The past decade has witnessed a significant growth in research on the stigma of mental illness and strategies to decrease its impact. On one hand, we may be encouraged by the number of attempts to study stigma and to develop antistigma campaigns. These efforts may ultimately tear down the barriers that are the result of stigma. Unfortunately, lacking in most of this research are studies that examine the effectiveness of real-world antistigma campaigns. In particular, what impact might antistigma programs have on masses of people? Just as clinical trials progress from efficacy studies to effectiveness research, stigma research must progress from studies conducted at the level of individuals to studies of population-sized interventions. Hence, research on change in the level of stigma will reflect the balance between external and internal validity that separates clinical and services research. Just as researchers focus on external validity in conducting clinical trials that feature effectiveness, so investigators of mass communication approaches must utilize research approaches that reflect real-world issues.
In this Open Forum, we hope to initiate critical thinking in this area by describing three programs that use different approaches to diminish stigma in mass audiences.
The stigma of mental illness can rob people who are labeled mentally ill of important opportunities that are essential for achieving life goals. Two goals, in particular, are central to the concerns of most people, including those with serious mental illness: obtaining competitive employment and living independently in a safe and comfortable home (1). Problems in housing and work may occur because of the disabilities that result from mental illness. Some people with mental illnesses lack the social and coping skills to meet the demands of independent living and of a competitive work force. However, the problems of many people with psychiatric disability are exacerbated by stigma. Several studies have documented widespread stigmatizing attitudes in the general public (2,3,4,5,6). Such attitudes have a deleterious impact on individuals' obtaining and keeping good jobs (5,7,8,9,10,11,12,13,14) and leasing satisfactory homes (10,13,15,16,17,18,19,20,21).
In recent years advocacy groups have targeted various components of stigma with several strategies, few of which have been formally evaluated. However, social psychology research on stereotypes of ethnic minority groups and other group stereotypes has provided some insight into the effectiveness of these strategies for reducing the stigma associated with mental illness. On the basis of this literature, we have grouped the various approaches to changing public stigma into three processes: protest, education, and contact (22).
Through protest, stigma is presented as a moral injustice; people are instructed not to act in this socially inappropriate way. For example, protest might include public rallies and boycotts targeting business behaviors that are stigmatizing. To augment their effects, protest-based approaches may systematically withhold economic benefits from a business that refuses to rectify stigmatizing images. Wahl's book, Media Madness (23), is replete with examples of media groups that have presented people with mental illness in a stigmatized fashion. Organized protest can be a useful tool for convincing media groups to stop presenting stigmatizing portrayals. However, protest programs that ask people to suppress their prejudice about a group can produce psychological reactions—"Don't tell me what to think"—and more negative attitudes (24,25,26). Thus, although protest may be useful for changing people's behavior, it may have little or negative impact on public attitudes about people with mental illness.
Educational approaches to change stigma challenge inaccurate stereotypes about mental illness and replace these stereotypes with factual information. Educational strategies aimed at reducing the stigma of mental illness have included public service announcements, books, flyers, lectures, movies, videos, and other audio-visual aids to dispel myths about mental illness and replace them with facts (27,28). A benefit of educational interventions is the relative ease and exportability of interventions that reach large audiences. Although education produces short-term improvements in attitudes (24,29,30,31,32,33,34), the magnitude and duration of improvement in attitudes and behavior may be limited (35,36).
The third strategy for reducing stigma is interpersonal contact with members of the stigmatized group—that is, face-to-face, mutual interactions between a person with mental illness and the general public. Contact has long been considered an effective means for reducing intergroup prejudice (37,38). Several studies that have focused specifically on the effects of contact on the stigma associated with mental illness have produced promising findings. Corrigan and Penn (22) found that contact with a person with mental illness produced greater improvements in attitudes than protest and education. In a subsequent study, contact again produced the greatest improvements in attitudes and participants' willingness to donate money to a mental health advocacy group (29).
The exigencies of changing stigma vary when the effort is moved from an individual target to mass audiences for whom one-on-one communication is by definition impossible. Three examples of mass approaches to antistigma programs are reviewed here. They were chosen for their prominence in the United States, and because each program reflects one of the three antistigma approaches discussed above. StigmaBusters is a protest group in which members respond to disrespectful media images with a range of actions from expressions of disapproval to boycott. Elimination of Barriers Initiative (EBI) uses an omnibus approach to education to challenge stigma. In Our Own Voice (IOOV) employs the contact approach; people with mental illness use the IOOV program to challenge public stigma.
One source of stigma is the popular media. Research suggests that many purveyors of movies, advertising, and newspapers contribute to the stigma associated with mental illness (39). StigmaBusters was developed as a way to challenge images presented in the media that are stigmatizing. StigmaBusters, now in its seventh year, is a group of the National Alliance on Mental Illness (NAMI). From an initial group of 850 members, StigmaBusters now has more than 15,000 national and international advocates who work together on the Internet (40). Members are directed to be vigilant for stigmatizing portrayals in the various media channels that influence Americans. When a disrespectful image is noted, members log the representation and report it to the central StigmaBusters. The log includes information about when and where the image was presented as well as the content of the message. StigmaBusters' staff investigates the report. When StigmaBusters confirms a disrespectful media representation, it may release a stigma alert to members that describes the stigmatizing image and includes the name of the person in authority to whom members should express their displeasure. Members are urged to contact newspaper editors, radio and TV station managers, and other people who have positions of authority over the entity that has presented the stigmatizing image.
Anecdotal evidence suggests that protest can change some media-related behaviors significantly (39). For example, in 2000 StigmaBusters played a prominent role in persuading ABC to cancel the program "Wonderland," which portrayed persons with mental illness as dangerous and unpredictable. During the first episode, a person with mental illness shot six bystanders on a busy street and then stabbed a pregnant psychiatrist in the belly with a hypodermic needle. StigmaBusters not only targeted the show's producers and several management levels of ABC, it also encouraged members to communicate with commercial sponsors, including the chief executive officers of Mitsubishi, Sears, and the Scott Company. "Wonderland" was eventually pulled from the station line-up, and several episodes were not shown. ABC decided to take a loss from unshown episodes rather than risk the further wrath of consumers.
Protest as used by StigmaBusters has a different function from the attitude suppression discussed above. Protest here has an impact similar to punishment. Namely, receiving letters from StigmaBusters members is an adverse consequence; media outlets reduce stigmatizing images in order to avoid more letters. Research on programs such as StigmaBusters thus might show that protest is effective as a punishing consequence that decreases the likelihood that the targeted persons or entities will repeat this behavior. Such research would be useful for examining the effects of legal penalties enacted under the Americans With Disabilities Act (ADA) and the Fair Housing Act. Employers who do not hire a person because of mental illness risk legal action under the ADA.
Conversely, StigmaBusters also identifies reinforcing consequences to affirmative actions that undermine stigma and encourage more public opportunities for people with mental illness. Positive consequences include government tax credits for employers who hire and provide reasonable accommodations for people with psychiatric disabilities. In 2004 StigmaBusters posted an alert encouraging members to praise Reader's Digest, which ran the story of Ed Wohlford, who had recovered from mental illness and was working in a job in Pinellas, Florida (40). StigmaBusters supports these types of antistigma, prorecovery messages by asking members to write letters that praise affirmative actions and encourage future similar actions.
Elimination of Barriers Initiative
The Center for Mental Health Services developed EBI to address stigma and discrimination associated with mental illness in eight pilot states: California, Florida, Massachusetts, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin. EBI is a large effort to diminish stigma by educating the public. Development of EBI products fell to the Gallup Organization in partnership with Vanguard Communications, the Mental Health Association of Southeastern Pennsylvania, and James Bell Associates. Overall goals for this three-year project included combating stigma and discrimination, reducing barriers to treatment, and building public support for recovery. Products of the marketing campaign included a kick-off town meeting in each state to engage a broad spectrum of stakeholders in a dialogue about stigma and discrimination; a portfolio of radio, television, and print public service announcements; and an expansion of state capacity through the delivery of communications training and technical assistance.
Evaluations have shown that EBI products have been widely distributed. The dissemination of EBI's public service announcement "Mental Health: It's Part of Our Lives" has been impressive (41). A total of 7,306 commitments for broadcast and cable use of the public service announcement were received, which represents a possible viewing audience of 150 million. Commitments for four EBI radio public service announcements, totaling 20,000 scheduled broadcasts, have a potential audience of more than 50 million. Print advertisements have been run by 120 newspapers and 11 magazines, which represents a circulation of more than four million.
EBI is an example of social marketing, a well-documented and tested approach to changing public attitudes. Using methods similar to those of commercial marketing, social marketers seek to influence behaviors of a target group so that the personal welfare of individuals within the group is enhanced (42,43). Social marketing has been widely used around the world to help groups of people overcome public health problems and other social welfare problems, most often through methods of mass communication. Social marketing programs consist of four steps: problem identification, description of targets of the marketing plan, development of technology for change, and evaluation of process and outcome (42,44). In the following discussion, we illustrate each point of social marketing with examples from the work world.
Problem identification orients the social marketer to the central problem that necessitates change in public attitudes and behaviors. In terms of stigma, many different problems can be identified. The problem might be biased decisions by employers that stymie work opportunities. Another problem is internalization of stigma, such that persons with mental illness believe that they are incapable of working or do not take advantage of vocational laws that are meant to promote work and other life goals. The central problem can be reduced to defining what each group needs to know differently, believe differently, and do differently.
Socioeconomic factors related to the problem are also assessed. For example, a depressed economy interferes with the ability of some people with mental illness to get work, because it increases competition for jobs to the extent that they become scarce. Taking such factors into account, a complete problem analysis includes a description of resources that are needed to successfully educate and persuade a given audience. This assessment includes both financial and human resources.
A second task in a social marketing campaign is to describe the target audience or audiences. This task is based on an environmental assessment; the audiences for a campaign need to match available resources to successfully communicate to them. The primary target is a group that is at risk of some unfortunate outcome if no change occurs—plausibly, people with mental illness who are unsatisfied with their current work activity or lack thereof. It is common in social marketing efforts to distinguish between primary and secondary targets (42). Secondary target groups are those whose behavior has an impact on the primary group. In the context of work, the secondary targets are employers, whose decisions influence job opportunities. Secondary targets might include "the competition"—an audience whose own goals may be diminished by a successful social marketing program. For example, a program seeking to improve the employment of individuals with psychiatric disabilities may decrease the number of openings available to other job seekers.
Segmentation—the process of dividing a mass audience into groups that can as a practical matter be targeted—is recommended early in the planning process of any social marketing effort. Selecting the number of segments to target is a function of priorities and budget. Marketing of any kind is a matter of trade-offs in targets and goals.
Understanding the perspectives of different segments within a potential audience in order to plan and implement a social marketing program is similar to the process used to develop psychosocial and other interventions for people with mental illness. For example, empowerment is prominent in the development of psychosocial programs and is also fundamental to social marketing programs. In both contexts, helping individuals to have control over their life decisions is believed to lead to the desired outcomes.
The third step in social marketing is the development of technology for change. This task involves the four P's of marketing: product, price, place, and promotion (44). The product will be an "idea" and will be developed as any commercial product would—to be acceptable to the audience for which it is designed. A social marketing effort might seek to "sell" the idea to people with mental illness; persons with mental illness are more likely to reach their goals more effectively if they assemble into an advocacy group that distributes public service announcements aimed at employers to get people back to work. Alternatively, the idea might seek to "sell" employers on achieving low turnover—a desirable outcome—if they employ people whom others might hesitate to hire. A social marketer would test the acceptability of the latter product among employers. If it seemed unlikely to achieve acceptance, the marketer might instead try to market the advocacy group idea to a more receptive audience.
Price is what members of a target audience have to give up to obtain a benefit. For those with a mental illness, the benefits of diminishing stigma are obvious and include having greater opportunities in work and to live independently. Costs would include the possibility that ignoring a disability would require a person to take on responsibilities on a job or in independent living for which he or she is not ready.
A different set of benefits and costs are pertinent for the secondary audience of an antistigma social marketing effort. Employers view the risk of problems (as a result of hiring people with mental illness) as a cost, whether or not they assign a dollar value to that cost. By taking such perceived risk into account, a social marketer can aim to reduce these employer concerns. For example, a local mental health group can offer employers orientation sessions to help reduce concerns that their employees will feel threatened by coworkers who take medication to control a mental illness.
Finally, a third set of costs and benefits accrue to a group undertaking social marketing. These can be monetary (direct costs of implementing a specific social marketing campaign) and nonmonetary (resources such as volunteers). Marketers also think in terms of "opportunity costs"; if a group was not targeting a given audience well, could they make better headway in reaching their objectives by targeting another audience?
Place means the channels of distribution through which the social marketing campaign will operate. Any products, including ideas, need to reach their primary targets and important secondary targets. Just as many psychiatric rehabilitation programs bring services to clients in their own neighborhoods or homes, the ideas that a social marketing group is "selling" are brought to the target audience.
The final item in the four P's, promotion, is simply communication via the Internet and print and broadcast media through the use of Web sites, news stories, and advertising. Imaginative social marketers also try to influence the content of movies, TV dramas, and even comic strips. Three major communication approaches may be employed: mass, selective, and personal (43). Mass promotion uses approaches that do not target a particular group but appeal to as broad an audience as possible. Selective promotion sacrifices numbers for the ability to target specific audiences—for example, using a business publication to reach employers. Personal communication is known in the commercial world as selling and is used in social marketing to the extent that resources are available. It is naive to expect that the president of a company will happen to see a public service announcement. A far more sensible approach involves a personal visit, which can occur when one person who has successfully struggled with the problem of stigma shares his or her experiences and accomplishments. This form of promotion is in effect contact.
The last step of social marketing is evaluation—assessing processes and outcomes. Process evaluation involves, for example, measuring the number of people exposed to a campaign. Outcome evaluation might involve testing the impact of a campaign.
Developed by consumers of mental health services, IOOV is a 90-minute standardized contact program in which people with mental illness interact with an audience on the topic of their mental illness. IOOV is also a program of NAMI. Audiences participating in formal contact programs have included police officers at roll call, physicians at grand rounds, employers and landlords at civic club meetings, and teachers during inservice trainings (45). The IOOV presentation is divided into six parts: Introduction, Dark Days, Acceptance, Treatment, Coping Mechanisms, and Success/Hopes/Dreams. Each part is augmented by a ten-minute videotaped presentation. The entire program is presented by people with mental illness who are comfortable acknowledging and talking about their illness. The program includes a well-developed training program for presenters as well as a fidelity checklist to ensure that facilitators adhere to the standardized format.
Several of the components of IOOV parallel social psychology research findings about elements of contact that decrease stigma (37,47). One element is interaction; contact is more effective when the members of the audience are able to exchange ideas through discussion with the contact person as peers (48). Another element is qualification—that is, a presenter's qualifications to discuss the topic in question. Given that individuals with mental illness are a hidden stigmatized group (49), the public cannot identify people with mental illness unless they self-disclose. The presenter in IOOV is a person with mental illness, even though he or she may not seem to be ill. The presenter has a history of being hospitalized and of taking medications (50) and is therefore qualified to discuss mental illness. Another element is content; the presenter focuses the message on important areas, such as recovery from mental illness (40).
Two unpublished studies of IOOV have examined its feasibility and effect on stigmatizing attitudes. The first was a descriptive study that examined more than 2,200 audience members' responses to items reflecting the amount and depth of information learned from the presentation (51). Almost three-quarters of participants said they received "lots of great information" from IOOV. Seventy percent of participants said that the presentation had excellent depth and scope. The second study was an experimental test of IOOV (52) in which 114 college students were randomly assigned to IOOV or a control condition in which they learned about psychology as a career. Research participants in both groups completed pre- and immediate posttest measures of knowledge, attitudes, and social distance (a form of discrimination in which the public avoid members of the stigmatized group). Results showed significant interactions for all three variables, suggesting that compared with participants in the control condition, those who participated in IOOV showed significantly greater decrements in stigmatizing attitudes.
Three different antistigma programs are discussed in this Open Forum: StigmaBusters, which is a form of protest; Elimination of Barriers Initiative, which involves education or social marketing; and In Our Own Voice, which relies on contact. These three approaches have several features that commend them, and the descriptions illustrate the processes that lead to stigma change. Very preliminary research offers initial support of the feasibility and impact of these programs. However, full endorsement of these or other approaches requires collection of data that support each as an evidence-based practice.
A separate literature search uncovered a handful of research studies of mass approaches to antistigma goals. The research was fairly rudimentary and the findings somewhat limiting; investigations have found that these programs lead to more affirming and less stigmatizing news stories (53), less negative attitudes about people with mental illness (54), and more positive attitudes about the treatment and experience of depression (54). However, the current body of research does not yield sufficiently definitive results to provide a template for future research of this kind. Future research needs to examine penetration, outcome, process, and exportability.
Penetration is a term common in advertising research. It refers to the proportion of a target audience that actually is exposed to a message. For example, widespread dissemination of the public service announcements produced by EBI could result in exposure to 150 million viewers; however, the number of people who actually saw the public service announcement is a researchable question. Outcomes represent the impact of the marketing campaign on the target audience. Outcomes can be assessed at various levels. Did someone notice a message? Can he or she recall it? Have the person's attitudes or feelings about the central problem improved? Are behaviors relevant to resolving the problem obvious? A marketer would expect In Our Own Voice to show more positive outcomes proportionate to audience size than EBI, but the base will be a smaller audience. Presumably, person-to-person contact is more compelling and thus more likely to be recalled than EBI. One interesting research question is whether having a lesser effect on more people is more beneficial than having a greater effect on fewer people.
Process assessment examines factors related to the antistigma campaign that are the inputs of a campaign rather than the outcomes (44). This research might measure such variables as choice of policy and infrastructure, dissemination of materials, and implementation of campaign elements. Exportability represents the ease of distribution: how many advocacy groups could use the marketing campaign? The three programs illustrate different levels of exportability. StigmaBusters could transcend even national boundaries and could be relevant in any culture. EBI is also a highly exportable campaign. It can mass produce advertisements and public service announcements and distribute them quickly. In Our Own Voice is an intervention that requires more effort. People with mental illness must graduate from the IOOV training program before facing a target audience.
This Open Forum is intended to stimulate interest in mass approaches to diminishing stigma. The three programs illustrate interesting aspects of how stigma can be changed and how the change can be measured. In addition, existing fields of study, such as social marketing, have been described as they might relate to antistigma efforts. Stigma continues to impede life opportunities for people with mental illness. That fact alone justifies analysis of alternative approaches to reducing such stigma among mass audiences.
Dr. Corrigan is affiliated with the Joint Research Programs in Psychiatric Rehabilitation at the Illinois Institute of Technology 3424 S. State Street, Chicago, Illinois 60616 (e-mail, firstname.lastname@example.org). Dr. Gelb is with the department of marketing and entrepreneurship at the University of Houston in Texas.