To the Editor:Dr. Corrigan and his colleagues reported that an antistigma educational presentation lowered several measurements of stigmatizing beliefs and attitudes among participants, whereas a presentation that focused on the greater propensity for violence among people with mental illnesses had the opposite affect. But what if the goals of groups that address violence among people with mental illnesses are different from the goals of groups that fashion antistigma campaigns? Then the comparison is between the impact on the unilateral objective of one project and the ancillary effects on that objective on another—the approach is akin to comparing the rain-stopping abilities of an umbrella and a T-shirt.
The only entity described by Dr. Corrigan and his colleagues as a proponent of violence education is the Treatment Advocacy Center. Yes, our center does address the heightened propensity for violence to help foment reforms that will, among other objectives, prevent future violence. Although such endeavors may to a small extent heighten stigma by increasing awareness of the problem, the magnitude of the effect should be gauged in a real-world context. To help readers gain perspective: a search of a database of leading newspapers that used both "Treatment Advocacy Center" and "violence" yielded a total of 71 articles, editorials, op-ed commentaries, columns, and other media pieces for the past five years, whereas a search of the same database that used both "mental illness" and "violence" yielded 536 media items from the past month.
The issue of violence emerges in conjunction with campaigns to establish programs such as assisted outpatient treatment, assertive community treatment, crisis intervention teams, and mental health courts that are designed for people who are most acutely and chronically afflicted with severe psychiatric disorders—the small subset of people with mental illnesses most prone to homelessness, hospitalization, incarceration, self-harm, and violence.
For example, the effort to bring assisted outpatient treatment to New York in 1999 was spurred by a succession of tragedies caused by individuals with untreated psychotic disorders. Inevitably, legislators, media, and the public focused on the incidents and on violence prevention, which may have resulted in increased stigma analogous to Dr. Corrigan's results. New York's legislature adopted assisted outpatient treatment swiftly and overwhelmingly, which may reflect Dr. Corrigan's additional finding that better knowledge of the causes of violence engenders support for treatment interventions. Furthermore, although the Corrigan study found that recognition of a connection between violence and mental illness had no affect on participants' support for increased resources, not only did New York mandate new funding for Kendra's Law but Governor Pataki also dedicated an unanticipated $125 million to community services three months after signing the legislation.
Since 1999 more than 5,600 people have either been placed in assisted outpatient treatment or received intensive service enhancements pursuant to Kendra's Law. For a group of 1,407 individuals who completed initial six-month assisted outpatient treatment orders, 63 percent fewer were hospitalized than in the six-month period before the orders (31 percent compared with 84 percent) (personal communication, New York State Office of Mental Health, 2003). Similarly, 55 percent fewer became homeless while in assisted outpatient treatment (5 percent compared with 11 percent). In addition, 75 percent fewer were arrested (6 percent compared with 24 percent) and 69 percent fewer had been incarcerated (4 percent compared with 13 percent). Among the first 2,433 individuals who were placed in assisted outpatient treatment, moreover, the rate of self-harm declined by 45 percent and the rate of harm to others fell by 44 percent (1).
By improving the quality of life of people with mental illnesses, Kendra's Law combats direct sources of stigma. These outcomes equate to fewer stigmatizing beliefs and attitudes among the other citizens of New York—people can't see what doesn't happen and newspapers can't print it.
Mr. Stanley is assistant director of the Treatment Advocacy Center in Arlington, Virginia.