Beat the Stigma

eat the Stigma

Posted by אמיר (אמיר) on 23/03/2007 at 15:16

Advocacy groups and other mental health stakeholders have argued that stigma is a major barrier preventing people with mental illness from accomplishing many of their life goals. In just the past five years, several groups have developed projects to attack this problem. The Substance Abuse and Mental Health Services Administration has supported a national conference on the stigma of mental illness, launched a technical support center - the Center to Address Discrimination and Stigma - for antistigma programs, and championed an eight-state initiative to change people's attitudes about mental illness. The World Psychiatric Association has implemented "Open the Doors" as an international effort to erase stigma. Each of these programs has used education, protest, and contact to change public opinion so that people with mental illness will no longer experience the prejudice and discrimination that rob them of many life opportunities. 

At the same time, another revolution has been occurring in a relatively quiet and uncoordinated fashion that may ultimately yield even greater effects on public stigma. People with mental illness who previously chose not to disclose their experiences have been coming out of the closet. These include such renowned individuals as John Nash, Mike Wallace, Patty Duke, Margot Kidder, and Rod Steiger. They also include people who happen to be our neighbors, coworkers, friends, family members, and others with whom we regularly associate. Research suggests that when people in the latter group - "People who are just like me!" - disclose their experiences with mental illness, the antistigma effect is greater than when famous people make such disclosures. 

Think of the societal impact that may result if "coming out" becomes a formal strategy of multiple stakeholder groups. Professional and provider groups should join with consumer-survivors and family advocates to strategize about the best ways for people with mental illness to "come out." We should not be naive about the risks involved in disclosing a mental illness. The discrimination in the workplace and in one's social life that often results from the stigma of mental illness is the driving force behind antistigma programs. Hence, a coalition that seeks to promote "coming out" must also aim to obtain interpersonal, legal, and other substantial support for those who step up to the challenge. 

Psychiatric services have been marked by several revolutions in approach and philosophy, including moral therapy, community-based care, empowerment, and recovery. Viewing some of the problems experienced by people with mental illness as social injustice and seeking to right the injustice through antistigma programs such as "coming out" may represent as great a shift in the public mental health paradigm as any previously seen.

Men and depression: battling stigma through public education

A two-year-old NIMH media campaign to raise awareness of depression among men is showing signs of success.

 National Institute of Mental Health (NIMH) officials estimate that more than 345 million people have encountered information about men and depression through its media campaign "Real Men. Real Depression." To reduce stigma and educate men and those close to them about the symptoms of and treatments for depression, the campaign uses testimonials of men who have battled the disease, including one from a New York Cityfirefighter who became depressed after 9/11.

"Real Men. Real Depression."--NIMH's ongoing attempt to address the fact that depression affects 6 million American men annually--was launched in 2003 and uses television spots, videos, print ads, posters, pamphlets, PowerPoint presentations and fact sheets to create awareness, says campaign manager Daisy Whittemore. To date, the agency has aired campaign public service announcements on 119 television stations and 874 radio stations and published ads in magazines and newspapers. The campaign has already spurred media coverage of men and depression by such print publications as Time, Sports Illustrated and The Washington Post and such TV networks as CNN and ABC, Whittemore says. Also, about 420 local organizations, including the University of Michigan and Caterpillar Inc., have used the materials to augment or create their own depression prevention initiatives for men.

"We've found this is a really good tool for increasing awareness among both men and therapists of the deadly repercussions of depression," says University of Iowa psychologist Sam Cochran, PhD, who studies depression in men. "These are well-done materials because they are constructing their message around the obstacles that men really face in getting help."

In fact, the materials were developed with those obstacles, like the stigma attached to having an emotional problem or asking for help, in mind, Whittemore says. Beyond that, the program gives all people, not just men, information on how to recognize depression in friends and family members--and offers men and the people who care about them a way to take the next step of seeking help: It includes a contact phone number and e-mail on all of its materials. Since the 2003 launch, NIMH has received about 4,800 campaign-related calls and e-mails.

In the trenches

Other avenues for men seeking help have come out of the local organizations that use the "Real Men. Real Depression." materials. For example, the volunteers and staff of the Mental Health Association of Illinois Valley go to community venues, like homeless shelters, to give short presentations about depression, hand out the NIMH pamphlets and explain how to get help.

In venues ranging from Salvation Army soup kitchens to Urban League meetings to the University of Illinois College of Medicine student gatherings, men are interested in the stories featured in pamphlets and videos, says Katie Jones, executive director of the Mental Health Association of Illinois Valley.

"This population, they really like the graphics; they like that it's multimedia," Jones says. "They don't like when I stand up there and give a speech; they want the materials that relate to them--and not just for themselves, but for men they know, to help them get off the hook of depression."

In evaluations of the presentations, Jones finds that about 93 percent of men say they have a better understanding of depression and how it manifests in men after viewing the NIMH materials.

One of the men featured in the materials, New York Cityfirefighter Jimmy Brown, says he has run into a lot of positive reactions, especially to the first-hand accounts of depression among the police and firefighters he works with in a peer support group.

"Especially with the men I've worked with, those who are in professions that tend to be macho, it's the stigma attached to admitting you have any kind of problems that gets in the way of beating depression," Brown says. "But when you see a real person up there, and you know it's a real person who has the same kind of thing I have, it creates an opening for them, and they know they're not alone and can go out and get help."

Brown gives the example of one fellow firefighter who benefited from seeing a "Real Men. Real Depression." video featuring Brown's personal story of overcoming depression.

"One fireman came up to me and said he'd been feeling real bad for a while and after seeing the piece it occurred to him to talk to his doctor," Brown says. "The doctor sent him to a psychologist who diagnosed him with depression. The long-story-short is he was diagnosed, treated and is feeling a lot better. That I've helped that one person by creating the connection between feeling bad and being depressed, that's what I did this for, and if there's anyone else we've helped, that's gravy."

Building bridges

To have that kind of impact with a broad range of men, the campaign includes the personal stories of men from many different ethnic and professional backgrounds.

Japanese-American attorney Bill Maruyama, another of the men featured in the campaign, says mental illnesses are not usually discussed within Asian families, in part, because of pressure to not bring shame onto a family. Because of this "code of silence," a lot of Asian people may think depression is not an issue within the community and that it's an illness Asian people do not experience, he says.

"The fact is there are Asian people who do get depressed, and the campaign makes that clear," Maruyama says. "Just by saying that, I think there has been an incredible impact. It's hard enough to get people to admit to their families that they have depression, so to publicize this on a broad scale is a big deal."

Indeed, organizers took pains to ask the men portrayed in the campaign broad and culturally sensitive questions, says Rodolfo Palma-Luliעn, a Latino portrayed in the campaign who was a student when the campaign began and now runs a student community outreach program at the University of Michigan.

"They asked how my family had dealt with my depression, which is an important question, especially with Latino men," Palma-Luliעn says. "We have a very organized family structure, lots of family involvement, especially in decision-making. Of course a family would be involved in the decision to seek treatment for depression, so it's important that family reactions be addressed in the campaign."

Checking outcomes

Empirical research addressing the perceptions and impact of the campaign is just beginning, but early results indicate that there might indeed be a lot of people among those "macho" populations helped by the "Real Men. Real Depression." materials, says psychologist Aaron Rochlen, PhD, of theUniversity of Texas at Austin.

In a study of 209 male college students, to be published later this year in the APA journal Psychology of Men and Masculinity,Rochlen and his research partners found that among the men who expressed a negative attitude toward help-seeking and had high levels of gender-role conflict--feelings that men should behave differently than women--the "Real Men. Real Depression." materials were slightly preferred to gender-neutral materials. Among the general group of men, no preference was expressed.

Rochlen says that finding demonstrates a remarkable quality of the campaign: It is tailored to the target audience of men resistant to mental health services.

"This is an example of psychology meeting marketing, of psychology taking on a business perspective and thinking hard about who its target audience is," Rochlen says. "It's clearly tailored to the specific audience that research has shown needs some direct, targeted and specific attention. We have to tell these guys that you're not weak or feminine if you admit to needing help, and that you can become a better man if you're willing to take a look at your emotions and your feelings."

For more information on the "Real Men. Real Depression." campaign, go to



U.S. Surgeon General puts mental health on the front burner

David Satcher says mental illness is a critical public health problem that the United States must address immediately.

  (American Psychological Association

Mental health and the role psychologists can play in promoting it have become a top priority for the U.S. Surgeon General's Office.

In December, psychologists' calls for increasing access to mental health services and furthering research on mental disorders got a sizable boost with the release of the first-ever U.S. Surgeon General report on mental illness. And Surgeon General David Satcher, MD, PhD, is fully backing the report's conclusions that support the role of federal and state governments in promoting parity for mental health services and in implementing mental health awareness campaigns to decrease the stigma of mental illness and encourage people to seek treatment.

"Mental Health: A Report of the Surgeon General"--a culmination of an extensive review of mental health research--concludes that while about one in five Americans has a mental disorder, most never seek treatment despite the availability of effective treatments. Often impeding their care, says the report, is a lack of insurance coverage and fear of the stigma attached to mental illness.

The Surgeon General's most important message to the American public is straightforward: Seek help if you have a mental health problem or think you have symptoms of a mental disorder.

APA's Public Policy Office contributed to the development of the Surgeon General's report on mental health by commenting on the initial outline, by providing feedback at briefings and meetings with those involved in its preparation, and by highlighting psychological research in key areas. The office also facilitated the participation of a number of APA members among those included in the list of contributors on page 23.

A week after the report's release, the Monitor visited with the Surgeon General to ask about the report's conclusions and his office's next steps.

Q. Your report recognizes that Americans need to pay more attention to mental health promotion and the prevention of mental illness. However, there aren't many federal initiatives or programs along those lines. Do you have plans for such programs in the future?

A. It's fair to say that this report is really more about mental illness than it is about mental health. The reason for this is that I don't think we know enough about mental health and how to prevent mental illness. That's one of the major things we hope will come out of this report--a major push for research and prevention of mental illness and the promotion of mental health. We need to continue the science, [and with that] I think you're going to see much more effort in that area over the next few years.

Q. The report also states that medication, along with psychosocial intervention, allow us to treat most mental disorders. However, managed-care companies most often only cover medication, because they see it as less expensive. How can we ensure that psychosocial intervention, not just medication, will be available to people who need them?

A. One thing we need to do is show the cost-effectiveness of psychological interventions. There are studies in the report that show that when you don't provide access for mental health treatment, people who have problems with depression or anxiety, for example, express those problems in other ways: lower back pain, abdominal pain, chest pain, headaches. But people don't think the system is receptive to dealing with underlying problems, like anxiety or depression, and they're not encouraged to talk about those things.

Another goal is to ensure parity for mental health services on the state and national level. Just since the report came out, there have been states in which parity legislation has been introduced. And at least 28 states have already passed parity laws. Unfortunately, they're not all equal, but I think we're making progress.

We also need to keep evaluating the impact of parity laws. We've got to be able to show that when you approach mental health as you would any other illness in terms of reimbursement and coverage, in the long run it pays off for individuals, families and the community. And it's not a bad investment for the nation or for health plans.

Q. The federal government is beginning its program of providing mental health parity to nearly 10 million federal employees. Will there be any evaluation of how parity is working--for example looking at whether more people are being covered for mental health problems?

A. That's what we're talking about right now. The implementation of the program will probably be delayed for a year. So, we have time to plan now to do a really good evaluation. It's a tremendous opportunity.

Q. Related to the supply and demand of psychologists, has your office done any studies to determine how many mental health professionals are needed to meet consumer needs, and what the projection might be for the future?

A. That was not included in this report. But what is included is the need to increase the supply of mental health service providers, and that includes psychologists and psychiatrists, as well as psychiatric nurses and primary-care providers. So many people who access the system see family physicians, internists or pediatricians for mental health problems--they're on the front line, and the role they could play in early detection and treatment or referral could be a great addition. They've got to be attuned to that, and it's got to become a greater part of their training, whether you're talking about undergraduate, medical school, nursing school, graduate education or continuing medical education.

Q. How can we foster more interdisciplinary collaboration?

A. It is critical to develop partnerships among the disciplines. We're talking with the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics and others about developing partnerships with APA and other groups [concerned about mental health] to raise the level of care for people with mental illness.

Q. One of the report's major themes is reducing stigma. In addition to educating and informing consumers, how else can psychologists reduce the stigma of mental illness?

A. Well, there's no substitute for public education and public awareness. I think the most important message in this report is the science--the fact that mental illnesses are real, that they have a physical/chemical basis--in essence, mental illnesses are physical illnesses. That message, when carefully, accurately communicated, will do more than anything to remove the stigma.

The other message that will help is that many mental illnesses are treatable. People can be returned to productive lives and positive relationships if they're treated appropriately.

Now, how do you convey those messages? That's why we're talking about the destigmatization campaign. Recently I visitedAustralia to examine a campaign they started back in the early '90s that is not just public education, it's public motivation. They've used vignettes on TV to show cases of people with mental illness who've been treated and returned to productivity right alongside people with diabetes who've had their diabetes controlled. They're making the point that just as diabetes can be diagnosed, treated and controlled, so, too, can mental health problems. That's the kind of effort we need in this country.

Q. We hear that you're planning to do several supplements to the mental health report. When will they be out and what are the topics?

A. The first supplement will examine the effects of race, culture, ethnicity and maybe even gender on mental health. We're talking about releasing that in three to six months. We're also interested in a supplement dealing with the elderly that will be ready by summer.

Another topic that people are interested in has to do with the unique role of the provider in mental health services. The doctor-patient relationship is important in any field, but many people feel that there is a special requirement of that relationship in dealing with mental illness.

And we're talking about working on a full-blown Surgeon General's report on substance abuse and treatment of addictive disorders, which could be released in the next two years. The Substance Abuse and Mental Health Services Administration is raring to go with that.

Q. Is there anything else you'd like to say to the nation's psychologists?

That doesn't happen by chance, it happens by planning and organizing and partnering. And that's what I hope we're going to do--we're going to come together across disciplinary lines in the interest of mental health and organize strategies for destigmatization, but also for substantially improving treatment and access to treatment and mental health services.

A lot of thought has gone into how we get the message out there. This was not meant to be a report to be on a shelf. It's meant to be a report to push to the American people.

The Surgeon General's report is available on the Internet at The full text of the executive summary will also appear in the February issue of APA's Professional Psychology. Copies of the report and the executive summary are also available by calling 1-877-9MHEALTH.

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