Australian and New Zealand Journal of Mental Health Nursing (2001) 10, 200–209

INTRODUCTION

Mental ill-health — and its profound stigmatiza-tion — carries with it a burden of human suffer-ing that at times is not only incalculable, butincomprehensible to non-afflicted onlookers. Itsconsequences to both the sufferers of mental ill-health and their families/friends can be deeplydehumanizing, culturally dispossessing and rad-ically alienating. This, in turn, can perpetuate a

most cruel injustice, notably, the denial of thementally ill’s moral entitlements to the things that other so-called ‘normal’ persons may take for granted: function, a sense of place in an intersubjective world, empathic connection withreciprocating others, peace of mind, happiness,participatory citizenship. The injustice thatmentally disordered people experience is oftencompounded by their entrapment in what JamesGlass (1989) calls ‘unfree states of being’ — anentrapment that pulls from two directions

from inside, confusion and self doubt, intensi-fied by lack of a sense of place; from outside,the suspiciousness of a social world that regardsmental disorders with fear and anxiety (Glass,1989; p. 195).

In the case of internal ‘unfree states of being’,the domination of a terrorizing or terrifying delu-sional world can be ‘just as deadly as any externaltyranny’, with one notable exception that its

FEATURE ARTICLE

Stigma, social justice and the rights of thementally ill: Challenging the status quo

Correspondence: Megan-Jane Johnstone, Department ofNursing and Midwifery, RMIT University: Bundoora WestCampus, PO Box 71, Bundoora, VIC 3083, Australia.Email: megan.johnstone@rmit.edu.au

Megan-Jane Johnstone, PhD, BA, RN, FRCNA, FCN(NSW).

An earlier version of this paper was presented as a keynoteaddress at the 26th Annual International Conference ofAustralian and New Zealand College of Mental HealthNurses: ‘Mental Health Nursing: Not Just Surviving.Thriving’, Gold Coast, Queensland, 3–7 September 2000. Ithas been revised for publication.

Accepted February 2001.

Megan-Jane JohnstoneDepartment of Nursing and Midwifery, RMIT University, Bundoora, Australia

ABSTRACT: People suffering from mental illness and other mental health problemsare among the most stigmatized, discriminated against, marginalized, disadvantagedand vulnerable members of society. Although much has been done in recent yearsto improve the status quo, it is evident that a great deal more needs to be done toimprove the moral standing of and to achieve social justice for the mentally ill. Akey contention of this philosophical essay is that unless the stigma of difference thatis attached to people with mental illness is overturned, their rights will continue tobe marginalized, invalidated, violated and/or ignored.

KEY WORDS: discrimination, ethics, mental illness, social justice, stigma.

source ‘lies hidden and obscure’ (Glass, 1989;p. 5). In the case of external ‘unfree states ofbeing’, the domination of what Meyers (1994)terms ‘culturally normative prejudice’ in main-stream society can be just as constraining andbrutal as any tyrannical political regime that rad-ically disrupts the political and cultural life of itscitizens via the processes of unjust imprisonment(adapted from Glass, 1989; p. 5).

The gross injustice faced by people withmental health problems and mental disorders isnot merely an abstraction; it is a lived reality andone that is frequently characterized by an in-tense and lonely struggle to survive and to ‘findone’s way back’ to a world of meaningful humanconnection, intimacy and shared identity. It isalso characterized by a torturous and punishing,but often unnoticed struggle to be heard. As asufferer of severe mental illness once pleaded ina letter to the world:

Dear Anybody

If anyone is out there please hear me. I fear Iam in the grip of some terrible nightmare. Firstof all, I have to tell you I am very sick. I feel likean animal on a leash but no one tells me whatto say … and I am sick, so very, very sick (‘Julia’– in Glass, 1989; p. 106).

James Glass, the researcher documenting thiscase, notes that, for this sufferer, it was enor-mously difficult

to do what normal [sic] people do, what normal[sic] persons take for granted: to make friends,to pursue intimate relationships, to performcommon tasks. Such actions were [for her] ‘likeclimbing Mount Everest’ (Glass, 1989; p. 109).

The struggle to be heard and find connectionwith empathic others is also discouragingly unre-warding. The case of ‘David’, a young man whoselife was severely interrupted by psychotic terror,is an example of this; Glass (1989) writes:

Psychosis for David was a lonely battle withoutawards, or congratulations. There were nomedals or testimonial dinners, no one to toasthis struggles, no spotlight. It was a lost world, asubterranean universe that had forged a des-perate isolation and left him without friends, ajob, or a place to stay wandering in his own inner

wilderness until the mania repeated itself. Atleast the efforts of persons living within con-sensual reality (the world of normal people)have an audience, a context in a given history orsociety, a dialectical frame with others. Thestruggles of psychosis, however, are silent,unwitnessed battles, non-dialectical and there-fore not part of any history (Glass, 1989; p. 49).

It is testimony to the enormous courage andresilience of the mentally ill that, despite theoverwhelming loneliness and painful life-struggle they endure and despite the discrim-ination and at times overwhelming psychicestrangement they experience, somehow theymanage to ‘keep on going’. For those who finallygive up the life-struggle, it is invariably far beyondthe point at which others not afflicted by mentalillness would find tolerable.

The issue of mental (ill)health, and morespecifically its profound ethical dimensions,affects us all. The suffering of those with a mentalhealth problem is a reality which we, either asindividuals, members of a (professional) group,or members of a given community, cannot ignore,at least not ethically. We should not be indiffer-ent to their suffering (Nagel, 1979). To ignore orto be indifferent to such profound human suf-fering would be to abandon those in distress andto compound their vulnerability in morallyunacceptable and culpable ways. We must notabandon the mentally ill and leave them lan-guishing on the margins of community, ofhumanity. Borrowing from the reflectionsof Brian Keenan (1992), an Irish national who in1985 was kidnapped by fundamentalist Shi’itemilitiamen in Beirut and held hostage for 4 years,and who, during his hostage years, took greatpersonal risks to support his fellow hostages.

We cannot abandon the injured and themaimed, thinking to ensure our own safety andsanity. We must reclaim them, as they are partof ourselves (Keenan, 1992; p. 288).

In this paper, attention is given to re-visitingthe problem of the stigmatization of mentalillness and the unjust burden of suffering itimposes on people already made vulnerable bytheir mental disorders and other mental healthproblems. It is an underlying assumption of this

STIGMA, SOCIAL JUSTICE & MENTAL ILLNESS 201

paper that unless the ‘stigma of difference’ thatis attached to people with mental illness is over-turned, the rights of those with mental healthproblems will continue to be marginalized, inval-idated, violated and/or ignored. This, in turn, willsee the mentally ill being perpetually excludedfrom having full membership of (and kinshipwith) the broader moral community.

THE GLOBAL IMPORTANCE OFMENTAL HEALTH

Mental health is recognized globally as being ofenormous social and public health importance. Itis also of economic importance, with the economicconsequences of mental ill-health predicted to bedire on account of lost productivity and the upfrontcosts of treating those afflicted. The imperativesof mental health promotion and prevention thushave an economic as well as a moral basis.

The World Bank and World Health Organiza-tion (WHO) predicts that by the year 2020 thehealth burden attributable to neuropsychiatricdisorders could increase by almost 50%, repre-senting 15% of the total burden; it is further predicted that ‘depression will contribute thelargest share to the burden of disease in the devel-oping world and the second largest worldwide’(Commonwealth Department of Health andAged Care & Australian Institute of Health andWelfare, 1999, p. 1).

In recognition of its economic, social andpublic health importance, mental health in theAustralian context has been designated as one ofthe five National Health Priority Areas (NHPA)in which Government wishes to achieve sub-stantial population health improvement(Australian Institute of Health and Welfare &Commonwealth Department of Health andFamily Services, 1997, p. 1). Although it is notknown how widespread mental ill-health is inAustralia, it has been conservatively estimatedthat ‘between one in five and one in four indi-viduals will be affected by a mental healthproblem or mental disorder at some point in theirlives’ (Australian Institute of Health and Welfare& Commonwealth Department of Health andFamily Services, 1997; p. 19) and that mental

ill-health ‘will indirectly affect the lives of manyothers’ (Australian Health Ministers, 1995; p. 1).In response to these estimates and the enormouspersonal and economic costs predicted to beassociated with them, in 1992 the Common-wealth Government and State and TerritoryGovernments of Australia endorsed the NationalMental Health Strategy. By endorsing thisstrategy, the respective Governments of Australia‘made a commitment to improve the lives ofpeople with mental illness and of the people whocare for them’ (McLennan, 1999; p. 1). The ful-filment of this commitment lies in achieving thestated aims of the strategy, namely to (i) promotethe mental health of the Australian community;(ii) where possible, prevent the development ofmental health problems and mental disorders;(iii) reduce the impact of mental disorders onindividuals, families and the community; and(iv) assure the rights of people with mental dis-orders (Australian Health Ministers, 1995).

Achieving these aims will, however, requiremore than the mere endorsement of a strategicdocument by Commonwealth, State and Terri-tory Governments of Australia. It will also requireof individuals and communities a major changein attitude toward the mentally ill (which remainslargely prejudicial and discriminatory) and amajor change in what Walker (1998; p. 179) refersto as ‘habits of perception’ that ‘erase or deform[the mentally ill’s] moral kinship among humanbeings’. Together with the Commonwealth, Stateand Territory Governments of Australia, mem-bers of the community must work cooperativelyand collaboratively to identify, expose and sub-vert the ‘culturally normative prejudice’ thatpervades our society — in this instance againstpeople with mental health problems and mentaldisorders — and the gross injustices this form ofprejudice legitimately perpetrates. Unless cul-turally normative prejudice against the mentallyill is subverted, it will stand as a potent block tothe solutions that might otherwise be found tothe economic, social and public health problemsposed by mental illness. Just how best to achievethis cultural revolution is an open question,however, and one which the discussion to followseeks to explore.

202 M-J. JOHNSTONE

STIGMA, SOCIAL JUSTICE & MENTAL ILLNESS 203

MENTAL HEALTH AS A MORALLYSIGNIFICANT PROBLEM

Before exploring the moral significance of mentalhealth/mental ill-health it is necessary to firstdefine what mental health is and its counterpartsmental health problem and mental disorder.

Mental health may be defined as the capacityof individuals and groups to interact with oneanother and the environment in ways that promotesubjective well-being, optimal development, anduse of cognitive, affective and relational abilities.It is much more than the absence of mental illness.It is the realization of one’s potential shaped byfactors such as biological make-up, gender roles,family life, human relationships, work opportuni-ties, educational achievements, and a variety ofstructural and socioeconomic determinants(Commonwealth Department of Health and AgedCare & Australian Institute of Health and Welfare,1999; p. 2).

Mental health problems and mental disorders,in turn, may be taken as referring to the spectrumof cognitive, emotional and behavioural disordersthat interfere with the lives and productivity ofpeople at school, work and home, and impact upontheir interpersonal relationships. The spectrumcovers cognitive impairment and disabilities,phobias, panic attacks, drug-related harm, anxiety,post-traumatic stress disorder, personality dis-orders, depressive disorders, schizophrenia andpsychoses (Commonwealth Department of Health and Aged Care & Australian Instituteof Health and Welfare, 1999; p. 1).

It is important to clarify here that the termmental disorder is not synonymous with the termmental health problem. The term mental disorderis essentially a diagnostic label that is applied toa person with a mental health problem afterhe/she consults a health professional for assis-tance in dealing with the problem, and is gener-ally taken to refer to ‘a clinically recognizable setof symptoms or behaviours associated in mostcases with distress and interference with personalfunctions’ (World Health Organization, 1992;p. 5).

Mental health or, more to the point, mentalill-health constitutes a significant moral problem/

ethical issue. Within mainstream bioethics dis-course, it is generally recognized that somethinginvolves a moral problem/ethical issues where ithas as its central concern (i) the promotion andprotection of people’s well-being and welfare(including their interests in not suffering unnec-essarily); (ii) responding justly to the genuineneeds of and significant welfare interests of dif-ferent people; and (iii) determining and justify-ing what constitutes right and wrong conduct ina given situation (adapted from Johnstone, 1999;p. 162).

Adjunct to these concerns is an additionalconsideration, namely, that people have a moralresponsibility to come to the aid of those who aresuffering and in distress. As Amato (1990) notesin his Victims and values: a history and a theoryof suffering:

There is an elemental moral requirement torespond to innocent suffering. If we were not torespond to it and its claims upon us, we wouldbe without conscience and, in some basic sense,not completely human. And without compas-sion for others and passion for the causes onbehalf of human well-being, what is best in ourworld would be missing (p. 175).

These considerations apply in the case ofmental health. As can be readily demonstrated,the moral problem of mental (ill)health funda-mentally involves (i) promoting and protectingthe well-being and welfare of persons (childrenand adults) at risk of harm due to their mentaldisorders and other mental health problems; (ii)protecting the mentally unwell from this harmwhich, in turn, requires a careful calculation andbalancing of the needs and interests of ‘differentpeople’, for example, those with mental healthproblems, their primary care givers, and others(such as family, friends, the children of mentallyill parents); and (iii) determining and justifyingthe ‘rightness’ and ‘wrongness’ of certain conductinvolving people with mental health problems ormental disorders.

As a moral problem, mental ill-health thusrequires a substantive moral response, not merelya social or a political response. This is particularlyevident with respect to the stigmatization of

mental illness and the unjust discrimination thatinvariably occurs as a result of this stigmatization.

STIGMATIZATION, PREJUDICE ANDDISCRIMINATION IN MENTALHEALTH

Mental disorder/mental ill-health stands world-wide as being one of the most stigmatized humanconditions (Bloch & Singh, 1997). People withmental disorders experience extraordinary prej-udice and discrimination as a result of this stigma-tization which, in turn, can compound thedistress and interference with personal functionthey are already experiencing as a result of theirmental disorder (Australian Health Ministers,1995; Burdekin, Guilfoyle & Hall, 1993; MentalHealth Consumers Outcomes Task Force, 1995).Equally serious, prejudicial and discriminatoryattitudes toward people with mental healthproblems may see them systematically and legit-imately excluded from, and marginalized to thefringes of society on the culturally normativegrounds that they are ‘inferior, undesirable, orthreatening’ (Meyers, 1994; p. 43).

In 1993, an Australian national inquiry into thehuman rights of people with mental illness con-cluded, unequivocally, that people affected bymental illness continue to ‘suffer from wide-spread, systematic discrimination and are con-sistently denied the rights and services to whichthey are entitled’ (Burdekin et al., 1993; p. 870).The inquiry found that discrimination was par-ticularly widespread in mainstream society, withthe mentally ill experiencing ‘stigma and dis-crimination in almost every aspect of their lives’ ranging from restrictions on eligibilityfor insurance and superannuation schemes, toemployment, education and training (Burdekinet al., 1993; p. 925). Equally disturbing was theinquiry’s additional finding that underpinningthis discrimination were deeply ingrained (andoften structurally reinforced) societal attitudesof fear, ignorance and intolerance of mentalillness and mental health disorders. There arenumerous examples of this.

In one 1999 case, for example, an accom-plished Australian academic and professor was

denied income protection insurance on thegrounds that she had a history of depression.Although she had developed and sustained a dis-tinguished career despite her history of depres-sion, was a leader in her field, had nearly 4 monthsof sick leave owing to her, and had rarely taken a‘mental health’ day off from work, the insurancecompany would not reverse its decision. It wassubsequently confirmed that at no time had thecompany contacted her general practitioner orpsychotherapist for an assessment of her condi-tion. When she telephoned the insurancecompany for an explanation, she was told, frankly,that it was ‘company policy’ to always refuse appli-cants who had a history of depression. This con-tradicted earlier advice she had received, notably,that her application would be considered on meritand that, at worst, her history of depression wouldbe made the subject of an ‘exclusion clause’.

After receiving advice that her application forinsurance had been refused, the professorrequested a letter citing the company policy ondepression to confirm what she had been told, sothat she could take further action — specifically,to raise it with the Human Rights Commission.Instead, she received a letter that stated simply:

We considered carefully all the information youprovided, but regret to advise that we mustdecline your application. […] Our decision todecline your application was based on yourmedical details (Letter from ...... to ......., dated5 October, 1999; Pers. comm., confidentialsource).

The professor later described to friends herfeelings of incredible rage at how unjust thedecision by the insurance company was. Her ragewas compounded by her deep sense of vulnera-bility at not having access to a means of protect-ing her income in the event of her beingincapacitated through unforeseen serious illnessor injury. As she was totally self-supporting, thissituation was an understandable source of anxietyto her.

The only thing that calmed her down was therecognition that, as she put it:

If I — an accomplished academic and a profes-sor with an impeccable work record — can’t get

204 M-J. JOHNSTONE

insurance in this instance, what chance doothers have who are less accomplished than I —who are on a lesser income, who are disabled,who suffer from more severe mental healthproblems than do I — what chance do they haveto achieve equitable access to this kind of insur-ance provision? (Pers. comm., confidentialsource).

Initially she planned to go public with her storyand to campaign for all Australians to declare ahistory of depression on their insurance applica-tion forms so that nobody would be eligible forincome protection insurance and then to see howthe insurance companies would fare — given thatsuch action would, in effect, undermine theirbusiness. Friends, however, persuaded her not totake the matter any further out of fear that thestigma associated with her mental health historycould seriously jeopardise her career and publicstanding and that, indeed, her mental healthhistory could be ‘used against her in someway’.To this day, she has not gone public with her story(Pers. comm., confidential source). Until now,her story has not been told in a public forum. Aspokesperson for the company defended theexclusion policy on the ‘reasonable’ and legiti-mated grounds that ‘the company had a duty toits shareholders not to take unacceptable risks’and that ‘a history of depression posed such a risk’(Pers. comm., confidential source).

Another consequence of the stigmatization ofmental illness has been the high incidence ofhuman rights violations that have occurred withinthe mental healthcare sector and the otherwiseavoidable harmful moral consequences thathave flowed from these violations. There arenumerous examples of this, ranging from thefamiliar situation of psychotropic medicationsbeing administered to mental health patientsagainst their considered wishes (Johnstone, 1999;pp. 229–230), patients being restrained unrea-sonably, patients being denied appropriateservices (especially problematic in the case ofpeople from non-English speaking backgrounds,the disabled, homeless persons, and those whoare drug and alcohol dependent), to the prover-bial ‘buck passing’ of responsibility by serviceproviders with respect to persons in a mental

health crisis. A poignant example of the latter canbe found in the case of Mary.

Mary had an 8 year history of paranoid schizo-phrenia. One evening, while driving, she became‘so disturbed by racing thoughts and altered per-ceptions of external stimuli that she felt unsafeand abandoned her car in the middle of a busyroad’. From a nearby telephone box, she rang aprivate psychiatric hospital in which she had pre-viously been a patient and sought assistance(Pers. comm., confidential source). She ex-plained to the nurse who received her call thatshe was ‘too frightened to drive’ in case she hurtother people, and was afraid to go home in caseher estranged husband (from whom she wasbeing divorced) would have her committed as aninvoluntary patient at a local psychiatric facility.Unfortunately, she no longer had any healthinsurance and, her only source of income was aninvalid’s pension. Thus she could not afford to bere-admitted to the private hospital where she hadbeen treated previously. Concerned about Mary’ssafety, the nurse secured the assistance of asecond nurse (who also knew Mary) to keep hertalking on the phone while arrangements for hersafe removal from the telephone box could bemade. Significantly, it took one whole hour beforeMary was ‘rescued’ and when found she was‘exhausted and sitting on the floor of the tele-phone box in tears’ (Pers. comm., confidentialsource). The difficulties encountered in this caseare as follows: (i) when the local police were con-tacted for assistance, their initial response wasthat the woman ‘had already requested assistancein person’ and that she ‘was a nutter who wanteda free ride home’; (ii) when the seriousness of thecase was explained, the police responded bystating they had no car available and that onewould have to be despatched via the PoliceDepartment’s Communication Centre (PDCC);(iii) minutes later the police called back to advisethe nurse that the PDCC had refused to dispatcha car, stating it was the ambulance service’sresponsibility to transport a psychiatric patient(the traffic hazard posed by the woman’s car wasignored); (iv) when contacted, the ambulanceservice responded appropriately and took thewoman to the emergency department of a local

STIGMA, SOCIAL JUSTICE & MENTAL ILLNESS 205

hospital; (v) the hospital, however, refusedadmission to the woman on the grounds that she‘did not live within the hospital’s region’; (vi) itwas recommended that the woman be subse-quently transported to another facility — specif-ically the one she feared; and (vii) some days laterit was revealed that the patient had never arrivedat the local psychiatric facility on the day inquestion; she had refused ambulance transport(out of fear of the designated hospital) andwalked home because her car had been hit bymoving traffic. The following day she was certi-fied because of her ‘deteriorating mental stateand erratic and dangerous behaviour’ and admit-ted into the very hospital she feared (Pers.comm., confidential source).

Had Mary not been suffering from a highlystigmatized health problem (viz. mental illness)there is room to speculate that she may not havebeen treated in such a discriminatory manner byeither the police or the regional hospital thatrefused to admit her.

In recent years significant efforts have beenmade in Australia to redress the problem ofhuman rights violations in mental healthcaresettings, and to provide a framework for assuringthe protection of the moral entitlements ofpeople suffering from mental health problems(see, in particular, the National Mental HealthPolicy [Australian Health Ministers, 1995] andthe Mental Health Statement of Rights andResponsibilities [Mental Health ConsumerOutcomes Task Force, 1995]). However, it isevident that a great deal more needs to be doneto improve the status quo. Certainly, initiativesaimed at educating the public, promotingmental health through mainstream health pro-motion activities, establishing preventativemental health programs as an essential compo-nent of care provision to people at risk of mentalhealth problems, and promoting research, areall essential to promoting better ‘mental healthoutcomes. If, however, there is to be a genuinepromotion and realization of ‘social justice,equity, access and a compassionate society withmental health as a primary goal’ (Raphael, 1995),what is also required is the subversion ofthe stigma that is still so thoroughly attached

to mental illness and other mental healthproblems.

SUBVERTING THE STIGMA OFDIFFERENCE

The mentally ill constitute a vulnerable groupand as such have endured gross violations of theirhuman rights. People who have ‘both a mentalillness and another disability are amongst themost disadvantaged of the vulnerable groups’(Sidoti, Guilfoyle & Hall, 1995, p. 45) and are ateven greater risk of having their human rightsviolated. In many instances these people havebeen denied moral status at all and hence anyclaim to having human/moral rights in the firstplace. The plight of deaf people troubled bymental illness provides a particularly poignantexample of this. In the Report of the reconvenedinquiry into the human rights of people withmental illness (in Victoria), for instance, Sidotiet al. (1995) report that:

deaf people who react to isolation within thepsychiatric hospital setting by becomingagitated are often misdiagnosed and treatedwith sedatives, seclusion or restraints. Usingrestraints to contain a deaf person who com-municates manually is equivalent to gagging ahearing person (p. 54).

Yet, as the report goes on to document, deafpeople have been secluded and restrained as ifthey were wild animals, primarily because theirsign language was not understood, not becausethey were ‘sick’ (Sidoti et al., 1995, pp. 54–55).

An important question to be raised here is howbest can the human rights of those with mentalhealth problems and mental disorders beachieved? How best can we promote socialjustice for this highly stigmatized and extremelyvulnerable group of people?

The short answer to this question is that, first,attention must be given to subverting the nor-malized culture of prejudice and discriminationwhich historically has denied moral status to thementally ill. This will require a concerted effortby all shareholders, including those who sufferfrom mental health problems/disorders and theiradvocates, to dislodge prevailing prejudices via

206 M-J. JOHNSTONE

critique and reform of existing systems of ethicsthat are appealed to conventionally to guidemoral conduct in human affairs. The challenge isnot so much to find or create a new moral system,however, as it is to reinterpret existing moralframeworks and to make them more inclusive ofthose who, historically, have been excluded onthe basis of stereotypical perceptions of their‘otherness’, that is, being ‘subhuman’, ‘inferior’,‘disabling’ and ‘a threat to social order’ and whichare used as criteria for justifying and legitimatingtheir exclusion (the case cited earlier of the pro-fessor being denied income protection insur-ance, being an example). But, it might be asked,from where do we start?

Quoting Michael Walzer (1987; pp. 17 and23), we have to ‘start from where we are’ and stepforward ‘into the thicket of moral experience’. Ashe goes on to explain:

We do not have to discover the moral worldbecause we have already lived there. We do nothave to invent it because it has already beeninvented […]. Insofar as we can recognize moralprogress, it has less to do with the discovery orinvention of new principles than with the inclu-sion under the old principles of previouslyexcluded men and women. And that is more amatter of (workmanlike)[sic] social criticismand political struggle than of (paradigm-shattering) philosophical speculation (Walzer,1987; pp. 20 and 27).

One of the principle tasks of ethics in mentalhealth domains then is not just the promotion ofhuman rights, but the dislodgement of prejudicevia moral reflection and argument. If people’smoral perceptions of the mentally ill are to betransformed, however, ‘nothing less than thereconstitution of the social identity of [this sociallyexcluded group] is required’ (Meyers, 1994; p. 93).According to Meyers (1994), an effective way ofachieving this kind of transformation is throughwhat she terms ‘dissident speech’ which, in thisinstance, can serve to reframe moral perceptionof the mentally ill in order to dislodge the deepseated and normalized prejudice that presentlyexists against them (Meyers, 1994; p. 108).Drawing on the work of Meyers (1994), dissidentspeech can take the following forms:

1. Mental health groups must find imagery thatfrees them from the self-doubt, self-contempt,and self-limitation that compounds institutional-ized oppression.2. Mental health groups must address morethan one audience if they are to achieve theirpolitical goals. Specifically, they must address:(i) sufferers and survivors of mental healthproblems/mental disorders who, as a social groupstriving for solidarity, are otherwise excludedfrom the ‘mainstream’ of society/broader moralcommunity; (ii) other sufferers and survivors ofmental health problems/mental disorders who donot consciously identify as a socially excludedgroup; (iii) other members of socially excludedgroups; and (iv) members of dominant groups.3. Collaborate with social scientists to achievestated goals (adapted from Meyers, 1994; p. 113).

In addition to Meyers’ strategy, we need toensure that there are ‘safe places’ where thementally disordered can go to contain — and tohold — their feelings of disintegration and thealienation they experience as a result, as well asto find someone who is ‘safe to talk to’. As onein-patient reflected shortly before her dischargefrom a psychiatric in-patient facility:

Here I am speaking to you about my feelingsand thoughts; and when I’m discharged, I’ll haveto be tremendously careful about who I speakto … At least here there are any number ofpeople who will listen. But outside the hospital,who is there? Maybe my boyfriend? But evenhe is frightened of what I am … I often thinkabout my discharge, where I will be put, whothey’ll put me with … Do I have to go back homeor to a halfway house? It’s so confusing becauseI feel so homeless, without any place to go, ormaybe nowhere is a place. I just don’t know. Itmakes me so sad; my life, I think, is like a leaf(quoted in Glass, 1989; p. 207).

Finally, we need to develop a different way oflistening to the mentally disordered. As Glass(1989) points out:

The language of madness [sic] requires a dif-ferent kind of listening than do the languages ofscience and of institutional power […]. Thesocial desire not to listen to such languages, tohide them away, to wrap them in scientific

STIGMA, SOCIAL JUSTICE & MENTAL ILLNESS 207

category, may indicate a deep fear of theirmeaning, of their potentially anarchic effect.The language of madness erodes whatMachiavelli called the fortresses of power(p. 21).

It is time that the fortresses of power —especially the power to exclude those deemedsocially deviant because of their mental healthproblems — is eroded and overturned. Not onlyis it time, it is a moral imperative of the first order.

CONCLUSION

In 1999, Professor Lewis Wolpert CBE, a distin-guished British embryologist and an accom-plished broadcaster, revealed publicly how hehad suffered a period of and had been immobi-lized by severe depression. In his book Malignantsadness: the anatomy of depression, he disclosesthat prior to his own experience he had beenunsympathetic toward depressed people stating:

I have to admit that I […] rather sneeringly pro-claimed that I believed in the Sock School ofPsychiatry — just pull them up when feeling low(Wolpert, 1999; p. viii).

He further discloses that his wife was embar-rassed by his depression and informed colleaguesand friends that he was suffering from ‘a minorheart condition.’ He explains:

She was worried that if the truth were known itwould affect my career. When I recovered, I wasuneasy about the stigma associated with depres-sion, and the shame felt by many sufferers; itseemed to me a serious illness of which oneshould not be ashamed. I therefore decided tomake my depression public and wrote an articleabout it in the Guardian newspaper. […] In factit was quite easy for me to write about since Ihad a secure academic position and so nothingto lose (Wolpert, 1999; p. viii).

Wolpert’s story yields many lessons. If he, adistinguished and influential member of society,had such a prejudicial attitude toward depres-sion, what hope is there for those burdened withthe suffering of depression and other mental dis-orders to challenge and change the status quo. Ifhe, a distinguished, articulate, securely employed

and influential member of society felt ‘uneasy’about his condition and his place in the world,how much more difficult must it be for those whoare ‘nonentities’, inarticulate, of non-Englishspeaking background, unemployed, homeless,poor, and disabled to feel at ease with their mentalhealth status and their place in the world.

The moral pathology of prejudice is extremelyresistant to change, as is the ‘stigma of difference’that underpins it (Meyers, 1994; pp. 4 and 43). Itis no small measure of the potency of the stigmaof difference that it ‘may be recreated both byignoring and by focusing on it’ (Minow, 1990;p. 20). As Martha Minow, Professor of Law atHarvard University, explains:

Decisions about education, employment,benefits, and other opportunities in societyshould not turn on an individual’s ethnicity, dis-ability, race, gender, religion, or membership inany other group about which some have depre-cating or hostile attitudes. Yet refusing toacknowledge these differences may make themcontinue to matter in a world constructed withsome, but not others, in mind. The problems ofinequality can be exacerbated both by treatingmembers of minority groups the same asmembers of the majority and by treating the twogroups differently (Minow, 1990; p. 20).

Nevertheless, despite this dilemma, we mustdraw attention to the stigma of difference thatinflicts so much injustice and harm on those suf-fering from mental health problems and mentaldisorders. We all have a moral responsibility toquestion and call into question the status quo; wemust challenge and change the stigma of differ-ence — the stigma of mental illness. For if we donot do these things, and if we do not submit to thekind of ‘social therapy’ that is necessary to fosterthe cultural revolution that is required to subvertthe normalized culture of prejudice that pervadesour community (Young, 1990; p. 153), we will havefailed not just the mentally ill, but ourselves. Howthen do we foster the cultural revolution that isnecessary in order to advance the interests andgenuine moral status of people with mental healthproblems and mental disorders? How are we toachieve social justice for this grossly disadvan-taged and socially marginalized group?

208 M-J. JOHNSTONE

STIGMA, SOCIAL JUSTICE & MENTAL ILLNESS 209

Drawing on the classic work of Martha Minow(1990), cited above, the following three recom-mendations are offered as a first step in theprocess of achieving both cultural revolution andsocial justice; we need to: (i) ‘take seriously theperspective of those [the mentally ill] who havenot been the norm in the past’; (ii) ‘expand thedefinition of who is the same, thus challen-ging the exclusory uses of differences’; and(iii) ‘broaden the definition of difference’ so thatmore traits (including previously devalued ones)‘become relevant to the distribution of a par-ticular benefit’ (adapted from Minow, 1990;pp. 95–96).

When the voices of those troubled by mentalhealth problems and mental disorders are heardin their capacity as value-added diversity to theoverall moral and cultural scheme of things, thenperhaps we can rest assured that the psychic dis-equilibrium and psychic estrangement thatthreatens to overwhelm and disadvantage us allis at last beginning to heal.

REFERENCES

Amato, J. (1990). Victims and values: a history andtheory of suffering. New York: Praeger.

Australian Health Ministers. (1995). National mentalhealth policy. Canberra: Australian GovernmentPrinting Service.

Australian Institute of Health and Welfare &Commonwealth Department of Health and FamilyServices. (1997). First report on national healthpriority areas 1996. Summary. Canberra: AustralianInstitute of Health and Welfare & CommonwealthDepartment of Health and Family Services.

Bloch, S. & Singh, B. (1997). Understanding troubledminds: a guide to mental illness and its treatment.Melbourne: Melbourne University Press.

Burdekin, B., Guilfoyle, M. & Hall, D. (1993). Humanrights and mental illness: Report of the NationalInquiry into the Human Rights of People withMental Illness (2 Volumes). Canberra: AustralianGovernment Printing Service.

Commonwealth Department of Health and Aged Care& Australian Institute of Health and Welfare.(1999). National health priority areas report:mental health 1998. Summary. Canberra: AusInfo.

Glass, J. (1989). Private terror/public life: psychosisand the politics of community. London: CornellUniversity Press.

Johnstone, M. (1999). Bioethics: a Nursing Per-spective, 3rd edn. Sydney: Harcourt Australia.

Keenan, B. (1992). An evil cradling. London: Vintage.McLennan, W. (1999). National survey of mental

health and wellbeing of adults. User’s guide.Canberra: Australian Bureau of Statistics/AusInfo.

Mental Health Consumers Outcomes Task Force.(1995). Mental health statement of rights andresponsibilities. Canberra: Australian GovernmentPrinting Service.

Meyers, D. (1994). Subjection and subjectivity. NewYork: Routledge.

Minow, M. (1990). Making all the difference: inclusion,exclusion, and American law. London: CornellUniversity Press.

Nagel, T. (1979). Mortal questions. Cambridge:Cambridge University Press.

Raphael, B. (1995). Foreword, in Mental HealthConsumers Outcomes Task Force. Mental healthstatement of rights and responsibilities. Canberra:Australian Government Printing Service.

Sidoti, C., Guilfoyle, M. & Hall, D. (1995). Humanrights and mental illness (Victoria): Report of theReconvened Inquiry into the Human Rights ofPeople with Mental Illness. Canberra: AustralianGovernment Printing Service.

Walker, M. (1998). Moral understandings: a feministstudy of ethics. New York: Routledge.

Walzer, M. (1987). Interpretation and social criticism.Cambridge: Harvard University Press.

Wolpert, L. (1999). Malignant sadness: the anatomy ofdepression. London: Faber & Faber.

World Health Organization. (1992). The ICD-10 clas-sification of mental and behavioural disordersclinical descriptors and diagnostic guidelines.Geneva: World Health Organization.

Young, I. (1990). Justice and the politics of difference.Princeton: Princeton University Press.