As the boy in Jerzy Kosinski's 1965 book, The Painted Bird, wanders about Eastern Europe fleeing the Nazis who have entrapped his Polish parents, he witnesses an event that is apocryphal in its depiction of stigma. He comes upon a professional bird catcher who paints a captured bird with many colors, and then releases it to the sky. The boy watches as the soaring, painted bird comes upon its flock and is mercilessly attacked by its own. The bird plummets, dead, to the earth below.
At a moment when mental health is so much at the forefront of the minds of Americans and our media it seems time, again, to try to understand the damaging views so commonly held about people with mental illness. Trustworthy information tells us that people with serious mental illnesses are no more dangerous than the general public -- if their condition is treated and they are not abusing alcohol or drugs; in fact, people with mental illness are far more likely to be victims of violence than they are to be perpetrators. In addition, ample evidence also exists that effectively managed mental illnesses need not be barriers to fulfilling and lasting relationships and to achieving career aspirations.
Yet, equally compelling evidence tells us that people fear, avoid, and otherwise stigmatize people with mental illnesses despite the fact that a bird remains a bird even if its feathers are painted. A new study sheds more light on this complex phenomenon, and may better direct efforts at its elimination.
The American Journal of Public Health recently published, online, a study (one of a group of papers) on stigma and discrimination against those who suffer from mental disorders. Individuals from the U.S., Europe, Asia and Africa (16 countries in all) were asked to read a short vignette describing either a person with schizophrenia or depression. While symptoms were clearly portrayed (such as paranoia, agitation, hearing voices in one case and sadness, difficulty concentrating, feeling worthless and discouraged in the other) no diagnostic label was offered, nor was gender or race, thus reducing other potential biases.
Study participants were then queried about their knowledge about mental conditions, including if it was a brain disease and if treatment can work. They were also assessed for stigma with questions about reluctance to interact with the person described, if mental illness renders people "inferior" or dangerous, and if someone would experience unwanted consequences if he or she revealed they had a mental disorder.
This study revealed that while there is generally widespread understanding about mental illness, "rejecting ... notions of individual weakness ... [and] moral failure," there was a "backbone" of stigma: People with mental illness were seen as having potential for violence (especially toward themselves), as well as problems meeting role responsibilities for children (e.g., caring and teaching), and were undesirable for marrying into families. While schizophrenia was more likely to be seen as a brain disease than was depression, there was greater stigma toward people with schizophrenia, including their social inclusion and meeting role responsibilities.
The Centers for Disease Control and Prevention (CDC) released complementary findings in a 2010 study of over 200,000 adults in 35 states, D.C. and Puerto Rico who were asked about their attitudes toward mental illness. They showed that despite generally positive public attitudes that mental health treatment works, those with mental illness continue to feel that others are not "caring and sympathetic." In other words, they still feel excluded among their own flock despite a public knowledgeable about mental illness and its treatments.
The authors of the American Journal of Public Health study raised doubt about whether educational campaigns that focus (exclusively) on mental illness as a medical condition, a brain disease, could reduce stigma about mental disorders.
What might engender trust in having people with mental illness serve in responsible roles and be more included in our families and communities? There are ways.
Tony Blair (UK Prime Minister, 1997-2007) established early in his administration a "Social Exclusion Unit" to implement policies to create opportunities for all to fully participate in the social and economic life of his country. These included people in poverty as well as those who by no choice of their own left them with little chance to live lives of community and contribution. Mike Rann, former Premier of the Australian state of South Australia, modeled a "Social Inclusion Unit" after Blair's work; his focus included indigenous people, those who are homeless as well as those with mental and addictive disorders.
Closer to home, two anti-stigma efforts in the U.S. are actively engaged in changing public opinion.
The first is Bring Change 2 Mind, an organization founded by Ms. Glenn Close, the remarkable film, television and stage actress. BC2M seeks "to end the stigma and prejudice surrounding mental illness." Their work is based on scientific research of what can work, and can be measured for effectiveness (their scientific advisory board is led by the first author of the AJPH article noted above). Ms. Close is working to encourage mental health "literacy" and encourage people to talk openly about mental health. BC2M also serves as a portal to other mental health organizations that can provide further education and direct help. Too many people do not understand mental conditions, their causes and consequences, or where to turn for treatment -- which (when delivered in a quality fashion) is as effective as are existing treatments for many other prevalent conditions such as diabetes, cardiovascular and lung diseases.
A second effort also underway is by a coalition of the National Council for Community Behavioral Healthcare and the Departments of Mental Health in the states of Missouri and Maryland. They are disseminating "Mental Health First Aid." MHFA is what every citizen can do when facing a mental health problem -- until a crisis abates or someone receives professional help. MHFA can be especially useful to high school teachers and college educators, to clergy and first responders, and many others since it teaches how to understand what is happening, be non-judgmental, provide support and reassurance, and encourage help when needed. It is the mental health version of CPR.
BC2M and MHFA are two ways by which we can reduce stigma. They provide the information and skills to enable us all to live and work side by side, where familiarity can breed confidence and comfort and counter prejudice, bullying and fear. When that happens we meet one of the best measures of a moral and effective society, namely, how it treats its vulnerable members.
Dr. Sederer's book for families who have a member with a mental illness, The Family Guide to Mental Health Care will be published by WW Norton in April 2013.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
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