Ending Discrimination Against People with Mental and Substance Use Disorders The Evidence for Stigma Change (2016) / Chapter Skim
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1 Introduction
1 Introduction
Pages 15-32
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From page 15... ...
Scholars and scientists have pointed to persistent stigma as a major barrier to the success of mental health reform. Stigma occurs and so needs to be addressed at multiple levels of society including the structural level of institutional practices, laws, and regulations; among both the general public and groups, such as health care providers, employers, and landlords; and as self-stigma, which reflects internalized negative stereotypes.
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From page 16... ...
protects people with mental disorders against discrimination in many areas of civic life, and it defines discrimination to include a range of actions, for example, segregation of persons with mental disorders in public arenas, such as nursing homes and employment settings; screening that intends to or does screen out people with mental disorders; and failure to make reasonable accommodations to the known disability of an otherwise qualified individual with a mental illness. In 2003, the President's New Freedom Commission on Mental Health declared that recovery was possible and identified stigma and the fragmentation of the mental health care system among the major barriers to care.
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adults said they had experienced a mental health problem within the past year; and 4 percent said that they had experienced a serious mental illness, one that met standard diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (Center for Behavioral Health Statistics and Quality, 2015) .2 In another survey regarding substance use, 24 million Americans aged 12 and older (9.4% of the population)
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Deinstitutionalization policies brought people with mental illness out of state hospitals and into the public sphere, and the community, mental health movement arose with participation from former patients, their families, and treatment providers. Part of the overall deinstitutionalization plan had been to provide services at the local level, but community mental health services were underdeveloped and underfunded as the savings from closed hospitals was often redirected to cover state budget shortfalls (Grob, 1991)
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. Despite extensive research on stigma and general agreement that stigma is persistent, harmful, and discriminatory, the evidence about what works to change negative behavioral health social norms is sometimes conflicting and not uniformly robust (Livingston et al., 2012; Pescosolido, 2013; Stuart and Sartorius, 2005)
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will use the recommendations for strategic planning within an ongoing program of research in the area of social norms and communications practices and to inform the SAMHSA Office of Communication's future activities to change behavioral health social norms. The committee will review and discuss evidence on (1)
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and label avoidance. People avoid being labeled with a behavioral health problem because of concerns about resulting discrimination or social rejection, and although this certainly occurs, self-disclosure of mental or substance abuse disorders can also have positive outcomes related to help-seeking and feelings of inclusion.
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and related evidence linking prevalent public attitudes and the experiences of people with mental illness (Evans-Lacko et al., 2012a; Mojtabai, 2010)
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Although it is beyond the scope of this report to describe the perspectives and debates among the stakeholders, some current controversies that may impede efforts to combine and leverage resources to reduce stigma are briefly described in this section. Different Diagnostics: DSM and RDoCs The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
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A services agenda has the goal of increasing access to and quality of health care services by people with mental and substance use disorders; a rights agenda applies a social justice approach to eliminate discrimination and promote equality and full civil rights (Corrigan, 2015)
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. A concern on the part of some behavioral health experts is that services agendas and mental health services researchers do not focus on people who are not seeking treatment and that this is a population in need of research attention.
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Among adults, women are more likely to obtain services from the general medical sector, while men are more likely to obtain services from specialty providers. The complexity of behavioral health care funding and service delivery systems challenges policy makers' efforts to implement and evaluate programs as part of health care reform (Garfield, 2011)
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. Access to lifesaving medical technologies, such as cardiac catheterization and revascularization procedures, is also less likely for people with mental disorders due to socioeconomic factors, lack of insurance, geographic remoteness from tertiary medical centers, and cognitive impairment that complicates informed consent and effective provision of aftercare (Druss et al., 2000)
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In fact, people with mental and substance use disorders are not a discrete, static, or homogeneous group. There is considerable variability across behavioral health conditions; among individuals in the
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Paired with the Affordable Care Act, which prevents insurance companies from denying coverage to people with preexisting conditions, including schizophrenia, depression, bipolar disorder, and drug or alcohol disorders, and allows people to remain on their parent's health plans until the age of 26, these legislative changes represent major steps forward in advancing the rights of people with mental and substance use disorders. Unfortunately, other forms of structural discrimination persist despite protections offered by the ADA and the ADAAA of 2008, which expanded protections for people with mental illness, along with the Fair Housing Act (Bazelon Center for Mental Health Law, 2014; Stuart, 2006)
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Chapter 4 presents the evidence on the effectiveness of stigma change strategies, including legislative and policy interventions, education, interventions that promote positive social contact between people with and without behavioral disorders (contact-based programs) , advocacy, and
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Chapter 5 outlines a research strategy for planning, implementation, and evaluation of stigma change campaigns, including a discussion of measurement of stigma-related constructs, research and design considerations, and cost-benefit analyses. The committee suggests areas of research and research questions for future inquiry into the nature of stigma and stigma change.
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