(p. 202) Overcoming Stigma II: Media and Mental Health Professionals
The stereotyped and negative portrayals of mental illness in various forms of public media remain as a core issue for those interested in stigma reduction. Although movement toward more accurate coverage in major media outlets is occurring, depictions still convey biased images of mental disorder as linked to violence, incompetence, and irrationality. In this chapter I emphasize two sets of strategies geared toward altering such portrayals: organized protest and intentional media depictions that can convey a different set of images. The hope is that each approach can produce accounts emphasizing realistic portrayals of mental illness, featuring stories and disclosures that are inspiring and humanizing.
Protest movements can raise the consciousness of members of society with regard to the prejudice, discrimination, and stigma that exist for many devalued groups. Actions include letters to editors of periodicals, confrontation of producers and sponsors of biased programming, boycotts of groups that promote insensitive and demeaning portrayals, picketing of films, and other procedures intended to both raise public consciousness and put a stop to biased coverage. To build general consensus, advocacy groups have promoted “watches,” in which consumers are directed to scrutinize media for stereotyped portrayals. These are directed largely toward television and film with respect to insensitive and prejudiced depictions of persons with mental disorders. Print media and advertisements can also be targeted.
(p. 203) For example, groups such as the National Stigma Clearinghouse aggressively communicate with the public and media outlets to confront negative images of mental illness in the media. Beginning in the 1980s, NAMI began to hand out “media watch kits” so that local chapters could monitor newspapers, television, and film for stereotypic, degrading images.1 Protest efforts emanating from such scrutiny can serve to alert media outlets and their sponsors that demeaning depictions of mental disorder are no longer acceptable and that executives, managers, and publicists need to uphold a higher standard. In addition, boycotts can provide a powerful economic incentive to alter advertisements and images, particularly if they are widely publicized and supported.
Take, for example, the case of a 1990 motion picture titled Crazy People, a comedy starring Dudley Moore and Darryl Hannah. A large protest accompanied the initial advertising for the movie:
The original newspaper and poster ads for this comedy … showed a cracked egg with hand and arms making a silly gesture and declared, somewhat ominously, “Warning: Crazy People Are Coming.” Representatives from a variety of mental health advocacy groups wrote to executives at Paramount, the film’s producer, about what they perceived as a totally unnecessary suggestion (and one inconsistent with the content of the film) of menace from “crazy people.” As a result, advertising for the film was changed, with new ads saying simply “You wanna laugh tonight?” and showing a picture of the stars.
The film was to have a major opening in Philadelphia:
A newspaper … ran a promotion offering free tickets to a screening of the movie for anyone who could prove that he or she was “crazy.” Representatives from [several organizations] wrote letters, marched in the street outside the paper’s offices, and arranged for a meeting with the paper’s editor and publisher in order to convey how troubling it was to have the paper treat “being crazy” as a joke. The paper responded favorably and published an apology for the ad, saying “this was … mean-spirited and wrong.” The paper also reportedly decided not to run any further ads for the movie … and to attempt to run more stories that presented other views of mental illness.2
Protest efforts like this can place considerable pressure on film producers and newspapers to correct images that are needlessly devaluing, with the hope that a key source of stereotyping and stigmatization can be stopped in its tracks. At the same time, protest efforts are energizing for those who initiate them, promoting identity and solidarity with respect to a group that deserves and demands justice.
As another example, a decade ago the editors of Superman comics planned the death of this beloved character to be shown in print. Advance publicity had revealed that his killing would be perpetrated by Doomsday, (p. 204) an evildoer from an interplanetary insane asylum, whose apparel featured a straightjacket. The National Stigma Clearinghouse learned of this content and contacted the publisher, D.C. Comics (and its parent company, Time Warner), to protest such a portrayal of the murderer of a much-admired superhero. When the issue was published (which quickly sold out), no reference to the mental status of Doomsday existed, and pictures of him did not include a straightjacket. In fact, D.C. Comics issued a statement in which it avowed sensitivity to nonprejudicial depictions in its comics.3 As these examples show, protest efforts can raise consciousness, provide accountability to purveyors of media, and reduce grossly stereotypic and inflammatory messages.
More recent campaigns have produced results as well. NAMI Stigmabusters represents an e-mail alert network that provides notices about particularly stigmatizing contents of media portrayals. In 2000 this group helped to play a role in the cancellation of the ABC prime-time series Wonderland, which depicted a mental facility and its patients in graphic, violent terms. For example, in an initial episode a patient, after gunning down several other individuals, stabbed a pregnant physician in the abdomen with a hypodermic needle. One means of protest was conducted through direct communication with the program’s major corporate sponsors. Much publicity ensued, and the program was cancelled after a few episodes.4
Are there potential downsides to protest efforts? For one thing, it is often a matter of judgment as to what is merely lighthearted and what is truly degrading. Some advocates with mental disorders have, in fact, contended that protest efforts can be overly serious in their goal of eliminating any and all humorous references to mental disorder. In fact, the ability to see humor in difficult situations can be an excellent source of coping—so long as the comic relief is not one sided, patronizing, or potentially humiliating. The point is not to remove appropriate humor from difficult life situations but rather to counter images that are patently unfair and stigmatizing, such as those that ridicule mental illness or feature incompetence or violence as the chief attributes of persons with mental disorders.
Another potential problem has already been mentioned: that of “rebound” when persons are asked to suppress established images. It is as though the efforts to push away the image trigger a set of mental mechanisms that actually reinforce the image.5 The fear is that protest efforts may lead to an entrenchment of the very depictions that are intended to be banished.
Rebound phenomena appear to invoke complex cognitive processes. One mechanism is that the active mental energy needed to keep the image at bay may prevent other kinds of mental processing from occurring. In other words, if a person is fighting to keep an image of “dangerous mental patients” out of her mind as a result of protest efforts, she may not notice that an interaction partner with mental illness is actually cooperative.6 The danger exists that when the public is forced to recognize biased accounts of stigmatized groups (p. 205) and asked to replace these images with more benign ones, the unwanted images may become more accessible and entrenched. Certain forms of protest in the name of destigmatization could therefore backfire.
Although this possibility is sobering, it is based largely on short-term social psychology experiments that reveal acute, paradoxical effects of mental suppression. Longer-term efforts to protest media portrayals may be far more successful. That is, when the replacement of images is gradual and when there is no call to suppress prior images, there may be little “bounce” in any rebound. Furthermore, to the extent that protests force media depictions to become more accurate and compassionate over the long run, future generations will experience a far different view of people with mental disorders than is provided by the current images. These long-term benefits are likely to considerably outweigh any short-term consequences related to suppression.
Finally, how can the effects of protest be evaluated? It is one thing to note that a particular protest effort has stopped a biased program or altered a stereotyped advertisement, but it is quite another to know whether such actions have fundamentally changed the attitudes and behavioral practices of the general public. Given the major role of mass media in people’s lives, it is difficult to imagine a randomized experiment (outside of an extremely short-term laboratory study) that could adequately test the effects of concerted protest efforts directed against stereotyped media images. How, for example, could a control group be formed that lacks access to the relevant media or views alternative images? It will be a major challenge for future investigators to design appropriately controlled trials. Still, given the massive sums of money linked to newspaper, television, and radio programming and advertisements, many powerful individuals and corporations have faith in the persuasive power of media messages. Change in this domain is essential.
Overall, despite potential dangers of stereotype suppression, which could result in the unintended intensification of stereotyped images, alterations in the content of inaccurate and demeaning portrayals of mental illness, promoted through active protest, are a crucial part of destigmatization efforts. Concerns regarding potential rebound from protest efforts appear overstated, given that the ultimate benefits can fundamentally change media images for years to come, outlasting any short-lived negative effects.7 Protest efforts also provide a means of empowerment for organizations and groups that band together to raise consciousness.
In 2005, as a positive means of promoting alternate media images, the federal Substance Abuse and Mental Health Service Administration (SAMSHA) sponsored the Voice Awards, presented to film, television, and radio writers, producers, and actors who portrayed realistic and sensitive characterizations of mental illness in 2003 and 2004. Among many contenders, “The Aviator,” “ER,” and “Monk” won in the film and television categories. The clear intention is to reward those who produce programs with accurate depictions of the realities of mental illness.
(p. 206) Marketing Strategies
In a breathtaking chapter, Sullivan and colleagues, who are professional marketers rather than mental health professionals or consumer advocates, place the issue of mental health stigma in the arena of marketing communications programs. Their analysis provides an intriguing window on the intentional fashion in which media experts create images through a host of strategies and public relations initiatives regarding various products, groups, and causes. I focus on their analysis of several types of procedures, with specific regard to mental health.8 Because space limitations preclude full development of these ideas, this overview is intended to generate thought about procedures that could influence the public’s view of individuals with mental illness.
One example is cause marketing. Here, a given product or service is linked explicitly with a cause, with proceeds from the product or service going to aid the cause. The expectation is that consumers will link the benevolence of the cause with the product or service in question, fostering loyalty to the product. At the same time, the cause is furthered via financial support and increased public awareness. An example is that of a lipstick product: Proceeds go directly to AIDS prevention research, with popular media celebrities headlining advertisements that make this explicit association.9 AIDS prevention efforts receive direct benefit, at the same time that consumers feel altruistic and potentially link these positive feelings with the product line. A pertinent question is whether a company might risk a particular commodity for cause marketing related to research or treatment for a major mental illness.
Alternatively, the more traditional practice of social marketing is not tied to any product or service per se. Rather, it pertains to attitude change through building perceptions of a desired social good or social improvement. Public service advertisements, websites, ads in public transportation, and the like may serve the end of social marketing, which is intended to raise consciousness about important societal concerns. Causes related to environmental, health-related (e.g., teen pregnancy prevention; antismoking), and antiracial discrimination concerns have all received extensive social marketing. Mental illness lags behind in these efforts.
Sullivan and colleagues suggest that one way of approaching social marketing for this topic would be to accentuate the missed opportunities for all of society if the potential of persons with mental illness fails to be realized. Along these lines, the message could presumably target fundamental similarities across all types of people and highlight the past contributions of prominent individuals with mental disorders.
In practice, social marketing typically targets specific audiences predicted to be amenable to attitude change. What are the key subgroups that might be targeted with respect to reducing the stigmatization of mental disorder? In other words, should the entire populace constitute the target group, or are there particular niches or subpopulations to which the campaigns should be geared? Clearly, additional research is needed on the particular kinds of persons most (p. 207) (or least) likely to benefit from social marketing campaigns related to mental illness stigma. Because adolescence is a time of increased risk for the emergence of a large number of mental disorders and because peer relations in adolescence are especially crucial, social marketing is being increasingly directed to this age group. In addition, the World Psychiatric Association’s programs to eliminate the stigma related to schizophrenia utilize social marketing strategies that are targeted toward students, employers, and criminal justice workers. Along these lines, speaker bureaus and media-watch organizations have been implemented in more than 20 nations, targeting these specific components of the population.10
The relatively new practice of buzz marketing involves the soliciting and compensation of “plants” to promote a particular product or service. For example, mothers of Little League teams or parents in parent-teacher associations might talk up a particular household product with other families in an attempt to generate “buzz” about that product line. Alternatively, attractive individuals may go to bars and clubs, promoting a certain brand of alcohol. The intention is to generate interest that is not tied to overt advertisement. Sullivan and colleagues ask whether mental health professionals would be willing to discuss, at community talks, positive images of mental illness, perhaps in return for incentives from local mental health associations. The relevant point is that the professionals would not be believed to be selling anything—rather, they would be perceived as delivering truthful messages in a realistic fashion. Indeed, the professionals in question may well be extremely truthful in such ventures. It is the incentives for providing such talks that characterize buzz marketing, the goal of which is to promote enthusiasm and commitment via word of mouth.11
More controversial are stealth marketing tactics. The example given by Sullivan and colleagues is that of a beverage company filling recycling bins in high-income, desirable neighborhoods with empty bottles of a particular product. Here, the objective is to link the product with the particular neighborhood in order to produce positive associations for the product, with the added benefit that typical advertising procedures (commercials, print ads) are completely bypassed. A core premise of both buzz and stealth marketing is to circumvent the usual modes of oral, print, or televised ads or “spots”: The goal is for the public to believe that the promotion of the product or service in question is entirely natural. A possible mental health example of stealth marketing (quite related to buzz marketing as well) might include the preplanned discussing of positive experiences in therapy by movie or television stars on talk shows or in interviews.
Another procedure (or, rather, set of procedures) is termed cultural seeding, whereby the public is inundated with multiple images of a given brand across different forms of media but without knowing that there is a concerted effort to foster explicit linkages. This is not a new concept: For many decades children’s products have appeared simultaneously on cereal boxes, television programs, and everyday items such as lunchboxes. Through more current efforts, products or brands are made mutually interdependent (e.g., via television (p. 208) commercials, CDs, websites, and clothing lines), presenting the consumer with multiple, linked references to their presence in everyday culture. The point is to have a multitude of images that do not always appear through direct advertising, toward the end of a “contagious” spread of the product or cause.
Along the line of several of these procedures, Sullivan and colleagues provocatively ask the following: “What if National Public Radio sponsored a reading series by authors who have a mental illness? Perhaps the subject areas in their writing could sensitize the public to stories of recovery and the complexities of living with mental illness.”12 The point here would be to link radio promotions, books, and television talk shows (or other means of communication) with the objective of providing mutual reinforcement of core messages. At least some media outlets are now promoting discussion of mental illness with compassion and reality. It will take concentrated efforts for advocates to position the right speakers and readers in the right media outlets, so that messages of disclosure become part of the general cultural dialogue.
For decades advertisers have promoted “integrated marketing communication,” through which messages are repeated and echoed across multiple forms of media. In recent years, the venues of such coordinated messages have expanded into the internet and through means such as sponsorships (e.g., corporate naming of sports stadiums or college football bowl games). Saturating markets with brands and images therefore has an expanded base of operations, some of which intentionally attempt to move away from direct advertisement strategies.
The potential for communication about mental disorder to utilize varied sources and outlets is already occurring. For example, in a subtle yet powerful series of spots that aired on MTV and other youth-oriented outlets several years ago, the National Mental Health Awareness Campaign promoted depictions of eating disorders, as well as depression and suicidality, aimed at increasing recognition and discussion of these mental disorders among adolescents and young adults. These public service announcements were sufficiently youth oriented and subtle to escape detection as traditional, pedantic messages; they ended with the posting of websites that featured information about mental disorders and related services for adolescents. These sites yielded millions of hits.13 This media project also exemplified the notion of targeting communication to a particular demographic niche—in this case, teenagers and early adults.
I add a final concept to this discussion, that of framing, which has recently emerged as a central theme of major political parties in the United States.14 Based on George Lakoff’s cognitive linguistic analysis, framing is the intentional attempt to use simple, direct, repeated messages about a political concept or cause, whereby the frame links to a deeper theme in the consumer’s psyche.15 For instance, the concept of “tax relief,” emphasized by Republican administrations, has at its very core the frame that taxation has overly and unfairly burdened the populace. This frame is embodied in the term relief, which invokes images of the release of a long-standing, unfair imposition on (p. 209) fundamental rights. Hence, tax relief is a metaphor that taps into a deep human value, contextualizing lowered taxes as an act of freedom and a casting off of oppression.
Debates about the ultimate value of framing are now part of the political landscape. For example, many contend that a frame cannot fundamentally reshape attitudes in the absence of sound, underlying concepts and principles related to the social or political issues in question. Still, framing plays a large role in major party politics in the current era.16 For mental health advocates, it would be an important exercise to come up with relevant frames regarding messages to the general public about mental illness and the rights and dignity of individuals who have such conditions. One such frame, promoted in recent years, is that mental illness is entirely neurobiological, constituting a disease like any other. As I have discussed repeatedly, however, this frame may promote images of mental disorder as immutable and indicative of a fundamental lack of humanity, despite the supposition that it will lead to blame reduction.
Alternate frames could emphasize notions of civil rights, which have a deep tradition in our society and are linked to core values that most members of the citizenry strongly hold. They could also link mental disorder to intensifications of problems that everyone encounters—facilitating a broadening of the boundaries of one’s ingroup. Another provocative frame is that of “neurodiversity,” a celebration of key differences in individuals’ neurological and psychiatric status, which may link with the notion of individuality (a strongly valued theme in many Western societies).17 Coming up with a viable message will not be an easy task, however, given the lack of consensus as to the underlying nature of mental disorder (see Chapter 1). Those interested in addressing media-related stigmatization would do well to rigorously explore the kinds of meaningful frames that could impart deeply held values and images while at the same time generating respect and compassion for people with mental disorders. Focus groups, public opinion polls, and astute political and psychological analysis could all play a role in such development.
On the whole, means exist beyond traditional public service announcements, with their penchant for dry facts and sober educational messages, to produce renewed media images of mental disorder and related personal and family struggles.18 Such procedures have the potential to alter, in fundamental ways, perceptions of the general public. A key challenge for the years ahead will be to configure ways of intentionally utilizing the types of public relations strategies described herein to reshape public attitudes. Although some may find it distasteful or even potentially manipulative to enact some of these tactics, particularly buzz or stealth marketing, it is worth noting that at present a multitude of images are intentionally displayed to the public about a variety of characteristics and traits, often in ways that reinforce highly negative stereotypes about mental illness. From this perspective, if the ends are worthy and the means are not unethical, it may be worthwhile to implement a range of strategies for altering public perceptions, so long as (a) appropriate targets are considered, such as adolescents,19 and (b) careful evaluation is performed in (p. 210) order to understand the impact of these strategies. Given the huge importance of media influences, discussion of this entire topic is sure to grow in the coming years.
Disclosure and Humanization
Beyond the tactics and strategies of protest that may alter media images and beyond the frames that may be invoked to contextualize mental disorder, what are the particular messages that should be included in media portrayals? A basic contention is that the more that mental illness can be humanized by its disclosure and “telling” in everyday narratives, the more that members of the populace can come to understand the underlying humanity of people and families who cope with its challenges. Realistic portrayals in books, stories, features, interviews, and commentaries, involving narratives of pain, strength, and coping, are the kinds of images that should promote interest, empathy, and compassion. Mental illness is certainly associated with despair, impairment, and threat, and these aspects should not be denied. Yet subtleties, competencies, and struggles are too often lost in the stereotyping (or occasionally the glorifying) of mental illness. Realistic, humanizing portrayals cannot substitute for face-to-face contact, but they may set the stage for such contact by enhancing interest and motivation.
What if stories of mental illness were prime-time, mainstream material? Despite its inaccuracies, the film A Beautiful Mind gave a humane depiction of schizophrenia that presented the counterstereotypic image of its association with extreme talent. As another example, on the HBO series America Undercover, the anxieties and panic disorder of actress Kim Basinger and former football star Earl Campbell have been vividly yet sensitively portrayed.20 Mental illness is now out of the closet in many facets of everyday media, although it is too often accompanied by sensationalism and depictions of violence.
Star power, which has been an effective lobbying and consciousness-raising strategy for a number of physical illnesses, is relatively underutilized in the case of mental illness, revealing the stigma associated with it. The more that the public can link mental illness with highly valued people, the more that positive associations can form.
Still, case reports, personal narratives, and television portrayals should include not only noteworthy, exceptional individuals with mental illness but also average people who are neither stars nor outcasts. The idea that people with mental illness are either exceptionally talented or globally flawed belies the fact that that mental disorder is part of everyday life. Models need not be heroic to convey a humanizing image. Depictions of resilience can promote the association of mental illness with strength, courage, and resolve—and with the view that change is entirely possible. Not everyone with mental disorder overcomes adversity, and it would be a mistake to force rose-colored glasses on the eyes of readers or viewers. Yet overcoming the stereotype that mental illness is inevitably linked with despair, tragedy, and progressive decline is essential.
(p. 211) Harrington discusses an important trend over the past few decades in case studies of those with neurological and psychiatric conditions, which have moved away from dry, objective reports of symptoms and syndromes toward more vivid and personalized depictions of the unique human being who presents with the symptoms and syndromes in question.21 For example, Oliver Sacks has published revealing portrayals of individuals with autism, Tourette’s disorder, and many other conditions.22 Along with first-person and family narratives about mental illness, these carry enormous potential for fostering increased humanization of neurological and mental disorders.
Disclosures are also important for the individuals who provide the narratives. The process of writing about difficult emotional events can promote psychological and even physical health.23 Narrative can therefore promote a “virtuous cycle” of personal freedom, public gains in knowledge, and increased contact. At a fundamental level, it takes mental illness out of the realm of the mysterious and unknowable and into the arena of openness, familiarity, and empathy.
Mental Health Professionals
The actual extent of stigmatizing attitudes and practices on the part of mental health workers and professionals toward their clientele is unknown. But even a small amount translates into many, many thousands of negative social interactions in any given year—with the potential for long-term damage to morale and the promotion of stigma by the very personnel entrusted with helping those with mental illness. Indeed, if the social workers, educators, counselors, psychologists, medical practitioners, and psychiatrists who constitute the “front lines” of mental health service delivery convey stigma and disparagement, those with mental disorders have real reason for pessimism.
Whatever their actual frequency, such practices should be placed in context. Recall that the mental health professions have low status; the entire enterprise appears to have received a pervasive “courtesy stigma” through its association with a clientele that is viewed as weak, unproductive, and blameworthy. Not only do the mental health professions suffer in terms of prestige, but pay scales for many mental health workers are on the low end of ranges for other professionals, revealing decreased status associated with this line of work. Those in the mental health fields must also contend with potent and frequently derogatory media images of helping professionals. For example, Gabbard and Gabbard provide insightful commentary on the checkered history of depictions of psychotherapists and psychiatrists in film, most of which convey unscrupulous, exploitative, comical, or odd images but rarely realistic or optimistic ones.24 Furthermore, work in the mental health fields can be quite stressful, given the problems related to mental illness itself and the lack of resources that often exist in current service delivery systems.
Mental disorder appears to be particularly stigmatized in the field of medicine itself. Michael Myers, a psychiatrist who specializes in physician health, (p. 212) contends the following about mental illness in general and the problem of suicide in particular:
The stigma attached to mental illness is greater in the house of medicine than in the general public. Stigma, a pernicious force, reinforces denial in physicians that they might fall ill, contributes to their delay in getting medical care, compounds suffering, confuses and frustrates doctors’ families, drives self medicating, and dangerously heightens the risk of death by suicide. And when physicians do kill themselves, the conspiracy of silence surrounding their deaths may aggravate feelings of isolation and shame in their survivors—and thwart our public health efforts at prevention.25
These pointed words speak to a fear of mental disorder among health professionals—an attitude that is likely to be communicated to patients and the public at large, whether explicitly or implicitly. That the medical profession does not tend to confront problems of depression and other mental disorders in its own ranks bespeaks the long-standing stigmatization of mental illness in a core profession intended to deal with such problems.26
As emphasized repeatedly throughout this book, the conceptual bases of mental health practice during much of the twentieth century involved a direct blaming of individuals and families for the mental health conditions they and their relatives suffered. Stigmatization of the very people being served was built into the theoretical foundations of the mental health profession almost from the time of its formal establishment.
All of these issues can set the stage for workers and professionals to “blame victims”—that is, to disparage the individuals who are intended to be helped by mental health services. Narrative evidence along these lines is disheartening.27 However, it is not just overt stigma and criticism that are potentially problematic; views of mental illness that emphasize pity and hopelessness are also communicated directly to patients and relatives. Furthermore, the health care system is permeated by a hierarchical model of expert-sufferer, doctor-patient relationships.
What can be done? I reiterate that a great many mental health workers are dedicated, respectful, and tireless in their efforts; blanket aspersions should not be cast on the field. Relatedly, the huge advances in mental health must be recognized, and these could not have been possible without strong professional and scientific commitment and dedication. In the spirit of encouraging set-breaking strategies for promoting healthier and more productive attitudes and practices on the part of mental health workers and professionals, I list potential strategies and solutions in headline form.
Increased Status for Mental Health–Related Work
To the extent that the general public views mental disorders as important, impairing, serious, yet treatable conditions, rather than ones that are malingered or imagined, the status of (p. 213) those professionals entrusted with their investigation and care should increase. Although there is no way to legislate or impose such views unilaterally, the suggestions made in Chapter 9 regarding education, contact, and empathy enhancement, plus those from earlier in this chapter on media-related tactics, all have the potential to lift the general status of mental illness to new levels of respect and social concern. Such increased status could, in turn, promote a higher level of professional prestige for those who work in the field.
More direct means of enhancing the public’s views of mental health professionals are possible as well. From their marketing perspective, Sullivan and colleagues call for intentional efforts to “brand” psychology and psychiatry in positive, humanitarian, and scientific terms via public relations campaigns. Some of the relevant terms and images could include the portrayal of those in the mental health field as a benevolent set of professionals and/or as humanistic healers. Catch phrases might include the perspective that therapy works, that it is continuously evolving, and that it causes more powerful benefits than one might think.28 Other themes could include the view that it is a sign of strength, rather than weakness, to receive help from individuals who are trained in giving it. There are bound to be other ideas. In short, it will require the careful analysis of target audiences, the implementation of focus groups, and the hiring of creative directors and other marketing personnel (working in tandem with professional leaders) to uncover compelling images and themes.
Still, images devoid of substance will not make a real difference. That is, the mental health professions must continue to strive for scientific rigor and professional competence, so that campaigns have real meaning. If those working in the field show stigmatizing practices and convey low expectations and hopelessness to clients and caregivers, no amount of public relations work can be expected to succeed. Overall, promoting the many positive attributes of the related mental health professions is worth pursuing.
Enhanced Training Methods and Procedures
Mental health professionals need to be educated in the types of treatment that have been documented to work. With literally hundreds of schools of psychotherapy in existence, an ever-widening arsenal of psychotropic medications, and a huge (and growing) list of alternative treatments, consumers face a bewildering assortment of intervention options. It is often quite difficult for those seeking treatment to know with any certainty which interventions have shown effectiveness for particular conditions.29 At the same time, many training programs promote treatment strategies that have little or no scientific support. “Empirically supported” and “evidence based” are the terms now used to signify those types of intervention that have undergone sufficient, well-controlled research to lead to firm conclusions as to their viability.30 To the extent that professionals know of and are skilled in the practice of these kinds of treatment, they will be greatly increasing the odds of successfully treating their clientele. This stance should produce a host of positive effects, including consumer satisfaction, positive regard (p. 214) for professionals, and a reduction of the stigma that can emerge when symptomatology goes untreated.
There are admittedly problems inherent in mere adherence to lists of evidence-based treatments. For one thing, certain types of treatment for a number of disorders have not received sufficient study. Providers therefore need training in how to devise and evaluate newly created or newly synthesized forms of intervention for unique cases, understudied conditions, or ethnic minority or impoverished subpopulations (see below). Relatedly, the results of short-term, tightly controlled experimental studies of therapy outcome may not generalize to the kinds of real-world, seriously impaired, multiply diagnosed, and diverse clientele that exist in the community. In other words, treatments shown to demonstrate “efficacy” in highly controlled studies may not reveal much in the way of “effectiveness” in the real world.31 Moreover, knowing that a treatment works does not tell us how or why it works; a huge need exists to discover the underlying mechanisms of change.32
Still, to the extent that the therapeutic field becomes more rigorous and evidence based, further improvements should appear in terms of client outcomes, enhanced status of professionals, and reduced stigmatization of mental illness. Such work cannot proceed without a renewed commitment to the funding of basic and applied research efforts in psychology and psychiatry.
At the same time, those involved in the selection and training of personnel in the mental health professions must consider the factors of responsiveness, respect, and empathy. Providers with the highest levels of technical skill cannot produce real benefit without the ability to enlist, connect with, and maintain contact with their patients and clients. Training efforts must emphasize the dual objectives of competence in empirically supported interventions and sensitivity to clientele, as well as their relatives and supports. To the extent that professionals and mental health workers can understand both the science behind treatments that work and the experiences of clients and family members, mutual respect and trust should build.
Staff members and professionals must also be aware of the increasingly multicultural nature of American society—indeed, of world society—and of the need for ensuring that clinical services are delivered with sensitivity to families and individuals of nontraditional backgrounds. In other words, training in culturally competent mental health practice is now being discussed and performed in training institutions.33 The intention is not to teach stereotypes about individuals from various ethnic, cultural, or socioeconomic groups, which would clearly be a step backward. Rather, it is to raise awareness of the belief systems, cultural practices, modes of communication, and response tendencies that may characterize various ethnic and cultural subgroups in order to foster more accurate diagnosis and more responsive communication regarding treatment.
In the middle of the last century, an acronym was coined regarding the types of clientele most likely to respond to psychotherapy. Known as “YAVIS” (p. 215) (young, attractive, verbal, intelligent, and successful), the term connoted the unfortunate facts that (a) those individuals prone to do well in verbal therapies were those, in many respects, least in need of effective intervention and that (b) psychotherapies were not typically adapted to patients of color or those of lower class status.34 Since this time, investigations of many forms of treatment (both psychological and pharmacologic) have indicated that clients with low resources, those who are single parents, and those of minority ethnic and racial status show greater likelihood of premature termination from intervention and a weaker chance of obtaining meaningful gains.35 It will take concerted efforts to dispense treatments that can benefit all members of society. Doing so could also help to reduce the sense that mental health professionals are insensitive to a non-middle-class clientele. To the extent that providers come to understand different means of expressing stress or pain among diverse members of the public, their tolerance and respect for clients of different backgrounds should rise—and their status in the eyes of society should reciprocally increase.
Different Models of Treatment
Some have contended, in fact, that the very nature of traditional mental health services can be limiting or even stigmatizing for many clients, particularly those with severe forms of mental illness. For instance, doctor-patient relationships emphasize the expertise of the provider and the weakness (and need for acquiescence) on the part of the recipient of care. A more coequal set of therapeutic relationships, in which clients gain empowerment, has been advocated. Corrigan and Lundin promote such alternate forms of care, marked by consumer-practitioner collaborations and, in some instances, the use of mental health consumers as direct providers of advocacy and self-help services to others in need.36
It is an open question as to whether all of the problems related to mental illness will be solved through such modes and models. More traditional means of providing pharmacotherapy and psychotherapy may well be of enormous benefit, so long as they are provided with sensitivity and rigor. Certainly, however, if providers can consider a more collaborative approach that includes the perspective of the sufferer, incorporates the understanding of the stigmatization that many individuals with mental illness experience, and offers a less authoritarian stance, enhanced care may result.
Support—and Therapy—for Professionals
Given the stresses inherent in mental health work, it would be advantageous for professional groups to provide systematic means of providing relief and support for their members. Collaborations with other professionals, including consultation and mutual support, constitute one avenue. Keeping up with current research on mechanisms of psychopathology and advances in empirically supported treatments is another. Doing so can reduce a sense of isolation and keep clinicians in touch with the wider community of scientists and therapists. Individual or group therapy for providers can also provide a safety valve for pressures and stresses in order to (p. 216) work through difficult issues such as keeping sufficient boundaries while simultaneously promoting real contact with clientele and facing the vulnerabilities and challenges raised by working with individuals who often present intense psychological, familial, and social challenges. Of course, the consulting therapists with whom professionals seek treatment and support will need to be as free of stigma as possible in order that they can provide expert guidance and support without, in turn, blaming the clientele who can promote distress.37
I do not wish to overstate the potential for stigma on the part of those in the mental health field, but I do not want to ignore its reality, either. Changes in the attitudes and practices of the mental health profession will require work that is broad and deep: reducing patterns of societal stigma, enhancing education and training programs, and promoting individual practitioners’ abilities and willingness to find ways of coping with stress and obtaining support. The key objective is to promote meaningful clinical benefit for people with mental illness, the topic of Chapter 11.
6. Corrigan and Penn (1999); see also Watson and Corrigan (2005), who discuss another mechanism for rebound—that is, the “reactance” that builds when people are instructed by authorities to do something, which can lead individuals to do the opposite.
7. Social psychological research on rebound prompted the cautionary points of Corrigan and Penn (1999) about protest efforts. Yet for the reasons just noted, rebound phenomena may not be all that salient for public protests of stereotyped media images; this is an area ripe for additional research.
11. Distantly related to buzz marketing, advocacy groups may promote awards for positive portrayals in the media. Indeed, as noted earlier, the Voice Awards, made during the summer of 2005 at a Hollywood banquet, honored a number of films, television programs, and authors for accurate, sensitive depictions of mental disorder in the media for the years 2003–2004. SAMSHA helped to initiate these awards as part of its Elimination of Barriers Initiative, which has fostered collaboration with the American Psychiatric Association, the American Psychological Association, the Mental Health Media Partnership, and State Mental Health Program Directors.
22. Sacks (1985, 1996). It is also the case that media portrayals that are simultaneously entertaining (i.e., promoting identification with the protagonist) and educational, along with after-presentation information sessions emphasizing counterstereotypic depictions of mental illness, can have noteworthy effects on public attitudes. See Ritterfeld and Jin (2006).
23. See Corrigan (2005a); see also Nairn and Coverdale (2005). Pennebaker and Seagal (1999) have shown via programmatic research that writing narratives about emotionally charged topics can provide important benefits for the writer.
31. For information on the distinction between efficacy (does therapy work under pristine conditions?) and effectiveness (does therapy work in the real world?), see Mintz, Drake, and Crits-Cristoph (1996).