Stigma in Child and Adolescent Mental Health Services Research: Understanding Professional and Institutional Stigmatization of Youth with Mental Health Problems and their Families
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To understand the low utilization rates of child and adolescent mental health services, it is necessary to recognize the kinds of professional and institutional stigma that may produce barriers to care. We address the large literature on the stigmatization of mental illness, linkages between such literature and children’s mental health services use, and the kinds of professional and institutional attitudes and practices that communicate shame and low expectations to youth and their families. It will take recognition of such stigmatizing practices—including overcoming resistance to the messages presented herein—to make real progress in the effort to increase utilization of evidence-based practices. Multi-faceted, multi-level, and multi-disciplinary approaches to both research and intervention are recommended.
KeywordsChildren Adolescents Mental health services research Underutilization Stigma
Stigma involves the deep discrediting of an individual as a function of his or her membership in a devalued group with low social power (Goffman 1963; Link and Phelan 2001). Tragically, mental illness has been identified as one of the most stigmatized attributes a person can have in modern society. In fact, stigmatization has been shown to add considerably to the burden incurred by mental illness per se, in terms of predicting decreased life opportunities and enhanced impairment (for review, see Hinshaw 2007). It is a key barrier to mental health services access and utilization (e.g., Corrigan 2005; Thornicroft 2006). Indeed, the President’s New Freedom Commission (2003) identified stigma as a “pervasive barrier to understanding the gravity of mental illness and the importance of mental health (p. 20).”
What are the reasons? First, stigmatization may lead to a lack of recognition that problematic behavioral patterns signify mental disturbance. Such problems may instead be attributed to weak personal will or moral flaw—or poor parenting—so that psychological services are not even considered. Second, stigmatization often produces a strong sense of shame and/or personal failure, meaning that an individual or family may not seek assessment or treatment even if they recognize that mental disturbance is present. Third, at an economic level, stigma has traditionally led to low rates of reimbursement for mental health services; as a result, even if treatment is sought, it may not be funded or covered. At a wider societal level, stigmatization has led to lower prioritization of mental health research and services than for conditions believed to be “physical” in nature (Barry et al. 2003). Overall, with real justification, Sartorius (1998) has claimed that stigma is the core issue faced by the entire mental health field, as it underlies the low status of the mental health professions, the marginal priority given to mental health research, the poor access to treatment that exists, and the difficulties in attaining ultimate life goals experienced by far too many persons with mental disorders (see also the Surgeon General’s report: U.S. Department of Health and Human Services 1999).
Across recent decades, the literature on stigma has become large and multifaceted, spanning such topics as the evolutionary psychology of the stigmatization of outgroup members (Kurzban and Leary 2001), social psychological forces driving prejudice and stigma (Hinshaw 2007), high rates of discrimination against individuals with mental illness (Thornicroft 2006), the key role of internalized stigma (i.e., self-stigma) in diminishing life opportunities (Major and O’Brien 2005; Watson and Corrigan 2005), and the effects of programs designed to counter stigmatization (e.g., Sartorius and Schulze 2005). Our focus is the interface between stigma and the huge issues of mental health service underutilization among children and adolescents in need of care. Although often assumed to be a significant factor in child mental health services research, the role of stigma is under-conceptualized and under-researched in this domain. One of our chief contentions is that the field lacks conceptual frameworks regarding help-seeking that could adequately account for the role of stigma as a barrier to receiving care. Indeed, our overarching premise is that conceptual models are needed to examine stigma and its relationship to help-seeking and service use for children and adolescents. Our focus is on both (a) professionals and institutions that deliver mental health services as potential purveyors of stigma and shame and (b) parents and caregivers as the primary recipients of such stigmatization.
Most of the literature on the stigmatization of mental illness focuses on the general population as a source—and on consequences of stigma for individuals and families who deal with mental disorder (Corrigan 2005; Hinshaw 2007). Yet it may well be the case that those entrusted with the responsibility to treat people with mental disorders, as well as the very service structures created by the field, are also contributors to stigmatizing attitudes and practices (e.g., Sadow and Ryder 2008; Wahl 1999). We explore this contention and extend existing albeit limited conceptual models, in order to foster understanding of professional and institutional stigmatization.
Although professional and institutional stigma exist across the age span (Servais and Saunders 2007), our focus is on child and adolescent mental health for the following reasons. First, although the developmental psychopathology of child and adolescent mental disturbance is voluminous (Beauchaine and Hinshaw 2008), the majority of mental disorders of adulthood have their origins in childhood or adolescence. In other words, mental disorders rarely begin in the adult years de novo; developmental precursors are highly likely to be evident in childhood. Thus, early detection, assessment, and intervention are of paramount importance; and if stigma precludes such evaluation and treatment, the consequences may be felt for decades to come. Second, the mental illnesses that begin in childhood and adolescence—such as autism, attention-deficit/hyperactivity disorder, learning disorders, child-onset conduct disturbance, and child depression—are quite likely to persist beyond the child or adolescent years (Beauchaine and Hinshaw 2008). Any factors that can help to initiate accurate detection and evidence-based service utilization during childhood or adolescence are therefore at a premium.
In this article we first document the existence of professional and institutional stigma and review the current research on what is known about this phenomenon. Next, we highlight the importance of several key constructs needed to understand the significance of professional and institutional stigma and its consequences for children with mental health problems and their families. We then present a conceptual model for examining those who stigmatize, with a focus on the factors influencing professional and institutional stigma, linking it to broader conceptual frameworks on service utilization and stigmatization. We conclude with implications for research and intervention. Readers will note that work in this area is quite preliminary; our manuscript is primarily an attempt to generate research and action in this important domain.
Professional and Institutional Stigma
Referring to child clients by their diagnosis (“that bipolar kid”), instead of consciously using people-first language and labeling the condition, not the youth;
Focusing exclusively on deficit models of client symptomatology and family dysfunction instead of consumer assets and family strengths;
Holding treatment planning meetings without the youth or family present, or keeping them in passive and information-furnishing roles;
Conceptualizing and treating children with mental health problems with an exclusive focus on their mental health condition, instead of taking a “whole child” approach that recognizes the need for a system of care and that acknowledges the multiple and intersecting aspects of the youth’s life; and
Having facilities for treatment of individuals with mental health problems that are physically difficult to access and in more disrepair than clinics treating physical health.
Although a focus on child mental health stigma is relatively new, such a focus on adults is extensively documented and provides needed background. Space does not allow a systematic review of all relevant investigations, but nearly half a century ago, Nunnally’s (1961) groundbreaking research included a survey of a large number of general medical practitioners. Although they had decent knowledge of mental disorder, their attitudes were as negative toward mental illness as were those of the general public. On semantic differential measures, the medical professionals described the term “psychotic” as ineffective, twisted, dangerous, and dirty. Given that a large percentage of professional contacts for mental disorder come from general practitioners, such stigmatization may be felt widely.
During the 1960s, research focused on staff who worked in the still-prevalent domain of large public mental hospitals. Core findings were that employees in lower status positions (e.g., psychiatric aides or technicians) showed the most authoritarian and pessimistic attitudes, whereas professional-level staff were generally more optimistic and humanitarian (Rabkin 1974). Some staff members held attitudes considered “benevolent,” yet these perspectives were actually associated with poor outcomes in patients. In other words, not only were authoritarian, harsh attitudes among staff linked with negative outcomes, but attitudes of benevolence—which may actually betray a kind of superiority, signifying that those with mental illnesses are not fully responsible—were also counterproductive (Cohen and Streuning 1962).
Across the ensuing decades, mental health care shifted from institutions to communities, but stereotypic beliefs and stigmatizing attitudes continued to be documented among professionals and trainees in both Western and non-Western venues (e.g., Aydin et al. 2003; Keane 1990; Mirabi et al. 1985). For instance, psychiatric patients have been branded by professionals as more immature, selfish, and aloof than general medical patients (Hinshaw 2007). Half of the medical students and physicians surveyed in London held beliefs in the dangerousness and unpredictability of individuals with schizophrenia and drug/alcohol problems (Mukherjee et al. 2002). In Switzerland, psychiatrists were just as likely as the general population to desire social distance toward persons with schizophrenia (Lauber et al. 2004) Negative attitudes continue to be documented (e.g., Servais and Saunders 2007).
A landmark investigation in the U.S. by Wahl (1999) revealed that, among a large sample of adults with serious mental disorders, hurtful and demeaning attitudes from mental health professionals (and, in particular, low professional expectations for change) were perceived as a primary source of stigmatization. This is a devastating finding; the vignettes and anecdotes recounted by Wahl should be read lest anyone believes that mental health professionals are uniformly helpful and respectful in their communication of respect and hope for those entrusted to their care. Note that primary care professionals are important here; they are gatekeepers and service providers for most youth with mental health problems (Brown et al. 2007; Sayal 2007).
Beyond personnel per se, institutional policies and practices can be stigmatizing. Institutional stigma is demonstrated as discrimination when policies reduce patient choice, whether intentional or not (Yang et al. 2007). During the days of massive state institutions, for example, much of the mental health enterprise entailed stripping so-called “mental patients” of fundamental rights and individuality as they entered “total institutions” (Goffman 1961). However, the major shift during the latter half of the twentieth century, when public mental hospitals were closed down in record numbers, led to community alternatives in many venues that have turned out to be just as dehumanizing as the large state facilities they were designed to replace (e.g., Barron 2009). With respect to child and adolescent mental health, recent exposes of the harshly abusive practices in special education and juvenile detention facilities graphically portray shocking conditions, in which neglect and even abuse are daily occurrences (e.g., Hinshaw 2007).
In adult mental health services, we note that coercion continues to exist through “outpatient commitment” to mandated treartment, often as an alternative to inpatient care or incarceration. Despite some positive effects of such outpatient commitment (e.g., Swartz et al. 1999; Swanson et al. 2000, 2001), erosion of quality of life and increased anticipation of stigma through perception of coercion have been linked to these institutional policies (Link et al. 2008; Swanson et al. 2003). This is a complex issue, to be sure, in need of better investigation.
A key issue is that many mental health workers, as well as special education teachers and juvenile detention and residential care staff, are employed in low-status, low-paying positions. Even clinical psychologists and psychiatrists (e.g., Dichter 1992) are less valued by their respective psychological and medical communities than specialists in other areas of these respective fields (see discussion in Hinshaw 2007). Note that researchers may well be included in the mix here. What Goffman (1963) termed “courtesy stigma”—the stigmatization that accrues from being linked or associated with a stigmatized outgroup—has surely existed for many years in the mental health fields. When the target population includes children and adolescents with mental disorders, a kind of double stigmatization may ensue, given the low status of both groups.
In addition, health and mental health professions have been quite slow to accept that mental disorders exist among their own members. Most professionals who receive any form of mental health treatment do not disclose this fact to their peers and many do not even discuss it with their spouses or partners—largely because, when such disclosures are made, ostracism and professional damage to reputation are highly likely to result (Goode 2003; Gottfredson 2004).
In short, through a combination of low-prestige jobs, stressful work situations, an admittedly difficult clientele in many instances, a youthful population who have not attained the age of majority, and general denial and shame regarding mental disorder within the mental health fields, it is conceivable that many mental health staff and professionals would blame or take out frustrations on their own clientele, explicitly or implicitly. Such tendencies are compounded by prevailing scientific and clinical models, which link mental disorder to both inner weakness and faulty family socialization practices (Hinshaw 2007). Furthermore, institutional policies and practices have reflected stigmatization, from the time of monolithic state facilities to more recent community alternatives that are, in many instances, as woeful as the large hospitals they were meant to replace. Special education and juvenile justice have played major roles in the placement and treatment of youth with mental disorders; longstanding issues of discrimination, segregation, and even abuse are documented. Even without overt stigmatization, the sheer red-tape and bureaucracy attending to institutions and service systems doubtless increase alienation and disenfranchisement on the part of many who seek or receive services (Hinshaw 2007).
Moreover, the very underpinnings of many forms of mental health services could well be stigmatizing. The typical model posits that a patient or client has psychological or psychiatric symptoms, in need of treatment by an expert; the patient passively receives intervention, in the form of medication or some form of psychological therapy. There is little room, in this view, for a strength-based approach (one that fosters protective factors) or a model that includes an explicit focus on the child/adolescent and his or her family as experts regarding their own situation. The recovery movement in adult mental health is focused on a view that symptoms of mental disorder can indeed be overcome on the basis of a more co-equal relationship between provider and recipient, one that intentionally builds competencies and strengths rather than focusing on deficits, symptoms, and weaknesses (President’s New Freedom Commission 2003; Substance Abuse Mental Health Services Administration (SAMHSA) 2005). Note that stigma is viewed as a major factor preventing such recovery (e.g., Perlick et al. 2001). Some of the most impressive evidence-based intervention strategies in adolescent mental health are based on fostering strengths and employing an ecological model of understanding problem behavior (e.g., Multisystemic Therapy for severely delinquent, substance abusing, and even suicidal behavior; see Henggeler et al. 2009). Whereas the recovery movement may tend to overlook the fact that mental disorders often do need symptom-based intervention and that professionals have relevant expertise, it does recognize that a one-sided perspective focused on expert provider versus ignorant patient may well be inherently stigmatizing.
Linking Stigma to Service Use (or Lack Thereof) by Children and Adolescents with Mental Health Problems and their Families
Because of their nearly exclusive focus on adult mental health conditions, existing stigma frameworks stop short when trying to understand the role of stigma—including institutional stigma—on service use patterns by children and adolescents with mental health problems, as well as their families. A recently published stigma framework, entitled the Framework Integrating Normative Influences on Stigma, or FINIS (Pescosolido et al. 2008), takes an interdisciplinary and multi-level perspective on factors that influence stigma, along with their consequences. The three levels of individual/psychological factors, community factors, and societal factors are noted as contributing to stigma. Yet, to provide understanding of the role of professional/institutional stigma and its impact on youth with mental health problems and service delivery, the FINIS model needs further explication. A recent paper (Mukolo et al. 2010) presented needed expansions in order to make stigma theory more relevant to the experiences of youth and to link stigma directly to service use. In our limited space herein, we focus on (a) stigma by association and (b) the linkage between stigma and service use.
The phenomenon of stigma by association was introduced by Goffman (1963) as “courtesy stigma,” which posited that stigma toward a devalued person typically extends to others who are associated with that person, including family members and professionals. (This term has been challenged by Thornicroft 2006, and others; we utilize the more contemporary term “stigma by association.”) Stigma among family members was reviewed initially by Lefley (1989). Experiences pertinent to family caregivers of individuals with stigmatized disorders have been documented and explored primarily among those caring for adults with mental illness (e.g., Gonzalez, et al. 2007; Larson and Corrigan 2008), particularly parents and adult children as caregivers (e.g., Angermeyer et al. 2003; Perlick et al. 2007). Direct exploration of stigma by association among families of youth with mental health problems is rare (e.g., Gray 1993; Norvilitis et al. 2002). More recently, stigma by association has been reported indirectly in the literature on caregiver strain. Brannan and Heflinger (2006) included stigma items in their “family perceptions of barriers” subscale; greater endorsement of stigma was associated with higher reports of caregiver strain among parents of children with serious emotional disorders. Underlying mechanisms of such stigma by association require explication, but the phenomenon is now on the radar screen of the field.
The focus of most literature on stigma and discrimination as deterrents to service use has also been based on adults with mental illness (Link et al. 1999; Thormicroft 2006). Avoidance and delay of help-seeking by individuals with mental illness have been documented, along with early termination from treatment (e.g., Sirey et al. 2001). The fear of stigma by association in families of adults with mental illness has also linked to a lack of acknowledgment of mental illness and a consequent avoidance of help-seeking (Yang et al. 2007). With children, stigma influences service use via the role of parents in help-seeking behavior (Brannan et al. 2003; Corrigan et al. 2001). Indeed, because parents/ guardians are the primary gatekeepers of service use (i.e., the ones who usually make and keep appointments and who must give permission to treat; see Sayal 2007), stigma by association linked to the parenting role is bound to play a key role in services access. Among families of children with serious emotional disorders, stigma has been documented as a potential barrier to receiving mental health services because of the pernicious influence of stigma on parents themselves (Brannan and Heflinger 2006; Heflinger et al. 2009; Owens et al. 2002). Note that stigma-related issues—including concern that not only would people in their community be likely to find out if a child received professional help but also would blame parents for the children’s problems—were the most-often-endorsed barrier to services among rural caregivers (McBride Murry et al. 2007).
Moreover, despite an underdeveloped empirical database, most of us in the field can think of multiple examples of families who have been far too ashamed to seek assessment for their troubled child, to explore obtaining school-based services or accommodations, or to consider family therapy or medication treatment options. In many instances, the problems of the child are considered to be a direct reflection of failures in parenting. The overarching association between service use and stigma may therefore follow the following chain of logic: (1) Not only are children with mental health problems targets of stigma, but so are their family caregivers; and (2) such stigma, and the anticipation thereof, is a powerful deterrent to seeking services, as it negatively influences whether services are considered or used, and whether referrals are followed. It also restricts the types of services sought, thereby increasing delays of receipt of services if they are, in fact, sought. Of course, the flip side is that if (and only if) appropriate evaluations of children are performed and if accurate diagnoses are given, the resulting path to evidence-based services can be empowering (see Hinshaw 2007). This perspective brings us to the role of professional and institutional stigma as it affects avoidance and delay of service use.
The Role of Professional and Institutional Stigma
Available stigma theory and research, almost all in the adult area, acknowledge public and private/personal stigmatizing of persons with mental health problems. Yet, there has been little attention specifically to the professionals who serve those with mental health problems—and the institutions within which they work—as core sources of stigmatization, especially related to child and adolescent mental health. Current conceptual models and research focus on either public stigma (in other words, on stigmatizers who are viewed as “others” in the community: family, neighbors, and the general public) or on self-stigma (i.e., the individual who is likely to have internalized the stigma). We propose that an additional type of stigmatizer must be recognized: professionals and institutions that are intended to serve youth with the stigmatized condition. This “level” of stigmatizer is distinct from the general public, we believe, because such professionals and institutions are designed to be the “solution.” In short, the field of child and adolescent mental health services research needs conceptual models and research paradigms that pay attention to (a) who is doing the stigmatizing, adding professions and institutions to the list of potential stigmatizers; (b) who is being stigmatized, adding parents/families of children with mental health problems; and (c) the consequences of stigma, adding avoidance or delay of treatment seeking.
In addition, we propose that in order to address the prevention or reduction of stigma, another dimension must be added: (d) which kinds of factors influence the professional stigmatizer? In short, those entrusted with the care of children, adolescents, and their families may actually create barriers to services for the very populations they are serving and supporting, whether such attitudes and practices are intentional or not.
First, at the individual/psychological level are both characteristics of the individual being stigmatized (i.e., the “target”) and characteristics of the stigmatizer, both individual and social. Regarding the target, characteristics include features of the disease/condition (e.g., concealability, contagion risk, formal diagnosis) and the target individual’s behavior (severity, frequency, visibility). Regarding the stigmatizer, relevant characteristics include (a) beliefs, attitudes, and values; (b) personality and emotions; (c) knowledge (about the disease/condition); and (d) anxiety (related to the level of threat felt regarding the stigmatized person or conditions).
At the community level are stigmatizers’ levels of familiarity with the disease/condition (e.g., contact), plus community values and norms, including the Western focus on individualism (Kleinman and Hall-Clifford 2009) and professional culture and values (Vawter et al. 2003). Many current attempts to reduce stigma include education and contact, with contact having garnered the most evidence for success (e.g., Corrigan 2005). Yet the “contact” approach is not sufficient for combating professional stigma. Pettigrew and Tropp’s (2006) landmark meta-analysis demonstrated that any contact between ingroups and outgroups can markedly reduce stigma and prejudice among the public. But what about mental health professionals—who are clearly in considerable contact with those with mental disorders? Recall that, in his landmark work on prejudice, Allport (1954) clarified particular types of contact that would be promoting versus reducing of stigma and negative attitudes. Specifically, contact under conditions of equal status, as well as everyday contact, is usually linked to reductions in prejudice. However, (a) many clients seen by professionals are, by definition, extremes in terms of severity; and (b) those who quickly get better aren’t seen any more, as they tend to leave treatment. Thus, those with mental health problems seen by the typical mental health provider are not representative. Our conclusion is that there needs to be a different view of and perspective on mental health clientele. At the same time, current training models tend to emphasize, as noted above, pathology and deficits, reinforcing an “us versus them” perspective on the part of providers (see Hinshaw 2007). Collaborative models of client contact, involvement, empowerment, and recovery are all too rare.
The role of the media in sustaining professional and institutional stigma also plays out at the community level of stigma influences. Despite some trends toward improvement in recent years, the news media continue to promote stories about dangerousness and mental illness instead of successes and recovery (Klin and Lemish 2008; Wahl 1999, 2003).
Finally, at a societal level, the primary factors influencing stigmatizers include personal power associated with wealth, as well as group membership (Phelan et al. 2008). But literature on such characteristics when the stigmatizer is a professional and the target is a child or adolescent with mental health problems is almost nonexistent. Let us speculate on just one aspect here. Not only are clinical psychology and psychiatry viewed as less prestigious aspects of general psychology and general medicine, respectively, than are other subdisciplines, but those in the field working with children and adolescents—who have less legal power and “social capital” than adults—are even lower on the hierarchy. Given that an essential component of stigma involves power differentials between those who stigmatize and those who are stigmatized (see Link and Phelan 2001), those professionals and institutions dealing with individuals with extremely low power (i.e., individuals with mental disorders, who are also children—and potentially of minority status) are in the territory of doubly and trebly stigmatized groups (see review in Hinshaw 2007). This low-status/low-power situation is likely to be a breeding ground for blaming and for stigmatizing attitudes on the part of professionals, staff workers, and institutional settings themselves. Relevant research on these contentions is essential.
Overcoming Resistance to the Message
Many continue to believe that scientists, practitioners, and educators in the mental health arena could not possibly contribute to stigma; after all, such individuals have been trained to directly counter prejudice and stigmatization. But without acknowledgment of the strong possibility of professional and institutional stigma—which is highly likely to spread quickly to communities, parents, and youth themselves—it will be extremely difficult, if not impossible, to provide for optimal mental health care for youth in need of services.
We recognize at the outset that this topic area is controversial and even contentious. How could it be the case, one might ask, that the very individuals and professional groups entrusted with the care of children and adolescents with mental disorders, who have spent many years and many dollars invested in training and who are by definition interested in providing help, could perpetuate stigmatizing attitudes and responses? In building our model, we have had to take a hard look at training models, professional practices, and relationships between consumers and practitioners; we ask that readers do the same. What could result is a fresh look at the ways in which all of us conceptualize our roles as scientists, clinicians, and policymakers, as well as research investigators, in the area of child and adolescent mental health.
Implications for Research, Practice, and Intervention
A major research agenda is to document the prevalence and intensity of such professional and institutional stigma among caregivers of youth who receive mental health assessment or intervention, as well as the child and adolescent recipients themselves. We simply don’t know enough at this time about the extent of such practices for this population, although our suspicion is that rates of stigma and disenfranchisement are extremely high, even if unintented. Indeed, as just one indicator, mental health service utilization is quite low for children and adolescents in dire need of relevant care. Despite the many structural barriers related to such underutilization, it may well be the case that the low status of child mental health professions and professionals, along with the communication of frustration and low expectations to such consumers as parents, teachers, and youth themselves, are key contributors to the problem. As for “next steps” to examine and address concerns regarding professional and institutional stigma toward youth with mental health problems and their families, the both research and intervention are needed.
Conceptual models and programs of research need to recognize and measure the presence, causes, and consequences of professional and institutional stigma. These models and programs of research must be multi-faceted and multi-level (Link and Phelan 2001), as well as multi-disciplinary (Kleinman and Hall-Clifford 2009). We need to integrate organizational and political theory into current models, to capture the community and societal factors (as well as any individual factors) influencing professional/institutional stigma and maintaining discriminatory behavior, structure, and policy. The challenges of evaluating multi-level interventions are many (Nastasi and Hitchcock 2009).
A range of research methods must be included. Qualitative studies can build theory and initial measures; ethnographic methods are particularly suitable for recognizing the multiple perspectives (Yang et al. 2007). In optimal mixed-method research (Weisner 2005), qualitative insights must be translated into quantitative indicators subject to hypothesis testing.
As a methodology, participant action research (PAR) is especially relevant in this area. When the focus of research is on disenfranchised groups, as it is in stigma research, Pullman (2009) emphasizes that PAR addresses “…(1) the democratic inclusion of stakeholders in decision making, including those traditionally excluded from research, (2) the generation of practical knowledge, (3) the importance of developmental changes in systems to make them more useful, (4) a continual process of communal reflection and action, and (5) the co-learning of professional researchers and participating community members (p. 45).” Stroul et al. (this issue) address steps needed to link children’s mental health services researchers with family advocates and policy makers, with stakeholders at all levels involved and engaged.
Interventions to address stigma must recognize the role of the professional/ institutional stigmatizer and, like research models, must be multi-faceted, multi-level, and multi-disciplinary. These kinds of interventions will raise important questions regarding appropriate collaborators, the level(s) at which to begin, choice of outcomes, sustainability, the link between theories of intervention and practice, and the important roles that youth with mental health problems and their families can play in the process (Schensul and Trickett 2009; Stroul et al. this issue). As noted in Fig. 1, interventions as well as research must be targeted to the individual, community, and societal factors that currently support professional and institutional stigma.
Clinicians and administrators should be sensitized to the phenomenon of stigmatization and analyze the policies and practices in their offices, with the collaboration of their clientele and consumer groups. Practices of stigma that include devaluation of client or family input into treatment planning, or policies that limit choice of treatment and/or support alternatives, should be recognized and addressed. Intervention at the public policy level can be a powerful tool in addressing disparities and discrimination (Alegria et al. 2003).
Intervention to reduce stigma needs to be aimed at the health services sector, not just the lay public or “individual” stigmatizers, although many factors are pertinent to both. In line with our proposed model recognizing community-level contributions to stigma, the structure and content of professional training and supervision need examination as potential contributions to child and adolescent stigma and discrimination. Much remains to be done in this arena, both at a micro-level (e.g., including better role-play methods for training) and a macro-level (e.g., re-examining the conceptual models of disorder upon which the entire child and adolescent field is based). Revamping and strengthening our approaches to the training of all levels of mental health professionals and administrators is critical. We reiterate that exposure to models based on resilience, strength, and recovery is essential, as is contact with successful clientele that can promote optimism rather than cynicism about the potential for growth and change.
Still, we must acknowledge that many public-sector providers must necessarily deal with children and adolescents who are victims of family-level, systems-level, and economic-level deprivation and trauma. It is inherently difficult to promote a model of care based on positive attributes when the harsh realities of multiple levels of negative influence are realized. Nonetheless, it is all to easy to fall into a mindset that some groups of youth, or some families, are simply not amenable to intervention. When we fall prey to such mindsets, whether intentionally or not, there is little likelihood of any success.
Many of the recommendations discussed in other contributions to this issue have relevance for reducing and preventing stigma among professionals and institutions. For instance, developing and preparing a workforce to implement effective mental health treatments (see Schoenwald et al. 2010) must include reducing or eliminating the stigmatizing attitudes and behavior of those professionals. Indeed, a multisystemic perspective on family heath (see Stiffman et al. 2010), which employs paraprofessionals who have experienced mental illness and successfully negotiated the service system themselves, may be appropriate and acceptable for families. Such perspectives encourage the kinds of contact that may well change attitudes and behavior. Changing organizational culture will also be crucial. Greater awareness of and respect for client and family perspectives, culture, and worldviews (see Alegria et al. 2010) comprise one step toward valuing (as opposed to devaluing and discriminating against) those who are seeking help. Next, reorganizing the service system to allow youth and their families to access services at the right time and right place (see Kelleher 2010) must recognize and address stigma and its deleterious consequences toward mental health specialty care. Finally, a public health model (IOM 2009; see Stiffman et al. 2010) that focuses on prevention and early intervention may provide a “normalizing” function to destigmatize childhood mental health conditions. In all, the task ahead is a huge one, but the major underutilization of child and adolescent mental health services is a challenge to us all.
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