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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
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3

The Science of Communication

This chapter describes a communications framework that attends to the behavioral and cognitive principles that would drive the selection of targets, messages, and delivery methods of an effective anti-stigma initiative. The chapter provides details about reaching specific target audiences for future campaigns that have been selected through a prioritizing process that includes stakeholder participation and is informed by relevant theory and formative research.

BACKGROUND

To change health-related public norms and behaviors, public health organizations often partner with communication scientists. The most effective and long lasting of these collaborative efforts have been based on communications science and informed by behavioral theory (Institute of Medicine, 2002). Health-related behavior is influenced by a range of structural, social, and psychological factors, which include access to health-related resources, prevalent social norms, and personal agency and intentions. Communication strategies can influence all of these factors, and communications strategies and communication science perspectives are relevant across structural, public, and self-stigma.

Historically, efforts to promote public perception of mental and substance use disorders as treatable diseases have been successful, but these efforts have not led to a general reduction of public stigma related to these disorders. Efforts to promote the perception of mental and substance use

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

disorders as diseases like any others have taken a mental health literacy approach. Mental health literacy campaigns are educational efforts aimed at improving understanding of behavioral health disorders, and their prevention and treatment (Jorm, 2012). Efforts to improve the public’s understanding of mental illness as a disease have been successful in reducing attributional stigma, that is, the belief that people are to blame for their behavioral health problems (Corrigan, 2004; Pescosolido et al., 2013), but blaming persists in regard to substance use disorders. The biogenic view of the origins of mental illness and addiction can discourage punitive attitudes and coercive approaches to treatment, and encourage sympathetic attitudes, and support of recovery-oriented treatment and rehabilitative services (Corrigan, 2004). However, this approach has also produced unintended consequences by bringing attention to the “differentness” of people with and without these disorders (Kvaale et al., 2013a, 2013b). This is a concern since one of the ultimate goals of anti-stigma campaigns is to promote attitudes of inclusion regarding people with mental and substance use disorders.

An added concern is that, while public health communications campaigns may increase public knowledge about mental and substance use disorders, changing behavior toward people with these disorders typically requires additional change in what is believed, felt, and desired in terms of outcomes. Habitual and unconscious behaviors are particularly difficult to change as are behaviors that are motivated by unquestioned social norms and/or strong emotions such as fear (Institute of Medicine, 2002). This may partly explain the persistence of the stereotype of dangerousness and unpredictability.

Communication efforts built on a foundation of behavioral theory will identify which public norms and behaviors to target, structure the message to be remembered so as to have lasting impact, and facilitate selection of the best message platform or source. The goal of stigma change efforts may be to reduce stigmatizing beliefs and behaviors or reinforce positive attitudes. Science-based communication campaigns to change stigma must begin by identifying the range of attitudes and beliefs in the general public, or within smaller target audiences, and determine which of those attitudes, beliefs, and/or behaviors should be targeted for change and which might be positive in influence and thus targeted for reinforcement.

Other essential steps in the planning include choice of target audience(s), behavioral objectives, a message strategy and implementation, and evaluation of plans. Activities in the planning phase include choosing which channels and settings will be used for message dissemination, conducting formative research and ongoing monitoring, and evaluation to support the effort (Institute of Medicine, 2002). Following

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

these steps helps to increase the effectiveness of behavioral health communication efforts in meeting campaign goals and objectives (Institute of Medicine, 2002). The next section will detail these steps and focus on how communication science principles and perspectives can be applied within a campaign to change behavioral health social norms and behaviors.

SETTING GOALS FOR BEHAVIOR CHANGE

Before attempting to identify a target audience, intervention designers must have a thoughtful discussion informed by stakeholder input about what specific behaviors they want to change or reinforce, based on scientific evidence linking those behaviors to a stated outcome related to the goals and objectives of the campaign (Institute of Medicine, 2002). An important consideration is the feasibility of the behavior or behavioral change—is it one that the potential target populations can reasonably perform? For example, asking someone to break laws to change their behavior is not tenable. The desired behavior change must also be specific, for example, a vague categorical directive to “eat healthier” rarely produces results, whereas a specific behavior change goal, such as “walk for at least 30 minutes a day” or “eat two additional servings of fruits or vegetables a day,” is more likely to result in behavior change (Institute of Medicine, 2002). Finally, it’s important to be realistic and specific about the timeframe over which the behavior change will be assessed and how the related success in meeting campaign objectives will be evaluated. Behavior change rarely happens quickly so a message that is delivered multiple times on a consistent and ongoing basis is more likely to change behavior in a lasting way than a one-time action (Institute of Medicine, 2002).

REACHING TARGET AUDIENCES

The source, the message, the platform, and the production features of the intervention will vary with the target audience and the goals of the intervention. A well-tailored message that is designed for a specific audience increases the likelihood of success in meeting project goals and objectives. This section will identify potential target audiences for stigma change and focus on the goals of the messages for various target audiences. There are many potential target audiences campaign designers might choose to focus on in a given campaign, and the examples provided here should not be considered comprehensive or exclusive. These examples are provided to guide campaign designers through the audience selection and message design processes and should not be used in place of formative research.

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

Among the stakeholders involved in stigma change efforts, there are many independent and sometimes mutually conflicting agendas. Likewise, an appreciation for the diversity of the U.S. public and the basic principles of communication science make clear that there cannot be a single target audience in our national efforts to reduce behavioral health stigma. Because stigma comes from many sources, there will be many targets on the receiving end of anti-stigma messages. Primary targets for stigma change campaigns include policy makers who have the ability to change laws that enable structural stigma against people with mental and substance use disorders; employers and landlords who have the power to deny livelihoods and housing to people with these disorders; mental health workers whose job is to provide nonjudgmental, culturally competent, evidence-based treatment; people with mental and substance use disorders who self-stigmatize in ways that reduce their quality of life; and the general public who can discriminate against or support and empower people with behavioral health disorders, notably through their support or opposition to policy, regulation, and legislation concerning people with mental and substance use disorders.

In addition to being diverse, potential target audiences are sometimes difficult to define. Targeting the full range of audiences with sufficient frequency would require a significant commitment of time and resources. Audience segmentation is a classic approach to choosing how best to focus and stage communication efforts and a necessary step in the process of design and development of communication campaigns (Atkin and Freimuth, 1989; Grunig, 1989; Rogers and Storey, 1987; Slater et al., 1997). Segmentation is a process by which a heterogeneous population is partitioned into subgroups or segments of people with similar needs, experiences, and/or other characteristics (Institute of Medicine, 2002); for example, we might segment high school students from college students when crafting messages about suicide. Audiences whose personal values and priorities resonate with a message process the message more deeply, remember it better, and are more likely to act on the message than an audience to whom the message is not so relevant (Institute of Medicine, 2002). Audience segmentation is most effective when it accurately identifies subaudiences for whom a particular message is relevant and distinguishes them from those for whom it is not relevant. Ultimately, the goal is to maximize the relevance of a message by targeting it to the audience most receptive to it.

An important precursor to detailed formative research for each target population is the discussion of the specific types of desired outcomes, such as awareness, belief change, or behavioral change. In the case of stigma change, this includes a need to understand how the potential audience contributes to stigma; for example, do they have a role in sup-

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

porting a loved one who experiences stigma first hand, or are they able to influence structural stigma from a leadership or decision-making position? Communication campaigns tend to fail for two reasons—failure to identify well-defined goals and objectives for the campaign (Kirby et al., 2001) and failure to reach the intended audience(s) in a sustained or adequately frequent manner (Snyder et al., 2004). Potential target audiences and related goals and objectives for stigma change campaigns are discussed briefly below.

Federal Legislators and State Law Makers

Legislators have considerable influence over the distribution of funding for mental health and substance use services and other social policies that influence the lives of people with mental and substance use disorders. Policy and decision makers who have negative attitudes toward people with mental illness may choose to block funding for services while those who hold positive attitudes may direct resources toward supportive services. In the case of policy makers, the ultimate goal may be a change in public norms and behaviors by reducing stigma at the structural level through the sponsorship and enactment of antidiscrimination or other supportive policies and laws. Objectives related to this goal would focus on preliminary steps aimed at changing the target audience’s beliefs about people with mental and substance use disorders or the nature of the disorders. Desired outcomes would be that legislators and decision makers develop more awareness of relevant issues, including better understanding of behavioral health disorders and related stigma, and greater empathy for people with these disorders. Decision makers must also come to believe and agree as a group that change is possible and needed. To enact change, legislators and decision makers must first form the intent to act, which requires creation of a positive attitude toward the act of creating a new policy. Once policy goals for reducing structural stigma have been established, formative research needs to identify key policy makers and characteristics that they have in common to set the stage for targeted and effective messaging.

Employers and Landlords

As noted earlier in this report, people with mental illness and substance use disorders are often perceived as being dangerous and unpredictable (Link et al., 1992, 1999a, 1999b). The high rates of unemployment, homelessness, and housing discrimination observed among people with mental illness and addiction are among the consequences of this stereotype. Consequently, employers and landlords are important target

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

audiences for anti-stigma messaging. In this case, the ultimate goal is to increase the hiring of peple with mental illness and to increase willingness to rent to people with mental illness. Employers and landlords are a relatively amorphous target audience. Formative research would need to be done in specific neighborhoods and communities to identify the targets for the messages. General characteristics might be established on the basis of research in one or two markets to allow for the development of messages, choice of platform(s) for delivery, and completion of other steps in the communications process outlined above. The messages could then be adapted and scaled-up for delivery in multiple employment and housing markets.

Younger Audiences

The increasing popularity of nontraditional media among young people has led to considerations of new ways to reach them. Although past efforts to combat stigma against mental and substance use disorders have typically relied on traditional print, and television-based media campaigns, in recent years both researchers and anti-stigma campaign designers have turned toward the internet and social media to deploy anti-stigma efforts, collect previously unavailable data, and track the influence of these contemporary media platforms on stigma. A recent review by Moorhead and colleagues (2013) systematically examined 98 studies on the influence of social media for health communication. They identified six key benefits to using social media in health communications: increased interaction with others; more available, shared, and tailored information; increased accessibility and widening access to health information; peer and social support; public health surveillance; and potential to influence health policy (Moorhead et al., 2013).

Young adults often turn to the internet to find support from like-minded peers on family and relationship problems and mental health concerns, such as depression, drug and alcohol use, eating disorders, and suicidality (Fukkink, 2011). Increasingly, formalized peer support programs are being established online. One example is the Dutch Share in Trust Project, which trains young adults (ages 16-23) to serve as peer counselors in a supportive online chat (Fukkink, 2011). Although research on this type of online support is still in its early stages, preliminary evidence suggests that young people may successfully provide positive socioemotional support for one another online (Fukkink, 2011).

In an effort to counter misinformation that is online and bring accurate, nonstigmatizing messages to the forefront, behavioral health organizations can use advertisements and search- engine optimization strategies to bring accurate and professional health resources to the top of internet

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

search results (Birnbaum et al., 2014). In addition, when designing educational online resources, campaign planners need to partner with young adults to help ensure that messages are engaging, appealing, and developmentally appropriate to the adolescents who are likely to seek information (Birnbaum et al., 2014).

In addition to online mental health forums, Twitter is increasingly used to replace stereotypes with the “real face” of mental illness. During one online protest of an offensive “mental patient” Halloween costume, Twitter users posted “lived experience selfies” with accompanying text that said, “This is what a real mental patient looks like” (Betton et al., 2015, pp. 443-444). As technology evolves, so do the potential platforms by which people with mental and substance use disorders can share their experiences.

Health Care Professionals

Health care workers’ attitudes and beliefs regarding the nature of mental and substance use disorders influence the treatment they provide to people with these disorders for both behavioral and somatic conditions (Keane, 1991; Levey and Howells, 1994). For example, in a review of articles about attitudes among emergency department caregivers, Clark and colleagues (2014) found that staff in those departments commonly reported feeling challenged by mental health problems, angry and fearful about aggressive or unusual behavior, and frustrated by what they saw as a “revolving door” of repeat admissions. However, staff who had been educated and trained in treating mental disorders were better able to engage with the patients and more likely to convey messages about hope and recovery.

Interventions directed at medical students have found that attitudes are more amenable to change early in their education and training, and that these attitudes tend to solidify as students progress through medical school and residency (Papish et al., 2013). Formative research can help to identify the specific attitudes and beliefs that prompt a subgroup of health care providers to stigmatize their clientele. So, for example, since research indicates that the stereotype of dangerousness and unpredictability is prevalent among health professionals (Levey and Howells, 1994), the objectives of an anti-stigma intervention for this audience would focus on improving mental health literacy about the relationships between violence and behavioral disorders, and increasing empathetic responses and decreasing aversive responses to people with mental or substance use disorders.

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

People with Mental and Substance Use Disorders

Self-stigma negatively influences decisions about seeking treatment and following regimens of care. Research in this area suggests that self-stigma is decreased after “coming out” as a person with mental illness and/or disclosing related experiences (Corrigan et al., 2013). Disclosure may elicit both affective change (more self-pride, self-worth, and hope) and cognitive change (knowledge that effective treatment exists and recovery is possible). To reach this audience and encourage selective disclosure or facilitate contact with someone who is already “out,” campaign designers should conduct formative, community-level research to identify local community resources. Community clinics and schools could be valuable hubs of information to get the word out via print materials such as posters and advertisements containing well-crafted messages. Additionally, high-profile individuals with mental illness and/or substance use disorders may be particularly effective in reducing self-stigma and encouraging selective disclosure.

Media Professionals

The role of media in perpetuating mental illness and addictions stigma is an important target for stigma change efforts (McGinty et al., 2014). The goals of communication targeted toward media professionals would be to educate them about appropriate language to use to describe mental illness and substance use disorders, to increase their sensitivity when covering behavioral health issues in the news, and to produce more balanced and fact-based reporting of violent events that involve people with serious behavioral health problems. The messages would have to get their attention, be remembered, and model appropriate behavior change, that is, the desired modifications in their reporting.

CHOOSING A MESSAGE SOURCE

The source that delivers the behavioral health messages has a strong impact on how messages are received, for example, whether messages are perceived as credible, meaningful, and relevant. The choice of a source needs to be made after the audience is selected because the source needs to be someone whom the target audience finds relevant and worthy of trust and respect. This may be someone the audience relates to or knows personally, someone who represents the target audience, a recognizable celebrity or public figure, someone whom the target audience regards as an influential role model, or someone who is friendly and anonymous, such as a fictional or animated character (Weinreich, 1999).

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

Every communication has a source either stated by the designer or inferred by the audience. Sources can be both proximal and/or distal. The distal source is the organization sponsoring the message. The proximal source is the person delivering the message. The proximal source generally has more powerful effects than the distal source, although trusted and distrusted distal sources can create a halo of credibility or lack thereof. The influence of proximal sources is greater in visual, audio, and audiovisual media, but there are exceptions to this rule. Text and print messages have both distal and proximal sources, and, in some cases, the distal source is more influential than the proximal source. For example, a well-known distal source such as a newspaper (e.g., the New York Times) may be more influential than the proximal source, the journalist(s) named in the byline.

A robust body of research suggests that people who are living successfully and openly with mental or substance use disorders are extremely powerful proximal sources (Borschmann et al., 2014; Corrigan et al., 2012; Griffiths et al., 2014; James and Glaze, 2006; Yamaguchi et al., 2013). From a communication science point of view, this is because they embody the message “I have a mental illness and I am like you. I have a life and a job, and I experience both good things and bad things.” As proximal sources, peers offer positive images and proof of concept all in one package. Audiences are likely to attribute them with high credibility because they have insider knowledge and experience.

People are more receptive to sources that are similar to themselves, and to people who embody characteristics, such as likeability, expertise, and trustworthiness. Message sources for target audiences should be selected with these characteristics in mind, and evaluative research can help identify the best choices among alternatives. For example, for legislators and policy makers, those in similar jobs (lawyers, administrators) with lived experience might be excellent choices. For the general public, an effective campaign might include many different sources from various demographic groups sending the same message. For example, landlords could be a message source for fellow landlords, and journalists, especially those with lived experience of mental or substance use disorders, could be the source of messages sent to other journalists.

MESSAGE GOALS AND DESIGNS

Once a target audience, a source, and objectives have been established, communication planning turns to the design of the message. The message should be specific, focused, and limited in scope. A message typically contains one main idea that is related to the campaign objectives (Ferguson, 1999). An effective message achieves the producer’s goals, which typically include capturing attention, holding the audience’s memory for informa-

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

tion, gaining acceptance, and ultimately changing attitudes, changing behavioral intentions, or changing behavior.

Several principles guide message design at both the macro and micro levels. Effective messages are argumentatively strong and engage the audience’s mental and emotional resources. Argumentatively strong messages are ones that generate mostly favorable thoughts (as opposed to unfavorable thoughts) in the target audience. Formative and evaluative research is necessary to craft argumentatively strong appeals to the target audience, but most argumentatively strong messages are ones that argue from the consequences to the targets of change (O’Keefe, 2013).

Formative and evaluative research is needed to guide the construction and testing of such arguments for the target audience, but what makes a message strong is that it highlights personal consequences that are salient to the targeted audience. This idea is simple and sounds common sensical but campaigns often fail by ignoring it. Such failure is usually due to one or more of the following reasons: (1) the message design was not driven by testing, (2) the message focused on consequences but not relevant personal ones, (3) the message focused on personal consequences but failed to test which were most salient in the target audience, and (4) the argument that was crafted did not fit with the desired campaign outcome. A carefully designed communication campaign would use a clear and well-defined methodology with specific goals and direct application to the communication campaigns. The Food and Drug Administration used such a methodology to design the first generation of its The Real Cost campaign.1 When exposed to a message through one or more media outlets, focusing attention to the message’s content will require engaging the audience both emotionally and cognitively. A variety of message features can gain and sustain an audience’s attention. Two features are particularly effective: the use of stories (i.e., narrative forms of information) and testimony (i.e., testimonial cases as exemplars) (Kim et al., 2012; Kreuter et al., 2007; Zillmann and Brosius, 2012). To ensure that core ideas and information remain mentally available to the target audience, communications strategies need to include well-crafted narratives and/or exemplars that deliver strong arguments and provide information in a form that is engaging, comprehensible, and memorable or mentally “sticky.”

For example, if the goal is to understand the specifics about why landlords do not want to rent to people with mental illness, intervention planners might conduct formative research that shows it is because the landlords think tenants with mental illness will not pay their rent and will damage the apartment. A message might provide information about the

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1 For more information about The Real Cost campaign, see http://therealcost.betobaccofree.hhs.gov/costs/index.html [March 2016].

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

proportion of renters with mental illness who pay rent on time or exemplars of such people successfully living in a variety of types of rental properties. Although numbers matter, research suggests that exemplars are stickier and more likely to determine what is remembered and believed.

Similarly, if the target audience is policy or decision makers and the goal is to change a law forbidding a certain action by a person with a mental illness, for example, holding public office, the message designers would want to know first if the law exists as a forgotten remnant on the books and most decision makers are unaware of it or if there is a current belief among the policy and decisions makers that people with mental illnesses are not capable of holding a public office. In the first case, raising the policy and decision makers’ awareness of the discriminatory law may be all that is necessary. In the second case, a message would be designed to convince the target audience that what they currently know and/or believe about people with mental illnesses is not accurate. At the same time, the goal would be to change the policy and decision makers’ affective stance from one of fear and doubt to one of calm and positive belief in the capabilities of people with mental illnesses.

As another example, efforts to encourage more balanced media coverage of mental illness and substance use disorders, along with related and tragic events including suicide and gun violence, could include programs that provide constructive feedback to journalists about how to cover issues related to mental health. Giving journalists alternatives and resources to inform their reporting is crucial. FactCheck.org,2 an online program sponsored by the Annenberg Public Policy Center is example of a program of this type. It provides journalists with data and information on the deleterious consequences of negative coverage and false political ads along with techniques about how to cover false and negative ads.

MAKING THE MOST OF THE MESSAGE

Message structure and content influence attention, cognition, emotion, and intentions. In designing a message, the producer can capture the audience’s attention, improve the audience’s recollection of the message, and elicit emotional responses through the use of structural features that work in accordance with people’s cognitive and physiological processes.

When designing audio and video messages, producers can direct audience attention to focus on specific moments and specific contents by designing messages with structural features that elicit orienting responses. An orienting response is a set of physiological responses (i.e., turning one’s sensory receptors toward the new event, decrease in heart

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2 For more information about FactCheck.org, see http://www.factcheck.org/ [March 2016].

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

rate, and increase in skin temperature and conductance) to things that are novel, or signal personally relevant information to the viewer (Graham, 1979). Examples of structural features in a message that elicit an orienting response include a change from sound to silence, scene changes, camera changes, movement from off screen to on screen, movement toward a still camera, changes from one voice to another, animation, and pop-up windows. The specific advantage of using such structural features is they are known to increase attention to the message for approximately 2 seconds, and in particular to draw attention to the feature that elicited the viewer’s orienting response (Lang, 1990; Lang et al., 2002, 2013b).

In addition to manipulating audience attention through structural features, the content of a message can also be used to focus attention in a specific moment. Motivationally relevant content presents an opportunity or a threat, elicits either an appetitive or aversive response, or corresponds with an individual learned motivator that has been developed and held over time. Introducing motivationally relevant content, images, or sounds increases audience attention and holds that attention as long as the motivationally relevant material is on screen (Lang, 2006; Lang et al., 2013a). Message producers should carefully consider which content they include and whether it stimulates an appetitive or aversive response in the audience. For example, when designing a message aimed at people with substance use disorders, producers should avoid including images of the substance (e.g., avoid including a picture of alcohol in a message aimed at alcoholics) as it can elicit both an orienting response and appetitive motivational activation that can result in attention and positive emotion to the substance, which would be an unintended negative response contrary to the objectives of the message and the goals of the campaign.

It is possible to maintain audience attention throughout an entire message. One approach is an expansion of the use of structural features. Incorporating orienting response-eliciting structural features at a rate of five or more per 30 seconds will produce steady attention that is maintained over that period of time. Another approach is to use a narrative (a chronological presentation of information) and ensure that the message tells a story with a clear beginning, middle, and end (Lang, 1989; Lang et al., 2000; Schneider, 2004). When using a narrative, it is also important to include emotionally relevant material throughout the message.

Although it may seem straightforward to control audience attention through the structural features of a message, the limits of human cognitive processing ability force message producers to make decisions about how many and which features to use. Memory is always a tradeoff with increasing structural and content complexity—when content is complex, there is a need to simplify structure, and when structure is complex, there is a need to simplify content. For example, orienting responses increase

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

memory if the thing one wants people to remember is the thing that elicited the orienting response (Lang et al., 2002) and if there is sufficient time to encode the thing one wants remembered. Thus, for a complex message, producers will need to devote more time and use fewer structural features (Lang et al., 1993). A message containing more complex content will require more time to encode it into memory, and a complex message will not be remembered as well when it is paired with fast-changing sounds, scenes, and animations.

Motivationally relevant material increases memory for specific moments or things if the thing that is motivationally relevant is the thing you want remembered, and if the motivationally relevant thing is integrated with the information you want remembered rather than simply co-occurring (Sparks and Lang, 2014). In the context of the example above, images of substances and paraphernalia in a message may lead to the unintended consequence of strengthening memory for positive feelings associated with substance use.

In some cases, a message producer may want the audience to remember having seen the message but not particulars of its content. In this scenario, the producer would use many orienting response-eliciting structural features (more than 10 in 30 seconds) and many different types of orienting and eliciting structural functions in multiple channels (Grabe et al., 2000). To promote recollection of the message but not all the content, the producer can use arousing negative emotional material (Lang et al., 1996, 2007). In these approaches, people will remember the arousing negative material and the information that follows it; however, their memory for the preceding information will be poor.

To increase memory for the message and its contents, producers need to consider the quality of the emotion. Positive emotion widens focus and memory while negative emotion narrows focus and memory (Yegiyan and Yonelinas, 2011). Producers can also use narratives to simplify message processing (Lang, 1989; Schneider, 2004). Using orienting response-eliciting structural features at a rate of about five to seven per 30 seconds and placing them so that important information follows them and is available for at least 3 seconds is a good way to increase memory (Lang et al., 2014a, 2014b). Using audio and video (multiple channel) redundancy, especially for important points, also increases memory (Lang, 1995).

Although messages with negative appeals can compel attention and capture memory, message designers should be cautious when using them. After viewing a message with a negative appeal, people will remember the negative thing very well, and they will have decent memory for things that followed it, but they will not remember things in the message that preceded it (Newhagen and Reeves, 1992). In this case, message designers need to pay particular attention to the priorities of the content before

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×

and after the negative appeal to decide accordingly. Moreover, people may engage in defensive processing, which results in low attention, poor memory, and dislike for the message (Witte and Allen, 2000). Message producers can make their message more likable by choosing attractive, familiar sources with friendly and dominant personalities who are polite, flatter the message recipient, and criticize with caution.

Messages that are not perceived as credible will not be effective, but producers can increase the credibility of messages by using sources that are likeable, and if appropriate, expert in the field (Reeves and Nass, 1996). People with the lived experience of behavioral health problems will be particularly credible sources. Credibility is further bolstered by presenting strong arguments in words and weak arguments in pictures (Lang and Yegiyan, 2008) as well as by using camera techniques that look “up” at the source (Reeves and Nass, 1996). Men are unfairly perceived as more credible than women, but message producers can use this to their advantage if they choose to do so (Reeves and Nass, 1996).

Message producers can draw on the automatic activation of human motivational systems to enhance the efficacy of messages. For example, pictures elicit greater motivational activation and larger biological imperatives (i.e., the motivation to approach or avoid the stimulus) than words while words reduce biological imperatives and increase thinking (Lang et al., 2015). If there is something one wants the message recipient to like or to do, a good approach is to associate the desired action with something they already enjoy doing (Lang et al., 2014b). Likewise, to steer people away from a particular attitude or behavior, associate the action in question with something the viewer already dislikes (Lang et al., 2014a). Finally, by using positive and negative emotions sequentially in messages, the producer can increase the viewer’s memory for messages (Keene, 2014; Thorson and Friestad, 1989). One final consideration for message producers is that pictures are more likely to shift implicit attitudes and words are more likely to affect thoughtful opinions or the viewer’s explicit attitudes. Used together, these techniques can create a message that affects behavior and attitude across multiple levels and domains.

CHOOSING THE MEDIUM BASED ON THE TARGET

Once a message is designed, the producers need to take steps to ensure that it is received as intended by the target audience. On the most basic level, messages that are not perceived are not effective, so the first requirement is that messages need to get to the target. Producers should consider which platforms will best reach their target. When presented with the choice of channels (i.e., social media, telephone calls, etc.), three questions should be asked: (1) What messages can be sent through a

Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
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particular channel? (2) How is each channel perceived by the audience? and (3) When multiple channels are present, how do they interact in their effects? (Institute of Medicine, 2002).

The list of potential communication channels below are examples and starting points for message producers to consider. This list should not be thought of as comprehensive or fixed.

  • For legislators and policy makers, face-to-face approaches might be best, followed by a letter or e-mail or a telephone call.
  • For landlords, good approaches might include mail, e-mail, and social media, which are used by many apartment complexes.
  • For employers, face-to-face workplace interventions have been shown to be effective (Stuart et al., 2014a, 2014b).
  • For people with behavioral health problems, face-to-face interaction with people with lived experience is best (Borschmann et al., 2014; Corrigan et al., 2012). Social media sites for people with lived experience are another possibility.
  • For health care workers, there are many avenues for messaging, including workplace informational materials; continuing education; face-to-face contact with people with lived experiences, especially those who are health professionals; and billboards near health care facilities and on buses and trains along routes that workers might use to get to work.
  • For journalists, there are also many avenues for messaging including professional conferences; journalism fellowships; curriculum in journalism schools; online guidelines and materials; and face-to-face contact with persons with lived experiences, especially those who are journalists.
Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Suggested Citation:"3 The Science of Communication." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442.
×
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Estimates indicate that as many as 1 in 4 Americans will experience a mental health problem or will misuse alcohol or drugs in their lifetimes. These disorders are among the most highly stigmatized health conditions in the United States, and they remain barriers to full participation in society in areas as basic as education, housing, and employment. Improving the lives of people with mental health and substance abuse disorders has been a priority in the United States for more than 50 years. The Community Mental Health Act of 1963 is considered a major turning point in America's efforts to improve behavioral healthcare. It ushered in an era of optimism and hope and laid the groundwork for the consumer movement and new models of recovery. The consumer movement gave voice to people with mental and substance use disorders and brought their perspectives and experience into national discussions about mental health.

However over the same 50-year period, positive change in American public attitudes and beliefs about mental and substance use disorders has lagged behind these advances. Stigma is a complex social phenomenon based on a relationship between an attribute and a stereotype that assigns undesirable labels, qualities, and behaviors to a person with that attribute. Labeled individuals are then socially devalued, which leads to inequality and discrimination. This report contributes to national efforts to understand and change attitudes, beliefs and behaviors that can lead to stigma and discrimination. Changing stigma in a lasting way will require coordinated efforts, which are based on the best possible evidence, supported at the national level with multiyear funding, and planned and implemented by an effective coalition of representative stakeholders.

Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change explores stigma and discrimination faced by individuals with mental or substance use disorders and recommends effective strategies for reducing stigma and encouraging people to seek treatment and other supportive services. It offers a set of conclusions and recommendations about successful stigma change strategies and the research needed to inform and evaluate these efforts in the United States.

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