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CMHS Consumer Affairs E-News
December 18, 2003, Vol. 03-119
MEMORANDUM
TO: Colleagues
FROM: Resource Center to Address Discrimination and Stigma Associated with
Mental Illness
SUBJECT: Informational update addressing discrimination and stigma
associated with mental illness
This is the second in a series of informational updates that you will be
receiving twice a year from the Resource Center to Address Discrimination
and Stigma (ADS Center), a program of the U.S. Department of Health and
Human Services, Substance Abuse and Mental Health Services Administration,
Center for Mental Health Services, and operated by a contract with the
Gallup Organization and the Mental Health Association of Southeastern
Pennsylvania. The ADS Center helps people design, implement and operate
programs that reduce discrimination and stigma associated with mental
illnesses.
Information and technical assistance about discrimination and stigma
associated with mental illnesses is available through the ADS Center by
phone at 800-540-0320 or email at info@adscenter.org, or via the ADS
Center Web site at www.adscenter.org.
In this issue are:
Spotlight on . . .
Research:
In my opinion: "Discrimination and Oppression as Traumatic Stressors," by Laurene Finley,
Ph.D., Project Director, PRIME (Partners Reaching to Improve Multicultural Effectiveness) Workforce Training to Reduce Racial and Ethnic Disparities
In my experience: Mad as Well: People Need Labels. Now You Have Mine," by Liz Spikol,
Managing Director, Philadelphia Weekly
To receive this memorandum or future memoranda by e-mail, please e-mail us
at info@adscenter.org. If you wish to comment on anything in the
attachments to this memorandum or tell us about your
anti-discrimination/anti-stigma work, please e-mail us at
info@adscenter.org or call us at 800-540-0320.
____________________________________________________
Important note: The contents of this memorandum do not necessarily
represent the views, policies and positions of the Center for Mental
Health Services, Substance Abuse and Mental Health Services
Administration, or the U.S. Department of Health and Human Services.
____________________________________________________
ADS Center
Resource Center to Address Discrimination and Stigma
1211 Chestnut Street, 11th Floor
Philadelphia, PA 19107
info@adscenter.org
www.adscenter.org
Who We Are
The goal of the Resource Center to Address Discrimination and Stigma (ADS
Center) is to enhance mental health consumer independence and community
participation by ensuring that people have the information they need to
develop successful efforts to counter discrimination and stigma.
According to the report of the President's New Freedom Commission on
Mental Health, "By increasing the public's understanding that mental
illnesses are treatable and recovery is possible, stigma and
discrimination will be reduced for people with mental illnesses"
All of the Center's information is available through its Web site at
www.adscenter.org, and via a toll-free number (800-540-0320) staffed from
9 a.m. to 5 p.m. Eastern Time, Monday through Friday, to provide
assistance.
The ADS Center is a program of the U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration,
Center for Mental Health Services, and operated by a contract with The
Gallup Organization and the Mental Health Association of Southeastern
Pennsylvania.
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Spotlight on . . .
Erasing the Stigma of Mental Illness (ETS) Through Education and Employment
Small program seeks to make large impact Erasing the Stigma of Mental
Illness (ETS) Through Education and Employment, a program of the Mental
Health Association in San Diego County, aims to eradicate the stigma of
mental illness and enlist corporate executives to employ individuals
recovering from mental illnesses.
Situation: "People with mental illnesses have one of the lowest rates of
employment of any group with disabilities - only about one in three is
employed," notes the report of the President's New Freedom Commission on
Mental Health. "The loss of productivity and human potential is costly to
society and tragically unnecessary"
Solution: In 1991, the Mission Valley East Rotary Club in San Diego,
Calif., began the "Erasing the Stigma of Mental Illness Through Education
and Employment Program" (ETS), administered at the time by Serving Hands
International, a nonprofit public benefit corporation.
"ETS educates interested Rotarian business leaders and entrepreneurs about
mental illnesses and how successfully they can be treated. Once these
business leaders understand the critical need to raise the awareness of
mental illness, ETS also makes them aware of qualified individuals who are
ready to return to the work force. ETS then helps the employers hire these
individuals so that they can again be productive citizens. The pride and
self-esteem people gain by being able to reenter the work force is
immeasurable. In addition, they are now off the payroll of taxpayers and
become productive taxpayers themselves - a great savings to society in
both human and monetary terms."
To educate the business community, the ETS Coordinator recruits speakers
who will tell the ETS story. The project uses both consumer and
non-consumer speakers for this purpose.
Results: ETS proved so successful in San Diego County that it received
recognition and endorsement from senior Rotarian leaders and such notables
as Rosalynn Carter, the late Mother Teresa, former National Institute of
Mental Health director Dr. Lewis Judd, and the late actor-advocate Rod
Steiger.
As of October 1995, the last date for which statistics are available, the
ETS program has been presented to more than 15,000 Rotarians and at that
time was expanding into 30 Rotary Districts throughout 22 states. Several
Rotary clubs became involved with their community mental health centers,
and numerous individuals with mental illnesses rejoined the mainstream
work force.
[Editor's Note: Currently, due to lack of funding, the Mental Health
Association in San Diego has had to limit its efforts in regard to ETS to
distributing information about how to begin an ETS project, and has been
unable to keep records of results since 1995. Information about ETS is
also available by mail from the ADS Center.]
Contact: http://www.mhasd.org/About_Us/Local/Education/education.html,
ETS, Mental Health Association in San Diego County, 2047 El Cajon
Boulevard, San Diego, CA 92104; Margaret (Peggy) Beers, Program Director;
e-mail: pbeers@mhasd.org; Phone: 619-543-0412; Fax: 619-543-0748
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Changing Minds, Advancing Mental Health for Hispanics
Nationwide program seeks to overcome barriers in mental health service
provision to Hispanics
Changing Minds, Advancing Mental Health for Hispanics aims (1) to
understand the belief systems of, and overcome barriers facing, the
at-risk Hispanic population in need of mental health services; (2) to
implement effective strategies to address the identified barriers; and (3)
to heighten awareness, acceptance, and understanding of mental illness
among the Hispanic population. The two-year anti-stigma and
anti-discrimination project focuses on research, training, information
dissemination, and evaluation as a means of increasing access to and
quality of mental health services for Hispanics.
Situation: The United States 2000 Census data highlighted the rapid and
ever-growing increase in numbers of people of Hispanic backgrounds in the
United States, while both "Mental Health: A Report of the Surgeon
General," and the supplement to this report, "Mental Health: Culture,
Race, and Ethnicity," as well as the report from the President's New
Freedom Commission on Mental Health, reported that Hispanics as a group
tended to underutilize mental health services and were over-represented
among the nation's most vulnerable groups, such as homeless people and
people in jails and prisons.
Solution: The New Jersey Mental Health Institute, Inc., (NJMHI) devised a
national program to address the mental health needs of the fast-growing
Hispanic population. Its objectives include making a positive difference
by focusing on systems change as well as making an impact on provider
agencies, direct service clinicians, and the Hispanic population in
general. "There are a number of objectives targeted to each group with the
goal of reducing stigma and discrimination and increasing both access to
and quality of mental health services for Hispanics," said project
director Henry Acosta.
The objectives focus on in-depth research, which entails a comprehensive
literature review and conducting an NJMHI study; creation of a model that
includes best practices for mental health agencies and clinicians;
information dissemination in the form of a nationwide quarterly
newsletter, trainings and conference presentations; and an evaluation.
Results: The project conducted a comprehensive, in-depth literature review
and analysis of professional literature on topics related to Hispanic
mental health. The report, entitled "Comprehensive In-Depth Literature
Review and Analysis of Hispanic Mental Health Issues with Specific Focus
on Members of the Following Ethnic Groups: Cubans, Dominicans, Mexicans
and Puerto Ricans," summarizes and analyzes professional literature
surrounding studies on barriers to care, utilization of mental health
services, and clinical best practices. The report also provides an
historical overview of each group and discusses issues relevant to each
group that may contribute to the views of mental health by members of that
group. The report is available at no cost to interested individuals.
Contact information: http://www.njmhi.org, Changing Minds,
Advancing Mental Health for Hispanics, New Jersey Mental Health Institute,
The Neuman Building, 3575 Quakerbridge Road, Suite 102, Mercerville, NJ
08619; Henry Acosta, M.A., M.S.W., L.S.W., Project Director; e-mail:
hacosta@njmhi.org; Phone: 609-838-5488, ext. 205; Fax: 609-838-5480
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The Anti-Stigma Project (On Our Own of Maryland)
Project challenges participants to examine stigma's impact on their
professional and personal lives
The Anti-Stigma Project is a project of On Our Own of Maryland, Inc.,
Maryland's statewide consumer/survivor organization. Its mission is to
fight stigma by raising consciousness, facilitating ongoing dialogues,
searching for creative solutions, and educating all participants within or
connected to the mental health community, including consumers, family
members, providers, educators, and administrators. The Anti-Stigma Project
challenges participants in its workshops to examine the impact of stigma
on both their professional and personal lives.
Situation: The stigma and discrimination that affect people who have
mental illnesses are not only found in society at large, but within the
mental health and addiction treatment/recovery communities (Reidy, 1993).
Solution: In 1993, On Our Own of Maryland, Inc., and the Maryland Mental
Hygiene Administration formed the Anti-Stigma Project, in order to counter
the discrimination and stigma associated with mental illnesses. The
project's workshops combine a variety of learning approaches, such as
group discussions, role-playing, and assessment surveys. Participants also
have an opportunity to analyze videotaped interviews with people who have
been affected by stigma.
"Our mission is to educate all participants, both within the mental health
community (including consumers, family members, providers, educators, and
administrators) and those connected to the mental health community in such
areas as law enforcement, government, education, and somatic healthcare,"
said Jennifer Brown, director of training and communications for On Our
Own of Maryland. "Although we are based in Maryland, we are also branching
out to national and international audiences. To date, we have traveled to
eight other states and three other countries: Wales, France, and Canada.
In addition, our CMHS-sponsored training videotape, 'Stigma . . . in Our
Work, in Our Lives,' is being used in 40 states and eight countries:
Germany, Canada, Japan, Finland, Wales, South Africa, Chile, and Sweden!"
Each workshop is team-facilitated by trainers with extensive and varied
experience in mental health, addictions and recovery, education and
communications. All of these core workshops can be tailored to meet the
specific needs of the organization/audience.
Workshops include:
Stigma in Our Work, in Our Lives, an interactive, half-day workshop
designed to reduce stigmatizing behaviors, attitudes and practices within
the mental health and addiction treatment/recovery communities.
Participants identify stigmatizing behaviors and attitudes and their
impact on the design, delivery, and receipt of services, and develop
possible solutions and action steps.
Stigma: Language Matters, a shorter, experiential workshop during which
participants explore the power of language as it relates to stigma,
develop alternatives to stigmatizing language and learn to integrate these
concepts into their professional and personal lives.
Responding to Stigma: Effective and Applicable Strategies for the
Workplace, a four- to five-hour workshop that applies a multi-layered
approach to identifying and implementing individual and systemic solutions
and to developing anti-stigma principles to guide systems and
organizations.
Stigma: It Doesn't Discriminate, a 90-minute interactive session, offers
six skits that acquaint participants with the many facets of stigma.
Results: "Almost all of the workshop participants indicated on the FY 2003
evaluations that they would pass the information and concepts learned
along to others, and 93 percent of the participants rated the workshops as
'excellent' or 'good,' "Brown said. "Anecdotal evidence shows that a
majority of the participants see the workshops as an agent for concrete
behavioral change."
Contact information: http://www.onourownmd.org, Jennifer K. Brown,
Director of Training and Communications, On Our Own of Maryland, Inc.,
1521 South Edgewood Street, Suite C, Baltimore, MD 21227; Phone:
410-646-0262, 1-800-704-0262, Fax: 410-646-0264, e-mail:
anti-stigma@usa.net
References:
Reidy, D. (1993). " 'Stigma Is Social Death': Mental Health
Consumers/Survivors Talk About Stigma in Their Lives." Education for
Community Initiatives, Holyoke, Mass.
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In Our Own Voice (NAMI)
Consumers address a variety of audiences in nationwide program
In Our Own Voice (IOOV) is an informational outreach program on recovery
created and coordinated by NAMI (formerly known as the National Alliance
for the Mentally Ill). IOOV is presented by trained consumers to other
consumers, families, students, law enforcement personnel, mental health
service providers, professionals, faith communities, and all people
wanting to learn about mental illness. It is designed to offer insight
into how people with serious mental illnesses cope with the realities of
their disorders while recovering and reclaiming productive lives with
meaning and dignity. NAMI notes that "it is also an opportunity for
consumers to gain self-confidence, self-esteem, and income while serving
as role models for the community."
Situation: Studies have shown that contact between people who have mental
illnesses and the general public is the most effective way to reduce the
discrimination and stigma associated with mental illnesses (Corrigan &
Penn, 1999).
Solution: In Our Own Voice offers presentations by people who have
experienced such psychiatric disorders as schizophrenia, bipolar disorder,
major depression, and other severe mental illnesses. NAMI notes: "These
presenters offer insight and hope by their example and testimonials of
their experiences." The presentations include a brief video featuring
consumers speaking about the topics of Dark Days, Acceptance, Treatment,
Coping Skills, Successes, and Hopes and Dreams. "The presenters also
provide opportunity for discussion about each section to enrich the
audience's understanding of living with mental illness. A Take Home Kit is
distributed to all attendees and includes resources and an opportunity for
program evaluation."
The presentations vary in length from 30 to 90 minutes, and offer an
opportunity for dialogue between the audience and the presenters.
Audiences have varied from five to 600 attendees, but 30 to 50 is the
preferred size of the group.
The goals of the program are "to meet the need for consumer-run education
initiatives, to set a standard for quality education about mental illness
from those who have been there, to offer genuine work opportunities for
consumers, to encourage self-confidence and self-esteem in presenters, and
to focus on recovery and the message of hope."
IOOV literature also notes: "Presenters are consumers who are ready for
the next step in their recovery and are willing to share their story. They
are selected from various sources including NAMI consumer members, day
program attendees, group home residents, and referrals from doctors and
providers. A trainer from NAMI's national office provides a two-day
training course for 12-16 consumer presenters. During the training,
presenters practice telling their personal stories, develop facilitation
skills, develop story points that will be relevant and meaningful to
specific audiences, and develop a professional presentation that they
could take to their communities."
Results: More than 1,900 presentations, attended by more than 34,000
people, have been given since the program's inception in 2000, and nearly
800 consumer presenters have been trained. According to a presentation at
the NAMI Annual Convention in June 2003, the results have been very
positive. The presentation, based on a survey that sorted some 25,000
completed IOOV evaluations but focused on those received from the 2,200
student audience members, reported that "an overwhelming majority of
students who saw IOOV found it to be informative and encouraging. Nearly
all student respondents were pleased with both the depth and scope of the
presentation."
More important was the assessment of respondents' views of recovery after
attending IOOV, since analyzing whether IOOV changed people's views of
mental illness is vital to evaluating the program's effectiveness. Toward
this end, the presentation noted that "I see people with mental illness in
a new light" was checked by 37 percent of respondents. "This suggests that
over one-third of the audience members changed their view of people with
mental illness after attending IOOV . . . Additionally, 15 percent of
respondents checked 'I see recovery as a real option for the first time
ever.' While this percentage may seem somewhat low, it still highlights
the ability of IOOV to promote the concept of recovery to its audiences
and reinforces another essential message of the presentation" (Wood, Wahl
& Adame, 2003).
In Our Own Voice must be
coordinated through the NAMI state or affiliate organization. "Contact
your NAMI state office or local affiliate about presentations in your
specific area. To inquire about having In Our Own Voice implemented in
your state, contact Ramiro Guevara Ramiro@nami.org or call NAMI at
703-524-7600."
References:
Corrigan, P., & Penn, D. (1999). Lessons from Social Psychology on
Discrediting Psychiatric Stigma. American Psychologist, 54, 765-776.
Wood, A., Wahl, O., & Adame, A. (2003). IOOV Presentation: NAMI Annual
Convention, Minneapolis, Minn.
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“see me” (Scotland)
Scotland: Nationwide campaign says, "See the person, not the label"
"see me" . . . Let's Stop the Stigma of Mental Health, Scotland's first
national anti-stigma campaign, aims to break down negative attitudes
toward people with mental health problems, which lead to stigma and
discrimination, and to promote greater public understanding of mental
well-being and mental illnesses. The campaign, funded by the Scottish
government as part of its "National Programme for Improving the Mental
Health and Well-Being of the Scottish Population," is an initiative of
five Scottish mental health organizations: the Highland Users Group,
National Schizophrenia Fellowship (Scotland), Penumbra, the Royal College
of Psychiatrists (Scottish Division), and the Scottish Association for
Mental Health. The "see me" campaign urges the public to "see the person,
not the label," and asks them to re-think both their attitudes and their
behavior toward people who have mental health problems.
Situation: The campaign's launch on Oct. 8, 2002, coincided with early
findings from a Scottish national survey revealing that, although one in
four members of the Scottish population has experienced a mental health
problem and nearly three-quarters know someone who has been diagnosed with
one, the stigma of mental illness is so great that half of respondents
said that if they developed a mental health problem they would not want
anyone to know about it.
The early findings of the national Scottish Survey of Public Attitudes to
Mental Health, Well Being and Mental Health Problems showed that a third
of those who had personally experienced a mental health problem reported
difficulties stemming from other people's attitudes, such as being
discouraged from participating in social events, discrimination at work or
verbal abuse in public places. This was in spite of the fact that 88
percent of people canvassed felt that people with mental health problems
should have the same rights as anyone else and 98 percent of those asked
recognized that anyone can have mental illness.
Solution: "see me" works with individuals, groups and organizations
across Scotland, tackling stigma and discrimination wherever they occur
and lending its support to those involved in local anti-stigma actions.
The campaign includes an advertising and press campaign, as well as
production of printed materials for local use. Its Web site includes a
"Stigma Stop Watch" media campaign.
The "see me" campaign, whose message is "See me as a person, not a label,"
focuses attention on the individuals behind the statistics. The campaign
recruited a number of volunteers who have experienced stigma and
discrimination because of their mental health problems, to talk publicly
about the impact of stigma. From being shunned in the family to losing a
job, the experiences of these individuals demonstrate the importance of
breaking down the ignorance and fear surrounding mental illnesses.
Launching the campaign, Scottish Health Minister Malcolm Chisholm said:
"Under [Scotland's] Disability Discrimination Act [DDA], discrimination on
mental health grounds is illegal, just as it is for physical illnesses. . . [We] hope that by raising general public awareness of mental ill
health issues and encouraging those with mental health problems to be seen
as individual[s] with a contribution to make to society, this may also
assist in making people more aware of their own mental health problems so
that they may seek help earlier. This helps people to recover and to get
on with their lives."
Results: "The findings of the evaluation demonstrate that the campaign has
got off to an extremely good start," according to a summary provided by
the "see me" campaign. (Note: This summary is available by e-mail, mail,
or fax from the ADS Center. Following are excerpts.)
"The aim of the evaluation of the first phase of the campaign was to
assess public recognition of the campaign and public understanding of the
key messages of 'see me.' "
"The campaign evaluation involved four key components: an omnibus survey
(1,001 adults respondents across Scotland); street surveys in Edinburgh,
Stirling and Aberdeen (525 respondents); focus groups predominantly with
local mental health activists ( 35 groups, of which three were with groups
of young people, 200+ participants in total), and a self-completion
questionnaire circulated to local groups. Additional evidence of the
campaign's impact was drawn from the amount of press coverage received,
visits to the Web site and orders received for campaign leaflets and
posters. . . ."
"The omnibus, street surveys, focus groups and self-complete[d]
questionnaires all confirmed that the campaign was successful in
communicating its key messages, with over 90% of respondents 'on message.'
. ."
"Focus groups were generally extremely positive about the campaign. There
was a real sense of enthusiasm and welcome for a national anti-stigma
campaign and signs that local action had been energized by it. The 'see
me' images were perceived as positive and normalizing. . . ."
"Regarding future campaign activity, participants were keen to see the
main messages of 'see me' reinforced, especially the 1 in 4 statistic and
'it could happen to anyone.' In addition, there were calls for a much
greater emphasis on recovery. People would also like 'see me' to encourage
people to seek help, and suggested messages like 'it's okay to talk about
it.' "
Contact information: http://www.seemescotland.org; Linda Dunion,
Campaign Director; "see me," 9-13 Maritime Street, Edinburgh EH6 6SB,
Scotland; Phone: 0131-624-8945; Fax: 0131-624-8901; e-mail:
info@seemescotland.org
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Research:
"Lessons from Social Psychology on Discrediting Psychiatric Stigma"
By Patrick W. Corrigan, Psy.D., & David L. Penn, Ph.D. American Psychologist, 54, 765-776.
Patrick W. Corrigan and David L. Penn have made a significant contribution
to the existing body of knowledge in a paper, "Lessons from Social
Psychology on Discrediting Psychiatric Stigma," published in the September
1999 issue of American Psychologist. They take a close look at research on
efforts to fight stigma among ethnic minorities and other groups.
Corrigan and Penn make the case that information about the efficacy of
efforts to reduce discrimination and stigma focused on ethnic minorities
provides important guidance for designing effective campaigns to fight
discrimination and stigma against people who have mental illnesses. The
article includes a discussion of how stigma and stereotypes are defined.
The authors suggest that stigma is a natural result of our need to
classify and categorize the world around us to make sense of it.
Stereotypes about groups of people are a convenience because they allow
us - and that means all of us - to make a quick impression about a person
in the stereotyped group. Of course, this is a natural adaptation that
frequently doesn't serve us well. That quick impression aided by a
stereotype distracts us from seeing a person as an individual, and clouds
our ability to test the stereotype against our own observations. The
resulting harm to people with mental illnesses is well understood and well
documented. The authors discuss the diverse manifestations of stigma
against people who have mental illnesses, and show where they are linked
to negative attitudes toward people with physical illnesses and
disabilities.
These discussions give the reader a foundation for understanding the
methods employed by anti-stigma campaigns. Reviewing those initiatives,
Corrigan and Penn note that efforts by organizations such as NAMI and the
National Mental Health Association as well as the Center for Mental Health
Services share three types of strategies: protest, education, and contact.
This discussion, on its own, provides a valuable overview of how methods
employed in anti-stigma campaigns have stood up to the limited body of
scientific review. For example, the authors cite studies that suggest that
messages presented to the public may appear effective at first but are, in
fact, compromised by the very resilience of stereotypes.
There is a balancing note of hope, too. The authors cite research showing
that, while people who have received information to debunk stereotypes may
not have given them up, their behavior in some cases will change for the
better. For example, an employer educated about the falseness of ethnic
stereotypes may not give up the negative, ingrained ideas, but his or her
hiring practices may change to reflect the new information.
In their conclusion, the authors affirm the importance of campaigns to
reduce the stigma of mental illness. "Decreasing stereotypes and
prejudices about severe mental illness could potentially diminish the
discrimination experienced by persons with these disorders," they write.
They argue that research about the social psychology of minority group
stereotypes offers useful ideas about how to fight stigma against people
with mental illnesses, and they go on to present several ideas based on
their own interpretation of the literature.
First, Corrigan and Penn warn against any effort that instructs
individuals to mentally suppress their negative ideas about people with
mental illnesses. Research shows that the outcome is parallel to the
natural response that occurs when a person is expected not to think about
an elephant. Just as an image of an elephant comes to the front of the
mind when the effort of suppressing the thought becomes too burdensome, so
will negative stereotypes come to the front of the mind when people are
instructed to suppress negative ideas about people with mental illnesses.
Protests and demonstrations may have this unintended effect, the authors
continue.
Second, public education campaigns are most effective when formal
instruction is accompanied by discussion and simulations.
Third, the authors make a case for the effectiveness of fighting stigma
through direct contact with people who have mental illnesses. They add,
"Contact effects should improve when there is equal status among
participants, cooperative tasks define the interaction, there is
institutional support for contact, there are high levels of intimacy, and
the person with severe mental illness does not greatly differ from the
stereotype."
Postscript by Patrick W. Corrigan, Psy.D.:
Since writing this paper, my colleagues and I have completed three
controlled research studies comparing the effects of protest, education,
and contact on public attitudes towards people with mental illnesses;
these can be found at www.stigmaresearch.org.
Results of these studies suggest that although education about the myths
and facts of mental illness can yield some positive change, contact
between the public and people who have mental illnesses produces the
greatest benefits. Hence, the more interaction between people with mental
illnesses and the public, the more stigma will be torn down. This poses a
challenge because the stigma of mental illness, like that experienced by
gay men and lesbians, is largely hidden. People with mental illnesses need
to weigh the real costs of coming out against the benefits to the
community at large as well as themselves.
Our research also shows that the greatest effects occur when the average
person comes out. Although there is some benefit when people like Mike
Wallace, Patty Duke, and John Nash tell their stories of recovery from
mental illness, public attitudes are most challenged when neighbors,
co-workers, and fellow churchgoers admit that they, too, have struggled
with and beaten mental illness. Hence, supporting people's coming out to
tell their stories at the local level may be among the most significant
strategies for erasing stigma.
Patrick Corrigan, Psy.D., is Professor of Psychiatry, University of
Chicago, and director of the Chicago Consortium for Stigma Research,
funded by the National Institute of Mental Health. He has successfully
struggled with bouts of major depression for more than 20 years.
David. L. Penn. Ph.D., is Associate Professor of Psychology, University of
North Carolina-Chapel Hill.
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"The Relationship of Causal Beliefs and Contact with Users of Mental
Health Services to Attitudes to the 'Mentally Ill' "
By John Read & Alan Law. International Journal of Social Psychiatry, 45 (3), 216-229.
Researchers John Read and Alan Law have replicated the results of previous
studies showing that there is a relationship between belief in the
"illness" model and negative attitudes toward people with mental
illnesses - including self-stigma on the part of these individuals. Their
study has also demonstrated that the idea that mental illnesses have a
psychosocial basis - i.e., that they are caused by environmental
stressors, such as trauma or poverty - is associated with positive
attitudes and reduced stigma. In addition, the amount of contact with
people who have mental illnesses is an even better predictor of positive
attitudes than acceptance of psychosocial causal beliefs, the researchers
found.
The idea that mental illness is an illness apparently just fuels the
stigma of psychiatric disorders, which are linked in the public's mind to
the image of people with such disorders as violent, unpredictable, and
unreliable, according to Read and Law. They offer the following quote from
a study by Hill and Bale (1980): "Viewing a person's behavior as being to
some extent under the person's control and therefore somewhat predictable
seems to be a prerequisite for meaningful interaction with a person. The
notion that psychosocial problems are similar to physical ailments creates
the image of some phenomenon over which afflicted individuals have no
control and thereby renders their behavior apparently unpredictable. Such
a viewpoint makes the 'mentally ill' seem just as alien to today's
'normal' populace as the witches seemed to fifteenth century Europeans
(pp. 289, 290)."
Yet, despite evidence that attempts to counter stigma by means of such
slogans as "mental illness is an illness like any other" have been
"largely unsuccessful," mental health professionals involved in
anti-stigma campaigns continue to promulgate this model, Read and Law
report. At the same time, they note: "Wilmouth et al. (1987) reported that
physicians were the least likely of six community groups to support the
building of a mental health facility near their own home."
Correspondingly, the authors cite a 1980 report by the National Institute
of Mental Health, which commented that treatment in a medical setting, by
a medical professional, or by "physical treatment modalities," results in
more stigma than non-medical alternatives (pp. 22, 23). This includes
internal stigma: "Farina et al. (1978) indicate that although individuals
may be able to maintain more self-respect if they blame their problems on
biochemical processes, along with this can come the belief that they are
more alien, less capable of ever functioning normally, and less acceptable
as a friend. As consumers of mental health services have repeatedly
pointed out, the stigma created by the medical model of mental illness
also leads to an internalization of stigma where clients may feel their
experience is being reduced to biochemistry, leaving them robbed of
individuality, complexity and meaning (Campbell, 1992; Lawson, 1991; O'
Hagan, 1992)."
The authors conclude that it is possible to change attitudes toward people
with psychiatric disabilities for the better, "at least in the short
term," and that, to accomplish this, information about the psychosocial
causes of and treatments for the disorders commonly called mental
illnesses may be helpful. They also suggest that anti-stigma campaigns
avoid traditional medical model messages.
In addition, they conclude, "[t]he public needs to be explicitly told that
there is less to fear from people living in the community with psychiatric
histories than from other groups of people, such as males in general."
They add, "it seems essential to involve psychiatric survivors and current
consumers of mental health services in any education campaign." Finally,
they suggest that different anti-stigma strategies might be used for
different demographic groups, including age and gender.
Postscript by John Read, Ph.D.:
We have since replicated this 1999 study twice:
Walker I, Read J (2002) The differential effectiveness of psychosocial and
biological causal explanations in reducing negative attitudes toward
'mental illness.' Psychiatry, 65, 313-325.
Read, J., Harre, N (2001) The role of biological and genetic causal
beliefs in the stigmatisation of 'mental patients.' Journal of Mental
Health, 10, 223-235.
Also, we have provided an updated review of all the relevant research in
this topic in:
Read, J, Haslam, N. (in press, 2004) Public opinion: Bad things happen and
can drive you crazy. In Read, J. Mosher, L, Bentall, R (eds) Models of
Madness: Psychological, Social and Biological Approaches to 'Schizophrenia
' London: Brunner-Routledge.
John Read, Ph.D., Director, Clinical Psychology Department, University of
Auckland, New Zealand
Alan Law, PGDipSci, Psychology Department, University of Auckland
References cited in above summary:
Farina, A., Fisher, J.D., Getter, H. & Fischer, E.H. (1978) Some
consequences of changing people's views regarding the nature of mental
illness. Journal of Abnormal Psychology, 87:2, 272-279.
Fisher, J.D. & Farina, A. (1979) Consequence of beliefs about the nature
of mental disorders. Journal of Abnormal Psychology, 88, 320-327.
Hill, D.J. & Bale, R.M. (1980) Development of the Mental Health Locus of
Control and Mental Health Locus of Origin Scales. Journal of Personality
Assessment, 44:2, 148-156.
National Institute of Mental Health (1980) Attitudes towards the mentally
ill: Research perspectives. Washington DC: Department of Health and Human
Services.
Wilmouth, G.H., Silver, S. & Severy, L.J. (1987) Receptivity and planned
change: Community attitudes and deinstitutionalization. Journal of Applied
Psychology, 72, 138-145.
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In My Opinion
Discrimination and Oppression as Traumatic Stressors
By Laurene Finley, Ph.D., Project Director, PRIME (Partners Reaching to
Improve Multicultural Effectiveness) Workforce Training to Reduce Racial
and Ethnic Disparities
It would be difficult to find anyone who would disagree about the
importance of understanding each person within his/her cultural context.
This means recognizing that each person has membership in one or more
groups as defined by race, ethnicity, age, socioeconomic status, gender,
religion, sexual orientation, and/or a history of social oppression.
Understanding the cultural context also means facing the harsh reality
that persons seeking recovery experience the multiplicative effects of
their mental illnesses or co-occurring disorders in addition to
discrimination and oppression resulting from their other group
memberships. They have the additional challenge of integrating the norms
and values of these various subgroup memberships while managing their
symptoms.
Oppression (e.g., racism, ageism, homophobia, sexism, etc.) is the
systematic and institutional use of power to exclude persons, reinforced
by regulations, laws, or policies. Apartheid, segregation, glass ceilings,
or policies against hiring persons with psychiatric disabilities are
clearly examples of "brick walls" denying persons from different cultural
backgrounds access to employment, housing, education, and healthcare as
well as to other advantages within the opportunity structure.
Cook & Roussel (1987) found that certain demographic variables such as
class, age, race and gender influenced employment outcomes for persons
with psychiatric disabilities. Women, for example, took longer to obtain
employment; being white increased a person's probability of achieving
competitive employment; and persons who were older were less likely to be
terminated from their employment for negative reasons. The data suggested
that many of the factors that influence participation in the labor force
in general also have an impact on people with psychiatric disabilities.
Corrigan, et al. (2003) sought to further understand perspectives about
sources of discrimination as experienced by persons with serious mental
illnesses who were members of other subgroups. Of the 1,824 persons
interviewed, approximately 53 percent reported some experience with
discrimination. The most frequent sources of discrimination were
psychiatric disability, race, sexual orientation, and physical disability.
Housing, employment, and interactions with law enforcement were areas in
which discrimination frequently occurred. The authors conclude that
programs need to target not only discrimination related to mental illness
but also that associated with other group characteristics.
Discrimination and oppression may take several different forms.
Micro-aggressions (Chestang, 1972; Hines & Franklin, 1982), e.g., daily,
accumulated, almost imperceptible slights, indignities, or humiliation,
may be just as debilitating as more overt forms of teasing, taunting,
physical assault or exclusion from privileges or rights. Internalization
of inferiority because of one's cultural status may be one of the most
debilitating effects of all. These types of toxic events change people's
attitudes about themselves and those who are like them. They may also
contribute to a learned hopelessness that may severely impact belief in
recovery.
As persons struggle to manage multiple sources of discrimination, they may
be perceived by mental health service providers as being "overly"
sensitive, having a "chip" on their shoulders, being too aggressive, or
passively withdrawing intellectually, emotionally, or physically. What we
may fail to realize is that these people may feel just as traumatized as
someone who has experienced the terror of war, rape or other violent acts.
Only recently has the mental health system begun to acknowledge the
profound impact of trauma on the lives of persons with psychiatric
disabilities. Figures vary: anywhere from 40 percent to 60 percent of
persons who use psychiatric outpatient services and 50 percent to 60
percent of those using inpatient services are acknowledged as having
reported histories of early childhood victimization (Herman, 1992).
Puig (1991) described the psychological and physiological effects of
discrimination and oppression that can follow a predictable course of
emotional, cognitive, behavioral, and/or characterological effects so
severe that they may meet many of the criteria for acute stress or
post-traumatic stress disorders that can be found in the DSM IV TR
(Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision):
Internalization of shame or humiliation,
Avoidance of situations that may remind persons of their original trauma,
Anger and rage toward the source or perpetrators of the trauma,
Denial,
Decreased belief in self-efficacy,
Emotional numbing,
An increase in physiological disturbances,
An increase in drug and alcohol abuse,
Learned helplessness.
Sanders-Thompson (1990, 1996) surveyed persons with residual symptoms
[such as those listed above] who reported having confronted incidences of
racism. Almost 35 percent had experienced some incident within six months
of the interview! Approximately 61 percent of these persons reported their
experiences as moderately to severely intense. These incidents were
further rated using a standardized scale of subjective distress. Two of
the most commonly noted responses to stressful life events - intrusion
(when flashbacks "intrude" into people's current lives) and avoidance (as
described above) reactions - were present at clinical levels. Avoidance
symptoms were still at clinical levels 90 days past the event.
Acknowledgement of the deleterious effects of discrimination and the
"isms" - racism, sexism, etc. - requires a more proactive response from
the mental health system. Providers are challenged to find methods that
promote coping, healing, advocacy strategies, and skill mastery to improve
the management of multiple sources of discrimination and the "isms."
One of the first steps in the healing process is to reduce the effects of
isolation and self-blame by putting a name or a label to the toxic events
that validates the experience. It is important to differentiate the
responsibility that belongs to the perpetrator and/or system
(system-blame) from that which belongs to the person. Some may require
ways to recognize the more subtle forms of discrimination and oppression.
In addition, there are a variety of cognitive-behavioral strategies that
both help to reduce the effects of the concomitant stressors and to
develop more coping behaviors, including knowing when it is better to
escape toxic situations (Finley & Pernell-Arnold, 1996).
Specific opportunities seem needed to ensure that individuals can develop
the strength to deflect the toxic effects of discrimination and confront
them proactively. Cook & Roussel (1987) suggested that special programs
may be required for subgroups of persons who, because of their "minority"
status, may have more difficulty obtaining employment. Alverson & Vicente
(1998), in research with Puerto Ricans, especially males, held that
cultural values, e.g., confianza (confidence in others), dignidad
(self-worth), verguenza (sense of shame or disgrace accompanying failure),
and orgullo (pride, honor) seem to play a significant role in providing a
psychological buffer against psychosocial stressors, such as seeking and
maintaining employment. Finley & Pernell-Arnold (1996) describe an
"inoculation against the 'isms' " cognitive-behavioral model involving
interactive strategies that build upon cultural strengths and teach
persons with psychiatric disabilities how to defend themselves against
discriminatory toxicity.
People seeking to recover from mental illnesses should be interviewed in
greater detail about their history of discriminatory life events - and
perceptions of their severity - emanating from multicultural experiences.
Assessments must more accurately reflect the potentially traumatic nature
of these life events. Common themes that contribute to intra- and
interpersonal and other recovery barriers must be identified.
Incorporating components of cultural identification into programs that
will enhance a person's awareness of his/her ethnic or cultural history
and traditions, and provision of same-cultural peer supports as well as
culturally based rehabilitation and/or socialization activities, are
examples of program modifications that may "inoculate" individuals, i.e.,
provide protective factors against discrimination (Finley, 1996;
Zickler,1999). We can no longer afford to believe that time will heal and
that the toxic effects of discrimination and oppression will disappear and
be forgotten.
Bibliography
Alverson, H. & Vicente, E. (1998). An ethnographic study of vocational
rehabilitation for Puerto Ricans with severe mental illness. Psychiatric
Rehabilitation Journal, 22(1), pp. 69-72.
Chestang, L. (1972). Character Development in a Hostile Environment
(Occasional Paper No. 3). Chicago: University of Chicago School of Social
Service Administration.
Cook, J.A. & Roussel, A.E. (August, 1987). Who Works and What Works:
Effects of Race, Class, Age, and Gender on Employment Among the
Psychiatrically Disabled. Paper presented at the American Sociological
Association Annual Meetings, Chicago, Illinois.
Finley, L.Y. & Pernell-Arnold, A. (1996). Inoculation Against
Discrimination and the ISMs. Unpublished Manuscript.
Herman, J. (1992). Trauma & recovery. New York: Basic Books.
Hines, P.M. & Boyd-Franklin, N. (1982). In M. McGoldrick, J. Pearce, & J.
Giordano (Eds.), Ethnicity & family therapy (pp 84-122). New York:
Guildford Press.
Puig, A. (Fall/Winter, 1990). Racism as a traumatic stressor. Directions.
Philadelphia, PA: Delaware Valley Association of Black Psychologists.
Thompson-Sanders, V. (1990). A preliminary outline of treatment strategies
with African Americans coping with racism. Psych Discourse, 25(6), pp 6-9.
Thompson-Sanders, V. (1996). Perceived experiences of racism as stressful
life events. Community Mental Health Journal, 33, pp. 223-233.
Zickler, P. (1999). Ethnic identification and cultural ties may help
prevent drug use, NIDA Notes, 14(3), pp. 7-9.
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In My Experience
Mad as Well
People need labels. Now you have mine.
By Liz Spikol, Managing Director, Philadelphia Weekly
Reprinted with permission from Philadelphia Weekly
"Magical thinking," as defined in psychiatric terms, is "a pervasive
thought process in which 'divine' messages are received, ritualistic
behaviors, such as avoiding cracks in the sidewalk, are rigorously
followed and things happen for 'a reason.' "
Lay people prefer to call this "being superstitious" or "religion." My own
magical thinking tends toward seeing everything as a sign from God telling
me what to do - whether to be kinder, more compassionate or the kind of
person who owns a mop.
For example, when a high school friend, now a doctor, contacted me for the
first time in 13 years via e-mail, I believed it was God's way of telling
me that a 103-degree fever and itchy, red spots equaled chicken pox. Never
mind that an old buddy was the one who pointed this out; God had surely
set the schedule.
Since my cyberdoc was the only person who ever "found" me through the
Internet, I continued to believe that our renewed connection was all part
of a divine plan to eliminate the middle man, a.k.a. my family doctor.
Now, though, I'm here to stun the psychiatric establishment with my
radical cure for magical thinking: Write a column in which you "come out"
about your continuing struggle with mental illness. I guarantee you'll
see, with first-time clarity, that being contacted by old friends has
nothing to do with God and everything to do with shocking people into
remembering you exist.
Aside from its curative properties, writing my first column four years ago
was refreshing and cathartic. I felt I had divulged enough that I could
move on and write about things outside myself, albeit making use of my
slightly "different" point of view. But the feedback I received -
especially from people I know and those who popped up suddenly - revealed
a basic, if banal, truth: people need labels. The deliberate omission of
my formal clinical diagnosis was, I thought, a bold move forward in the
crusade to rehabilitate the language of "madness." . . .
I imagined that avoiding a label would allow people to see the complexity
and range of experience that almost always lies behind a pat descriptor.
Saying "Jim's an alcoholic" doesn't tell you much about Jim's life, but
this supposed shorthand sure does make him tidy.
In my case, people wanted to know what kind of crazy I am. They wanted to
color me inside the lines of known variables and were frustrated when they
couldn't.
The overarching problem seemed to be an inability to determine if I'm
"really" mentally ill (schizophrenic, manic depressive) or simply as crazy
as the rest of us (with "issues"). I can't begin to count the number of
people who tried to get me to admit that I was exaggerating or taking
artistic license. Every one of these conversations ended the same way:
"But, come on, Liz. Aren't we all a little 'mentally ill'?" "No" was not
enough. I invariably had to supply the diagnostic label. I was surprised
to learn that, without a specific term, my illness - and my life as I
struggle to manage the illness - simply cannot exist.
One person thought the column was a joke entirely. Medically speaking,
labels are de rigueur, miraculously pulling together untethered strands of
symptoms and variables into a readily identifiable thing, Latin name
included. Just as we wouldn't refer to a diabetic as "a person down on her
insulin," we should likewise avoid ambiguity when talking about
psychiatric problems. Especially in print.
To be fair, I do understand wanting that certainty labels provide. When I
met a woman at a party recently, and we had exhausted the topic of our
host's way with phyllo dough, I felt marooned. Without some vital stats, I
realized, I was going to have to move on to how hummus is overrated and,
in my opinion, kind of gritty.
It seemed silly to have nothing to say, but there I was, out of ideas. So,
though I hated to do it, and offered my apologies, I took that terrible
but well-traveled path to social grace: "What do you do?"
The woman, who just two seconds earlier seemed enchanted by my ethnic food
repartee, shot me a steely look. "What do I do? I'm a person. That's what
I do."
I wanted to shove the Algerian dates, in all their exotic plumpness, up
her nostrils until she suffocated. And yet she unwittingly provided all
the identifying information I required. Label: unfriendly.
So while I've been slightly irritated by the constant pressure to name my
particular insanity, I know it's only natural to crave a framework.
Precisely because we structure our lives carefully, organizing each
personal universe with thoughtful deliberation, we try to keep things that
threaten that order at a distance, forestalling anxiety and uncertainty.
The "known" always feels better than the "unknown," which is why it's
music to my ears when someone tells the truth, even if that truth is that
it was a one-night stand and he never wants to see me again.
Sure, romance and declarations of love are better, but only with
follow-through. Waiting by the phone, or checking your e-mail 20 times a
day, are all about wanting to know where to place him, how to incorporate
him into the structure.
Too many people without assigned roles make life seem less manageable. And
if you don't believe me, grab any Elizabethan drama; it's not for nothing
"the Fool" has a title.
So for all my friends, new and old, who desire specificity and definition,
get out the Sharpie, write "Spikol" on a box and fit me in where you can.
Manic depression, obsessive-compulsive disorder and dissociative disorder,
n.o.s. [not otherwise specified]. Look them up if it's still not clear;
they're only labels, after all.
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The Center for Mental Health Services is a component of the Substance
Abuse and Mental Health Services Administration, United States
Department of Health and Human Services.
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