American Foundation for Suicide Prevention Campaigns: a Critique and Alternative use of Stigma Theory- Kerri Barton

Several suicide prevention campaigns have been developed over the past decade by the American Foundation for Suicide Prevention (AFSP) that attempt to solve the complicated and sensitive problem of suicide through the use of television, radio, and billboard advertisements promoting suicide awareness. However, instead of using more recent and effective interventions such as the Stigma Theory, the campaigns push facts onto their audience and fail in their use of the Advertising Theory.

According to the American Foundation for Suicide Prevention, 33,000 people die from suicide each year in the United States (1). Overall, it is the 11^th leading cause of death in the US, and the 4^th leading cause of death among adults between 18 and 65 (1). Among 15-24 year-olds, suicide is the third leading cause of death, following unintended injuries and homicide (1). It is estimated that 90 Americans take their own life everyday, and about 2,300 more attempt to do so (1). However, suicide is a preventable cause of death, as it has been reported that about 90 percent of all people who die by suicide have a diagnosable psychiatric disorder at their time of death (1).

These rates are obviously alarming, and have prompted the American Foundation for Suicide Prevention and several other agencies to implement interventions to reduce this rapidly increasing problem. The campaign created by AFSP projects its message through television, radio, and billboard advertisements (2). The television and radio advertisements, which began in 2000, target an adolescent audience, telling them “don’t keep suicide a secret” (2). The billboards, which can currently be seen in Minnesota and Nebraska, are targeted toward an older audience and instruct highway drivers who are depressed to seek treatment (3). Even though this campaign has several positive aspects, it relies too much on facts, it inefficiently uses advertising in the media, and it targets the wrong audience. The following critique will discuss these three failures and give an alternative approach that may be more effective.

Campaign Critique

An all too common failure of suicide prevention interventions is the frequent use of facts and statistics in advertisements and curriculum-based programs (4). The AFSP campaign is no exception. Three of their billboards contain a list of the number of deaths from suicide, DWI/DUI, and homicide in Minnesota, Washington, and Ohio (3). These billboards are most likely on the side of a highway or busy street, and it would probably be very difficult for a driver going 60 miles per hour to read a list of statistics. How then, could these advertisements reach out to people in need of help? All of the billboard ads urge readers to visit the campaign website: www.depressioncanbefatal.org, which is a very simple website containing a few statistics about clinical depression and a questionnaire that helps to screen for depression (3). A study done in 1991 by Shaffer et al. evaluated the effectiveness of three suicide prevention campaigns among students in the US, and found that “the majority of the students who attended the programs were fairly knowledgeable about suicide before program participation, and most held favorable attitudes toward help seeking” (4). Thus, it is apparent that most who are at risk for depression already know they are at risk for suicide since they probably already have contemplated doing so, and do not need more facts pushed at them about their condition. What they really need is professional help and a push to seek such treatment.

In addition to the billboards, the television and radio advertisements urge viewers and listeners to visit the AFSP website homepage, which is completely lackluster and does not contain any other resources someone can seek help from (1). The National Suicide Prevention Lifeline is listed toward the bottom of the homepage, and you can find it if you look hard enough (1). If someone felt that they were seriously depressed or contemplating committing suicide, they would have a difficult time finding help on this website. They would merely find the latest projects and promotions by AFSP, and clicking on their links on the left side of the page would lead them to more facts and the ability to watch the commercials again (1). The WHO reports several factors that lead an individual to suicide (9). There are usually multiple and complex factors that all combine to result in an individual committing the act (9). Thus, suicide should not be reported in a simplistic way, as it is in this campaign. Suicide is never the result of a single factor or event. Mental illness and impulsiveness each play an important role (9).

Besides this, it has been proven in past attempts at adolescent public health interventions that the opposite affect may occur in this age group (6). An evaluation by Hornik, et al of the National Youth Anti-Drug Media Campaign observed that antidrug advertising was conveying a message that drug use was commonplace among youths (6). Thus, the target audience who saw the ads believed the only way they could fit in was to smoke marijuana like all of their peers are doing (6). The same effect is likely to occur among adolescents with thoughts of depression or suicide. If they see an advertisement telling them about the thousands of suicides that take place every year, they may be more inclined to take this option and “follow the trend.” The WHO’s article on preventing suicide reports that specific groups in the population such as young people suffering from depression are even more vulnerable to imitating suicide behaviors of others (9).

A second flaw of the campaigns by AFSP is the audience chosen to be targeted in the television and radio advertisements. Essentially the purpose of these advertising campaigns is to prevent suicide among adolescents. Their commercials are currently airing in 85 markets nationwide, reaching about 88 million television viewers (2). The message of each commercial is that “Suicide Shouldn’t Be A Secret” and features adolescents telling stories about friends they lost to suicide and instructing viewers to “tell someone” if someone they know is thinking about committing suicide (2). Thus, the target audience of these commercials is not even those thinking about committing suicide themselves, but rather their peers.

More evidence needs to be found as to whether targeting the peers of those at risk for suicide is more beneficial than targeting the suicidal teenagers themselves. It is rare to see an anti-smoking or anti-drug use campaign targeting peers of teenagers who smoke or do drugs instead of the teenagers performing the risky behaviors themselves. A public health report from the Centers for Disease Control and prevention stated that “recent research has shown that mass media campaigns can be effective in preventing smoking among youth if the messages are based on appropriate educational objectives and communicated with sufficient reach, frequency, and duration to high-risk youths” (7). They do not say that targeting the friends of those who smoke will be an effective mass media campaign. Instead, it is important to reach the high-risk group in order to intervene effectively. In addition, the National Institute of Mental Health suggests that research helps determine which factors of programs can be customized to help prevent suicide in specific groups of people and before being put into effect, prevention interventions should be tested through research to evaluate their effectiveness (8).

A recent teen suicide prevention campaign created by the Substance Abuse and Mental Health Services Administration (SAMHSA) called “We Can Help Us” focuses on changing the thoughts of young people contemplating suicide (10). The initiative actually empowers adolescents that they can help themselves, and there are many others just like them who have been in their situation and survived to tell others about it (10). The campaign website contains several personal stories from teenagers who have been clinically depressed or attempted suicide (10). In most of the stories, the teens did not seek help until things began to get out of control, or when they were so close to killing themselves it scared them into seeing a doctor about their problem (10). Many of them felt embarrassed about their condition and were too ashamed to seek help (10). Thus, the AFSP messages may not be helpful in many situations if those who are thinking about ending their life are not even seeking help from others or speaking about their feelings outwardly.

A third major flaw of the AFSP campaign is its failed use of advertising theory for a public health intervention. An article by Evans and Hastings focuses on public health branding and reports that “brands, recognition of brands, and the relationship between brand and consumer are essential to marketing and largely explain the tremendous success of product advertising and the growth of the global consumer economy…” (11). They define brands as a collection of associations tied to a specific name, mark, or symbol representing the product or service (11). Thus, in order to have a successful public health campaign and to effectively “sell” the product of interest (suicide prevention), the program should contain a recognizable image associated with it. The campaign should be marketed across several media outlets (i.e. television, radio, print ads, and the internet) and contain the same message and image throughout. Even though the AFSP campaign does use several different media outlets to convey their message, including television, radio, print ads, and the internet, it fails to have a recognizable image that reaches the target audience across a large population.

One of the most famous and successful marketing campaigns in the US is Nike. Their trademark “swoosh” is highly recognizable in American culture (13). Even more relevant is the largely successful “Truth” campaign, which intended to reduce the prevalence of smoking among adolescents (14). This campaign targeted teens across several media outlets, including television, radio, MySpace, YouTube, and Facebook. It empowered teens with the ability to rebel against tobacco executives by not smoking, and, according to an article by Hicks, “(a) study found that since 1998 the percentage of youth using tobacco in the past 30 days had declined by 7.4 percentage points… in middle school and 4.8 percentage points… in high school” (15). The campaign had such a powerful “brand image” that they are still selling apparel and other merchandise associated with the campaign. Even though the television advertisements have been taken off the air, the campaign website is still available for viewing (14). It is apparent that the AFSP program has not been able to reach this level of notoriety among its audience yet. The television advertisements do not promote a specific brand, symbol, or recognizable image one can associate with suicide prevention. There is also no connection between the colors, images, and people portrayed on television, the billboards, and their website.

Besides lacking a “brand image,” the campaign overall fails to have an effective “shock factor” that would essentially lead to change. The billboards displayed are targeted mainly toward adults and those who frequently drive on highways in Minneapolis and Nebraska (3). They are yellow and blue in color, and project these messages: “Depression: #1 Cause of Suicide,” “Prevent Suicide, See your Doctor,” and “Ohio Deaths 2004: Suicide 1319, DWI/DUI 495, Homicide 492” (3). Two of the billboards show a black and white photo of a person who died from suicide, but their deaths are dated in the 80s and 90s (3). An article on Wikipedia discusses the aspects of an effective billboard: “they have to be readable in a very short time because they are usually read while being passed at high speeds. Thus there are usually only a few words, in large print, and a humorous or arresting image in brilliant color” (12). Three of these billboards that list the number of deaths associated with suicide and other causes are much too difficult to read at high speeds. They also lack a captivating or shocking image to leave an impression on their audience. Calvin Klein is notorious for having shocking billboard advertisements that show models barely clothed engaging in risqué positions (16). The billboards usually do not even contain any words at all except for “Calvin Klein,” but the posters are very eye-catching and successful, as it appears in Times Square in New York City. It is unlikely that the billboard advertisements created by AFSP will be in Times Square any time soon.

Besides the billboards, the television commercials also lack a “shock factor” to captivate their audience. An advertisement promoting breast cancer awareness created by ReThink Breast Cancer shows a woman’s breasts throughout the entire commercial (17). Although somewhat controversial, the commercial is has reached a wide audience and has over 800,000 hits on YouTube (18). The “truth” campaign also had several shocking facts and images on their commercials, one of which included stacking body bags of the number of people who die annually from smoking outside of a large tobacco company (14). The AFSP commercials fail to captivate their audience with such imagery.

Creating an Effective Intervention

In response to the flaws that have been pointed out above, there is hope for an effective suicide prevention program. A 1993 article in American Psychologist looks at several approaches to suicide prevention efforts. They conclude that there are several more efficient and effective strategies to try to solve this problem (5). Garland, et al suggests implementing primary prevention programs, suicide prevention education for professionals, education and policy formation on firearm management, education of media professionals about the social “herd mentality” in adolescent suicide, more efficient identification and treatment of at-risk youth, and crisis intervention and post-intervention programs (5). In addition to these alternate approaches to creating a public health intervention aimed at suicide prevention includes that of the use of Stigma Theory.

An article in the International Encyclopedia of Public Health conveys that stigma is an omnipresent force that can have severe consequences and may even reduce the life opportunities of those being affected by it (19). Stigma results from a collection of internal psychological processes at the individual level, interpersonal social interactions between individuals and groups, and even larger impacts from the level of culture and politics (19). A news article from the United States Department of Defense explains how stigma associated with mental illness is the biggest block mental health practitioners are forced to encounter in helping patients in need, reducing suicide rates, and improving the military force (20).

According to the National Institute of Mental Health, more than 90 percent of those who die by suicide have depression, other mental health disorders such as bipolar disorder, or they have a substance-abuse problem often in combination with a mental health disorder (8). According to Johns Hopkins University psychiatrist Dr. Kay Redfield Jamison, "We have good treatments for the major psychiatric illnesses. What's difficult is getting people to recognize that they have a problem ... and to set aside the stigma or work around it" (20). An article in Clinical Psychology: Science and Practice discusses mental health stigma and demonstrates the connection between stigma signals, stereotypes, and behaviors in a comprehensive diagram, as shown in figure 1 (21).

Fig. 1: The relationship between discriminative stimuli and subsequent behavior

Clinical Psychology: Science and Practice 2006

The article argues that this model can be used to better understand the stigma around mental health (21). One of the most important descriptive stimuli involved with mental illness is that of labeling. According to labeling theory, those who are termed mentally ill, or those who are known to be labeled as such (i.e. being observed coming out of a psychiatrist's office), are subjected to stigma and the negative effects that result (21). A study found that those who were labeled "mentally ill" in the public had lower incomes than an equally impaired group without labels (21). The labels given to individuals with a mental illness in our society are a significant hindrance to those who need professional help. Because of this, many individuals may feel that going to see a psychologist or counselor as a bad thing, and not go at all. Many tend to consider what their friends or family would think of them if they revealed that they were going to see a psychiatrist or psychologist for their mental disorder, and sometimes the thought of being called “crazy” will prevent them from getting the treatment they need. In addition to labeling, many of the symptoms that are associated with mental illnesses, such as inappropriate or bizarre behavior, language impairment or irregularity, and talking to oneself out loud are another set of signals that may result in additional stigma toward mentally ill and may frighten the public (21). They also lead to stereotypes of dangerousness and social ostracizing, as demonstrated in Figure 1. Research has shown that these kind of behaviors and symptoms tend to produce an even greater stigma effect than that associated with labeling alone (21). All of these factors will lead to an individual with a mental illness to feel discriminated against, rejected from society, and maybe even hopeless. They may even feel that they do not want to burden their friends, families, or a doctor with their problems.

The main stigma associated with clinical depression is the corresponding treatment. Taking anti-depressant medication has a stigma attached to it that the person is reliant on their “crazy pills.” A British woman reports: “Well I'm too worried about telling people I'm on medication. There are very, very few people that I talk about the ECT to...because it does feel...well I don't really want to talk about it because I hate it and it's horrible and also I feel there is big stigma attached and if they hear about that they'd think I was really mad” (23). In addition, a 43 year old British man reported refusing treatment at a hospital because of the stigma associated with depression: “I regret not going to the hospital. I listened to too many people and I suddenly thought I am going to be labeled a loony. I wasn't aware obviously because it hadn't happened to me before so I was...yes it did stop me from going there” (23).

Thus, a successful public health intervention would be one that promotes positivity around seeking professional help for a mental illness and one that reduces the stigma associated with the act. The CDC reports that in 2006, 15.7% of Americans reported being diagnosed with clinical depression by a healthcare provider at least once in their lifetime, and many more go undiagnosed (22). This is a high prevalence in the population that should be disclosed to those who feel alone in their illness. A campaign that promotes this idea that there are several others who face the same day-to-day challenges and that there are several resources available for those in need is likely to succeed. A 40 year old woman with depression reports: “First of all I was relieved, the first time I saw the psychiatrist I talked to him for three hours. To have someone say that what I was feeling was not that unusual. I thought I was the only person in the world who felt like that” (23).

Looking to the successful campaigns mentioned above such as the “truth” campaign, Nike, and “ReThink Breast Cancer,” it would be effective to create an anti-suicide campaign that creates a brand image for itself and one that reaches across several media outlets, including television, radio, print ads, and many internet websites such as Facebook, Twitter, and YouTube. The campaign should create a positive slogan, such as “get help, stay alive,” or “choose life.” A brand image can be created by using the same font, colors, and characters in all forms of advertising. The focus of television commercials should be to educate the public about the prevalence of depression among adults and teenagers alike, and that no one is alone in their mental illness. The commercial should direct viewers to a website that contains resources for those who are depressed or thinking about committing suicide, and also for the general public to learn about their peers who are suffering silently. The campaign website should be colorful, inviting, and captivating to a wide audience, including young people. There should be real stories from those who suffer from a mental illness and how they decided to seek help and get treatment. It is important to empower the people suffering with the tools to help themselves. This will give them confidence that they can get better and will seek the treatment they need. In order to reach a wide audience across the nation, projecting the campaign on Facebook, Twitter, and YouTube is important. Facebook is a very important outlet for young people, and creating a captivating webpage here would be effective. In addition, Twitter and YouTube are also popular, and would probably reach an older audience at the same time. An additional media outlet to project the campaign could be through podcasts, which can contain a series of educational videos and audio that include teaching positive “self-talk” and empowering messages.

It is very important that the program is positive and projects a “choose life” message or a positive image around mental illness. Empowering the public to change and help themselves would lead to more positive outcomes instead of instilling fear and anxiety within them. Endorsing advertisements that show or describe gruesome suicides may lead to the opposite effect of what’s desired, as described earlier about suicide imitation (5).

To conclude, the American Foundation for Suicide Prevention’s campaigns, which can be found on television, radio, and billboards, fail to meet the needs of controlling the national suicide epidemic. Although it makes a commendable effort to promote suicide awareness, it is too fact-based, targets the wrong audience, and fails to use advertising effectively. An alternative solution to solving the problem of suicide would be to recognize and decrease the stigma associated with mental illness and its increasing impact on suicide. Empowering those in need with the tools to help themselves and increasing public acceptance and awareness of this problem will lead to a decrease in this horrible national tragedy.

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