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SD County Aims To Erase Stigma Associated With Mental Health Challenges

SD County Aims To Erase Stigma Associated With Mental Health Challenges
How far have we come in terms of accepting and understanding mental illness as a society? It is estimated that self-stigma keeps 50 to 60 percent of individuals with mental health challenges from getting treatment. We'll discuss a new initiative launched by San Diego County's department of Mental Health Services that aims to educate San Diegans about mental illness.

MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. San Diego County officials released a startling statistic this week. They say a quarter of the adult population and 20% of kids suffer from either diagnosable mental illness or an emotional or behavioral problem. That means in any given year about 750,000 San Diegans struggle with a mental health issue. One of the many reasons people don't get help for mental illness is the stigma attached to mental and emotional problems, so the county is launching a new education campaign aimed at reducing that stigma and increasing awareness about mental disorders. Joining me to talk about mental illness in San Diego are my guests. Alfredo Aguirre is director of Mental Health Services for the County's Health and Human Services agency. And, Alfredo, welcome to These Days.

ALFREDO AGUIRRE (Director, Mental Health Services, San Diego County Health & Human Services): Yes, good morning. Thanks for having me.

CAVANAUGH: Markov Manalo is recovery educator for Recovery Innovations of California. Markov, good morning.


MARKOV MANALO (Recovery Educator, Recovery Innovations of California): Thank you. Good morning to you.

CAVANAUGH: And David Peters is a marriage and family therapist here in San Diego, and a frequent guest on These Days. David, good morning. It’s good to see you.

DAVID PETERS (Marriage & Family Therapist): Always good to join you, Maureen.

CAVANAUGH: And we’d like to invite our listeners to join the conversation. Do you think a lack of education about mental illness prevents people from getting help? What do you think San Diego County health officials can do about that? Give us a call with your questions and your comments. The number is 1-888-895-5727, that’s 1-888-895-KPBS. Alfredo, that number again, 750,000 San Diegos – San Diegans, that is, suffering from mental illness on – at any given year, I think that’s the end of that. How did…



CAVANAUGH: How did you determine those numbers?

AGUIRRE: Well, it’s pretty much consistent with the national data, with what the researchers are telling us. So obviously with a county our size, with our demographics, we really do reflect the national data. So we are very comfortable with those figures because once you take into account mental disorders, it’s a broad spectrum of diagnoses, anywhere from anxiety disorder, depression, major mental illness like schizophrenia, then you have your childhood disorders as well.

CAVANAUGH: So give us a little bit more of an idea of the broad area of mental illness and mental disorders that we’re talking about. You’re talking about anything from depression to schizophrenia but what are the things in the middle there?

AGUIRRE: We have varying degrees of anxiety. Some of it is as a result of trauma or abuse such as Post Traumatic Stress Disorder. You know, issues that happen in school, violence at home, in the community, so you have those social factors but, again, you have your various disorders that have genetic and biological roots. And those include the various forms of depression from, you know, more mild to moderate but also major depression where it becomes quite disabling, individuals who lose time at work, are not able to function effectively in the community, affects their relationships at home with their family, those are the impacts. So really the breadth of this is quite impressive. And if you just think about, you know, your own family, as I think about mine, my family of origin, it’s all there, and the statistics ring out for me, at least personally.

CAVANAUGH: Now, David Peters, are the numbers we’re talking about surprising to you?

PETERS: Not surprising at all. As Alfredo has pointed out, it encompasses a wide range of disorders so you include even minor cases of anxiety which are significant enough to disrupt someone’s work life and home life and cause someone physical symptoms but the person walking around through the day might not know they’re suffering an anxiety disorder. What the general public doesn’t realize is that right next door or in your child’s classroom or maybe your child’s teacher or a coworker are struggling with some form of anxiety or depression or other disorder. A lot of kids and adults go through brief periods where extreme stress leads them to have symptoms of depression or anxiety which are not a major disorder but we call an adjustment disorder where it’s clinically significant. It could ruin their lives if it’s not attended to and by attending to it early enough, we can prevent a more serious, debilitating illness.

CAVANAUGH: And do pressures along the lines of, let’s say, the recession, looking for work, does that also bring perhaps an incipient emotional problem to a head where it really does start to impact somebody’s life?

PETERS: Certainly, it’s an added stressor. I wouldn’t go as far as to say a recession causes mental illnesses but in any population you’re going to get a certain percentage that are vulnerable to mental illness. And then you add to it chronic job stress or going six months to a year without a job while you’ve got children to take care of and the chronic fear and anxiety can drag you under, separate from a recession. Just I’ve got several clients at any given time just because of their work environment is so bad, the emotional abuse is so bad that they crash themselves into a serious depressive disorder, anxiety disorder, and so I’m working with them, trying to help hold them together with cognitive therapy and advice on getting medications from the doctor while they’re suffering and, hopefully, they find another job or another employer within the year so it doesn’t get any worse. So there’s a wide range of influences in society that will undermine our functioning.

CAVANAUGH: We are taking your calls about this new San Diego County mental health awareness and education program, 1-888-895-5727. There are a number of people who have questions and comments but before we get to them, Alfredo, I do want to talk specifically about the public awareness campaign that San Diego County is launching. What is it that you observed in the community that led you to focus on the idea of breaking down stigmas and discrimination against seeking mental health treatment?

AGUIRRE: We felt in order to make a difference in terms of helping individuals overcome various major illnesses – major – various mental illnesses and be able to achieve recovery, we had to deal with the issue of stigma. We felt that was a major barrier in individuals seeking care or even individuals being able to identify family members, primary care providers being able to detect mental illness and provide the – and do the appropriate referral. We also did some polling and in, for example, 45% of San Diegans said they would feel afraid to tell people about their mental health disorder. We felt that was a pretty impressive statistic and pretty telling. Another one, 48% of people feel a person with mental illness is dangerous, and the reality is those individuals with mental illness tend to be – are more prone to be victims than to be the perpetrator. So, again, those perceptions get in the way of people seeking care.

CAVANAUGH: And, you know, San Diego County, as we all know, is having a hard time making ends meet, as are all government entities. Where is the funding coming from for this new outreach, this new education campaign?

AGUIRRE: In 2004, the voters of California voted for Prop 63, which provided for dedicated funding to transform mental health systems across the state. Certainly in California – in San Diego, we received our allocation and one of the efforts was to address the issue of prevention and early intervention and build a more supportive community. The state was supposed to do a statewide campaign and they still are but they were very slow at getting out of the block so San Diego, in terms of our own planning process, we said, well, we need to get out in front with this. This is too important for us to wait. Let’s get out in front and actually our county is taking the lead in terms of the breadth and the depth of our campaign. Not only this, but down the road we’re also going to be doing a photo novella project in terms of working with the Latino community to help better understanding of mental illness in the Latino community as well as a housing discrimination effort. So when you roll all these efforts together, we are definitely taking the lead and, in fact, I know counties are very interested to see how we do and the kind of results that we achieve, so there’s a lot of focus here on this county.

CAVANAUGH: We’re taking your calls at 1-888-895-5727. Bruce is calling us from San Diego. Good morning, Bruce, and welcome to These Days.

BRUCE (Caller, San Diego): Good morning. 20% at any given time is such a staggering figure that one wonders does this mean 20% really have something that, as you say, is seriously debilitating? Is this a change from what it was 10, 20, 40, 80 years ago? Or is this – is there some element of this that’s essentially reclassification or a definition issue? I mean, when you get to the point where if you define illness as being different from normal and you classify such a large fraction of people as not normal, then, you know, what is normal?


BRUCE: And how should we think about this number?

CAVANAUGH: Bruce, thank you very much. Let me go to you, Alfredo, for that. How should people in San Diego think about this number of 25% of adults, 20% of kids?

AGUIRRE: Yeah, I think over the years when we look at the prevalence of mental illness, some of the data was very uneven and it still is to some degree, although the one in four is actually 25% of people in a given year who experience a mental disorder. That has been pretty consistent and pretty much agreed upon by the experts. But, again, you need to know that mental disorders has, you know, encompasses a breadth of diagnoses. A subset of that, of course, is major mental illness where, you know, that’s when the individual who called talked about disabling results of that condition. That’s around 5 to 9% of the population. But, again, the data, for example, 1% of the population has schizophrenia, so that kind of gives you an idea. When you roll up all these diagnoses, we are looking at 25% with varying degrees of impact on the ability of an individual to function effectively. So is it, you know, are all these disabling? No. But certainly a subset of them can be.

CAVANAUGH: Markov Manalo, I want to get you in on the conversation. You’re a recovery educator for Recovery Innovations of California. And I know that you, yourself, are on the road to recovery from mental illness. Can you share with us how mental illness affected your life?

MANALO: It was from the very beginning, so it seems but certainly through high school and college there were opportunities and hard work that were washed away because of ongoing problems that rose again and again.


MANALO: And I do believe that I had not received – I had not chosen to seek help for years, actually decades.

CAVANAUGH: And that was because you were – there was a stigma attached to having a mental illness and you were sort of afraid how other people would take it?

MANALO: Well, part of it was that, Terry (sic). Another part of this campaign is to deal with self stigma. So the ideas that I had about myself and that illness worked against me, worked against my eventual wellness.

CAVANAUGH: I understand. Now how comfortable are you now even after being a peer counselor and helping other people get on the road to recovery from mental illness? How comfortable are you now speaking about your mental illness? Is it still a problem?

MANALO: More so than before, Terry. I still sometimes wait to exhale, you know. I am dedicated to this campaign and this cause but I know that there will be people who will end the conversation as soon as the disclosure of a diagnosis, you know, is shared.

CAVANAUGH: You mean like in a social situation, they’ll just sort of walk away?

MANALO: Yes, yes. And this has been the case with, you know, many other people in recovery who have, you know, shared such stories and sad anecdotes with me.

CAVANAUGH: And, David, what do you hear about people who come in to see you, perhaps they get a diagnosis of depression or another anxiety disorder, do they share this with the members of their family, their friends, their employers? Or are they hesitant to do that?

PETERS: I think you see a wide range of response to that. Most certainly, the majority won’t share it with their employer because in the employment setting, you’d have no idea what people’s bias may be. And I think the caller’s question was telling because the assumption is, well, there can’t be that many people with mental illness, we’d see them. You know, they’d be acting crazy in the streets. But if you include, you know, Obsessive Compulsive Disorder, which can be concealed here and there, and, you know, chronic fatigues or the chronic anxiety disorders, these things can be concealed here and there, so people don’t share them openly. With family members, I’ve worked with family members where one person is taking medications and in therapy and they don’t tell anybody else in the family. They don’t want anybody to know. And other families where it’s openly talked about with a sense of humor and everybody can be relaxed about it. And when we’re able to talk about something, that takes us a quarter of the way to healing right away because it allows – if I’m able to talk about something that’s debilitating me, that allows greater brain participation within myself, it allows my executive ego, so to speak, to help process the symptoms that I experience and look at them objectively. So just being able to talk about it openly is actually already on the road to healing. If I have to keep something secret then my brain, every day, has to selectively camouflage something and work my sentences around a topic so as to not reveal something that’s happening and that’s a real cost in terms of mental health and my ability to relate to people, my ability to be intimate with people, my ability to be a leader at work. All these functions that we have in our life are impacted if we have to keep something quite and silence it within ourself.

CAVANAUGH: Let’s take another call. Kathryn is calling us from Pacific Beach. Good morning, Kathryn, and welcome to These Days.

KATHRYN (Caller, Pacific Beach): Good morning. Thanks for taking my call.

CAVANAUGH: You’re welcome.

KATHRYN: I wanted to agree or just to thank the creators of this program about stigma. I actually didn’t have trouble seeking professional help for my condition. I had to seek treatment for an eating disorder and Post Traumatic Stress. What was harder for me is seeking social support from my friends. And during the period of time where I couldn’t fully function, I really needed to lean on my friends. So I found that once I started seeking out a few trusted people and talking to them about it, it did bring the pressure down. But for the most part, you know, if a middle aged woman says I sought treatment for an eating disorder, that’s sort of a conversation stopper. So for the most part, I am still under cover but I wanted to thank the creators of the program.

CAVANAUGH: Well, thank you, and, Kathryn, thank you for your call. We have to take a short break. When we continue, we’re going to talk more about the San Diego County education program to try to reduce the stigma and discrimination against people who seek treatment for mental illness here in San Diego. We’re taking your calls at 1-888-895-5727. You’re listening to These Days on KPBS.

CAVANAUGH: A new statistic released by San Diego County finds that about 750,000 San Diegans struggle with a mental health issue on any given year. And we’re talking about a new education campaign being launched by the county aimed at reducing the stigma and increasing awareness about mental disorders. I'm Maureen Cavanaugh. You're listening to These Days. My guests are Alfredo Aguirre. He’s director of Mental Health Services for the County's Health and Human Services agency. Markov Manalo is recovery educator for Recovery Innovations of California. And David Peters is a marriage and family therapist here in San Diego. We’re taking your calls at 1-888-895-5727. Alfredo, one of the things that you mentioned was trying to get the word out as part of this education campaign to primary care providers. What is it that you want them to know about mental health issues that they don’t do as a routine thing now?

AGUIRRE: Yeah, I think it’s a couple of things. One is the importance of improving their capacity to detect signs of mental illness in terms of their patients. The other is helping doctors realize and seek the appropriate training, and there certainly does exist so they’re more up to the training points around the interface of psychotrophic medication and other medications, so that’s another piece to it which involves training. The other thing we’re doing is not only just sending material to the primary care physicians but following up and making sure they under – you know, they know the material arrived and helping them, answer any questions they may have around resources. The material will also indicate the resources they can seek for their patients. The other thing is we actually have a general website for this campaign. It’s and within that overall website, we’re going to have a web page just primarily dedicated to primary care physicians.

CAVANAUGH: David, what is your take on how patients who come in to their primary care physicians with, you know, perhaps they’re feeling tired or anxious or they can’t sleep, you know, with something that could be a sign that there is some mental health issue brewing. How is that usually treated on that level?

PETERS: Well, unfortunately, Maureen, we still have a situation where almost 90% of psychotropic medications are prescribed by primary care physicians and not by psychiatrists who merely have far more training in selecting which medication and what amount of medication is going to be appropriate. It would be like getting your car repaired by someone who specializes in home mechanics. What we want – What would be really helpful is to have the primary care physicians be able to recognize and then also have the courage to urge their patients to seek out help from a mental health provider. One of the worst things we can do with most mental illnesses is prescribe a medication and send someone on their way because psychotherapy is really a critical component. We want to have as little medication used as possible. Medications come with side effects and with costs. And a lot of times, conditions can be treated permanently with psychotherapy services rather than medications. And I’ve had clients come in after spending years waiting for medications to work, their life slowly getting more tangled and having more disruption to the quality of their life and they finally come in for counseling. I say, well, but you’ve been on medications for how many years? And who’s prescribing this? It’s their primary care physician. And I said, have you been to a therapist before? No, they were trying to do it without seeing a therapist. So essentially they’re having a mental health issue treated without mental health counseling and frequently the issue is not in the person’s head but in their environment.


PETERS: Commonly, I’m working with a family member where they’re holding symptoms of a problem which is really a family-wide problem. You know, why is Junior acting out of control? Put him on medications. Well, wait a minute. Let’s talk with mom and dad and see what the home life is like. Maybe that’s the bigger issue and we don’t have to use medications. So if we can get people moved out of the physician’s office into a mental health provider, frequently we can have a much more efficient resolution of the problem.

CAVANAUGH: We’re taking your calls and, in fact, we have a full bank of calls right now. If you’d like to comment or ask a question, you can go online, Let’s take a couple of calls back to back, if we can. Sam is calling us right now in Scripps Ranch. Good morning, Sam, and welcome to These Days.

SAM (Caller, Scripps Ranch): Good morning and thank you for taking my call. I was wondering at some point do symptoms of anxiety in, let’s say, a teenage become more than just normal anxiety for that age and become something that requires medical attention?

CAVANAUGH: Sam, thank you for the question. Who would like to take that? David.

PETERS: Well, I think it’s going to vary widely. The key to measure is to what extent it is undermining your quality of life. Many people experience common anxiety, many people experience sadness. Sadness is not depression, anxiety is not a panic attack. We have to be careful. The common emotions we feel, even the most uncomfortable ones, are not mental illness. Those are emotions that we’re supposed to have in order to help us function as living human beings. But when I have an emotional experience or a brain activity that is slowly debilitating me, if the quality of my work at the office is being undermined, if my family members are suffering because I’m suffering, if I’m not as good a parent because of the anxiety or depression I’m experiencing, then I’m affecting other people and the…

CAVANAUGH: Or if you’re a teenager, as our caller said, if perhaps you’re not being able to do your schoolwork.

PETERS: Yeah, as a teenager, certainly, if you find you’re not able to focus and study because of obsessive thoughts or because of your worries, well, so your grades are getting impacted, your ability to go to college is being affected by something that could be treated. And frequently the issue is far less serious than the person thinks it is when they’re concealing it. And once they’re able to talk about it, they can, you know, resolve it rather quickly.

CAVANAUGH: Let’s take another call. Greg is calling from Oceanside. Good morning, Greg. Welcome to These Days.

GREG (Caller, Oceanside): Good morning. You know, I have to think that the looming ten thousand pound gorilla in this whole equation is actually financial and insurance issues. It’s easy to say, well, go see your mental health professional, you know, go do this, go do that with, you know, professionals but the fact is that probably in this county there may well be a million people who simply can’t afford to get this kind of help if they need it.

CAVANAUGH: Well, thank you for the call. I think that’s very important, Greg. And, Alfredo, as part of these education campaign are – is the county going to help people find a therapist or a doctor to work with them?

AGUIRRE: Yes, we actually do – I want to, again, remind people of our county’s Access and Crisis Line. It’s a 24-hour a day, 7 days a week, line. It’s – I can leave you the number if you’d like…


AGUIRRE: …it’s 800…

CAVANAUGH: We can put it on our website.

AGUIRRE: 800-479-3339. And that line is very resourceful in helping individuals who may be struggling with mental illness to find a provider. Yes, there is the issue, particularly if you have a – an illness that perhaps isn’t as pronounced, isn’t as serious. The county’s charge in terms of our mental health services is to work with individuals with basically serious mental illness, or if you’re a child or adolescent, a serious emotional behavioral disorder. So – But we also operate the MediCal plan for mental health – especially mental health services and that does cover the range of diagnosis. But there is a – the caller is absolutely right. There’s a reality that people with lower level mental health problems may not have the means to seek private care, yet there are a number of nonprofits, there are some low fee offices, organizations, that will provide mental health services and the Access and Crisis Line, again, is quite resourceful. And, of course, what’s really going to be important—and David mentioned this earlier—is the importance of primary care, again, having the capacity to be in a – to have the comfort level to deal with, you know, to feel like they can manage mental health problems in their office and feel comfortable about prescribing psychotropic medications. That’s another – and, as mentioned earlier, the predominance of psychotropic medications prescriber is primary care. But the caller’s absolutely right that there is a deficiency in resources, certainly.

CAVANAUGH: Markov, I’m wondering, as you sought treatment for your mental health problem, did the cost of finding that treatment, did the cost of that treatment affect where you went or if you went to seek treatment?

MANALO: No, not – not actually, Maureen. I was in bad enough shape and I was in poor enough shape that I was able to access the services of the county. And I have to say that I was provided excellent care, and that was my situation.

CAVANAUGH: I wanted to ask you, what is your job as a peer counselor? What do you do? What kind of issues and questions do you deal with with people who are also struggling with mental illness?

MANALO: Well, I work for an agency called Recovery Innovations of California and that agency is peopled, staffed completely by other peers, people who have had – lived the experience. What we do, largely, is to share the story and the belief of recovery, of hope and choice and many other, you know, qualities that people have in common as they get better. So what I do specifically is I have – I get to share and – ideas and principles and practices of recovery to people who are interested in themselves becoming…


MANALO: …you know, peer support specialists.

CAVANAUGH: Do – When people tell their friends and their family, when they actually do tell people that they are struggling with mental illness and share that, is that a step on the road to recovery?

MANALO: I would say yes, and it’s not an easy step. There is a lot of courage required in being able to share something. Sometimes that information is often, you know, used against you, especially if there’s, you know, dissention in the family. So…

CAVANAUGH: But it can help.

MANALO: Absolutely so.

CAVANAUGH: Let’s take another call. Lisa is on the road. She’s calling us. Lisa, good morning. Welcome to These Days.

LISA (Caller, Mobile): Good morning. Hi, Alfredo, it’s Lisa Garcia.

AGUIRRE: Hello, Lisa.

LISA: Yeah, I…

AGUIRRE: Good to hear from you.

LISA: Pardon me?

AGUIRRE: Good to hear from you.

LISA: Yeah, I was – I’m stuck in traffic. A couple other comments I would like to make. First of all, there are a lot of companies—I’m very lucky to work for CRF, which is a company that helps people get back on their feet after they’ve had a break or a nervous breakdown, as the old way it used to be, where you can try to go back to work. That’s one thing. So that if you do need some support of some kind, that that helps. And also, I’m also, you know, like, you know, as one person, like Marko on your panel, has – is RICA, so I’m also the president of Recovery International, which is also another program where we do cognitive style therapy where it’s been around the longest and we don’t charge. We work in conjunction with a therapist. So…

CAVANAUGH: Well, Lisa…

LISA: …there’s – Pardon me?

CAVANAUGH: I was going to say thank you very much for calling in and for telling us that. I appreciate it. We have a limited amount of time left. I wanted to – You know, David, you’ve been sitting here, you’ve been hearing what the county proposes in terms of this new education outreach. I’m wondering, from what you hear do you think that this kind of an effort is going to provide results?

PETERS: Well, I’ll say one thing, in the short time we’ve been describing it, one would underestimate what it can provide. In the time I spent kind of online myself researching what was going to go on and what was provided, I was amazed at the breadth and the depth of the program. There’s a lot of components that could take another hour just to describe let alone discuss, including youth peer support lines, family peer support lines, the outreach to veterans. This is an extensive, wide-ranging program. And just as we’ve seen money invested in smoking cessation advertisement on television, which in the state of California it really significantly reduced the incidence of smoking among all ages, a campaign of this breadth and depth, as it’s going to be unfolding in the next couple of years, could have a significant impact in getting people connected to help. So I’m really quite hopeful about it and, frankly, it would be worth spending a whole ‘nother hour just describing everything that’s available. Maybe we can make sure people know the link to the website and get a view of how many different ways they can access services.

CAVANAUGH: Absolutely. We will put that on our website but why don’t you give us that website address again if somebody wants to go there right now and take a look.

AGUIRRE: Certainly. It’s in order to…

CAVANAUGH: And you’re going to be adding to that as this campaign develops.

AGUIRRE: As this unfolds.

CAVANAUGH: I want to – We’re out of time. I want to thank you all so much, Alfredo Aguierre, Markov Manalo and David Peters, thank you.

AGUIRRE: Thanks.

CAVANAUGH: And thanks to everyone who called in. If we didn’t get to your call, please go online with your comments, Stay with us for hour two of These Days coming up in just a few minutes here on KPBS.