There is significant evidence that the stigma surrounding mental illness causes multiple problems. People are reluctant to seek services for fear of what others might think (1). Those who do come in are sometimes encouraged to drop treatment by family or friends, and occasionally by professionals such as primary care providers or clergy who believe the person can “just get over it” on their own or with sufficient faith (2). Even those of us who enter mental health professions have generally grown up in environments rife with such stigma-producing notions (3). Some of us continue to have concerns about communicating with our patients’ family members due to issues of patient trust, confidentiality, or left-over, outmoded beliefs that families either cause mental illness or exacerbate its symptoms (4). If we are to eradicate stigma, we must start within our own house—medicine—and start early. This article describes how one program has contributed to meeting this goal. We believe there are several lessons to be learned from our experience.
The Medical Student Program
The Indiana University School of Medicine is a large (292 students per class), Midwestern school with a 6-week psychiatric clerkship in the junior year. We no longer have a behavioral sciences course as such but, like many other medical schools, have gone to a primary-care based freshman course that the Department of Psychiatry co-leads. This leaves a 12-session course for sophomore medical students on psychopathology and the mental status examination, plus a 6-week clinical clerkship experience (that has subsequently been reduced to 4 weeks) to educate medical students not entering graduate residency training in psychiatry about mental health issues, and to attempt to provide or solidify motivation for psychiatric training in those students so inclined.
The Indiana University Department of Psychiatry first used presentations by patients’ family members to educate medical students about issues of communication and stigma reduction in the mid-1970s when Nancy C. A. Roeske, M.D., invited the Indiana Chapter of the National Alliance for the Mentally Ill (now renamed the National Alliance on Mental Illness, NAMI) to address what was, at that time, our freshman medical student behavioral science course. The NAMI families discussed their own experiences with stigma and the problems it caused for them. The presentations had a great impact on faculty members who were present to lead small group discussions right after each lecture session. The first-year medical students, however, were not prepared to understand the issues of stigma and gave poor ratings to these presentations. When others had to take over the course after Dr. Roeske’s death, NAMI’s presentation was in danger of being dropped. This issue became even more acute shortly thereafter, when the medical school began planning for primary care to take over the “behavioral sciences” portion of the students’ education (5).
Our solution, which we implemented in 1989, was to move the NAMI session from the freshman year to the junior-year rotation in the belief that these more clinically oriented students might better understand the points about communication and stigma that the family members presented. Even today, some students may not understand the issues of stigma and family heartaches about mental illness, but others have been appreciative and complimentary of the presentation. The family members who made presentations painted a picture of past approaches to treatment and how families were often blamed for the person’s illness. Their experiences came mainly from the time when family dynamics were theorized to be the etiologic agent of mental illness, leading to the “logical” conclusion that the patient should be separated from the family. During those early years of the “Decade of the Brain,” the NAMI presenters used a portion of the time given to them to emphasize the importance of the biological basis of mental illness. The strategy, of course, was to shift from a stigmatizing focus on family dynamics as the etiologic agent to a more medical focus on biologically based causes and treatments. NAMI supported its presentation with brain imaging from persons with schizophrenia and bipolar disorder done at the Brookhaven Laboratories and portions of works by E. Fuller Torrey (6), Nancy Andreasen (7), and Daniel Weinberger (8).
As knowledge of the biological basis for psychiatric disorders became more fully accepted, student feedback indicated a need for less information about the brain coupled with a greater need for information about NAMI itself and its programming. This came at a time when NAMI-Indiana was expanding both staff and programs. The NAMI-Indiana program director therefore joined the presentation team. The current presentation team consists of the professor of record, who is also a NAMI member and provides an introduction to the topic, the program director, and two other NAMI members. Even with the decrease in overall lecture time within the clerkship to promote “active learning” that has occurred in many medical schools, including ours, the NAMI presentation has remained firmly anchored in the junior medical student schedule.
Since 1994, NAMI-Indiana also has assisted the Department of Psychiatry in assessing medical student interest in psychiatric patients, illnesses, and training (9). We jointly devised an instrument to determine the students’ attitudes and understanding of mental illness as well as their attitudes regarding patients and families. The instrument is a 23-item, Likert scale survey divided into three sections of questions regarding mental illness, ways professionals might interact with families, and mental health treatment and professionals, followed by a 7-question demographic section. In order to match pre- and postrotation results for each student while protecting anonymity, we devised a coding scheme for students to use in a way that was acceptable to our institutional review board. Students were asked to develop an eight-letter code that only they will know. They do so by using the first three letters of their mother’s first name, a two-digit number for children in their family (examples: “03” or “10”), and the first three letters of the month in which they were born. They are to write that code on the survey instrument, as well as to keep it for future reference, but if they do not keep it they can easily reconstruct it.
Pre- and Postrotation Medical Student Results
Results of paired-sample t tests (Table 1) revealed that students possess stronger beliefs in both biological and social causes of mental illness after the 6-week psychiatric rotation. Significant pre/post differences in the recognition of the acknowledged effectiveness of psychotherapy and psychotropic medications increased after the rotation. After the rotation, students were significantly more likely to agree that the cost of psychiatric treatment is worthwhile. After the rotation, students disagreed significantly more with the statement that persons with mental illness do not get better, regardless of treatment. Interestingly, however, students agreed more after the rotation that treating persons who abuse alcohol or drugs is a waste of time. Significant pre/post changes were found in students’ attitudes toward the settings in which mental health treatment is provided. After the rotation, students were more aware of the benefits of multifaceted treatment efforts that extend beyond the hospital. Finally, the students indicated that they were more familiar with NAMI and the KEY (for Knowledge Empowers You) Consumer Organization after the rotation.
There were no significant pre/post differences in students’ attitudes toward chance causes of mental illness or in their attitudes toward the role of the family in the treatment and recovery of relatives with mental illness. The psychiatric rotation did not have a significant impact on the students’ willingness to consider a career in psychiatry (9). However, the goal of the NAMI presentation remains the reduction of stigma, so perhaps it is not surprising that no trend toward greater interest in psychiatry as a career choice was found.
We hope to provide students with some understanding of why families may show evidence of significant stress and perhaps even be absent from the patient’s life at any given time. One basic message is that an educated and supported family is the best ally medical practitioners can have in working with those with mental illness—just as has been shown for many other illnesses (10, 11). NAMI-Indiana recently has tightened up and shortened its presentation from 2 hours to a single hour so as to better hold the students’ attention.
The Psychiatric Residency Didactic Program
The relative success of the NAMI presentation to junior medical students became a factor in planning for the residency didactic curricular revisions initiated by the Department of Psychiatry in 1997. Because many of the entering residents do not come from within our own medical school, NAMI-Indiana was asked to provide a second presentation annually in a new course on schizophrenia for first-year psychiatric residents.
This course on schizophrenia is approximately five afternoons in length, or 17.5 contact hours (Table 2). The NAMI-Indiana presentation usually occurs in the first session and has been positively received by the residents. The NAMI speakers have agreed to provide a different presentation from that given to our junior medical students, so as not to bore residents who are recruited from within our own school. But the session covers much of the same material, providing a learning experience that encourages all of our residents to communicate with and educate not just their patients but members of the patient’s family as well.
NAMI-Indiana began to include members of their new consumer group in these presentations, which encouraged another consumer advocacy group in our state, KEY Consumer Group, to be invited to make its own presentation to the residents. Too often, first-year psychiatric residents see patients only in inpatient and emergency settings, when patients are certainly not at their best functional level. By including consumers from NAMI and KEY, we have been able to expose the first-year residents to people with identical diagnoses to those on our inpatient units who demonstrate the high level of functioning that can be achieved by our patients.
We believe that these educational collaborations between advocacy groups and academia show promise for increasing inclusion of family and psychiatric patients in communication about psychiatric disorders, treatment, and stigma issues. Our preliminary measures of medical student responses seem to bear this out. A limitation of this study is its focus on students in only one medical school. Another is the lack of long-term follow-up. We cannot assume that any changes in attitudes achieved by our efforts with junior medical students are necessarily long lasting. Neither do we know whether we are using the most efficacious approaches to changing medical students’ attitudes about mental illness, persons who have mental illness, or their families.
Further work is needed to determine how successful the interactions between first-year residents in psychiatry, family members, and consumers managing their recovery will be in the long term for our residents. Our goal is that this experience will lead to increased dialogue about treatment and discussion of stigma-related issues once these trainees are in practice.
We intend to develop a survey similar to the medical student instrument, but geared to the greater knowledge and psychiatric sophistication of residents, to assist in this process. Mental illness stigma remains a high priority for those of us in the mental health arena, but it has proved quite difficult to address. However, our students’ exposure to advocacy groups does seem to offer promise as an approach.
The authors thank Nancy E. Butler, M.D., and the Department of Psychiatry, Indiana University School of Medicine for including NAMI-Indiana in medical student education.