stigma and barriers to care - Uniformed Services University of the ...

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
We discovered that for most sectors the percent that dropped out is pretty close to
the percent who completed treatment and said they were cured. We found a dropoutto-cure
ratio of 15% to 23% for psychiatrists, and 19% to 27% for other mental
health specialists. In the general medical category, 30% dropped out compared to
22% that continued what they thought was an effective course of treatment. Dropout
is an enormous problem.
When we asked, “How come you quit” sometimes people said it was not effective
but very often they said, “It was not as painful anymore as it was before. I can
function at least minimally. As soon as I can function at least minimally I can handle
it myself.” There is this embarrassment about getting treatment and people get out
very quickly. Dropout tends to occur early in the treatment course, particularly in
general medical. The more providers you have the less likely you are to drop out.
If you have a self-help group you are very unlikely to drop out. When you look at
the average number of visits to a self-help group in America it approaches 17 times
a year. Close to 50% of all visits for a mental health problem each year are visits
to a self-help group. It is a small number of people going a large number of times.
We originally thought self-help groups were competing with professional
treatment but that is not the case. It is worth noting that most people who are in a
self-help group are in for reasons other than substance problems. The people who
are in self-help groups for emotional problems are often also seeing a mental health
professional of some sort. If you do both of those things your probability of dropping
out of professional treatment is substantially lower than if all you are doing is
seeing a professional.
It is interesting that in the mental health world we have not done much with
self-help. There is not a great deal of coordination between self-help and professional
treatment. That is quite different in other areas of medicine. If you go to
Sloan Kettering in New York for example, people who are getting treatment for
cancer are deeply invested in self-help groups. Nurses often run them for patients
and their families.
People who fly in from California for treatment are in treatment eight hours
a week. Five of those hours are with a facilitator in a self-help group, one hour is
with social workers, a half hour is with a resident, and two and one half minutes
are spent with a doctor. The idea is a pyramid of care where self-help is integrated
into the system and people feel that they are connected. The dropout problem is
considerably lower in some areas than it is in psychiatry. It could well be that we
should focus our energy on some combination of these concepts.
What do we take away from this The NCS-R and NCS comparisons demonstrate
a dramatic increase in treatment with no real reduction in mental illness
stigma. Why did that occur We originally thought recognition that help was available
caused it. Clearly that is not going on. Then we thought there was an increase
in the recognition of a problem. That does not seem to be it either. At this point
we honestly do not know the answer. Clearly some dramatic increase in treatment
occurred without changes in stigma and perceptions of treatment effectiveness. One
possibility is that there actually was a change in perception of stigma that we did
not pick up.
Sociologists in the audience may remember the work of Richard LaPierre. In the
1950s, LaPierre studied discrimination by calling hotels and asking if they would be
willing to have a black person stay at the hotel. The vast majority said no. Then he,
a black person, showed up and registered. The vast majority of the hotels let him