Stigma Stoppage Starts in Hearts, Minds, and Institutions

Many in the behavioral healthcare field are devoted to fighting stigma. This fight occurs on many fronts, ranging from mental illness to addiction to developmental disabilities. The main battle plan seems to be to eradicate a destructive point of view through education. The inadequacy of this solution is evident even when it is done well. Changing hearts and minds is a beginning, but institutions must follow.

It is said that sunlight is the best disinfectant. Oprah Winfrey and Prince Harry shine bright lights on stigma in the new series, “The Me You Can’t See,” in which they share their painful histories. They also give celebrities, like Lady Gaga, and non-celebrities an opportunity to tell their life stories. Each speaks in detailed ways about coping with trauma, emotional suffering and years of waiting for professional help.

We have long sought such honesty and courage. Many behavioral leaders hoped decades ago to find a single celebrity as the public face for depression. We now have had many share their experiences, and we have reached a new height in exposing a range of problems. Stories of the famous never fail to shatter preconceptions. We are continually reminded how every person lives with some degree of pain.

There is nothing negative to be said about these efforts, other than they are necessary but not sufficient. The hope for sunlight as a disinfectant refers to how publicity can play a role in fights on social issues. An enduring illustration of this idea is on the masthead of The Washington Post every day: “Democracy Dies in Darkness.” Yet awareness and acceptance do not force institutions to change. We must confront institutional change directly.

Stigma creates a sense of otherness that relies on social isolation. We need to break down this isolation to reveal that the other is a social fiction. Healthcare is a prime target for institutional reform, especially insofar as it sustains the experience of otherness. Behavioral healthcare institutions must be a key focus with their history of isolated care. Providing care in private, separate settings has major drawbacks.

What sort of structural change is needed? We could reduce services in isolated, specialty settings (little sunlight) and move therapists into primary care (sunlit). Primary care teams could focus on emotional struggles, viewed on a continuum, without a category for “other.” People like Prince Harry might overcome the toxicity of masculinity earlier, share their pain, and find relief. This is institutional change.

Few social problems go away because a light shines on them. We need to change the conditions sustaining them for generations. People who publicly share their stories today are heroes, and we need them to activate others across the behavioral health continuum. A critical group to activate will be behavioral healthcare executives. Institutional change of the sort described here depends on it.

The disinfectant analogy does not push them (us) to meaningful action. Behavioral executives have long supported a public awakening, but then what? Carry on as if the system will be fine after dosing it with disinfectants? We need a healthcare system that facilitates self-disclosure. The journey to better mental health could begin for many by responding to inquisitive primary care professionals.

Getting help today for a behavioral health problem is just too hard. The shame of stigma stops many. Others get lost trying to navigate our fragmented array of clinics outside the primary care system. Other complexities confront us as well, but big changes need simple plans. To ensure that getting help is easy for everyone, we need a coalition of passionate people in support of a simple plan.

The best recent example of this is the passage of the federal parity law. Years of lobbying by coordinated interest groups led to straightforward legislative changes. The institutional changes described here could be a second phase of parity. Insurance-based discrimination was just a beginning. We now need sunlit primary care offices with behavioral healthcare skills, not more headlines.

Primary care will not come knocking on our door. We need behavioral health leaders to drive these system reforms, even if this is not in anyone’s current job description. Executives get important things done. Let us create a healthcare system that attracts people in pain and encourages them to speak. Celebrities can shed light on the problem. Experts can bring lasting structural change.

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