Reducing the stigma of mental illness. (Professional Exchange).

In a recent national survey, Pescosolido, Monahan, Link, Stueve, and Kikuzawa (1999) found that while Americans' current knowledge of mental illness is greater than in 1950, Americans continue to fear people with mental illness. Each year, an estimated 50 million Americans will experience a mental disorder while only one fourth of them will seek mental health services (Center for Mental Health Services, [CMHS] 2000). This figure represents about one-third more Americans than those diagnosed with cardiovascular disease. Why do Americans refuse to seek help for mental illness? We contend that this disparity results from the stigma attached to mental illness. Counselors must educate the general public about the misconceptions of mental illness and advocate for parity in mental health insurance coverage.

WHAT IS STIGMA?

The word stigma originated in ancient Greece and is derived from a word meaning to mark someone. The American Heritage College Dictionary (Berube et al., 1993) defines stigma as a mark of disgrace or reproach. Stigma is not simply the use of negative labels or wrong words; it is disrespectful to the individual who has mental illness. It further discourages the individual from seeking the help needed for fear of discrimination (CMHS, 2000). Furthermore, stigma encourages fear, mistrust, and violence against people with mental illness. Clifford Beers described this stigma in his 1908 book, A Mind that Found Itself (1966). This book, written 93 years ago, gives a chilling account of Beers' experiences in a mental hospital at the turn of the century. Today, stigma still exists because of negative portrayal in the media, specifically, in newspapers and entertainment. Newspapers emphasize the mental illness background of perpetrators of violent crimes (National Mental Health Association, [NMHA] 2000). The entertainment industry portrays people with mental illness with negative terms (NMHA, 2000). Additionally, research on television viewing by Granello and Pauley (2000) "suggests that television portrays inaccurate and unfavorable images of mental illness" (p. 171). For example, this past television season, the popular series, ER aired six episodes that starred Sally Field as Abby's mother. Field's character was described as Abby's "bipolar mother," (Episode Guide, 2001). The publicity write-ups describing these episodes included adjectives such as: mentally unbalanced, mentally disturbed, unstable, unpredictable, disconnected, suicidal, and a broken woman. These derogatory terms fuel stigma and negative attitude towards persons with mental illness. Although monumental achievements have been made in medicine, science, and technology during the past 93 years, unfortunately, the same success has not been realized with stigma and mental illness.

CURRENT ANTI-STIGMA CAMPAIGNS

Surgeon General Satcher has set a national standard by calling attention to the problem of stigma and mental health with Mental Health: A Report of the Surgeon General (Satcher, 1999). The Surgeon General acknowledged the huge problem of stigma and stated that it must end. He indicated that research and avenues to communicate that research to the public are critical ways to combat stigma. His recommendations also included evaluating current anti-stigma campaigns for their effectiveness. Most recently, Surgeon General Satcher outlined the following specific suggestions to overcome stigma and discrimination in mental health (Simmons, 2001):

* Increase public awareness of effective treatments

* Tailor treatments to age, gender, race and culture

* Facilitate entry into treatment

* Reduce the financial barriers to treatment (p. 19).

Many statewide anti-stigma campaigns have been launched to counter the negative effects of stigma. For example, South Carolina's Department of Mental Health [SCDMH] launched their Anti-Stigma Campaign in May 2000 to raise awareness and reduce fear associated with mental illness (SCDMH, 2000). The South Carolina campaign includes statewide public service announcements, a speaker's bureau, and volunteers who work with professionals who deal with mental illness on a daily basis. Additionally, SCDMH consumers and family members of consumers are visiting university campuses in South Carolina to educate journalism students about mental health. SCDMH also created a program called the Palmetto Media Watchers Program (2001). The Palmetto Media Watchers write letters and send emails to the media when they see mental illness portrayed negatively in the media.

There are several web sites dedicated specifically to fighting the stigma of mental illness. One such web site is MiSanity (http://www.misanity.org/first.html) whose acronym stands for Mental Illness Stigma Action Network in Touch with You. It was formed in 1997 to promote mental illness recovery by confronting stigma. The Promoting Recovery by Confronting Stigma Project is a nonprofit organization underwritten by PLAN of Northeast Ohio. The web site (http://www.misanity.org/first.html) includes anti-stigma study groups, action groups, and a research component that is studying how this model promotes the general recovery of its members (PLAN of Northeast Ohio, 1997). The National Stigma Clearinghouse (1990), a grassroots, all-volunteer, not-for-profit organization, was created to "track stigmatizing stereotypes of mental illness and provide information about stigma to concerned activists" (p. 1). This organization's web site (http://community-2.webtv.net/stigmanet/STIGMAHOMEPAGE/index.html) focuses on inaccurate images of mental illness in the media and collects information on stigma that is provided to mental health professionals and others interested in fighting mental illness stigma. The web page also links to other web pages that promote sensitive language use. The Words Matter (Maio & Caras, 2001) web page lists positive words and phrases to use "in shifting vocabulary closer to reality and away from judgmental cliches" (p 1). For example, one listing advocates using person-first language. Specifically, person-first language focuses on the need to identify the person before the descriptor: "The person who has had mood swings," or "the person who has anxiety" instead of saying "the schizophrenic" or the "bipolar."

COUNSELORS AND THE FIGHT AGAINST STIGMA

Counselors must advocate to end the stigma and discrimination against mental illness. To meet this challenge, several avenues exist. These include education, research, awareness, and advocacy. With regard to education, counselors can educate individuals in their home communities and at their schools. Mental health awareness fairs can be held in the schools. Awareness campaigns and public forums can be scheduled on college campuses and in communities. To expand overall education, counselors should contact radio and TV stations and encourage them to provide accurate information in their news that correctly educates their audience about mental illness. Public service announcements such as the those created by the American Counseling Association titled "Counseling at Its Best" are available. Additionally, counselors should become involved and respond to the many false statements about mental illness and people with mental illness to correct misconceptions (NMHA, 2000).

To add to the knowledge base of counseling that fights stigma, counselors must constantly engage in research. Messina (1999) identified a "body of research and theory about the practice of mental health counseling" (p. 289) as Building Block 6 of the foundational building blocks of the counseling profession. Similarly," [r]esearch that will continue to yield increasingly effective treatments for mental disorders" (Satcher, 1999, p. 9) and effective dissemination of that research will have a significant impact in the fight against stigma. An excellent example of research on stigma comes from the Chicago Consortium for Stigma Research. The Consortium is dedicated to "understanding the phenomena of stigma, developing and testing models that explain why it occurs, and evaluating strategies that help to diminish its effects" (Chicago Consortium for Stigma Research, 2001, p. 1). With continued research and education, the stigma of mental illness can be overcome.

In promoting awareness, counselors should participate in national lobbying organizations such as the National Mental Health Association and the National Alliance for the Mentally Ill. Counselors should support professional organizations such as the ACA and the American Mental Health Counselors Association (AMHCA) that continuously work together to support mentally ill persons as well as fight against stigma. Counselors should lobby their state's mental health providers and state counseling organizations to begin anti-stigma campaigns such as those described in this article. Another avenue of awareness exists in the many professional organizations and web sites devoted to anti-stigma education. Counselors should support these movements and / or begin their own movements from their own agencies and states. Locally, counselors should participate in local civic organizations and community public forums.

With regard to advocacy, counselors should contact legislators advocating for parity in the insurance coverage of mental illness. Tipper Gore's Mental Health Conference at the White House and Rosalynn Carter's Symposia for Mental Health at the Carter Center have helped reduce myths about mental illness. Counselors should support political candidates with strong mental health agendas. Additionally, counselors must encourage politicians and celebrities to speak out on mental health issues. Prominent celebrities like Mike Wallace, Patty Duke Austin, Dick Cavett, Marie Osmond, and Rod Steiger should be encouraged to continue talking about their own mental illnesses and their successful treatments.

Additionally, organizations such as the National Alliance for the Mentally Ill (NAMI), which is "dedicated to improving the lives of people with mental illness" (2001, p. 1), regularly honor individuals who further public knowledge and awareness of mental illness. For example, NAMI (2001) gave its Outstanding Media award to Sally Field for her role as Maggie in ER. This award was presented because Field's portrayal of Maggie was portrayed realistically and was not stereotyped as violent nor was her character made the butt of derogatory jokes. We believe this award and other similar awards make essential contributions in educating about mental illness.

Another means for counselors to advocate for mental health is to lobby for mental health insurance and for HMOs to recognize mental illness as a disease by paying for treatment of mental illnesses. Currently, several insurance companies discriminate against persons with mental illness. AMHCA and the ACA continue to lobby for insurance coverage for both the services of counselors and the independent reimbursement of licensed professional counselors to eliminate this discrimination. AMHCA's Office of Public Policy and Legislation is dedicated to working with state and federal governments to "educate policymakers about the role of mental health counselors" (2001, p. 1). ACA's office of Public Policy and Legislation works to have professional counselor services included in all appropriate legislation and works with legislators to support professional counseling services. Although this recognition is emerging, much more remains to be accomplished.

CONCLUSIONS AND RECOMMENDATIONS

Although change does not happen immediately, it can happen. Counselors must work to erase the stigma of mental illness. In their fight against stigma, counselors must be aware that this battle is about the very foundation on which counseling is built. Specifically it is about:

* Client welfare

* The worth and dignity of every person

* The opportunity to live a better life

* The opportunity to combat discrimination

In summary, one fourth of the estimated 50 million Americans that experience a mental illness will not seek mental health services because of the stigma associated with mental illness (CMHS, 2000). We believe that the disparity between those who experience a mental illness and those who obtain services for that mental illness is related to the stigma and fear that surrounds mental illness. When insurance companies and HMOs cease discriminating against persons with mental illness and counselor services are recognized and reimbursed, many more persons with mental illness will be empowered (emotionally and financially) to step forward and seek the mental health services they need. In the meantime, counselors must continue to work to educate about mental illness stigma as well as to advocate for mental health in their communities. Continued research and education will help overcome the stigma of mental illness. Kindness, understanding, and encouragement can replace stigma.

REFERENCES

American Mental Health Counselors Association. (2001). AMHCA's Office of Public Policy and Legislation. Alexandria, VA: Author. Retrieved June 18 2001 from the World Wide Web: http://www.amhca.org/publicpolicy.html

Beers, C. W. (1966). A mind that found itself: An autobiography (7th ed.). Garden City, NY: Doubleday.

Berube, M. S., et al. (Ed.). (1993). The American heritage college dictionary (3rd ed.). Boston, MA: Houghton Mifflin.

Center for Mental Health Services. (2000). Anti-stigma: Do you know the facts? Rockville, MD: Author. Retrieved December 26, 2000 from the World Wide Web: http://www.mentalhealth.org/stigma/factsheet.htm

Chicago Consortium for Stigma Research. (2001). CCSR mission. Chicago, IL: Author. Retrieved June 13, 2001 from the World Wide Web: http://www.stigmaresearch.org/

Episode guide. (2001). NY: NBCi. Retrieved June 12, 2001 from the World Wide Web: http:// www.nbci.com/LMOID/bb/fd/0,946,-0-4184,00.html?tv.show.er.ep-but.4184

Granello, D. H., & Pauley, P. S. (2000). Television viewing habits and their relationship to tolerance toward people with mental illness. Journal of Mental Health Counseling, 22, 162-175.

Maio, H., & Caras, S. (2001). Language matters. Retrieved June 13, 2001 from the World Wide Web: http://www.peoplewho.org/documents/wordsmatter.htm

Messina, J. J. (1999). What's next for the professional of mental health counseling? Journal of Mental Health Counseling, 21, 285-294.

National Alliance for the Mentally Ill [NAMI]. (2001, June 14). NAMI honors Hollywood actors for confronting mental illness in drama and real life. Arlington, VA: NAMI. Retrieved June 18, 2001 from the World Wide Web: http://www.nami.org/pressroom/20010614.html

National Mental Health Association. (2000). Stigma: Building awareness and understanding about mental illness. Alexandria, VA: Author. Retrieved December 26, 2000 from the World Wide Web: http://www.nmha.org/infoctr/factsheets/14.cfm

National Stigma Clearinghouse. (1990). About the National Stigma Clearinghouse: A welcome to newcomers. NY: Author. Retrieved December 26, 2000 from the World Wide Web: http://community-1.webtv.net/stigmanet/AbouttheNational/

Palmetto media watch: Ensuring accurate portrayals of mental illness. (2001, January 5). South Carolina: South Carolina Department of Mental Health. Retrieved July 23, 2001 from the World Wide Web: http://www.state.sc.us/dmh/pmw-website.htm

Pescosolido, B. A., Monahan, J., Link, B. G., Stueve, A., & Kikuzawa, S. (1999). The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health, 89, 1339-1345.

Plan of Northeast Ohio. (1997). Promoting recovery by confronting stigma project description. Ohio: Author. Retrieved December 26, 2000 from the World Wide Web: http://www.misanity.org/first.html

Satcher, D. (1999). Mental health: A report of the Surgeon General. Washington, D.C.: Department of Health and Human Services.

Simmons, J. (2001, May). Satcher outlines plan to destigmatize mental illness. Counseling Today, pp. 1, 19.

South Carolina Department of Mental Health. (2000). The anti-stigma campaign. South Carolina: Author. Retrieved December 26, 2000 from the World Wide Web: http://www.state.sc.us/dmh/thecampaign.htm

Kaylene Brown is a doctoral candidate in the Counselor Education Program, Email [e-mail]. Loretta J. Bradley, Ph.D., is a professor, Counselor Education. Both are with Texas Tech University, Lubbock.