DATE: Fall 2004

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 in rural communities

This is the fifth in a series of informational updates that you have been receiving periodically 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. The ADS Center helps people design, implement and operate programs that reduce discrimination and stigma associated with mental illnesses. In this issue are:

• Spotlight on...
• Project Relate (Nebraska)
• Sowing the Seeds of Hope (Regional U.S.)
• Rural Minds (England)
• Research...
• ?Effects of a unit of instruction in mental health on rural adolescents' conceptions of mental illness and attitudes about seeking help?
• ?The treatment of persons with dual diagnoses in a rural community?
• ?Rural attitudes toward and knowledge of mental illness and treatment resources?
• In my opinion: ?Fighting stigma in rural areas: What's different? What works?? by David Lambert, Ph.D., president, National Association for Rural Mental Health
• In my experience: ?Do Rural Areas Offer More Opportunities to Tackle Stigma?? by Anne Donahue, Vermont State Representative and editor, Counterpoint

To receive this memorandum or future memoranda by e-mail, please e-mail us at promoteacceptance@samhsa.hhs.gov. 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 promoteacceptance@samhsa.hhs.gov or call us at 800-540-0320.

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.

The Resource Center to Address Discrimination and Stigma (ADS Center) is committed to helping to reduce discrimination and stigma. Please visit our Web site, www.adscenter.org and contact us via a toll-free number, 800-540-0320, which is 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.

In This Edition...

The theme of this edition of the Memorandum is Rural Issues.

The stigma and discrimination associated with mental illnesses are even worse in rural areas than in urban areas. According to the report of the President's New Freedom Commission on Mental Health: ?In rural and other geographically remote areas, many people with mental illnesses have inadequate access to care, limited availability of skilled care providers, lower family incomes, and greater social stigma for seeking mental health treatment than their urban counterparts.? As might be expected, the stigma associated with having a mental disability in rural areas leads to under-diagnosis and under-treatment of mental disabilities in these areas (http://www.nrharural.org/dc/issuepapers/ipaper14.html).

Statistics compiled by the Western Interstate Commission for Higher Education tell the same story: More than 60 percent of rural Americans live in areas that have a shortage of mental health professionals. In addition, more than 90 percent of psychologists and psychiatrists and 80 percent of MSWs work exclusively in metropolitan areas. It is no surprise that more than 65 percent of rural Americans get their mental health care from their primary care provider and that the mental health crisis responder for most rural Americans is a law enforcement officer.

Spotlight on...

Nebraska campaign employs lively media strategies to address discrimination and stigma

Project Relate (Local/Statewide)
www.projectrelate.org/

Launched on April 7, 2004, Project Relate is a public service campaign that strives to help the public relate to people with mental illnesses, demystify and personalize mental health issues, and break down the stereotypes associated with mental illnesses. It is a joint effort of mental health service providers, advocacy groups, and non-profit organizations across Nebraska.

Situation: Nebraska currently ranks 49th in the nation for resources allocated to treatment of people with mental illnesses, and mental illness affects 91,000 Nebraskans. More than 23,000 of those are children under the age of 17. The campaign was particularly timely because of its tie-in with LB1083, a legislative bill intended to move Nebraska from its heavy reliance on three state-run psychiatric hospitals to a system that depends on a greater array of community-based services, such as group homes. Project Relate had the support of Nebraska Governor Mike Johanns, who signed LB1083 on April 15, 2004.

Solution: The Project Relate campaign against discrimination and stigma is centered around advertising, featuring eight 30-second TV and radio commercials, a series of print ads and billboards, as well as an educational Web site devoted to mental health information and resources. The public service announcements were produced by the Omaha Federation of Advertising, which selected the Kim Foundation, one of the Project Relate partners, as the recipient of its annual non-profit organization public service project.

In addition to speaking out against stigma and providing information about mental illness to the community, Project Relate also aims to provide a clearinghouse of mental health resources across Nebraska. The Project was created by The Kim Foundation with support from several partners.

Results: During the three-month campaign, over 2,300 television, radio, billboards, and print ads ran, all free of charge. The value of the media time and space received is more than $215,000. The value of the creative and agency time spent developing the campaign is more than $100,000. Feedback from consumers and mental health providers was extremely positive:

?I met yesterday with some representatives from the Nebraska Psychiatric Nursing Association. One of the County hospital nurses told me that several of her patients were talking about the Project Relate campaign and were very encouraged by [it].?-Diana Waggoner, executive director, The Kim Foundation

?I received a call from one of our county commissioners today, Deb Schorr. She attended the Project Relate breakfast and was very impressed with the campaign. The County is looking at the current mental health system and liked what Project Relate is doing to reach out to those in need. She is impressed with the collaborative effort and asked how they could be of assistance in Phase 2 of the campaign.?- Dave Miers, coordinator of mental health services, BryanLGH [Lincoln General Hospital] Medical Center

?? [It is] exciting to see a focus on reducing stigma from a community-wide perspective. ? All of the reform planning and the information about the efforts to reduce the stigma associated with mental illness have provided such hope to so many people. What our consumers say to us is ?finally others are noticing mental illness.? -Aileen Brady, associate director, Community Alliance

Contact: info@projectrelate.org. All radio and print ads are available for download from the Web site (www.projectrelate.org).

Spotlight on...

Seven rural states collaborate in a multifaceted campaign to counter stigma and discrimination

Sowing the Seeds of Hope (Regional)
http://www.agriwellness.org/

Sowing the Seeds of Hope (SSoH) was designed and initiated in 1999 by the Wisconsin Office of Rural Health and Wisconsin Primary Health Care Association and is now a collaborative effort of project leaders in seven predominantly rural states: Iowa, Kansas, Minnesota, Nebraska, North Dakota, South Dakota, and Wisconsin. The federally funded campaign is administered by AgriWellness Inc. and coordinated through a different group in each state (e.g., mental health coalition, religious organization, etc.).

Situation: Negative stigma about mental health services, geographic barriers, and a perception that providers do not understand the agricultural issues of rural residents often deter some rural families from seeking necessary assistance. In addition, some residents do not have health insurance or adequate behavioral health coverage.

Solution: Each state that is part of SSoH chooses a project leader, who then determines how to use the funds most effectively within his or her state. The states collaborate to share best practices, which include the following:

• Social marketing through publications, including annual reports, and articles in the Des Moines Register and The New York Times; press releases; and other media activities, including radio and television appearances, and presentations at conferences and meetings
• Outreach to identify persons in need of services
• Training and education of behavioral health care providers, community health workers, natural helpers, the faith community, and others who serve the agricultural population
• Education of community citizens about agricultural behavioral health issues
• Information clearinghouses
• Crisis hotlines for the agricultural population
• Direct services through vouchers, contracts with approved providers, and other means to ensure that all the agricultural population has access to necessary services
• Prevention of more serious difficulties through early intervention
• Coalition building with organizations, agencies, and communities
• Advocacy for behavioral health care of the underserved agricultural population
• Retreats and support group activities for farm couples and families

Results: SSoH programs have reached 25,000+ farm residents in 520+ outreach events; 740+ providers have received specialized training in agricultural behavioral health; 7,310+ farm residents have received stress education assistance; crisis telephone hotlines in five states have responded to 33,000+ farm and ranch callers; more than 5,600 farm families/residents have received specialized counseling services; and 650+ persons have participated in farm couple retreats and ongoing support groups. Despite drought, floods and continuing economic challenges to family-sized farming operations, the suicide rate has not increased in states that have had SSoH services.

SSoH's work has been featured on ABC, CNN, National Geographic Television, NPR and the Farm Bureau Radio Network. The SSoH program has been selected as a ?best practice model,? which is included in Rural Healthy People 2010: A Companion Document to Healthy People 2010.

Contact: Michael R. Rosmann, Ph.D., AgriWellness, Inc., 1210 7th Street, Suite C, Harlan, IA 51537. Phone: 712-235-6100; email: agriwellness@fmctc.com.

Spotlight on...

British mental health organization focuses on rural dwellers

Rural Minds (International)

Rural Minds was launched in 1997 as part of a three-year project of Mind, a leading mental health charity in England and Wales.

Situation: Rural Minds is Mind's response to the disadvantages experienced by people with mental disabilities who live in rural communities in England. Rural Minds aims to promote better mental health for rural residents, developing innovative support and care networks; to provide information and training for volunteers and professionals working in rural communities; and to influence purchasing decisions to provide accessible rural mental health services.

Solution: In July 2003, Rural Minds published a Rural Policy Toolkit to help mental health providers implement Mind's Policy on Rural Issues and Mental Health and to support the development of mental health services in rural areas. Mind's Policy on Rural Issues and Mental Health aims to reduce the stigma around mental health issues, increase understanding of mental distress in rural areas, recognize cultural diversity in rural communities, increase access to mental health services, use information technology appropriately, and reach out to farming communities.

Results: Rural Minds has organized conferences, meetings, and training events reaching mental health providers and consumers across the country. The group produces the Rural Minds Digest newsletter; has developed a network of stakeholder organizations and individuals; maintains a database of rural mental health projects; and campaigns nationally for better rural mental health services. As of August 2004, the organization has also created a Rural Minds Resource Center at Stoneleigh in England.

Beginning in April 2004, Mind's rural work was being integrated with its core activities so that rural issues are evident in all areas of Mind's work.

Contact: Keith Elder, c/o South Staffs CVS, 1 Stafford Street, Brewood Staffs ST19 9DX. Phone: 01902 850060; email: ruralminds@ruralnet.org.uk.

Research

Effects of a unit of instruction in mental health on rural adolescents' conceptions of mental illness and attitudes about seeking help.Esters, I.G., Cooker, P.G., Ittenbach, R.F. (Summer 1998) Adolescence, 33(130): 469-476.

This study investigated the effects of mental health education on rural adolescents' conceptions of mental illness and their attitudes about seeking professional help for emotional problems. Forty students who were enrolled in a rural Mississippi high school participated. Twenty of these students were designated as the treatment group; the other 20 were the control group. The three-day unit focused on the roles of various mental health professionals and on the etiology, symptoms, diagnosis, prognosis, and treatment of mental illnesses. Students' conceptions of mental illness were measured using J. Cohen and E. L. Struening's (1962) Opinions about Mental Illness Questionnaire. Students' attitudes toward seeking psychological health were measured using the Fisher-Turner Pro-Con Attitude Scale (E.H. Fisher and J.L. Turner, 1970). The results indicated that the scores on both scales increased significantly for the treatment group. In addition, these scores did not decrease significantly when the students were tested again 12 weeks later. (PsycINFO Database Record (c) 2003 APA, all rights reserved)

The treatment of persons with dual diagnoses in a rural community, Howland, R.H. (Spring 1995) Psychiatric Quarterly, 66(1): 33-49.

This article describes the characteristics of a rural community mental health system, which illustrate the difficulties in treating persons with dual diagnoses of psychiatric illness and substance abuse in rural communities. These problems include a fragmented service system, centralized services in a large geographic area, overly restrictive regulations, conceptual differences in treatment approaches, confidentiality and stigma in a rural culture, and the academic and professional isolation of mental health workers. This isolation was found to lead to high turnover and a shortage of staff with sufficient training and experience to work with persons with dual diagnoses. The study suggests some recommendations to address these problems and to improve the delivery of services to persons with dual diagnoses. (PsycINFO Database Record (c) 2003 APA, all rights reserved)

Rural attitudes toward and knowledge of mental illness and treatment resources. Flaskerud, J.H., Kviz, F.J. (March 1983) Hospital & Community Psychiatry, 34(3), 229-233.

Stigma is thought to be a major factor in the resistance of rural residents to mental health services. Through mail questionnaires and personal interviews, data were gathered from 3,057 rural residents in six Midwestern states on their attitudes toward and knowledge of mental illness and mental health services. The survey also examined the relationships between the demographic characteristics of the respondents and their knowledge and attitudes. In contrast to previous research, the survey reported positive attitudes about mental health treatment. It also indicated a high level of awareness of a variety of mental health services and apparent satisfaction with those services. The study discusses possible reasons for the discrepancies between the findings of the present study and studies reporting negative attitudes. (PsycINFO Database Record (c) 2003 APA, all rights reserved)

In my opinion:

Fighting stigma in rural areas: What's different? What works?

By David Lambert, Ph.D.

The report of the President's New Freedom Commission on Mental Health ? Achieving the Promise: Transforming Mental Health Care in America ? strongly promotes addressing the significant challenges of serving persons with mental illnesses in rural areas. These challenges include the stigma attached to mental illness.

To realize the opportunity created by the President's New Freedom Commission to push the rural mental health agenda forward, it is important to understand how stigma in rural areas is similar to, and different from, stigma in urban areas; and to review approaches that have worked to combat stigma in rural areas.

What's different?
Rural mental health advocates use the image of the pick-up truck parked in front of the community mental health center to depict how stigma works in rural areas. You may not have told your co-workers or neighbors that you (or your wife or your daughter) are being treated for major depression, but parking your truck in front of the center may be the same as posting a sign on your lawn stating that someone in your family has a mental illness.

This metaphor contains a large kernel of truth as well as an element of exaggeration. Because rural communities are smaller, neighbors are likely to know more about each other's business than urban residents know about their own neighbors' affairs. Fear of disclosure deters many rural residents from seeking mental health care. This is unfortunate since availability of and access to mental health services are major barriers to care in rural areas, and considerable obstacles needed to be overcome to make these services accessible and available in the first place.

The challenge of reducing stigma to make mental health care acceptable is not unique to rural areas. For rural residents, as for city dwellers, knowledge about mental illness and available treatment, and knowing others who have been successfully treated for mental illness, go a long way toward reducing stigma and helping people get the care they need. What is likely to differ between rural and urban communities is the cultural context and logistics required to provide information about mental illness and effective outreach to persons needing mental health care.

Some successful programs and approaches
Idaho's Better Todays. Better Tomorrows. For Children's Mental Health (www.isu.edu/irh/B2T2/) has been successfully combating stigma in rural and frontier areas for four years. The program is a social marketing effort to educate parents, school staff, mental health professionals, and community volunteers who care for children and youth about mental disorders and their treatment.

The foundation for addressing stigma issues in Idaho began with a statewide campaign in 1997 that included television ads, a video for teens, and a public television documentary. Launched in 2000 in Red Flags, Idaho, Better Todays has now offered educational programs statewide to 112 rural and frontier communities. Nearly 2,000 people have been trained through presentations and classes about the signs and symptoms of mental disorders in children and teens. The program shares the latest scientific information with various professional, parent, and community audiences.

Better Todays has found that different rural and frontier areas pose different challenges. As Better Todays director Ann Kirkwood explains: ?The self-reliant culture of the rural West (what I call the 'cowboy up' culture) stands in the way of treatment seeking. Rather than obtaining needed care, consumers, children, and parents are encouraged by cultural norms to tough it out. This, of course, leads to the seriousness of conditions, family crises, and acting out behavior in the community, which includes law enforcement problems. It also contributes to our high suicide rate. Many in the juvenile justice and law enforcement communities contend they do not have the training or resources to deal with youth who formerly would have been helped in other social contexts. We are providing community trainings (including law enforcement and juvenile corrections) to assist them in understanding signs and symptoms of mental disorders in children/youth.?

Schools in more rural and frontier areas often do not have school psychologists ? or even counselors with any mental health training. When children/youth self-identify as having mental disorders, there is an insufficient safety net in the school environment. Better Todays provides a basic level of training to these professionals so that they are better equipped to help children who self-identify.

Better Todays is funded by a grant from the Idaho Governor's Generation of the Child Initiative. Additional support comes from the National Institute of Mental Health Constituency Outreach Program, Telehealth Idaho, and the Substance Abuse and Mental Health Services Administration. Better Todays director Ann Kirkwood won an International George Peabody Award for excellence in broadcasting for the documentary and teen video.

Information about mental disorders and their treatment is critical to change attitudes about mental illness and to begin to lift the veil of stigma preventing persons from seeking, or being encouraged to seek, help for their mental illnesses. However, information alone is often not enough to get rural dwellers to needed care. Outreach by mental health services is crucial to overcome barriers of distance, culture, and stigma.

There are a number of promising practices and approaches to rural mental health outreach (see Rural Mental Health Outreach: Promising Practices in Rural areas. Rockville, MD. Substance Abuse and Mental Health Services Administration. 2003).

One program that has successfully addressed these barriers of distance, culture, and stigma over many years is the Farm Resource Center (FRC) (www.quincynet.com/analists/npmessag/n5138.htm). The FRC was established in southern Illinois in the mid-1980s with seed money from the Rural Crisis Recovery Act, contained in the Farm Bill of 1987. The FRC has since expanded its services into other states and is also currently assisting rural farming communities in Pennsylvania, West Virginia, and North Carolina. Key elements of the FRC model that have evolved over time are that services are not driven by diagnostic codes, are provided without cost to the consumer, are accessible through a confidential toll free number, and are provided by culturally sensitive workers.

The FRC recruits and trains mental health workers from the areas it serves. As Roger Hannan, FRC's executive director, explains the relation of worker to farmer: ?Although workers must be very professional in the performance of their jobs, they should be able to tolerate walking out to the barn or shop as part of the 'get acquainted' ritual, during which the farmer evaluates his or her readiness to deal with personal emotional issues.? To overcome the distance (both physical and emotional) between consumer and outreach worker, FRC trains its workers to ?deliver services at or near the consumer's choice of location ? ideally at their kitchen table.?

The Better Todays and Family Resource Center programs demonstrate the importance of providing information and outreach, respectively, to overcome stigma in rural areas. It is also important to address sources of misinformation about mental illness and any discriminatory rules and policies that may perpetuate stigma.

A small pilot project convened in Portland, Maine (funded by the Maine Department of Behavioral and Developmental Services) ? The Community Mental Health Stigma Project ? has developed a framework to begin to identify how stigma is rooted in and often perpetuated by rules and policies ? formal and informal ? of community institutions such as the media, schools, employers, and public safety. The goal of this project is to give individuals and community organizations in the southern half of the state, including its rural areas, a tool to assess how policies in their community and state are contributing to or reinforcing stigma. Portland and other areas in Maine have made important strides in informing the public about mental health and in trying to combat stigma. This project builds upon these efforts by developing a draft stigma assessment tool that allows a community to examine the source and extent of stigma within its local institutions and to develop effective ways to address it. This effort is gro unded in a community development perspective that recognizes that a community's ideas, values and beliefs are interrelated ? as are a community's assets and challenges.

The challenge
As the programs described above (and others) demonstrate, there are successful ways to fight stigma in rural areas. However, as is often the case, new challenges seem to keep pace with our advances, pushing us to continue to improve our knowledge and programs. Rural America is becoming increasingly diverse, both culturally and ethnically. Successful outreach and anti-stigma programs will need to retool and hire and train more culturally competent staff. In addition, pressures on state budgets continue to challenge the ability of even the most successful anti-stigma and outreach programs to stay afloat ? particularly when anti-stigma initiatives and outreach are viewed as ?non-core? services. The challenge remains not only to increase and refine our knowledge and skills to fight stigma in rural areas, but also to move this effort into the mental health mainstream so that we can get the funding to apply this knowledge to the task at hand.

David Lambert is president of the National Association for Rural Mental Health and an associate professor at the Muskie School, University of Southern Maine.

In my experience...

Do Rural Areas Offer More Opportunities to Tackle Stigma?
By Anne Donahue

As surely as euphemisms ratify stigma under the guise of protecting against it, hiding psychiatric illness protects in the short term but blocks understanding and acceptance in the long term.

Secrecy is the hallmark of shame; whispering about something makes it seem as if it is inappropriate to discuss it out loud. So when we treat mental illness differently from any other illness, we encourage the public attitude that there is something different ? something to be ashamed of ? about ?mental? contrasted with ?physical? illness.

In the past year, I have been involved in three incidents that illustrated the fine line between eliminating and reinforcing stigma.

Stigma of Suicide
Because Vermont is more a large community than a state, with just over 600,000 in total population, it offers more opportunities for open, collaborative dialogue in the public arena. Yet the pressure is often greater in rural communities to ?respect the family? and to criticize news media that ?exploit? the revelation of the means of death or of the identity of one who committed suicide.

But should it be? The first question is, Who should control whether someone's privacy is sacrificed to the greater good of a public message that says, ?Succumbing to a mental illness is no more shameful than dying in a car accident or from a heart attack??

There were three highly visible suicides in Vermont this past year. As usual in a rural community, everyone knew who they were. But, also as usual, their names were only communicated in whispers. The state mental health agency did not disclose their names and also withheld certain facts surrounding the deaths due to requirements of patient confidentiality and privacy requests of the families.

When the state police report was later released, the local county newspaper reported on the new facts that had been disclosed and identified the names of the victims. Counterpoint, the state consumer newspaper I edit, ran an editorial supporting the county newspaper and strongly arguing for ?normalcy? in handling such incidents. I cited William Styron, who wrote in his essay ?Darkness Visible? that the denial of suicide by others is the way in which the sufferer is ?unjustly made to appear a wrongdoer.?

Were we who loved these individuals willing to have their memories tainted by a stigma of having done something wrong? What does anyone learn of the pain we suffer from mental illness if we insist upon hiding it? I pointed out that it was under the guise of ?family privacy? that the state attempted to withhold information that demonstrated its neglect of two of the individuals, who had been patients at the state's only public psychiatric hospital: the records of the efforts they had made to cry out for help in the hours before their deaths.

The third death was of a well-known and loved public figure. His name was known, and his death by his own hand in his barn was also well known in his broad circle of family and friends. The local county newspaper published a straightforward account of his death while the state's leading daily did not. Why not? Wouldn't it have reported, ?died after a struggle with cancer? or ?from a heart attack while shoveling snow??

Vermont's Press Association recently held an ethics conference, and one of the dialogues was about suicide: is it okay or not okay to include it as a normal aspect of a story?

Shared at the conference was the Counterpoint editorial quoting William Styron. So a consumer perspective made it into a conversation about the changing understanding of confidentiality as a potential aider and abetter of stigma rather than protecting against it.

Benevolence Backfires
The second incident was about the well-intentioned benevolence that small towns foster and that can backfire.

I had run for local public office for the first time the previous fall and had been elected as the representative of three small towns (combined population, 6,500). I did so only because I was reasonably confident that my recovery was secure enough to handle the stress of the part-time state legislature, which meets for four months each year. As I am a long-time mental health advocate, my history as a consumer was not a secret.

As the session extended into May, with long hours and tense negotiations over bills, my sleep began to suffer and my early warning signs of irritability and exaggerated emotions began to appear. I desperately needed help in protecting my sleep but had a new primary care physician replacing the one who had known me for 10 years. There was miscommunication and an abrupt departure by the doctor, and I broke down sobbing in the physician's office.

The office was closing for the day. I was offered a phone call or a cab ride. I was unresponsive and was left sitting on the office steps, still curled up and crying ? as the staff locked up and went home.

Several weeks later, the practice's executive director asked to meet with me. She was horrified about what had happened and wanted to use the incident as an opportunity for staff training. The staff had told her that they had felt terrible but simply didn't know what else to do. The director told me that what bewildered her was why they did not, at the very least, call the county's emergency mental health screeners rather than leaving me alone there.

The staff looked at her in horror. Call the screeners? For me? But I was an Important Person. They could not imagine exposing me in that way. Better to abandon me collapsed on their steps, in tears and at risk, than to stain me with the public label of weakness and relapse ? ?proof? that someone with a mental illness can't handle that kind of job after all.

Yet I had been doing a very good job and was well respected by my constituents. Why would it be all right for a politician to return from a heart problem but not have a temporary psychiatric setback? Was my community denied the opportunity for progress in understanding mental illness because I was shielded from its eyes when I, its successful representative, had a brief medical crisis? In this instance, ?protecting? me not only placed me at great medical risk but hurt all of us by buying into the stigmas we are trying to break down.

'Out of the Closet'
The third incident occurred this past spring, when a unique dialogue on how ?protection? may exacerbate stigma evolved among caregivers, family members and consumers in Vermont in a series of e-mail exchanges. Eventually, that dialogue contributed to a recent decision by our one academic medical center to take its psychiatry department ?out of the closet.?

The decision was sparked by a commentary on the distastefulness of the term ?behavioral health,? a would-be kinder, gentler phrase than psychiatric illness: a reality-softener intended to protect against stigma.

Cyberspace exploded. ?I think we have the ability and the responsibility to . . . make it known that we are not embarrassed or offended by the terms psychiatry, psychiatric illness, etc., any more than we are about neurology or neurological illness,? a consumer wrote.

?Use of euphemisms is both a ratification of stigma and evidence of the misunderstandings that perpetuate it,? noted a psychiatrist. ?Only when we can openly call psychiatry psychiatry, psychiatric illness psychiatric illness, psychiatric care psychiatric care, psychiatric services psychiatric services, and psychiatric units psychiatric units will the public know that we are serious when we say that people suffering with these cruel diseases deserve the same respect and dignity as everyone else, and that we are not embarrassed to call things what they are.?

It was, one writer said, an issue that had bothered her for some time, but she thought she was the only one.

A few months later, Fletcher Allen Health Care in Burlington, Vermont ? some of whose staff had participated in the impromptu exchange ? discussed the issue with faculty, nursing, attending physicians, and representatives of family and consumer advocacy groups. As a result, the ?mental health units? at Fletcher Allen are once again ?inpatient psychiatry,? as they were called years ago.

It isn't automatically the right answer. The stigma isn't gone. Will some people in need be frightened away by that label? But, as one doctor concluded, ?We can empower ourselves by not succumbing to the words others use to patronize and define us.? More bluntly put by a consumer: ?To me, behavioral health implies [that] if I would just change my behaviors I wouldn't have a mental illness. That's utterly ridiculous.?

Anne Donahue, an attorney, is a Vermont State Representative; editor of the statewide mental health newspaper Counterpoint; public speaker for Vermont Psychiatric Survivors; and a member of the legislative oversight committee on reform of the public mental health system and replacement of the state hospital, as well as on the public advisory committee on state hospital alternatives.

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.

Content in the InfoUpdate is current at the date of publication. Content and technology may change after the time of publication and affect the information presented here. If you are trying to locate a specific resource or research article, please contact the ADS Center directly.