By Koh Li Lian
What is Oppression?
Mary Rogers (1997), in sharing on feminist ideas, defines oppression as “an experiential notion” and referred to “how people in the lower reaches of social hierarchies react over time by way of their identities and emotions”; and a measure of “the toil of social hierarchies and systems of domination on the more dominated”. The concept of the dichotomy of men and women parallels the concept of abnormality and sanity. The ‘sane’ persons often dominate persons who are deemed to be ‘abnormal’ due to their mental states.
Adam Podgórecki’s (1993) definition of oppression as “an external or internal man-made limitation of the available options of human behaviour of an individual or a group” strikes a chord with me. Oppression can be experienced publicly or privately, does not exist naturally and may be directed to an individual or a collective group. He speaks of false consciousness, which indicates that oppression could appear in covert and implicit forms and may not be explicit to the public’s eyes, such as in racial domination and oppression of females.
Social oppression refers to man-made oppressions and reinforces conformity towards social norms. Oppression, in this case, signifies disputes between opposing interests and perspectives and the level of oppression depends on the strength of the dominated and the dominator (Podgórecki, A., 1993). Sometimes, the dominated may prevail over the dominator when they fight for their rights.
Social oppression is observable in the mental health system, which deals with people whose behaviour deviates from the normative social and cultural expectations of the society. Thus, boundaries and rules are set for such persons who do not conform to societal norms. Social institutions are set up to accommodate persons with mental illnesses. During times when these systems are not able to accommodate them, some may end up in the legal and judicial system.
Stigma occurs when a person deviates from the social norms and thus, the public view him or her as less whole and less human. Persons with mental health problems may also experience self-stigma, which involves discrimination of self and seeing oneself as less perfect as compared to the collective group.
Different professionals may hold different perspectives about mental disorders, which in turn would affect their responses towards persons who exhibit differing social behaviours. How do we respond to them in humanistic ways and not always from the expert positions? Do professionals necessarily know more or know everything? Often times, the treatment and perceptions of persons with mental disorders depend greatly on the treatment team dynamics, which is largely determined by the management and treatment style of the doctor in charge. Doctors are seen as the leaders of the mental health team, largely due to their professional standing in the medical field. But do they necessarily know the best? How can we bridge a compromise between the medical model, social model and consumer model of mental healthcare?
Mental health institutions in Singapore, such as the Institute of Mental Health (IMH) and step-down care services, are beneficial in helping persons with mental health problems access services. But they may also oppress them.
Erving Goffman (1961), in his paper on ‘Total institutions’, speaks of oppression in mental hospitals, which are places set up to care for people who are assessed to be incapable of looking after themselves and thus, pose threat to the community, though unintentionally. In a mental institution, such as IMH, routines, which serve to maintain structure, may be oppressive for patients. For example, when a person is admitted to the hospital, he would need to abide by all rules and the way that the rules are being administered may not always be humanistic. They enjoy little privacy and every move is watched and calibrated for them.
How then can space be organized in IMH such that patient’s rights to privacy and best quality care are respected and acknowledged? How can professional staff continue to practise with human touch and critical thinking despite being burdened by audit procedures and paperwork? The struggle is in practising with a critical and inquiry mind and passion in the heart to benefit the patients in a social institution laden with bureaucratic procedures and rational-legal authority.
Oppression and Power
Oppression is closely linked to the notion of power. According to Michel Foucault, power and knowledge are unavoidable linked closely (Hunt & Wickham, 1994). He went on to assert that the “exercise of power is through the production and dissemination of truth” and “knowledge is a major source of power”. So how is truth produced and disseminated?
Foucault opined that truth is generated by discourses, which determines how certain ways of thought processes, speech and action came about and are organized. Discourses are articulated through the use of language and words, which denotes certain meanings. Meanings need to be understood within ‘institutional practices’, which takes into account the context or environment where people live in.
For example, how one understands the concepts of mental illness and mental health is largely determined by their ideas of social and cultural norms, which are generally set by people in power and of high standing in the society. The discourse of mental illness in Singapore determines what gets to be included or excluded and what needs to be acted on or not in the social, political and legal contexts in Singapore. As such, if the belief that ‘people with mental illness are aggressive and violent’ were taken as the truth, people would react with more angst when they hear of media reports of mentally ill persons who commit acts of aggression, although research indicates that they are no more violent than the general population (Chang, A.L., 2007; Elbogen, E.B., Johnson, S.C., 2009).
To take this a step further, Herbert Blumer (1969) offers a different perspective through his discussion on symbolic interactionism. He asserts that meaning is created in the process of interaction between people, who act or respond toward the actions of others based on their interpretation of the meaning behind the actions. For instance, if I believe that a person, who speaks weirdly to me, is trying to make fun of me, I would probably turn hostile and retaliate by telling the person off. Alternatively if I hold the perspective that the person might be doing so because of a difficult grasp of the local language, I would respond by asking the person to clarify what he is saying. My perspective of the reality affects my actions and responses towards the other person, who then responds based on his or her interpretation of my responses towards him or her. This may be termed as ‘point of view’, which depends greatly on how one interprets reality.
These perspectives are made up of words and people make sense of situation through the use of words. For instance, if I call a person ‘mad’, it could mean that this person is mentally unwell or that this person is angry. If one thinks the latter, one may react by scolding back as one is also influenced by another perspective that ‘one should not lash out at another person, just because one is angry’. Alternatively, if one empathises that this person who is ‘mad’ may be having a bad day at work, one may respond with a calm and comforting voice, asking after the person who is described as ‘mad’.
The social world is organized based on which discourse and perspective takes centre stage at a given time and depends largely on who articulates them. For instance, mental health issues were largely neglected for many decades until it landed on the table of the politicians in year 2007 with the enactment of the National Mental Health Blueprint. Since then, more emphasis was placed on the development of mental health resources, including manpower increases, enhancing the training and career prospects of mental health professionals, training of general practitioners in identifying and treating mental disorders in the community, networking with community partners to battle stigma and the expanding of community mental health teams. These are commendable efforts in advocating for the mental health scene and at deinstitutionalization in Singapore but more needs to be done.
Implications for Social Work
As much as clients experience stigma and oppression, psychiatric social workers often also experience oppression in their work. For instance, they tend to experience rejection when applying for step down care facilities for their clients, as most facilities do not cater for persons with mental illnesses. How can psychiatric social workers speak such that their representations of clients’ voices are heard and how may they enhance the competence of clients who can then get their voices heard by others?
Confidentiality is highly valued in the mental health system. This creates a double jeopardy, as with confidentiality, mental health professionals are cautious in releasing information and in this process, it creates mystery and increases lack of understanding, resulting in impediments in speaking up for persons with mental disorders. It also prevents mental healthcare from public scrutiny. How can we then manage confidentiality sensitively and appropriately such that relevant personnel, be it partners in external agencies or the media, are able to gain access to sufficient and relevant information to aid their work with our clients?
Psychiatric social workers often have to comply and deal with increasing paperwork, which tends to limit the time spent with clients. Audit procedures are implemented with good intents but when translated into work protocols, the planning and execution may at times be hasty. How can bureaucratic procedures be managed more effectively?
Increasing Client Competence
It is vital that clients are assisted to find a voice for themselves, so that their concerns and needs are heard and recognized by the society. Rather than acting on clients’ behalf, social workers need to focus on ways to empower clients to stand up for their rights. For instance, social workers can educate clients in accessing services and in requesting for relevant medical information from their treating doctors, so that they can make informed choices about their treatment.
Research, Advocacy and Policy
How can social workers play key roles in advocating for the rights of persons with mental health problems? Social workers should incorporate research, advocacy and policy work into their everyday work and see them as interrelated entities, and not as secondary work, which can only be fulfilled ‘when I have more time’. Policy and research go hand in hand and cannot be separated. When we publish journal papers and our research work, it signifies a soft approach in advocacy work, which when supported by policy makers, may be incorporated into policy-making.
It is also vital that we maintain good links with the media as they can help to highlight the positive elements of mental health problems, rather than merely surfacing major negative news, which only touches the tip of the iceberg. A balance has to be struck between maintaining confidentiality and advocacy through media.
There is a long way to go in enhancing community services in mental health but having a good start signifies a battle half won. More community services need to be established, including enhancing the client-staff ratio of the community mental health professionals who can then know all their clients better and establish close rapport, so as to ensure good treatment and recovery outcomes.
Mental disorders and Law
Many persons with mental disorders often need prolonged psychiatric treatment but many tend to default treatment. Some may end up committing crimes, when they are mentally disturbed. A study done across five jails in Maryland and New York reveals that the prevalence rate of inmates with serious mental illness was 14.5% for males and 31.0% for females (Steadman, Osher, Robbins, Case & Samuels, 2009). Prison is often not the best place for offenders who have mental disorders and commit petty crimes, as these persons may not receive the best psychiatric care. It is not beneficial for persons with mental disorders to be imprisoned, as they are often more vulnerable to abuse and neglect in the prisons and more susceptible to ‘contamination’ by other hardcore criminals.
With the implementation of the community-based orders, in place of imprisonment, such as the Mandatory Treatment Order (MTO) in January 2011, some gaps are addressed. But they are not all encompassing and there is need for further research and scrutiny to enhance the acts.
Embracing Diversity and Celebrate Differences
Not everyone values diversity and most fear people different from who they are. Social workers work with oppressed people and in the mental health arena, social workers play a key role in advocating for a change in the social conditions of persons with mental health problems, so as to ensure equal opportunities for all to realise their potentials and to live their lives to the fullest.
According to the SASW Code of Professional Ethics (2004), “social workers avoid discrimination and prejudice, respect individual differences and accept that professional responsibility must take precedence over personal aims and views”. It is every social worker’s duty to understand the nature of social diversity and oppression in mental health, to examine their own perspectives, values and attitudes towards persons with mental health problems and take steps in identifying, understanding and resolving ethical dilemmas.
So what does this mean for the work of social workers? Do we help clients to work within the system and learn to adjust and cope with the demands and realities in life and the existing environment, as akin to Max Weber’s idea of finding ways to navigate within the ‘iron cage’ of rational-legal authority? Or do we want to follow Karl Marx’s idea of revolution and advocate for the society to change to accommodate to the needs of individual persons? The dilemma of social control or social change is an age-old issue in social work. The way to go is in finding a middle ground, which accommodates both aspects.
Oppression towards persons with mental health problems remains prevalent in Singapore. New initiatives have been proposed and implemented to improve service delivery and treatment for mental disorders. In this pursuit, more can be done to accommodate the voices of service users. Professionals, including social workers, need to embrace the principles of human rights and constantly self reflect on their beliefs and attitudes towards mental health and mental disorders, so as not to perpetuate oppression towards the very people whom we strive to empower. It takes many helping hands and efforts for continued improvement and thus, increasing and sustaining constant networking with key stakeholders, including the policy makers and the media, is crucial. There is beauty in differences and the difference we can make is to embrace and celebrate the totality of diversity.
Blumer, H. (1969). Symbolic interactionism: perspective and method. USA: University of California Press.
Podgórecki, A. (1993). Social oppression. USA: Greenwood Press.
Chang, A.L. (2007, Oct 29). S’poreans fear mental patients, study finds. The Straits Times.
Code of Professional Ethics (2nd Revision). (2004). Retrieved March 17, 2011 from http://www.sasw.org.sg/site/constitution/code-of-professional-ethics-preamble-guiding-principles.html
Elbogen, E.B., Johnson, S.C. (2009). The Intricate Link Between Violence and Mental Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry, 66(2):152-161.
Goffman, E. (1961). Asylums: essays on the social situation of mental patients and other inmates. USA: Doubleday.
Hunt, A. & Wickham, G. (1994). Foucault and law: towards a sociology of law as a governance. Finland: Pluto Press.
Rogers, M. F. (1997). Contemporary Feminist Theory: A Text/Reader. McGraw-Hill.
Steadman, H.J., Osher, F. C., Robbins, P. C., Case, B., Samuels, S. (2009). Prevalence of Serious Mental Illness Among Jail Inmates. Psychiatr Serv, 60: 761-765.
Koh Li Lian is currently a Masters student at the National University of Singapore. She was previously a medical social worker at the Institute of Mental Health (IMH) for 7 years. She is currently a social worker at the Counselling and Psychological Services (CAP) department under the Family and Juvenile Court.