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Overcoming Stigma:
Strategies for Integrated Care Settings
Gretchen Grappone, LICSW
Marty Boldin, LICSW, MLADC, LCS, CPS
Gretchen Grappone, LICSW
[email protected]
Trainer and consultant in VA Medical Centers, civilian
hospitals and community mental health centers
DBT & CBT clinician at community mental health center
Social worker on inpatient behavioral health unit
Person with lived experience of depression
Marty Boldin, LICSW, MLADC, LCS, CPS
Ph.D. candidate and Dean's Fellow, Boston
University School of Social Work
Recovery representative to the Governors
Commission for Alcohol and Drug Abuse Prevention,
Treatment, and Recovery
Addiction and mental health treatment professional
with 30 years of clinical experience
Objectives for Today
Review the most common types of stigma
associated with mental illness and substance use
Recognize the effects of stigma on clients, family
members & health professionals
Explain strategies for assessing and addressing the
presence of stigma in a clinical setting
MHCGM’s Stigma Assessment &
Reduction Initiative
“Effective stigma change initiatives
attend to all relevant dimensions of the
stigma complex, regardless of the
specific level that is the target of the
Ending Discrimination Against People with Mental and Substance
Use Disorders: The Evidence for Stigma Change
(National Academies of Science, Engineering & Medicine, 2016)
Defining Stigma
Stereotypes, prejudice and discrimination that
are associated with mental illness and substance
use disorders
Involves loss of status among an individual or a
group and separation from non-stigmatized
(Corrigan & Watson, 2002; Link and Phelan 2001)
Defining Stigma
(in a more palatable way)
Negative attitudes about, and behavior
toward, people with a mental illness or
substance use disorders
Actions that result in a LOSS OF
(Thornicroft, Rose, Kassam & Sartorious, 2007)
Different Types of Stigma
We endorse/perpetuate/experience stigma
either explicitly (within our own awareness)
or implicitly (outside of our awareness)
(Stull et al., 2013)
Public Stigma
General public endorses stereotypes and
prejudices that result in discrimination against
people with mental illness
(Corrigan, Roe & Tsang, 2011)
Also referred to as social stigma or enacted
(Livingston & Boyd, 2010)
Self-stigma, also called internalized stigma,
happens when a person with mental illness or
substance use disorder endorses negative
stereotypes about themselves
(Barney, Griffiths, Jorm, &, Christensen, 2006)
Self-stigma often viewed as an internalization of
public stigma
(Corrigan & Rao, 2012).
Perceived Stigma
Belief that stigmatizing ideas about mental illness
and substance use disorders are held by others
(Brohan, Gauci, Sartorius & Thornicroft, 2011)
Label Avoidance
Choosing not to seek mental health or substance
use treatment to avoid being assigned a stigmatizing
(Corrigan, Watson, Byrne & Davis, 2005)
Some argue label avoidance as one of the most
harmful forms of stigma.
(Corrigan, Roe & Tsang 2011)
Stigma by Association
The effects of stigma are extended to someone
linked to a person with mental health difficulties.
(Van der Sanden et al., 2013)
Also known as courtesy stigma and associative
(Goffman,1963; Verhaeghe & Bracke, 2012)
Health Professional Stigma
Any time a social worker, doctor, nurse, occupational
therapist, nursing home employee, psychologist,
physical therapist, pharmacist, hospital employee,
drug and alcohol counselor, dentist, mental health
counselor, licensed nursing assistant, APRN, or
health center employee allows stereotypes and
prejudices about mental illness and substance use to
negatively affect client/patient care.
(Grappone, 2014)
Structural Stigma
Laws, institutional policies or other societal
structures that result in decreased opportunities
for people with mental illness or substance use
Happens at all levels of public and private
(Corrigan, Markowitz & Watson, 2003; Bos,Pryor, Reeder &
Stutterheim, 2013; National Academies of Science, Engineering &
Medicine, 2016 ).
Effects of Stigma
“We argue that stigma is in fact a central
driver of morbidity and mortality at a
population level.”
(Hatzenbuehler, Phelan, & Link, 2013)
Life expectancy 20-25 years less than people
without mental illness (mostly due to preventable
(Colton & Manderscheid, 2006; Lawrence et al., 2013)
Effects of Stigma
People with mental illness less likely to receive
evidence‐based treatments for heart disease,
stroke, asthma & diabetes
(Druss et al., 2010)
One study suggests the higher level of stigma
endorsed by health professional, the less likely
patient with mental illness is referred to a
(Corrigan et al., 2014)
Effects of Stigma
Diagnostic Overshadowing
Health professionals inaccurately attributing
physical symptoms and behaviors to a person’s
mental illness or substance use disorder
(Jones, Howard and Thornicroft, 2008)
Effects of Stigma
% of people unwilling to
be friends
work closely
marry into
Alcohol dep.
(Pescosolido, 2013)
Effects of Stigma
Borderline Personality Disorder
Research shows people viewed as manipulative,
dangerous, treatment resistant by health professionals &
public (Rivera-Segarra et al., 2014)
Stigma in military may be enhanced due to a culture that
requires self-reliance & toughness (Tanelian & Jaycox, 2008)
Effects of
Substance Use Disorder Stigma
People with substance use disorder seen as being
more responsible for their illness than those with
mental illness
(Corrigan, Kuwabara & O'Shaughnessy, 2009)
Substance users seen as violent, manipulative and
unmotivated by many health professionals
(Boekel et al.,2013 )
Perceived stigma can cause people to drop out of
substance abuse treatment
(Brener et al., 2010)
Effects of Stigma
in the ER
Emergency room staff are often not trained to work
with people with mental illness and may view them
as disturbing to other patients, difficult to treat and
ER staff may be at an increased risk of
stigmatizing attitudes since, by the nature of their
work, they see patients when they are in crisis
(Newton et al., 2008; Santucci, Sather & Baker, 2003; Olshaker & Rathlev,
2006 Thornicroft, Brohan, Kassam & Lewis-Holmes, 2008)
Effects of Stigma on the Family
Family & caregivers report fewer social connections
(Lazowski et al., 2012)
Parents feel shame, fears labeling of child, feels
responsibility for illness of child & is a barrier to treatment
(Koerting et al., 2013)
Significant other or relatives blamed when client does not
follow treatment plan
(Corrigan & Miller, 2004)
Effects of Stigma at a
Mental Health Center
Stigma by association in mental health
professionals linked to:
Less job satisfaction
More emotional exhaustion
Self-stigma in recipients of service
(Verhaeghe & Bracke, 2012)
Effects of Co-Occurring Stigmas
Structural racism linked to increased risk of heart attack
in Blacks (Lukachko et al., 2014)
Societal homophobia linked to 12-year shorter life
expectancy for gay, lesbian & bisexual individuals and
more likely to die as a result of suicide much younger (at
37 years old vs. 55 years old for low-prejudice areas)
(Hatzenbuehler, 2014)
Obese individuals viewed as unintelligent, lazy,
unsuccessful, lacking willpower (Puhl & Heuer, 2010)
Effects of Stigma on
Mental Health Professionals
“So many people have begged me to come forward,
and I just thought — well, I have to do this. I owe it
to them. I cannot die a coward.”
Marsha Linehan, Ph.D. (Carey, 2011)
“Silence about mental illness bred a quiet ugliness
and set in place the conditions for unnecessary
suffering and death.”
Kay Redfield Jamison (Jamison, 2009)
Effective stigma reduction strategies
Focus on changing behaviors rather than changing
Focus on sustained anti-stigma programs rather than
Increase knowledge of effectiveness through
(Stuart, 2015)
Effective stigma interventions
Contact with someone in recovery most effective
way of reducing public stigma
(Corbiere, Samson, Villotti & Pelletier, 2012)
Education about mental illness not as effective
as contact interventions (except for teens)
(Corrigan, Roe & Tsang, 2011)
Effective stigma reduction strategies
Most effective when targeted, local,
credible, continuous & involve contact
(Corrigan, 2011)
Effective stigma interventions
Mental Health Commission of Canada
addresses health professional stigma
through targeted behavioral changes (skill
acquisition, exposure to uncomfortable
topics in primary care settings)
(MacCarthy et al., 2013)
Structural stigma reduction
Include stigma assessment and interventions
throughout in clinical treatment
(Acosta et al., 2014)
See example:
Clinical Stigma Assessment and Action Plan
(Atlas Research, 2015)
Consider using validated self-stigma assessment
with clients
(Ritsher, Otilingam, & Grajales, 2003).
Structural stigma reduction strategies
Stigma Reduction & Action Plan
Clinical treatment plan & Agency plan
(Grappone, 2015)
Planning session
Groups will pick one type of stigma and
brainstorm agency strategies for assessing
& reducing stigma
Q&A with Rik Cornell, LICSW
The Mental Health Center of Greater Manchester’s
Stigma Assessment and Reduction Initiative:
Creating sustained structural stigma reduction
Objectives for Today
Review the most common types of stigma
associated with mental illness and substance
use disorders
Recognize the effects of stigma on clients, family
members & health professionals
Explain strategies for assessing and addressing
the presence of stigma in a clinical setting
Atlas Research
805 Fifteenth Street NW, Suite 910
Washington, DC 20005