A new report recently released by the National Academies of Sciences, Engineering, and Medicine (NAS) recommends a federally led, comprehensive approach to reduce the continuing stigma associated with mental health disorders and substance use disorders. A special NAS committee was created to delve into the reasons that stigma still persists and its consequences, as well as identifying evidence-based approaches to addressing stigma.
The study, Ending Discrimination against People with Mental and Substance Use Disorders: The Evidence for Stigma Change, highlights that stigma continues to be high, especially regarding schizophrenia and substance use disorders.
Even with increased knowledge and awareness, the committee said that beliefs about the underlying causes of substance use disorders have shifted away from the idea of illness in the direction of blame. This is true even though understanding, knowledge, and willingness to talk about the conditions have risen dramatically.
The NAS report shows that there are several effective efforts to reducing stigma such as contact-based mental health anti-stigma interventions where people with lived experience of mental illness interact with the public describing their challenges and stories of success. Additionally, the research shows that in-person contact and video contact were very effective intervention types for changing attitudes and reducing social distance.
However, the NAS report makes very clear that changing stigma in a lasting way will require coordinated efforts based on the best possible evidence, which are supported at the national level and planned and implemented by a representative coalition of stakeholders.
Stigma Occurs at Three Levels
The NAS study shows that at an institutional level, courts, school systems, businesses, social service agencies, universities, and the government all stigmatize those with mental health or substance use disorders. One consequence is that those with the disorders are overrepresented in the criminal justice system.
At the public level, educators, employers, journalists, and members of law enforcement also stigmatize and stereotype individuals with mental health disorders or substance use disorders. In addition, and at another level, individuals with behavioral health disorders self-stigmatize, avoiding disclosure of their illnesses or not seeking treatment for fear of being labeled.
Evidence-Based Strategies to Reduce Stigma
The report identified several strategies to address stigma related to mental health and substance use disorders, including, but not limited to:
- Education, such as mental health literacy campaigns;
- Advocacy and protest (e.g., letter writing and Twitter campaigns, etc.);
- Programs that facilitate social contact between people with and without behavioral disorders (contact-based programs);
- Contact-based education programs, which combine contact with educational content designed to raise public awareness of selected issues or increase public knowledge about mental health and substance use disorders;
- Media campaigns delivered over a range of platforms, including traditional and newer social media; and
- Peer programs in which people who have disclosed their conditions offer their experience and expertise to individuals and families, programs that range from informal peer-led programs to peer specialized services in health services systems.
According to the report, disclosure of one’s experience with mental or substance use disorders, which is central to both contact-based programs and peer programs of all types, has both risks (being labelled, experiencing discrimination) and benefits (increased likelihood of receiving treatment, decreased self-stigma, increase feelings of inclusion). Ideally, it is done selectively in an informed, supported, and planned manner.
Contact-based interventions alone and contact-based education programs have the strongest evidence base for reducing stigma. Educational programs alone are not effective for adults, but are effective in changing younger people’s attitudes.
The NAS Committee said that communication campaigns can be effective, but tend to fail for two reasons: failure to identify well-defined goals for the campaign and failure to reach the intended audience or audiences in a sustained or adequately frequent manner. Protest and advocacy strategies serve to expand the stakeholder base, garner support, and provide a forum for consensus.
Regardless of the type of intervention, anti-stigma strategies have often resulted in both intended and unintended consequences.
The NAS Committee did identify several general features of effective communications’ programs that can inform the work of organizations that are implementing anti-stigma and anti-discrimination initiatives:
- Identify specific target groups and specific goals appropriate to each group (e.g., legislators and policy makers, employers and landlords, educators, health care practitioners, and people with mental health and substance use disorders).
- Make strong appeals that are relevant and personally consequential to particular audiences, for example, young people or veterans.
- Understand how a particular audience orients to a message and what kinds of cues and styles hold their attention so that the message is absorbed and remembered.
- Know what matters most to a specific target group.
The committee identified structural stigma and stereotypes of dangerousness and unpredictability as major sources of public and self-stigma. The committee said that given the importance of reducing stigma in these areas, early efforts should focus on development of a communications campaign that targeted policy and decision makers to challenge specific laws, policies and regulations that discriminate against people with mental health and substance use disorders.
Such a campaign could develop evidence-based public service announcements to hold in readiness for tragic events, such as mass violence, suicide by school and college students, and suicide clusters.
Overarching Recommendation and Tasks
As part of a comprehensive effort to reduce stigma, the committee recommended the Department of Health and Human Services (HHS) should initially take lead responsibility among federal partners and key stakeholders in the design, implementation, and evaluation of a multipronged, evidence-based national strategy to reduce stigma and to support people with mental health and substance use disorders. Key tasks under this recommendation include:
- Evaluate current laws and regulations related to persons with mental health and substance use disorders to identify opportunities to promote changes to support people on the path to recovery.
- Support the development of a strategic plan for research and dissemination of evidence about effective strategies to change social norms related to mental health and substance use disorders
- With the federal agencies and other partners, HHS would then develop a process of identifying and engaging grassroots efforts in each state to promote the implementation of evidence-based programs and fidelity monitoring of service delivery.
Click here for more information about the NAS report.
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