Efforts Aimed at Reducing Stigma
There are a number of strategies that have been proposed for reducing the stigma experienced by individuals with mental health difficulties. Clement et al. (2010) consulted with a panel of 32 experts attending an international conference on mental health stigma. Consensus was reached that the use of ‘recovery-oriented’ (i.e. supporting the notion that people with mental health difficulties can still lead full and meaningful lives) and ‘see the person’ messages (advocating a holistic appreciation of the person rather than the illness) were to be recommended and that ‘social inclusion/human rights’ messages and efforts aimed at highlighting the high prevalence of mental health difficulties are also worthy of consideration (Clement et al. 2010).
There has been consistent support for the importance of Social Contact Theory (see Pettigrew and Tropp 2006) in reducing mental health-related stigma. ‘Social Contact’ initiatives aim to break down stigma by facilitating opportunities for people with no experience of mental health difficulties the chance to meet with those who have had mental health difficulties. Extending earlier work on Intergroup Contact Hypothesis (Allport 1954), Pettigrew (1998) proposed that for maximum benefit the nature of the social contact should be such so as to facilitate:
- 1. Equal status between the groups in the situation
- 2. Common goals
- 3. Intergroup cooperation
- 4. Support of authorities, law, or custom
- 5. Friendship potential.
Evans-Lacko et al. (2012b) investigated the impact of social contact on stigma by administering questionnaires to 403 participants (70% paper, 30% online) living in England. A total of 83 of these individuals completed online questionnaires at four to six weeks’ follow-up. The results were positive and emphasized the importance of providing opportunities for positive social contact. The findings also supported the idea that social contact interventions can be implemented and effective at a mass level. In another study conducted in England, Clement et al. (2012) investigated whether recorded video clips compared to live social contact interventions were superior to reducing stigma by utilizing a randomized control trial methodology with 216 student nurses. Nurses were randomly allocated to one of three conditions: (1) viewing a DVD of mental health service users and informal carers discussing their experiences (DVD); (2) watching a service user and carer talk about their experiences in person (live); or (3) attending a lecture that focused on stigma and mental health (Control). There were no significant differences between the DVD and Live conditions. The combined social contact groups (DVD/live) demonstrated superior outcomes compared to the Control condition, which were maintained at four-month follow-up. The DVD was adjudged to be the most cost-effective option, and the live sessions were considered the most popular.
Corrigan et al. (2012) conducted a meta-analysis of outcome studies evaluating efforts to reduce stigma. The participants recruited to the 79 independent studies came from 14 countries across Europe (N = 22,179), North America (N = 14,307), South America (N = 63), Asia (N = 1299) and Australia (N = 516). Notably, however, there were no participants from Africa recruited to any of the studies. Both education and social contact were found to have positive effects on lowering mental health-related stigma experienced by both adolescents and adults. Social contact was however found to be superior than education for lowering stigma experienced by adults. The inverse was the case for adolescents, with education being found to be more effective. The authors concluded that face-to-face contact was superior to contact by video. More recently, Griffiths et al. (2014) conducted a meta-analysis of randomized controlled trials investigating interventions for reducing stigma related to mental health difficulties. The vast majority of these studies were conducted in HICs. Only one study had been conducted in a middle-income country [i.e. Turkey, see Bayar et al. (2009)], and no studies had been conducted in low-income countries, as identified in the review. The results of the meta-analysis indicated that there was no evidence supporting the idea that stigma interventions were efficacious in reducing self-stigma or perceived stigma.
A systematic review conducted by Mehta et al. (2015) sought to address concerns that research studies investigating anti-stigma campaigns had focused too much on short-term outcomes and that the research has tended to have been conducted in HICs. Of the 80 studies included in the review, 11 had been conducted in middle-income countries and none had been carried out in low-income countries. The 21 studies with medium to long-term follow-up outcomes (i.e. a minimum of four weeks’ follow-up) for which effect sizes could be calculated failed to support the notion that social contact interventions were superior to other forms of intervention at improving attitudes towards people with mental health difficulties. The reasons why the post-intervention superiority of social contact interventions is not retained in the longer-term remain unclear. Mehta et al. (2015) and Thornicroft et al. (2015) have highlighted the need for more rigorous research to be conducted into anti-stigma campaigns—particularly in LMICs.
Mittal et al. (2012) conducted a review of empirical studies that have specifically investigated self-stigma reduction strategies. Of the 14 studies included in the review, only one was conducted in a middle-income country (i.e. China; Fung et al. 2011) and none was conducted in low-income countries. In particular, two prominent approaches for self-stigma reduction were identified: (1) interventions aimed at altering the stigmatizing beliefs/atti- tudes held by the person and (2) interventions aimed at enhancing skills for tolerating self-stigma through improved help-seeking behaviour, self-esteem and/or empowerment. The review indicated that the second approach in particular appears to be increasingly recognized by stigma experts as offering promise (Mittal et al. 2012). It is suggested that high-risk groups be targeted to pre-empt the potential development of self-stigma so that the impact on the individual can be reduced (ibid.).
Rusch et al. (2005) have highlighted how people who have experienced mental health difficulties (‘consumer’ groups in particular) can be a powerful resource in reducing stigma. In addition, research has demonstrated that involving people with a lived experience of mental health difficulties in the care and treatment of others can serve to reduce stigma. Specifically, research conducted in Ontario, Canada, found that Peer Support Workers do not regard stigma as a barrier for getting work and they were more likely to be employed (Ochocka et al. 2006). In addition, Mowbray et al. (1998) reported that Peer Support Workers acknowledged that through their work they were altering attitudes to mental health difficulties and in turn were serving to reduce stigma.