Treatment and Stigma of Mental Illness

The act, whether it be real, perceived, or potential, of being discriminated against raises passionate negative emotions in almost every American citizen. It is significant, then, to note that mental illness, which affects a substantial portion of the American population, is often untreated or under-treated due to the individual’s legitimate fear of being discriminated against if they are identified as being mentally ill. This issue, which has tremendous social and economical impact, must be addressed by the appropriate widespread education of our society and the implementation of effective broad-spectrum anti-stigma programs. It is essential that discrimination against the mentally ill be afforded the judicial and legislative prohibitive measures that will prevent its continuation.

The spectrum of mood disorders, which include clinical or major depression, dysthymia, cyclothymia, and bipolar affective disorder, once known as manic depression, are among the most commonly diagnosed mental illness. These depressive disorders often occur in intermittent periods of exacerbation, quite brief, followed by extensive periods of high productivity on the part of the patient, or even full remission without recurrence of any symptoms at all. In this manner the depressive disorders differ from other serious mental illness such as schizoaffective disorder, schizophrenia, or other psychotic disorders, which are less receptive to treatment and unlikely to resolve. The average citizen, however, does not make this distinction in the severity of mental illness.

At the same time that our society places stigma against depression, we have come to use the term in common language in a way that does a disservice to those who are experiencing true clinical depression. Students may say they are “depressed” because an assignment is particularly challenging, employees may say they are “depressed” because they have to work on a holiday weekend, but this use of the word to indicate displeasure is grossly inaccurate. By describing dissatisfaction as depression, we fail to do justice to what true clinical depression can be, and thus make false judgments against those who do seek treatment, basing their situation on our society’s common terminology.

What percentage of the population is actually affected by diagnosable and treatable mental illness? According to studies by the National Institute of Mental Health, “an estimated 26.2 percent of Americans ages 18 and older – about one in four adults – suffer from a diagnosable mental disorder in a given year” (NIMH, 2007). To put this in perspective, nearly 51 million Americans suffer from some sort of a mental illness, while a commonly diagnosed life-altering medical condition, diabetes, affects “nearly 21 million American children and adults” (American Diabetes Association, 2007). An individual with diabetes may suffer similar episodic periods of being unable to function due to exacerbation of their illness, as well as the myriad of other extreme challenges of daily life, but without the addition of the stigma associated with mental illness.

Society continues to differentiate between medical and mental illnesses in terms of acceptance, treatment, and judgment of the ill, and “despite unprecedented knowledge gained in just the past three decades about the brain and human behavior, mental health is often an afterthought and illnesses of the mind remain shrouded in fear and misunderstanding” (U.S. Department of Health and Human Services, 1999). This differentiation between mental and medical illness is understandable, given the complexity of the brain, and yet the association of stigma and discrimination in the case of mental illness is not. Consider again diabetes, or heart disease, or cancer, all of which are major medical illnesses which have a huge impact on the lives of many American citizens and their families, yet which are relatively free of discrimination, and almost certainly not associated with any stigma. Each of these illnesses, like many mental illnesses, is likely to have a familial or genetic inherent risk, however unlike mental illness; the risks can be reduced by healthy behaviors. Diet, exercise, avoiding fats and maintaining an ideal body weight, eliminating caffeine and nicotine have all proven to be effective in reducing the risks of the above mentioned medical diseases. All of these healthy behaviors, or the lack of them, involve for the most part a personal choice. “Evidence also suggests that the public views those with mental illness as characterally, even morally, flawed” (Wahl, 1999) while it is the neurobiological disorders of the brain, not receptive to those same healthy lifestyle personal choices, that are the source of stigma.

Conflicting viewpoints on the etiology of depressive disorders contribute to the confusion on how to treat the mentally ill, in terms of medical treatment, therapy, social supports and societal assistance among others. “While there are numerous biological, psychological and environmental theories of the causes of depression, laypeople have traditionally viewed depression through a psychosocial framework” (Goldstein & Rosselli, 2003). Studies conducted in order to evaluate the efficacy of treatment provided under each of the various models have indicated that the belief system the individual holds regarding the cause of depression does have an impact on which treatment method will be most effective for that particular individual.

The different schools of thought as to the cause of depression are factors in the controversy surrounding mood disorders in general, and have helped to feed the antipsychiatry movement, which ranges from opposition to the use of psychotropic medications, to protesting the very concept of mental illness as an illness at all. One leader in the anti-psychiatry movement is Dr. Peter Breggin, who once held a teaching fellowship at Harvard Medical School, but has become well known for his “relentless crusade against the conventional wisdom of psychiatry” ( Gorman & Park, 1994) and whose “ preachments would be laughable, say critics, if they weren’t so dangerous”. The danger lies in the discontinuation of medications by those who listen to his advice and then are at risk for rapid deterioration and exacerbation of their psychiatric symptoms.

Disagreements concerning best practices or appropriate treatment often differ in other medical specialties, and trends in patient care change with advancing technologies and new scientific developments. Obstetrics, for example, has experienced numerous significant changes over the past several decades, and different methods of assisted childbirth fall in and out of favor, but there is no “anti-birth” movement from midwives against those who perform caesarian section deliveries. In this manner, the field of psychiatry is unique, for while advocates for different methods of treatment in other medical areas may have their differences, they do not disagree with the idea of the need for treatment as a whole. This anti-psychiatry phenomenon has an impact on the stigma that remains against mental illness.

Stigma against the mentally ill manifests itself in many ways, one significant issue being related to employment opportunities. One high profile example of how the stigma of mental illness impacts on an individual’s ability to obtain employment that he or she might be extremely well qualified for, but is ineligible for simply because of their psychiatric history, can be found in the case of United States Senator Thomas Eagleton; named as George McGovern’s Vice Presidential running mate in 1972. Within two weeks, McGovern requested that Eagleton withdraw his nomination, based on the information that “Eagleton had admitted to being hospitalized and receiving electroconvulsive-“shock”- therapy for depression” ( Feldman and Crandall, 2007). While the public is currently becoming more accepting of depression, as more and more individuals are seeking treatment for themselves or for family members, “Any open admission of an illness associated with asylums would have been the kiss of political death” (Tucker, 2006) offers one explanation for Eagleton’s lack of objection to the end of his political aspirations.

This feeling has not changed drastically today. In a telephone survey conducted by the Depression and Bipolar Support Alliance (DBSA) in 2002, “24 percent of respondents would not vote for a political candidate with a mood disorder” and “25 percent said they believe that people with mood disorders are dangerous, can easily be identified in the workplace, and cannot form and maintain long-term, stable relationships. A fifth (19 percent) said that people with mood disorders should not have children” (Bender, 2002). What outrage would be expressed if similar concerns were raised about diabetics, those with high blood pressure, or other chronic but common medical conditions?

Individuals who disclose having received treatment for a mental illness on a job application are less likely to be hired for a position, even if they possess higher qualifications, education, skills or applicable job training than another applicant. This can be described as nothing short of discrimination. A consumer of mental health treatment who chooses not to disclose this information on a job application also then faces the potential loss of employment if, at anytime after being hired, his illness is revealed and, along with it, his falsification of the application. For those employers who continue to question past mental health treatment on their employment application also include the disclaimer that falsification of the data on the application is grounds for immediate termination.

Workplace discrimination occurs in means other than just the denial of employment. “Those consumers who get or retain jobs may also face more subtle forms of discrimination involving violation of legal mandates that many employers do not fully understand and, hence, fail to fulfill” (Wahl, 1999). These may include such issues as not being allowed to take time off for a doctor’s appointment, necessary to maintain their stability, or being placed in a hostile work environment. “Workers who have a disability, especially those with mental illness or substance abuse disorders, have little chance of prevailing when they file employment discrimination cases against their employer” (Hausman, 2002). This suggests that an employee who has experienced depression and returned to his prior level of productivity, but has lost his position due to the illness, is less likely to win back his employment through litigation. As more consumers of mental health services become aware of the odds against them, they become less likely to attempt to assert their rights.

Discrimination against the mentally ill also occurs at an extremely high rate in the areas of health and life insurance. “Although diagnostic systems are developed by social work and other mental health professionals to better understand mental illness, they unintentionally exacerbate the stigma of mental illness” (Corrigan, 2007). This occurs when a diagnostic label or coding of a mental disorder is used in order to bill for treatment, to justify the use of a particular medication, and once entered in the database of the health plan, the individual seeking treatment is now, undeniably, classified. Consideration for severity of symptoms is not included in the process, and an individual who takes an antidepressant medication, has never been hospitalized or made a suicide attempt, and is considered psychiatrically stable, will be denied health or life insurance if attempting to purchase it privately. At the very least, it may be available with greatly increased premiums and greatly reduced benefit coverage.

What is it about the mentally ill that allows for this continuation of stigma and discrimination, in light of all other cultural and diversity acceptance programming? “Much of the stigma against mental illness is engrained in deep and ancient attitudes held by virtually every society on earth” (Jamison, 2006). With that being acknowledged, in our advanced society, awareness and education should be the keys to decreasing the misunderstandings and fear that lead to stigma. However, most members of the general population base their opinions on mental illness on the information that is provided to them by the media. This information is rarely positive, and if anything, the more horrific the details, the more likely it is that the public will be made aware of an incident involving the mentally ill.

Here, the media, much like the general public, rarely make a distinction between the specific diagnoses of mental illnesses that prompt the newsworthy event. Instead, the derogatory terms of crazed and lunatic and psycho are used, and this only continues the myth that all mental illnesses are comparable. For this reason, the stigma applied to a person suffering from a depressive disorder is no different from that towards someone with an antisocial personality disorder or a paranoid schizophrenic.

Unfortunately, highly publicized events such as the multiple murders that occurred recently on the campus of Virginia Tech. committed by a young man who was mentally ill and had not received adequate treatment, tend to sway the balance of public opinion in the direction of fear and a desire to keep the mentally ill away from themselves and their families. However, it is far more likely for the mentally ill to be “a greater danger to themselves than to others-owing to high rates of suicide and to illnesses and injury” (Wahl, 1997) than it is for them to act out in a homicidal rage.

To better understand the risks that the mentally ill add to the rest of society, it is important to note that, just as with any other human being, the potential for violent behavior increases in the presence of substance abuse, such as illegal drugs or alcohol. In fact, in the absence of any alcohol of substance abuse, “A recent study by the MacArthur Foundation has provided evidence that the mentally ill pose no more ofa threat than any other person in the general population” (Empie, 2002).This means that when appropriate treatment is provided, as opposed to the self-medicating of symptoms that often is a factor in the use of alcohol and illegal drugs, the mentally ill are no more likely to be violent or participate in criminal activity than anyone else. This distinction is important in regards to substance abuse disorders not only to offer reassurance about public safety, but to point out the irony in the fact that over the past decades, open admission of a substance abuse problem and participation in a drug rehabilitation program has become almost trendy. Admission to a psychiatric facility lacks that status.

News headlines are not the only way by which people obtain the information that shapes their perceptions of the mentally ill. Consider other media, in which the portrayal of the mentally ill in movies, television, and novels, the common source for the formation of opinions of many American citizens. The mentally ill are portrayed as dangerous lunatics, criminals, the villains in gruesome horror films, or as the source of humor and mockery for their impairments. The mentally ill are stereotyped as being noticeably different from “normal” members of society in most of these depictions.

Attitudes in the media may be slightly different off-camera, and the world of the arts and entertainment may be more forgiving when it comes to prominent members who suffer from mental illness, as more and more celebrities reveal their own struggles with depression and other mood disorders. Well known celebrities such as Patty Duke Astin, Jane Pauley, Art Buchwald, Mike Wallace, Carrie Fisher and Brooke Shields, have been the exceptionally popular and attractive “faces” of mental illness. Best-selling authors including Patricia Cornwell, Kay Redfield Jamison , Michael Crichton and others, publish books that are read by millions of individuals, and it is unlikely that most of the readers are even aware of the writer’s depression. Would they still read the words if they knew, or would the diagnosis invalidate everything, even fictionalized, that the author had to present?

While celebrity acknowledgement about mental illness and depression has increased awareness among some members of society, there follows the anti-psychiatry backlash, such as that displayed by Tom Cruise when he denounced Brooke Shields in particular, and psychiatry in general, during a television interview. Cruise, active in Scientology which expends a great deal of effort into the anti-psychiatry movement, is entitled to his opinion. It is, however, important to note that in spite of his statements of his knowledge of psychiatry, he is, in fact, an actor and an entertainer, not a medical professional. Certainly everyone is entitled to their own opinion, on topics ranging from politics, to health matters, to religion. But stating one’s opinion as though it were scientific fact, while attacking a large percentage of the population, does little to give credence to any argument. Mr. Cruise received rapid negative feedback from his peers, from organizations such as the National Alliance on Mental Illness, and from the general public.

The majority of the American people who suffer from depression and those who were outraged by Mr. Cruise’s statements, are not seeking careers in politics or attempting to become television personalities or movie stars, they are simply trying to live normal lives with meaningful employment. They want to provide for themselves and their families, and maintain the security of health insurance that the cost of prescription medications makes so imperative. They want not to be shamed, ridiculed, discriminated against, feared or hated, simply because of brain chemistry and neurobiology that was not of their choice. This makes them similar to every other minority group that has suffered discrimination based on skin color or ethnicity, and yet they have not had the widespread support of community, society and the government that has helped to eliminate those types of discrimination.

Challenging stereotypes and stigma is one of the supreme goals of the National Alliance on Mental Illness (NAMI), along with providing support and education to consumers of mental health services and their families. One such program is “In Our Own Voice”, (IOOV) a session in which mental health clients describe their journey through the episodes of illness to recovery, honestly, openly, and with the intention sharing their own stories with others. This program is presented in a variety of formats, such as recorded media produced by NAMI, but it is more powerfully eloquent when offered face to face.

“Audience participation is an important aspect of IOOV because the more audience members become involved, the closer they come to understanding what it is like to live with a mental illness and stay in recovery” (NAMI, 2007). Increased awareness is a major key in learning acceptance and tolerance of anything, or anyone, who is judged to be different. By attending a presentation of IOOV in their own community, members of society who might otherwise be fearful or intolerant of the mentally ill can be made aware that the mentally ill are not fundamentally different from themselves. Awareness and understanding can decrease stigma, because when the face of mental illness is up close, society has to examine the basis for stigma, and finds it lacking.

IOOV presenters such as Mary Smith * state that “It gives me the chance to show people who I really am, I’m not a label, I’m not a weirdo, and they don’t have to tell their kids to cross the sidewalk when I walk down the street” (M. Smith*, personal communication, September 2007). In her own personal testimony, Mary* describes periods of depression beginning in early adolescence, and many lengthy periods in which she was able to live “just like everyone else” (M. Smith*, personal communication, September 2007). She attended and graduated from college, and rose fairly rapidly through the ranks of an information technology company, eventually obtaining a high paying job, one which she was challenged by and enjoyed. She married, had two children, and continued to have intermittent periods when she describes feeling flat and out of touch with life, but was free from any acute episodes of depression until the age of 32.

Mary* describes her impaired functioning in a profound depression as being “in a pit” and adds tearfully that she loved her family, but wanted to die anyway. A suicide attempt by overdose, and Mary found herself hospitalized psychiatrically for the first time, first in a local acute hospital setting, and then in a state institution. By the end of her treatment episode, she had lost her job, her health insurance, and although she returned to her family home her marriage was, in effect, over, as “he just couldn’t handle me not being perfect anymore” (M. Smith*, personal communication, September 2007).

In the ten years that have followed, Mary has been receiving treatment through a local Mental Health agency, and has worked towards regaining independent living. She now has a job at a local large retailer, and shares an apartment with a peer from one of her support groups. She may never resume the high level of functioning that she once had, but in her words “I’m not giving up on that completely” and “some of us do make it” (M. Smith*, personal communication, September 2007).

Mary’s story is an example of losses experienced as a result of her illness. Other mental health consumers may never be devastated in quite this manner, but almost all individuals who receive a form of psychiatric treatment or counseling experience some form of loss, or one or more instances of discrimination, or misunderstanding. Based on the processes in her brain, due to her illness, she was judged by her family, her spouse, her employer, and members of her community. Speaking out now via the In Our Own Voice program is a way in which she shares her story and her humanness, the similarities of her life and those of the members in the audience, and attempts to reconnect to society to show them there is no reason to fear her or her illness.

President George W. Bush has said “… Americans must understand and send this message: mental disability is not a scandal – it is an illness. And like physical illness, it is treatable, especially when the treatment comes early” (New Freedom, 2003, p.10.). In order to act upon this, every citizen must be aware of potential discrimination, and act accordingly. Each responsible individual should challenge employers who continue to query past treatment for mental health issues on job applications. Those with authority should review health insurance policies and become aware of the disparity in treatment availability for depression, versus a broken arm, and state that this is unacceptable. Every citizen should be aware of the National Alliance on Mental Illness’ programs to reduce stigma, and support them as appropriate. Most importantly, in dealing with family, friends, neighbors, coworkers and others, provide them the same support that would be given to anyone recovering from an acute medical illness, with care and concern, but without patronization.