Challenging the Stigma of Mental Illness: Lessons for Therapists and Advocates

Reducing the stigma of mental illness

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Contrasting perspective on erasing the stigma of mental illnesses: What says the dodo bird? Lack of contact fosters discomfort, distrust, and fear Cook et al. Contact interventions aim to overcome this interpersonal divide and facilitate positive interaction and connection between these groups Shera, In contact-based behavioral health anti-stigma interventions, people with lived experience of mental illness or substance use disorders interact with the public describing their challenges and stories of success.

These strategies are aimed at reducing public stigma on a person-to-person basis but have also been shown to benefit self-stigma by creating a sense of empowerment and boosting self-esteem Corrigan et al. Historically, contact with people with mental and substance use disorders occurred in person and through video, but now contact increasingly occurs over the internet.

A Norwegian survey conducted in found that almost 75 percent of participants found it easier to discuss personal problems online rather than face to face, and almost 50 percent said they discuss problems online that they do not discuss face to face. For young people in particular, online interaction might be especially beneficial and appealing.

Online help-seeking is quite prevalent among adolescents who often feel empowered online and take comfort in the anonymity an online environment provides Gould et al. The Australian internet-based mental health service Reach Out! Frequently, contact-based interventions are combined with education where factual information is presented, and the people with lived experience support and personalize the information by relating it to their own life experiences. Results of a meta-analysis of 79 studies found that effect sizes for contact on attitude change and intended behaviors were twice those of education alone Corrigan et al.

In another meta-analysis, interventions combining education and contact were equally effective as education-only interventions Griffiths et al. Although combined interventions generally show an advantage over educational interventions alone, they are implemented less often Borschmann et al. A systematic review of anti-stigma programs aimed at college students by Yamaguchi and colleagues found that in-person contact and video contact were the most effective intervention types for changing attitudes and reducing social distance.

Corrigan and colleagues found that in-person contact is superior to video contact, with in-person contact having twice the effect size as video contact. A systematic review of 13 studies found that education and contact-based interventions are commonly used for stigma related to substance use disorders Livingston et al. The preponderance of available evidence suggests that interventions that combine contact with education will be most effective. Because contact-based strategies can be used to reduce both public and self-stigma, there is a wide range of potential intervention targets.

One approach to integrating contact-based interventions into day-to-day activities is through the use of peer services see Chapter 3. When integrated into service-provision teams, peers can help others to identify problems and suggest effective coping strategies Armstrong et al. An example is found in Active Minds, a grassroots college student mental health advocacy group that reaches out to young people on college campuses across the United States with several programs including a speakers bureau. Peer support also acts as a counterbalance to the discrimination, rejection, and isolation people may encounter when trying to seek mental or substance use treatment and services.

The supportive effects of peer interventions can help sustain longer term and more regular treatment utilization Deegan, ; Markowitz, ; Solomon, Ultimately, peer services can advance both the rights and the services agenda by facilitating treatment-seeking, fostering greater employment options, enhancing quality of life, and increasing self-efficacy in the peer service providers Akabas and Kurzman, ; Gates and Akabas, The value of peer support services in both traditional health care settings and independent programs is well recognized.

Professionalization of peer services can be seen as part of overall efforts to improve the quality of behavioral health care and services in the United States through a certification process, such as those that exist for other providers of care and services to those with mental and substance use disorders.


The program has spurred the development of a peer support workforce that can be mobilized across states. A certification commission provides independent oversight to the program and has developed guidelines for achieving competency in a wide range of domains: Protest strategies are rooted in advancing civil rights agendas.

In the context of this report, protest is formal objection to negative representations of people with mental illness or the nature of these illnesses. Protests are often carried out at the grassroots level by those who have experienced discrimination and by advocates on their behalf. A call to action can also energize unengaged stakeholders by raising awareness about the harmful effects of stigma. Group protests also provide opportunities for stakeholders to meet and develop a sense of solidarity and common purpose.

Target groups for protest and advocacy campaigns are opinion leaders, such as politicians, journalists, or community officials. The goal is typically to suppress negative attitudes or to remove negative representations or content. When protest focuses on legislative reform, the goal is often to enhance or enact protections of rights, increase access to social resources, and reduce inequalities. Activities in the early years of the campaign included ACT UP members chaining themselves to the offices of pharmaceutical companies involved in the development of experimental drug treatment.

Unfortunately, the available evidence concerning the outcomes of protest related to mental illness suggests that while protest may have positive outcomes in some instances, these strategies may also trigger psychological reactance or a rebound effect in which negative public opinion is strengthened as a result of the protest Corrigan et al. Monitoring discussions around protest and related strategies in newspapers, radio, and television, as well as social media can aid in efforts to evaluate the outcomes of these strategies.

The internet serves as a potential platform for advocacy and for monitoring changes in social norms. Psychiatrists and psychologists in particular have been identified as potentially valuable voices against stigma online, and there are calls for health professionals to take up advocacy blogging to further educate the public about mental health conditions and counter stigmatizing stereotypes Peek et al.

The United States has a long history of using legal and policy interventions to protect and normalize stigmatized groups Cook et al. In the s and s, there was a significant drop in the mortality rate of black Americans that can be linked to legislation that prohibited racial discrimination in Medicare payments for hospital-based care Almond et al.

In , in part as result of mental health advocacy efforts, Congress amended the Americans with Disabilities Act ADA to allow people with mental illness to be covered by the ADA even when medication. The ADAAA also recognizes that people may have intermittent symptoms and that some people are treated unfairly as a result of perceived rather than actual impairment. Throughout this report, the committee stresses the important of addressing stigma at the structural level.

Much of the knowledge base concerning structural stigma, including empirical evidence, concepts, and theories, comes from research on gender and ethnic or minority differences. Structural stigma can be intentional or unintentional, overt or covert. Policies that disqualify people with mental illness from receiving health insurance coverage are an example of overt structural stigma; in contract, failure of police officials to distinguish between mental health apprehensions and suicide attempts on criminal record checks is an example of covert structural stigma or of stigma at the structural level Mental Health Commission of Canada, Researchers in the United States have found that people with mental illness favor approaches that address institutional and structural discrimination over those that focus on public education Mental Health Commission of Canada, Addressing sources of structural stigma can also promote mental and physical well-being, for example, medical and mental health care visits by lesbians, gay men, and bisexuals decreased after same-sex marriage was legalized in Massachusetts Hatzenbuehler et al.

Mental illness, stigma & discrimination - Wulf Rössler

Multidisciplinary, multilevel ecological approaches are needed to understand and address structural stigma and to engage groups and organizations, including lawyers, journalists, educators, and business and property owners, to address the root causes of structural stigma. The section describes the findings from large-scale campaigns in and outside the United States, including three national-level campaigns from Australia beyondblue , Canada Opening Minds , and England Time to Change.

Challenging the Stigma of Mental Illness: Lessons for Therapists and Advocates

The large-scale campaigns in the United States reviewed by the committee included the Eliminations of Barriers Initiative and What a Difference a Friend Makes, along with notable state-based initiatives such as the California Mental Health Services Authority, and efforts on the part of the U. Departments of Defense and Veterans Affairs VA to reduce mental health stigma and encourage treatment-seeking among members of the military and military veterans, including Make the Connection and the Real Warriors campaign.

Under the California Mental Health Services Act, a statewide prevention and early intervention program was set up, composed of three strategic initiatives that focused on 1 reduction of stigma and discrimination toward those with mental illness, 2 prevention of suicide, and 3 improvement in student mental health. Each initiative is implemented with the help of community partner agencies. Preliminary evaluations of the act show that social marketing materials designed for the program reached a large number of Californians.

Beyond the reach of the materials, findings show that stigma against mental illness has decreased in California, with more people reporting a willingness to socialize with, live next door to, and work with people experiencing mental illness. People also reported that they are providing greater social support to those with mental illness Collins et al.

In particular, Make the Connection focuses on sharing positive stories of veterans who reached out to receive help for their mental health problems Langford et al. The Real Warriors campaign is a large-scale multimedia program with the goal of facilitating recovery, promoting resilience, and supporting the reintegration of service members, veterans, and families.

The Real Warriors campaign is based on the health-belief model and serves as an example of an evidence-based media campaign, and notably one informed by ongoing independent evaluations Acosta et al. The committee focused on Time to Change England , Opening Minds Canada , and beyondblue Australia because of the national-level scale of these campaigns and the robustness of the outcome evaluations see Table The committee invited researchers from these three campaigns to present their findings at a public workshop held by the committee in April see Appendix A.

Presenters were asked to address three questions: The researchers were also asked to share both the successes and the challenges of the campaigns. The committee members discussed the information obtained during the workshops and from the relevant peer-reviewed literature and deliberated about how best to apply the findings within a U.

The three foreign campaigns are summarized below based on the key questions stated above. Table and the discussion that follows summarize the lessons learned from successful well-evaluated national-scale campaigns about how to inform a national dialogue and improve public attitudes and behaviors concerning people with mental and substance use disorders at the population level using multifaceted, long-term strategies that engage state, local, and grassroots community groups; permit the scaling up of successful smaller scale interventions; and facilitate research on what works to reduce stigma in population subgroups, such as racial and ethnic minorities and relevant target groups, such as educators, employers, and health care providers.

Findings from the evaluation of Time to Change in England highlight the importance of long-term data collection, establishment of baseline trends, and ensuring a match between complex, evolving social processes such as prejudice and acceptance with nuanced triangulated evaluation methods, while specifying outcome indicators targets for change as knowledge, attitudes, or behaviors Evans-Lacko et al.

Funding covered the development and implementation of the anti-stigma activities, as well as evaluation activities, including the collection of nationally representative baseline data and follow-on surveys of the English population from which progress could be measured in the future. Funding also allowed the campaign to do formative research during the first year involving more than 4, people with direct experience of mental health problems to provide input on stigma and discrimination and specific targets for change, which then guided the campaign.

Based on insight from the developmental phase, the mass media campaign including national television, print, radio, and outdoor and online advertisement and social media as well as cinema targeted specific groups of individuals. The film Schizo, 9 one component of the national-level campaign, was shown in movie theatres across the country, and later adapted for use in the United States. Nationally representative surveys of the general public concerning knowledge, attitudes, and behavior in relation to people with mental health problems were used to assess change over time.

Data were collected at the community level during these social contact events in different cities across England to assess the relationship between the quality of the social contact and intended stigmatizing behavior and campaign engagement. Grassroots-level components also included volunteer-led activities contact-based and peer-service programs at college campuses and other public places that provided data on the impact of disclosure of mental or substance use disorders on self-stigma and the sense of well-being and empowerment, again through the use of validated tools.

Time to Change is notable for the depth and breadth of its evaluation. Although the campaign included various types of activities at multiple levels of society, the main outcome measures were common across most activities. To assess changes among the general public, the main outcome measures included the following validated assessments: Additional assessments included monitoring of changes in media reporting; surveys of relevant groups including trainee teachers, medical students, and employers; and cost-benefit analyses.

The multilevel, multifaceted approach increased public understanding of stigma and discrimination against people with mental illness, which formative research in the first year had revealed to be low at the start of the project. Triangulation, use of a variety of different research methods, allowed the researchers to tease apart complex social norms about mental illness and increased understanding of the mediating role of social contact in explaining the effects of the anti-stigma interventions.

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Challenging the Stigma of Mental Illness: Lessons for Therapists and Advocates. Patrick W. Corrigan, David Roe, Hector W. H. Tsang. ISBN: Mental illness deprives many people of opportunities to live full and Challenging the stigma of mental illness: Lessons for therapists and advocates.

The findings also underscore the importance of measuring both direct and indirect effects, and to consider the mechanisms of change including openness and disclosure, contact, and awareness. The national scale social marketing campaign included mass media components and assessment of knowledge, attitudes, and behavior across the country.

The social marketing mass media component of the campaign was most effective at influencing intended behavior toward people with mental illness. Other intended behaviors, including willingness to work with, live nearby, or continue a relationship with someone with a mental health problem, showed more modest improvements. Critically, there was also a significant reduction in levels of discrimination reported by people with mental illness.

Assessment of newspaper coverage across England revealed an increased proportion of balanced, anti-stigmatizing articles reporting on mental health issues. Time to Change adds to the growing evidence base supporting the effectiveness of social contact and demonstrates the value of creativity in designing community level, contact-based programs to reduce public stigma. The grassroots-level activities reduced self-stigma through its community initiatives.

Among the participants with mental health prob-. Participants were asked to describe their meetings in terms of positive contact factors including the sense of social equity and the feeling of working together toward common goals. People without mental illness who reported more contact factors were more likely to say that they would be more supportive of people with mental illness in the future Evans-Lacko et al. In this study, data were synthesized from a number of interventions across England.

The findings indicate that social contact interventions can be implemented and evaluated on a large scale, and suggest that larger sample sizes and the use of control groups could facilitate research on differences among population subgroups. Finally, Time to Change provides data on the cost-effectiveness of long-term, multilevel, national-scale anti-stigma efforts. Awareness was strongly associated with campaign burst expenditure and increased awareness was positively associated with increased knowledge, more favorable attitudes, and improved intended behavior.

The annual program cost for Time to Change was 0. In the s, the Australian government launched a national initiative to improve the knowledge and skills of primary care practitioners and other health professionals regarding mental health problems. At the time, the knowledge and skills of the general public were not seen as important. The initiative grew out of efforts beginning in the s to improve the knowledge and skills of primary care practitioners to address mental health problems.

There were five priority areas: Information was disseminated and messages conveyed over multiple media platforms, including television, radio, the internet, and print media.


The activities are largely funded by the Australian national government and some of the territorial state governments, with some financial and in-kind support from nongovernmental sources. The organization began its work in as a 5-year initiative yet it continues. There were many varied activities including mass-media advertising, sponsorship of events, community education programs, training of prominent people as champions, and web and print information. Mental Health First Aid training was developed in Australia in by Betty Kitchener starting as a small volunteer effort that has now been replicated in many other countries Clay, Other prominent interventions included Mind Matters, programs in high school that are incorporated into regular lessons; RUOK Day—people ask others about their mental.

The campaign also provides funding to initiate and continue research on depression and anxiety, and over the course of the campaign, the funded research activities have grown in number and been more aligned with stakeholder-identified priorities Dunt et al.

Periodic surveys of national mental health literacy were conducted in Australia from the mids allowing researchers to monitor trends in public attitudes before and during the implementation of beyondblue.

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They would prefer a rights-based or social justice model that shifts the emphasis away from attitudes to the need for social and economic equity for people with disabilities in all areas of life, including access to health services, education, and work. Schizophrenia Bulletin, 33, Factor analyses of family stereotypes, prejudices, and discriminations. This report contributes to national efforts to understand and change attitudes, beliefs and behaviors that can lead to stigma and discrimination. Organizations such as Time to Change http:

Survey respondents viewed vignettes of depressed persons and then responded to questions about a range of possible interventions seeing a psychologist, taking antidepressants, having psychotherapy, and dealing with it alone and whether they thought these would be effective in treating depression. During its first 5 years, beyondblue had higher levels of activity in some Australian states and territories than in others, creating de facto treatment and control groups. In states with higher levels of activities those that provided a higher level of support , there was greater improvement in public awareness of depression as a problem, beliefs about the benefits and efficacy of treatment, and positive attitudes about people with depression Jorm, ; Jorm et al.

Meta-analyses of trials of Mental Health First Aid training program outcomes show moderate increases in knowledge about mental illness and smaller effects on attitudes and behaviors. Improvements were sustained over 6 months.


To date, the program has trained and certified 2 percent of Australian adults, with a goal of 11 percent. People and organizations will pay for this training as they pay for other first-aid training. This allows program sustainability beyond government funding periods Jorm and Kitchener, Although the researchers are not certain which interventions led to these improvements, it is clear that the concept of mental health literacy as a desirable aim was incorporated into national and state policy goals. A national survey found that at the year mark in the implementation of the campaign 87 percent of Australians were aware of its work.

Between the publication of the first beyondblue report in and the second in , there was a significant nationwide increase in the availability of primary care services for depression Dunt et al. According to the report, researchers were unable to determine whether people with depression experienced a reduction in stigma and discrimination as pub-.

The Mental Health Commission of Canada was launched in with federal funding. It is the largest systematic effort of its kind in the history of Canada. The commission began Opening Minds with a small, public education media campaign designed to communicate positive messages about people with mental illness. The results were disappointing and the commission decided against a costly, long-term social media campaign Stuart et al.

Instead, the project team issued a request for interest. It was distributed to a wide network of government agencies, universities, stakeholders, and existing grassroots anti-stigma programs across Canada. These initiatives shared one thing in common: The project team linked them with Opening Minds researchers for evaluation and scale-up of effective programs. Work focused on four target groups: Principal investigators were recruited from leading Canadian universities for each target group. The project teams used similar evaluation strategies so that researchers could compare outcomes across settings to help determine which program activities would yield the greatest effects.

The goal was to develop effective, evidence-based models that could be replicated and disseminated to other communities and stakeholders who want to begin antistigma efforts. This activity brings together youth from local high schools to a regional summit where they participate in exercises, learn about the problems created by stigma, and hear stories from people with lived experience of mental health problems or mental illnesses. Equipped with toolkits and examples of anti-stigma activities, these students go back to their schools and lead anti-stigma efforts bringing mental health awareness along with messages of hope and recovery.

The youth champions are also supported by a coordinator who links them with a coalition of community groups, which also provides resources and access to speakers. The program comprises a 2-hour workshop that includes six key ingredients such as a PowerPoint show of famous people with mental illness that also functions as an introduction to stigma; a group exercise comparing earaches with depression to illustrate the need for timely treatment and social support; a short discussion of the definition of stigma as a form of prejudice and discrimination; along with locally made films, myth-busting countering myths about mental illness , and a keynote speech by a person with mental illness that engenders discussion among participants.

Workshops were originally developed for use by emergency room staff, but they were later adapted for other groups. The program objectives are to raise awareness among health professionals of their own attitudes; to provide them with an opportunity to hear personal stories of mental illness, hope, and recovery from people with mental illness; and to demonstrate that health care providers can make a positive difference. The program also includes pre- and posttests as well as take-home resources and the opportunity to sign an anti-stigma commitment.

Reporting on Mental Health 12 includes sections that help journalists distinguish among various mental disorders stressing that mental illness is a broad category and reporting should specify diagnoses , and guidelines for interviewing people with and about mental illness, and appropriate language to use when reporting on mental illness, suicide, and addiction. Researchers evaluated the Opening Minds programs using mixed methods, including qualitative methods such as focus groups and standardized instruments to measure stigma and social distance pre- and postprogram implementation.

The researchers developed fidelity scales for contact-based education programs. This was done to ensure that programs followed best practice guidelines. In the Opening Minds campaign, researchers worked with existing anti-stigma initiatives and aided them in evaluating their programs and implementing change to improve those outcomes.