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Confronting and changing the stigma of mental illness

“Who is Crazy?”. Confronting and changing the stigma of mental illness. Mental Health Planning Council San Francisco, California June 19, 2008 Sarah Altman, MD, MPH Karen Hopp, MD . Sarah Altman, MD, MPH Clinical Instructor, UCSF Attending Inpatient Psychiatrist,

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Confronting and changing the stigma of mental illness

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  1. “Who is Crazy?” Confronting and changing the stigma of mental illness Mental Health Planning Council San Francisco, California June 19, 2008 Sarah Altman, MD, MPH Karen Hopp, MD

  2. Sarah Altman, MD, MPH • Clinical Instructor, UCSF • Attending Inpatient Psychiatrist, San Francisco General Hospital • Karen Hopp, MD • Private practice • Psychiatry & primary care medicine • Woodland Healthcare, Woodland, CA

  3. Objectives • Describe stigma and its effects on individuals, families & communities • Understand selected models in anti-stigma research • Summarize what is known about effective strategies to reduce stigma and discrimination • Provide information about available resources

  4. A Letter From A Resident… “Dear Dr. Fink, I am a PGY-4 resident in psychiatry. I am also mentally ill. I am bipolar and a recovering alcoholic. It has been difficult and trying at times. Sometimes I feel as though it is too much and I should reevaluate my goals…..”

  5. What is STIGMA? • Word originally referred to the mark or brand that was put on Greek slaves to separate them from free men • “A sign of disgrace or discredit which sets a person apart from others.” – Goffman, 1963

  6. The Experience of Stigma • SHAME • Blame • Secrecy • The “black sheep of the family” role • Isolation • Social exclusion • Hopelessness (Byrne, 2000)

  7. Common themes: The Concept of Stigma STEREOTYPING (The neutral PERCEPTIONS of difference) PREJUDICE  (Negative BELIEFS about this difference) DISCRIMINATION (Negative ACTIONS taken) Adapted from work by Corrigan et al and Link and Phelan

  8. “People with Mental Illness are…” • Dangerous therefore they should be feared and excluded • Incompetent  therefore they should be controlled and should not be allowed to make their own decisions • Lack willpower therefore they need to be cared for and should not be independent (Corrigan, 2004), (Byrne, 2000)

  9. Less likely to be hired Less likely to have apartments rented to them More likely to be rejected by friends and family More likely to be falsely accused of a crime More likely to be arrested and spend more time in jail that someone else similarly charged The Discrimination of Stigma (Rusch, 2005) (Read, 2006)

  10. Public stigma consists of three elements  stereotypes, prejudice, and discrimination, in the Context of POWER, that leads to negative treatment of the stigmatized group Self stigma occurs when members of the stigmatized group internalize the public attitudes toward them, and leads to self-defeating beliefs and behaviors including avoiding treatment Public vs. Self Stigma (Corrigan, 2004)

  11. “They called me mad, and I called them mad, and damn them they outvoted me” – Nathaniel Lee, patient from England, 16th century

  12. Public stigma consists of three elements  stereotypes, prejudice, and discrimination, in the Context of POWER, that leads to negative treatment of the stigmatized group Self stigma occurs when members of the stigmatized group internalize the public attitudes toward them, and leads to self-defeating beliefs and behaviors including avoiding treatment Public vs. Self Stigma (Corrigan, 2004)

  13. The Double Bind • People suffering from a mental illness have to deal both with the consequences of the illness and the STIGMA • The number one predictor of STIGMA is having the LABEL of mental illness, causing people to avoid treatment (and the label) as well as maintain secrecy in order to “pass” (Rusch, 2005) (Link, 1987)

  14. Stigma also affects… • Families – “courtesy stigma” leading to lack of disclosure and support • Mental Health Field – within training programs and work settings, also seen in lower levels of funding for “mental” vs. “physical” health care (Corrigan, 2005)

  15. Why Stigma? Why Now? • Unfortunately, research suggests public stigma is getting worse over the last few decades…. • A U.S. sample population in 1996 was 2.5 times more likely to endorse dangerousness stigma than a comparable population in 1950 • This finding has been replicated on 4 other continents. (Read, 2006)

  16. A look at our own attitudes… • Would you… • Be willing to start work with a person with mental illness? • Like to live next door to a person with mental illness? • Make friends with a person with mental illness? • Rent a room to a person with mental illness? • Like your child to marry someone with a mental illness? • Trust a person with mental illness to take care of your child? (Social Distance Scale, Link et al. 1987)

  17. Definition of Social Distance • Social distance is… the relative willingness of one person to participate in relationships of varying degrees of intimacy with a person who has a stigmatized identity (Bowman, 1987) • INCREASED Social Distance means LESS interpersonal involvement

  18. A Community Sample(n=844) (Lauber et al, 2004)

  19. Research around Social Distance • Factors that increased social distance: • Schizophrenia vs. depression diagnosis • Belief in the biomedical model of illness • Factors that decreased social distance: • Positive attitude to lay helping and to community psychiatry • Contacts to persons with mental illness (Lauber, 2004)

  20. StigmaStrategies for Change What does the literature tell us? What can we do to change it?

  21. The science of stigma is in its infancy. “The recognition of the enormous personal, social, and still unmeasured economic toll of stigma, and the absence of a conceptual framework or an evidence base for interventions, are driving a movement to reinvent a science of stigma.” Keusch, Wilentz and Kleinman, February 2006

  22. Academic Psychiatry, 32:2, March-April 2008Special Issue:Reaching Out to Families and Overcoming Stigma

  23. Challenges • Social distance ≠ actual behavior. • People know what they should say, but often act differently. • Measuring opinions doesn’t give insight into why people have these opinions.

  24. Interventions • Protest Corrigan, River et al., 2001 Corrigan & Gelb, B, 2006 Rűsch et al., 2005

  25. Interventions • Protest • Education Corrigan, River et al., 2001 Corrigan & Gelb, B, 2006 Rűsch et al., 2005

  26. Interventions • Protest • Education • Contact Corrigan, River et al., 2001 Corrigan & Gelb, B, 2006 Rűsch et al., 2005

  27. Evidence for Interventions • Intervention trials • Real-world experience

  28. Limitations of the research data • Uncontrolled trials • Very small controlled trials • Self-reported measures • Surrogate markers.

  29. Intervention Trials • Small: n = 90, 100, 150, 200, 500, 1500 • Short • intervention hours = 1 or less, 2, 4, 8 • one week-long full-time intervention

  30. Pre-test & post-test measurements • Knowledge about mental illness • Attitudes: Attribution scales • Attitudes: Social distance scales

  31. School Children & Police Officers Community College Students(as surrogates for the general public) • 6 Uncontrolled trials in England and USA Pinfold V, et al., 2003 (England) - 3 trials Watson A, et al., 2004 (USA) Warner, 2005 (Colorado) Spagnolo, Murphy, Librera, 2008 (New Jersey) • 1 Nonrandom controlled trial in Germany Schulze B, et al., 2003 • 2 Randomized controlled trials in USA Corrigan, River, et al., 2001 Corrigan, Rowan, et al., 2002

  32. Anti-stigma Intervention Studies • Protest → No measurable effect on attitudes

  33. Anti-stigma Intervention TrialsResults • Protest → no effect • Education → Positive effect on knowledge Minimal effect on attitudes, perhaps greater in school children Less effect on social distance Longer interventions → more effective

  34. Boulder Police Officers Disappointing increase in knowledge. Warner, 2005 (Open the Doors)

  35. English PoliceSmall Improvement in attitudes Pinfold V, et al., 2003 (Open the Doors)

  36. American middle schoolers Small improvement in attitudes Watson et al. 2004

  37. Anti-stigma Intervention TrialsResults • Protest → no effect • Education → modest, limited effects • Contact→ Greater impact on social distance than education alone. Impact still very small.

  38. Contact → Significant changes in some attitudes: • The depressed patient was held less responsible for being depressed. • Depression can improve with treatment. • Psychosis can improve with treatment. __________________________________ But not others: • The psychotic patient was held no less responsible for having psychosis. Corrigan, River, et al., 2001

  39. Contact • New Jersey • n = 426 adolescents • 1 hour informational session developed and facilitated by consumers of mental health services • significantly less stigmatizing attributions on 7 of 9 factors Spagnolo, Murphy, Librera, 2008

  40. Protest Revisited • Grassroots efforts directed at the media • Reduce the presentation of negative images about mental illness in the media • Increase the presentation of positive images about mental illness in the media

  41. Short-lived ABC sitcom • Only 5 episodes aired in 2006, though 13 were filmed. • By the third episode of the show multiple sponsors had withdrawn there support

  42. Social Marketing • Changing Minds campaign – United Kingdom Royal College of Psychiatrists • Elimination of Barriers initiative – USA SAMHSA • Open the Doors – Calgary,Canada • Like Minds, Like Mine – New Zealand New Zealand Ministry of Health Crisp, et al., 2004 Akroyd & Wylie, 2002 Sartorius & Schulze, 2005 Vaughan & Hansen, 2004

  43. “Like Minds, Like Mine”Mass Media Component • “Contact” via media portrayal • Asked: “Are you prepared to judge?” • TV spots ran 1 wk on/3 wks off for 8 mos • A Phase 2 strategy utilized more in-depth 60-second mini-documentaries • Download from www.likeminds.govt.nz Vaughan & Hansen, 2004

  44. New Zealand: % agreeingMental illness… adapted from Akroyd & Wylie, 2002

  45. New Zealand: % disagreeingPeople with mental illness are… adapted from Akroyd & Wylie, 2002

  46. Social DistanceWillingness to accept “a person who has had experience of mental illness” as… adapted from Akroyd & Wylie, 2002

  47. Social Distance in schizophrenia: Willingness to accept someone as… adapted from Akroyd & Wylie, 2002

  48. Experience of persons with mental illness in New Zealand lot less stigmalittle less stigma little more stigmalot more stigma from Akroyd & Wylie, 2003

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