Communicating About Mental Illness: What Works, What Doesn’t?
Abstract
A controversial informational campaign regarding the risk of opioid addiction raises important questions about public messaging and stigma.
“Keep your name off the next gravestone.”
In a letter last month, the Massachusetts attorney general told the U.S. Attorney’s Office for the District of Massachusetts that the ResistTheRisk campaign is stigmatizing, ineffective, and counterproductive.
That’s the message on an image of a tombstone surrounded on both sides by gravemarkers with the words: “24 Years Old—Pain Pill Overdose” and “19 Years Old—Pain Pill Overdose.” Behind the tombstones is a graveyard stretching out to a black horizon.
The image and others like it are part of a campaign initiated in November 2017 by the U.S. Attorney’s Office for the District of Massachusetts (USA-DoM) and the New England Field Division of the Drug Enforcement Agency called “ResistTheRisk.” Aimed at alerting young people about the risks of opioid addiction, the images are part of a multimedia strategy that incorporates buses and subways of the Massachusetts Bay Transit Authority. On the website of ResistTheRisk, the public is invited to share the images on social media and elsewhere.
The campaign includes three other dramatic images, one of which is a newborn lying in an intensive care unit with feeding tubes and wires and these words superimposed over the image: “The first years of my life were spent in detox. Opioid withdrawal=Tremors. Seizures. Irritability. Vomiting. Trouble Feeding.” On the campaign website, the public is invited to share the images on social media and elsewhere.
Personal Narratives, Barriers to Care Are Key Messages
In October 2015, the Johns Hopkins Center for Mental Health and Addiction Policy Research convened a forum of 45 researchers, clinicians, foundation and government representatives, and consumer advocates interested in identifying evidence-based communication strategies to increase public support for policies benefiting people with mental illness or substance use disorders. The group formulated the following recommendations around five kinds of messages:
Sympathetic personal narratives (stories that humanize the experiences and struggles of individuals with mental illness or substance use disorder) can increase audiences’ receptivity to messages by enhancing engagement and eliciting emotional responses. A key strength of narratives is their ability to blend stories about individuals with contextual information about policy issues, especially barriers to care.
Messages blaming people with mental illness or substance use disorder for their condition can decrease the public’s willingness to help these groups and increase support for punitive policy options. Studies show that messages blaming individuals with mental illness and substance use disorders for their conditions are associated with negative emotions and increased support for coercive treatment, segregated treatment, and other punitive policies.
Messages highlighting structural barriers to mental illness and substance use disorder treatment can raise support for effective public policies without increasing stigma. Messaging strategies highlighting inadequate insurance coverage, provider shortages, and lack of availability of evidence-based services can increase the public’s willingness to allocate additional resources to mental illness and substance use disorder treatment and do not elevate stigma.
Messages emphasizing violence by people with mental illness may increase public support for expanding mental health services but are stigmatizing. In an experimental study of a narrative describing structural barriers to treatment faced by an individual with schizophrenia, a version of the narrative was tested in which the same individual went on to commit a public shooting. Although both narratives were equally effective in increasing the public’s willingness to pay additional taxes to improve mental health services, the violence narrative also increased stigma in the group exposed to them compared with the control group of individuals exposed to no narratives. That suggests that messages about barriers to care, as opposed to the depiction of violence, drive public support for allocating additional resources to expand public mental health services.
Messages focused on treatment effectiveness can reduce stigma associated with mental illness and substance use disorders, but effects on policy preferences are uncertain. Narratives portraying individuals with untreated and symptomatic mental illness and substance use disorders increase public stigma; compared with these depictions, portrayals of people experiencing successful treatment recovery decrease stigma.
But ResistTheRisk has elicited protests from addiction experts and public health officials in Massachusetts, who say the campaign is a textbook example of how not to do a public campaign about mental illness and substance use disorders.
“It makes no sense to tell people with addiction, who try but cannot stop, to simply resist,” addiction specialist Richard Saitz, M.D., M.P.H., chair of the Department of Community Health Sciences at the Boston University School of Public Health, told Psychiatric News.
“The slogan for the entire campaign is a big mistake,” Saitz said. “The images of tombstones are telling youth they will die if they use drugs, but young people know other people who use drugs and have not died. Young people take risks, and they don’t like adults telling them what to do. They might be more likely to try drugs when told not to use them and that they will die.”
Saitz adds that the image of a suffering baby implies it is the fault of the mother with addiction. “There is no such thing as a baby being ‘in detox,’ ” Saitz said. “Most babies with neonatal withdrawal syndrome do not require tubes and wires, so the image was unnecessarily inflammatory in that regard as well. Stigmatizing those with addiction could lead to fewer women with addiction and pregnancy seeking care.”
A coalition of 86 stakeholders wrote a letter in November to the office of the USA-DoM protesting ResistTheRisk. Signers included, among others, David Henderson, M.D., chair of psychiatry at Boston University; Derri Shtasel, M.D., director of public and community psychiatry at Massachusetts General Hospital; Pedro Bonilla, M.D., director of emergency psychiatry at Beth Israel Deaconess; Leena Mittal, M.D., director of the reproductive psychiatry consultation service at Brigham and Women’s Hospital; and Johji Suzuki, M.D., director of addiction psychiatry at Brigham and Women’s Hospital.
A December 5, 2017, letter from Massachusetts Attorney General Maura Healy to the USA-DoM reiterated many of the same arguments.
At press time, a spokesperson for the USA-DoM told Psychiatric News that the image of the newborn was removed from Boston trains but remains on public transit around the state and will continue to be part of the campaign. No other changes have been made to the campaign, the spokesperson said (see box).
How Can Public Messaging Change Public Policy?
The Massachusetts campaign and the objections that have been raised about it reveal a question relevant to clinicians, patients, policymakers, and organized medicine: What kinds of public messages are effective at changing behavior, decreasing stigma, and increasing public support for access to and treatment for mental illness and substance use disorders?
Research to answer that question is an emerging field of study, says Emma McGinty, Ph.D., an assistant professor in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health. “With some notable exceptions, it’s an area that has not gotten a lot of attention,” she told Psychiatric News.
In a paper posted online October 2, 2017, in Psychiatric Services, McGinty and colleagues reported the recommendations of a policy forum convened in October 2015 by the Johns Hopkins Center for Mental Health and Addiction Policy Research to assess what is currently known about how communication strategies influence public support for mental illness and substance use disorder policies.
In addition to calling for more research about what works and what doesn’t, the panel of 45 experts formulated recommendations around five communication strategies, with an emphasis on two that are particularly effective: personal narratives describing struggles with mental illness or substance use disorders and illustrations of the barriers people face in getting treatment.
“People are much more likely to read or listen to a story that tells a personal narrative than one that is heavy on facts,” McGinty said. “A key piece is weaving the personal story into some broader context about the problems and barriers confronted by people seeking mental health treatment. Ideally, the message includes information about why those barriers exist and policy solutions that remedy the problem.”
The forum found messaging around the subject of violence and its relationship to mental illness to be more complex. Linking violence and mental illness can be stigmatizing, but under some test conditions, it can also increase willingness to support publicly funded treatment. However, communication about barriers to care for people who might be violent produces the same result without the stigmatizing effects.
The really difficult issue—when it comes to changing people’s attitudes and beliefs—is around addiction. McGinty said that however much the “disease model” may have become popularized, the idea that substance use is a personal choice is deeply entrenched. “The issue of ‘moral failing’ is a big one and is more prominent than it is with other mental illnesses,” McGinty said.
What Should Campaigns Encompass?
So, if ResistTheRisk relies on all the wrong messages, what would be an effective public information campaign about the risk of opioid addiction?
Saitz said that for those with opioid addiction, public information campaigns should show people who have received treatment and are doing well—people in recovery enjoying life and their relationships during and after treatment and being productive at work. “We should show people they can ask for help and show them how to get it.”
Acting Attorney for District of Massachusetts Responds to Campaign Criticism
In response to criticism about the ResistTheRisk campaign, initiated by the U.S. Attorney’s Office for the District of Massachusetts, Acting Attorney General William Weinreb issued the following statement:
“Based on information and advice we have received from many sources, including law enforcement, we believe many vulnerable people still do not know what an opioid is; how harmful and risky it can be; and how difficult it is to distinguish real prescription pain pills from counterfeits, among other things. The ResistTheRisk campaign is designed to grab the attention of teens and young people and deliver an important message: Don’t use pain medication that is not prescribed for you. Don’t buy it on the streets; don’t take it at parties; don’t sell it or share it with friends. It is illegal and potentially deadly.
“Unlike other messaging campaigns, which are focused on the important problem of ensuring that addicts receive appropriate treatment, our campaign is focused on changing the public’s view of pain pills. The fact that pain pills are sometimes prescribed by doctors does not mean they are safe for recreational use. Many pain pills purchased from friends or on the street, or taken at parties, are counterfeit pills that may contain fentanyl in potentially fatal amounts. Even genuine prescription pain pills may prove harmful or fatal if taken in certain ways or certain amounts. Individuals without a prescription for pain pills should resist the risk of using them recreationally.
“We purposely designed our campaign to be attention-grabbing in order to deliver an important message. The attention our ads have already provoked shows that people are taking notice. We applaud others who are delivering other anti-drug messages in other ways and hope they are successful as well.”
He added, “For youth, let them know that someone may want them to try drugs—perhaps a peer who wants them to be intoxicated and do risky, harmful things while intoxicated. Also show positive examples of youth having a great time without using opioids and instead doing things they could do only off of drugs—driving, meeting partners and enjoying each other, and not being the guy in the corner not interacting or having a good time.”
Certainly, public messaging about mental illness and substance use—how a message is conceived, formulated, and disseminated—matters. And in the digital age, social media such as Facebook and Twitter can be engines for dissemination of information, some of it faulty.
“Any agency that does a public health campaign should be required to consult with those with expertise in the condition and its risks and with health messaging/health behavior experts—especially if public money is involved,” Saitz said.
McGinty said medical organizations and individual physicians can be among the most potent message carriers, countering the faulty information people may get elsewhere.
“Physician groups like APA are respected disseminators of these public health messages and advocates in Congress for the messages to be taken seriously,” McGinty said. “Individual physicians are often a person’s most trusted source of information about health and illness. Psychiatrists who interact with people with mental illness and substance use and their families should be aware of the faulty or misinformed messages they may be hearing outside the clinic and incorporate accurate information in their day-to-day communication with patients.” ■
