Communication Strategies to Counter Stigma and Improve Mental Illness and Substance Use Disorder Policy

Communication strategies that employ sympathetic narratives, or stories that humanize the experiences and struggles of individuals with mental illness or substance use disorder, are a promising technique for reducing stigma and increasing support for policies that benefit people with behavioral disorders. Policy makers, advocates, and journalists have long used stories about individuals to illustrate policy problems and potential solutions. Communication research empirically demonstrates the persuasive power of narratives, which blend stories about individuals, or “individual depictions,” with broader contextual information about the problem at hand. In the absence of contextual information, individual depictions can prevent audiences from understanding the role of societal drivers of the policy problem and instead suggest that the individual depicted is to blame for the problems he or she faces (25). This is problematic from a policy support perspective given research demonstrating that the public is more likely to support policies benefiting individuals whose problems are perceived as stemming from societal causes outside of individual control rather than policies benefiting individuals who are perceived to be responsible for causing their own problems (25–27).

Narratives help to overcome concerns about the role of individuals in their own misfortune by blending engaging stories about individuals with contextual information about a larger social problem. For example, a narrative tells a story about a specific individual with drug dependence but also describes the social and environmental risk factors that contributed to that individual’s condition and places the individual’s story in the larger context of the problem of drug dependence in the United States. Sympathetic narratives have been shown to enhance audiences’ engagement with the issue being described and elicit emotional responses, both of which may enhance receptivity to the narrative’s message (28–30). Although limited, the existing research suggests that narratives are a promising strategy for improving support for both mental illness and substance use disorder treatment policies (5,31,32).

Messages that blame people with mental illness or substance use disorder for their condition decrease the public’s willingness to help these groups and increase support for punitive policy options. Attribution theory suggests that when considering the causes of social problems, people typically exaggerate the role of individual responsibility and underestimate the importance of factors outside of individuals’ control, such as community resources and exposure to environmental factors (33,34). This “fundamental attribution bias” can influence the public’s policy preferences. Public perception that an affected group is responsible for the problem it faces can lead to lower support for policies benefiting the affected group and higher support for policies punishing the affected group. In contrast, when the public views the cause of the problem as wholly or mostly outside of individual control, it is more likely to support policies benefiting the affected group. Based on existing research, this concept appears relevant for both mental illness and substance use disorders.

Corrigan and colleagues (35,36) and Weiner and colleagues (37) have demonstrated that blaming individuals with mental illness for their condition is associated with negative emotions and attitudes, including increased anger, decreased pity, and support for mandatory and segregated treatment. It is important to note that although mandatory treatment policies, such as assisted outpatient treatment, are viewed as punitive by some stakeholders, who perceive such policies as restricting civil liberties (38,39), other groups view policies that expand mandatory treatment as a beneficial approach that helps people with mental illness and substance use disorders get needed treatment (40,41). In the context of substance use disorders, an analysis of 2013 national survey data found that attributing responsibility for prescription opioid use disorders to the people experiencing such disorders was correlated with increased desire for social distance, acceptance of discrimination, and support for punitive policies—for example arresting individuals who obtain multiple opioid prescriptions from different doctors—and with lower support for increasing government spending on substance use disorder treatment (17).

Although these studies suggest that communication strategies blaming people with a mental illness or substance use disorder for their condition can have detrimental effects on stigma and policy attitudes, increasing the degree to which the public attributes responsibility for these conditions to factors outside of affected individuals’ control may be insufficient to reduce stigma and increase support for beneficial policies. In the latter half of the 20th century, many consumer advocates believed that educating the public on the neurobiological causes of mental illness was the key to stigma reduction (12). This idea informed the design of communication campaigns. In the 1990s and early 2000s, the predominant stigma reduction strategy in the United States was the “Disease Like Any Other” campaign. Led by the National Alliance on Mental Illness, the campaign equated mental illnesses and substance use disorders with other biological conditions like diabetes (12).

As a result of this and other education efforts, Americans’ endorsement of the neurobiological causes of both conditions increased from 1996 to 2006, but corresponding decreases in public stigma toward individuals with these conditions did not occur (12). Some evidence suggests that endorsement of the biological disease model may increase stigma, potentially as a result of increased perceptions of the permanence of mental illness and substance use disorders, which may produce pessimism about the potential for recovery (42,43).

The public endorses multiple causes of mental illness and substance use disorders. Some Americans recognize a neurobiological component of substance use disorder etiology and endorse poor character as a cause of the condition (12,44). Therefore, it is possible that in order to decrease stigma, it is not sufficient to increase public endorsement of causal factors outside of the control of individuals with mental illness and substance use disorders, such as neurobiological causes. We may also need to decrease endorsement of causal factors within the affected individuals’ control. Although endorsement of neurobiological causes increased from 1996 to 2006, the proportion of Americans who viewed poor character as a cause of schizophrenia and major depression remained unchanged (31% and 32%, respectively, in 2006), and the percentage of U.S. adults attributing alcohol use disorder to poor character increased, from 49% in 1996 to 65% in 2006 (12).

Increased endorsement of neurobiological factors may increase public support for expanding mental health and substance use disorder treatment independent of stigma, but this relationship has not been directly tested. National survey results showed an increase of 9 percentage points in public support for increasing government spending on mental health services from 1996 to 2013, from 50% in 1996 to 59% in 2013 (14,16), but it is unclear whether this increase was attributable to parallel increases in endorsement of neurobiological causes of mental illness during this period. Furthermore, these survey results should be interpreted with caution: the 2013 survey was conducted in the month following the mass shooting at Sandy Hook Elementary School in Newtown, Connecticut, by an individual widely believed to have a serious mental illness. This shooting prompted a national dialogue on mental illness and may have led to a temporary increase in the proportion of Americans supporting increased investment in mental health treatment (45,46).

Messages highlighting structural barriers to mental illness and substance use disorder treatment can raise support for beneficial policies without increasing stigma. These messages have the potential to counter the public’s propensity to form opinions consistent with fundamental attribution bias theory. Communication strategies emphasizing structural barriers to treatment—such as inadequate insurance coverage, provider shortages, and lack of availability of evidence-based services, for instance, supported employment—are one of the most common messaging strategies used by consumer advocacy groups hoping to garner public support for improving the mental illness and substance use disorder service systems (47–49). This strategy emphasizes the structural shortcomings that contribute to poor outcomes among people with mental illness or substance use disorders and that are directly addressable through public policy.

A limited body of experimental research suggests that this approach holds promise for improving support for public policies benefiting those with a mental illness or substance use disorder. A randomized message-framing experiment conducted in 2016 showed that compared with a control arm, a short narrative describing an individual with schizophrenia who faces multiple structural barriers to treatment, including inadequate insurance coverage and provider shortages, increased the public’s willingness to pay taxes to improve the public mental health service system and their support for expanding a range of service options, including community-based outpatient treatment, supportive employment, and long-term hospitalization (5).

In a 2014 study conducted by using a national online survey panel, Kennedy-Hendricks and colleagues (31) tested the effect of a brief written narrative describing the barriers to accessing evidence-based opioid use disorder treatment faced by a low-income pregnant woman, such as a long waiting list for methadone treatment. Compared with both the control arm and a narrative describing the same woman without mentioning barriers to treatment, messages about barriers to treatment did not change social distance attitudes but were associated with increased feelings of sympathy and pity, as well as greater support for beneficial policies, including expanding Medicaid health insurance benefits to cover prescription opioid use disorder treatment. Barriers-to-treatment messages were also associated with decreased support for punitive policies, including a policy requiring health care providers to report pregnant women with opioid use disorders to the state’s child welfare agency (31).

Messages that emphasize violence by people with mental illness may increase public support for expanding mental health services, but such messages are stigmatizing and should be avoided, especially considering that equally effective alternative strategies exist. Multiple experimental studies have shown that messages emphasizing acts of violence by people with mental illness increase public stigma toward this group (5,50–53). Until recently, less was known about how violence-focused messages influence support for expanding mental health treatment. In the previously mentioned experimental study of a narrative describing structural barriers to treatment faced by an individual with schizophrenia, a version of the narrative was tested where the same individual went on to commit a public shooting (5). Unlike the narrative that did not involve violence, this narrative increased stigma compared with the control group of individuals exposed to no narratives. Both narratives were equally effective in increasing the public’s willingness to pay additional taxes to improve mental health services and their support for expanding all of the mental service options measured. That suggests that messages about barriers to care, opposed to the depiction of violence, drove public support for allocating additional resources to expand public mental health services (5). This study built on a prior study by Corrigan et al. (51) of a college student sample. In that study, messages linking mental illness with violence were delivered in a face-to-face educational intervention. Compared with a control group, participants in the intervention had elevated stigma toward persons with mental illness, but the intervention did not increase willingness to allocate resources to psychiatric rehabilitation or mandated care.

To our knowledge, no experimental research has been conducted on the effects of communication strategies linking substance use disorder with violence. This topic warrants future study given survey research showing that the public perceives people with substance use disorder as more likely to be violent than those with mental illness (12,44).

Messages that focus on treatment effectiveness may reduce stigma related to mental illness and substance use disorders, but their effects on policy preferences are uncertain. Research has demonstrated that public stigma is tied, in part, to the symptoms and behaviors associated with untreated mental illness and substance use disorders, particularly positive psychotic symptoms and related behaviors, such as talking to oneself and a decline in personal hygiene (12,44,54). Limited existing research suggests that communication strategies focused on disseminating messages about successful treatment and recovery—a strategy credited with major reductions in the public stigma surrounding HIV/AIDS (55)—may reduce the public stigma surrounding both mental illness and substance use disorder, although in the experimental studies conducted to date such messages have not influenced public support for mental illness or substance use disorder policy.

Using data from a telephone survey of a nationally representative sample of youths ages 14 to 22, Romer and Bock (56) found that youths reported less stigma toward an individual of their own age described as having been treated for depression versus the same individual with untreated depression. In a 2013 experiment using a nationally representative online survey panel, McGinty et al. (54) found that short narratives describing individuals experiencing successful treatment for and recovery from schizophrenia, prescription opioid use disorder, and heroin use disorder reduced stigma compared with depictions of untreated individuals with the same conditions. Comparing depictions of successfully treated versus untreated mental illness or substance use disorder is valid, given that such portrayals are often pitted against one another in policy debates. However, when measures of stigma are compared between respondents exposed to portrayals of successful treatment versus a control group of respondents exposed to no messages, stigma reduction effects largely disappear (5,54).

Two large national experiments have shown that compared with a control arm, depictions of successful treatment and recovery do not increase public support for allocating resources to expanded mental and substance use disorder services (5,54). Given studies showing that narratives describing barriers to treatment increased support for expanding mental and substance use disorder services (5,31), narratives depicting successful treatment, which show people with mental illness or substance use disorders accessing and benefiting from services, may fail to convince audiences of the need to improve the existing treatment system.

Given the high prevalence of and low rates of treatment for substance use disorders in the United States, communication strategies should aim to improve support for policies that expand access to evidence-based treatment for this group. To succeed, such strategies may need to overcome the dominant public perception that people with a substance use disorder have a high degree of control over their substance use behaviors and, therefore, are able to stop using substances without the help of medical or psychosocial treatment (6,17,23). Available evidence suggests that communication strategies emphasizing the neurobiological causes of mental illness and substance use disorders do not decrease stigma (12), but these strategies may increase support for expanding treatment independent of stigma. Communication strategies designed to increase public support for expanded substance use disorder treatment by improving the public’s understanding of substance use disorder treatment options and the efficacy of those options should be explored. A 2015 public opinion survey found that only 19% of Americans surveyed thought methadone—the gold standard for opioid use disorder treatment (57)—was the best way to treat heroin dependence, instead endorsing strategies like Narcotics Anonymous that involve being completely drug free (58). This suggests that communication strategies dispelling myths and emphasizing the efficacy of medication-assisted treatments like methadone may increase public support for expanded funding and delivery of such treatments.

“Harm reduction” refers to strategies aimed at reducing negative consequences associated with drug use (59). Harm reduction strategies such as syringe exchange programs and safe consumption sites have been shown to reduce HIV transmission and increase engagement with drug treatment and other social services (60,61). Another harm reduction strategy, administration of naloxone, can save lives by reversing the course of opioid overdose (62). Harm reduction strategies have not been widely implemented in the United States, in part because of low public support for policies designed to reduce the negative consequences of drug use without eliminating drug use itself (63). However, the ongoing opioid crisis may be increasing Americans’ openness to this type of strategy. As of November 2016, 45 states had passed policies designed to increase access to naloxone (64).

Although a window of opportunity for enactment of harm reduction approaches may be opening, little is known about which communication strategies increase public support for such strategies. To our knowledge, only one message-framing experiment has focused on harm reduction. In a 2015 study, Bachhuber and colleagues (32) tested a narrative describing a young woman who died from a prescription opioid overdose. The narrative combined a sympathetic description of the woman with educational messages about naloxone, including messages refuting the idea that use of naloxone encourages people to continue using prescription opioids by providing a “safety net” from overdose (32). The narrative went on to counterargue that, in fact, many people whose lives are saved by naloxone view the experience as a wake-up call and enter treatment (a point supported by research) (32). Compared with a control arm, this narrative raised public support for policies that would train first responders to use naloxone, provide naloxone to friends and family members of people at risk of opioid overdose, pass laws to protect people if they call for medical help for an opioid overdose, and pass laws to legally protect people who administer naloxone (32). This study suggests that a sympathetic narrative combined with educational messages about harm reduction approaches, including messages that refute common misconceptions about that approach, may hold promise for increasing public support for evidence-based harm reduction strategies.

Mental illness and substance use disorders are linked in the public psyche with racial, ethnic, and class characteristics that independently engender stigmatizing attitudes (23,65,66). However, there is a lack of understanding regarding the extent to which stigma and reluctance to support beneficial policies are related to race, class, or other stigmatizing characteristics. This lack of understanding is one of the challenges with overcoming public stigma toward people with mental illness or substance disorders and garnering public support for beneficial policies. This issue is often highlighted in the context of the current prescription opioid epidemic. Opinion leaders assert that because the current epidemic affects whites living in nonurban areas, unlike the prior heroin and crack cocaine epidemics, which predominantly affected low-income, urban communities of color (67,68), policy responses have shifted toward a more helpful and less punitive approach (69–71).

Limited experimental research has examined these issues. In a nationally representative experiment conducted in 2014, Kennedy-Hendricks et al. (31) tested two versions of a narrative depicting a pregnant woman who had prescription opioid use disorder, one version in which she was portrayed as having low socioeconomic status and another version in which she was portrayed as having high socioeconomic status. Respondents who read the high–socioeconomic status narrative were less likely than those who read the low–socioeconomic status portrayal to blame people with prescription opioid use disorders for their condition and were less likely to support punitive policies targeting pregnant women with prescription opioid use disorders (31). Further work is needed to understand how stigma and policy attitudes related to race and class interact with attitudes about substance use disorders and whether these interactions vary by specific substance use disorder. For example, because crack cocaine has long been associated with urban, poor, African-American communities, the interaction of stigma and policy attitudes related to race and class with public attitudes about substance use disorders may be different for cocaine use disorder than for other conditions like opioid use disorder or cannabis use disorder.

Given the need for policy solutions to address significant racial disparities in drug-related arrests, prosecution, and incarceration in the United States, research to disentangle the role of race and socioeconomic status in public attitudes toward substance use disorders is particularly important for illicit drugs. No prior studies have examined these issues in the context of mental illness. Given significant racial and ethnic disparities in diagnosis of conduct and oppositional defiant disorder, one avenue for future research might consider how public attitudes about race influence the effectiveness of communication strategies designed to improve public support for allocating resources to services for children with these conditions.

The past decade has witnessed major changes at the national and state levels in the mental illness and substance use disorder policy landscape, including but not limited to passage of the federal Mental Health Parity and Addiction Equity Act (72); the multiple mental illness and substance use disorder provisions of the Affordable Care Act (73); the Office of National Drug Control Policy’s allocation of significant new resources to expand medication-assisted opioid treatment (74); and state-level legalization of marijuana for medical and, in some cases, recreational use (75). Currently, very little is known regarding how public perceptions of these policies affect public stigma and policy attitudes. The policy feedback literature suggests that enactment of public policies can lead to changes in public perceptions of the worthiness of the population targeted by the policy and shift political power by creating new constituencies (76). These factors, along with perceptions of the effectiveness of these public policies, can also influence public attitudes regarding enactment of new public policies. For example, over the past 60 years, deinstitutionalization of state psychiatric hospitals and commitment laws emphasizing civil liberties over medical need have contributed to high rates of homelessness and criminal justice involvement among people with serious mental illness (2,77). Mental illness policy scholars have asserted that these policies increased public stigma toward mental illness by increasing the likelihood of the public’s exposure to negative examples of people with conditions like schizophrenia—either in person or through the news media. Scholars suggest that this stigma, along with recognition of the problems of homeless and criminal justice involvement resulting from deinstitutionalization, has galvanized state efforts to enact assisted outpatient treatment laws (2,78–82).

Communications research focused on policy feedback is of particular interest in two domains. First, research should consider how the policies designed to ensure equity in how the health insurance and health care delivery sectors approach mental illness and substance use disorder compared with general medical conditions influences public stigma and support for other mental illness and substance use policies. These policies include insurance parity regulations and efforts to improve integration in the financing and delivery of mental illness and substance use disorder and general medical services. Second, future research should assess the influence of messages emphasizing shifts away from punitive policy approaches on public stigma and policy preferences. For example, the prescription opioid epidemic has contributed to a shift away from punitive, criminal justice–oriented drug control and toward an increased public health emphasis on prevention and treatment (74). To date, little is known about how this type of policy shift influences public attitudes about mental illness and substance use disorders and whether policy feedback operates differently for mental illness than for substance use disorder. Future policy feedback research should also consider how the policies of interest influence self- and structural stigma and how those dimensions of stigma in turn influence public stigma and support for policy.

The consumer mental health movement in the United States has long framed its mission and values in terms of civil rights and citizenship. The major mental illness and substance use disorder policies of the last century, including deinstitutionalization, passage of the Americans with Disabilities Act, and the federal insurance parity law, have shared this antidiscrimination, full-citizenship orientation, seeking to prohibit discrimination on the basis of mental illness and substance use disorder and ensure that people with these conditions have the same rights as all other citizens. To our knowledge, no large-scale experimental studies have tested how messages framing public policies as designed to protect the rights of people with mental illness or substance use disorder influence public stigma and policy support. In addition, little is known regarding whether and how rights-oriented messages, which have most commonly been applied to mental illness, can be used to shift public attitudes about issues related to substance use disorders.

Future research should also test the persuasiveness of messages in competition with each other. Most current experimental research compares attitudes among respondents exposed to a single messaging strategy compared with those of respondents assigned to a control arm. In reality, mental illness and substance use disorder policy debates expose the public to multiple competing messages simultaneously. In particular, future research on competitive framing in the mental illness and substance use disorder policy context should examine inoculation and preemptive refutation strategies. A growing body of communications research suggests that inoculation strategies, which present audiences with weakened forms of competing messages, help audiences to develop counterarguments to offset future competing messages (83–85). Inoculation strategies often include refutational messages that explicitly point out the flaws in competing arguments. For example, a message tested by Bachhuber et al. (32) refuted the idea that naloxone availability encourages continued opioid use.

Future research should also assess the duration of effects of mental illness and substance use disorder policy communication strategies. Most existing experiments have tested effects at a single point in time, immediately following message exposure. In one exception, Niederdeppe and colleagues (30) compared the effects over time of inoculation messages refuting pharmaceutical industry arguments against policies to curb prescription opioid misuse and a narrative combining a description of a woman experiencing prescription opioid use disorder and arguments in favor of the policies. They found that the narrative had stronger effects than the inoculation messages on respondents’ attitudes over time.

Future research should also consider how communication strategies influence support for beneficial mental illness and substance use disorder policies among specific stakeholders, including policy makers and interest groups. Although public opinion is a key driver of policy development and policies with strong public support are most likely to be enacted (86), support from policy makers and interest groups—as opposed to the general public—is the impetus for some mental illness and substance use disorder policies. More than half of Americans are not aware of the provisions of the Mental Health Parity and Addiction Equity Act (87), suggesting that the dedicated efforts of consumer advocacy groups and leading political proponents, such as former Congressman Patrick Kennedy, drove parity enactment (72). Similarly, public opinion may not have played a major role in Congress’s decision to pass the uncontroversial 2016 21st Century Cures Act, which received little public debate and includes provisions to expand mental illness and substance use disorder treatment. It is worth noting, however, that public demand for solutions to the opioid epidemic is high (7), and expanded opioid use disorder treatment is a key component of the 21st Century Cures law (88).