The ADS Center produces a semi-annual memorandum which spotlights campaigns and includes articles from those fighting discrimination and stigma, and those experiencing it.

DATE: Winter 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

This is the third in a series of informational updates that you will be 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...
• Read the Signs (England)
• Entertainment Industries Council, Inc. (U.S.: National)
• Wisconsin United for Mental Health (Statewide)
• Research:
• Police, Criminal Justice Systems, and the Stigmatization of Mental Illness
• In my opinion: ?Fighting Stigma in Law Enforcement: The Message Has to Come from the Heart,? by Major Sam Cochran, Coordinator, Memphis, Tenn., Police Department Crisis Intervention Team
• In my experience: ?Cops, Crisis, and Changing Culture,? by Tom Lane, Director, Office of Consumer Affairs, NAMI

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.

According to the report of the President's New Freedom Commission on Mental Health, ?Increasing public understanding about mental health and mental illnesses requires action at every level of government and in the private sector. The first step is to reduce the stigma surrounding mental illnesses, using targeted public education activities that are designed to provide the public with factual information about mental illnesses and to suggest strategies for enhancing mental health, much like anti-smoking campaigns promote physical health.?

Please visit our Web site, http://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.

Spotlight on...

England:
Campaign uses popular media to teach young people to ?read the signs? of mental illnesses

The Department of Health in England has created a campaign called ?Read the Signs,? which uses colorful images resembling road signs to educate young people about the symptoms of mental illnesses. The campaign has been promoted through popular media as well as the Web site www.readthesigns.org.

Situation:In England, mental illnesses have had an impact on many young people, but as a group they lack understanding of mental health issues. Research conducted in December 2002 among 15- to 21-year-olds in England revealed that a large percentage of young people know someone who has been affected by mental illnesses. Among a survey group of 1,001 young people:

• 86 percent know someone who has experienced a mental health problem.
• 68 percent know someone who has experienced depression.
• 17 percent know someone who has experienced schizophrenia.
• 49 percent know someone who has self-harmed.
• 35 percent know someone who has attempted suicide.
• 25 percent are worried about the mental health of a young person they know.

However, the study also indicated that young people had insufficient information about mental health issues:

• 97 percent felt that young people know relatively little about mental health issues.
• 61 percent felt that young people were likely to be dismissive of people with mental health problems.
• 96 percent felt that more information should be made available to young people.

Solution:The Department of Health launched ?Read the Signs,? an England-wide campaign to increase youth awareness of mental health issues. At the center of the campaign is a set of eyecatching signs with messages such as ?No Thanks,? ?No Sleep,? and ?Keep Out,? illustrating warning signs of mental illnesses such as decreased appetite, insomnia, and withdrawal. Other materials include a 30-second animated clip, a Web-based game (www.mindnseek.net), and magazine ?advertorials.? Additionally, the campaign named ?Read the Signs ambassadors,? young people who speak publicly about their experiences with mental illnesses.

Results:has generated numerous media exposures in outlets popular with English youth:

• BBC Radio 1 conducted its first on-air mental health campaign, Oct 6-12, 2003.
• MTV has aired a 30-second Read the Signs animation, as well as winning entries from a mental health filmmaking competition, which attracted over 70 entries from young filmmakers. The popular rock band Radiohead contributed a musical track to the campaign, which was used as background music for the films.
• Advertorials and interviews with Read the Signs ambassadors have appeared in magazines popular with young people, such as NME, Kerrang, FHM, Cosmogirl, and 19.

Contact:http://www.readthesigns.org/, Amanda Duffy, The Forster Company, 49 Southwark Street, London SE1 1RU, United Kingdom, Phone: 020-7403-2230, Fax: 020-7403-2240, E-mail: amandaduffy@forster.co.uk

Spotlight on...

National entertainment association seeks to encourage positive portrayals of mental health consumers

The Entertainment Industries Council, Inc. (EIC) is a non-profit organization founded in 1983 by leaders in the entertainment industry to provide information, awareness and understanding of major health and social issues among the entertainment industries and to audiences at large. Among its initiatives is an effort to promote accurate and positive portrayals of people with mental illnesses. Through its Web site, http://www.eiconline.org/, EIC provides resources to people involved in developing stories and scripts for movies and television.

Situation: The entertainment media, particularly movies and television, are very influential in shaping public perception. For example a 2001 study published in Health Affairs (a bimonthly, peer-reviewed journal that explores health policy) indicated that television substantially increased awareness of health care issues, at least in the short term.

Unfortunately, when it comes to portraying people with mental illnesses, the media has too frequently provided the public with damaging stereotypes. A 1998 study published by the Screen Actors Guild revealed that more than 60 percent of characters with mental illnesses were portrayed as violent, a rate three times that of other characters.

Solution: Two years ago, EIC hosted a conference for producers, directors, writers and both network and studio executives to educate those in the entertainment industry about mental health issues. The conference featured then Surgeon General David Satcher, M.D., Ph.D.; former ER executive producer and current Law and Order: SVU executive producer Neal Baer, M.D.; Academy Award-winning actress Sally Field; and best-selling author and Johns Hopkins University professor of psychiatry Kay Redfield Jamison, M.D. In addition, EIC president and CEO Brian Dyak has been a featured speaker at multiple conferences sponsored by the Suicide Prevention Center. His lectures covered engaging the media to promote awareness of and gain support for mental health issues.

On an ongoing basis, EIC provides a number of resources to motion picture and television writers, researchers, producers and development personnel to help them accurately portray health and social issues, including mental health, substance abuse, HIV/AIDS, and gun violence. According to the organization's Web site:

Contrary to popular belief, incorporating accurate portrayals of health and social issues into your show or film can actually help ratings, rather than hurt them ? just ask the creators and researchers of C.S.I., Judging Amy, Strong Medicine, The Practice and other productions that frequent EIC's services for information. Why not help educate audiences while entertaining them?

The Web site offers story ideas, as well as fact sheets, ?myth busters,? firsthand testimonials and Web links. In order to encourage the accurate depiction of mental health issues, the Web site offers the following 10 depiction suggestions:

• Try to provide accurate information about the particular disorder being portrayed.
• Try to avoid connecting mental illness with violence by emphasizing the ?CRAZED KILLER.?
• Try exploring the difficulties persons with mental disabilities face in terms of stigma and stereotyping and how both impede the recovery process. Emphasize the importance of social support.
• Consider showing main characters seeking out mental health treatment for problems they are experiencing.
• When incorporating a character with a mental disability, try to give an empathetic portrayal of the difficulties encountered in coping with the problem.
• Consider showing people with mental disabilities as productive, functioning members of society who are coping with their problem.
• Try to avoid labels and pejorative terms like ?PSYCHO,? ?MENTAL CASE,? and ?WACKO.?
• If portraying a suicidal individual, consider showing some of the warning signs and the importance of intervention.
• Consider showing that with proper treatment, medication, and social support, many people with mental illness can greatly improve or recover.
• Try to emphasize that people who have experienced psychiatric disabilities aren't just the sum total of their illness ? They're People First ? People With Problems.

Results:The entertainment industry is featuring an increasing number of positive and accurate portrayals of people with mental illnesses. Examples include Sally Field's portrayal of a character with bipolar disorder on ER, a man with schizophrenia who is a victim of crime rather than a perpetrator on Law and Order: SVU, a teenager's coping strategies after a suicide attempt shown on Seventh Heaven, and a realistic depiction of a person with obsessive-compulsive disorder on Judging Amy.

Contact information: http://eiconline.org/resources/topicareas/mentalhealth.php Laura Baker, Manager, Corporate Communications, Entertainment Industries Council, Inc., 1760 Reston Pkwy, Suite 415, Reston, VA 20190; Phone: (703) 481-1414; Fax: (703) 481-1418; E-mail: eiceast@eiconline.org

References:

Brodie, M. et al. (2001) Communicating Health Information Through the Entertainment Media. Health Affairs 20: 192-199.

Gerbner, G. (1998) Casting the American Scene: A Look at the Characters on Prime time and Daytime Television from 1994-1997. Screen Actors Guild, Los Angeles, Calif.

Spotlight on...

Wisconsin: Statewide campaign uses radio and television to promote online mental health screening

Wisconsin United for Mental Health (WUMH) is a statewide coalition of mental health organizations formed in 2002. The coalition supports the Web site http://www.wimentalhealth.org/, conducts legislator and media briefing activities, conducts anti-stigma initiatives, works with the business community to provide information about mental illnesses, and engages in other activities to combat discrimination and stigma. The coalition has launched a statewide campaign, funded by an educational grant from Eli Lilly and Company, to encourage people to take the Web site's online screening tests for depression, bipolar disorder, generalized anxiety disorder, and post-traumatic stress disorder.

Situation: Leaders in Wisconsin's mental health community have identified difficulties in reaching people, especially men, who might be experiencing a mental illness and encouraging them to seek treatment. According to the President's New Freedom Commission on Mental Health:

Too many Americans are unaware that mental illnesses can be treated and recovery is possible. In fact, a wide array of effective mental health services and treatments is available to allow children and adults to be vital contributors to their communities. Yet, too many people remain unserved, and the consequences can be shattering. Some people end up addicted to drugs or alcohol, on the streets and homeless, or in jail, prison, or juvenile detention facilities. . . . Sadly, only 1 out of 2 people with a serious form of mental illness seeks treatment for the disorder.

Solution:WUMH has launched a statewide campaign to educate people about the fact that mental illnesses are real, common, and treatable. Through its Web site, the campaign offers confidential online screening for depression, bipolar disorder, generalized anxiety disorder, and post-traumatic stress disorder. The screening tests consist of a series of questions, such as whether a person is experiencing persistent sadness or feeling empty inside or has lost interest in activities that he or she used to enjoy. The screening tests are not meant to replace clinical evaluation and treatment, but rather to link people with health care services. Upon completion of the screening, the user is given information about local health care providers who could make a diagnosis and provide treatment. Additionally, the Web site serves as a resource for people to get information about mental illnesses.

To help inform the public about the online screening tests and to raise Wisconsinites' awareness of mental health issues, the campaign has prepared recorded public service announcements and print editorials, and campaign leaders have made themselves available for press interviews.

Results:The campaign has been successful in promoting the online screening through radio and television; approximately 75 percent of participants learned of the online screening through these media. More than 1,570 radio and television public service announcements (PSAs) have aired, and several radio and television stations have aired news stories about the campaign and online screening.

Additionally, editorials written by the campaign's co-chairs have been carried by several daily and weekly newspapers, and several papers have carried stories about the campaign and the online screening.

The campaign has successfully reached a number of people who might be experiencing mental illnesses without realizing it. The impact has been widespread, even among hard-to-reach groups. More than 875 people from all of Wisconsin's geographic regions have participated in the four online screening tests offered. Significantly, the campaign has been particularly successful in reaching people who are not currently receiving treatment for a mental illness. For each screening test, approximately 85 percent to 90 percent of participants indicated that they were not receiving treatment.

Contact Information:http://www.wimentalhealth.org/About, Mental Health Association in Milwaukee County, 734 N. 4th St., Suite 200, Milwaukee, WI 53203; Cara Hansen, co-chair; e-mail: cara@mhamilw.org; Phone: (414) 276-3122; Fax: (414) 276-3124

Research

Police, Criminal Justice Systems and the Stigmatization of Mental Illness

Mental health consumers, especially those with little relief from their symptoms who are homeless or live in poorer neighborhoods, often come into contact with police. In particular, people with mental illnesses are disproportionately the victims of crime or witnesses to it, in which case their testimony affects police interventions into criminal activity or to protect those who are threatened.

Because these interactions are so frequent, and because police are so often the first line of contact with local mental health, social service and criminal justice systems, the attitudes and beliefs they hold regarding people with mental illnesses play a critical role in the lives of many consumers.

Efforts since the 1960s to educate the police about mental disorders have increased general awareness within police departments around the world. Yet many long-standing biases persist that affect the way police deal with mental health consumers in their communities.

In recent years, a surge in research by committed investigators in the fields of social psychology and psychiatry has sought to clarify whether mental health education can effectively reduce these biases, and to measure the extent to which stigmatizing attitudes towards people with psychiatric disabilities may manifest as discrimination in the course of daily police work.

Research teams based in Israel, the United Kingdom and the United States have conducted studies in police attitudes and mental illness education and come up with an array of provocative conclusions. In spite of geographic and cultural differences, their findings present a coherent picture: although certain biases are currently less prevalent among police than in the past, and some may be reduced through education, many stigmatizing attitudes continue that affect police interactions with mental health consumers everywhere. The studies reveal that persons with mental illnesses are still deemed by police to be untrustworthy and more dangerous than the population at large, and that police routinely treat people differently when they know or believe they have a history of mental illness.

Israel:
Police Attitudes toward Mental Illness and Psychiatric Patients in Israel. (Kimhi, R., Barak, Y., Gutman, J., Melamed, Y., Zohar, M., and Barak, I. Journal of the American Academy of Psychiatry Law. 26: 4. 625-630. 1998.)

In their study of 93 police officers in metropolitan Tel Aviv, the research team found that many were well educated about some mental disorders and interventions: 88 percent were able to diagnose symptoms of schizophrenia and/or schizoid personality disorder. Additionally, most (73 percent) of the officers disagreed with the statement that ?mentally ill patients should be kept behind walls,? and felt that people with mental illnesses could be safely housed in the community.

In their personal lives, however, the opinions of the Israeli officers tended to be quite different. Over half of the survey respondents, who were all male but varied widely in age, stated they had personally known someone with a mental illness (54 percent), and several reported having a relative with mental illness (5.7 percent). Thirty-eight percent of the policemen stated that they could be friends with a psychiatric patient as well. But a strong majority of the officers (80 percent) said they would not marry a former mental patient, while a striking 90 percent would object to one of their children doing so.

The stigma surrounding mental illness was more apparent when it came to the work lives of the policemen. Half of the respondents (50 percent) would refuse to work in a psychiatric hospital, 54 percent stated they would not hire ?a mental patient,? and just under half (48 percent) would be reluctant to work with someone who had been hospitalized for mental illness.

These results show that, while general knowledge of some aspects of mental illness has increased in the last generation (against a similar study conducted in the 1970s), stigmatizing views of persons with mental illnesses are still widely held by police. Though police in Tel Aviv are now less likely to recommend coercive hospitalization in cases involving a person with a psychiatric history, they still tend to view these people as dangerous to others (39 percent) and themselves (49 percent).

Among the causes for concern, the researchers point out, is that a large percentage of the surveyed officers did not know the answers to many of the survey questions. Although it's not clear to what extent their training includes education on mental illness, the researchers suggested that better training on the issue could serve to further reduce the discriminatory views held overall: ?We call for further efforts to dispel the myths regarding mental illness that exist among police personnel.?

United Kingdom:
Reducing Psychiatric Stigma and Discrimination: Evaluating an educational intervention with the police force in England. (Pinfold, V., Huxley, P., Thornicroft, G., Farmer, P., Toulmin, H., Graham, T. Social Psychology and Psychiatry Epidemiology. 38. 33-344. 2003.)

U.K. researchers wanted to know how effective education and training programs were in reducing stigmatizing views in police officers. To accomplish this they surveyed a large group (119) both before and four weeks after the officers completed a two-part mental illness awareness training. The tested group of police in Southeastern England was 11 percent female and the range of ages and experience was broad in order to ensure accurate results.

The training workshops, conducted by a combined group of mental health providers and people diagnosed with mental illnesses, involved personal narratives that detailed the lives and struggles of those with severe mental illnesses, as well as educational talks and experiential exercises to help participants relate to the subjective experience of symptoms such as ?hearing voices.?

Among the important findings, researchers determined that the workshops helped officers feel more comfortable with the subject of mental illness and more confident to respond to it in the course of their work. Also, despite the fact that a significant number (35 percent) were doubtful at the outset that the sessions would be beneficial, most (73 percent) recommended afterwards that the training be delivered to other staff as useful in police work.

After the workshop trainings, police also showed increased knowledge and sensitivity to a range of mental health issues, including prevalence and the likelihood of recovery from mental illness. Officers completing the training also rated higher the chance that they ?would not find it difficult to work with? someone with a mental illness.

Studies revealed that the trainings had a clear albeit small effect on the general change of attitudes towards people who have mental illnesses. Especially interesting to the researchers was the finding that female officers showed a consistently stronger change in attitude across the board, suggesting that the workshops, designed to elicit compassion and reduce social distance, were less effective for male officers.

Yet despite the fact that the officers held more positive views overall, certain beliefs ? in particular the notion that those with mental health problems were likely to be dangerous ? were unchanged after the training. The researchers point out that in the case of police officers who are often called upon to intervene in crisis situations, this idea may be even tougher to eradicate. ?Unfortunately, where the police are concerned, knowing someone with mental health problems away from the work environment may not be enough to counteract experience as a police officer supporting mentally distressed individuals, where minority incidents may support popular stereotypes.?

Chicago:
Police Responses to Persons with Mental Illness: Does the label matter? (Watson, A., Corrigan, P. and Ottati, V. Journal of the American Academy of Psychiatry and the Law. In press. 2003.)

?You are patrolling on foot at the local train station. The ticket agent approaches you and points to a man sitting on a bench . . . he states that he has no money and no way to get to his home.?

If you're a police officer in this situation, would you respond differently if you were told the man had a mental illness? What if he were the victim of a crime, or a witness to one? Would you be likely to believe his story or to assist him?

Researchers at the University of Chicago wanted to determine if police would routinely treat people with mental illnesses differently than those not given such a label. To accomplish this they devised questionnaires and a series of four vignettes, in which the subject, named Steve, was a witness to, a suspect in, or a victim of a crime; or a person in need of assistance (the situation summarized above). They also employed an attitude survey in which officers rated their opinions and feelings about Steve.

Three hundred eighty-two police officers, of whom 41 (11.3 percent) were women, responded to the survey. All or most of the respondents were from police departments in the metropolitan Chicago area, though they were diverse in age and police experience.

For many, the study revealed no significant difference in the way officers stated they would treat Steve based on whether or not they were told he had schizophrenia. There was also a noticeable ?benevolent? bias: when officers were informed of Steve's label of mental illness they were more likely to report feeling pity for him, attributing less responsibility to him for the situation and being more generally willing to assist him. Overall, the police officers did not rate Steve's story as less credible when told he had a mental illness.

Some results, though, reveal that discrimination is likely to occur in certain cases. Officers indicated that they would not consider Steve credible in cases where he was the victim of a potential crime. In this vignette, officers who were responding to Steve's complaint against a neighbor would be less likely to speak with or warn the neighbor, or even to register an official report. This finding was strong despite the fact that there were no specific symptoms of Steve's illness provided, beyond the diagnosis of schizophrenia, that should have led officers to doubt his story. As the researchers point out, ?This could be particularly harmful in light of the increased vulnerability to victimization of persons with mental illness.? (Other research has revealed this bias to adversely affect police action in cases of reported domestic violence and sexual abuse as well, leading to an increased potential for endangerment where the victim is known to carry a psychiatric diagnosis.)

The research team also discovered that suspicions as to Steve's credibility would make police less likely to follow up on his testimony as an eyewitness, potentially decreasing the chances of rapid intervention. ?[In] situations in which it is important to get information dispatched quickly, the delay could result in failure to apprehend an offender. The point here is that officers treated the witness information differently based solely on whether or not they knew he had a mental illness.?

* * *

Other studies on stigma and discrimination in the criminal justice system have focused particularly on the treatment of people with mental illnesses by law enforcement and justice agencies, and the barriers to getting help that they encounter during and after incarceration. The following abstracts describe several important findings of this research. For further details refer to the authors or journals cited.

How police and public attitudes play a role in the increasing numbers of persons with mental illness in jails and prisons

The police and mental health. (Lamb, H. Richard; Weinberger, Linda E; DeCuir, Walter J. Jr. Psychiatric Services. American Psychiatric Assn. 53(10) Oct 2002, 1266-1271.)

Abstract
?With deinstitutionalization and the influx into the community of persons with severe mental illness, the police have become frontline professionals who manage these persons when they are in crisis. This article examines and comments on the issues raised by this phenomenon as it affects both the law enforcement and mental health systems. Two common-law principles provide the rationale for the police to take responsibility for persons with mental illness: their power and authority to protect the safety and welfare of the community, and their parens patriae [government as parent] obligations to protect individuals with disabilities. The police often fulfill the role of gatekeeper in deciding whether a person with mental illness who has come to their attention should enter the mental health system or the criminal justice system. Criminalization may result if this role is not performed appropriately. The authors describe a variety of mobile crisis teams composed of police, mental health professionals, or both. The need for police officers to have training in recognizing mental illness and knowing how to access mental health resources is emphasized. Collaboration between the law enforcement and mental health systems is crucial, and the very different areas of expertise of each should be recognized and should not be confused.? (PsycINFO Database Record (c) 2002 APA, all rights reserved) http://psychservices.psychiatryonline.org/cgi/content/abstract/53/10/1266

* * *

Persons with severe mental illness in jails and prisons: A review. (Lamb, H. Richard; Weinberger, Linda E. Psychiatric Services. American Psychiatric Assn. 49[4] Apr 1998, 483-492.)

Abstract:
"Objective: The presence of [persons with severe mental illnesses] in jails and prisons is an urgent problem. This review examines this problem and makes recommendations for preventing and alleviating it. Methods: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1970, and all pertinent references were obtained. Results and Conclusions: Clinical studies suggest that 6 [percent] to 15 percent of persons in city and county jails and 10 [percent] to 15 percent of persons in state prisons have severe mental illness. Offenders with severe mental illness generally have acute and [long-term] mental illness and poor functioning. A large proportion are homeless. It appears that a greater proportion of [persons with mental illnesses] are arrested compared with the general population. Factors cited as causes of [persons with mental illnesses] being placed in the criminal justice system are deinstitutionalization, more rigid criteria for civil commitment, lack of adequate community support for persons with mental illness, mentally ill offenders' difficulty gaining access to community treatment, and the attitudes of police officers and society. Recommendations include mental health consultation to police in the field; formal training of police officers; careful screening of incoming jail detainees; diversion to the mental health system of [persons with mental illnesses] who have committed minor offenses; assertive case management and various social control interventions, such as outpatient commitment, court-ordered treatment, psychiatric conservatorship, and 24-hour structured care; involvement of and support for families; and provision of appropriate mental health treatment.? (PsycINFO Database Record (c) 2002 APA, all rights reserved) http://psychservices.psychiatryonline.org/cgi/content/abstract/49/4/483

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In my opinion...

Fighting stigma in law enforcement:
The message has to come from the heart
By Major Sam Cochran

The Memphis Police Department pioneered the Crisis Intervention Team (CIT) in 1988 after the police shooting, a year earlier, of a 27-year-old man who had mental illness. The people in Memphis ? including the Police Department, the city administration, family members of people who had mental illnesses, and those individuals themselves ? were determined to change law enforcement crisis services and to do so within a context of safety, understanding and dignity. Fifteen years later, the CIT model has proven so successful that similar programs have been established in approximately 50 to 80 diverse communities, cities and counties around the country.

What makes the CIT so successful? As I have said often, it's more than just training! Although the 40-hour training is substantial, what really makes the CIT effective is its foundation of sensitivity and understanding interwoven within the framework of community partnerships. This gives birth to community ownership ? which is the CIT heartbeat.

Although many law enforcement agencies are making positive strides toward meeting the demands and complexities of crisis events, these efforts are more often than not formatted within the context of training hours only. However, the expectation that training by itself will resolve the issues of stigma is not realistic. Mere training is not enough to compensate when there is no infrastructure of services and care. To combat the devastating effects and trauma brought about by the stigma of mental illness requires a profound community outcry, joined with linkages to appropriate community service infrastructures. CIT is a profound course of action. It is a hope, a voice, a necessary plan to correct the harmful and life-taking tragedies of stigma's past and present.

The Memphis CIT consists of nearly 240 officers assigned to the Uniform Patrol Division, which comprises more than 900 officers, linked to the 911 Dispatch System, choreographed for an immediate crisis response. CIT officers, who volunteer for the program, must submit to a thorough selection process. Crisis calls with a mental illness component require special talents and attributes that are not found in all officers; CIT members share attributes of good judgment, maturity and leadership. (Some law enforcement officers can't get along with citizens while writing a traffic ticket, much less with someone in a serious psychiatric crisis!)

The Memphis team maintains citywide coverage 24 hours a day, seven days a week. When CIT officers ? who wear an identifying pin ? arrive on the scene, they are in charge. This does not negate the supervisor chain of command; it enhances clarity and responsibility and provides order during a crisis assessment in defining an appropriate response/disposition.

The results speak for themselves. After the Memphis CIT hit the streets, the number of people we were putting in jail decreased, and the officer injury rate also reflected a significant reduction in regard to crisis calls. Another positive change is that CIT officers became advocates for consumers and set an example for future qualified officers to follow. Consumers also saw a positive change in the police and have since been more willing to call the police themselves regarding their personal crisis or as a citizen calling for other law enforcement services.

One of the most important and rewarding parts of the CIT training is the eight hours of officer and consumer interaction. Officers and consumers meet each other openly and build new relationships of understanding. This has been a very positive component and serves to offset some of the stigmas often associated with people who have mental illnesses.

No matter which way you look at the problems in the criminal justice system in regard to people who have mental illnesses, the bottom line is about stigma. Stigma comes in many different disguises ? but all are treacherous. A lot of times, it's even the good intentions that stigmatize individuals who happen to have a mental illness. That's a tragedy within itself.

Many people are trying to address crisis services, and they say, ?We're going to provide extra training.? That's great; it needs to be in place. But one of the most important things I need to say ? not only to law enforcement officers but also to communities ? is that people with mental illnesses have special needs and are deserving of special care and services. This is an uncompromising position and should be recognized accordingly. The CIT program, by having a special crisis response, underscores this message. No matter how good or well intentioned, generic training does not deliver that message ? at least, not with the necessary passion.

I wish we could say that CIT ends stigma, but it's only one avenue. We need many different avenues to combat stigma ? because it's generated and inappropriately nurtured in so many different ways.

One thing is clear: The message in regard to CIT and stigma has to come from the heart, and it has to be a changed heart. You can't just say, ?We need to educate our officers about mental illness.? We've been doing that for years. But mere education about mental illness is not enough to combat the hurtful and tragic effects of stigma. So you have to have a change of heart. You have to have a change of mind. And these changes must be profound.

Until that happens, you can have the best training program in the world, but if you don't have the necessary support ? partnerships, community service infrastructures ? I'm afraid you're not going to be able to meet the full potential of CIT: changing of hearts.

I suspect that if you were driving down the street and saw a man carrying a white cane with a red tip who was having difficulty crossing, you would witness a traffic jam with people stopping and exiting their vehicles to help this individual walk across the street. Yet every day we pass by individuals in severe crisis because of mental illnesses, and we never see them. We don't see them with our eyes, and we don't see them with our hearts. Sadly, stigma blinds more than our eyesight.

The family members and the consumers: they're the people who inspire us. They're the people we need to address our attention and service to. With passion, we ask, ?Who are ?the mentally ill'?? They're our fathers, our mothers, our sons and daughters, our cousins, aunts and uncles. They're us.

Major Sam Cochran, a 29-year veteran of the Memphis, Tenn., Police Department (MPD), is the coordinator of the MPD Crisis Intervention Team, a specialized group of officers within the MPD's Uniform Patrol Division. ?CIT ? It's more than just training.?

In our experience...

Cops, Crisis, and Changing Culture
By Tom Lane

I often say that I have not only been a recipient of mental health services but I have also been a recipient of law enforcement services. These days, that message is usually delivered to a law enforcement organization or in the context of advocacy efforts at the intersection of the mental health and criminal justice systems. It has been a humorous way to break the ice when I am speaking to a group of law enforcement first responders; after all, it is because of my contact with law enforcement that I'm asked to speak.

The culture of law enforcement, as part of the larger culture of the criminal justice system, is very different from the culture of the public mental health system or the culture of the national consumer/survivor movement: different values, different purpose, different people.

Looking back on some of my own experiences, I recall events and circumstances that have underscored the negative. I remember the time I was so depressed, so down, so hopeless. Existing in a travel trailer in rural Northern California, unemployed, isolated and with no transportation, I thought about killing myself. I called the suicide crisis line but, when I couldn't promise I wouldn't hurt myself, four deputy sheriffs were dispatched. I was getting a law enforcement response to a mental health crisis.

In retrospect, I have some understanding of why the deputies had weapons drawn, seemingly ready to shoot. In law enforcement culture, at least at that time in the rural Northern California county I lived in, the main frame of reference for responding to a ?mental? call (yes, that's how the deputies referred to the dispatch to my trailer) was through a lens of dangerousness and public safety. But the primary reason those deputies were in my driveway, holding me at gunpoint, was because I wanted to die; that seemed to escape them.

No doubt most of the training those deputies had received regarding mental illness and psychiatric disabilities had emphasized violence, dangerousness, and potential threat. We know the focus on these concerns is a major part of the stigmatization and discrimination that is perpetuated in other segments of American society, including the media. Yet in the law enforcement community, those issues are founded on the experiences of thousands of cops. What else might the deputies responding to the ?mental? call about me have expected? How can we change the experiences of law enforcement first responders, as well as law enforcement administrators and trainers, relevant to mental illness?

About two years after my experience in California, I was asked to help train the Albuquerque, N.M., Police Department Crisis Intervention Team (CIT). Albuquerque had started a CIT initiative about a year earlier, based on the very successful Memphis model. Major Sam Cochran's excellent contribution to this Memorandum, ?In My Opinion,? explains the origins and evolution of the Memphis Crisis Intervention Team.

A cornerstone of the Memphis training is having consumers and family members share their experiences living with mental illness. I stood in front of a roomful of cops to tell my story, and no one had a gun pointed at me. This was better.

I have to admit that my own prejudices and misconceptions about cops had made me anxious. I've learned that prejudice, stigma, and discrimination all have similar roots.

Over the next couple of years, I had the pleasure of participating in three additional Albuquerque CIT trainings, as well as in Police Academy cadet training. The opportunity to have a dialogue with those cadets was especially important. It was gratifying to plant those seeds of change. Instead of the one-sided view portraying people with mental illnesses as violent and dangerous, the cadets also heard about the challenges of trying to access inadequate services and supports. They heard what it was like to live in substandard housing, trying to stay clean and sober, when drugs and street life were mostly all you saw. They asked questions. I answered.

It has always been important to me to be willing to answer the hard questions; that is the beginning of tearing down the misconceptions. Most importantly, the cops I got to spend time with as a trainer heard about the reality of recovery, of the vital and unique role that peer supports and services and mutual self-help play. They heard that people with mental illness could be well.

Much of my own advocacy work has been focused on the many challenges inevitably found at the intersection of the mental health and criminal justice systems. Understandably, one of the best places to start untangling these problems is with the law enforcement community. Over the past five years, I have been fortunate to be involved with a number of initiatives where cops were at the table as critical partners. Some of these were local projects, such as implementing the Memphis CIT model in the Ft. Lauderdale, Fla., Police Department. (This was another place that Major Cochran's path crossed mine; I was again a trainer, and Sam always makes every effort to be at the ceremony of the first graduating class of a new CIT.)

Some of the projects I have been involved in have been statewide and some national. After all that work, I've come to think about cops the same way I think about auto mechanics: some are really good at what they do and some aren't. In the final equation, people bring to their work, whether it's as law enforcement professionals or mental health advocates, the influence of their individual experiences. Everyone is also influenced by those things one doesn't know; the trick here is knowing what those things are.

When it comes to fighting the stigma and discrimination associated with mental illness, a little education goes a long way. Often, our beliefs and assumptions are based on those same two factors: what we know and what we don't. In my experience, the most accurate beliefs are based on an investment of time in getting to know the truth. I can't think of a better return on investment than what comes back when people living with mental illnesses have the opportunity to talk with cops in an open dialogue. As Sam says in his article, it's about changes in the heart.

I've found some of the law enforcement professionals who are willing to be at the table, who are willing to look for a better way, to be some of the best advocates in combating stigma; but the stigma and discrimination associated with mental illness are so pervasive that the work is never done. Combating stigma is a continual process. This seems to be especially true when the very culture of a system, like the criminal justice system, has incorporated many of the most extreme manifestations of stigma and discrimination.

It's much more likely than it used to be that the person who shows up at a mental health crisis situation will be a cop; but law enforcement agencies understand that this is not what they are trained for, nor is it the best use of their time. Think about an officer who faces the prospect of spending his entire shift in a hospital emergency room, waiting for a mental health evaluation for the person he found in crisis. Is it so hard to imagine that officer lumping the person together with the problem? The report of the President's New Freedom Commission on Mental Health concluded what law enforcement first responders have known for a long time: the public mental health system is in shambles and in need of transformation.

So how does change happen? One way it happens is with dialogue, with a willingness to unlearn those beliefs and attitudes that feed the stigma and discrimination monster. It happens when the experiences aren't just the worst case ones, and the law enforcement professionals responding to a crisis have seen people in recovery, know people in recovery, and know the value of offering hope for recovery.

Cops aren't trained to be social workers, and law enforcement culture isn't known for being warm and fuzzy; but the choice to offer compassion, help, and hope is a reflection of our humanity. Choosing to perpetuate stigma and discrimination is a reflection of our fears and ignorance. I think we all know what the right choice is.

Tom Lane is director of consumer affairs of NAMI.

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