Ending Stigma: On the Strength of a Comprehensive Strategy

Editor’s note: Second in a 3-part “Ending Stigma” series | Part I

Success in ending stigma depends on prioritizing our strategies and tactics. We need strategies for institutional as well as cultural change. Healthcare is the institution we can best impact, and one bold strategy is to destigmatize our services by locating them in primary care. Mental health awareness campaigns are trusted tactics within a strategy of cultural change. Success will not be easy.

Social stigmas place many into the “other” category. Ending stigma is difficult because the negative judgment and the fear related to the other gets deeply ingrained into everyone’s character. Behavioral health experts recommend greater understanding and empathy, but is this enough? Stigmas are not encapsulated ideas to be removed. They are rooted in our identities in highly individualized ways.

Do people and societies change based on a greater awareness of facts and past misunderstandings? No, we often need a strong plan of action. Consider the opioid crisis. It mushroomed to epidemic levels over the past decade despite abundant factual reporting. A recent story noted how fentanyl-laced pills are adding to overdoses. The earnest comment was, “we have to get the word out.”

However, this urgent story is like many similar ones over the years. The word is already out. It is time to say society’s response has been feeble and we need real solutions, not more awareness. We cannot specify to what degree stigma about addiction contributes to the lack of an aggressive plan to end this epidemic. In any case, awareness of the problem is not moving the needle toward resolution.

How does awareness differ from the strategy we employed for federal insurance parity? The parity battle attacked a discriminatory social policy and forced change in how people are treated, not viewed. We face similar challenges on access to care, an issue tied to stigma. Roughly 90% of those with substance use disorders and 35% with serious mental illnesses do not get needed care. These rates reflect powerful social factors that will not change easily.

Is medicalization, as epitomized by casting addiction and depression as brain diseases, the key to shattering stigma? A large new survey focusing on addiction suggests not, and awareness campaigns for depression are discouraging. After decades of depression campaigns featuring medications for presumed brain chemical imbalances, stigma persists and many people avoid needed services.

Stigma will not end based on changes in cultural norms alone. We must not only change how people think, but also how people are treated. For example, what if behavioral health became a normal part of primary care? What if we treated stigmatized conditions like depression and addiction as basic health problems and we welcomed discussion of emotional health for all people at least annually?

As a tactic, awareness campaigns must be factual. Yet some experts promote unproven claims regarding brain-based behavioral diseases. There seems to be an unwarranted assumption that any promotion of the biomedical model is a nail in the coffin of stigma. For example, thought leaders in addiction recently criticized stigmatizing language, but included an odd rejection of the term “medication-assisted treatment (MAT).”

These leaders argue that the MAT label devalues medicines for opiate addiction. They suggest these medicines are treatments in their own right, not treatment aids, and accordingly, we should say we have medications to treat opioid use disorders much as we have others for cancer. However, this ignores the reality that cancer is unlike addiction. Addiction care needs equally important psychosocial treatments.

While applauding MAT medications is warranted, medicalization is an uncertain path for ending stigma. This approach does not eliminate the other so much as it biologizes certain groups of others. Instead of dismissing the other as a social construction that divides us, the other survives as a biological reality. This is not only a weak strategy, but it is also limited to social stigmas presumably tied to a disease.

Societies tend to praise or blame subgroups based on unfounded prejudice and stereotype. Principled societies strive to overcome these artificial, destructive standards. Our field should join such striving.  For example, some of us have unique emotional challenges, but they are variations on problems of living that we all share. The biological basis of behavior is secondary in the context of these concerns.

Changes in cultural norms must be accompanied by institutional changes in how people access care. Let us redefine stigma by its consequences and focus on it as a discriminatory lack of access to care. Stigma is at the heart of why many in need fail to get care. Other factors contribute, but stigma can be thought of as the organizing principle for poor access. Let us end the discriminatory lack of access to care.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.