Working with schools
High school students are a popular target group in the WPA global antistigma program; this group has been selected by at least a dozen projects, from Calgary to Ismailia, Egypt. The popularity of this target group has less to do with the likelihood that students will stigmatize people with mental illness and more to do with their ready accessibility and the opportunity to influence the attitudes of a coming generation. When meeting with school principals, project members can frame the effort to reduce stigma as an important component in diversity training and point out that mental illness is often neglected in health education.
Examples of messages that were used in the high school antistigma programs in Calgary and Boulder include "No one is to blame for schizophrenia," "People with schizophrenia are people with schizophrenia," and "Watch your language"—that is, don't use derogatory terms to refer to people with mental illness.
Media that were used included speakers with mental illness, the Web page of the WPA program (www.openthedoors.com), a teaching guide on schizophrenia (available on the Web page), and an art competition for students to produce antistigma materials.
To mount the art competition in Boulder, organizers obtained the support of the school principals and art teachers. A consumer speakers' bureau and a project coordinator with a background in visual arts made presentations in art classes. The presenters announced a juried competition, with money prizes, for students to produce artwork dealing with stigma and mental illness. (Some of the entries can be viewed by going to www.mhcbc.org and clicking on Anti-Stigma Project.) A public art show with an awards ceremony was mounted after each annual competition, and an exhibit of all the entries was displayed in participating high schools.
The impact of a social-marketing campaign is increased if the target group receives the same message from different sources (the media multiplier effect) (
29). In Boulder, interior bus advertisements reach a predominantly younger audience and are free for public-service announcements. The WPA project in Boulder installed several bus advertisements with antistigma messages, including one that used student art with the statement, "Sometimes those that are different are the most amazing." Cinema patrons are also predominantly younger people. The Boulder project ran slides with three different antistigma messages among the advertisements that preceded the main feature on 16 local cinema screens. One message read, "Don't believe everything you see at the movies: mental illness does not equal violence." Exit surveys revealed that 18 percent of cinema patrons recalled the content of at least one of the three messages displayed. Thus, during three months of displaying the slides, more than 10,000 people would have been able to recall one message two hours after seeing it. The total cost was 36 cents for each person who recalled seeing a message, which compares very favorably with usual commercial media costs (
30).
Outcomes from high school interventions have been positive throughout the WPA project. In Calgary more than 3,000 students participated in the intervention. Post-testing was conducted at different times, from minutes to weeks after the intervention, depending on the classroom. The proportion of students who answered all the questions about mental illness correctly increased from 12 to 28 percent on pre-post testing and the proportion who expressed no social distance between themselves and someone with schizophrenia increased from 16 to 30 percent (
24). (An example of a social distance question is "Would you be upset to be in the same class with someone with schizophrenia.") In Vienna positive changes in attitudes were evident three months after the intervention (
31). At three sites in Egypt students were tested about their knowledge about schizophrenia and its treatment before and after the intervention. The students' scores doubled after the intervention, and the proportion of students who believed that someone with schizophrenia would be likely to commit a crime decreased from 56 to 29 percent (
32). In Leipzig, Germany, students were tested about their attitudes toward a person with schizophrenia; scores improved substantially during a three-month follow-up in the group of 90 students that received the intervention but not in the control group of 60 students (
33).
Working with the criminal justice system
Criminal justice personnel are underrecognized partners in the management of mental illness. The police bring people who are acutely disturbed into care or protective settings. Jail officers struggle to manage people with acute psychosis in environments that are totally unsuited to the task. Judges wrestle with the disposition of mentally ill offenders. Probation officers supervise people with mental illness, even though the officers do not have access to consultation about the person's capacity to respond to directives. Yet there are few programs that attempt to provide criminal justice personnel with the education necessary to perform these essential parts of their jobs. For this reason, the Boulder antistigma project, and other WPA program sites, selected criminal justice personnel as a target.
Police training. Mental health professionals, consumers, and police officers collaborated in developing a one-day, eight-hour pilot training course, which was pilot tested with seasoned officers and rookies in the county's largest city (population 100,000). Applying lessons learned from pre-post testing in the pilot program, the project undertook the training of the entire police department in the county's second largest city (population 70,000). To minimize the disruption of police services to the community, the training was delivered six times, to a portion of the department's officers each time, at change of shift in the afternoon or evening before the officers went on duty.
The training, an abbreviated form of the pilot course, comprised two, two-hour sessions on adult and child disorders and was presented by psychiatrists, consumers, and their family members. The content included the features, course, treatment, and outcome of psychotic disorders; the diagnosis of childhood disorders; myths about schizophrenia; the diverse characteristics of people who attempt suicide; and a discussion of why people with psychosis should not be kept in jail. The classes discussed why people with borderline personality disorder are often not admitted to a hospital. This topic is important if the training is to be successful, because police officers everywhere are likely to complain about bringing someone in for evaluation after a suicide attempt, only to learn later, as commonly phrased, "She got home before I did!"
Pre-post testing of the officers conducted immediately before and after the training, revealed no improvement in attitudes toward people with psychosis, but it revealed a 48 percent improvement in scores of knowledge about adult and child mental disorders. The proportion of officers who held inaccurate beliefs about the causes of schizophrenia fell from 24 to 3 percent, but another misconception scarcely changed. The proportion who held a mistaken belief about the usual behavior of people with schizophrenia fell only from 82 to 71 percent. After training, 71 percent of the officers still believed one or more of the following statements: people with schizophrenia are always irrational, much more likely to be violent than the average person, or usually unable to make life decisions. Officers retained these beliefs, even though they heard a presentation by a quietly eloquent, middle-aged woman with schizophrenia who was working full-time as a university library supervisor.
We subsequently realized that police encounters with people with psychosis nearly always occur when the person is acutely disturbed, and officers have little opportunity to meet people with schizophrenia who are working, in stable relationships, or rarely hospitalized. We concluded that police training must intensively expose officers to people who have recovered from psychosis if it is to effect attitudinal change. A model program that uses consumers to provide police training has been established in the WPA antistigma project in Kent, England (
34). Subsequent police training sessions in Boulder County have ranged from four to seven hours in duration, have achieved modest improvements in attitudes and substantial gains in knowledge of mental illness, and will reach all the county's officers by the end of 2005.
To make the training available to police officers across Colorado and elsewhere, the Boulder project collaborated with the U.S. Department of Corrections to produce a training manual and PowerPoint presentation. This eight-hour training program, available from the author, can be delivered by professionals with a moderate level of expertise, consumers, family members, and police officers.
Judges, attorneys, and probation officers. Psychiatrists, people with mental illness, and family members provided three training sessions on adult disorders and one training session on child disorders to judges, attorneys, and probation officers (approximately 12 in each category). Nearly all the county judges attended. A pre-post test conducted directly before and after the training revealed that judges' accuracy of knowledge about schizophrenia improved from 47 to 74 percent, and some judges reported immediate changes in sentencing practice. After the training sessions were completed, the judges requested two more training sessions on juvenile disorders.