Challenging Dogma - Fall 2008

Thursday, December 18, 2008

The Policy Implications of Stigma in Relation to Mental Illness - Tim Washburn

Approximately twenty-six percent of Americans age eighteen and older suffer from a diagnosable mental disorder in any given year. When extrapolated to the census data this means we have approximately fifty seven million people with mental disorders in this country (1). The current treatment of those with mental illness tends to be contrary to public health methods. Public health is defined as the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals (2). Our current health care system tends to medicalize mental illness by treating the symptoms with a reactionary approach rather than a preventative approach. In the words of Michael F. Hogan, Ph.D., Chairman of the New Freedom Commission on Mental Health, “Too often, today's system simply manages symptoms and accepts long-term disability (3).”
The stigma toward mental health in this country lies beneath the framework of mental health care. Stigma is a barrier to care and an influencing factor in public opinion and policy making. This paper criticizes the approach taken to mental health care and examines the role that stigma plays in resource allocation, media influence and the role of public health professionals. Stigma is defined as an attribute, behavior, or reputation that is socially discrediting in a particular way (4). When defined by mental health experts the definition becomes, “the negative effects of a label placed on any group including those who have been diagnosed as having mental health problems (5).” Stigma results in people distancing themselves from the mentally ill by avoiding living, socializing, or working with the identified person. Stigma deprives people of their dignity leading to low self-esteem, isolation, and hopelessness as well as deterring those with mental illness from seeking care to avoid being labeled as mentally ill.
A Segregated History of Mental Health
The field of mental health has been segregated from the rest of healthcare for a number of reasons starting with the work of Rene Descartes in the seventeenth century. Descartes viewed the mind as completely separate from the body. The mind was seen to be the business of organized religion where the body was the concern of physicians. This definition ushered in the separation of mental health and physical health that persists today (6). The separation has been exacerbated by the advances in medical technology in health care that led to the cure of two specific mental illnesses. First, tertiary syphilis is an advanced stage of syphilis that occurs when the bacterium invade the brain and causes neurological deterioration, paralysis, and death. When it was discovered that penicillin would cure this illness the medical field was awarded credibility over the mental health field for the treatment (7). Similarly, pellagra was traced to a nutrient deficiency that was treated with nutritional supplementation of niacin eliminating the patient’s delirium (8). These cases gave credibility to the medical field while leaving the unexplainable mental disorders to the mental health field. We know today that mental health and physical health are inseparable and are essentially one in the same yet the stigma of an inferior field of mental health still exists.
Lack of Resource Allocation for Mental Health Care
The idea of an inferior methodology of treatment for mental illness lends itself to the social theory of Skitka and Tetlock. Their theory explains the decision making process of a policy maker when allocating resources outlined below:
To summarize, policy makers are given limited resources and typically allocate funds based on the need for the program, the effectiveness of the program and the responsibility of the participants regarding their need for the program (10). If policy makers view mental health services to be inferior and therefore less effective they may be less willing to fund such programs.
Research shows that psychiatric disorders are viewed as more blameworthy than physical health conditions like cancer and heart disease (11). Using Skitka and Tetlock’s model we see that a view of blaming those with mental illness for their condition may lead to a decrease in allocation of funds as well.
Finally, policy makers often make their decisions of resource allocation within healthcare by what population is experiencing the greatest hardship. This is typically on a scale of which group is more likely to die from their condition (12). This process does not lend itself well to mental illness where death is not an easy way to characterize the need. The mental health field may use activities of daily living (ADL’s) and quality-adjusted life years (QALY’s) instead of risk of death for a more accurate picture.
When we apply Skitka and Tetlock’s model to the resource allocation for mental health funds we see three distinct disadvantages inherent in the nature of mental illness and the impact that stigma can have on policymaking and resource allocation.
Eighty five to ninety percent of the mentally ill are unemployed. Since health insurance is linked to employment in this country the majority of the mentally ill are also uninsured. This creates a downward spiral for the mentally ill of being unemployed, therefore not having health insurance, therefore not getting treatment for their mental illness, therefore having further difficulty finding a job due to mental illness and so on.
There is no current return on investment (ROI) analysis of where healthcare dollars should be allocated. The economic cost of untreated mental illness is more than $100 billion each year in the U.S. (13). The majority of the mentally ill can be treated and live productive lives and contribute to society. This realization, follow by a ROI analysis, should lead to a higher funding of mental health services given the reduction of cost to society of untreated mental illness.
Media’s Role in Stigma of the Mentally Ill
Anthropologists use the term enculturation to refer to the process of internalizing the culture of the society. The media plays an important role in depicting the language, beliefs, customs and traditions of a society (14). Over-reporting negative stories about people with mental illness can be misleading and create an implied link between mental illness and violence and further the stigmatization of those with mental illness (15). The idea that “if it bleeds it leads” in news organizations creates a formula of sensationalizing and stigmatizing the mentally ill. The Hollywood portrayal of the mentally ill with such characters as Norman Bates in Psycho and Dr. Hannibal Lecter in The Silence of the Lambs further exacerbates this stigma of the mentally ill being violent.
Studies show that news reports focus on violent behavior and dangerousness regarding people with mental illness but the mentally ill are rarely violent and account for only three to five percent of all violence in the country (16). The news media almost never include statistical facts and context with any story of violence perpetrated by a mentally ill person. The exclusion of people with mental illness speaking on their own behalf in the press leads the watcher to believe that the mentally ill are too disturbed and dysfunctional to communicate.
The role of the media in defining our society is powerful and is currently counterproductive toward the mentally ill, only serving to further the stigma. The media sensationalizes violence from mental illness when it could be used to reshape popular opinion and advocate for funding and programs to help the mentally ill.
Public Health and the Mentally Ill
Unmet mental health need among adolescents is alarmingly high, as more than seventy percent of teens that require mental health care do not receive services. Given that twenty percent of adolescents suffer from a mental health disorder and that unmet need is a critical problem, removal of stigma as a barrier to care should be a priority of the public health community (17). Studies show that the initial mental health intervention experience of teens greatly influences their willingness to use mental health care services in the future (18). The first contact is typically a guidance counselor in a school setting that is more than likely overworked, underpaid, and undertrained to meet the needs of and provide care for a mentally ill teen. The public health community should be focusing their efforts toward ensuring this crucial first point of contact is successful to ensure future use of mental health resources if needed.
Given that stigma is a barrier to seeking care for mental illness the public health community should also make a priority of both reducing that stigma and putting in place a proactive approach to dealing with mental illness. It has been demonstrated that proactive interventions to identify those at risk for mental illness can be effective. A coordinated effort between schools, law enforcement officers, domestic violence specialists, community residents, early childhood educators and care providers, court personnel, child welfare workers, and mental health practitioners can lead to early intervention and improved outcomes in mental health care (19). The current approach of treating mental illness in emergency rooms, or worse yet jails, goes against the principles of public health.
The school dropout rate begins to increase sharply in 9th grade; therefore addressing youth when they are still in school seems to be the best venue for screening. The public health community should be focusing on community based, proactive interventions as a preventative measure to treating mental illness rather than leaving the medical profession to reactively treat the symptoms.
The three critiques summarized in this paper are inextricably linked. We can view the three arguments in a sequence. The media’s influence can have an effect upon the opinions of the public and therefore the opinions of the policy makers. This leads to reduced funding for mental health programs in turn leads to the public health professionals not having the adequate funding to implement mental health programs.
Proposed Intervention
Given the media’s effect on public opinion and the resulting poor resource allocation toward mental health programs, my suggestion is to launch a media campaign to alter public opinion. A media campaign can serve two purposes: media advocacy and enculturation through social diffusion. Media advocacy’s goals are to influence public opinion, policy makers and ultimately policy (20). Social diffusion theory can be utilized in tandem with the media to help shape culture and to reduce stigma.
Media advocacy focuses on changing the behavior of policy makers and not on changing the behaviors of individuals. Its goal is to influence policy makers to vote a certain way and to set the agenda for the issue of concern. Media advocacy is done through advertising campaigns, news media, radio, press releases, opinion pieces, You Tube and any other mass media outlet. The details of the policy agenda will be addressed later in the proposed intervention.
Social diffusion theory explains how media can be used to reduce the stigma that surrounds mental illness by altering the perceptions of the public and influencing the culture of society. Under the social diffusion umbrella, the theories of diffusion of innovation and social marketing theory are highly applicable in regards to a media campaign.
Diffusion of innovation describes how a behavior makes its way into a population and either is or is not accepted. The theory suggests a slow rate of adoption up to a “tipping point,” or the point at which the adoption rate increases in relation to time, followed by a rapid rate of adoption (21). If a media campaign is well crafted and is successful in reaching this tipping point it can have a chance at reducing the stigma surrounding mental illness.
Social marketing theory can help determine the information to communicate in a media campaign and how to package that information. A media campaign is most effective when research is conducted on the target population and the message is tailored accordingly. It may be beneficial to enlist a professional marketing team to assist in the development and implementation of a media campaign if the budget allows.
The “Truth” campaign is an example of how a media campaign can have great results. The “Truth” campaign was an anti-smoking media campaign funded by the State of Florida through its landmark victory against the tobacco industry. It included an earmarked budget of $200 million for a state-run pilot program to fight youth tobacco use. The “Truth” campaign is estimated to have been responsible for a twenty-two percent decline in youth smoking between 1999 and 2002 in the state. The Truth campaign utilized market research in designing their media plan, which resulted in unprecedented results and serves as a great example of an unorthodox yet effective public health strategy (22).
The major news media excludes people with mental illness speaking on their own behalf. The suggestion is to reach out to people that are in the public eye to speak out about their illness. The list of successful and famous people throughout history who are widely believed to have had manic depression or bipolar disorder (as documented by historians, biographers, private letters, etc.) is significant and includes Ludwig van Beethoven, Abraham Lincoln, Albert Einstein, Sigmund Freud and Isaac Newton. A more contemporary list includes Carrie Fisher, Richard Dreyfuss, Jean-Claude Van Damme, Margot Kidder and Linda Hamilton, all of who have spoken publicly about their struggles. "If well-known people in entertainment or politics talk about their experience, it provides people with a knowledge that they're not alone, and that it's an illness that's very treatable," says Mark D. Smaller, Ph.D., a Chicago-based psychotherapist and the director of the Neuro-Psychoanalysis Foundation in New York and London. "The more well known people speak out, the more it facilitates other people getting help (23)."
The final component of the media campaign is to boycott and protest programs and networks that foster the stigma of mental illness. Writing letters to and speaking out against offending programs and networks can be successful. The ABC program “Crumbs” that depicted mental illness in a derogatory light was cancelled after mental health advocates spoke out against it. Shows such as “Intervention” (24) on the A&E network present real life people, not actors, battling mental illness and shows how they can overcome their illness with treatment to lead productive lives. This is real progress we can point to as an example of another unorthodox yet powerful public health intervention that combats the stigma of mental illness.
The next step in the proposed intervention is to secure proper funding for mental health care. The ultimate goal is to pass legislation to make mental health care an entitlement program in the United States. An entitlement program is a government program that provides individuals with personal financial benefits, goods or services to which an indefinite number of potential beneficiaries have a legal right whenever they meet eligibility conditions that are specified by the standing law that authorizes the program (25).
Using our media campaign and social marketing, this goal could be realized. A conceivable way to pass this type of legislation would be to tack it onto Medicare, an existing entitlement program. The Americans with Disabilities Act defines mental illness as a disability (26). If the government can recognize the problem then it may choose to help fix it.
An integral part of the argument to have mental health care as an entitlement program is that it will save money. Most people with mental illness can be treated and live normal, productive lives. As mentioned above, the economic cost of untreated mental illness is more than $100 billion each year in the United States. (27). We would actually save money with an increase in economic productively and a reduction in acute care for untreated mental illness. In these tough economic times any new government program proposal needs to be budget neutral to have a chance of passing into law. This proposal would save the government money in the long term. For evidence of this we can look to the private sector and analyze the implementation of employee assistance programs (EAPs).
EAPs are programs that are typically outsourced or implemented through an organization’s human resources department. These programs offer confidential evaluation, treatment and referrals for a range of personal problems including family and marital issues, mental health, financial and legal problems and substance abuse (28). The results of these programs are noteworthy:
· More than 70% of all Fortune 500 companies have implemented EAPs
· Firestone Tire and Rubber estimated EAP savings of $1.7 million or $2,350 per person involved
· United Airlines reported a return of $16.35 for every dollar invested in EAP costs
· Scoville Manufacturing estimates an annual cost savings of $186,550 credited to their EAP
Undoubtedly a government mental health entitlement program will look very different than an EAP program but the government can use the example as a starting point for a ROI analysis. With a proactive mental health care plan we could potentially save the country millions of dollars. The suggestion is to conduct a comprehensive ROI analysis to support the proposed policy.
The final piece of the proposed intervention is to redesign how the medical establishment treats mental illness. I propose a system more in line with public health practices that focuses on prevention and early detection starting in elementary school. The model exists today in which elementary school children receive mental health evaluation and treatment at school.
Morgan Stanley Children's Hospital of New York conducts a program that serves children aged four to ten, and grades pre-K through five. The program consists of three parts. The first component is an in-school clinic program comprised of comprehensive clinics in five elementary schools. The second part is the Mobile Outreach, Referral and Education (MORE) program comprised of urgent evaluation, short-term treatment, and referral services in another six elementary schools. Finally, a school-based trauma services, prevention and outreach program in all eleven of the schools served. The program operates in collaboration with parents, teachers and school student support staff to give them tools to improve the behavioral and mental health status of their children (29).
This sort of early intervention makes it more likely that the person receiving care will have a positive first experience. This is critical to making the individual willing to reach out for care if he or she needs help in the future. Being exposed to mental health care at an early age will help remove the stigma of mental illness.
In summary, the multifaceted issues regarding mental health care require a multifaceted solution. The proposed approach deals with three major impediments of a coordinated mental health care system in the United States. The media influence on stigma, the policy implications on funding and the resulting approach of medicalized care deserves our utmost attention if we hope to make progress with mental heath care. The proposal of an alternate media campaign, a mental health care entitlement program and a public health approach to mental health care can serve our mentally ill, save money for everyone and enlighten our society.
1. The National Institute of Mental Health. (n.d.). (National Institutes of Health) Retrieved November 15, 2008, from
2. Public health. (n.d.). Retrieved November 15, 2008, from Wikipedia:
3. President's New Freedom Commission on Mental Health. (2002, December 2). Retrieved November 15, 2008, from Mental Health Commission:
4. Stigma (sociological theory). (n.d.). Retrieved November 15th, 2008, from Wikipedia:
5. Carter, M. (2005). Keep Quiet about It. Community Care , 38-39.
6. U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration , Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, Rockville, MD.
7. (Ibid)
8. (Ibid)
9. Corrigan, P. W., & Watson, A. C. (2003). Factors That Explain How Policy Makers Distribute Resources to Mental Health Services. Psychiatric Services , 54 (4), 501-507.
10. Skitka, L. J., & Tetlock, P. E. (1993). Providing Public Assistance: Cognitive and Motivational Processes Underlying Liberal and Conservative Policy Preferences. Journal of Personality and Social Psychology , 65 (6), 1205-1223.
11. Corrigan, P. W., & Watson, A. C. (2007). The Stigma of Psychiatric Disorders and the Gender, Ethnicity, and Education of the Perceiver. Community Mental Health Journal , 43 (5), 439-458.
12. (Ibid)
13. The National Institute of Mental Health. (n.d.). The National Institute of Mental Health. (National Institutes of Health (NIH), U.S. Department of Health and Human Services) Retrieved November 15th, 2008, from
14. DeFleur, M. L., & Ball-Rokeach, S. J. (1989). Theories of Mass Communication (Fifth ed.). White Plains, NY: Longman Inc.
15. Friedman, R. A. (2008, July/August). Media and Madness. The American Prospect , pp. 2-4.
16. (Ibid)
17. Chandra, A., & Minkovitz, C. S. (2007). Factors that Influence Mental Health Stigma Among 8th Grade Adolescents. J Youth Adolescence (36), 763-774.
18. (Ibid)
19. Hyde, M. M. (2008). National Evaluation of the Safe Start Demonstration Project: Implications for Mental Health Practice. Best Practices in Mental Health, 4 (1), 108-122.
20. Edberg, M. (2007). Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, Inc.
21. Wikipedia. (n.d.). Retrieved November 15th, 2008, from Diffusion of innovations:
22. Social Marketing Institute. (n.d.). Retrieved December 10, 2008, from Success Stories:
23. Rustad, M. (2008, September 29th). Living with Bipolar Disorder. Retrieved Dec 7th, 2008, from Revolution Health:
24. A&E. (n.d.). Retrieved December 7th, 2008, from Intervention:
25. Auburn University. (n.d.). Retrieved December 10th, 2008, from A Glossary of Political Economy Terms:
26. Americans with Disabilities Act. (n.d.). Americans with Disabilities Act. Retrieved December 7th, 2008, from
27. The National Institute of Mental Health. (n.d.). The National Institute of Mental Health. (National Institutes of Health (NIH), U.S. Department of Health and Human Services) Retrieved November 15th, 2008, from
28. Dictionary. (n.d.). Retrieved December 7th, 2008, from Case: New York Presbyterian. (n.d.). Elementary School Children Receive Mental Health Evaluation and Treatment at School. Retrieved December 7th, 2008, from New York Presbyterian:

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