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Addressing Mental Health Stigma

Posted: 18 May, 2015   Recommendations: 17   Replies: 64

Mental illness is a major contributor to the burden of disease worldwide, accounting for 37% of healthy life years lost from Noncommunicable Diseases (WHO, 2010). The 2010 Global Burden of Disease study prepared by a team of scholars from Harvard School of Public Health and World Economic Forum found that mental illnesses cost the global economy around $2.5 trillion a year, and this loss is expected to rise to $6 trillion by 2030. Mental illnesses are also risk factors for cardiovascular diseases, respiratory diseases, and diabetes. So, the true costs of mental illness might be even higher.

Given the evidences that show the dramatic effects of mental illnesses, there is heightened awareness globally to increase its diagnosis and management. Yet, one of the biggest challenges in bringing mental health programs to be adopted in the community level is the persistent and harmful stigma about illnesses among families and communities. Such misperceptions about mental health can result in social restrictions, delay in treatment, poor quality of life, and even low self-esteem (Girma et. al 2014).

To discuss the challenge of the reducing mental health stigma, GHDonline is pleased to welcome the following group of panelists who will share current and past efforts to address this critical issue:

• Helen Christensen, PhD – Chief Scientist and Director of the Black Dog Institute
• Samuel Law, MD, FRCP(C) – Assistant Professor of Psychiatry at the University of Toronto
• Rupinder Legha, MD – Psychiatrist/Pagenel Fellow at Zanmi Lasante and Partners in Health; Research Fellow in Global Health and Social Medicine, Harvard Medical School
• Lisa Smusz, MS, LPCC – Founder of Smusz & Associates Consulting Services; Instructor at California State University, East Bay
• Tatiana Therosme, BA – Psychologist and Mental Health Community Health Worker Supervisor at Zanmi Lasante, Haiti
• Graham Thornicroft, PhD – Professor of community psychiatry at King's College London

Our panelists will offer insight into the following questions:

• What are mental health and stigma reduction programs that you are currently involved in?

• What are the biggest challenges that you face while addressing mental health stigma in your setting?

• What programs and interventions are currently in practice to address these challenges? How do you measure success of these programs?

• Are there successful mental health educational efforts that have been applied to different settings and diverse populations?

• How do we keep ensuring that mental health is a priority in the policy agenda of governments?

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve healthcare delivery in underserved populations in the US.

In an effort to understand the impact of our Expert Panels, we have created a short (4 question) survey. Your responses are greatly appreciated—please take the survey before the discussion begins:

We look forward to a rich discussion next week – please join the conversation and share your questions or comments!



Emily Mendenhall Replied at 9:42 AM, 18 May 2015

Dear colleagues,

I look forward to following this panel. Also, may I offer a new resource
edited by Dr. Brandon Kohrt and myself, with a forward by Vikram Patel: Global
Mental Health: Anthropological Perspectives

Jessica Ludvigsen Replied at 9:58 AM, 18 May 2015

In preparation for next week's discussion, I want to share a number of resources that might be of interest.

Attached resources:

Christian Rusangwa Replied at 9:59 AM, 18 May 2015

Thanks Sudip,

Indeed this is a crucial topic and it has a significant impact on the
treatment outcomes as well as quality of life improvement.



Jessica Ludvigsen Replied at 10:05 AM, 18 May 2015

Emily - thank you for sharing that interesting resource with us!

I would also like to add one more resource to the bunch.

Attached resource:
  • Darkness Invisible (external URL)

    Link leads to:

Meika Bhattachan Replied at 11:26 AM, 18 May 2015

Thank you Sudeep for sharing the discussion.

This is indeed a very interesting topic.

Sandeep Saluja Replied at 11:43 AM, 18 May 2015

As a clinician,I have been actively involved with treatment of psychiatric illnesses in the community and take the liberty of putting forward two small issues from a clinician's perspective.
One of the reasons,I have been more succesful in this endeavour has been the fact that I do not carry the label of being a psychiatrist and yet feel comfortable and confident in treating such patients.
Further,I feel the best way to remove stigma is to be able to treat patients effectively.Whatever may be the care givers or other persons perceptions of the illness,they are all removed once they see clinical results for themselves.Any counselling of the care givers and others becomes meaningful after that.Treating one patient ensures that many more are brought to you and the community becomes more receptive to perceiving psychiatric problems as a biological illness much like any physical problem.

Ntihabose Corneille Killy Replied at 3:39 PM, 18 May 2015

Thank you for bringing this topic,
I am looking forward participating in this discussion on the challenge of
the reducing mental health stigma.

Sherine Shawki Replied at 3:56 PM, 18 May 2015

Thank you so much for starting this discussion . I am so interested in that topic . In my country ,Egypt , stigma caused by mental health illness is so harmful . It may decrease the opportunities of marriage . Not only the opportunities of the patient but of all members of his family . In my country , people think that mental illness is a hereditary illness which will definitely pass through generations. I believe it is very important that people should know more about mental illnesses. It is the responsibility of the public health professionals to enrich people with the knowledge they need to know about mental illness.

Israel Ajayi Replied at 4:15 PM, 18 May 2015

Interesting topic

Evelyne MUKAKABANO Replied at 4:31 PM, 18 May 2015

Mental health crisis can be the root cause of household poovrety and vis
and stigma can be extrapolated to family members
Here we are trying to build capacity to village community health workers
and all social affairs to each administrative level to prevent mental
health problem from the pregnancy by using rapid SMS from village to MOH
Also I am involve in preventing GBV as district trainer

Ntihabose Corneille Killy Replied at 4:47 PM, 18 May 2015

Good points Evelyne and I say Hi to you,
One point to add for your intervention:your experience is case of Rwanda.
Remember here we are multinationals.

Evelyne MUKAKABANO Replied at 4:58 PM, 18 May 2015

Thank you for you point
however bringing our experinces is the key of discussion
so I implore everyone to bring on the panel its experince
Thank you

Dr. Ntizimira R. Christian Replied at 5:26 PM, 18 May 2015

Thank you for this crucial topic. I was working on the impact of mental health issue among Palliative care patients survived from the Genocide against Tutsi happened in 1994. We hope this issue will be well addressed.

Ernest MUHIRWA Replied at 2:07 AM, 19 May 2015

Am Ernest MUHIRWA from Partners In Health/Rwanda with background of Public Health
Actual the problem of Mental Health is one among the global burden.

This is our time to provide more on this one, your ideas will be helpful for the world.

Pantaleon Shoki Replied at 5:44 AM, 19 May 2015

Great, looking forward to participate

Murali Ramachandran Replied at 6:17 AM, 19 May 2015

Dear colleague,
Thanks for the mail.
Look forward to participation.

daniel chemane Replied at 7:05 AM, 19 May 2015

Dear sudip
I appreciate the invitation and will be an honor to be part of this

Elisha Oliver Replied at 2:45 PM, 19 May 2015

Thank you for the invitation. I look forward to participating.

Be Well,


Elizabeth Glaser Replied at 1:23 AM, 21 May 2015

Thanks for the invite.

Please, if possible, could there be some discussion of stigma as it relates to addictions/substance use disorders?

Those living with addiction suffer stigmatization from society and health providers, while also struggling to access any form of service.Treatment of this illness, if it occurs , is usually through the criminal justice system.


Thaddeus Musembi Replied at 2:25 AM, 21 May 2015

I'm grateful to receive the invitation to participate on the topic
captioned above. I do expect the forum will address the proper treatment of
the illness and how to handle the patients and other useful means as

To my knowledge and experience, as days go by, a number of people with
mental illness increases and the societies have no education on how to care
of them and so, they end up roaming on streets like the homeless or
livestocks without a keeper.

Professionally we call them patients, but they are left on their own
without being attended, this is vivid to most developing countries.
I confirm to fully particopate , so that I can learn fromvthe experts.


Sudip Bhandari Replied at 3:45 PM, 22 May 2015

A reminder that our very short Expert Panel survey is open until Monday morning - your responses to these 4 questions will help us evaluate the impact of these types of discussions here at GHDonline and provide us with incredibly helpful feedback. Please take a moment to fill out the survey if you haven't already:

Abubakar Danlami Balarabe Replied at 5:03 PM, 22 May 2015

Thank you for the invitation, looking forward to a fruitful and educating discussion.

A/Prof. Terry HANNAN Replied at 7:34 PM, 22 May 2015

23 responses so far and the discussion has not even begun. WOW. This shows what an important topic this is. The panellists are superb. I look forward to what emerges.

Ignacio De Gabriel Hernández Replied at 9:31 PM, 22 May 2015

Hola y muy buenas noches,desde Huatusco,Ver México. Soy médico cirujano con ejercicio profesional de mas de 20 años yveo con suma preocupación que los trastornos mentales van en aumento.Hace algunos años hasta llegué a considerar normal la depresión en las personas de 40 años o mas y básicamente sin ser psiquiatra,con escuchar a los pacientes me enetré que la mayor problemática está asociada a los estímulos externos ( pérdidas familiares-desempleo,enfermedades crónicodegenerativas etc) sin embargo veo con mayor preocupación a una juventud,sumergida en violencia extrema,estress incontrolable,depresión mas intensa,mas intentos de suicidio y me pregunto ¿dónde está la prevención de toda ésta expresión de patología mental...¿dónde está la expresión genética o por qué la genética de una conducta normal ahora se está convirtiendo en patológica?..
Pero por otro lado,por favor explíquenme cómo es ésta modalidad de panel en línea..
saludos nuevamente

Ingrid Bremer Replied at 9:48 PM, 23 May 2015

Looking forward to further discussion of this interesting and important topic.

Yudha Saputra Replied at 10:27 PM, 23 May 2015

Dear colleagues,

Thank you very much for the invitation, and also shared valuable resources and information. To be honest, I'm not really understand if there any kind of this stigma in my society (Indonesia). Hope this discussion could improve our awarness of this stigma.

Let's the fun begin!

Warm Regards,

Dorcas Gwata Replied at 6:57 AM, 24 May 2015

Dear colleagues

I am very much looking forward to our discussions on this public health issue.
Stigma is not just aligned to mental health alone, we have seen how this has spanned out in the Ebola crisis, with women and children carrying the heaviest burden.

Looking forward to further discussions


Dorcas Gwata
Clinical Nurse Specialist. CAMHS. NHS and Zimbabwe

Madhuri Gandikota Replied at 8:02 AM, 24 May 2015

Dear All,

Thank you very much for inviting me to join in this panel discussion. A very great panel.
I certainly look forward to it.

I am not a subject matter expert in this area, but as Elizabeth Glazer has rightly pointed out, I also wonder about the
" association of mental illness to substance abuse" . Is substance abuse the cause of mental illness or the outcome?.


Rajan Dewar Replied at 9:01 AM, 24 May 2015

Thank you for these wonderful insights and important discussion.
1. I wonder what the real role of an individual health care professional could be in the REMOVAL OF STIGMA associated with mental health at least in the LMIC setting. Doctors and social workers do educate and advocate for medical issues (cancer, TB, AIDS, Malaria etc) of families in our villages (South India). Not so much for mental health. The STIGMA associated is thought to be cultural. Somehow I feel they are limited or hesitant in modifying cultural and societal thought processes.
2. I wonder about resource allocation and available resources in LMIC settings for mental health (and Stigma). Resource allocation 'experts', strongly feel that they get more out of their dollar (or equivalent) spent on an 'organic' disease. Mosquito nets and Mammograms get more attention publicity (and resources) than mental health services (almost none for stigma removal). Fighting for these resources is challenging in LMICs.
3. Please expand and share your thoughts on alcoholism and drug abuse: we do have a lot of alcoholism in the villages; a couple of decades ago, there used to be a stigma for an alcoholic / these men would be labeled as a 'drunkard', and villagers would ostracize them... But these days when alcoholics are a majority in a small community, there seems to be a growing stigma for being a minority "non-alcoholic adult male".

Helen Christensen Replied at 7:46 AM, 25 May 2015

Hello everyone

Helen Christensen from the Black Dog Institute adding a post. I think I must be ahead of you all - though it is Monday evening here.

As a general interest article on research looking a evidence-based programs I'd like to recommend a reference from my colleague Tony Jorm, who has undertaken research in stigma for 15 years.

A few general comments; Stigma has been conceptualised in so many different ways; and there is now more attention to different types of stigma - stigma around depression, anxiety and suicide.

The topic for today was to consider the different projects looking at stigma reduction - plenty of studies I have been involved in looking at stigma in communities that use the Internet, communities that use Lifeline and crisis services, studies of young elite athletes, and most recently, studies using psycho-education for school students - the latter showing that education programs improve mental health literacy and also lower stigma.

The latter study of students who undertook the HeadStrong program showed improved awareness led to better mental health and acceptance.
Mental health lessons for secondary school students reduced stigma and thus have a potentially lifelong effect. 208 year nine and 10 students from 10 schools across NSW took part in the mental health literacy program HeadStrong. Students participated in the standard secondary school PDHPE (Personal Development, Health and Physical Education) curriculum. People in the HeadStrong group changed their attitude with regards to seeing people with mental illness as dangerous and unpredictable. The program is available free of charge for all schools through our website. The link is here

The study is published here

Look forward to your responses

Lisa Smusz Replied at 11:28 AM, 25 May 2015

Good Morning from California,

Lisa Smusz joining the conversation here. How fantastic to see so many posts and discussion here before the panel even "officially" began! Physicians are such vital partners in mental health care and reducing stigma. In the US 50% of people seek mental health support solely from their general physician, meaning half of all the behavioral health care in the U.S. is provided by general medicine providers and 70% of all psychotropic medications are prescribed not by psychiatrists, but by general physicians, including 80% of all antidepressants. (See California Primary Care report in links below for more info on stats).

As Helen stated, today we were asked to talk about mental health and stigma reduction programs we have been involved in.

Currently, I am a consultant working on the Each Mind Matters Campaign (EMM) which is run by the California Mental Health Services Authority (CalMHSA) (I've included links to both the campaign website itself, and to CalMHSA should you wish to learn more or follow-up directly with them). It's an exciting and ambitious campaign for a variety of reasons.

California is the most populous state in the US (more than 37 million people as of 2010), and has a highly heterogeneous target population; no single racial or ethnic group forms a majority of the population and more than 200 languages are known to be spoken within the state. This presents unique challenges for a stigma and discrimination reduction program, not only in terms of making messages and materials available in language, but more importantly in making sure that the strategies being utilized to reduce stigma are effective with a variety of sub-populations. (More about this in upcoming discussion threads). The campaign is also interesting in that CalMHSA has partnered with RAND to evaluate the campaign, making the largest investment in stigma research (regarding practices/programs in addition to measuring attitudes) ever in the US. (Links to current findings given at the end of this thread). By this summer they will have finished a return on investment analysis of SDR investments which will help us to understand and demonstrate to others (such as policy makers) the critical economic need to remove stigma to reduce both human and societal costs.

In addition to discussing Each Mind Matters, I am also happy to share information and resources from more localized campaigns I have had the pleasure of working on in the San Francisco Bay area with specific populations such as: African American and Asian Pacific Islander communities in the Bay Area, University-wide campaigns reaching out to both faculty and students, people running housing communities, primary care, and the very important issue of reducing internalized stigma amongst people living with a mental health diagnosis.

Lastly, although not specifically a stigma and discrimination reduction program, I would be happy to share information about exciting work done recently in California utilizing people who have recovered from mental health challenges as peer providers in primary care settings. These efforts (including one I worked on in the San Francisco Bay Area) have had very promising early results in reducing hospitalization as well as reducing costs in in-patient and emergency room settings.

Thank you to GHDonline for selecting this topic, looking forward to a rich discussion all week and learning about all the efforts and research being conducted by colleagues.

Attached resources:

Abubakar Danlami Balarabe Replied at 5:46 PM, 25 May 2015

Hello every one,

I think we should start the discussion from our cultural perception of stigma as it affect mental illness and substance abuse, so that at the end of this discussion we will be able sum up a global perception of the phenomena. It will also enable us to decipher research presentations more accurate.

Rupinder Legha Replied at 6:13 PM, 25 May 2015

Hi, Everyone,

My name is Rupi Legha, and I am a psychiatrist working for Partners in Health. As a Pagenel Fellow in Global Mental Health Delivery, I have been working in Haiti for nearly two years, accompanying the Zanmi Lasante (ZL) mental health team. Tatiana Therosme, my colleague, is a psychologist at ZL, and her official role is supervising our cadre of community health workers who have been trained in basic mental health skills. Tatiana and I wish to share with you our experience with stigma reduction, particularly vis-a-vis the ZL team's efforts to develop community-based mental health services at 11 ZL clinics/hospitals. These efforts are part of a three-year project funded through Grand Challenges Canada and intended to build mental health capacity beyond the immediate post-2010 earthquake.

The ZL catchment area contains approximately 1.3 million people in Haiti's Central Plateau and Lower Artibonite Valley. In rural Haiti, community ties provide a critical safety net in a region where extreme poverty is the norm and families try to survive on 1-2 dollars of income each day. Mental health is highly stigmatized. For example, epilepsy is often construed as a form of spirit possession, while psychosis can be construed as evidence of a curse. These illnesses can cause people to drop out of school, to never marry and have a family, and to be shunned by their peers. Patients and their families often pursue traditional healers and religious outlets as their first form of treatment. Accessing biomedical care, even when individuals do consider it as an option, is difficult. Within Haiti, there are approximately a dozen psychiatrists but to our knowledge, none of them works full time in the rural areas. Individuals who do receive biomedical treatment are often referred to one of two public psychiatric facilities, located in the Port-au-Prince area, removed from rural Haiti where 60% of the population lives. Although clinicians do their best, these facilities face significant human resource and funding challenges and are unequipped to provide humane care. Patients are sometimes assaulted or even raped there, and due to the limited resources, their mental illness may worsen. Since the earthquake, there have been renewed efforts to prioritize mental health within the Haitian ministry of health (Ministère de la Santé Publique et de la Population). However, there is no national mental health policy.

So, within this context, how does the ZL mental health team attempt to reduce stigma related to mental illness?

In recent years, our efforts have focused on training community health workers, nurses, physicians, psychologists, and social workers in the diagnosis and treatment of mental illness. Community health workers hold meetings with local leaders, including priests and traditional healers, to discuss different kinds of mental illness, particularly its etiology, how it affects people, how they can identify it, and where to refer people. They also challenge misperceptions, for example, that different kinds of mental illness are contagious. Last, they provide hope to communities and community leaders, that there are effective treatments available. The trainings for various role providers are the starting point for developing an effective mental health system that provides quality, humane care. And when role providers, patients, families, and community members witness individuals recovering from mental illness--this is perhaps our most effective stigma reduction activity. In recent weeks we treated an adolescent boy with epilepsy whose mother and ten siblings had died from complications related to seizures. He is now seizure-free. We are currently providing treatment to a psychotic woman who had previously been tied up and beaten and shunned by her neighbors. It is critically important for role providers to see patients recover from these illnesses, as they often harbor the same misconceptions of mental illness as the patients.

Last, we wish to make the point that stigmatizing beliefs must be considered in the larger context of health inequity and poverty. Haitians have often been maligned for their belief in voodoo and spirit possession--which certainly shape perceptions of mental illness. However, when one thinks of the 13-year-old boy who has watched his entire family perish from a treatable condition, is it any wonder that his grandmother might conclude that a higher power has cursed her family? In a country where a mother might watch all five of her children die in childbirth and subsequently become psychotically depressed, is it any wonder that she and her family might fear a curse and her neighbors, a contagion?

Rupi Legha and Tatiana Therosme

Samuel Law Replied at 7:25 PM, 25 May 2015

I feel much honored to be part of the panel on this very important, complex, and challenging topic. I come to this panel as a community psychiatrist working in Toronto, Canada. My clinical work is informed by my affiliation with my university, my studies in public health, and continued learning through teaching and research. I enjoy community mental health work, often in cross-cultural contexts, as locally in Toronto we have very diverse ethnic populations; and beyond, having worked in New York, the Canadian arctic, Ethiopia, and China. I would say my potential contribution to this topic is in knowledge translation – how to use knowledge gained from researchers to understand various facets of stigma, and how to choose and implement some validated and sensible stigma-reducing activities in clinical work.

One example of my experience in this comes from my work on an international project in China to develop a community psychiatry service for the severely mentally ill. We planned to use outreach and community visit to clients’ homes as a way to engage and monitor and prevent illness relapse in patients – an approach that is highly valued and reasonably accepted in the west. It became clear that it is not the case in China, and it is debatable whether visiting people at home to care for them is actually doing more damage than good. Visiting families in China by mental health workers signifies to others in the neighborhood that someone is ill or abnormal in the house, and the stigma associated is strong. The client and family often feel very ashamed and worried about the visit. It is a barrier to good care.

To resolve this, we consulted local community mental health experts, social workers, and clinicians, and reviewed literature. We had come to the conclusion to roll with this by changing the location of visit to more neutral, public places, such as parks, restaurants, tea shops, shopping malls, etc. With time, as clients became more aware and trusting of our work and their illness became more stable, they had become more confident and less concerned about home visits. These simple processes of engagement and adaptations have led to meaningful changes in clients’ sense of stigma. What we did had support from local experts and practitioners, and were informed by research that shows having consistent and caring contact with the clients will help, having mental health professionals who are non prejudiced will help, and having effective treatment will help. We had also invite families to the clinic for psychoeducation. We have had positive outcome from that as well, as predicted by anti-stigma research. Overall, there is less resistance to home visits as a result of the above efforts. I think it also illustrates how different cultural settings manifest stigma in locally important and meaningful ways and it is important to understand them, before we tackle them.

I look forward to discussing this area more with our online community.

Samuel Law

Som Kumar Sharma Replied at 1:53 AM, 26 May 2015

Hi All,

We need to understand Social and cultural practices on the issue.

Graham Thornicroft Replied at 6:47 AM, 26 May 2015

For a review of what we know about reducing stigma in low and middle income countries see:

Graham Thornicroft Replied at 7:11 AM, 26 May 2015

Re: National level campaigns to reduce stigma

Details of the Global Alliance against Stigma are at:

Details of the Time to Change progrramme in England are at:

And some of our findings for the impact of the programme over the first 4 years are at:

Graham Thornicroft Replied at 11:45 AM, 26 May 2015

Re: What are the biggest challenges that you face while addressing mental health stigma in your setting?

I have summarised these in my book called 'Shunned' published by Oxford University Press

in brief the main barriers concern problems of knowledge, attitudes and behaviour

1 knowledge becasue most people have limited information about mental health problems, and much of this is factually wrong

2 attitudes because most studies show that attitudes towards peoploe with mental illness are almost universally negative

3 and behaviour because people with mental illness experience many forms of discrimination which are socially excluding

For details about papers that discuss these issues in more detail please see

Graham Thornicroft

Elizabeth Omondi Replied at 3:30 PM, 26 May 2015

Interested in mental health within the criminal justice system in the USA or other territories. Any studies on this?

As well as link between mental health and suicide rates among cancer patients especially those in resource limited settings.

Great exchanges so far.

Thanks much,


Samuel Law Replied at 4:01 PM, 26 May 2015

For me, one of the biggest challenges is related to the concepts of stigma held by mental health workers ourselves. It is often talked about in academic settings that there is a persisting misconceptions about stigma by the patients and their families, and one can change that by working at the patient and their family's level. I would say sometimes it is the opposite. Patients and families may know too well what stigma is –and these are not misconceptions. Because they knew too well how hard, as a person with mental illness, it is to have social acceptance, relationships and marriages, and how rejecting and prejudiced the world can be. As a result: they delay in treatment, they have low self esteem. NOT because they don’t understand stigma related to mental illness, but because they knew too well what happens to them in the long run. I think it has very important information related to how how we address stigma.

Elizabeth Glaser Replied at 5:19 PM, 26 May 2015

Thank you for raising this point. That reticence to seek care (because of poor experiences) may spill over into deferring care for medical issues , too. However, if a person is honest about their mental health history, in my opinion, the clinician may not be as thorough or may dismiss symptoms, attributing complaints to the preexisting mental illness , even if that illness is in remission.
One cannot either dismiss the medical compliant or conveniently parcel out the the mental health component when caring for a person with comorbid medical and mental health issues. All clinicians should understand prevention and treatment in mental health because these issues will be relevant regardless of where one works. You might be caring for person with diabetes on a medical unit who also is coping with schizophrenia, a new mother in maternity with bipolar illness, or a vet in the ICU with PTSD and substance abuse, etc. When medical clinicians collaborate with colleagues in mental health , we can help men and women have better outcomes in both body and mind.

Lisa Smusz Replied at 7:36 PM, 26 May 2015

Today we were asked to discuss the biggest challenges we have faced while fighting stigma in our settings. In response, I would like to thank and support some of the comments of others in this thread:

Both Samuel Law and Elizabeth Glaser raised the important (and sometimes difficult to discuss) topic of how stigma may influence those of us who are working in the mental and physical healthcare worlds, and how it may impact the quality of the care we as practitioners provide. This was also one of the challenges our team faced when implementing a local stigma reduction campaign in the San Francisco Bay Area. In an effort to address this particular challenge we tried several strategies, including partnering with a local medical school and local graduate programs to provide presentations on stigma and the perspective of people with mental health challenges to medical students and future mental health providers, as well as developing a "lunch and learn" training for medical staff of local facilities (see link to one film produced for this program below).

Another important challenge was raised yesterday by Abubakar Danlami Balarabe: effectively addressing stigma in a culturally responsive manner. As I mentioned in a previous post, our particular state has no dominant ethnic or cultural group and speaks more than 200 languages. Addressing stigma within each of these unique communities in an effective, research-based manner (not just translating materials) has been one of the more complex and important challenges our teams have faced in many campaigns I have been a part of. In response, we have taken the approach of building relationships with leaders from the communities we are trying to connect with, acting in a supportive role to learn about what works in their community and how we can support them in addressing stigma. (See an example of one such project, a fotonovella developed for the Spanish-speaking Latino community who may seek help from a spiritual leader, in the links below).

I look forward to more discussion about these, as well as other challenges participants have faced, and the strategies that have been used to address them in future conversations this week. I will post some of the approaches and tools I have seen tomorrow, as well as findings about their impact in tomorrow's thread.


Attached resources:

Helen Christensen Replied at 9:04 PM, 26 May 2015

Quick one from me here. Most of our research shows that self stigma is a huge issue - people are often more stigmatising of themselves than others.
Some of the work we did with MoodGYM showed that self stigma might best respond to CBT - a specific program aiming to "be kinder to yourself" might also facilitate help seeking and provide the necessary empowerment to respond to stigma proactively.

Pierre Bush, PhD Replied at 12:03 AM, 27 May 2015

Hello Colleagues,
As someone who practices in the veterans administration hospitals, I have seen challenges in caring for mental health veterans. Sometimes I have seen healthcare workers abused by mental health patients. Usually we have police around, but sometimes they are not present when for instance a phlebotomist goes to draw lab work (they should be present). It becomes difficult to have other phlebotomists approach the abusing patient. The worker who was once assaulted by a mental health patient three years ago did not want to come back to work for us after she underwent therapy for a dislocated shoulder( ?). She was a good worker. It becomes really a challenge for workers to feel confident and provide care for such patients. This topic is very interesting and fascinating. I would like to conduct a research on the extent of abuse of healthcare workers by mental health patients in order to provide sound data on the problem and the appropriate recommendations on how to address it.
This challenge adds to the challenge of caring for the veterans who suffer from PTSD: according to VA records collected through 2007 (

Attached resource:

Pierre Bush, PhD Replied at 12:10 AM, 27 May 2015

Attached resource:

Graham Thornicroft Replied at 4:01 AM, 27 May 2015

Re: 3. What programs and interventions are currently in practice to address these challenges? How do you measure success of these programs?

Our approach at King's College London is to measure:

1 knowledge
2 attitudes and
3 behaviour (discrimination)

we have created a set of scales/measures in these domains, and to measure barriers to access to care

These are freely available by going to

Graham Thornicroft KCL, England

Eileen McGinn Replied at 10:13 AM, 27 May 2015

hi from Eileen in NYC:

Health care is not health: according to WHO Social Determinants of Health (SDOH), the greatest part of health outcomes depend on "daily living conditions" where people are born, grow up, are educated, work, play and live, not specifically on health care. Mental health care is also not the same as mental health (MH) outcomes. I know this is problematic in settings where there is no or poor or sporadic health care, and I think this WHO Europe idea is not fully applicable to all settings, where equity is poor. Nevertheless, the Social Determinants of Health such as good stable housing, affordable and safe schools, safe neighborhoods, acceptance of differences without bullying, good transport, sexual and reproductive rights, decent work with good wages, parks and exercise areas for leisure, adequate transport, complete and accurate health information, etc. are the foundation and building blocks for good health and MH (or "wellbeing" as it is sometimes called now). So it is not that MH is stigmatized: MH is prized, but the MH conditions and services are usually stigmatized. I agree that stigma can come from health professionals, as some have stated here. It also comes from public media, mass media, and traditional schools for professionals who work in this area. I believe that social inclusion is very important for marginalized and oppressed people/populations, including community-based participatory research (CBPR), where the population in question makes important contributions to the research, and not just doing the interviewing. I also think that the UN human rights instruments are important here, such as the Convention on the Rights of Persons with Disabilities (CRPD). I have some other info on Goffman and others who have written about stigma, and I will try to find them in my computer.

Elizabeth Glaser Replied at 12:17 PM, 27 May 2015

were you referencing "Stigma: Notes on the Management of Spoiled Identity," Erving Goffman? A great book.

Goffman broke down the concept into three areas: stigma of character traits, physical stigma, and stigma conveyed by a group identity. To over simplify, we might think of it as :(1) act different, (2) look different, (3) be part of a group that is different.

Social determinants may influence how we, as a culture , assign certain behaviors, stereotypes and physical characteristics into these categories. With time, categories can shift and diminish in size. What we are engaged in now is an effort to remove mental illness as a category of persons that are different.

Internalized stigma is a weed with roots in society.While CBT and other modalities can help individuals cope with stigma on a day to day basis, it does not change the greater society that sets the categories. However when many people from a stigmatized category ( and supporters) are able to join together, they can work to change the public perception of the group from abnormal and thus stigmatized, to normal .

In this discussion, there seems to be a dichotomy evolving between social scientists and practitioners ; the social scientists are discussing the larger reasons for stigma and the clinicians are focusing on interventions to address the stigmatization of clients that they see every day. These are the macro and micro manifestations of stigma . To bring about change we need to understand the determinants to create effective interventions at individual, household, community and national levels.

Samuel Law Replied at 5:31 PM, 27 May 2015

Q3: What programs and interventions are currently in practice to address these challenges? How do you measure success of these programs?
As mentioned, I see myself as a consumer of research based approach in anti-stigma interventions. One of the anti-stigma with "best evidence" is family psychoeducation and mutual help groups. In my work with people with chronic and serious mental illness in the community, many of my patients have tenuous or fractured relationships with their families. Families and patients alike have low level of knowledge on the illness they suffer from, and all of them have invariably experienced negative attitudes and various forms of discrimination in the course of their illnesses. Having a mutually supportive, sharing, and informative forum with psychoeducation and support as a focus for these patients and families have been very positive. Our evaluations have been more qualitative, with families reporting having more understanding and empathy towards their family members with illness, having more settled sense that they are not alone, and they are not at fault in creating their families' illness, and feeling a little more confident and prepared to cope with their lives.
Another in-direct intervention we are trying is the use of some elements learned from "Acceptance and Commitment Therapy" (ACT). The tenets of this psychotherapy approach is to accept certain realities in life that are not changeable. A good example is to accept the fact that one has been affected by schizophrenia or depression, instead of trying to minimize or replace this reality with some more palatable versions. Furthermore, "Committing" to something that is truly personally meaningful and rewarding and focusing on these more achievable (part of the work to make them so, as these goals are more under one's control) goals will be liberating and in turn, less stigmatizing. This is more related to self-stigmatization as others have mentioned before.
In previous posting, I had mentioned the difficult and seemingly insurmountable problems related to stigma, such as social discrimination -eg. no marriage prospects or jobs, etc. I should say that one solution for that defeatism inducing situation is to deconstruct the problem of stigma into smaller parcels to tackle and one will gain sense of efficacy as one gains mastery over these problems. The ACT approach I think offers some benefit in this regard.
Lastly, I agree with Elizabeth Glaser that so far there are some divide between the macro (academic) and the micro (practitioner). It is my hope that as the macro info provided so far inform the practitioner, the micro questions will become more focused and our collective wisdom can be better utilized.
Samuel Law

Lisa Smusz Replied at 10:25 PM, 27 May 2015

Q3: What programs and interventions are currently in practice to address these challenges? How do you measure success of these programs?

In addition to my comments yesterday regarding the challenges of creating programs that are culturally responsive, and the challenge of examining our own biases we as practitioners may hold, I would like to call out the issue of internalized stigma as a significant challenge as have other commenters. And, as both Samuel Law and Elizabeth Glaser have stated earlier, I too have noted the understandable differences in responses and questions posted by the more research focused members vs. the practitioners of the group so I will attempt to incorporate elements of both in my response to today's question above.

On several of the campaigns I have worked on, we utilized Dr. Patrick Corrigan's approach known as the "contact method" in order to reduce stigma within a targeted community. Essentially, his approach states that local, credible, continuous contact (between a person who has recovered from/lived with a mental illness and someone from the target population) is the way to achieve and sustain attitudinal change. (For those interested in the research basis for this strategy, please see the link below to read Dr. Corrigan's research)

Utilizing this orientation suddenly made the issue of internalized stigma incredibly pressing: How do you get people to share their experiences openly with others if their own internalized stigma has not been addressed? Much of the local campaign I was running at the time then became centered not around outward stigma reduction efforts, but to focusing on the person with the mental illness themselves and helping them overcome internalized stigma, and then in turn helping to create opportunities for them to have contact with others in the target population. There were a variety of programs we piloted to try and address this challenge including a mask making approach (, cultivating a speaker's bureau, and then finally implementing Dr. Corrigan's "Coming Out Proud" program. (For practitioners seeking tools to implement, links to both the facilitator's manual and the participant's workbook are included below. For those interested in outcomes and research regarding this strategy, see Dr. Corrigan's research list cited below).

The campaign I currently consult for utilizes a public health model. This campaign focuses on making changes in systems (such as educational institutions, amongst policy makers, within primary care, etc), as well as in communities (such as faith communities, specific cultural and ethnic populations, etc), and individuals (via individuals sharing their stories, wearing lime green awareness ribbons, social media campaigns, PSAs on how to be a supportive friend, etc). The outcomes from this initial work have been quite promising. (Please see the RAND reports via the link below "Outcomes for CalMHSA Each Mind Matters campaign). (For practitioners, a number of tools that might be useful can be found at:

Enjoyed hearing everyone's comments, and thinking about this issue from both a higher-level research perspective and an implementation perspective.
Thanks again to all.

Attached resources:

Rupinder Legha Replied at 2:29 PM, 28 May 2015

Are there successful mental health educational efforts that have been applied to different settings and diverse populations?

Rupi Legha, Partners in Health psychiatrist working with the Zanmi Lasante mental health team in rural Haiti, here.

In response to this question (and also echoing previous responses), our educational efforts have been extremely helpful. The basis of their success has been adapting the messages to meet the needs and to address the realities of the local context. This is key to applying the educational efforts to different settings and diverse populations.

I can provide one specific example. Last summer, the Zanmi Lasante mental health team, which is based in rural Haiti, developed training materials for epilepsy. Four manuals were developed for four cadres of providers: psychologists/social workers, community health workers, physicians, and nurses. We also developed an epilepsy system of care in which each role provider was assigned key tasks and responsibilities (in the clinic and community setting) to ensure the highest quality, most comprehensive care possible.

Stigma reduction and related educational efforts are an incredibly critical component of epilepsy management. Within our communities epilepsy is often mistaken as spirit possession or even a curse. We see countless individuals who go for years or even decades without treatment. They often present with extensive burns and histories of severe depression (or even suicide attempts/suicidal ideation), and many if not most drop out of school and are unable to develop meaningful friendships or other relationships. Because epilepsy is so devastating (and there is a fear of contagion), other members of the community may--sadly but understandably--shun afflicted individuals.

For our curricula materials, we assigned key educational messages to all four groups of role providers. Our educational messages that we asked community health workers to convey were adapted very carefully to the local context. Meaning, in our manuals, we developed appropriate language--of course in Haitian Kreyol (not in English or even French--for addressing explanatory models and misperceptions. For example, "Epilesy is an illness in the brain that causes people to have seizures." "Epilepsy can cause other mental health problems, like depression," " It is an illness that can be treated with medication." Other key psychoeducational messages--which we have applied for the management of other illnesses--include giving hope by explaining treatment and prognosis: "Epilepsy is not a punishment," "People with epilepsy can live well and with good health," "People with epilepsy can marry and have children." All of these messages are very relevant to the rural Haitian context because they address key perceptions/misperceptions. We trained physicians to deliver education that was similar but more related to treatment. Key messages included "People with epilepsy can live a happy and productive life if they adhere to proper treatment," and "Epilepsy is not a curse. It is an illness that affects the brain. It can be treated, the same as other illnesses can be treated."

How did we develop these clear messages? The local mental health team was the heart and soul of this effort. While I (a U.S. trained psychiatrist based in Haiti) and another neurologist from the states supported the effort, we made sure the team's knowledge of the local context drove the effort. So, in summary, educational efforts can apply across diverse settings only if they are adapted to meet the needs and realities of the local context. And this process, in turn, must be driven by local clinicians/role providers.

Samuel Law Replied at 5:53 PM, 28 May 2015

Q 4: Are there successful mental health educational efforts that have been applied to different settings and diverse populations?
I find the various manifestations of stigma related issues across different cultures and settings very interesting; and I do think, beyond the local-ness of these issues, there are some universal aspects. I find the summary of Prof. Graham Thornicroft very helpful, (knowledge, attitude, behavior) and applying these elements at the core of different programs reassuring. I found the following articles from different settings also informative on their respective background issues and the different foci of the efforts to address stigma. As you can see, these are some good examples on a few relevant issues; eg: how to address health care staff attitude and knowledge (China), social distance and external and internal stigma (Japan), working with other/at times competing professionals such as faith healers, schools and families (Middle East), community agencies (Israel), and many others (the European article).
I think one of the notable thing in this forum is that there is a lot of information made available and there is a lot to digest, on a complex issue. If there are specific comments or starter questions, the panel is more than eager to pitch in, I suspect
Samuel Law

Attached resources:

Lisa Smusz Replied at 5:19 PM, 29 May 2015

Hi all,
Sorry for the late post. Always a bit behind due to the time zone out West, and had a heavy teaching load last night.

Wanted to share a few good research and tool resources in response to Question 4:
Are there successful mental health educational efforts that have been applied to different settings and diverse populations?

I wanted to share a wonderful project (both the research findings and the downloadable in-language tools) from my colleague Rose Wong at CSUEB. Her SF Bay Area Chinese American Depression Education project has some wonderful research and tools for combatting stigma, specifically around depression within the Chinese American community both in Chinese and English with materials specific to different age demographics (see below).

Also, for those interested in research around global stigma reduction, especially from an epidemiologist's perspective, please read my colleague Dr. Lawrence Yang's research. Wonderful research that has been applied in many settings. (See links below).

Lastly, I wanted to share tools from the Each Mind Matters Sana Mente campaign which is targeted at reducing stigma amongst the Spanish-speaking Latino population in California, but has materials that would be useful in many Spanish-speaking settings.


Attached resources:

Lisa Smusz Replied at 5:49 PM, 29 May 2015

Catching up a bit, had a few last brief thoughts and samples to share on our last question: 5. How do we keep ensuring that mental health is a priority in the policy agenda of governments.

Essentially, I think keeping mental health in the mind of policy makers and governments is a matter of letting them know that the issue has a significant impact on their population (including voters), that it has both human costs (which are best conveyed through real people willing to come and share well-prepared stories with them), and that it also has adverse financial consequences to society.

One area I think folks like me who advocate for the cause could improve in, is to not focus only on the original "ask" but to continue the relationship with the policy makers, keeping them abreast of progress, letting them know how efforts have been working and what specific type of continued investments are needed to fully realize the goal.

To that end, part of the EMM team recently prepared some infographics based upon our recent RAND study to share this information in a quick, easily digestible format to keep the issue in the forefront of the consciousness of very busy policymakers (attached for your review).

Thanks again to all for an interesting and engaging discussion and all the new resources and research shared here. Please feel free to connect with me on LinkedIn ( if you would like to engage in further discussions or collaborate in the future. Always looking to find like-minded people around the world who share a passion for this same issue so we can continue to learn from one another.

With gratitude,

Attached resources:

Samuel Law Replied at 6:09 PM, 29 May 2015

On q5: I agree with the point on continuity in the connection and dialogue with policy makers beyond the first "ask". One other thought I have is to use the language of economics that many policy makers and politicians understand well. Putting opportunity costs, DALYs numbers, and decision analysis based arguments forward to argue that there can be "no health without mental health" is a worthwhile direction to take. I see that the recent British Journal of Psych issue focusing on anti-stigma has a piece on the economic costs, for example.
Thank you all, and please keep well. I take away much knowledge from you.
Samuel Law

Samuel Law Replied at 5:29 AM, 30 May 2015

Here is the article for the economic analysis piece on anti-stigma work I mentioned.
Samuel Law

Attached resource:

Sudip Bhandari Replied at 8:59 AM, 1 Jun 2015

Many, many thanks to our exceptional panelists, and all of our community members who participated in this incredibly rich discussion. We greatly appreciate the insights everyone has shared, and look forward to continuing to discuss these important topics in 2015.

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Anita qaffari.MD Replied at 6:44 PM, 18 Jun 2015

Stigma To a patients with a mental illness and their families, and to mental health caregivers. At its worst, this stigma nullifies personhood and constitutes an abuse of human rights. But other forms of discrimination are more subtle and more structural. Psychiatrists, psychologists, psychiatric nurses, and psychiatric social workers are not the only professionals who are targets of discrimination; it is our experience that health policy experts are also adversely affected by stigma, with the result that many shy away from making mental health care a priority. This situation may at last be undergoing positive change. The Ministry of Health in China has begun to advocate for patients with mental illness and to advance their interests, and similar agencies in other countries have begun to do so as well. There is other evidence that the deeply institutionalized stigma surrounding the field of mental health is being challenged and overcome. This may be the most difficult barrier to quantify and yet the most important to address.

Anita qaffari.MD Replied at 11:14 AM, 19 Jun 2015

I forgot to mention using BRFSS questionnaire for Stigma

Marie Teichman Replied at 11:51 AM, 17 Aug 2015

Many thanks again to our panelists and members who participated in this Expert Panel discussion last May!

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Johanna Hanrieder Replied at 1:56 PM, 17 Aug 2015

Especially diagnosis of mental health disorders should be made while considering that
social construction of diseases or the economic impact of not being able to work should not be the only
reasons for prescribing drugs for "improvement" of mental health. For example definitions of symptoms
and pathology of diseases like depression and ADHD have been changing during the last years mainly by
influences of pharmaceutical companies. ADHD concerns children and therefore it is questionable,
if deficits of the social environment (e.g. insufficient school system) or the children should be "treated"
(investment of money in production of drugs or for improving education?)

Christophe BABUNGA M Replied at 4:12 AM, 18 Aug 2015

Thanks so much for posting this topic about mental health stigma, which poverty, and household problems can be the origin of a mental breakdown or mental illness.
Christophe BABUNGA

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