barriers include inadequate comparative information and poorly structured mechanisms to enable meaningful choices of plans, providers, and treatments1; poor general and health literacy (IOM, 2004a); a tension that can sometimes occur between consumer-directed and evidence-based care (IOM, 2001); and providers’ lack of understanding of cultural differences.

When one is diagnosed with a mental and/or substance-use (M/SU) illness (and sometimes an M/SU problem), additional obstacles to decision making arise from the lingering stigma attached to some of these illnesses and from the practice of coerced treatment. The effects of this stigma and coercion (especially as they relate to perceptions of patients as having impaired decision-making abilities and posing a danger) are complex and have substantial ramifications for the delivery of patient-centered care. These issues and related evidence are presented in the following four sections of this chapter, which address, respectively:

  • Effects of stigma and discrimination in impairing patient decision making, patient-centered care, and patient outcomes. Understanding these effects points to actions that can counteract stigma and discrimination.

  • Two stereotypes that uniquely stigmatize individuals with M/SU problems and illnesses—impaired decision making and dangerousness—as well as additional stigmatizing misperceptions about drug dependence.

  • Coercion into treatment that results from concerns about impaired decision making and dangerousness.

  • Actions clinicians, organizations, insurance plans, and governments (federal, state and local) can take to combat stigma and discrimination and support patient-centered care.

The committee’s recommendations for achieving patient-centered M/SU care are presented in the final section.


“Stigma” is defined as the negative labeling and stereotyping of a group of individuals that is based on some observable trait they share and that


Some consumer information needs and choices pertain to the patient’s role as a consumer in the health care marketplace, that is, as a purchaser of health insurance and chooser of both health plan and individual providers. Other information needs and choices relate to consumers’ role within the patient–health care provider treatment relationship, one that involves selecting among different treatments and being active partners in the management of their illness and recovery. This chapter addresses the individual’s role as patient within the treatment relationship; the patient’s role as informed consumer and purchaser in the health care marketplace is discussed in Chapter 8.

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