Judith Warner, a senior fellow at the Center for American Progress and a contributing writer for the New York Times Magazine, moderated the first panel of the workshop, which focused on the successes and challenges of national, state, and local campaigns aimed at changing social norms around behavioral health.
Mark Hatzenbuehler, assistant professor of sociomedical sciences and co-director of the Center for the Study of Social Inequalities and Health, Columbia University, conducts research on the causes of mental health disparities related to sexual orientation, the health consequences of exposure to structural forms of stigma, and the identification of biopsychosocial mechanisms linking stigma to adverse health outcomes. He spoke about the effects of structural stigma on the health of lesbian, gay, and bisexual (LGB) individuals.
Peggy Swarbrick, associate professor at Rutgers University and director of Collaborative Support Programs of New Jersey, an agency run by and for people in recovery, is involved in research training and consultation in the area of wellness and health promotion and in the development of strategies for enhancing recovery through participation in valued occupations. Her talk focused on the concept of the wounded healer and the benefits of peer counseling.
Lawrence Yang, associate professor of epidemiology, Columbia University, conducts research on how culture relates to stigma and how to implement interventions to improve social and symptomatic recovery among people with such stigmatizing conditions as mental illness and HIV/AIDS. His particular focus is on psychosis in Chinese groups. His presentation
addressed the role of culture in determining the nature of stigma and how to tailor messages to encourage behavioral change in ways that account for cultural variations in stigma.
Finally, Helena Hansen, assistant professor of psychiatry and anthropology, New York University, and research scientist, Nathan Kline Institute, New York State Office of Mental Health, is conducting research on the mainstreaming of addiction treatment into general medical settings; on the corporate marketing of psycho-pharmaceuticals to different ethnic and social groups; and on the role of physicians in crafting public health interventions at the community, institutional, and public policy levels. She spoke about structural competency, an approach to helping clinicians work better with community organizations, policy makers, and other nonhealth providers so as to work toward improving the mental health of patients in a more holistic and culturally sensitive way.
STRUCTURAL STIGMA AND THE HEALTH OF LESBIAN, GAY, AND BISEXUAL POPULATIONS: IMPLICATIONS FOR CHANGING SOCIAL NORMS
Hatzenbuehler began by stating that research on LGB populations offers important insights relevant to the topic of improving behavioral social norms related to mental illness and substance use. His talk was organized around three main points: the effect of social norms on the health of stigmatized groups, how social policies shape social norms about stigmatized groups, and reductions in prejudice toward LGB populations compared with prejudice toward those with mental illness.
Social Norms Affect the Health of Members of Stigmatized Groups
Hatzenbuehler’s first point was that social norms can affect the health of members of stigmatized groups in powerful ways. For example, his research and that of his colleagues has shown that LGB populations who live in communities where residents endorse very high levels of antigay prejudice have increased mortality risk. This was found through an analysis of data from the General Social Survey (GSS)-National Death Index study. Hatzenbuehler and colleagues aggregated individual responses up to the community level for four items in the GSS that ask about people’s attitudes toward homosexuality, producing an average prejudice score for each community participating in the GSS. Measures of the sexual orientation of individuals living in those areas were linked to mortality information on these individuals to examine how differential exposure to high or low levels of prejudice affects mortality risk. The researchers found that about 92 percent of LGB respondents who lived in a low-prejudice community were still
alive at the end of the study, compared with 78 percent of those who lived in the highest-prejudice communities. Hatzenbuehler explained that these results were obtained after controlling for multiple established risk factors for mortality at both the individual and community levels. He added that these results translated into a life expectancy difference of 12 years on average (Hatzenbuehler et al., 2014).
Social Policies Shape Social Norms About Members of Stigmatized Groups
On his second point, Hatzenbuehler remarked that it seemed intuitive that policies reflect social norms, but that emerging evidence shows that social policies in many ways also shape social norms about members of stigmatized groups. His research has shown that social policies, in particular those that differentially target stigmatized groups for social exclusion, affect health in many ways. He presented one example using data from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative longitudinal study of adults in the United States. Respondents were first interviewed in 2001 and were reinterviewed 4 years later in 2005, following the passage of state constitutional amendments banning same-sex marriage. This provided a natural experiment with which to examine changes in the prevalence of mental health and substance use disorders among individuals from before to after these policy changes. Hatzenbuehler presented results for mood disorders, which include major depression and dysthymia. The researchers found a statistically significant increase (37%) between 2001 and 2005 in the prevalence of mood disorders for LGB individuals living in states that had passed an amendment to ban same-sex marriage. In contrast, Hatzenbuehler said, the results showed a trend toward a protective effect among LGB respondents living in states that did not ban same-sex marriage (Hatzenbuehler et al., 2010).
Hatzenbuehler’s analyses also showed that the effects of same-sex marriage bans were specific to the LGB respondents. He and his team ran the analyses again comparing LBG individuals with heterosexuals living in those states that had banned same-sex marriage. Compared with a 37 percent increase in mood disorders among the LGB respondents, he reported, there was only a 3 percent increase among heterosexual respondents living in those same states, which was not a statistically significant increase. He observed that these analyses improved the ability to draw causal inferences about the relationships between social policies and health. He did not have time to show all of the results, but informed the audience that they include data showing that health actually improves when social policies surrounding LGB populations are more inclusive.
Greater Reductions in Antigay Prejudice Than in Mental Illness Prejudice
Hatzenbuehler’s third and final point was that attitudes toward gays and lesbians have been improving much more dramatically relative to attitudes toward individuals with mental illness. He pointed to data from the Pew Research Center (2016) showing increases in support for same-sex marriage between 2001 and 2014. By contrast, results from a meta-analysis of changes in population attitudes toward mental illness showed that over a 15-year period, acceptance worsened for schizophrenia and remained stable for depression (Schomerus et al., 2012). Hatzenbuehler suggested that there are many complex reasons for this difference in attitude change over time toward LGB people versus those with mental illness. Data showing increases in social connections with gay or lesbian people indicated that in 2013 nearly two-thirds of respondents in the United States said they had a close friend or family member who is gay or lesbian. This represented almost a complete reversal from two decades earlier, in 1993, when only about a fifth of respondents said they had a close friend or family member who is gay or lesbian.
Hatzenbuehler added that Matthias Angermeyer in Germany has been collecting attitude data in a population-based sample using good proxy questions about social contacts among individuals with mental illness (i.e., whether people know someone close to them who has been in psychiatric or psychological treatment for a mental illness). Over two decades, these data showed only slight increases in social contact with individuals with mental illness, in stark contrast to the data on contact with LGB individuals.
Hatzenbuehler closed by suggesting that further research on the factors that explain the large group differences in changes in prejudice toward LGB individuals compared with those with mental illness might increase understanding of these factors and provide strategies for improving social norms related to mental illness and substance use disorder.
Swarbrick began by explaining that peer counseling is based on the premise that having people in recovery help others pursue their recovery fosters hope and optimism, and that those who bear a wound are most sensitive to those with a similar wound. Peer counseling, she asserted, provides unique skill, focus, and knowledge as well as social support to facilitate the long-term recovery of people in the community. Peer counselors accomplish this, she said, by helping their peers develop coping and problem-solving strategies for illness self-management. She added that peer counselors draw on their own lived experiences and empathy to promote hope, insights, and skills and to help their peers engage in treatment, access community sup-
ports, and establish a satisfying life. Peer counselors, she argued, can have a transforming effect on larger systems of care and on society by enhancing long-term recovery outcomes and elevating public and professional perceptions of hope for recovery (Swarbrick et al., 2010).
Swarbrick suggested that peer counseling has grown out of a response to social stigma attached to addiction and mental disorders and a history of exclusion. She explained that the wound to which she referred is not only the illness itself or the challenges in overcoming it, but also the related social stigma and discrimination. She asserted that self-stigma, which people take on in response to public stigma, may be reduced through contact with peer counselors who counter these negative messages and can elicit hope.
Swarbrick stated that the messages conveyed through peer counseling are that people can transcend their symptoms, challenges, and illness and become contributing members of society. These messages, she observed, can get the public’s attention, especially with regard to economic implications: people in recovery may not have to be dependent on disability benefits, are able to contribute to society by working and paying taxes, and can become an asset for other people in service delivery.
Swarbrick went on to say that peer counseling can benefit not only those receiving the service but also those delivering the service—the peer counselors themselves. She noted that some research has been done in this area, but more is needed to show outcomes, immediate and longer-term impacts, and core costs. She argued that there is value in educating people through success stories.
In closing, Swarbrick urged the field to counter stigma that exists in its own mental health system. She asserted that providers sometimes insinuate that peer counselors are in a “less-than” role. She stated that peer counselors are intended not to replace professionals, but to be a strong complement or alternative to traditional roles that often may pathologize and further stigmatize people.
CULTURE AND HOW IT SHAPES AND PROTECTS AGAINST MENTAL ILLNESS STIGMA: EMPIRICAL ILLUSTRATIONS FROM CHINESE GROUPS
Yang first explained that his work focuses on social factors that influence the course of schizophrenia and that his training is in clinical psychology, anthropology, and psychiatric epidemiology. From the perspective of anthropology, he presented some of his research, which theorizes that culture provides a lens by which stigma is expressed and experienced and that cultural norms can be leveraged to reduce stigma. He used an illustration within the Fujianese Chinese group, which he said is the most recent Chinese immigrant group in the United States. This group migrated
from the Fujian Province, a coastal region of Southeast China, which has a long history of migration because it offers few opportunities for work.
As background, Yang described three core cultural orientations for Chinese people. The first is Renqing, the notion of give and take, or reciprocity, in relationships. The second is Guanxi, the notion of social exchange networks. This core cultural orientation is key to Chinese individuals, Yang explained. If people join a social network and gain entry, they access the social and material resources of every network member. Also, these social networks offer opportunities to obtain key life statuses (such as work or marriage partners). Because social membership is so important, Yang said, it is also prized, and entry in and out is very powerful. To gain entry, he continued, one must have Face, the third cultural orientation. He elaborated that Face has two important aspects. The first is Lian, or core human decency, and building upon that is Mianzi, which refers to accruing social status. Perpetuation of one’s lineage, Yang noted, is a core goal.
Turning back to the Fujianese, Yang explained that when they come to the United States, they arrive in very structurally vulnerable positions. They are smuggled in by “Snakeheads” (an international smuggling gang) to whom they owe $80,000 and are in fear of being executed if they do not repay the debt. Yang explained that they are also very vulnerable as a result of being in an undocumented status, and their main goal is to pay back their debt.
Shifting to stigma, Yang quoted from the 1999 surgeon general’s report on mental health (U.S. Department of Health and Human Services, 1999): Stigmatization “reduces patients’ access to resources and opportunities (e.g., housing, jobs) and leads to low self-esteem, isolation, hopelessness . . . outright discrimination and abuse. More tragically, it deprives people of their dignity and interferes with their full participation in society” (p. 6).
As stated in this quote and as known from empirical studies, Yang said, stigma affects all life domains; however, stigma looks different within different cultural settings. He observed that the field has not had a good way of formulating this until recently. A paper by Yang and colleagues (2007) postulates how culture shapes stigma. The core concept is that mental illness stigma acts in culture-specific ways to impair an actor’s capacity to take part in the core, everyday engagements that certify one as a fully viable (or fully moral) member of a local community.
More plainly, Yang explained that there is a set of core everyday engagements through which people participate within each cultural group in order to be seen as a whole person. He added that stigma affects everything about a person’s existence, but has the greatest impact on the person’s ability to participate in these core social activities that define personhood within a cultural group. He referred to Swarbrick’s earlier statement about the importance placed in the United States on being a contributing, taxpaying member of society.
Yang continued by observing that what matters most changes according to cultural group, and what matters most within different cultural groups can be discovered empirically. Among the Chinese, including the Fujianese, the proposition is that stigma will coalesce most forcefully around an individual’s capacity to obtain employment, repay debt, fulfill family obligations, and extend the ancestral line. Yang illustrated how culture affects stigma through responses by Fujianese people to interview questions about their attitudes toward those with mental illness. He found that the core social activity that is most meaningful is one’s ability to work/earn money; accordingly, people with mental illness may be rejected because of their inability to earn money. But if the person is still able to engage in these core activities within a core cultural group, the stigma of mental illness is mitigated. Identifying “what matters most” in a cultural group therefore provides a roadmap for countering stigma toward mental illness within different cultural settings.
Yang shared some quotes from the interviews:
Interviewer: Most of you within your community would think people with mental illness would make a person lose face.
Participant (man with schizophrenia): No, because he goes to work. He still goes to work and he goes home.
Interviewer: You said if a person with a mental illness continues to work that is not considered a shameful thing.
Participant: Yes, right.
Yang pointed out that in this culture, a person with mental illness can engage in what matters most, this core behavioral norm. He shared another quote from the perspective of a man with mental illness:
Interviewer: What do you fear would happen if you tell your friends about your mental illness?
Participant: The sky will collapse (joking). There’s nothing that will happen. I’m still young, and I have my hands and feet. I have my ability. I can work in any field. No problem. Besides, I’m married, no problem.
Yang spoke about another new area of his research with Chinese communities that shows how deep stigma can be within different cultural communities. People with mental illness may lose social “face” (i.e., social status), but not lose face as that signals that they are still a decent human being. From the perspective of people with mental illness, they did not do anything to bring on the condition; everyone gets ill at some point in his or her lifetime. One can get one’s social “face” (or social status) back through engaging in treatment and recovery so that one can get back to work or through building social face within one’s local community.
So the process of changing behavioral norms for different cultural groups involves understanding the norms from a deep cultural perspective. Yang found within this Chinese cultural context that it is possible to use this perspective to preserve face within the group and to gain leverage in decreasing stigma. In many other different cultural groups, one can embark on the same process of identifying “what matters most” to combat stigma. In closing, Yang said that he hoped he had provided a framework for understanding how culture and its interpretation can influence behavioral norms to impact stigma. The task is to understand what matters most (core norms), how it shapes stigma, how it may protect against stigma, and how one might find flexibility in these norms to help in different groups.
THE ROLE OF CLINICAL PRACTITIONERS IN COMMUNITY AND INSTITUTIONAL PROMOTION OF MENTAL HEALTH AND ADDICTION TREATMENT
Having heard presentations on the reasons that communities, institutions, and public policies are key targets in efforts to decrease stigma in behavioral health, Hansen said she would discuss how communities, institutions, and policies could be targeted for positive change. She focused on the role of clinical practitioners as treatment providers, service designers, and administrators who have front-line knowledge of the challenges faced by people with mental illness.
Hansen explained that clinical practitioners hold significant cultural capital in their communities, such that when they speak about health issues, audiences do listen. She noted that current events are pushing the health field to work at the community institutional and public policy levels. As an example, she cited provisions in the Affordable Care Act incentivizing clinics to track and approve patient outcomes at the population rather than the individual level. National polls of physicians, she noted, such as a Robert Wood Johnson study, have found that physicians do recognize social causes as major barriers to improving their patients’ health (Robert Wood Johnson Foundation, 2011).
On the other hand, Hansen stressed that clinical practitioners in the United States receive almost no training in how to think and act at the structural systemic level, to collaborate with community groups across institutional sectors, or to communicate with policy makers. Thus, she argued, they recognize the importance of social drivers to health outcomes but do not know how to act on those drivers. She suggested that this may be related to record levels of burnout and dropout from clinical practice among physicians who cite such systemic issues as lack of time with patients and unsatisfying relationships with patient communities as reasons for leaving clinical practice.
Hansen shared highlights from a project on which she has worked with Jonathan Metzl of Vanderbilt University called “Structural Competency.” She reported that they have hosted three national meetings, launched two webinar series with the American Medical Students Association and with the State University of New York, and edited a special journal issue on the topic of structural competency. The idea, she explained, is that clinical trainees and practitioners need to learn how to promote health at levels above the individual patient. Efforts to this end can range from collaborating with community organizations and across service sectors, such as school systems, criminal justice, and housing services, to conveying the health impact of policies to policy makers.
Hansen and Metzl developed a four-part scheme for health professional training and continuing education. The first part, Hansen said, is to recognize structures that shape clinical interactions—for example, by looking beyond patient noncompliance with nutrition recommendations or appointments to ask what barriers (such as lack of produce in neighborhood stores or lack of transportation) impede compliance. The second part is to rearticulate clinical presentations in structural terms, which entails presenting clinical cases among clinicians in terms of neighborhood and institutional factors that impinge on health. The third is to observe and practice structural interventions by providing practitioners with hands-on experience in community and institutional health projects. Finally, Hansen said, the fourth part is to develop structural humility, which means helping practitioners recognize the limits of their clinical expertise and the need to collaborate with experts on community and institutional dynamics, and expect gradual rather than dramatic sudden change from this work.
To illustrate how this scheme might work in practice, Hansen presented two snapshots from her research on addiction treatment and explained how they led her to structural interventions. The first was from her earlier research with Pentecostal ministries, which are founded and run by self-identified former addicts. Hansen characterized this as a type of ministry that is prevalent in black and Latino neighborhoods in the United States and also in Puerto Rico. These ministries, she said, cultivate spiritual power as a way to combat addiction and are opposed to the use of psychotropic medications. One unanticipated finding of her research was that many of the ministries were collaborating with clinics to provide onsite HIV testing and transportation to HIV treatment appointments.
Building on ideas from that research, 3 years later Hansen initiated a psychiatry elective that sends New York University residents to the Brownsville Partnership, a partnership of community-based organizations and service agencies in one of the poorest neighborhoods of Brooklyn. The psychiatry residents conducted a needs assessment and worked with church leaders to develop programs for youth gang diversion; parenting support
for families at risk of foster care placement; and support groups for survivors of chronic violence, the type that is endemic in the neighborhood in Brownsville.
Hansen also shared that her research on the use of buprenorphine for opioid dependence in public clinics uncovered two barriers to its dissemination in public clinics. First, physicians’ incentives for prescribing buprenorphine in their offices for opioid dependence were geared toward private practice patients in more affluent and white neighborhoods. The second barrier cited by Hansen was New York State’s mandatory prescription drug monitoring program, which made community prescribers hesitant to treat opioid dependence with buprenorphine for fear of making an error in prescription monitoring. These two findings led Hansen to join “From Punishment to Public Health,” an advocacy coalition of clinicians, public health researchers, and disillusioned corrections officers who are working with policy makers to realign drug policy away from criminal justice and toward mental health interventions. Through this group, she testified to the State Assembly in New York and also collaborated with policy makers and policy analysts around reducing disparities and prescriber liability in buprenorphine treatment.
Hansen ended by arguing that there is a window for changing behaviors not just of patients but also of clinicians by endorsing a norm of clinical intervention at the community, institutional, and policy levels. She asserted that research is needed on the impact of and promotion of clinician involvement in structural interventions. She believes this research can occur in clinics where there are medical–legal partnerships or in volunteer organizations such as Health Leads, which matches student volunteers with patients who need help with a number of social service needs. But, she noted, clinician involvement also can take place farther upstream in community participatory interventions and cross-sector collaborations.
Patrick Corrigan, session discussant and committee member, provided highlights of the four presentations that illustrated U.S. campaign efforts aimed at changing behavioral health norms. He noted that important evidence had been presented of associations among stigma, mental health, physical health, and state policies related to gay marriage. The voice of people with lived experience had been highlighted, emphasizing the power of peers and peer counseling. The overriding importance of culture in shaping attitudes toward mental illness had been illustrated in the context of opinions, attitudes, and perspectives of a Chinese community. Evidence had been shared suggesting that many line-level clinical providers now understand that social determinants are key factors in the health of people with
mental illness, and that clinicians can address these factors at structural levels.
The discussion that followed reflected the complexity of changing social norms, as had been stressed in Leshner’s keynote address (Chapter 6). Topics included the importance of work, how policies shape social norms, what changes need to be made at the policy level to make change happen, and the use of participatory research to learn “what matters most” as a base for changing social norms.
The Importance of Work
Swarbrick was asked to differentiate between competitive employment and meaningful activity. She replied that there is much value in such meaningful activities as running drop-in centers and other volunteer activities, but a desired impact is to increase the number of people who are paid competitive wages through employment. There has been a significant movement toward credentialing peer counselors, she noted. One aspect of the training curriculum is how to help people obtain paid work. According to Swarbrick, the impacts—fiscally, emotionally, and socially—can be profound.
How Policies Shape Social Norms
Rebecca Palpant Shimkets asked Hatzenbuehler to elaborate on the role of policy and contact in the dramatic shift in social norms around LGBT issues. He replied that the social movement that predated the health movement was a generation in the making. The social movement that started in the late 1960s, he said, culminated in many ways with the AIDS crisis in the community and then continued thereafter. He noted that researchers in the sociology of social movements look to the LGBT movement as one of the real success stories in motivating political will to change norms and ultimately policies that had been having negative impacts on that group.
Judith Warner asked Hatzenbuehler to elaborate on ways in which policies shape social norms. She asked what the policy agenda would be for fighting mental health stigma. Hatzenbuehler replied that he was unable to present it, but that there is some interesting, emerging, accumulating work on the impact of policies in actually shaping norms. For instance, he said, two longitudinal panel studies that have followed individuals before and after passage of laws that banned smoking and laws that banned same-sex marriage have shown an increase in negative attitudes toward smokers and LGBT people, respectively.
Hatzenbuehler went on to say that a range of laws and policies target differential treatment of individuals with mental illness. As one example, he
cited the Mental Health Parity law, which took a long time to effect and is now supposed to ensure equal treatment for mental and behavioral health relative to medical health. In his opinion, many institutional and social barriers have prevented the effective implementation of these laws and policies. Corrigan added that there are laws in the United States that make mental health status relevant to divorce, to family opportunities, and to claims of discrimination. He argued that unless these types of laws are written with sunset clauses, which they rarely are, active efforts are needed to eliminate them even when the public is against them.
Specific Changes Needed at the Policy Level to Make Change Happen
An audience member directed a two-part question to Swarbrick and Hansen concerning what specific changes are needed at the policy level to make change happen in practice. The discussion focused on training and certification. Hansen responded first to the question of how health professionals can be paid to practice in structurally competent ways. She said a problem in clinical practice and education is that despite growing awareness of the social determinants of health, there is no understanding of how to operationalize this awareness and a corresponding lack of education and training. She observed that engagement in a structural intervention at any of the levels she had mentioned in her presentation heightens clinicians’ awareness of the structural causes behind their patients’ difficulties and of the stigma they experience, and also reduces individual blame.
Hansen said she could answer the question about the incremental changes in practice that can be made by such medical education bodies as the Association of American Medical Colleges, which certifies medical schools, and the Accreditation Council for Graduate Medical Education, which certifies residency programs, rather than addressing how higher-level government policy can effect changes in practice. She noted that these professional organizations have already been moving in this direction by requiring training in what is termed “systems competency”—an understanding of how the health care system works, which she characterized as an important move in the right direction. But she believes more work could be done to expand systems competency in health and social services and to incorporate collaborative efforts of clinicians.
Swarbrick then responded to a question about how to encourage the movement of people with lived experience into the workforce in a way that would allow them to be paid. She suggested that people with lived experience could become involved in teaching in academic settings and in shaping curriculum.
Lisa Rubenstein of the Substance Abuse and Mental Health Services Administration’s Child, Adolescent, and Family Branch added a comment
about certification and professionalization of family members and other adults who are connected with youth with lived experience. She noted that the Centers for Medicare & Medicaid Services had issued a memorandum 2 years previously urging states to fund these peer services. In addition, Youth Move (a national organization for youth with lived experience) has been developing criteria for youth certification. Rubenstein suggested that the organization needs to do a better job of communicating this work not only to make it accessible to families and youth, but also to encourage clinicians to view these youth as professionals and partner with them.
Paul Lee, a therapist from Pittsburgh, then asked how more African American men can be recruited into academic training as therapists to meet the needs of other African American men who have low comfort with traditional therapy and often cannot identify with white therapists. Hansen replied that this question raises the idea of the value of community participatory research and program development. These strategies, she said, democratize community expertise and can spur the development of mental health interventions and evidence-based practices that are tailored, through extensive consultation with community experts, to increase acceptability and comfort in context.
What Matters Most
Yang commented that Lee’s question had brought to mind the research he had presented on “what matters most.” He suggested that what might be important among African American male youth in some communities is the notion of masculinity and proving one’s manhood. Thus, he said, the messaging around engagement in therapy might promote that capacity instead of threatening it, which, he suggested, is what therapy basically does now.
Bruce Link then commented that at the level of structural stigma, the policies that matter most may be those that strike at the heart of what matters most. For LGBT communities and individuals, for example, he suggested that this might be marriage, which has influenced same-sex marriage laws. Hatzenbuehler added that laws that confer protection around employment, nondiscrimination, hate crimes, and antibullying protections in schools, and even same-sex marriage laws, tap into a broader notion of belongingness, inclusion, and feeling protected in one’s environment. Yang added that messaging focused on addressing stigma around mental illness should be based on more thorough and complex research that can yield understanding of the nuances involved, especially for the various communities the messaging is trying to reach, such as African Americans, Chinese groups, LGBT individuals, and many others.
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