Tuesday, December 19, 2006

How the Framing of Mental Illness in Public Health has Contributed to the Social Problem of Stigma - Lisa Pinnow

Mental illness, defined by the National Mental Health Association is “a disease that causes mild to severe disturbances in thinking, perception and behavior”. (NMHA) Over 44 million people suffer from mental health disorders each year and yet only one-third are diagnosed. (Bossolo) In this paper I will criticize public health for not including mental illness as an integral part of the public health system. Like cancer and other physical diseases this illness can be stabilized and even cured. However, unlike other chronic and infectious diseases, it bears a heavy stigma due to the prejudice associated with mental illness. The Labeling Theory states that society has certain norms and rules that individuals must follow and failure to adhere to these rules defines abnormal behavior. The mentally ill are often discriminated against because their behavior does not always correspond with that of the general public. (SparkNotes) Limited access to information from the public health community has caused society to fear and reject those with mental illness. The lack of empathy and misunderstanding towards this illness has created emotional, physical, and social barriers.

The treatment of mental illness has come a long way since the prehistoric treatment of spells and rituals and the barbaric lobotomies of the 1940s. (History of Psychiatry) The history of mental illness demonstrates how deep its roots of rejection extend. The first asylums in the United States during the 19th century were established to ‘remove people with mental illness from the flux and disorder of urban life and to provide them with orderly regimens that could bring equilibrium to their disordered minds’. (Link) In 18th century England, the first hospital to accept mentally ill patients allowed the public to pay a penny to see those labeled as ‘lunatics’. (Wikipedia) The stigma of mental illness has been created over time due to society initially believing that mental illness was controlled by the sufferer, however, when it wasn’t, they were labeled as unpredictable and considered a community risk. The portrayal of the mentally ill as violent, erratic, and unstable has contributed to the negative attitude of society, often viewing these individuals as a threat to the community. Over time this negative response has created a stigma of mental illness, which has affected acceptance and course of treatment. These stereotypes have shaped the misconceptions of mental illness and are the basis for related stigma and discrimination.

Public health has fallen short in creating parity between mental, infectious and chronic diseases in terms of discriminatory limits on treatment and insurance. Mental illness is a term that groups together all illnesses affecting the brain, in the same way that heart disease groups together illnesses affecting the heart. With this in mind, shouldn’t mental illness be treated in the same way as infectious and chronic disease? Individuals who have experienced heart attacks often fully recover, which can also be true for someone who has been appropriately diagnosed and treated for a mental illness. But most of the general public is unaware of this because information about mental illness is not readily available. The lack of similarity in treatment of these patients compared to those with other diseases such as diabetes, heart disease, and obesity has contributed to the stigma of mental illness. The significant level of inequality in treatment has enhanced negative public opinion.

Prevention and intervention are major factors in treating physical health, but these factors do not apply in the treatment of mental illness. Obesity is one example of a physical illness that has become a public health precedent. As a result of the growing epidemic of obesity, it has become a priority of public health. The publicity about obesity not only has caused society to become more comfortable discussing it but also the discrimination associated with this topic has declined. Obesity is now considered to be a disease and that being overweight is a symptom. In 1985, Tufts-NEMC’s opened the Obesity Consultation Center, which offers patients several weight loss options to maintain a healthy weight and prevent health problems that can accompany excess weight. (Tufts) The problems of obesity have also created a niche in marketing by selling a range of larger items for those who suffer from this disease. Mental illness is not as highly publicized nor is the general public knowledgeable or comfortable in dealing with the subject. Where is public health’s intervention and prevention for mental illness?

There have been multiple programs launched to educate society, however, the success rate is too small to change the cultures of the time. The public health system has failed in their responsibility to educate the entire population about mental illness. A substantial number of the population with mental illness do not seek medical treatment due to fear of prejudice, rejection, and misunderstanding. Without treatment this can also cause other health risk behaviors such as smoking and binge drinking.

Public health needs to change the way that society and health professionals perceive those who are mentally ill. Health professionals’ awareness and knowledge about the multiple components of treating the mentally ill is inadequate due to the fact that many are misdiagnosed. Incorrect diagnoses and labeling can cause various negative side effects for patients being treated. One major component of treating patients is the many cultures that make up the population within the United States. For instance, some cultures look disapprovingly or do not believe in expressing emotion and/or weakness so they often do not obtain treatment. Public health has failed at properly training and educating professionals in cultural competence. Health professionals have a duty to assist those who are ill however, particularly in treating mental illness some clinicians can sometimes cause more harm than good. It is also important to realize that health professionals are individuals with personal beliefs and opinions too and their attitude may affect those they treat. They also have the task of improving public opinion about mental illness and providing resources to educate and therefore reduce the stigma.

The media is often used to sway public opinion. Unfortunately, the media often belittles and degrades those who are mentally ill therefore influencing society to reject the mentally ill. Frequently, the news portrays those who are mentally ill as violent and dangerous and labels them as ‘crazy’ or ‘mad’. Media adds to the reservoir of this stigma by presenting the mentally ill as unacceptable. Yet public health does nothing to correct the inaccurate information that is communicated to society.

An example of media misrepresenting mental illness is “Crumbs”, a new sitcom about two brothers who return home to deal with their mother who is being discharged from a psychiatric facility. (ABC) The National Mental Health Association (NMHA) requested that ABC pull the sitcom because it did not only make light of someone with a serious mental illness but depicted mental health professionals as unethical. (MHA) One episode revealed the main character having an affair with an orderly while receiving treatment for their mental illness. (MHA) Although this series did not last through its first season it fed on the stigma surrounding mental health by poking fun at it.

According to the American Psychological Association in 2004, 87% of the population lacks insurance coverage and 81% of Americans state that high costs keep them from seeing a mental health specialist. (Bossolo) As a manager in an outpatient psychiatry department I have seen firsthand how caps on inpatient days, outpatient visits, and limited mental health insurance coverage only hurt and financially burdened the mentally ill. By limiting mental health benefits and coverage the public health is setting the example to society that it is less important than other diseases. Even those patients with insurance are often restricted in terms of their treatment options because of the high costs of treatment and the yearly limits on mental health visits with a varying scale in copayments. The public health system has to realize that individuals with mental illness need treatment in order to manage everyday life and some treatments require visiting their clinician weekly for medication and/or psychotherapy. Lack of treatment for mental illness due to the high cost or lack of access can also cause the patient to suffer concurrent physical illnesses such as high blood pressure, and high blood cholesterol and asthma.

Changing the culture of society to accept and equally treat the mentally ill will not occur in one day or one year. The current programs working towards educating the public and reducing the stigma of mental illness are not sufficient enough to accomplish this goal. The American Psychiatric Association’s 2006 Consumer Survey on Mental Health stated that “forty-four percent of American adults report knowing only ‘a little’ or ‘almost nothing at all’ about mental illness”. (2006consumersurveyfacts) There needs to be a large-scale campaign to educate the population and reduce the stigma such as the World Psychiatric Association’s International Programme to Fight the Stigma and Discrimination towards schizophrenia. (Open) This campaign should be about educating society about mental illness and fighting the associated stigma and discrimination of all mental illnesses, not just schizophrenia.

To change culture, the entire population must receive accurate information about mental illness and the seriousness of mental health. The public health system has to study how best to reach different subpopulations within our society and find ways to combat the stigma. Educating society about mental illness will decrease the prejudice and ignorance towards the mentally ill. If mental illness received as much publication as other diseases or even dangerous habits such as smoking, the general public’s negative attitude would change towards the mentally ill. Resources such as presentations, the media, celebrity experiences, posters, ads, newspapers, magazines and in the classroom must be utilized to reach out to the greater population.

One way to reach the general public is through our many avenues of communication and technology that exist today. Each day mass media bombards us with images and messages from the moment we get up in the morning until we drift off to sleep each night. Television for example, can be a positive method to create worldwide awareness. Popular programs such as 60 Minutes, Dateline, sitcoms and the general news should use the fact that they are broadcasting on national television (or even internationally) and use that time to educate the public. By interviewing professionals and the general public about their experiences with mental illness others might be able to understand and learn that they or someone they know needs treatment. Knowledge and information about where to seek treatment would open the door for individuals who need a starting point. Mike Wallace of 60 Minutes is a perfect example of a celebrity who has discussed his experiences with clinical depression and treatment on television and today leads an accomplished life. (NMHA) His message to the world makes people realize that they too could lead a fulfilling life by seeking treatment.

For those who do not watch or own a television other means of teaching the public about mental illness should be emphasized. The public health system needs to promote the importance of mental health and also to teach that mental health disorders are similar to any other disease. Standards need to be established to ensure that accurate and positive information is publicized. Another possibility would be establishing and promoting more advice hotlines, so individuals would have the opportunity to speak with a professional about mental illness. By creating a safe environment for individuals to obtain more information hopefully more will seek help for themselves, family, or friends. The public health system should also educate students about mental illness. Today many children see mental health professionals for a multitude of reasons such as learning disabilities, family issues, peer pressure, attention deficit disorder and attention deficit hyperactivity disorder. Those that do see a mental health professional often feel segregated due to fear of rejection from their peers. However, given positive information about mental health students will learn how to deal with their thoughts and feelings and as a result will therefore gain self confidence. Children must also learn to use and understand the meaning of the correct terminology so they will not label others as crazy, unstable or unusual. Not only will this have a positive impact on their experience at school and their education but also opening them up to treating other individuals equally.

Public health also must educate and train health professionals to clearly diagnose patients. The numerous cultures that exist within the United States are an important dynamic that health care professionals need to focus on in the management of the mentally ill. The need for education and training in cultural competence is essential in order to clearly diagnose and treat patients. (Link) Health professionals need to be aware of the effects of culture and ethnicity particularly in the field of psychiatry since symptoms of mental illness are diagnosed from verbal and nonverbal cues, eye contact and facial expression of the patient. (Vedantam) Due to the difference in cultures, simple facial responses have different meanings, for example for some cultures eye contact is a sign of disrespect. Failing to acknowledge the many differences in cultures that exist not only discourage the mentally ill from seeking help due to fear of misinterpretation but also correlates with the stigma.

Public health officials need to create a uniform policy for both mental and physical health services and the corresponding insurance coverage. This policy should include equality for coinsurance, deductibles, and day and visit limitations and maximum out of pocket caps. (Bossolo) The mentally ill would more apt to seek treatment if insurance coverage and policies for mental health benefits were equivalent to those of infectious and chronic diseases. Mental illness is a disease that requires immediate action and treatment as in any other illness.

The stigma of mental illness began long ago and has not only increased but has become an inherent part of our culture. Negative terminology and labeling that results from discrimination has delayed many individuals and their families from seeking medical and psychiatric care. When you consider the medical advances public health has made in the treatment of infectious and chronic diseases, mental illness has actually progressed very slowly. The stigma associated with this disease has limited the access to care. Although there have been several mental health commissions, policies and procedures created to help the mentally ill these initiatives do not begin to compare to the advances in other biological, physical and environmental illnesses. (WebMD) Going forward public health needs to focus on not only the treatment of the population of the mentally ill, but also work to eliminate the stigma of mental illness. Public health needs to wage an aggressive war to combat the lack of education, knowledge, and prejudice against mental illness.


Mental Illness and the Family: Stigma: Building Awareness And Understanding About Mental Illness. National Mental Health Association. Retrieved October 17th, 2006 from, http://www.apa.org/releases/insurance.html

Introduction to Abnormal Psychology. Spark Notes. Retrieved on November 8, 2006 from, http://www.sparknotes.com/psychology/abnormal/intro/labelingtheory.html

Pols, Dr. Han. September 1, 2003. History of Psychiatry. Retrieved October 27th, 2006 from, http://www.usyd.edu.au/hps/course2003/3010.html

Link, B. G. PhD, Phelan, J. C. PhD, Bresnahan, M., MPH, Stueve, A., PhD, and Pescosolido, B. A., PhD. Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance. SB780 Course Reader. September 1999. Vol. 89, No. 9. Page 111.

Bethlem Royal Hospital. last modified November 16, 2006. Wikipedia Encyclopedia. Retrieved Nov 3, 2006 from, http://en.wikipedia.org/wiki/Bethlem_Royal_Hospital.

Obesity Consult Center. Tufts-New England Medical Center. Homepage. Retrieved on December 1, 2006 from, http://www.obesityconsult.org/

ABC, Inc. “Crumbs”, About the show. Retreived on November 16, 2006 from, http://abc.go.com/primetime/crumbs/about.html

NMHA Requests That ABC Immediately Pull Crumbs from Broadcast. National Mental Health Association. Retreived on November 16, 2006 from, http://www1.nmha.org/newsroom/stigma/crumbs.cfm

National Mental Health Association Fact Sheet: Mental Illness. National Mental Health Association. Retreived on November 18, 2006 from, www.nmha.org/infoctr/factsheets/14.cfm

American Psychiatric Association. April 25, 2006. American Psychiatric Survey, Fact Sheet: Consumer Survey on Mental Health. Retrieved October 27th, 2006 from, http://healthyminds.org/multimedia/2006consumersurveyfacts.pdf

Open the Doors. Information on the Global Program. Retrieved on December 3, 2006 from, http://www.openthedoors.com/english/01_01.html

Vedantam, Shankar. MIND AND CULTURE: Psychiatry's Missing Diagnosis Racial Disparities Found in Pinpointing Mental Illness. Washington Post. Tuesday, June 28, 2005; Page A01. Retreived on November 20, 2006 from, http://www.washingtonpost.com/wp-dyn/content/article/2005/06/27/AR2005062701496.html

WebMD, Mental Health: Causes of Mental Illness, Medically reviewed by Cynthia Haines, MD, July 2005. Retreived on November 30, 2006 from, http://www.webmd.com/The National Health and Medical Research Council of Australia. 2001. Mental Illness: The Facts. Mental Health Matters. http://www.mental-health-matters.com/articles/print.php?artID=656


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