Commentary on Need for National Anti-Stigma Campaign

Commentary: The United States Has a National Pro-Stigma Campaign.  It Needs a National, Evidence-Based Anti-Stigma Campaign to Counter It

 

Philip T. Yanos, Ph.D.

John Jay College of Criminal Justice/The Graduate Center, CUNY

Joseph S. DeLuca, MA

John Jay College of Criminal Justice/The Graduate Center, CUNY

Lauren Gonzales, Ph.D.

Adelphi University

In Press in Stigma and Health.

“©American Psychological Association, 2020. This paper is not the copy of record and may not exactly replicate the authoritative document published in the APA journal. Please do not copy or cite without author’s permission. The final article will be available, upon publication, via its DOI: 10.1037/sah0000223”

The publication of new findings on the United States (US) public’s views on mental illness by Pescosolido, Manago and Monahan (2019) is a punch in the gut to those of us who make the reduction of mental illness-related stigma our life’s work.  Findings indicate that, between 1996 and 2018, endorsement of the expectation that a hypothetical person meeting criteria for schizophrenia is likely to be dangerous has not decreased but increased, such that now nearly 70% of US residents expect the person to be dangerous.  Parallel to this change has been an increase in support for the use of coercive methods such as involuntary hospitalization, even for a vignette of an individual with non-clinical “daily troubles.”

Stigma is a global phenomenon, so it is important to consider what about the above findings is specific to the US.  As Pescosolido and colleagues (2013) have elsewhere demonstrated, expectations of violence are part of the “backbone” of stigma that is most persistent around the world.  Yet, findings indicate that other countries have chosen a different path in how to respond to mental illness-related stigma over the past 10 years.  The United Kingdom (UK), a nation that the US is culturally and economically similar to, can be looked at specifically for comparison.  In the UK, where the “Time to Change” anti-stigma campaign has been continuously operating for over a decade, attitudes and intended social distance toward people diagnosed with mental illness have steadily improved, with a roughly 10% improvement in attitudes toward and 11% decrease in desire for social distance from people diagnosed with mental illness from 2009-2017 (Robinson & Henderson, 2018).[1]

Researchers will correctly note that the methods used to measure stigma in the US and UK studies are different (specifically, UK researchers used measures asking about “mental illness” generally rather than focusing on responses to vignettes).  Yet, the clear difference in the direction of the findings (getting worse versus getting better), cannot be denied.  So, what is it that’s different about the US over the last 10 years?

Pescosolido and colleagues speculate that something about the public discourse in the US has led to an increased conflation of psychosis with violence (specifically after mass shootings), leading the public to absorb the false message that psychosis usually leads to violence and believe it to be fact.  We agree that mass media and political discourse are partly responsible.  A key difference between the US and our peer countries is the influence that organizations such as the National Rifle Association (NRA) have on discussions around mental illness.  NRA talking points about mental illness have two major themes: 1) people with mental illness are subhuman “monsters,” and 2) the mental health system fails in its responsibility to protect the US public from said “monsters” (New York Times, 2012).  These talking points are often echoed by political figures (including the US’s current president) (Rev.com, 2019), national news outlets (which mentioned a connection with mental illness in 73% of discussions of mass shootings in 2019) (McCormack, Ahmad, & Zweerink, 2019), or are presented in sanitized form by think tank writers who communicate with policy circles (Eide, 2020).  Evidence indicates that these talking points have had an impact on attitudes, with 83% of US residents endorsing the view (increased from 78% in 2011) that the mental health system’s presumed failure to identify dangerous individuals is to blame for mass shootings (Saad, 2019).  Mainstream mental health advocacy organizations protest these statements, but in many respects they have been complicit with the narrative put forth by organizations such as the NRA.  On occasions following a mass shooting, there is often a call for increased funding for mental health initiatives, and mental health advocacy organizations have not rejected these calls (Denis & Sun, 2013).  There are also specific “advocacy” organizations within the US that place a particular emphasis on promoting a connection between mental illness and violence, and whose voices compete with the voices of more mainstream organizations (Jaffe, 2011).  These organizations have a particularly strong influence on both media accounts and policy, and therefore have a potentially greater influence than more mainstream organizations.

So, what is to be done?  First, an alarm needs to be sounded and mainstream mental health advocacy organizations in the US (Mental Health America, National Alliance on Mental Illness, and the American Psychiatric Association) need to come together in demanding that presidential candidates place a national anti-stigma campaign on the national agenda[2].  We are particularly in need of this because of the pro-stigma efforts that organizations like the NRA have been waging[3].  Second, the campaign needs to be carefully constructed and led by stigma experts.  In 2016, the National Academy of Sciences issued a report authored by esteemed experts on the topic that lays out a roadmap for how this could be accomplished (Committee on the Science of Changing Behavioral Health Social Norms, 2016).  Contact, which can successfully override the effects of scientific skepticism, will clearly need to be a major component.  Targeting specific groups (as Canada’s campaign has done), including young people and the media, rather than just focusing on broad public service messages, might be a sensible strategy.  Third, the campaign cannot just focus on educating people about mental illness as a “brain disease,” as Pescosolido et al.’s findings indicate that endorsement of biogenetic explanations for mental illness are associated with greater endorsement of stigma.  Fourth, the campaign needs to have a sustained commitment.  This is essential since it appears that the effects of Time to Change were not evident until after year five of the campaign.

All of us need to get on board this train.  Stigma drives people away from services, leads people to lose hope and consider suicide, and causes them to withdraw from their communities and social ties.  We are all affected by stigma whether we have a mental illness diagnosis or not.  We cannot wait, so let’s put aside whatever differences we have for the time being and make this happen.

References

Burnam, M. A., Berry, S. H., Cerully, J. L., & Eberhart, N. K. (2014). Evaluation of the California Mental Health Services Authority’s Prevention and Early Intervention Initiatives: Progress and Preliminary Findings. Rand Health Quarterly4.

Collins, R. L., Wong, E. C., Roth, E., Cerully, J. L., & Marks, J. (2015). Changes in mental illness stigma in California during the statewide Stigma and Discrimination Reduction Initiative. Rand Health Quarterly5.

Committee on the Science of Changing Behavioral Health Social Norms. (2016). Ending discrimination against people with mental and substance use disorders: The evidence for stigma change. Washington, DC: National Academies Press.

Dennis, B., & Sun, L. H. (2013). After Newtown, support for mental-health spending grows. Washington Post. https://www.washingtonpost.com/national/health-science/after-newtown-support-for-mental-health-spending-grows/2013/02/23/0d8d75ca-7495-11e2-aa12-e6cf1d31106b_story.html

Eide, S. (2020). In defense of stigma. National Affairs. https://nationalaffairs.com/publications/detail/in-defense-of-stigma

Jaffe, D. J. (2011). There’s no stigma to having a mental illness. Huffington Post. https://www.huffpost.com/entry/theres-no-stigma-to-havin_b_850024

Link, B. G., & Phelan, J. (2014). Stigma power. Social Science and Medicine, 103, 24-32.

McCormack, A., Ahmad, A., & Zweerink, K. (2019). The Fox News spin zone.  Columbia Journalism Review. https://www.cjr.org/special_report/fox-news-gun-shootings.php

New York Times (2012). Text of the NRA speech.  Accessed online: http://www.nytimes.com/interactive/2012/12/21/us/nra-news-conference-transcript.html

Pescosolido, B. A., Medina, T. R., Martin, J. K., & Long, J. S. (2013). The “backbone” of stigma: Identifying the global core of public prejudice associated with mental illness. American Journal of Public Health, 103, 853-860.

Pescosolido, B., A., Manago, B. & Monahan, J. (2019). Evolving public views on the likelihood of violence from people with mental illness: Stigma and its consequences. Health Affairs, 38, 1735–1743.

Rev.com (2019). Donald Trump statement on mass shootings: Full transcript of speech and remarks. Rev.com. https://www.rev.com/blog/donald-trump-statement-on-mass-shootings-full-transcript-of-remarks

Robinson E. J., & Henderson, C. (2018). Public knowledge, attitudes, social distance and reporting contact with people with mental illness 2009–2017. Psychological Medicine, 1–10. https://doi.org/10.1017/S0033291718003677

Saad, L. (2019). More blaming extremism, heated rhetoric for mass shootings.  Gallup News.  https://news.gallup.com/poll/266750/blaming-extremism-heated-rhetoric-mass-shootings.aspx

[1] Note that Canada has also been operating a national campaign, Opening Minds, since 2009, but has not published data on changes in attitudes or intended social distance that would allow for a comparison with US figures.

[2] Note that some local campaigns have been initiated in the US, most notably, California’s statewide initiative Each Mind Matters.  Results from this initiative were mixed, however, with analyses indicating that over a one-year period, California residents became more aware of the program’s slogan, endorsed more awareness of stigma, and reported lower intended social distance, but showed minimal to no change in regard to peer support or recovery beliefs and reported being significantly less likely to disclose a mental health diagnosis (Burnam, Berry, Cerully, & Eberhhart, 2014; Collins, Wong, Roth, Cerully, & Marks, 2015).  These findings might be partly due to the limited time period studied, and that any local campaigns in the US are likely to be of limited effectiveness given that there is significant shared media and interaction between the US’s 50 states.

[3] We hesitate to speculate about the motivation for this effort, but it is plausible that it is driven, at least in part, by interest in maintaining power and influence, as suggested by some stigma theorists (e.g., Link & Phelan, 2014).

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