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Mental Health, Stigma and Barriers to Care 17 in. What people tell you and what they actually do are not always the same thing, and the disparity is not always in a bad direction. It could be that our simpleminded questions just did not work very well. You might be familiar with Charles Turner’s work published in Science a number of years ago which used ACASI interviews to get information about stigmatizing behaviors. These interviews are administered with a laptop at a person’s house. You plug in a little headset on it, turn around the computer and let people answer the questions privately. Essentially the computer will digitally ask a question such as, “How often do you have sex with small animals - often, sometimes, rarely, or never” You just punch in the answer and then the computer will follow up with a series of questions. Turner did a series of experiments in which a random half of the respondents were asked, “How often do you have sex with small animals” Then the other random half of the people had the question asked privately on the computer. They found that when you ask the questions in a private, less embarrassing way, more people admit to stigmatizing behavior. They found that people were more willing to admit drug problems, sexual things, illegal things, but not mental illness. There was no change. Does that mean that mental illness was less stigmatizing, or does it mean that it was so much more stigmatizing than having sex with a small animal that people would not admit to it There is good reason to believe that it was the former— that actually mental illness is becoming less stigmatizing than it was in the past. These techniques represent an interesting paradigm that we have not tried in studies of stigma. To the best of our knowledge it looks like people are willing to tell you that they have these problems if they are asked in the appropriate way. We know from the work of Greg Simon and colleagues that when you pose mental health screening questions in a primary care waiting room, patients will check off the boxes in very high proportions, even though most of them are likely not there for treatment of the emotional problem. We also know from those same studies that when you do thoughtful outreach with stages of change interviewing, you can get a substantial proportion of those people into treatment. If you use thoughtful case management, such as that being implemented in RESPECT-MIL, you can keep them in treatment. The problem we have is that case management does not often happen, and when they get typical treatment it is so lousy that it is not worth the effort to get them into treatment. What I conclude from this is that stigma is not that big of a deal, at least for the things I am interested in. Stigma, as a practical matter, is probably doing quite a bit to get people not to reach out for help. I did not show you the data about reasons for dropping out of treatment but it is clear that we can implement structural processes to reach out to people, get them into treatment, and keep them in treatment. The question is, “Do we want to get a worldview change in the way the world sees mental illness, or do we want to make practical changes to get them to enter and stay in the treatment” My guess is that the latter is going to be more effective in the short run. To the extent that we can work on the former, that is great—but I would not hold my breath. I think the action is in trying to do outreach, recognize that there are embarrassment issues and that they do not go away when the person gets into treatment. They are still there—sometimes bigger—so you have got to keep holding their hand. We could
18 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism do much better, at least on the treatment side, if we address those things in a more proactive way rather than a societal way. Thank you very much. DR. BELL: Do you have any idea about how people are welcoming prevention DR. KESSLER: Yes, we have done rigorous research and discovered beyond a shadow of a doubt that people want to quit smoking after they have cancer. It is much more difficult before they have cancer. Prevention is a very tough sell. Further, early intervention is something that is in a woefully neglected state of affairs in the mental health arena. Hendricks Brown can tell you from his work at Hopkins with behavioral researchers that at the age of four, children already have mental illness. So we could try prevention and early intervention, but you have got to start at about six months of age if you want to do that. What is more important is that the vast majority of people with a mental disorder do not get into treatment. In our data if you look at age of onset of your first mental illness and age of first contact with a treatment system, the difference is 12 years. Most people who have serious disorders in adulthood have onset in childhood and get treatment when they go to college, join the military, or get into a relationship that falls apart at the age of 22. I wish we could do a better job of early intervention with mild disorders when people are in pain and are interested in getting treatment. There are lots of kids out there, usually sitting in the back of the room, the quiet kids who are scared to death, who would love to have somebody reach out to them. They are not going to seek care of their own volition. That is the biggest bang for the buck. Early intervention, primary prevention of secondary disorders to try to influence the course of illness, is really where the action is. Of course, we know exactly where these kids are five days a week, nine months a year, from 9:00 to 3:00. It is a crime that we are not doing more in the schools. DR. HENDRICKS BROWN: Ron, do you have any information on changes in stigma associated with mental disorders after September 11th DR. KESSLER: We do, however I have never looked at that. It turns out that we were in the field then and half of our survey was done. We could see a clear blip in 30-day prevalence of disorder. We did not see any blip at all in lifetime disorder which is comforting. It likely means that most of the people who had the extreme distress reactions were people who had a history of disorder in the past, but we never looked at the stigma issue.
Page 1 and 2: FORUM ON HEALTH AND NATIONAL SECURI
Page 3 and 4: From the Conference Series: FORUM O
Page 5 and 6: 9 Day 1 Discussion ................
Page 7 and 8: ii Bruce G. Link, Ph.D. Professor,
Page 9 and 10: iv Alisha H. Creel, Ph.D. Assistant
Page 11 and 12: vi Kenneth W. Schor, D.O., M.P.H. C
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