From Poster Child to Wanted Poster

Serious mental illnesses are unique in a peculiarly somber way. They are the only diseases that can, when things go horribly wrong, produce a mortality and injury rate among people who don't suffer from them. As a result, the stereotype linking "madness" to violence against innocent victims holds an unyielding grip on popular culture, and media commentators struggle to "explain the unexplainable"-even though the answers are more readily available than they think.

Against this backdrop of public misapprehension, the ongoing campaign against stigma and discrimination attempts to promote an attitudinal shift from misunderstanding and fear to knowledge and compassion. Unfortunately, mental illnesses only grab the public's attention when high-profile tragedies become front-page news. For the mental health community that must continually cope with image issues, a conundrum emerges-how to put a human face on mental illness without painting a picture that is either too rosy or too fatalistic.

At no time was this challenge more poignant than after the Michael B. Laudor story broke. A virtual poster child for the promise of mental health treatment, Laudor had seemingly surmounted the obstacles schizophrenia had placed in his path. A Yale Law School graduate, he parlayed the story of his life into book and movie deals worth $2.1 million. The Laws of Madness-the proposed title of his biography-would have finally brought to bookstores and the silver screen one individual's valiant struggle to overcome stigma and discrimination, and to prevail against all odds.

Then, in June, the bottom fell out. In a bizarre chain of events that still isn't fully understood, Laudor allegedly killed his fianc, Caroline Costello, by stabbing her 10 times with a chef's knife. Together since 1991, Laudor and Costello were reputed to be a devoted and loving couple. Costello was pregnant with their first child at the time of her death.

Upon surrendering to New York police shortly after the murder, Laudor was reportedly agitated and disheveled, still wearing blood-stained clothing. A June 29, 1998, Time magazine article claimed that Laudor had "confessed to attacking Costello."

The day after the June 18 incident, Laurie Flynn, the executive director of the National Alliance for the Mentally Ill (NAMI), told the Washington Post that she "burst into tears" when she heard the news. "[Laudor] was a tremendous inspiration," Flynn went on to say. "We are so grateful when we see these wonderful stories of people who succeed despite the difficulties of mental illness."

In an interview with Psychiatric Times, Flynn acknowledged that a balance is necessary when depicting mental illness to the public. "What we try to find is the right mix [of individual stories]-a mix that says schizophrenia is serious, and that it is the most serious, devastating illness of this size and scope in the country," Flynn said. "At the same time we need to show that if people do get treatment, they can do a lot better."

Flynn said the Laudor incident presented a difficult moment. "The reaction-mine and everyone else's that I know in NAMI-to that particular tragedy was intensified because he exemplified reclaiming the dream," Flynn said. "When you read about a kid who followed that path and got his life back, it was enormously hopeful. After that amazing, remarkable and atypical success, to see him implode was unbearably sad."

When Russell Eugene Weston Jr. stormed the country's Capitol building in July and allegedly killed two police officers and wounded a tourist during a blazing gun battle, the sadness deepened even further. Weston's life as a mountain recluse, and his history of largely untreated schizophrenia, soon occupied the front pages.

For Nada L. Stotland, M.D., chair of the American Psychiatric Association's Joint Commission on Public Affairs and head of psychiatry at the Illinois Masonic Medical Center in Chicago, the publicity in the aftermath of the recent tragedies was actually more sensitive than in years past, a testament to the inroads mental health advocates have made into increasing understanding of brain disorders. Nevertheless, Stotland said that since "we still haven't gotten past stigma" in this culture, describing the realities of mental illness still presents a problem. "How do you say that mental illnesses are awful, and then say that they can be overcome without raising false expectations?" she said.

For psychiatrists, there is another problem. When professionals advocate for mental health resources, it is difficult not to appear as if "you're trying to feather your own nest," Stotland said. "You need to talk about mental illnesses in stages," she added. "First you have to fight a certain level of stigma, or people don't even want to talk about it, they don't want to mention it, and they don't want to hear about it."

Moe Armstrong is the director of consumer and family affairs for the Vinfen Corporation, an organization that provides consumer services through the Massachusetts Department of Mental Health. Recently, NAMI honored Armstrong with the Lionel Aldridge Award, recognizing his advocacy efforts. For the past 30 years, Armstrong has struggled against schizophrenia, and from his personal vantage point he concedes there is a lot more to do before the public reaches a realistic understanding of mental illness.

"It's been a two-edged sword. I'm not normal. I need some kind of mental health care, and we need to build a system that is community-oriented," Armstrong said. "We haven't done a good job of defining that and helping the public understand what we can do in community mental health. "We are a lot more capable of surviving with this mental illness [schizophrenia] than people give us credit for," he added, "if we are taught how to live with the symptoms. But most people haven't been taught how to live with the symptoms, or what I call the 'weirdness.'"

Part of the problem, Armstrong said, is that mental health is an expert-driven field, and that experts are the ones who talk about the mentally ill. Ultimately, individuals with mental illnesses must speak out and have a greater impact on the way they are depicted to the public. He added that at times he resents efforts to use celebrity spokespeople as examples of mental health success stories. "Everyone's pain is real," he said.

Meanwhile, pharmaceutical companies marketing psychiatric medications also face pressures, but they are tinged with cynical references to market share and profit. When Eli Lilly and Co. launched a direct-to-consumer advertising campaign for its drug Prozac, for instance, some media pundits criticized the effort as promoting medications that most people did not need.

Rachel Bloom, a spokesperson for Zeneca Pharmaceuticals, the Wilmington, Del.-based manufacturer that recently began marketing the new antipsychotic, quetiapine fumarate (Seroquel), conceded that depicting an evenly balanced picture of mental illness is a Herculean task. Zeneca recently collaborated with the APA in producing a video about schizophrenia called "Critical Connections," aimed at giving patients a sense of hope that they can achieve a gratifying life.

"It's a difficult message to send, and a difficult message to explain," Bloom said. "When you think in terms of sound bites, how do I convey the image of what the mentally ill are actually suffering and what hardships they're actually going through, and then turn that around in the same sound bite and capture the positive part of it? It's a difficult story to tell."

Michael Faenza, president of the 416,000-member National Mental Health Association, says it may now be time to deliver the message about mental illnesses more aggressively. "Many of us have lacked the courage at times to really confront the discrimination and the lack of attention and care for people with mental illnesses," he said. "Our elected public officials and opinion leaders deserve a much more aggressive response to their neglect. Many people in our field...choose to be exceedingly statesmanlike-so diplomatic that the importance of their message gets lost in their civility."

The implications of inaction are severe. According to some estimates, more than 1,000 homicides a year are committed by mentally ill individuals. Meanwhile, the National Advisory Mental Health Counsel says that 40% of the 3.5 million people suffering from schizophrenia and bipolar disorder may not receive treatment during any given year. Though other studies indicate that the mentally ill are no more violent than other Americans, it is also clear that many acts of violence could have been prevented if treatment were available.

"We have not adequately portrayed the inhumanities and the human suffering that result from lack of treatment, and the neglect of important social institutions in this country to treat mental illness fairly," Faenza said. "On one hand, it's understandable that the mental health community portrays people with mental illnesses in the best light in terms of response to treatment and the potential for recovery, because we are all trying to overcome a tidal wave of ridicule and negative images. But if the American public understood the reality of the hundreds of thousands of children and adults who are caught in the criminal justice system in this country because they don't have access to community-based services, and saw the kind of suffering and degradation that takes place because of incarceration and because of homelessness, they would be horrified."