foster and permit stigmatizing attitudes and behaviors at the locus of care delivery.

Combating Stigma and Supporting Decision Making at the Locus of Care Delivery

Health care clinicians, organizations, insurance plans, accrediting organizations, and government bodies can counter the adverse effects of stigma on patient-centered M/SU health care by taking several concrete actions. These include (1) endorsing and supporting decision making by M/SU health care consumers as the default policy in their organizational polices and practices; (2) involving M/SU health care consumers in service design, administration, and delivery; (3) providing decision-making support to all M/SU health care consumers, including those under coercion and making decisions about diversion programs; and (4) supporting illness self-management practices for all consumers and formal self-management programs for individuals with chronic illnesses.

Endorsing and Supporting Consumer Decision Making in Organizational Polices and Practices

All organizations have cultures, defined as the dominant and commonly held beliefs, attitudes, values, and behaviors that shape organizational goals, policies, and procedures (Schein, 1992). In health care, the effect of an organization’s beliefs, attitudes, values, and behaviors on the practices of its individual members is so widely accepted that substantial analysis and tool development have taken place to help organizations create, for example, “cultures of safety” (Bagian and Gosbee, 2000; Wong et al., 2002). Desired cultures can be consciously built and objectively assessed. Recently, for example, the Agency for Healthcare Research and Quality (AHRQ) developed a survey instrument for use by hospitals in assessing the extent to which they have been effective in creating an internal culture of safety (AHRQ, 2005). Organizations similarly can create cultures that endorse and support consumer decision making through their leadership and formal policies, and through employee education in the adverse effects of stigma and the capabilities of M/SU consumers to engage in decision making.

Leadership and policy practices Effective leadership within an organization is essential to achieving cultural change (Davenport et al., 1998; Heifetz and Laurie, 2001). If patient-centered care is to be provided and decision making by consumers of M/SU services is to be ensured, leaders within treatment organizations must see that their organizational culture

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