Consumer Affairs News from the Center for Mental Health
Services
http://www.mentalhealth.samhsa.gov/consumersurvivor/
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CMHS Consumer Affairs E-News December 18, 2003 Vol. 03-119
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Discrimination & Stigma with Mental Illness
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 . . .
- Erasing the Stigma of Mental Illness (ETS) Through Education and Employment
(Mental Health Association in San Diego, Calif.)
- Changing Minds, Advancing Mental Health for Hispanics (N.J. Mental Health
Institute)
- The Anti-Stigma Project (On Our Own of Maryland)
- In Our Own Voice (NAMI)
- "see me" (Scotland)
Research:
- "Lessons from Social Psychology on Discrediting Psychiatric Stigma," by
Patrick W. Corrigan, Psy.D., and David L. Penn, Ph.D.
- "The Relationship of Causal Beliefs and Contact with Users of Mental Health
Services to Attitudes to the 'Mentally Ill,' " by John Read, Ph.D., and Alan
Law, PGDipSci
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" (p. 24).
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 . . .
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" (p. 29).
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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Spotlight on . . .
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/index.htm, 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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Spotlight on . . .
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/asp.htm, 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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Spotlight on . . .
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).
Contact:
http://web.nami.org/education/ioov.html 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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Spotlight on . . .
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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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.
Last Updated on
04/14/04
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