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Portrayals of Serious Mental Illness: Precursor to Violence or Treatable Health Condition?


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Principal Investigator(s):

Emma McGinty
Johns Hopkins
Email: bmcginty@jhu.edu
Home page: http://www.jhsph.edu/faculty/directory/profile/2908/emma-beth-mcginty

Sample size: 2848
Field period: 2/6/2016-4/11/2016

Abstract:

In the ongoing national policy debate about how to best address serious mental illness (SMI), a major controversy among mental health advocates is whether drawing public attention to an apparent link between SMI and violence, shown to elevate stigma, is the optimal strategy for increasing public support for investing in mental health services or whether non-stigmatizing messages can be equally effective. We conducted a randomized experiment to examine this question.

Hypothesis/Research Questions:

1. How does portrayal of SMI as a treatable condition influence social stigma, willingness to pay for mental health services, and support for treatment options?

2. How does portrayal of SMI as a precursor to violence influence social stigma, willingness to pay for mental health services, and support for treatment options?

3. How does social stigma influence willingness to pay for mental health services and support for treatment options?

Experimental Manipulations:

Narrative #1: Successful Treatment Engagement & Recovery

The text below is an excerpt from a radio program that aired four months ago:

“My name is Michelle Johnson, and my son Keith has schizophrenia. Keith was a star student and athlete all through high school. After he graduated from college, Keith got a good job managing a restaurant in our city. Then, a year later, everything changed: Keith was diagnosed with schizophrenia. In a matter of months, he lost his job and his apartment. Sometimes he stayed at home with us, but often we couldn’t find him. Keith’s father and I were so scared. We didn’t know what was happening to our son or how to help him. Finally, we took Keith to the emergency room. The doctors there recommended inpatient treatment and tried to find Keith a bed at one of the city’s mental health facilities, but none were immediately available. While we searched for an opening in inpatient treatment, Keith saw a local psychiatrist once a week and received home visits from the city’s intensive treatment team, which helps people with serious mental illness get the care they need and also assists with housing and employment. After more than a month, we found Keith a spot in an inpatient program. Once he started the program, Keith did well. He began taking medication regularly and participating in therapy. After two weeks, he was discharged to continue treatment in the community and came to live with us.

That was three years ago. Today, Keith continues to take medication, see his doctor regularly, and receive visits from the intensive treatment team. He has his own apartment, which the intensive treatment team helped him find, and a full-time job at a local business, which he found with help from the city’s supported employment program. I am so grateful that we were able to get Keith the treatment he needed, but we are unfortunately now badly in debt. Our insurance covered only a small part of Keith’s treatment costs. We have used up almost all our savings and still struggle to pay the medical bills. Our society must make it easier for families to get the mental health care they need.”

Narrative #2: Unsuccessful Treatment Engagement (Individual Choice)

The text below is an excerpt from a radio program that aired four months ago:

“My name is Michelle Johnson, and my son Keith has schizophrenia. Keith was a star student and athlete all through high school. After he graduated from college, Keith got a good job managing a restaurant in our city. Then, a year later, everything changed: Keith was diagnosed with schizophrenia. In a matter of months, he lost his job and his apartment. Sometimes he stayed at home with us, but often we couldn’t find him. Keith’s father and I were so scared. We didn’t know what was happening to our son or how to help him. Finally, we took Keith to the emergency room. The doctors there recommended inpatient treatment and tried to find Keith a bed at one of the city’s mental health facilities, but none were immediately available. While we searched for an opening in inpatient treatment, Keith saw a local psychiatrist once a week and received home visits from the city’s intensive treatment team, which helps people with serious mental illness get the care they need and also assists with housing and employment. After more than a month, we found Keith a spot in an inpatient program. Once he started the program, Keith did well. He began taking medication regularly and participating in therapy. After two weeks, he was discharged to continue treatment in the community and came to live with us.

That was six months ago. For the first month, Keith continued to take his medication, see his doctor regularly, and receive visits from the intensive treatment team. Then he suddenly stopped treatment, and his symptoms returned. He told me he did not like the way the medication made him feel and that his doctor did not understand him. His psychiatrist said Keith needed to return to inpatient care, but there were no spots available in the inpatient program where he did so well and Keith refused to go to a different program. Our son has left home and often sleeps on the street. We are unfortunately now badly in debt. Our insurance covered only a small part of Keith’s treatment costs. We have used up almost all our savings and still struggle to pay the medical bills. Our society must make it easier for families to get the mental health care they need.”

Narrative #3: Unsuccessful Treatment Engagement (Policy Failure)

The text below is an excerpt from a radio program that aired four months ago:

“My name is Michelle Johnson, and my son Keith has schizophrenia. Keith was a star student and athlete all through high school. After he graduated from college, Keith got a good job managing a restaurant in our city. Then, a year later, everything changed: Keith was diagnosed with schizophrenia. In a matter of months, he lost his job and his apartment. Sometimes he stayed at home with us, but often we couldn’t find him. Keith’s father and I were so scared. We didn’t know what was happening to our son or how to help him. Finally, we took Keith to the emergency room. The doctors there recommended inpatient treatment and tried to find Keith a bed at one of the city’s mental health facilities, but none were immediately available. While we searched for an opening in inpatient treatment, Keith saw a local psychiatrist once a week. Keith needed to see a doctor more frequently, but no appointments were available. Keith’s psychiatrist said that the city used to have an intensive treatment team that made home visits to provide needed care and also assisted with housing and employment, but the program was cut last year. After more than a month, we found Keith a spot in an inpatient program. Once he started the program, Keith did well. He began taking medication regularly and participating in therapy. After two weeks, he was discharged to continue treatment in the community and came to live with us.

That was six months ago. For the first month, Keith continued to take his medication and see his doctor regularly. Unfortunately, Keith still could not see his psychiatrist as often as needed, and after a month his symptoms began to return. His psychiatrist said Keith needed to return to inpatient care, but there were no spots available in the inpatient program where he did so well. We are still looking for inpatient treatment for Keith, but our son has stopped treatment, left home and often sleeps on the street. We are unfortunately now badly in debt. Our insurance covered only a small part of Keith’s treatment costs. We have used up almost all our savings and still struggle to pay the medical bills. Our society must make it easier for families to get the mental health care they need.”

Narrative #4: Unsuccessful Treatment Engagement (Individual Choice) + Stranger Violence

The text below is an excerpt from a radio program that aired four months ago:

“My name is Michelle Johnson, and my son Keith has schizophrenia. Keith was a star student and athlete all through high school. After he graduated from college, Keith got a good job managing a restaurant in our city. Then, a year later, everything changed: Keith was diagnosed with schizophrenia. In a matter of months, he lost his job and his apartment. Sometimes he stayed at home with us, but often we couldn’t find him. Keith’s father and I were so scared. We didn’t know what was happening to our son or how to help him. Finally, we took Keith to the emergency room. The doctors there recommended inpatient treatment and tried to find Keith a bed at one of the city’s mental health facilities, but none were immediately available. While we searched for an opening in inpatient treatment, Keith saw a local psychiatrist once a week and received home visits from the city’s intensive treatment team, which helps people with serious mental illness get the care they need and also assists with housing and employment. After more than a month, we found Keith a spot in an inpatient program. Once he started the program, Keith did well. He began taking medication regularly and participating in therapy. After two weeks, he was discharged to continue treatment in the community and came to live with us.

That was six months ago. For the first month, Keith continued to take his medication, see his doctor regularly, and receive visits from the intensive treatment team. Then he suddenly stopped treatment, and his symptoms returned. He told me he did not like the way the medication made him feel and that his doctor did not understand him. His psychiatrist said Keith needed to return to inpatient care, but there were no spots available in the inpatient program where he did so well and Keith refused to go to a different program. Our son has left home and often sleeps on the street. We are unfortunately now badly in debt. Our insurance covered only a small part of Keith’s treatment costs. We have used up almost all our savings and still struggle to pay the medical bills. Our society must make it easier for families to get the mental health care they need.”

Michelle Johnson spoke these words on a radio program three months ago. Keith’s untreated schizophrenia went on to have terrible consequences: it led him to commit last week’s shooting in Oliver Park. Witnesses say Keith arrived at the park around 12:30pm and appeared agitated, pacing up and down and talking to himself. At approximately 12:35pm, Keith took a gun out of his bag and began to shoot. A father and his two teenage daughters, who were eating lunch in the park, were shot and killed before Keith was tackled by a security guard from a nearby building. According to a friend who Keith stayed with in the days prior to the shooting, Keith had begun to believe that strangers on the street were government agents with plans to harm him. Keith Johnson is now in a secure psychiatric facility awaiting trial.

The text below is an excerpt from a radio program that aired four months ago:

“My name is Michelle Johnson, and my son Keith has schizophrenia. Keith was a star student and athlete all through high school. After he graduated from college, Keith got a good job managing a restaurant in our city. Then, a year later, everything changed: Keith was diagnosed with schizophrenia. In a matter of months, he lost his job and his apartment. Sometimes he stayed at home with us, but often we couldn’t find him. Keith’s father and I were so scared. We didn’t know what was happening to our son or how to help him. Finally, we took Keith to the emergency room. The doctors there recommended inpatient treatment and tried to find Keith a bed at one of the city’s mental health facilities, but none were immediately available. While we searched for an opening in inpatient treatment, Keith saw a local psychiatrist once a week. Keith needed to see a doctor more frequently, but no appointments were available. Keith’s psychiatrist said that the city used to have an intensive treatment team that made home visits to provide needed care and also assisted with housing and employment, but the program was cut last year. After more than a month, we found Keith a spot in an inpatient program. Once he started the program, Keith did well. He began taking medication regularly and participating in therapy. After two weeks, he was discharged to continue treatment in the community and came to live with us.

That was six months ago. For the first month, Keith continued to take his medication and see his doctor regularly. Unfortunately, Keith still could not see his psychiatrist as often as needed, and after a month his symptoms began to return. His psychiatrist said Keith needed to return to inpatient care, but there were no spots available in the inpatient program where he did so well. We are still looking for inpatient treatment for Keith, but our son has stopped treatment, left home and often sleeps on the street. We are unfortunately now badly in debt. Our insurance covered only a small part of Keith’s treatment costs. We have used up almost all our savings and still struggle to pay the medical bills. Our society must make it easier for families to get the mental health care they need.”

Michelle Johnson spoke these words on a radio program three months ago. Keith’s untreated schizophrenia went on to have terrible consequences: it led him to commit last week’s shooting in Oliver Park. Witnesses say Keith arrived at the park around 12:30pm and appeared agitated, pacing up and down and talking to himself. At approximately 12:35pm, Keith took a gun out of his bag and began to shoot. A father and his two teenage daughters, who were eating lunch in the park, were shot and killed before Keith was tackled by a security guard from a nearby building. According to a friend who Keith stayed with in the days prior to the shooting, Keith had begun to believe that strangers on the street were government agents with plans to harm him. Keith Johnson is now in a secure psychiatric facility awaiting trial.

Narrative #6: Unsuccessful Treatment Engagement (Individual Choice) + Family Violence

The text below is an excerpt from a radio program that aired four months ago:

“My name is Michelle Johnson, and my son Keith has schizophrenia. Keith was a star student and athlete all through high school. After he graduated from college, Keith got a good job managing a restaurant in our city. Then, a year later, everything changed: Keith was diagnosed with schizophrenia. In a matter of months, he lost his job and his apartment. Sometimes he stayed at home with us, but often we couldn’t find him. Keith’s father and I were so scared. We didn’t know what was happening to our son or how to help him. Finally, we took Keith to the emergency room. The doctors there recommended inpatient treatment and tried to find Keith a bed at one of the city’s mental health facilities, but none were immediately available. While we searched for an opening in inpatient treatment, Keith saw a local psychiatrist once a week and received home visits from the city’s intensive treatment team, which helps people with serious mental illness get the care they need and also assists with housing and employment. After more than a month, we found Keith a spot in an inpatient program. Once he started the program, Keith did well. He began taking medication regularly and participating in therapy. After two weeks, he was discharged to continue treatment in the community and came to live with us.

That was six months ago. For the first month, Keith continued to take his medication, see his doctor regularly, and receive visits from the intensive treatment team. Then he suddenly stopped treatment, and his symptoms returned. He told me he did not like the way the medication made him feel and that his doctor did not understand him. His psychiatrist said Keith needed to return to inpatient care, but there were no spots available in the inpatient program where he did so well and Keith refused to go to a different program. Our son has left home and often sleeps on the street. We are unfortunately now badly in debt. Our insurance covered only a small part of Keith’s treatment costs. We have used up almost all our savings and still struggle to pay the medical bills. Our society must make it easier for families to get the mental health care they need.”

Michelle Johnson spoke these words on a radio program three months ago. Keith’s untreated schizophrenia went on to have terrible consequences: last week, he killed his father and two teenage sisters. Neighbors say Keith arrived at his parents’ house around 12:30pm and appeared agitated, pacing up and down the driveway and talking to himself. At approximately 12:35pm, Keith entered the house, took a gun out of his bag, and began to shoot. Keith’s father and two teenage sisters were killed; his mother was not home at the time. According to a friend who Keith stayed with in the days prior to committing the shooting, Keith had begun to believe that his family members were government agents with plans to harm him. Keith Johnson is now in a secure psychiatric facility awaiting trial.

Narrative #7: Unsuccessful treatment Engagement (Policy Failure) + Family Violence

The text below is an excerpt from a radio program that aired four months ago:

“My name is Michelle Johnson, and my son Keith has schizophrenia. Keith was a star student and athlete all through high school. After he graduated from college, Keith got a good job managing a restaurant in our city. Then, a year later, everything changed: Keith was diagnosed with schizophrenia. In a matter of months, he lost his job and his apartment. Sometimes he stayed at home with us, but often we couldn’t find him. Keith’s father and I were so scared. We didn’t know what was happening to our son or how to help him. Finally, we took Keith to the emergency room. The doctors there recommended inpatient treatment and tried to find Keith a bed at one of the city’s mental health facilities, but none were immediately available. While we searched for an opening in inpatient treatment, Keith saw a local psychiatrist once a week. Keith needed to see a doctor more frequently, but no appointments were available. Keith’s psychiatrist said that the city used to have an intensive treatment team that made home visits to provide needed care and also assisted with housing and employment, but the program was cut last year. After more than a month, we found Keith a spot in an inpatient program. Once he started the program, Keith did well. He began taking medication regularly and participating in therapy. After two weeks, he was discharged to continue treatment in the community and came to live with us.

That was six months ago. For the first month, Keith continued to take his medication and see his doctor regularly. Unfortunately, Keith still could not see his psychiatrist as often as needed, and after a month his symptoms began to return. His psychiatrist said Keith needed to return to inpatient care, but there were no spots available in the inpatient program where he did so well. We are still looking for inpatient treatment for Keith, but our son has stopped treatment, left home and often sleeps on the street. We are unfortunately now badly in debt. Our insurance covered only a small part of Keith’s treatment costs. We have used up almost all our savings and still struggle to pay the medical bills. Our society must make it easier for families to get the mental health care they need.”

Michelle Johnson spoke these words on a radio program three months ago. Keith’s untreated schizophrenia went on to have terrible consequences: last week, he killed his father and two teenage sisters. Neighbors say Keith arrived at his parents’ house around 12:30pm and appeared agitated, pacing up and down the driveway and talking to himself. At approximately 12:35pm, Keith entered the house, took a gun out of his bag, and began to shoot. Keith’s father and two teenage sisters were killed; his mother was not home at the time. According to a friend who Keith stayed with in the days prior to committing the shooting, Keith had begun to believe that his family members were government agents with plans to harm him. Keith Johnson is now in a secure psychiatric facility awaiting trial.

Outcome Variables:

Domain 1: Societal willingness to pay for improved mental health services

1. Would you be willing to pay any additional taxes to improve the mental health service system in the United States? (yes/no)

2. (If yes to item #1), Would you be willing to pay $50 per year more in taxes to improve the mental health services system in the United States?

3. (If no to item #2), Would you be willing to pay $25 per year more in taxes to improve the mental health services system in the United States? Note: the order of questions 1-3 will not be randomized.

4. The treatment options for persons with serious mental illness are effective at controlling symptoms. (5-point Likert scale: strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, strongly disagree)

5. People with serious mental illness can get treatment when they need it. (5-point Likert scale: always, very often, sometimes, rarely, never) Note: questions 4 and 5 are needed in order to interpret willingness to pay questions 1-3. For example, they will help us understand if respondents’ unwillingness to pay for mental health services stems from their beliefs about the ineffectiveness of treatment and/or the perception that access to services is already sufficient.

Domain 2: Social Stigma

1. How willing would you be to have a person with mental illness marry into your family? (5-point Likert scale, definitely willing, somewhat willing, neither willing nor unwilling, somewhat unwilling, definitely unwilling)

2. How wiling would you be to have a person with mental illness start working closely with you on a job? (5-point Likert scale, definitely willing, somewhat willing, neither willing nor unwilling, somewhat unwilling, definitely unwilling)

3. People with serious mental illness are, by far, more dangerous than the general public. (5-point Likert scale, strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree, strongly disagree)

Domain 3: Expanded Treatment Options Do you favor or oppose (5-point Likert scale, strongly favor, somewhat favor, neither favor nor oppose, somewhat oppose, strongly oppose):

1. Expanding outpatient public mental health treatment options in the community?

2. Expanding public programs to find housing and subsidize housing costs for people with mental illness?

3. Expanding public programs to help people with mental illness find jobs and provide on-the-job support as needed?

4. Expanding community crisis-response programs to help people with serious mental illness manage crises and connect to services?

5. Reducing legal restrictions on involuntary treatment to make it easier to treat someone with serious mental illness without their permission because they are considered a dangerous threat to themselves or others?

6. Reducing legal restrictions on involuntary treatment to make it easier to treat someone with serious mental illness without their permission because they are considered incompetent to make treatment decisions?

7. Creating more long-term psychiatric hospitals where people with serious mental illness can stay for long periods of a month or more?

Summary of Findings:

Study results showed that narratives emphasizing violence and barriers to treatment were equally effective in increasing the public’s willingness to pay additional taxes to improve the mental health system (55% and 52% versus 42% in the control arm). Only the narrative emphasizing the link between SMI and violence increased stigma. For the mental health advocates dedicated to improving the public mental health system, findings offer an alternative to stigmatizing messages linking mental illness and violence.

References:

McGinty EE, Goldman HH, Pescosolido BA, Barry CL. Communicating about Mental Illness and Violence: Balancing Increased Support for Services and Stigma. Under Review.

 


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