Discrimination against individuals with mental illness.

Mental illness affects one in four American families (National Institute of Mental Health, 1988). Further, approximately 2.8 percent, or 1.5 million, of adults in the United States have some type of serious mental illness (National Advisory Mental Health Council, 1993; O'Keeffe, 1994). Serious mental illness includes stress related brain disorders such as schizophrenia, bipolar disorder, and chronic obsessive-compulsive disorder (Liberman, 1992). Discrimination is prevalent despite the large number of persons affected by mental illness. Gelb (1980) has claimed that persons with mental illness suffer from prejudice and discrimination because they appear deviant and are "ill" in a way that is not understood.

Negative attitudes about mental illness have been widespread throughout history. Society has rejected persons with mental illness (Collier, 1993). Many helping professionals have avoided providing services to persons with serious mental illness (Mechanic & Aiken, 1987). Insurance companies have failed to provide adequate payments for services to treat mental illness (Morlock, 1989). In fact, many individuals with mental illness have no insurance, inadequate insurance, or inequitable benefits. Many persons with mental illness are denied insurance and others have limits placed on the amount of benefits they can receive. Medicare and private health care pay for fewer inpatient hospital days per year for individuals with mental illness, compared to individuals with general health disorders (e.g., diabetes or cardiovascular disease) who receive more or unlimited inpatient hospital days (National Advisory Mental Health Council, 1993).

Discriminatory practices are also found in outpatient care for persons with mental illness. Data from the Bureau of Labor Statistics were analyzed and results revealed that 89% of participants in the study, in 1984, had some private sector outpatient coverage, however limitations were placed on the coverage such as additional copayment charges, higher deductibles, and fixed dollar limitations (Sharfstein, Stoline, & Koran, 1995).

The Americans with Disabilities Act (ADA) was designed to eliminate discrimination against persons with disabilities. The ADA defines a disability as (a) a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (b) a record of such an impairment; or (c) being regarded as having an impairment. An individual with a history of mental illness would meet the first and second criteria of having such an impairment (Adams, 1991). Even with the passage of the ADA persons with mental disabilities still experience sociopolitical rejection and neglect (West, 1992). As West has stated, "Our failure as a nation to deal humanely -- even sensibly -- with this problem is a scandal that unfortunately seems to shock precious few of those responsible for the making and carrying out of public policy" (West, 1992, p. ix). Modifying the environment has helped improve the lives of those with physical disabilities (e.g., ramps have been built to provide wheel chair access). Yet, society has not provided accommodations for persons with mental illness because they need a special social milieu to offset their disabilities (Liberman, 1992). New techniques should be developed to help mental health professionals modify the environment for individuals with mental illness; adhering to the ADA mandate (Mueser, Wallace, & Liberman, in press),

Resistance to accommodations for persons with mental disabilities may be due to the perceived cause of their disability. Rubin and Roessler (1995) suggested that the willingness of society to attend to the needs of persons with disabilities is influenced by factors such as the perceived cause of the disability, the economic conditions, the body of medical knowledge, the sociocultural philosophy, and the perceived threat of the disability group to the community. Further, Rubin and Millard (1991) suggested that public support and funding depend on whether the individual can contribute to society. Hahn (1985a) purported that public policy is shaped by the attitudes of members of society. Hahn (1985b) claimed that attitudes mold behavior which influence public policy.

Negative attitudes affect the possibility of employment for persons with mental illness. Many persons with mental illness have the ability to contribute to society, but job skills training is often needed. Jacobs (1988) noted that some persons with mental illness already possess job skills, but job training will vary depending on the skills of the individual and the type of job desired. Anthony and Blanch (1987) claimed that although persons with mental illness are included in federal mandates for vocational services, mental health agencies have paid little attention to their employment needs. Noble and Collignon (1987) claimed that stereotyping is a barrier to employment because laypersons and professionals share the same attitudes concerning mental illness (e.g., individuals with mental illness are dangerous, or "normalization" of lifestyle is not feasible).

The purpose of this paper is to propose that mental illness be treated as other disabilities covered under the ADA. Therefore, individuals with mental illness should receive services commensurate with other disabilities, including the right to equal insurance coverage. Stressful life events in the client's social life and community environment, often due to attitudinal barriers and unfair treatment, will be discussed because stress can lead to relapse in persons with mental illness. Attitudinal barriers responsible for discrimination will be examined. The ethical principle of beneficence will be discussed by pointing out unfair insurance coverage and societal and professional discrimination against individuals with mental illness. Finally, suggestions will be made to help ameliorate discrimination against persons with mental illness.

Stress Exacerbates Symptoms of Mental Illness

Serious mental illnesses are believed to be brain disorders that are exacerbated by stress (Liberman, 1992; Nuechterlein & Dawson, 1984). For example, Nuechterlein and Dawson (1984) reported that stressors in the environment may contribute to psychotic relapses in persons who are vulnerable to schizophrenia. Socioenvironmental stressors such as homelessness or job discrimination can precipitate relapse in a person with schizophrenia. An increase in the amount of stressful life events has been found in the three to four week period before relapse in some individuals with schizophrenia (Lukoff, Snyder, Ventura, & Nuechterlein, 1984). Nuechterlein et al. (1992) found that prodromal signs of relapse may be present in about 60 percent of persons with schizophrenia. Stressful life event frequencies were examined in the months prior to relapse in 11 patients. Comparisons were made with the life event frequencies of the same individuals during other intervals in which there was no relapse. A significantly greater number of life events was found in the month preceding relapse compared with a month for the same individuals that did not precede a relapse. Moreover, Caton, Koh, Fleiss, Barrow, and Goldstein (1985) studied 119 persons with chronic schizophrenia following hospital discharge and found that interpersonal stress was a significant predictor for rehospitalization.

Negative Attitudes Against Persons with Mental Illness

Attitudinal barriers against persons with mental illness increase stress and precipitate relapse. Stereotypes are often maintained through the process of handicapism. Handicapism is a set of assumptions and practices that endorse the differential treatment of individuals who have disabilities. As a result of handicapism, individuals with disabilities become isolated, resulting in few opportunities to develop friendships with persons without disabilities (Bogden & Bilken, 1977). As a result, negative attitudes against persons with mental illness predominate.

Public attitudes affect funding related to publicly supported mental health services (Rabkin, 1980). As rated by a social distance survey, Tringo (1970) found that individuals with mental illness were rated as the least desirable group of individuals with disabilities; persons with alcoholism and mental retardation were rated higher. Brennan (1964) has claimed that many persons have a fear that persons with mental illness are dangerous. As a result, negative public attitudes concerning mental illness are formed. In addition, publicity of aberrant cases such as the case of John Hinkley Jr., the individual who attempted to assassinate President Ronald Reagan, has portrayed persons with mental illness as dangerous. Further, this stereotype has been sustained by the media when mental illness is linked to violence in movies such as Silence of the Lambs (Torrey, 1994). However, results from epidemiological data has revealed that mental illness rates are not proportional to violence rates (U. S. Department of Health and Human Services, 1981). Torrey (1994) found three variables that were more predictive of violence in persons with mental illness; substance abuse, noncompliance with medication, and a history of violence. However, these three variables have often been omitted when persons with mental illness are reported to be more violent than persons in the general population. Torrey (1994) claimed that persons with drug and alcohol abuse problems, as a group, are more dangerous than persons with serious mental illness.

Societal discrimination has been exhibited by the differential treatment of individuals with mental retardation, compared to individuals with mental illness. The federal government accepted the responsibility for financing the care of individuals with mental retardation through Title XIX of the Social Security Act, but they did not assume the same responsibility for individuals with mental illness. As a result, there has been a significant improvement in conditions of care for individuals with mental retardation, but these gains have not been found for persons with mental illness (Noble & Collignon, 1987). Noble and Collignon (1987) have claimed that state governments have attempted to balance their budgets by minimizing costs for the care of persons with mental illness. Further, cost-saving has been possible because most voters are not concerned about services for individuals with mental illness, and individuals with mental illness and their families lack sufficient votes to make changes in the system (Noble & Collignon, 1987).

Negative attitudes towards persons with mental illness have been found among helping professionals. For example, Wilk (1994) reported that many clinical social workers have negative attitudes about persons with mental illness. A systematic random sample of 400 social workers was selected from a national association, resulting in the return of 216 questionnaires. Results indicated that 52% supported commitment in the absence of effective treatment, 63% were opposed to the right to refuse all treatment, and 57% were opposed to allowing involuntarily committed patients the right to refuse psychotropic drugs. Moreover, 6% felt that it was desirable for involuntarily committed patients to participate in experimental research: 7% did not oppose it, or were neutral or did not respond. Eighty-one persons received special coursework or training in mental illness, 39 had special coursework or training on legal rights, 59 had worked in psychiatric hospitals, and 41 claimed that mental illness was their specialty. These beliefs reinforce the notion that persons with mental illness are less than human.

Negative attitudes against persons with serious mental illness have been found in other professions. Mirabi, Weinman, Magnetti, and Keppler (1985) conducted a survey in Texas of 436 mental health professionals and paraprofessionals. Results revealed that 658 claimed working with individuals with mental illness was not rewarding. In fact, 85% preferred not to work with persons with mental illness. Johnson (1990) has claimed that negative attitudes exist in academic institutions. Many faculty were neither exposed to, nor trained to work with persons with serious mental illness. In fact, it is possible for students in psychology to complete their training without exposure to a client with serious mental illness (Johnson, 1990).

Several factors have been reported as being responsible for the avoidance of individuals with mental illness. Talbott (1979) claimed that low status, low pay, and feelings of isolation from mainstream medicine have led to a dearth of qualified psychiatrists to work with persons with mental illness. Minkoff (1987) purported that clinicians working with persons with serious mental illness often felt like "outsiders" in their profession and many ceased treating chronic patients. As a result, they were able to advance in their career and to increase their income. Judd (1990) has claimed that psychiatrists feel they have been treated like second-class citizens in the medical profession. Further, Sharfstein et al. (1995) have claimed that psychiatrists treat approximately twice as many patients with no insurance than do other medical doctors. The likelihood of professionals working with persons with serious mental illness may be decreased because insurance companies provide limited coverage for mental illness, and persons with serious mental illness will most likely need long term treatment.

Discriminatory Insurance Practices

Persons with mental illness have not been reimbured by insurance companies to the same degree as other health disorders. The National Advisory Mental Health Council's (1993) report indicated that 79% of employees with mental health insurance had more restrictions placed on hospital coverage for mental illness than for other types of illness. Restrictions included shorter inpatient hospital days for mental illness, compared to longer or unlimited days for "physical" illness. Medicare programs have placed more restrictions on coverage for mental illness than for general health conditions. Sharfstein et al. (1995) have reported that Medicare Part A, hospital insurance, has limited the amount of days of inpatient mental health care in psychiatric hospitals to 190 days for a lifetime. This limitation has led to an increase in the number of mental health patients being cared for in general hospitals and extended care facilities because limitations, in these facilities, are the same as for other medical disorders. In addition, Medicare Part B, supplementary medical insurance, limited the amount of charges that physicians can receive for outpatient mental health care (50% of the charges or a maximum of $250).

Medicaid is responsible for the majority of long term health care in the United States (Koyanagi, 1990). Medicaid is a combined Federal and state program that is the primary source of health insurance for mental health consumers (Carling, 1995). However, Medicaid has placed limits on mental health coverage for persons with mental illness, similar to private insurance companies (Hatfield, 1990). Medicaid payments are run by states, therefore, payments vary depending on the consumers place of residence (Sharfstein et al., 1995). Medicaid covers mental health care for persons in psychiatric hospitals under the age of 22 and over the age of 65, eliminating coverage for many persons with mental illness (Koyanagi, 1990). Further, Koyanagi reported that Medicaid provides coverage for persons with mental retardation living in halfway houses, group homes, or adult foster homes, but denies such coverage for persons with mental illness.

Discriminatory insurance practices have been found in private health care as well as public health care. Insurance companies have placed inside limits on services for persons with mental illness. Limits include higher cost sharing, limited hospital stays, and limited outpatient visits (Sharfstein, Stoline, & Goldman, 1993). Sharfstein and Taube (1982) reported that Blue Cross/Blue Shield decreased their mental health coverage in 1982 by placing limitations on both inpatient as well as outpatient visits. A 50 visit limit was placed upon outpatient treatment, and a 60-day limit was placed upon inpatient care. Employers have tried to curb costs of mental health care by implementing in-house employee assistance programs or contracting out mental health services to independent companies or a mental health subsidiary of an insurance company (Sharfstein et al., 1993). Often times persons with chronic mental illness are denied insurance because they are believed to require large amounts of service. However, persons with other chronic illnesses such as diabetes are not denied health care on these grounds (Pollack, McFarland, George, & Angell, 1994).

There has always been differential treatment for persons with mental illness in regard to insurance coverage (Sharfstein et al. 1995). Sharfstein et al. (1995) reported that the Bureau of Labor Statistics for 1979 to 1984 revealed the following: 13% of insurance payments for mental health came from private insurance companies whereas insurance companies pay 28% of the expenses for other medical disorders. Further, fewer than half of privately insured individuals have insurance coverage for inpatient psychiatric treatment that is equal to their coverage for other illnesses. Moreover, mental health care coverage has been declining. In 1984,48% of insured persons had equal coverage for mental and general health compared to 58% in 1981. Fixed dollar caps have been placed on annual or lifetime benefits for mental health care. Other limitations include fewer days of care for mental disorders as compared to general health problems (Sharfstein et al., 1995). In addition, co-payments for mental health services and restrictions on treatment have been found in health maintenance organizations as well (DeLeon, VandenBos, & Bulatao, 1991).

Costs for Treatment in the Community versus Inpatient Setting

The cost of community treatment is much lower than inpatient treatment (Aviram, Minsky, Smoyak, & Gubman-Riesser, 1995). However, Aviram et al. (1995) have claimed that nationwide persons with mental illness are being kept in state hospitals despite the fact that the are ready to be discharged. In December 1988, all New Jersey state hospitals were surveyed and results indicated that of 2775 patients, 45% were determined to be eligible for discharge according to legal and clinical determinations. Discharge ready was determined by the legal procedure used by courts in New Jersey and by the Level of Care Survey used by the New Jersey Division of Mental Health. Aviram et al. claimed that discharge ready patients had a higher level of functioning than nondischarge ready patients and could succeed in community placement with support or supervision. The results of this study are important because the average cost of maintaining an individual in a mental hospital is approximately $90,000 (New Jersey Department of Treasury, as cited in Aviram et al" 1995) per year whereas community placement is estimated to vary from $ 18,000 to $30,000 (New York State Commission on Quality of Care for the Mentally Disabled, as cited in Aviram et al., 1995). It appears obvious that inpatient care is more expensive than outpatient care, therefore, reform needs to be implemented to maintain individuals with mental illness in the community.

Insurance and Employment Practices

Insurance costs can affect employment for persons with mental illness. There is a fear that an employer may fire or not hire persons with disabilities, including mental illness, because of concerns about the cost of insurance coverage (O'Keeffe, 1994). Since the employment section of the ADA was implemented on July 26, 1992, there were approximately 3,358 charges of discrimination reported to the Equal Employment Opportunity Commission (O'Keeffe, 1994). Approximately one half of the complaints were due to individuals being released from their jobs for a health condition, or a disability. Mental illness was one of the 12 most frequently reported conditions (Disability Compliance Bulletin, as cited in O'Keeffe, 1994). Carling (1994) stated that "Besides the obvious economic benefits, employment offers other important psychological and social opportunities" (p, 105). Persons with mental illness often are denied this opportunity.

Ethical Principle of Beneficence

Beneficence is an ethical principle grounded in the belief that one has a moral obligation to act in a way that promotes the well being of the client (Beauchamp & Childress, 1989). There is no clear public policy regarding health care and rehabilitation services for persons with disabilities (Rubin & Roessler, 1995). Persons with disabilities are not guaranteed the right to medical and rehabilitation services. However, a beneficent society would be comprised of individuals and organizations willing to provide services to individuals with mental illness. Helping professionals are not acting beneficently when they avoid, or discriminate against persons with mental illness. It is not considered beneficent to avoid working with individuals with mental illness, to focus on nonpsychotic clients, or to agree that patients be required to participate in experimental research. Members of society, policy makers, and insurance providers are not acting beneficently when they endorse inequitable insurance coverage for persons with mental illness.

An example of acting beneficently could be seen when applying the Fair Opportunity Rule. Beauchamp and Childress (1989) described the Fair Opportunity Rule as the basis to provide more resources to persons with disadvantaging properties (i.e., mental retardation). Under the Fair Opportunity Rule, individuals would have a moral right to receive a greater share of the resources of society for meeting their basic needs to offset the disadvantages that they received as a result of the "lottery of life", (i.e., disadvantages for which they had no responsibility). The term lottery of life means that the individual has disadvantaging properties resulting from congenital, disease, or accident (Howie, GatensRobinson, & Rubin, 1992). This rule should apply to persons with mental illness as they suffer from disadvantaging properties due to the lottery of life.

Society as a whole, policy makers, insurance companies, and many helping professionals have not always promoted the welfare of those with serious mental illness to an optimal degree. Many persons with mental illness are not able to advocate for themselves. It should be the duty of helping professionals, including rehabilitation counselors, who work with persons with mental illness to advocate for better services. For example, the Code of Ethics for Rehabilitation Counselors, Canon 3 (ARCA, CRCC, NRCA, 1987) states that rehabilitation counselors should serve as advocates and promote access for persons with disabilities. Although, advocacy and beneficence are not directly stated in the APA Ethical Principles of Psychologists (APA, 1992); Principle F: Social Responsibility implies that psychologists have an ethical obligation for advocacy. The code has indicated that psychologists should advocate for laws and social policies that will benefit their clients and the public. Therefore, it is imperative that psychologists and rehabilitation counselors advocate for beneficent treatment for persons with mental illness.

Pollack et al. (1994) claimed that mental health professionals should become active participants in advocating for health care reform for persons with mental illness. Mental health consumers have become empowered and have been successful in including psychiatric disabilities in major pieces of legislation such as the 1990 Americans with Disabilities Act and the Federal Fair Housing Act Amendments of 1989 (Carling, 1995). Further, Carling proposed that advocates should work closely with the self-help groups at the local and state levels. At the agency level, mental health professionals should enlist consumer involvement in all areas of planning to include the development and evaluation of programs, setting priorities, and making funding decisions. Agency officials should appoint consumers to serve on the board of directors. As Carling points out, organizations would not exclude persons with mobility impairments from serving on the board of directors for their respective group.

It is important to include professionals, consumers, and family members in advocating for better services for persons with mental illness. The National Alliance for the Mentally Ill (NAMI), an advocacy and self-help group, was formed in 1979 (Liberman, 1988). NAMI members have been active at the local, state, and national level. NAMI has over 1,000 affiliates with chapters in every state (Carling, 1995). NAMI has its national headquarters in Washington, D.C. and lobbying efforts have been successful in improving the services for persons with serious mental illness (Mechanic, 1994). NAMI members were involved in transferring the research in mental health to the National Institutes of Health (NIH), establishing the Substance Abuse and Mental Health Services Administration (SAMHSA), and the formation of research and demonstration programs within NIH and SAMHSA (Mechanic, 1994). Therefore, NAMI members have demonstrated that their advocacy efforts can change public policy.

Mental health professionals may differ in their belief towards advocacy of consumers and their families. Hatfield (1990) claimed that some mental health professionals may be threatened by consumer empowerment while other professionals support the collaboration between professionals and consumers. Rehabilitation counselors should welcome the consumer movement and enjoy the advantages of consumers participating in their own rehabilitation plan. Rehabilitation counselors can assist consumers and families in education about their illness and participate with consumers in advocacy movements proposing policy change. Sharfstein et al. (1993) has asked for psychiatrists to become unified and advocate for more equitable treatment for persons with mental illness. Rehabilitation counselors should take an active role in advocating for parity in services for consumers of mental health services as well, Advocacy can take place at the local, state, or national level. Rehabilitation counselors can become members of advocacy groups such as NAMI whose membership includes professionals from all disciplines. By working with mental health consumers, rehabilitation counselors can help ensure that persons with mental illness receive equitable insurance treatment afforded other disability groups. Once parity in insurance practices is achieved individuals with mental illness may enjoy the same benefits as other disability groups protected under the ADA.

To conclude, societal discrimination becomes obvious when examining Title XIX of the Social Security Act. The federal government, controlled by public policy, endorsed inequitable treatment for persons with mental illness, compared to persons with mental retardation (Noble & Collignon, 1987). Further, professional discrimination has been shown when professionals exhibit negative attitudes and avoid working with persons with mental illness (Mechanic & Aiken, 1987; Minkoff, 1987; Mirabi et al., 1985). Insurance discrimination has been shown in both private and public sectors (Sharfstein et al., 1993; Sharfstein et al., 1995). Fewer services are provided to individuals with mental illness. Services that are provided are more expensive than those for persons with general health disorders (National Advisory Mental Health Council, 1993).

Prejudice and discrimination are difficult problems to change, but if professionals, consumers, and their families work together to advocate for better treatment the quality of life for individuals with mental illness can improve. "Without doubt, patients and family members need the help of mental health professionals" (Johnson, 1989, p. 555). Discrimination by professionals can be reduced if helping professionals work together. Liberman (1992) has claimed that there should be an alliance among the helping professionals, many of whom have been "working in rival camps" (p. xiv.),

Hahn (1985a) claimed that persons with disabilities constitute a minority group. Hahn claimed that persons with disabilities experience problems similar to those of other minorities. Therefore, it is important for those with mental illness to identify themselves as victims of discrimination and to try to persuade others that they have suffered from bias and discrimination. Insurance discrimination can be ameliorated if persons in the "minority-group" advocate for less biased policies by insurance companies. NAMI has successfully lobbied for better services for persons with mental illness (Johnson, 1989). However, much work is still needed to improve the quality of life for persons with mental illness. Rehabilitation counselors can play a role in that effort by working along with consumers and family members in advocating for better services. Rehabilitation counselors can join local NAMI groups and encourage consumers and their family members to become active in advocacy. Team work can help improve the lives of an underserved population, persons with mental illness.

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Sue R. Noe, Southern Illinois University Rehabilitation Institute, Carbondale, Illinois 62901