goodfellow2010

International Journal of Mental Health
ISSN: 0020-7411 (Print) 1557-9328 (Online) Journal homepage: http://www.tandfonline.com/loi/mimh20
Images of the "Insane," the "Mentally Ill," and the
"Depressed" in Nouméa, New Caledonia
Benjamin Goodfellow , Laurent Defromont , Fanny Calandreau & Jean-Luc
Roelandt
To cite this article: Benjamin Goodfellow , Laurent Defromont , Fanny Calandreau & Jean-Luc
Roelandt (2010) Images of the "Insane," the "Mentally Ill," and the "Depressed" in Nouméa,
New Caledonia, International Journal of Mental Health, 39:1, 82-98
To link to this article: http://dx.doi.org/10.2753/IMH0020-7411390105
Published online: 08 Dec 2014.
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International Journal of Mental Health
International Journal of Mental Health, vol. 39, no. 1, Spring 2010, pp. 82–98.
© 2010 M.E. Sharpe, Inc. All rights reserved.
ISSN 0020–7411 / 2010 $9.50 + 0.00.
DOI 10.2753/IMH0020-7411390105
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Benjamin Goodfellow, Laurent Defromont,
Fanny Calandreau, and Jean-Luc Roelandt
Images of the “Insane,” the “Mentally
Ill,” and the “Depressed” in Nouméa,
New Caledonia
A Mental Health Survey in the General Population
ABSTRACT: Social representations of mental health in the population of
Nouméa and its suburbs (Greater Nouméa) in New Caledonia were studied
during the third phase of the survey “Mental Health in the General Population: Images and Realities,” conducted in August 2006. Method: A representative sample of 904 participants taken from the population of Nouméa and
Greater Nouméa were interviewed using the survey questionnaire. Analytical
results were interpreted in the light of the results of the preceding survey, the
specialized literature, and the cultural and social context in New Caledonia.
Results: Data for the social representation of the “insane” person revealed
dehumanizing aspects related to a lack of human features, incomprehensible
behavior, and danger. The social representation of the mentally ill person
Benjamin Goodfellow is a psychiatrist in the Georges Pompidou European Public Hospital
Emergency Department in Paris and a collaborator of the French WHO Collaborating Center
(WHOCC) for research and training in the field of mental health in Lille, France. Laurent
Defromont is a psychiatrist in the public health service, head of the Information and Medical
Research Department (Département d’Information et de Recherche Médicale) of the Lille
City Public Mental Health Center (Etablissement Public de Santé Mentale) and a collaborator
of the French WHOCC for research and training in the field of mental health in Lille, France.
Fanny Calandreau is a psychiatrist in the public health service, head of out-patient care in
the General Psychiatry Department, Albert Bousquet Hospital in Nouméa, New Caledonia,
and a collaborator of the WHOCC for the survey “Mental Health in the General Population:
Images and Realities.” Jean-Luc Roelandt is a psychiatrist in the public health service, head
of sector 59G21 of public psychiatry in Lille, France, and head of the French WHOCC for
research and training in the field of mental health in Lille, France.
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was found to be a medicalized transition of the insane person, bearing more
human and comprehensible aspects similar to those observed in France.
Conclusions: The social representation of the depressed person comprise
cultural variants and may be a promising gateway for campaigns to promote
mental health. The social representation of the insane person comprises
cultural invariants that are more archaic and probably involve universal
features of human disposition (i.e., fear of the unknown in someone who
violates the norms of human behavior). These variations may be essential
to the understanding of exclusionary attitudes.
Historians, philosophers, scientists, and psychiatric practitioners have recently
started focusing on the exclusion of people suffering from mental disorders. This
theme is a main preoccupation of the Mental Health in the General Population
(MHGP) survey [1], as one of its aims is to promote mental health. We analyze the
representations of the general population related to exclusionary attitudes toward
people suffering from mental disorders in the socioanthropological section of the
survey.
Many authors highlight the relation between a population’s knowledge of mental health and their attitudes toward people believed to have a mental disorder.1
In general, lay knowledge, discourse, behaviors, and attitudes concerning mental
health and people identified as suffering from mental health problems are very
heterogeneous. Star [2, 3] reported that the populations she studied appear to have
a good, although heterogeneous, knowledge of mental health that varied within the
population surveyed and among the geographic areas concerned but that coexisted
with stereotyped images and frightening archetypes implicitly although strongly
attached to the mentally ill. Pénochet and Guimelli [4] suggested that the positive
human aspect plays a central role, while the negative, inhuman, and dangerous
aspect plays a peripheral role in the structure of the representations. This assumption remains to be confirmed, but there is apparently a clearly stratified structure
to the thinking, attitudes, beliefs, and behaviors related to the vast fields of mental
health, insanity, and psychiatry. There appears to be no interchange or communication between the strata. This heterogeneity could explain why it is so difficult to
find a single common word to use when talking about mental health.
The Concept of Social Representation
According to Jodelet [5], a social representation is a “socially elaborated and shared
form of knowledge that has a practical aim and plays a role in constructing a social
group’s reality” (p. 53; see also [6]). This concept was introduced by Moscovici
[7] in 1961, inspired by the works of Durkheim. Its complexity arises from the fact
that it spans many fields of human science. The main difficulty in understanding a
social representation, however, is that it is both a psychological and a social concept
and therefore combines individual and collective dimensions. One particular field
that has specialized in its study is social psychology.
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To understand the implications of the concept social representation, it is worth
examining Jodelet’s [6] definition in detail. A social representation is “socially
elaborated and shared,” meaning that it is created and is necessarily transformed
whenever an interaction or an exchange occurs (i.e., when language is used to communicate) (p. 53). It also means that it is not only the sum of several individuals’
representations but only exists on a collective scale. Social representation defines a
collectivity in that the members of a social group can recognize each other through
it. The form implies that a social representation is a semiotic concept; it takes the
place of something else. It signifies or designates something by the particular form
it takes, just as the shapes of letters form a word. It is a piece of knowledge, which
means that it is definite, not questionable, like reality. It has a practical aim, which
implies that it is used to exert an action on the environment or on other people. Only
unquestionable knowledge can be used for action, which requires an absence of
doubt. The social representation “plays a role in constructing a . . . reality” in that
it is knowledge (p. 53). Jodelet provided an example that illustrates the point. At
the beginning of the AIDS epidemic, before scientists provided any clear, reliable
information about the virus, many lay theories were put forward concerning its
origin and how it was transmitted. These lay theories appear to have led to attitudes
of exclusion that were often inappropriate to the disease. This “reality” is a social
group’s reality. It relates to what has been said before and implies that a group, a
collectivity, or a sum of individuals must share the same reality to be defined as
a social group. This reality is constructed using—among other elements—social
representations.
Study Site
New Caledonia is a set of Melanesian islands and archipelagoes in the South Pacific
Ocean. According to Kirch [8], it was settled in 1,000 b.c.e. The first inhabitants
were descendants of the Austronesians who left Taiwan at least 500 years earlier.
These people then populated all the remaining islands in the Pacific Ocean. According to Angleviel [9], New Caledonia has been known to Europeans since its
discovery by J. Cook in 1774, and it officially became French in 1853. New Caledonia was successively a penitentiary, a settlement, and a mining colony, and its
main economic activity is now nickel mining.
According to Angleviel [9] and Barbançon [10], slightly more than one-half of
the population is composed of Kanaks (i.e., descendants of the first Austronesians);
the remainder is composed of Europeans, that is, descendants of convicts and of
the French colonial and penitential staff, or recent Europeans immigrants, most
of whom were born in France, as well as descendants of the black birding communities (i.e., the regional workforce hired at the end of the nineteenth century
to build the colony)—most of whom came from New Hebrides, Indonesia, Wallis
and Futuna Islands—and finally, recent immigrants from the Pacific, China, and
Vietnam.
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Method
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Sample and Questionnaire
The representative sample was comprised of 904 people taken from the population
of Nouméa and its suburbs, Païta, Dumbea, and Mont Dore (i.e., Greater Nouméa;
total population = 146,000). The sample was constructed using the quota sampling
method, with data taken from the New Caledonian Institute of Statistics and Economic Studies (Institut de la Statistique et des Etudes Economiques de Nouvelle
Calédonie: ISEE) and from the last census (in 1996), adjusted for the time of the
survey. This survey was part of the general MHGP [1] survey, Nouméa being one
of its third-phase sites. For a more detailed description of the method used in the
present study, see the companion part of this work [11], which describes the epidemiology of mental disorders in Nouméa and Greater Nouméa investigated in the
same survey. Three open-answer questions (whose answers are analyzed herein)
were included in the socioanthropological section of the survey questionnaire and
were asked at the beginning of the interview, following a general presentation of
the goals and methods of the study during which the interviewees were informed
that they would remain anonymous and after their informed consent was obtained.
The three questions (asked in French) were: “In your opinion, what is an insane
person?” “In your opinion, what is a mentally ill person?” and “In your opinion,
what is a depressed person?” The three questions were asked in random order to
avoid any statistically significant interference between the questions. The answers
were recorded word for word by the interviewers, who had previously been trained
in a three-day session.
The three items, “insane person,” “mentally ill person,” and “depressed person”
(in French), came up in a preliminary survey based on unstructured interviews
in a test population selected from a range of international sites covered by the
MHGP survey. Data collected during the interviews were analyzed by an expert
committee including various specialists. After a number of validation steps, the
socioanthropological questionnaire was constructed using questions concerning
three archetypes called the “insane person,” the “mentally ill person,” and the
“depressed person.”
Analysis of Answers Using ALCESTE
Analysis of the answers given by the 904 interviewees (2,695 answers were taken
into account) required a statistical tool that could summarize the answers in a comprehensible way. Accordingly, we used the Analyse des Lexèmes Cooccurrents dans
un Ensemble de Segments de Texte (Analysis of Lexemes that Co-Occur in a Set of
Text Segments; ALCESTE) program [12, 13]. It reveals words or lexemes (i.e., the
grammatical root of the words that co-occur in text segments). According to Reinert
[13], the co-occurrence of particular words in context units (the text segments)
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International Journal of Mental Health
Figure 1
Hierarchical Descending Classification
Cl. 1 ( 494uce)
+
Cl. 2 ( 357uce)
+
+
Cl. 3 ( 744uce)
+
Cl. 4 (1082uce)
+
+
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+
obeys certain rules, and these rules are determined by the person who speaks. The
ALCESTE method is based on the hypothesis that when people talk about a topic,
they associate particular words in a particular way. By analyzing co-occurrences
of particular words in particular context units, the program defines a set of classes
or an arborescence of classes that becomes increasingly narrow. The entire text is
initially considered as a single theme (i.e., the subject of the text). However, minor
themes can be revealed in the text. ALCESTE uses this idea and creates an arborescence called a “hierarchical descending classification,” which is illustrated by a
dendrogram (see Figure 1). The relevant number of classes (or themes) is defined
by the software. The classes are clusters of co-occurrences of particular words. As
previously mentioned, co-occurrence is studied in text segments or context units.
In our methodology, the context units are the answers given by each interviewee
(they are short and correspond to the repetition of the same question); we did not
use the random segmentation and double analysis proposed by ALCESTE. The
co-occurrence of lexemes is determined statistically. Simultaneously occurring
(co-occurring) words are given χ² association coefficients. The higher the χ², the
less the allocation to a class can be due to chance. A class (or theme) is defined by
a list of words that are strongly linked to this class. This allocation makes it possible to determine the answers with the strongest statistical link to a class (i.e., the
most typical answers for a given theme).
ALCESTE not only defines classes with which particular co-occurrences of
words are associated, but it is also possible to associate indicators with them.
For instance, by defining a rule that the context unit is the answer given by one
interviewee to one of the three questions in the questionnaire (i.e., the elementary
context unit [ECU]), a group of answers called the initial context units (ICU) can
be determined, which shows whether the themes are associated with the proposed
indicators.
The lists of words must be placed in their respective contexts (the ECUs), but
the meaning of the co-occurrence of words must also be found, as in component
analysis. The designer of the ALCESTE program stresses that an analysis of this
type can only provide working hypotheses: χ² is only an index and cannot be
considered a probability.
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Answers were analyzed in two steps, applying the method used by Defromont
[14, 15]:
• A primary analysis of the answers to the three questions provided information
on the relevance of the three archetypes used.
• A secondary analysis examined the composition of the three representations
in more detail.
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Results
ALCESTE analysis of the text containing the 2,695 answers from the 904 interview­
ees yielded a four-branch dendrogram (see Figure 1) corresponding to four main
classes. One of the classes corresponded to answers concerning the insane person,
one to answers concerning the mentally ill person, and two classes concerned the
depressed person. Three classes were obtained in the secondary analysis involving the answers to the question, “In your opinion, what is a depressed person?”
All the classes are illustrated by lists of words with their respective χ² association
coefficients. The words are put into context using the ECUs related to each class.
Instead of providing lists of meaningless words, we prefer to describe the themes
revealed by interpretation of the data. For a more detailed description, see Goodfellow [16].
For details of the ALCESTE analysis of the answers to the three questions during the first phase of the MHGP survey (1998–2000), see Defromont [14, 17] and
Defromont and Roelandt [15]. The surveys were conducted in the Indian Ocean,
France, and French Guadeloupe. We used Defromont’s work for comparison and
to shed light on the results of this study.
Primary analysis of the representations of the insane person (Table 1) reveal two
themes in Nouméa; one is related to deficiency, and the other, to behavior.
• The first theme in the social representation of the insane person is related to
deficiency. It can be found with slight variations at all the sites. In Madagascar,
the insane person is considered to be lacking reason and self-control; in Grand
Comore and Mauritius, to have altered human functions, including reason;
and in France, to lack reason, self-control, and responsibility. In Nouméa,
the insane person has lost the ability to reason, to perceive reality, and to be
aware of his or her actions.
• The second theme in the social representation of the insane person describes
behavior. In Madagascar, the behavior of the insane person is noticeable
because it transgresses moral standards. In Grand Comore and Mauritius,
the person’s behavior (and speech) is absurd and violent. In France, it is
meaningless and incomprehensible and is also directly related to danger. In
Nouméa, what the insane person does plays a central role in the definition
provided by the interviewee. The verb does is overrepresented. The person
does meaningless, strange, and unpredictable things, which imply danger.
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International Journal of Mental Health
Table 1
Representation of the Insane Person at Different Survey Sites
France
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Madagascar
Grand Comore
Mauritius
1st
representation
2d
representation
Nouméa
• Amoral, inde- • Absurd
• Altered
• Word insane • Strange and
cency, nudity,
and violent
relation to the
criticized:
incomprehenrelated to filth, behavior
world and to
negative word sible behavior;
wanders
society
to replace
danger
• Failure, defiaround
mentally ill
cient intellec- • Deficiency
• Deficiency
• Deficiency
tual
(intellectual)
• Deficiency
(loss) of rea(unreason(incapacity)
son, of his or
functions.
able, not
• Various origins:
• Health-care in her sense of
thoughtful)
reality, of conmental fatigue,
a psychiatric
scious behavior
troubles, drugs
environment
The central themes revealed in Nouméa were sometimes found at other survey
sites to be related to the social representations of depression and mental illness,
implying that the concepts are not well differentiated.
The social representation of the mentally ill person (Table 2) is strikingly similar
in France and in Nouméa. The mentally ill person has a disease, in contrast with the
insane person who simply is insane. The specialized vocabulary used implies that
the mentally ill person is comprehensible in medical, psychological, and psychiatric
terms. The mentally ill person has become more accessible than the insane person,
at least to specialists, and needs treatment and medication. Heredity is an important
aspect in France and in Nouméa: mental illness occurs at birth; it is genetic. On the
other hand, in Nouméa, the descriptions of the mentally ill and the insane do not
overlap as they do in France and in surveys in the Indian Ocean. This difference
may be due to the time interval between the first phase surveys (1998–2000) and
the survey in Nouméa (August 2006). Jorm, Christensen, and Griffiths [18, 19]
reported a major change in the attitudes of Australians toward mental health issues
over a period of eight years, which could be true for the Noumean representations
of the mentally ill and the insane.
The descriptions of the depressed person in Madagascar and Grand Comore
resemble the descriptions of the insane person (Table 3). In Mauritius, however,
the descriptions of the depressed person resemble those in France and Nouméa
(Tables 3 and 4). Three subcategories can be identified in the representation of the
depressed person in Nouméa (Table 4). The first is a phenomenological category
very similar to the humoral theory proposed by Defromont [14, 15, 17] in France:
It is a descriptive category describing a state of mind or a disposition. The second
category is also quite close to the humoral theory, although more explicative than
the former category. This state is a medicalized category and describes a frail and
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Table 2
Representation of the Mentally Ill Person at Different Survey Sites
France
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Madagascar
Grand Comore
• Abnormal
or strange
behavior
and way of
speaking
• Deficiency:
lack of conscience and
self control
• Very similar
to the insane
person
Mauritius
1st
representation
2d
representation
Nouméa
• Tired and
• Disease,
• Insane person • Disease, use
affected
specialized
and mentally
of medical,
vocabulary
ill person very psychological,
• Role of stress
similar: altered psychiatric
and alcohol as • Heredity, psyrelation to real- terms
external stress chic/physical
ity and to the • Heredity, cerefactors
ambiguity
world
bral impairment
• Must undergo • Danger
•
Moments
of
treatment
lucidity
ailing constitution explained by the “lack of something.” The third category can
be compared to the nervous theory described by Defromont [14, 15, 17] but with
two peculiarities: explosiveness and alcohol/drugs.
The answers given in Nouméa to the question, “In your opinion, what is a depressed person?” were analyzed according to the different ethnic communities. The
results of the analysis are not given here as the sample was too small, but they suggest that (a) phenomenological traits were more readily attributed to the depressed
person by Europeans born outside New Caledonia and by Europeans born in New
Caledonia; (b) constitutional and medicalized traits were attributed by Europeans
born outside New Caledonia (born in France for the most part); (c) Europeans born
in New Caledonia tended to attribute sadness, weeping, and explosiveness to the
depressed person; and (d) Kanaks tended to attribute addictive problems, loss of
control, and danger to the depressed person. This description resembles that given
for the insane person and suggests that the representations of the two characters
are not clearly individualized in the Kanak community in our sample.
Discussion
Beyond the limits related to the representativeness of our sample with respect to
the general population of Nouméa and Greater Nouméa, the aim of this survey is
to reveal the social representations related to exclusionary attitudes toward people
suffering from psychic disorders. Sperber [20] stressed the importance of using
an epidemiological type of approach to cultural representations, which are a form
of social representation. He argued that the epidemiological type of approach is
a complement to the anthropological type of approach, as it can identify variants
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International Journal of Mental Health
Table 3
Representation of the Depressed Person at Different Survey Sites
France
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Madagascar
Mauritius
• Abnormal • Fatigue,
behavior
loss of
• Deficiency: courage,
sadness
memory,
con• Troubles,
science,
alcohol,
knowledge, drugs
reason,
control
• Harmful
events,
trouble
1st representation
2d representation
• Humoral • Nervous
theory
theory
• Symptoms: • Nervous dischanging
ease, loss
mood,
of control of
pessimism, nerves
bleak
• Accumulaoutlook,
tion/catharlack of
sis.
motivation, • Origin: emosuicide
tional shock
• External
origin (personal or
professional shock)
Nouméa (general analysis)
1st representation
2d representation
• Phenom• Social/ envienological
ronmental
• Sadness, • Gets worked
weeping,
up, has
bleak outexplosive
look, suicide outbursts
• Nervous.
• Sensitive,
• Vanquished, drinks alcohol.
isolation
• Victim of his
or her environment,
family, or
professional
problems
Table 4
Representation of the Depressed Person in Nouméa (Second Analysis)
1st representation
Phenomenological/
humoral
• Weeps all the time, mood
swings
• Sadness, bleak outlook,
lack of motivation, suicide
2d representation
Medicalized
• Psychological and nervous disease
• Fragile constitution
• Lacks something
3rd representation
Aggressive/ explosive
• Gets angry/ has outbursts
• Alcohol, cannabis
• Family problems, needs
help, needs to talk
and invariants in these representations and help clarify what makes them vary (or
not vary). In our approach, the investigation of social representations is based on
the repetition of answers given by an entire population. This repetition was used
to reveal the main trends that structure social representations.
In our methodology, the opinion of the interviewee was respected and the
questionnaire was totally anonymous: No one can be traced. This anonymity
was important in ensuring the freedom of speech of the person who accepted the
interview. The questions were simplified as much as possible so that they could
be clearly understood.
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The Depressed Person in Nouméa: The Variant
As previously discussed, the aggressive/explosive and addictive type of depressed
person specific to Nouméa and Greater Nouméa intermingles with other types of
description. The depressed person appears to be the most heterogeneous of the
three representations. To shed light on these particularities, we should turn to the
works of Salomon, an anthropologist working in New Caledonia, and colleagues
[21–23].
Bensa and Salomon [21], who studied field data and New Caledonian legal archives to investigate the relation between Kanaks and the legal system, reported a
close relation between alcohol consumption and violence in the Kanak community.
The authors stressed the particular role of alcohol in Kanak culture and that it did
not exist before the arrival of the first Europeans. In spite of colonial measures
aimed at limiting it, alcohol consumption has reached considerable proportions
since then. Consumption of alcohol is said to have originally been a mainly male
activity related to manly values. One important finding of these authors was that
the traditional Kanak authorities tended to consider alcohol consumption as benign
and very often, if not an excuse, at least an attenuating circumstance for violent
behavior, especially violence against women. Alcohol use/misuse was reportedly
a frequent source of conflict with the French legal system.
In another survey of female members of the general population in New Caledonia, Hamelin and Salomon [22] analyzed the relation between kinship and violence
against women and the ethnicity related to violence within the family. This survey
was based on the observation that in New Caledonia, the family is perceived as a
source of protection and solidarity in a society that fails to structure individuals,
which may be due to the absence of alternative socializing institutions. However,
the survey was also based on the observation that the family represents a space
where violence, especially gender-based violence, is created and reproduced. The
authors reported that economic and communitarian cleavages often overlap and
that the colonial history is still a very sensitive issue. The colonial past has reportedly led to an unbalanced sex ratio with a higher proportion of males, which could
also explain why the representations have been profoundly marked by violence
against women. Accordingly, the survey results showed that 14 percent of women
interviewed had been molested by a relative in the 12 months preceding the survey,
most of them being young Kanak women with no income of their own. The results
suggest that adopted women are more vulnerable and that gender-based violence
often continues from childhood and adolescence (18 percent of the women were
sexually molested before the age of 18 according to all authors) to adulthood.
In another survey of the general population investigating the relation between
alcohol and violence against women, Hamelin and Salomon [23] reported social
and cultural differences in alcohol consumption and in violence within couples.
Concerning gender-based violence, young Kanak women living in rural settings
were found to be the primary victims of violence, especially women living in the
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International Journal of Mental Health
Loyalty Islands. These authors observed that excessive alcohol consumption by
women (six or more glasses on a single occasion, six times or more per year) is
widespread and is a recent phenomenon related to social and cultural changes in
the past few decades in New Caledonia. However, the excessive alcohol consumption by women is far below that of their male partners, which has a major impact
on levels of physical and sexual brutality. Excessive consumption of alcohol by
women was found to be related to psychological distress.
The results of the epidemiological axis of the MHGP survey in New Caledonia
described in the companion part of this article [11] reveal that the prevalence of
mental disorders is higher in Nouméa and the Greater Nouméa than in France but
that the overall distribution of mental disorders is similar except for disorders related to alcohol use, drug use, and post-traumatic stress disorder, which are more
common in New Caledonia than in France.
The observations of the surveys previously mentioned could explain the overrepresentation of disorders related to alcohol consumption, drug use, and post-traumatic stress disorder. They could also explain the characteristics of the depressed
person specific to Nouméa and Greater Nouméa, where the depressed person is
described as being subject to explosive outbursts, anger and is thus likely to be
violent, drink alcohol, and to have family problems that he or she does not talk
about. The family aspect in the socio-environmental dimension of the depressed
person described by the Kanaks interviewed in our survey suggests a link with
Hamelin and Salomon’s [22] survey on violence and kinship. The depressed person
could be considered to be a vector of representations of psychological suffering
with which any individual can identify without fear of being considered insane.
This vector should thus become familiar and inherit traits related to social and
cultural facts in the population to which the individual belongs. In our case, the
depressed person encountered in Nouméa, especially in the Kanak community,
could indicate the existence of a relation between the representations of alcohol
use and violence, on the one hand, and psychological suffering, on the other. Our
epidemiological method enables us to illustrate quite obviously the results of the
socio-anthropological surveys we have mentioned.
The Insane Person: The Invariant
As previously mentioned, the perception of the insane person is international; that
is, an insane person is defined in the same way all over the world. This definition
calls to mind the works of Star [2, 3]. In 1950, she conducted a pioneering survey
on a representative sample of 3,500 individuals taken from the general population
of the United States. The aim of the survey was to analyze the place of mental illness and psychiatry in popular thinking. The method was the same currently used
in similar surveys throughout the world. The three main themes observed were the
following: (a) deficiency of intellect or loss of reason, (b) loss of self control, and
(c) lack of responsibility for their actions. The behavior of the mentally ill was
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also perceived as not being appropriate in the context. Normal people are supposed
to make their behavior comprehensible. If they cannot, their mental health can
be questioned. Star concluded that the mentally ill were considered to have lost
human characteristics, were completely dehumanized, and because of the loss of
reason, self-control, responsibility for their actions, and their incomprehensible
behavior, they were perceived as dangerous. Indicators of exclusion of the mentally
ill were overwhelmingly present (two-thirds of the population interviewed). The
mentally ill frightened them. Star concluded that although psychiatric knowledge
was widespread in the population, fear was still very present because of the stereotypes revealed in her survey. She optimistically referred to it as a transition
period during which advances in science and understanding had not yet had time
to change perceptions and stereotypes related to mental illness. Fifty-six years later,
perceptions are the same according to our survey.
The American definition of the mentally ill person corresponds to that of the
insane person in the MHGP survey. These definitions basically have two dimensions:
loss or deficiency, on the one hand, and behavior, on the other. The former relates
to the loss of, or deficiency of, human characteristics (e.g., intellect, conscience,
reason, and control). The insane are not human; they are altered. This trait is related
to the behavior of the insane who cannot be understood; their behavior does not fit
any norm and cannot be recognized (i.e., it is unpredictable). The behavior is thus
dangerous and, therefore, makes insane people dangerous (not to mention their loss
of behavior control). According to U.S. interviewees in the 1950s, the mentally ill
are not responsible for their actions, as the insane are not in the MHGP survey.
Loss or deficiency appears to characterize the insane” There is no explanation
for it: This is simply how it is. The behavior can be compared to a stigma, making
them stand out from others, visible from afar. There is no need to talk to them to
see that they are insane. This behavior also makes them dangerous, because they
are unpredictable and incomprehensible. There is little reflection involved. It is
more like a chain of reflexes, more automatic than reasoned, as it is not understood.
The dimension of loss simplifies comprehension.
Star [2, 3] already showed that this representation is related to a strong level
of exclusion. The MHGP survey results suggest that the mentally ill person is a
medicalized insane person. Supposedly, then, the mentally ill person should be less
subject to exclusion, but this outcome does not appear to be the case. The cause of
mental illness becomes physical and is consequently medicalized, giving medicine
all rights in treating and controlling the mentally ill person. This definition explains
how the population can identify with a depressive person but not with an insane
person and even less with a mentally ill person.
Conclusion
Our results suggest opposing distributions of social representations concerning
the insane person and the depressed person. One appears to be homogeneous and
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International Journal of Mental Health
possibly universal (i.e., insane person), and the other appears to be heterogeneous
(i.e., depressed person). Social representations concerning the depressed person
are matched the peculiarities of each cultural group, as if each group develops its
own image of the depressed person using familiar and acceptable features that
characterize the group when something goes wrong with one of its members. On the
other hand, representations concerning the insane person depend much less on the
cultural context. The designation of the person’s behavior appears to be a stigma.
Intermediate elements can be observed between these two images and distributions.
In our survey results, these elements were based on medicalized vocabulary. The
description of the mentally ill in the MHGP survey is one illustration of this trend,
even if it tends to be closer to a medicalized insane person than a depressed person.
However, different transitional elements can also be found in the description of
the depressed person.
Using the image of the depressed person may prove to be valuable in prevention programs and in fighting the stigma attached to psychiatry and its users. Our
results suggest that it is an acceptable character in the social representations of the
populations we interviewed. As previously mentioned, the “depressed person” is
familiar, human, a comprehensible character with whom we can identify without
being afraid. This image opens the way for psychiatry and its users to become more
popular and more acceptable in society, and possibly even a way to counter the
exclusionary attitudes the users may suffer from. These images were used during
the “Defeat Depression” campaign in Great Britain [24, 25] and the “Beyondblue”
campaign in Australia [18].
Fighting stigma and exclusion is a concern for many other fields in our society,
and other professionals and the users of psychiatry themselves have much to offer.
If fear of the incomprehensible is international (or even universal) and fundamental
in human disposition, then the fight against stigma and exclusion may never end.
The represented object to which fear is attached may change at each step of the
fight. The goal may, in fact, not be to eliminate inevitable fears but rather to redirect
them. We have seen that the images of the insane person and the mentally ill person
are too deeply anchored to allow modification. Identification is thus impossible,
and trying to change these images would be useless. It is preferable to use the image of the depressed person, with which people can identify. For instance, when
the interviewees of the MHGP survey who had a disorder detected by the MINI
were asked if they had been cured for insanity, mental illness, or depression, the
majority answered depression. This redirection does not involve stigmatizing new
populations but rather fighting policies that tend to do so and questioning current
stigmas. The point is to encourage flexibility in human thinking by questioning the
tendency to remain stubbornly attached to particular attitudes.
Note
1. See Star [2, 3], Link Phelan, Bresnahan, Stueve, and Pescosolido [26] and Masuda
et al. [27] in the United States; Angermeyer and colleagues [28–32] in Germany; Jorm and
Spring 2010
95
colleagues [18, 19, 33–36] in Australia; Paykel and colleagues [24, 25] during the “Defeat
Depression Campaign”; Crisp, Gelder, Rix, Meltzer, and Rowlands [37] during the “Changing
Minds” campaign, to which the Lancet dedicated a special issue [38–43], and Haghighat [44,
45] in England; Pénochet and Guimelli [4], Livet [46], and Gaussot [47] in France; and other
authors worldwide [48–54]. Authors such as Elks [55], Stark Paterson, and Devlin [56], and
Farrow and O’Brien [57] analyzed the way the media deal with mental health issues.
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