinstitutionalisation represented a revolution of rights in mental health law that began with the exercise of the fundamental right to liberty.113 For others, the
unplanned and reactionary process of deinstitutionalisation was seen as the first step down a pathway of unfairness, intolerance and ignorance.114 The media’s
stigmatised reporting of the association of violence in the community with mental
108
David Rothman, ‘The Rehabilitation of the Asylum’ (2000) The American Prospect
<http://prospect.org/article/rehabilitation-asylum>.
109
Rachel Merton and Jenna Bateman, ‘Social Inclusion: Its Importance to Mental Health’ (Research Report, Mental Health Coordinating Council, 2007).
110
Lamb, above n 102.
111 John W Parry, Criminal Mental Health and Disability Law, Evidence and Testimony: A Comprehensive
Reference Manual for Lawyers, Judges and Criminal Justice Professionals (American Bar Association, 2009) 22-23.
112
Lamb, above n 102.
113 Mechanic and Rochefort, above n 106. 114
Mark J Mills and Bonnie D Cummins, ‘Deinstitutionalization Reconsidered’ (1982) 5 International Journal of Law and Psychiatry 271.
illness made the public increasingly fearful.115 The wealth of data collected over the past six decades has identified, measured, confirmed, and reconfirmed the fact that the public has held fast to negative attitudes and opinions regarding people who experience mental illness and that it is largely unwilling to accept any deviation away from established standards of normalcy. What deinstitutionalisation did succeed in doing was reveal the ‘elephant in the room’. Stigma was a phenomenon that had to be studied if effective strategies were to be developed to reduce its negative impact on the lives of people experiencing a mental illness.
3.
STIGMA: BEING DIFFERENT BY BEING ‘ILL’
The origin of stigma is rooted deeply in the control mechanism of the law and punitive processes of ancient cultures wanting to indelibly identify miscreants as deviant participants in normal society.116 The concept of stigma arose from the Greco-Roman practice of tattooing delinquent slaves117 and criminals,118 usually on the face, with missives indicating status and offence. Herodas Bion described his freed slave father as having ‘not a face, but a narrative on his face, the mark of his master's harshness’.119
Plato ordained that 'if anyone is caught committing
sacrilege, if he be a slave or a stranger, let his offence be written on his face and his hands'.120 The Romans adopted both the Greek practice and the Greek term used to describe the markings. This word has passed into present English language use as ‘stigma’. Its meaning, and the message it conveys are as widely understood today as they were in antiquity, although the stigmatising process has grown beyond the simplicity of imposing an identifying mark on a person’s body.
The stigmatised contemporary does not even need be aware of their discredited position in society, although research suggests that children within a stigmatised
115
Fuller E Torrey, ‘The Association of Stigma with Violence’ (2011) 168 The American Journal of Psychiatry
235.
116
‘Cut off the hands of thieves, whether they are male or female, as punishment for what they have done’ The Qur’an, 5:38
117
A third century Hellenistic legal code clause states that masters may not 'sell slaves for export, nor tattoo them”. The prohibition applied only to good slaves because another clause states that if a slave commits a crime, the injured party 'shall give him not less than a hundred lashes of the whip and tattoo his forehead”.
118
W Mark Gustafson, ‘Inscripta in Fronte: Penal Tattooing in Late Antiquity’ (1997) 16 Classical Antiquity
79.
119 Christopher P Jones, ‘Stigma: Tattooing and Branding in Graeco-Roman Antiquity’ (1987) 77 The Journal
of Roman Studies 139, 148.
120
group become aware at a very early age that they are discriminated against.121 The stigmatiser needs only to hold the erroneous belief that the stigmatised person is less worthy, less credible and less able than normal members of society.
Stigmatisers do, however, share common attributes such as feelings of antipathy, distrust and even pity toward the stigmatised person but importantly, they share the desire to subdue and control individuals who are different.122 For the stigmatised mental illness group, this is achieved primarily through legal interventions such as civil commitment, involuntary treatment, guardianship processes and in family law, the making of parenting orders, a subject discussed in Chapter Six.