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: Fall 2003

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. 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...
• 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:

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, ?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 will be available through its Web site [www.samhsa.gov/stigma], which is scheduled to be launched soon, 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.

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

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

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.

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 Information: http://www.nami.org/template.cfm?section=In_Our_Own_Voice 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.

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

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 author s 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 m ind 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 http://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.

?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.

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 ha ve 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 t oxicity.

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.

In our 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.

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.

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