A significant body of evidence has begun to emerge for changing stigmatizing public attitudes toward mental illness. Strategic stigma change (SSC) is, in a nutshell, in vivo contact between people in recovery and targeted members of the general public. Public stigma represents the prejudice and discrimination that affect people with mental illness when appreciable segments of the general population endorse negative stereotypes about psychiatric disorders (1,2). Although eliminating prejudicial attitudes is important, most advocates desire behavior change—quashing discrimination or, viewed more affirmatively, promoting social inclusion (3).
The convergence of evidence has led to five principles that constitute SSC. This column reviews their implications for social marketing, the paradigm that now guides large-scale, mainly government-funded, antistigma programs. SSC targets many types of stigma. Although this column addresses public stigma, SSC can be adapted for other types, including self-stigma and label avoidance (4,5).
SSC evolved over ten years of collaboration among investigators at the National Consortium on Stigma and Empowerment (NCSE), which is housed at the Illinois Institute of Technology. NCSE and coinvestigators at Yale University, the University of Pennsylvania, Temple University, and Rutgers, the State University of New Jersey have been supported by funds from the National Institute of Mental Health and have completed research and development through extensive partnerships with consumer advocacy groups and other stakeholders. Many of our first-generation studies were summarized in a 2005 article (1), and the entire portfolio of research can be found on the NCSE publications page (www.stigmaandempowerment.org). More recently, SSC has been informed by evaluations of social marketing efforts of the U.S. Department of Veterans Affairs and Department of Defense and of the State of California.
The Best Practices column typically addresses strategies of interest to service providers of all kinds. A different audience is addressed here, namely advocates whose agenda is defined by the pernicious effects of stigma and the importance of stigma change. Advocates are broadly defined and include current and past service users, persons who are eligible for services but have chosen not to seek them, and persons who might identify themselves as survivors or ex-patients. Family members frequently join advocacy groups, as do many provider organizations. Professional groups such as the American Psychiatric Association and World Psychiatric Association have joined the “movement” against stigma in the past few years.
The five principles or strategies are defined by the acronym TLC3: targeted, local, credible, continuous contact.
Contact is fundamental to public stigma change
Contact with people with mental illness is fundamental to public stigma change. In this context, contact should be distinguished from education. Education is the most common form of antistigma program and typically contrasts the myths of mental illness with facts. Contact involves planned interactions between people with mental illness and key groups. Although research has examined video or other media-based contact, in vivo or face-to-face contact seems most effective (6). Research generally shows that contact (or contact integrated with education) has greater effects than education alone on attitudes and behaviors (although behaviors are more difficult to assess and thus are less often examined) and that positive outcomes of contact seem to last longer than the effects of education (1,7). Several factors enhance contact and are incorporated into the other four SSC principles.
Contact needs to be targeted
Rather than focusing on the population as a whole, contact is more effective when it targets key groups, typically people in positions of power, such as employers, landlords, and health care providers (8). Other important SSC target groups include faith-based and other community leaders, legislators, school personnel, entitlement counselors, and media outlets. Targeting not only suggests the “who” of strategic contact but also the corresponding “what”: what needs to be changed. Negative behaviors need to be changed to affirming behaviors: more employer hires, landlord leases, and high-quality health services for people with mental illness. Each of these goals involves specific behaviors that are included in SSC objectives. For example, employers with job openings need to interview people with mental illness, consider reasonable accommodations, offer positions, and provide appropriate supervision that may include job coach participation.
Venue and timing must be considered in plans to contact targets. Where are good places to contact targets? Large numbers of employers can be contacted through civic groups such as Rotary International. Times and opportunities for planned contacts may already exist. For example, weekly staff meetings and grand rounds offer excellent opportunities for contacting health care providers.
All elements that define the target inform the message. What information should be incorporated in the message? As research has shown, contact stories include “way down” messages (the person experienced symptoms and disabilities that impeded goals) and “way up” messages (the person achieved recovery and attained goals). These stories culminate in the stigma punch line, namely, that despite the way-up message, many goals are impeded by stigma and ongoing discrimination. However, this generic message typically needs to be enhanced for specific target groups. Employers want to know that employee recovery means successful work outcomes, and landlords want to know that tenants with mental illness respect property.
Local contact programs are more effective
The interests of target groups are influenced by locally defined exigencies. “Local” has several meanings but may include geopolitical and diversity factors. For example, it seems reasonable to assume that a target group's interests are shared within a geographical region, such as the Northeast, or more narrowly within a state, such as Vermont. Nevertheless, Vermont is more homogeneous than many other states, where there is usually greater variation in rural, urban, and suburban considerations. It is also important to consider sociopolitical factors in more narrowly defined areas. Large cities include neighborhoods of varying socioeconomic status, and this variation is likely to influence target group interests. For example, employers in impoverished parts of a city and in wealthy suburbs will require different types of contact. Resources for people with mental illness differ in rural and urban areas, which calls for different contact programs. Research findings on racial-ethnic disparities in health and health care underline the importance of considering ethnicity and religious background in crafting local contact programs. These are just a few examples of the array of factors that need to be considered in developing local strategies.
Contacts must be credible
Three considerations guide credibility. First, the contact should embody the considerations of the crafted program—that is, the individual in the contact role should be similar in ethnicity, religion, and socioeconomic status to the target group. Second, the contact should be in a role similar to that of the target group. Ideally, employers, landlords, health care providers, and police officers who have mental illness should make a presentation to other employers, landlords, health care providers, and police officers. Although this goal is appealing, it has inherent problems. People in certain roles who publicly disclose their mental illness may experience serious consequences; for example, police officers may lose their gun permit, thereby ending their law enforcement career.
In response to the contact's message that people with mental illness recover, a member of the target group should provide an additional message: a person in recovery can be successful. For example, employers should tell other employers that a person in recovery will be a good worker. A good solution is the contact partnership, which combines a consumer in the role of the contact and a target group member who also speaks to the group. A compelling Rotary meeting would feature a person with mental illness who talks about her recovery, followed by a presentation from her boss, who describes the successes that resulted from hiring her.
The third consideration is a bit more complex: namely, the consumer contact should be in recovery. Research suggests that not all contact decreases stigma; for example, exchanges with people who are actively psychotic and homeless may yield no change or make things worse (9). Interactions are most effective with people with serious mental illnesses who work, live independently, have good relationships, and have a satisfactory quality of life, which are all benchmarks of recovery. However, researchers have also noted that recovery is an elusive concept; some studies suggest that it may have been attained before people accomplished work and independent living goals per se—for example, the person with hope about achieving his or her personal goals. In fact, many advocates and researchers prefer to define recovery as a process (a journey marked by hope and goal attainment regardless of symptoms) rather than an outcome (being symptom free, for example). Moreover, limiting consumer contacts to people who are “symptom free” may increase public stigma by implying that others with mental illness are somehow less than whole. People in the process of recovery are good contacts for stigma change.
Contact must be continuous
A one-time contact may have some positive effects, but the effects are likely to be fleeting. Multiple contacts should occur, and the quality of the contact should vary over time. “Carbon copies” have limited effects. This calls for different consumer and target partners and an array of messages, venues, and opportunities. This principle reminds advocates that stigma change is not easily accomplished and requires ongoing efforts and continuous quality assessment of those efforts.
The Substance Abuse and Mental Health Services Administration, the Department of Defense, the Department of Veterans Affairs, many state governments, and nongovernmental organizations have funded social marketing programs in the United States. These programs can be categorized as population-focused public service campaigns and consumer contacts. Public service campaigns, often anchored by compelling public service announcements (PSAs), have several benefits. They provide the best penetration into the population and the most efficient way for the message to be heard by the greatest number of people. They typically include shrewdly crafted sound bites, which viewers of the PSA may recall some time later. The concern, however, is whether penetration leads to impact. Does learning a sound bite yield any meaningful behavior change in any important group?
SSC programs have alternative benefits that may enhance impact. They yield more personalized messages. The contact can extemporaneously identify stigmatizing issues emerging from the group and craft responses in the situation. As a result, SSC is more interactive, reflecting a give and take among audience and contact. The exchange provides an opportunity for assessing how the contact and message are affecting the target group. It also provides a first step for ongoing efforts to brainstorm with the audience about ways to overcome stigma. SSC programs can help ensure less redundant messaging. Programs can schedule future contacts to approach prejudice and discrimination with different stories and messages.
SSC programs combined with other antistigma efforts have great potential to eliminate stigma, to ensure that people with mental illnesses have the same opportunities as others, and to promote personal empowerment. In a community that embodies these principles, people with serious mental illnesses are better able to achieve their goals and enjoy the quality of their life.
This work was supported in part by National Institute of Mental Health grants MH62198-01 and MH08598-01 to support the National Consortium on Stigma and Empowerment.
The author reports no competing interests.