1. Psychiatric Conditions: Bias and Shame Prior to engaging in this discussion, read Chapters 7 and 8 in your text as well as the articles by Clark, et al. (2013) and Cummins (2013).
cmober
86141419.pdf
California’sHistoricEfforttoReducetheStigmaofMental Illness: The Mental Health Services Act
In a historic effort to re-
duce the stigma of mental
illness, California voters ap-
proved the Mental Health
Services Act in 2004. The
law funds a comprehensive
statewide prevention initia-
tive that places stigma and
discrimination reduction at
its center, with 25 projects
providing interventions at
the institutional, societal,
and individual levels.
Stakeholders selected
specific strategies from
the research-based California
Strategic Plan on Reducing
Stigma and Discrimination.
Strategies range from social
marketing to increase public
knowledge to capacity build-
ing at the local level, includ-
ing training that emphasizes
participation by consumers
of mental health services
and cultural competence. Col-
lectively, these strategies aim
to foster permanent change
in the public perception of
mental illness and in the in-
dividual experience of stigma.
We examined the context,
planning,programming,and
evaluation of this effort. (Am
J Public Health. Published
online ahead of print March
14,2013:e1–e9.doi:10.2105/
AJPH.2013.301225)
Wayne Clark, PhD, Stephanie N. Welch, MSW, Sandra H. Berry, MA, Ann M. Collentine, MPPA, Rebecca Collins, PhD, Dorthy Lebron, PhD, and Amy L. Shearer, BA
MORE THAN A DECADE AGO,
the US surgeon general identified the stigma of mental illness as the most formidable obstacle to prog- ress in improving mental health.1
Goffman refers to stigma as a spoiled identity.2 In the case of mental illness, stigma includes negative beliefs (e.g., people with mental health problems are dan- gerous), prejudicial attitudes (e.g., desire to avoid interaction), and discrimination (e.g., failure to hire or rent property to such people). The desire to avoid labeling one- self negatively or to conceal one’s problems from others appears to cause treatment avoidance, in- crease dropping out, and reduce adherence.3 Today, California is addressing this social injustice and improving the well-being of its communities through a compre- hensive statewide initiative sup- ported by Proposition 63, the Mental Health Services Act (MHSA).4
Passed by California voters in 2004 amid calls for fundamental changes to mental health care, the MHSA begins to fulfill Cali- fornia’s 30-year-old promise to build a community-based mental health system as an alternative to institutionalization.4 By imposing a 1% tax on personal income in excess of $1 million, the MHSA provides funding and a framework to transform California’s tradi- tional community mental health system to one focused on preven- tion and wellness, while expanding services to underserved popula- tions and California’s diverse communities.
In several ways, the MHSA re- sembles a blueprint for fulfilling the transformative goals identified in the New Freedom Commis- sion’s Achieving the Promise: Transforming Mental Health Care in America in 2003.5 The MHSA provides resources to mend a fragmented service delivery sys- tem, invest in strategies that sup- port recovery from symptoms, promote community integration rather than institutionalization, and empower clients of mental health services (consumers) and their families to direct their own care. Like the commission’s report, the MHSA makes an explicit commit- ment to reduce stigma and its negative consequences. Further- more, following the surgeon gen- eral’s call to apply a public health approach to mental health,1 the MHSA requires that 20% of all funds (which average $1 billion annually) must support a wide range of prevention and early in- tervention strategies,6 including programs to reduce not only the stigma of mental health diagnosis and treatment but also discrimina- tion against people with mental illness.7 Efforts supported by the MHSA aim to improve knowledge, change attitudes, increase help- seeking behaviors, reduce stigma, and challenge discriminatory policies.
STIGMA REDUCTION AT FOREFRONT OF TRANSFORMATION
Although policy directives called for transformation, it took
the involvement of individuals and families who had experienced the negative consequences of stigma and discrimination to ensure the MHSA’s commitment to ade- quately addressing it. Consumers and their families were partners in the process, from drafting the MHSA to campaigning for its pas- sage. Together with the voices of underserved ethnic and cultural groups, the involvement of these stakeholders enriched—and lengthened—planning and imple- mentation efforts.8 The MHSA mandated stakeholder participa- tion in planning, implementation, and oversight of MHSA programs at the state and local levels.9---12
Such stakeholder involvement meant new ways of doing business for state and local entities, but they saw significant success: by 2008, more than 100 000 people had participated in MHSA planning throughout the state.13
An example of stakeholder in- volvement was the development of the California Strategic Plan on Reducing Mental Health Stigma and Discrimination, a comprehen- sive 10-year plan to “fight the stigma and discrimination associ- ated with mental health chal- lenges.”14(p10) Because the MHSA stipulates that a Mental Health Oversight and Accountability Commission (MHSOAC) develop strategies to overcome stigma,15
the MHSOAC, in partnership with the California Department of Mental Health, established an ad- visory committee of diverse ex- perts and stakeholders, especially consumers and families, to
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develop and publicly vet the state strategic plan. The plan was adopted in 2009 after 2 years of development, and applies scien- tific knowledge to practice by identifying methods to reduce public, institutional, and self-stigma through the implementation of 4 strategic directions with more than 25 specific activities.14
PREVENTION AND EARLY INTERVENTION STATEWIDE PROJECTS
The MHSOAC further sought to fulfill its role by taking a public health approach to stigma reduc- tion. By exercising a statutory mandate to approve prevention and early intervention expendi- tures, the MHSOAC made stigma reduction an essential part of these efforts.16 In May 2008, the MHSOAC approved an invest- ment of $160 million in preven- tion and early intervention funds for 3 statewide projects to be implemented within 4 years: $40 million for suicide prevention, $60 million for improved student mental health, and $60 million for stigma and discrimination reduc- tion.17 Although MHSA funds flow directly to counties to administer mental health programs, a state- wide approach could supply in- frastructure and coordination to launch such a significant change to service delivery and to supple- ment local prevention and early intervention programs. Guidelines developed by the MHSOAC for the statewide initiative required use of strategies from the state strategic plan.17 This ensured that this 1-time allocation of funds would apply well-researched, stakeholder-supported recom- mendations to preventing and re- ducing stigma and discrimination.
The counties decided to act collectively and determined that
the most efficient and effective method to administer the initiative would be to form a joint-powers authority and pool their local funds for a statewide effort. The California Mental Health Services Authority represents county gov- ernments whose members provide public mental health services. Along with stakeholders, it devel- oped an approach to respond to the guidelines for the initiative that could reach across California’s diverse populations. The impact of this single investment, in which short-term outcomes must be measured within 4 years, was maximized by applying strategic policy and program principles, such as leveraging other local, state, and federal resources and using data-driven policies and evidence-based, promising, and community-defined practices.18
Figure 1 provides a timeline of key events that led to California’s historic effort to reduce the stigma of mental illness through a com- prehensive statewide initiative. Such an approach would not have been possible without the framework and funding that the MHSA provided and support from state and local governments and stakeholders.
EMPHASIZING STIGMA AND DISCRIMINATION REDUCTION
As in similar national ef- forts,19,20 the California Mental Health Services Authority approached the initiative as
an opportunity for mental health to become a part of wellness for individuals and the community, reducing the potential for stigma and discrimination against indi- viduals with mental illness.21(p13)
After delays occurred in the design phase of the initiative, the authority moved promptly and
developed an implementation work plan to achieve the recom- mendations made in the state strategic plan and conducted a 52-day public comment process to solicit stakeholders’ priorities for funding.22 The work plan pla- ces stigma and discrimination re- duction strategies as the center- piece, ensuring that these efforts are included in the suicide pre- vention and student mental health components. Attaining a measur- able reduction in stigma and a measurable increase in the un- derstanding of mental health challenges is part of the approach to preventing suicide and improv- ing student mental health. The final work plan consists of 3 com- plementary components—stigma and discrimination reduction, stu- dent mental health, and suicide prevention—that are being imple- mented through 25 projects, with an independent statewide evalua- tion conducted by the RAND Corporation.
The work plan to implement the initiative incorporates ele- ments some theorists argue are necessary to achieve shifts in deeply ingrained attitudes and behaviors, by producing mutually reinforcing changes at multiple levels, typically with a multicom- ponent approach.23 Figure 2 de- picts how stigma can exist at the level of the institution, society, and individuals and shows that these levels influence one another. Suc- cessful interventions capitalize on these interdependencies. This model of change suggests that re- ductions in mental illness stigma will likely occur to the extent that social norms, individual actions and beliefs, and institutional prac- tices and policies converge to support acceptance of individuals with mental health problems and to the extent that interventions are targeted at these multiple levels.
The work plan uses this con- ceptual model to employ effective strategies identified in the state strategic plan and consistent with Corrigan’s research results, which indicate that stigma reduction efforts are more effective if they are targeted to specific populations or population groups (e.g., em- ployers, landlords, teachers), con- tinuous, credible (using people from the same population groups and similar socioeconomic level to communicate the message in a culturally relevant manner), local, and focused on contact with peo- ple with lived experience instead of on dispelling myths.3 The re- sulting work plan for the initiative has a stigma and discrimination reduction component consisting of 4 program areas, with 10 pro- jects, all designed to promote per- manent change in public percep- tion of mental illness and individual experience of stigma. Table 1 has a detailed description of the research base, program design, objectives, and intended outcomes for all 10 projects.
The Strategies for a Supportive Environment Program aims to create a supportive environment for people with mental illness, their families, and communities by establishing social norms that recognize mental health as integral to well-being. The program ad- dresses findings that many people are unwilling to work closely or socialize with someone with schizophrenia or to have such a person marry into their family.39
In addition, many adults describe individuals with mental illness as likely to be violent toward others and themselves.39 The program consists of 3 projects, each em- phasizing active involvement of stakeholders within and outside the mental health community. The networking project uses a consortium of members
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responsible for coordination of strategies and outreach to various key targets of stigma reduction efforts, such as law enforcement and education. The social market- ing project disseminates stigma and discrimination reduction messages to targets of change in knowledge, attitudes, and behav- iors, such as youths and people of influence (e.g., property owners and employers). The capacity- building project uses contact strategies to supply messages at the individual and local level, which, evidence suggests, may ef- fect attitudinal changes more suc- cessfully than do educational or protest strategies.40---42
The Values, Practices, and Pol- icies Program promotes aware- ness, accountability, and changes in values, practices, policies, and procedures within systems and
organizations to encourage re- spect for and to protect the rights of people with mental health challenges. The program ac- knowledges that stigma and dis- crimination occur daily in our communities, a leading reason why three quarters of the 2.2 million Californians (8.3% of the state’s population) who report mental health needs also report unmet needs.43 Individuals aged 18 to 24 years report the most unmet needs, along with adults older than 65 years, Asians, Afri- can American males, and Latinos and Asians born abroad.43 This demonstrates the demand for ap- proaches tailored to specific age, ethnic, and cultural groups. Al- though evidence exists about the short-term impact of educa- tional interventions on attitudes toward mental illness,44---46
identifying the longer-term impact and effectiveness of the compo- nents of educational and training interventions can be challeng- ing.47---50 The 5 projects in this program will be evaluated to de- termine whether their approach has enough efficacy to warrant continued funding. As training in- terventions with an educational basis, they are a relatively low-cost stigma and discrimination reduc- tion approach that can be dis- seminated widely.51---53
The Promising Practices Pro- gram identifies existing stigma and discrimination programs that are successful but have gone unrec- ognized, particularly in under- served communities of color. This program assesses the presence, pen- etration, and range of stigma and discrimination reduction programs for underserved communities of
color and establishes a baseline for comparison and a gap analysis for project planning and implementa- tion statewide. The project is a partnership among research en- tities, such as Columbia Univer- sity’s Mailman School of Public Health, and mental health advo- cates and stakeholders.
The Advancing Policy to Elim- inate Discrimination Program aims to identify and eliminate discriminatory practices and poli- cies. The program examines exist- ing laws, policies, and practices that explicitly or implicitly result in discrimination. The program will provide information and ac- tivities that increase awareness and understanding of existing laws and regulations that protect people with mental illness and their family members against discrimination.
2004
MHSA/Prop. 63 is passed by California
voters with grassroots support
MHSOAC approves $160 million investment in
PEI Statewide Initiative
2005
2009
Stigma and Discrimination Reduction (SDR) Strategic Plan
developed with evidence-based approaches and stakeholder input
MHSOAC develops Initiative Guidelines; required use of
strategies from the State Strategic Plan
2008 2010 2012–2014
Programs conclude in 2014;
evaluate short-term outcomes
Evaluate key outcomes identified in MHSA
Request for Proposals (RFPs) released;
providers selected; contracts negotiated
Complete assessments for
program design and implementation
Dedicated 7.5% of resources to
evaluation; selected RAND as evaluator
Work plan developed with stakeholders;
approved by MHSOAC
1999 2003
Report calls for transformation of mental health system; serves as a
blueprint for Prop. 63
Stakeholder involvement is required by
the MHSA in planning, implementation, and oversight
2011 2015
Stigma identified as the “most formidable
obstacle” to improving mental health
US SURGEON GENERAL REPORT ON MENTAL HEALTH
PRESIDENT’S NEW FREEDOM COMMISSION REPORT
PASSAGE OF THE MHSA/ PROP. 63
STAKEHOLDER PLANNING PROCESS BEGINS
PEI STATEWIDE GUIDELINES RELEASED
STATE STRATEGIC PLAN ADOPTED
JOINT POWERS AUTHORITY (JPA) FORMED
PROVIDERS SELECTED BY RFP PROCESS
IMPLEMENT PEI STATEWIDE INITIATIVE
EVALUATE OUTCOMES
Note. MHSA = Mental Health Services Act; MHSOAC = Mental Health Oversight and Accountability Commission; PEI = prevention and early intervention; Prop.= proposition.
FIGURE 1—Timeline of the Mental Health Services Act/Proposition 63: Prevention and Early Intervention Statewide Initiative.
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To achieve synergetic impact, the statewide initiative targets stigma at the institutional, societal, and individual levels in its suicide prevention and student mental health efforts.
Approximately 90% of persons who die by suicide are found to have had a mental disorder.54 The Suicide Prevention Social Market- ing Program aims to increase public awareness that suicide is preventable, improve recognition of those at risk, encourage help- seeking behavior, and establish links to mental health services. As in the stigma and discrimina- tion reduction campaign, multiple social marketing strategies target high-priority and high-risk popu- lations, such as older adults, youths, and Latinas.
The Suicide Prevention Train- ing and Workforce Enhancement Program strengthens Californians’ abilities to recognize mental illness signs and symptoms by providing a range of training options for gatekeepers, caregivers, and other
community members through Applied Suicide Intervention Skills Training, safeTALK and e-suicide safeTALK. Training tar- gets range from first responders such as campus police to peer support providers. Many gate- keeper training efforts have dem- onstrated effectiveness.55
The Regional and Local Suicide Prevention Capacity-Building Pro- gram expands accredited local suicide prevention hotlines and warmlines to support help-seeking behavior throughout California. Some evidence indicates that crisis lines effectively link individuals in need with mental health services.56
The Student Mental Health Program recognizes that educa- tional institutions are key to suc- cessful prevention and early intervention strategies, which incorporate stigma and discrimi- nation reduction strategies in ap- propriate training, materials, speakers bureaus, and other educational strategies. Mental
health programs provide op- portunities for students (from pre- school through higher education), families, and staff to better under- stand mental wellness and to rec- ognize signs of bullying or other stigmatizing practices, which delay the identification of students at risk for mental health problems, who may have poor self-image. Stigma and discrimination reduc- tion resources will be incorporated into student mental health activi- ties at all levels.
SUPPORTING LASTING CHANGE THROUGH RIGOROUS EVALUATION
In light of the unprecedented breadth and scope of the statewide initiative, the work plan mandated a comprehensive multilevel eval- uation. All projects are required to conduct their own program eval- uations as well as to participate in an independent statewide evaluation conducted by the RAND Corporation. Goals for the
statewide evaluation include establishing baselines and com- munity indicators; improving data collection, surveillance, and program evaluation; identifying innovative programs with poten- tial for replication; and launching a research agenda to design re- sponsive policies and effective programs that reduce stigma and discrimination, prevent suicide, and improve student mental health.21
RAND’s comprehensive evalu- ation will assess changes in struc- tures, processes, and short- and long-term outcomes of the state- wide initiative (Table 2). Within each area, RAND distinguishes changes attributable to training sessions and other in-person out- reach (e.g., speakers bureaus) from changes attributable to social marketing and media advocacy.
Finally, RAND will attempt to identify expected changes associ- ated with each outcome specified in the relevant portion of the stigma and discrimination reduc- tion evaluation conceptual model: individual-level changes, social changes, and institutional and policy changes (Figure 2). As the conceptual model indicates, these changes are reciprocal—likely to build on one another and provide momentum for additional change as stigma and discrimination re- duction efforts continue. However, the changes are likely to occur in the order listed, with individual change happening most rapidly in response to the various efforts and social and institutional change taking longer.
INITIAL FINDINGS
At the close of the first year of implementation (June 2012), emerging baseline and assessment data established that stigma was prevalent in California. Data
• Laws
• Practice
• Policies
• Community discussion
• Media portrayals
• Norms
Stigmatizer
• Social
distance
• Stereotypical
beliefs
• Negative
attitudes
• Exclusionary
behavior
Stigmatized
• Treatment -
seeking
• Adherence
• Well -being
Policy/Practice Change
Individual Change
Social Change
SDR Intervention
Note. SDR = stigma and discrimination reduction.
FIGURE 2—Change at multiple levels expected from stigma and discrimination reduction intervention.
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TABLE 1—Stigma and Discrimination Reduction Projects Funded by the Mental Health Services Act: California, 2011–2014
Project Description Research Base for Program Design Objectives/Intended Outcomes
Networking Consortium comprises ethnically and culturally
diverse representatives from across life span:
employers, law enforcement personnel, veterans,
primary care physicians, etc.
Members represent targets of stigma and discrimination
reduction efforts, helping to tailor strategies to appeal
to key targets of change. Consortium supplies credibility
aspect of Corrigan’s model. 23
Support coordination and sustainability of SDR
programs.
Support meaningful roles for consumers and
families.
Incorporate SDR practices in advocacy activities.
Engage diverse communities.
Social marketing Reduces stigma and discrimination through
education, support, and social norm change
with targeted campaigns in partnership with
community organizations to deliver messages
locally.
Messages target Californians across the lifespan:
pre-inoculation, age 0–8 y; inoculation, age
9–11 y; mobilization, age 14–24 y; people
with Influence, age ‡ 25 y.
Consistent with Corrigan’s model, delivers targeted,
local, continuous, and credible contact strategies.23
Mobilization campaign launches ReachOutHere.com,
Web-based forums with a virtual contact strategy in
which trained peer facilitators lead discussions about
mental health topics and encourage help-seeking
behavior.
People with influence campaign focuses local social
marketing on power groups, such as landlords
and employers. Tactics include a PBS-produced
documentary, speakers bureaus, ethnic press and
outreach events in cultural communities, and parent
and caregiver blogs.
Age £ 13 y: increase knowledge of mental health and illness and effect of stigma and achieve
behavior change by maturing into teens willing
to disclose and offer support to others.
Age 14–24 y: increase awareness and engagement
with peers, decrease perceptions of stigmatizing
difference, increase perception of power to
influence change, and achieve behavioral change
through disclosure, support, and activism.
Age ‡ 25 y: increase awareness of documentary, community forums, and speakers bureaus;
decrease perceptions of stigmatizing difference;
increase perceptions of new norms; achieve
behavioral change through increased willingness
socialize, hire, and be a neighbor to persons
living with mental illness.
Capacity building Builds statewide capacity to address stigma
through contact strategies. Improves social
integration while reducing self-stigma by going
into communities, identifying existing local
speakers bureaus, and strengthening their
capabilities, especially related to cultural
competence.
Strategies selected are supported with evidence that
using individuals with mental illness experience to
combat stigma can foster feelings of empowerment,
self-reliance, self-esteem, and can increase knowledge
of services, rights, housing, employment, and other
relevant issues. 14
Identify gaps in local capacity and build on
existing programs.
Implement community contact strategies that
are culturally competent, including unique
approaches for LGBTQ persons and veterans.
Increase public’s knowledge, attitudes, and
behaviors toward people with mental illness,
and in the long term sustain SDR efforts
through contact strategies.
Resource development Identifies existing best practices and gaps in
SDR training across multiple systems (schools,
primary care, law enforcement, etc.) to
disseminate and develop effective resources.
Provides resources to resolve dilemmas communities
face when they are interested in implementing an
SDR program but are uncertain which to use
effectively to achieve intended objectives.
Design instruments and tools to evaluate existing
SDR programs.
Disseminate best practices and training materials
through an Internet clearinghouse.
Support the statewide use of more effective SDR
programs.
Standards and guidelines
for accurate portrayals
Partners with consumer advocates and experts
in ethnic media to reduce stigma by working
with entertainment, news, and social media
professionals.
Aims to combat images of mental illness disseminated
by media and entertainment industry,24 whose
portrayals are often inaccurate, associate mental
illness with violence, and promote stigma, according
to research.25,26
Increase media knowledge of mental illness.
Decrease stereotypical attitudes among people in
media, because portrayals of the mentally ill can
negatively or positively affect self-efficacy.
Increase accurate stories and encourage changes in
organizational policies.
Continued
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collected by the Field Research Corporation on middle school youths (aged 11---13 years) are of particular concern. Overall knowledge of mental illness was low, confirming misconceptions and stereotypes. For example, 80% believed that “people with mental illness are more likely to act in ways you don’t expect,” and two thirds believed that “vio- lent behavior is a form of seri- ous mental illness.”57 More
encouraging was that youths saw mental illness as a highly relevant subject— 9 out of 10 believed that “young people my age can have a mental illness just like adults,” and 61% believed that it is “very common in the U.S.”57
Data collected by Field from adults confirmed a prevalence of stereotypical attitudes and dem- onstrated ambivalence toward stigma’s impact, especially among Hispanics and Asians/Pacific
Islanders. Less than a majority (46.5%) believed that persons with mental illness are just like everyone else; a majority were unsure about whether treatment is possible (54%) and whether peo- ple with mental illness are dan- gerous (61.7%).57 Only a slight majority (52%) believed discrimi- nation occurs.57 Acceptance of persons with mental illness as friends, family members, students, and patients was high, but
respondents reported high levels of rejection of such individuals as babysitters, job applicants, tenants, coworkers, and neighbors.
Findings from a media analysis of the largest California newspa- pers further established stigma’s prevalence. In English-language media, negative portrayals of peo- ple with mental illness (37.1%) outnumbered the positive (24%), but 51.1% of stories acknowl- edged treatment and 54.5%
TABLE 1—Continued
Promoting integrated
health
Achieves SDR by supporting the integration of
behavioral health, primary care, and social
services, including strategies to achieve parity
between medical and mental health services
and financing.
Encourages integration to address association between
poor mental health and comorbid chronic health
conditions, risky health behaviors, increased physical
disability, and decreased quality of life. 20
Recognizes that stigma must be reduced to break
down barriers between systems that serve people
with mental illness.
Work toward positive changes in organizational
policies, practices, and level of integration.
Decrease stigmatizing attitudes and behaviors
among providers.
Decrease stigmatizing attitudes and beliefs among
stakeholders.
Increase individual empowerment, service
satisfaction, and health.
Mental health and
system partners
Supplies cultural competency enhancements to
National Alliance on Mental Illness affiliates
who will provide educational interventions to
mental health providers, teachers, school
administrators, parents, and students
statewide.
Addresses stigma in the mental health provider
community, which can cause people to avoid or
discontinue services.14
Employs IOOV, interpersonal contact strategies with
success in reducing stigmatizing attitudes and social
avoidance. 27–29
Create positive changes in knowledge, attitudes,
and behaviors among public, especially
teachers, school administrators, and youths.
Change teacher/school disciplinary actions and
referrals.
Decrease stigma among health care providers and
criminal justice staff.
Increase reach to ethnic and cultural communities.
Mental health in the
workplace
Implements a workplace mental health program
aimed at fostering systems change, adapting
and deploying existing best practices, and
providing supports for managing mental illness
in the workplace.
Addresses evidence that workplace wellness programs
are cost effective for employers,30 against whom the
second most common ADA complaint involves
discrimination and harrassment because of mental
illness. 31
Reduce stigmatizing attitudes and behaviors by
increasing employee productivity and decreasing
absenteeism.
Address workplace mental health issues such as
stress and maternal and family mental health.
Promising practices Assesses the presence, penetration, and range
of SDR programs for underserved communities
of color and establish a baseline for comparison
and a gap analysis for project planning.
Recognizes that stigma and discrimination are
understood and experienced differently within
underserved communities of color and attempts to
addresses gaps in understanding of culturally relevant
approaches to mental health service delivery in
California.32–35
Design instruments and tools to evaluate whether
programs employ promising practices in
communities of color.
Create an accessible database and provide statewide
dissemination.
Support more culturally responsive SDR programs
statewide.
Advancing policy Examines laws, policies, and practices that
explicitly or implicitly result in discrimination.
Provide information and activities to increase
understanding of existing protections.
Acknowledges that despite powerful antidiscrimination
laws, including the Fair Housing Act and the ADA,
with mechanisms for enforcement, people with mental
illness continue to experience discrimination.36–38
Increase awareness of laws, policies, and practices
that address discrimination through training.
Create policy recommendations for action needed.
Launch long-term change to eliminate
discriminatory practices.
Note. ADA = Americans with Disabilities Act; IOOV = In Our Own Voice ; LGBTQ = lesbian, gay, bisexual, transgender, queer; PBS = Public Broadcasting Service; SDR = stigma and discrimination reduction.
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provided sources for help seek- ing.58 In Spanish-language media, 70% of the portrayals were nega- tive, with only 14% acknowledg- ing treatment and 1% providing sources for help seeking.58
In focus groups conducted among diverse populations state- wide, most participants did not know how to define mental health stigma. Those who identified as having a diagnosis of mental ill- ness felt that they had been la- beled unfairly, leading to negative perceptions of their character. Fo- cus groups with military respon- dents revealed the greatest desire to hide a mental illness diagnosis for fear of being shunned or losing job opportunities. Overall, most respondents were not aware of efforts to reduce the impact of stigma and discrimination.59
These initial findings validate the need for the initiative and are already being used to further fo- cus project objectives and strate- gies. The social marketing cam- paign, in collaboration with the
Student Mental Health Program, has prioritized efforts to educate elementary school students, rather than beginning in middle school. The Entertainment Industries Council, whose project is to edu- cate content creators, is strength- ening efforts targeting Spanish- language media to provide needed assistance with reducing poten- tially stigmatizing messages. The capacity-building project is redi- recting resources to enhance the capacity of small, community- based organizations to address multiple stigmas that uniquely affect underserved communities of color. Through the use of data to inform implementation, as re- quired by the initiative’s design, more effective interventions are already emerging.
CHALLENGES AND DIRECTIONS
California’s historic initiative to reduce the stigma of mental illness puts into practice more than a
decade of knowledge and advo- cacy. Key elements aligned to support this comprehensive ap- proach were federal leadership; the MHSA, which provides funding for mental health pre- vention and early intervention strategies; a research-based and stakeholder-supported strategic plan; and an administrative mechanism to facilitate a signifi- cant but time-limited statewide initiative.
The magnitude of the statewide scope, aiming to reach California’s more than 37 million ethnically and culturally diverse residents,60
poses substantial challenges. It is essential to maximize the oppor- tunity provided by this 1-time investment to plan, implement, and evaluate programs so that strategies that work are sustained and able to support long-term change.
An analysis of effective struc- tures, processes, and short-term outcomes is possible, but it will be several years before an analysis
of lasting changes in knowledge, attitudes, and behaviors can be conducted. The initiative’s role is to launch fundamental change by providing infrastructure, fostering collaboration across systems, and contributing to the knowledge base of effective stigma reduction efforts. Projects that show initial promise may be adopted as pre- vention and early intervention strategies to sustain in the future, but others will not. At the end of 4 years, the initiative must provide a roadmap for change that is as constructive as possible.
The synergy created by the 25 projects is already shifting the di- alogue about mental illness in California to emphasize not only recovery but also the outcomes beyond it: prevention and essen- tial well-being. This approach promotes mental health through innovative methods. By design, California’s stigma and discrimi- nation reduction efforts will pro- vide new knowledge on effective strategies and how to achieve
TABLE 2—Evaluation of Projects Funded by the Mental Health Services Act: California, 2011–2015
Evaluation Question Evaluation Approach
What structures have been created to reduce stigma and discrimination? Synthesis of individual program evaluations, articulating major products such as new training programs,
materials and resources, organizations, and Web sites.
Are they likely to be effective/of good quality? Assess short-term program outcomes such as participant evaluations and shifts in knowledge and
attitudes from training.
Review curricula to determine whether training and Web sites include elements known to reduce stigma.
Test media message efficacy through experiments.
Are they sustainable? Qualitatively review activities undertaken and obstacles and successes experienced during program
implementation.
Are they reaching the right people? Identify people who used/were reached by program and their demographics, focusing on key subgroup
targets and geographic location.
For media-related programs, include items on the statewide survey.
Are they increasing knowledge, reducing stigma and discrimination,
and increasing help-seeking in California, among individuals?
Analyze statewide longitudinal survey data.
At the societal level? Analyze content of entertainment media and journalism coverage.
Analyze social norms reported in statewide survey.
At the institutional level? Analyze responses of people with mental illness in statewide survey regarding problems in previous year with
schools, employment, corrections officers, the health care system (behavioral and physical), and housing.
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Published online ahead of print March 14, 2013 | American Journal of Public Health Clark et al. | Peer Reviewed | Reducing Stigma, Including Self-Stigma | e7
them, identify noneffective strate- gies and how to avoid them, rec- ommend ways to eradicate mental health stigma, and create sustain- able measures for monitoring progress at the individual, social, and institutional levels. We invite you to follow our efforts as we report on them at http://www. calmhsa.org. j
About the Authors Wayne Clark is with the Monterey County Behavioral Health Department, Monterey, CA. Stephanie N. Welch, Ann M. Collentine, and Amy L. Shearer are with the California Mental Health Services Authority, Rancho Cordova. Sandra H. Berry and Rebecca Collins are with RAND Corporation, Santa Monica, CA. Dorthy Lebron is with Lebron Consulting Group, Monterey, CA. Correspondence should be sent to
Stephanie N. Welch, 3043 Gold Canal Dr, Suite 200, Rancho Cordova, CA 95670 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link.
This article was accepted December 27, 2012.
Contributors W. Clark was the lead author and provided content direction. W. Clark, S. N. Welch, and A. M. Collentine developed concepts. S. N. Welch was the primary content developer and conducted the literature review. S. H. Berry provided content development support. S. H. Berry and R. Collins contributed to data collection and analysis. A. L. Shearer provided literature review support and contributed to data collection. A. M. Collentine and A. L. Shearer reviewed content. D. Lebron contributed analytic support.
Human Participant Protection No protocol approval was required because no human participants were involved.
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