Joseph Adu & Abe Oudshoorn Western University, Ontario, Canada)
How might public policy facilitate intentional “social contact” between people with and without lived experience of mental illness in order to break the stigma and improve mental health outcomes?
The World Bank, OECD, and UN have each described how policies can be designed and redesigned to influence society positively through programs and interventions that target human behaviours based on the inclusion of important human and societal factors in decisions. As ‘social animals’ our desires may be insatiable, and our thinking and actions often guided by our social environment and policies. The World Bank (2015, p3) noted that people within a given context often “share a common perspective on making sense of the world around them and understanding themselves”. This presupposes that those human actions are “influenced by social expectations, social recognition, patterns of cooperation, care of in-group members, and social norms” (ibid, p.7). Left unchecked, these social expectations and recognitions can disenfranchise or exclude the less privileged in society, including people with mental illnesses. They can be made unable to speak up about the issues affecting them in daily life.
Innovative public policies can attempt to change this status quo of silence. These policies need to be based on a more realistic, more human, understanding of the behavioural problems faced by those with mental illness. Policies facilitating intentional “social contact” could play an important part in reducing social stigma and changing social norms around mental health.
I use the term Social Contact to describe an intentional, facilitated engagement between those with lived experience of mental illnesses and those without, with the goal of boosting societal understanding. This type of positive dialogue has been found to be effective in reducing both self-stigma and social stigma (Stuart et al. 2014a, b; The National Academies Press, 2016). Simply put, social contact-based education enhanced self-esteem and reduced social stigma. It appears to deliver improved outcomes related to mental illnesses, reduces re-hospitalisation, and reduces psychological distress experienced by family members of those with mental illnesses. Although social contact is capable of reducing mental illness stigma broadly, it depends crucially upon an enabling environment and the psychological resilience of the affected individual to disclose their condition. Additionally, it is not just about having people together in the same space, it requires intentionality of dialogue if it is to have impact. Hence the importance of public policy interventions for social contact rather than a wholesale voluntary initiative by those involved.
Facilitated intervention does, of course, come at a cost, but mental illness is one of the most significant global health challenges of the modern era. The WHO has estimated that it accounts for 1 in 5 years lived with disability, leading to more than $1 trillion per year in economic losses. Initiatives using Social Contact could play a valuable role in tackling this extensive harm to wellbeing. It could be incorporated into existing initiatives and policy experiments to confront harm, focused on the generation of direct and purposeful connections between people with and those without mental illness.
It could be a fruitful endeavour for experiments with social contact interventions to directly consider the potential to scale up contact-based approaches in order to boost cost-effectiveness. Policies could also be developed to incorporate social contact-based education into existing anti-stigma campaigns, to build societal buy-in. Viable policies are needed urgently to crowd out current negative perceptions around mental illnesses, and crowd-in social contact-based education and open discussion of mental illness.
Better communication, rooted in behavioural insights and current evidence, needs to help bridge the ‘we and them’ gap in our communities. Social contact-based education could play an important role in achieving this, given the human importance of stigma, norms and expectations within this particular global health challenge.
Current social structures appear to compel family members to overlook or conceal their loved ones struggling with mental illnesses, due to the direct fear of social stigma and indirect fear of stigma by association. This, in turn, has negative consequences; preventing identification of the need to seek assistance, and reinforcing the affected individual’s sense of stigma. To effectively address stigma that family members themselves still feel, despite a plethora of media campaigns designed to counter stigma (Psychiatry.org), evidently requires something more in terms of evidence-based behavioural interventions. Social contact approaches may help with this important ambition, by humanising and localising the realities of mental illness.
On current evidence, initiatives based on social contact do appear to be more effective in reducing stigma than other forms of public education such as mass media campaigns with diminishing returns (Adu et al., 2021; Corrigan et al., 2012; Psychiatry.org).
Tackling stigma is an important step towards improved wellbeing of persons with mental illnesses. Where stigma persists, it puts up barriers to treatment and supported recovery (Public Health Agency of Canada, 2006; van der Sanden et al., 2016; Psychiatry.org). Social contact approaches need ideally to be an upstream intervention, not reserved exclusively for contexts where illness has already been formally diagnosed. An upstream intervention can also have positive spillovers. Stigma can extend beyond the immediate family; secondary stigma felt by family members can lead to reduced social interaction, isolation, and fear. Therefore, social contact stigma reduction may build a healthier environment for family members of those living with a mental illness.
Currently, too many people who experience mental illnesses still encounter stigma and isolation within their workplaces, neighbourhoods, and even families due to differential power relationships within all levels of society, capable of undermining fair treatment (Livingston, 2013; Psychiatry.org). This is concerning in the context of human behaviour where “it’s ok to not be ok” and “it’s ok to ask for help” are ubiquitous in public narratives. Clearly there is a further step needed to make this a reality within the complexities of family and social life. Untreated or poorly treated mental illness is still associated with higher morbidity and mortality, increased engagement with criminal justice systems, and (very importantly) reduced social networks (Corrigan et al., 2014, Livingston, 2013). Both families and individuals need to be open to seeking assistance without fear of negative social ramifications. Family members themselves appears to be at increased risk of poor health if feeling unsupported in caring for a relative living with a mental illness.
Ultimately, our plea is to prioritise research and practice in social contact-based engagement and education, to reduce the existence of mental illness stigma. This can be upstream (i.e., behavioural public policy), broadly available, to reduce stigma globally. This can also be localised, targeted to family members seeking better understanding for example in the context of a new diagnosis. Such initiatives are being enacted around the world as seen in Canada, the UK, Australia, Ireland, and New Zealand, and should be supported by behavioural research and related policies to ensure the integration of evaluation into program delivery (The National Academies Press, 2016).
One good example of research-based social contact work in Canada is the Opening Minds Initiative, which focuses on integrating persons with mental illnesses in intentional ways into society. This is currently being implemented in various workplaces and post-secondary institutions, to bridge the gap between people with and without mental illness (Mental Health Commission of Canada). For the Opening Minds-type initiatives to scale up their programs on social contact-based education, it will be good to incorporate them into existing programs (i.e., training institutions such as basic and post medical education) within the health, community, and social care systems. As well, this initiative could be included in all high school curriculums to ensure continuous education on the need to allow persons with mental illnesses to fully participate in their communities.
Ultimately, social contact approaches need to be fully embraced as a new frontier in public education to reduce mental illness stigma, given that traditional, non-interactive media campaigns can only take us so far (Adu et al., 2021;Psychiatry.org). The one-on-one interaction involved in contact-based interventions fosters social inclusiveness among persons with lived experiences of mental illnesses, thus directly tackling the social context and norms. Although contact-based approaches are notably expensive and labor-intensive in comparison to public education, it will need to be driven by evidence, with support from policymakers. Given the high cost of mental illness on societies (The Lancet Global Health; Livingston, 2013), these more expensive interventions can prove cost-effective. Despite the fact the extant literature appears to support face-to-face social contact over online engagement, the Covid 19 pandemic has also accelerated the adoption and normalisation of online contact. Data gathered pre-Covid may, therefore, inaccurately reflect the potential effectiveness of online social engagement within this “new normal”. It is arguable that it would now be prudent for actors of social contact-based education to consider again experimentation with online social interaction (see Griffiths et al., 2014; The National Academies Press, 2016). This could present an opportunity to see whether this experience might affect the effectiveness of online approaches, given the potential for higher cost-effectiveness and scaling ability.
Behavioural science has shown the importance of accounting for social context in public policy design. It follows quite naturally that social contact between those with and without a mental illness should be a focus for tackling the stigma and norms of mental illness.