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This article is about Veterans struggles with mental health and suicide. The author discusses that Veterans have a higher risk of suicide. The suicide rate of Veterans is increasing and because of this, Congress passed the Commander John Scott Hannon Veterans Mental Health care improvement act. This increase in Veteran suicides made people realize there should be more healthcare precautions in place for them.

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The gun control debate complicated an effort to encourage frank talk by health professionals about the risks posed by firearms.

The Department of Veterans Affairs has been trying to develop ways to talk to veterans about guns and suicide for more than a decade, but the topic is so fraught that progress has been slow. Credit... Andrew Kelly/Reuters

The suicide rate among military veterans keeps edging higher, and to address it Congress passed a major bill this fall, named in honor of a Navy SEAL named Cmdr. John Scott Hannon who was an outspoken proponent of veterans' mental health treatment before he took his own life with a gun in 2018.

But at the last minute, lawmakers stripped the bill of a proven prevention technique that saves veterans' lives, and might have saved the life of Commander Hannon. Why? Because the provision in question touched a third rail in Washington politics: the danger posed by firearms.

The Commander John Scott Hannon Veterans Mental Health Care Improvement Act, now awaiting the president's signature, still does things the commander's family says he would be proud of: funding community organizations that work with veterans, and scholarships to train more mental health professionals.

But before it was modified, the bill would also have required health care workers who treat veterans to be trained on how to talk with at-risk patients about the danger of having guns in the house and about how to reduce that risk - a strategy known as lethal-means safety.

Evidence shows that reducing access to lethal means can drastically cut the risk of suicide. And for veterans, especially, the lethal means are overwhelmingly firearms.

The suicide rate among veterans has been climbing for more than a decade, and is now roughly double that of the nation as a whole. Americans who die by suicide use a gun about half the time, but among veterans, the figure is 70 percent.

The lethal-means provision that was stripped from the bill was introduced by Representative Lauren Underwood, Democrat of Illinois. "I'm a public health nurse, so I'm trained to look at the data and design policies that are effective and evidence-based," Ms. Underwood said in a statement. "The data we have shows there's no solution to the veteran suicide crisis without improving lethal-means safety."

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"The data we have shows there's no solution to the veteran suicide crisis without improving lethal-means safety," Representative Lauren Underwood, Democrat of Illinois, said in a statement. Credit... Anna Moneymaker for The New York Times

The Department of Veterans Affairs has been trying to develop ways to talk to veterans about guns and suicide for more than a decade, but the topic is so culturally and politically fraught that progress has been slow and uneven, in part because doctors do not want to alienate patients.

The lethal-means provision would have provided mandatory training to nearly all Veterans Affairs doctors and mental health professionals, as well as private doctors who treat patients with veterans' health benefits.

Like the conversations doctors have had for years with cigarette smokers, the approach involves making sure the patient understands the dangers of easily accessible guns, and then asking whether the patient wants to come up with a plan to reduce those dangers. Suggestions include locking up the guns in the house or storing them with a friend, relative or local gun club until the patient's risk of suicide has subsided.

The lethal-means safety approach has broad support among major veterans' groups, and it was included in a list of 10 suicide prevention recommendations released by the White House in the spring.

But some veterans' groups opposed the strategy, saying the mere suggestion that veterans remove guns from their homes could deter them from seeking mental health care.

"This emphasis on firearms misses the point," Sherman Gillums, chief of strategy for the veterans group Amvets, which opposed the legislation, said in a commentary posted online before the bill was passed. He said veterans' mental health care should focus on better therapy techniques and reducing reliance on medications, adding, "I'm not encouraged by this emphasis on the action that was taken and not the underlying cause."

Anything that smacks of gun control is political kryptonite for conservatives. Despite White House backing, Ms. Underwood was unable to find a Republican co-sponsor for the lethal-means safety provision. House Democrats added the provision to the bill, but it was removed during negotiations with the Republican-controlled Senate, according to two people familiar with the negotiations.

Despite the setback, prevention experts say it makes sense to continue to expand lethal-means safety, whether or not it is mandated by law.

"If you want to really make a dent in preventing suicide, this would have the most impact," said Russell Lemle, the former chief psychologist for the San Francisco Veterans Affairs hospital system.

For years, he said, the medical profession has generally tried to reduce suicide by treating patients' underlying mental health issues. But epidemiologists have realized that impressive gains can be made by making the physical act of suicide more difficult and less lethal.

"Suicide is often an impulsive act," Dr. Lemle said. "If we can put distance between the impulse and the means, we can make a real difference."

When access to an especially lethal method is restricted, the suicide rate often drops. Up until the 1960s, the ovens and stoves in many British homes used coal gas, which was rich in dangerous carbon monoxide and was implicated in many deaths, accidental or intentional. As the country transitioned to safer natural gas the suicide rate fell by one-third.

Bangladesh struggled in the 1990s with a high rate of suicide by ingesting toxic insecticides. After the country banned the most lethal poisons in 2000, the suicide rate dropped by one-quarter.

Veterans Affairs has trained more than 20,000 health care workers in recent years to talk to patients about lethal-means safety. Credit... Gene J. Puskar/Associated Press

The United States applies the same principle to physical locations like the Golden Gate Bridge in San Francisco and the Coronado Bridge in San Diego, where barriers and nets are starting to be installed to protect suicidal people.

Because so many suicides are gun deaths, they present a huge opportunity for prevention if doctors and other health workers can find an effective way to talk to veterans about guns, according to Dr. Matthew Miller, who teaches epidemiology at Northeastern University and is a leading researcher on gun violence.

"We know the risk is there," Dr. Miller said. But studies show that only about 10 percent of gun owners are aware of the higher risk, he said, suggesting that there is enormous room to inform people and encourage them to change their habits.

Veterans Affairs has trained more than 20,000 health care workers in recent years to talk to patients about lethal-means safety. The language removed from the John Scott Hannon bill would have made that training mandatory for many more health care professionals.

"If there is a good relationship with the patient, it doesn't have to be culturally charged, it can come from a place of real concern, just like a doctor might talk about the risks of smoking," Dr. Miller said.

Those conversations, though, carry their own risk. Opponents say that required lethal-means safety stigmatizes mental illness and may deter people from seeking care, which is also a criticism of so-called red flag laws that allow the police in several states to temporarily confiscate firearms from people who are deemed by a judge to be a danger to themselves or to others.

A survey of veterans who served in the military after 2001 found that 21 percent were hesitant to get mental health care from Veterans Affairs because they were worried their guns would be confiscated.

The department's first effort at lethal-means safety was to give away gun locks to veterans. The program was met with an uproar when recipients of the free locks were asked to give their addresses and say how many guns they owned. Opponents accused the department of trying to start a federal gun registry.

Dr. Lemle, who became a senior policy analyst at the Veterans Healthcare Policy Institute after leaving Veterans Affairs last year, said the system's reluctance to speak openly about the problem of guns had only fueled disinformation.

"The idea is not to restrict anyone," Dr. Lemle said. "This is not a gun rights issue, it's about coming up with a mutually derived plan to be safe. For too long, I think we've been afraid to talk about it, to the disservice of our patients."

Commander Hannon, whom the prevention bill is named after, may be a case in point. After a 23-year career serving around the world with the SEALs, he retired in 2011 and moved to Montana, where he struggled for years with post-traumatic stress, traumatic brain injuries and bipolar disorder. He found solace in therapy programs that used animals, and in helping other veterans.

He owned several guns. Out of concern for his safety, his family stored the guns with a fellow SEAL at one point, but he soon demanded them back. His sister, Kim Parrott, said the family never formally learned how to talk to him about the dangers guns pose to veterans with mental health disorders.

"It would have been tough," Ms. Parrott said, indicating that her brother and other veterans were attached to their firearms. "But I see how that could change."
If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) or go to SpeakingOfSuicide.com/resources for a list of additional resources.

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Focusing on Firearms Proves Contentious in Struggle to Reduce Veterans' Suicides

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The gun control debate complicated an effort to encourage frank talk by health professionals about the risks posed by firearms. The suicide rate among military veterans keeps edging higher, and to address it Congress passed a major bill this fall, named in honor of a Navy SEAL named Cmdr. John Scott Hannon who was an outspoken proponent of veterans' mental health treatment before he took his own life with a gun in 2018.

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In this article Charlotte Tucker explains what PTSD is and the effects it can have on Veterans. Some veterans talked about their experiences with PTSD and how it affects them. They also talked about the stigma against PTSD and ways to help it. Article 1 and 2 are similar because they both talk about Veterans struggles. Article 1 talks about suicide and how PTSD can lead to Veterans suicide. Article 2 talks about veterans experiences and what to do when things get bad with their PTSD. Both articles focus on mental illness with veterans and how it affects them.

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Iraq in 2003 was a nightmare C.J. Grisham could not wake up from. It was sustained, almost daily combat for months, and Grisham, a first sergeant in the Army, said he could feel the strain.

Once, he said he was forced to shoot a person being used as a human shield. Another time, he helped an Iraqi family extract a dead loved one from a burned car. He started to have flashbacks, vivid nightmares and suicidal thoughts - all signs of post-traumatic stress disorder.

"It's like a million voices in my head telling me that I'm not good enough to be alive," he told The Nation's Health.

The voices told him he should be dead. They said his depression was a sign of weakness and that it was his selfishness that let his friends die.

"It's maddening, and I look forward to the day the voices end," he said.

A 2008 study by the Rand Corporation found that as many as 20 percent of U.S. veterans who served in Iraq and Afghanistan suffer from PTSD or major depressive disorder. As the disorder becomes more widely known among veterans and their doctors, researchers are making strides in improving their understanding and treatment. And yet, to the general public the problem is generally not well understood, mental health professionals say.

According to the American Psychiatric Association, PTSD is the result of a traumatic event that involves actual or threatened death or serious injury or a threat to the physical integrity of oneself or others. Symptoms include intrusive recollections such as flashbacks and dreams, avoiding stimuli associated with the trauma, and hyperarousal, which is characterized by difficulty falling asleep or staying asleep, irritability and exaggerated startle responses.

"I get extremely nervous in crowded situations and become hypersensitive to my surroundings," Grisham wrote in a blog post. "Before entering any building, I make a quick survey of all people around me and seek out any and all exits. I sit with my back to a wall so I have a good view of people approaching me. I get startled and anxious at unexpected and loud noises. What I don't get is violent. What I don't do is threaten people."

One of the most common misconceptions about PTSD is that veterans who suffer with it are violent, said Francine Roberts, PsyD, a Marlton, N.J., psychologist in private practice who works with first responders, emergency service providers and veterans on critical incident stress management.

"There was an incident not long ago where a veteran had a violent outburst, and the media was all over it, talking about how folks with PTSD are violent," she told The Nation's Health. "But the opposite is the truth. Veterans have no more potential for violence than anyone else."

Acting out against others is rare, she said, but self-directed violent behavior, such as suicide, is much more common among veterans with PTSD, she noted.

Rob Ulrey writes for a military blog using a pen name because he worries about the stigma associated with PTSD. He agreed to allow The Nation's Health to use his name so he could spread the word that people with PTSD are not dangerous.

Ulrey was stationed in Bosnia in 1996 when a vehicle he was in experienced what was then called a mine strike. Today, they are known as improvised explosive devices. He was injured and spent time at a base in Germany where an astute social worker, who was himself a Vietnam War veteran, saw the symptoms and helped Ulrey get his PTSD diagnosis. He underwent treatment for a year and thought he was better.

But recently the night terrors returned. He would wake up five to seven times a night, sweating so badly the bed would be drenched.

"For a long time I didn't think I was bad enough to need treatment," he told The Nation's Health. "I didn't want to take an appointment from somebody who needed it more than I did. You could call it age, or maturity, but I was suffering with it for so long that it was finally time to fix me."

Grisham was diagnosed officially in 2009, six years after his combat tour. He finally sought help when he realized that he would not be able to convince his troops to seek help when he was trying to hide his own pain.

Both Grisham and Ulrey emphasized that PTSD can be treated. The U.S. Department of Veterans Affairs has an entire arm, the National Center for PTSD, dedicated to conducting research on PTSD, and VA medical centers nationwide provide PTSD care for veterans.

During a recent press call, clinicians and researchers at the VA highlighted some of their most promising research, much of which involves peer support and outreach. That peer support is important, particularly to members of the military, because of the bond service members feel for each other.

"Soldiers who deploy together spend long, harsh months together," said Marcia Valenstein, MD, associate director for research programs at the Serious Mental Illness Research and Evaluation Center at the Ann Arbor VA Center for Clinical Management Research.

"Strong personal bonds are formed (during deployment) and when they fight, they fight for their buddy," Valenstein said. "They maintain that link to their buddy, and they're more able to reach out to them."

Valenstein is evaluating a program that pairs National Guard soldiers with buddies as they return from overseas. The buddies can provide a sounding board for each other and encourage one another to seek help if needed.

Other research efforts include a clinical trial in which soldiers write about their thoughts and feelings and a study looking at using a combination of medical treatment and psychotherapy to find a ratio and dosage that works best.

One of the most important changes that may be slowly happening is lessening the stigma associated with PTSD and other mental health disorders. In the past, soldiers have been concerned that seeking help for PTSD would damage their careers or shade the way their commanders look at them. But as researchers are better understanding the problem, soldiers, spurred in some cases by leaders who have professed their own struggles with PTSD, are seeking help.

"Stigma is something we've been working on," said Joel Kupersmith, MD, VA's chief research and development officer, during the press call. "There's been improvement, and it's our observation that there are more individuals in mental health care (now than in previous years.)"

Ulrey and Grisham both report improvement in their symptoms since starting treatment. Grisham said cognitive behavioral therapy has "virtually eliminated" the survivor's guilt portion of his PTSD.

Ulrey is finding help through medication and psychotherapy.

Ulrey said his message for his fellow soldiers is that help is available, they need only seek it out.

"You were strong enough to make it this far," he wrote in one blog entry. "Don't give up. Dig a little deeper and make that final push."

For more information on PTSD in veterans, visit www.ptsd.va.gov.

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U.S. veterans struggle with pain, stigma of post-traumatic stress: New research aimed at mental health

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Iraq in 2003 was a nightmare C.J. Grisham could not wake up from. It was sustained, almost daily combat for months, and Grisham, a first sergeant in the Army, said he could feel the strain. Once, he said he was forced to shoot a person being used as a human shield.

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In this article Adam Felman explains how mental health affects people's daily life, relationships, and physical health, and how factors in peoples lives can affect their mental health. The author also explains the different types of mental illness. Articles 2 and 3 connect because they both deal with mental health and ways to help mental health. In article 2 Tucker talks about veterans and their experiences with PTSD. She also talks about ways to help the mental illness. In article 3 Felman talks about different mental illnesses and how to treat them.

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The word health refers to a state of complete emotional and physical well-being. Healthcare exists to help people maintain this optimal state of health.

According to the Centers for Disease Control and Prevention (CDC), healthcare costs in the United States were $3.5 trillion in 2017.

However, despite this expenditure, people in the U.S. have a lower life expectancy than people in other developed countries. This is due to a variety of factors, including access to healthcare and lifestyle choices.

Good health is central to handling stress and living a longer, more active life. In this article, we explain the meaning of good health, the types of health a person needs to consider, and how to preserve good health.

In 1948, the World Health Organization (WHO) defined health with a phrase that modern authorities still apply.

"Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."

In 1986, the made further clarifications:

"A resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities."

This means that health is a resource to support an individual's function in wider society, rather than an end in itself. A healthful lifestyle provides the means to lead a full life with meaning and purpose.

In 2009, researchers publishing in defined health as the ability of a body to adapt to new threats and infirmities.

They base this definition on the idea that the past few decades have seen modern science take significant strides in the awareness of diseases by understanding how they work, discovering new ways to slow or stop them, and acknowledging that an absence of pathology may not be possible.

Mental and physical health are probably the two most frequently discussed types of health.

Spiritual, emotional, and financial health also contribute to overall health. Medical experts have linked these to lower stress levels and improved mental and physical well-being.

People with better financial health, for example, may worry less about finances and have the means to buy fresh food more regularly. Those with good spiritual health may feel a sense of calm and purpose that fuels good mental health.

Physical health

A person who has good physical health is likely to have bodily functions and processes working at their peak.

This is not only due not only to an absence of disease. Regular exercise, balanced nutrition, and adequate rest all contribute to good health. People receive medical treatment to maintain the balance, when necessary.

Physical well-being involves pursuing a healthful lifestyle to decrease the risk of disease. Maintaining physical fitness, for example, can protect and develop the endurance of a person's breathing and heart function, muscular strength, flexibility, and body composition.

Looking after physical health and well-being also involves reducing the risk of an injury or health issue, such as:

minimizing hazards in the workplace

using contraception when having sex

practicing effective hygiene

avoiding the use of tobacco, alcohol, or illegal drugs

taking the recommended vaccines for a specific condition or country when traveling

Good physical health can work in tandem with mental health to improve a person's overall quality of life.

For example, mental illness, such as depression, may increase the risk of drug use disorders, according to a 2008 study. This can go on to adversely affect physical health.

Mental health

According to the U.S. Department of Health & Human Services, mental health refers to a person's emotional, social, and psychological well-being. Mental health is as important as physical health as part of a full, active lifestyle.

It is harder to define mental health than physical health because many psychological diagnoses depend on an individual's perception of their experience.

With improvements in testing, however, doctors are now able to identify some physical signs of some types of mental illness in CT scans and genetic tests.

Good mental health is not only categorized by the absence of depression, anxiety, or another disorder. It also depends on a person's ability to:

enjoy life

bounce back after difficult experiences and adapt to adversity

balance different elements of life, such as family and finances

feel safe and secure

achieve their full potential

Physical and mental health have strong connections. For example, if a chronic illness affects a person's ability to complete their regular tasks, it may lead to depression and stress. These feelings could be due to financial problems or mobility issues.

A mental illness, such as depression or anorexia, can affect body weight and overall function.

It is important to approach "health" as a whole, rather than as a series of separate factors. All types of health are linked, and people should aim for overall well-being and balance as the keys to good health.
Find out how mental health can affect physical health here.
Good health depends on a wide range of factors.

Genetic factors

A person is born with a variety of genes. In some people, an unusual genetic pattern or change can lead to a less-than-optimum level of health. People may inherit genes from their parents that increase their risk for certain health conditions.

Environmental factors

Environmental factors play a role in health. Sometimes, the environment alone is enough to impact health. Other times, an environmental trigger can cause illness in a person who has an increased genetic risk of a particular disease.

where a person lives

the state of the surrounding environment

genetics

their income

their level of education

employment status

Access to healthcare plays a role, but the WHO suggest that the following factors may have a more significant impact on health than this:

The social and economic environment: This may include the financial status of a family or community, as well as the social culture and quality of relationships.

The physical environment: This includes which germs exist in an area, as well as pollution levels.

A person's characteristics and behaviors: A person's genetic makeup and lifestyle choices can affect their overall health.

It is possible to categorize these as follows:

According to some studies, the higher a person's socioeconomic status (SES), the more likely they are to enjoy good health, have a good education, get a well-paid job, and afford good healthcare in times of illness or injury.

They also maintain that people with low socioeconomic status are more likely to experience stress due to daily living, such as financial difficulties, marital disruption, and unemployment.

Social factors may also impact on the risk of poor health for people with lower SES, such as marginalization and discrimination.

A low SES often means reduced access to healthcare. A 2018 study in Frontiers in Pharmacology indicated that people in developed countries with universal healthcare services have longer life expectancies than those in developed countries without universal healthcare.

Cultural issues can affect health. The traditions and customs of a society and a family's response to them can have a good or bad impact on health.

According to the Seven Countries Study, researchers studied people in select European countries and found that those who ate a healthful diet had a lower 20-year death rate.

The study indicated that people who ate a healthful diet are more likely to consume high levels of fruits, vegetables, and olives than people who regularly consume fast food.

The study also found that people who followed the Mediterranean diet had a lower 10-year all-cause mortality rate. According to the International Journal of Environmental Research and Public Health, this diet can help protect a person's heart and reduce the risk of several diseases, including type 2 diabetes, cancer, and diseases that cause the brain and nerves to break down.

How a person manages stress will also affect their health. According to the National Institute of Mental Health, people who smoke tobacco, drink alcohol, or take illicit drugs to manage stressful situations are more likely to develop health problems than those who manage stress through a healthful diet, relaxation techniques, and exercise.

The best way to maintain health is to preserve it through a healthful lifestyle rather than waiting until sickness or infirmity to address health problems. People use the name wellness to describe this continuous state of enhanced well-being.

The define wellness as follows:

"Wellness is the optimal state of health of individuals and groups. There are two focal concerns: the realization of the fullest potential of an individual physically, psychologically, socially, spiritually, and economically, and the fulfillment of one's roles and expectations in the family, community, place of worship, and other settings."

Wellness promotes active awareness of and participating in measures that preserve health, both as an individual and in the community. Maintaining wellness and optimal health is a lifelong, daily commitment.

eating a balanced, nutritious diet from as many natural sources as possible

engaging in at least 150 minutes of moderate to high-intensity exercise every week, according to the American Heart Association

screening for diseases that may present a risk

learning to manage stress effectively

engaging in activities that provide purpose

connecting with and caring for other people

maintaining a positive outlook on life

defining a value system and putting it into action

Steps that can help people attain wellness include:

The definition of peak health is highly individual, as are the steps a person may take to get there. Every person has different health goals and a variety of ways to achieve them.
Learn more about the health benefits of socializing here.
It may not be possible to avoid disease altogether. However, a person should do as much as they can to develop resilience and prepare the body and mind to deal with illnesses as they arise.

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What is health?: Defining and preserving good health

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The word health refers to a state of complete emotional and physical well-being. Healthcare exists to help people maintain this optimal state of health. According to the Centers for Disease Control and Prevention (CDC), healthcare costs in the United States were $3.5 trillion in 2017. However, despite this expenditure, people in the U.S.

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In this article the authors talk about the different types of mental illness and the stigma on mental illness. They talk about public stigma and how this stigma affects people with metal illness. They also talk about ways to stop the stigma surrounding mental illness and normalize talking about mental health. Articles 3 and 4 are connected because they both talk about mental illness and how to help it. Article 3 talks about the different types of mental illness and how to treat it. Article 4 talks about ways to better the society around people with mental illness and normalizing talking about mental health to help people with mental illness.

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Many people with serious mental illness are challenged doubly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness. As a result of both, people with mental illness are robbed of the opportunities that define a quality life: good jobs, safe housing, satisfactory health care, and affiliation with a diverse group of people. Although research has gone far to understand the impact of the disease, it has only recently begun to explain stigma in mental illness. Much work yet needs to be done to fully understand the breadth and scope of prejudice against people with mental illness. Fortunately, social psychologists and sociologists have been studying phenomena related to stigma in other minority groups for several decades. In this paper, we integrate research specific to mental illness stigma with the more general body of research on stereotypes and prejudice to provide a brief overview of issues in the area.

The impact of stigma is twofold, as outlined in Table ​Table1. 1 . Public stigma is the reaction that the general population has to people with mental illness. Self-stigma is the prejudice which people with mental illness turn against themselves. Both public and self-stigma may be understood in terms of three components: stereotypes, prejudice, and discrimination. Social psychologists view stereotypes as especially efficient, social knowledge structures that are learned by most members of a social group ( 1- 3). Stereotypes are considered "social" because they represent collectively agreed upon notions of groups of persons. They are "efficient" because people can quickly generate impressions and expectations of individuals who belong to a stereotyped group ( 4).

PUBLIC STIGMA

Stigmas about mental illness seem to be widely endorsed by the general public in the Western world. Studies suggest that the majority of citizens in the United States ( 13, 15- 17) and many Western European nations ( 18- 21) have stigmatizing attitudes about mental illness. Furthermore, stigmatizing views about mental illness are not limited to uninformed members of the general public; even well-trained professionals from most mental health disciplines subscribe to stereotypes about mental illness ( 22- 25).

Several themes describe misconceptions about mental illness and corresponding stigmatizing attitudes. Media analyses of film and print have identified three: people with mental illness are homicidal maniacs who need to be feared; they have childlike perceptions of the world that should be marveled; or they are responsible for their illness because they have weak character ( 29- 32). Results of two independent factor analyses of the survey responses of more than 2000 English and American citizens parallel these findings ( 19, 33):

1. fear and exclusion: persons with severe mental illness should be feared and, therefore, be kept out of most communities;

2. authoritarianism: persons with severe mental illness are irresponsible, so life decisions should be made by others;

3. benevolence: persons with severe mental illness are childlike and need to be cared for.

Although stigmatizing attitudes are not limited to mental illness, the public seems to disapprove persons with psychiatric disabilities significantly more than persons with related conditions such as physical illness ( 34- 36). Severe mental illness has been likened to drug addiction, prostitution, and criminality ( 37, 38). Unlike physical disabilities, persons with mental illness are perceived by the public to be in control of their disabilities and responsible for causing them ( 34, 36). Furthermore, research respondents are less likely to pity persons with mental illness, instead reacting to psychiatric disability with anger and believing that help is not deserved ( 35, 36, 39).

The behavioral impact (or discrimination) that results from public stigma may take four forms: withholding help, avoidance, coercive treatment, and segregated institutions. Previous studies have shown that the public will withhold help to some minority groups because of corresponding stigma ( 36, 40). A more extreme form of this behavior is social avoidance, where the public strives to not interact with people with mental illness altogether. The 1996 General Social Survey (GSS), in which the Mac Arthur Mental Health Module was administered to a probability sample of 1444 adults in the United States, found that more than a half of respondents are unwilling to: spend an evening socializing, work next to, or have a family member marry a person with mental illness ( 41). Social avoidance is not just self-report; it is also a reality. Research has shown that stigma has a deleterious impact on obtaining good jobs ( 13, 42- 44) and leasing safe housing ( 45- 47).

Discrimination can also appear in public opinion about how to treat people with mental illness. For example, though recent studies have been unable to demonstrate the effectiveness of mandatory treatment ( 48, 49), more than 40% of the 1996 GSS sample agreed that people with schizophrenia should be forced into treatment ( 50). Additionally, the public endorses segregation in institutions as the best service for people with serious psychiatric disorders ( 19, 51).

STRATEGIES FOR CHANGING PUBLIC STIGMA

Change strategies for public stigma have been grouped into three approaches: protest, education, and contact ( 12). Groups protest inaccurate and hostile representations of mental illness as a way to challenge the stigmas they represent. These efforts send two messages. To the media: STOP reporting inaccurate representations of mental illness. To the public: STOP believing negative views about mental illness. Wahl ( 32) believes citizens are encountering far fewer sanctioned examples of stigma and stereotypes because of protest efforts. Anecdotal evidence suggests that protest campaigns have been effective in getting stigmatizing images of mental illness withdrawn. There is, however, little empirical research on the psychological impact of protest campaigns on stigma and discrimination, suggesting an important direction for future research.

Stigma is further diminished when members of the general public meet persons with mental illness who are able to hold down jobs or live as good neighbors in the community. Research has shown an inverse relationship between having contact with a person with mental illness and endorsing psychiatric stigma ( 54, 57). Hence, opportunities for the public to meet persons with severe mental illness may discount stigma. Interpersonal contact is further enhanced when the general public is able to regularly interact with people with mental illness as peers.

SELF-STIGMA

Low self-esteem versus righteous anger describes a fundamental paradox in self-stigma ( 64). Models that explain the experience of self-stigma need to account for some persons whose sense of self is harmed by social stigma versus others who are energized by, and forcefully react to, the injustice. And there is yet a third group that needs to be considered in describing the impact of stigma on the self. The sense of self for many persons with mental illness is neither hurt, nor energized, by social stigma, instead showing a seeming indifference to it altogether.

We propose a situational model that explains this paradox, arguing that an individual with mental illness may experience diminished self-esteem/self-efficacy, righteous anger, or relative indifference depending on the parameters of the situation ( 64). Important factors that affect a situational response to stigma include collective representations that are primed in that situation, the person's perception of the legitimacy of stigma in the situation, and the person's identification with the larger group of individuals with mental illness. This model has eventual implications for ways in which persons with mental illness might cope with self-stigma as well as identification of policies that promote environments in which stigma festers.

CONCLUSIONS

Researchers are beginning to apply what social psychologists have learned about prejudice and stereotypes in general to the stigma related to mental illness. We have made progress in understanding the dimensions of mental illness stigma, and the processes by which public stereotypes are translated into discriminatory behavior. At the same time, we are beginning to develop models of self-stigma, which is a more complex phenomenon than originally assumed. The models developed thus far need to be tested on various sub-populations, including different ethnic groups and power-holders (legislators, judges, police officers, health care providers, employers, landlords). We are also learning about stigma change strategies. Contact in particular seems to be effective for changing individual attitudes. Researchers need to examine whether changes resulting from anti-stigma interventions are maintained over time.

All of the research discussed in this paper examines stigma at the individual psychological level. For the most part, these studies have ignored the fact that stigma is inherent in the social structures that make up society. Stigma is evident in the way laws, social services, and the justice system are structured as well as ways in which resources are allocated. Research that focuses on the social structures that maintain stigma and strategies for changing them is sorely needed.

References

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Understanding the impact of stigma on people with mental illness

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Many people with serious mental illness are challenged doubly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness.

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I learned a lot about mental illness from these articles. In article 1 I learned about how PTSD affects veterans. I never realized how much veterans go through and how much help they really need to get through their PTSD. Veterans experience a lot of things when they are deployed. This article helped me see what we can do to help veterans from committing suicide. In article 2 I learned about how veterans deal with PTSD. In the article some veterans talked about their experience with PTSD and what they did to help it. They talk about ways other veterans can get help themselves. In article 3 I learned about different mental illnesses and how to  treat them. I also learned the effects these mental illnesses how on a person. This article can help me a lot because now can see different symptoms to mental illnesses and help people with these mental illnesses. In article 4 I learned about the stigma around mental illness. The author taught us about how this stigma affects people with mental illness in everyday life. I believe we should normalize talking about mental illness and not ostracize it.