6

Setting the Stage

The Workshop on Opportunities and Strategies to Promote Behavior Change in Behavioral Health opened with a keynote address delivered by Alan Leshner, chief executive officer emeritus, American Association for the Advancement of Science. He laid the foundation for his presentation by stating that negative behavioral social norms (i.e., stigma) have been a major issue for at least 75 years and still remain one of the largest problems facing the field of mental and addictive disorders. He asserted that stigma requires a new set of approaches based on scientific evidence. Stigma is pervasive at multiple levels, he said, hinders identification and diagnosis of people with the disorders, and delays entry into and reduces persistence in treatment because of the associated shame. It also decreases the availability and support of treatment, slows recovery, and interferes with individuals’ full integration into the community. Not only are people with mental illness and addictive disorders stigmatized, Leshner noted, but so are their families and caregivers, professionals, and researchers who study them.

Leshner elaborated on several factors that lead to stigma and need attention:

• There is gross misunderstanding of the causes and nature of mental illnesses.
• Sometimes there is even a lack of belief in these illnesses.
• Individuals with mental illness and substance use disorder often behave strangely.
• Occasional crime and violence on the part of people with mental illness and substance use disorder engender fear and anger.

• These illnesses impose a societal burden.
• Many believe that patients will never really recover.

Regarding the quality of treatment today, Leshner said it is good but not great, and needs to be improved.

Leshner asked how can science help. Attitudes, behaviors, and social norms are changeable, he argued, and can be studied and evaluated. Successes have been achieved in addressing blood pressure, tobacco use, drunk driving, and HIV/AIDS, he observed, and the March workshop hosted by the Committee on the Science of Changing Behavioral Health Social Norms summarized in Part I of this volume provided examples of successes and lessons learned in the area of behavioral health.

However, Leshner emphasized that changes in social norms will not result from science alone, education alone, or increased understanding of the problem of brain diseases alone. Appropriate social and health policies need to accompany efforts to change social norms. Further, a targeted form of applied science is needed in which the central questions are what works, for whom, and under what circumstances. In particular, he argued, researchers need to be specific about the problem to be addressed; the attitudes and behaviors to be changed; and whom to change—individuals with the illness, the general public, sectors of the public such as employers, school personnel, or rental agents. There are many different players, he observed, and no one intervention is going to affect all of them.

To answer these questions, Leshner said, the nature of mental illnesses and their complexities need to be acknowledged and addressed. For example, it is important to admit that much remains unknown about the causes and etiology, or the pathophysiology, of mental illnesses and addictive disorders. It is known that these illnesses and disorders are biological at their core, but the complex nature of biological, behavioral, and social components at the individual, family, peer, and community levels must all be addressed. Adding to the complexity, he noted, is the interrelatedness of such social problems as delinquency, academic failure, runaways, unwanted pregnancies, suicidal behavior, and drug/alcohol-related traffic accidents.

According to Leshner, other key areas to be studied are what makes the stigma of mental and addictive disorders so intransigent, why the strategies of the past were not successful, and what other successful behavior or norm change efforts have accomplished that might be adapted and/or copied. He stressed as well that initiatives and strategies to change social norms around mental illness and substance abuse will be as complex as the interventions used to treat the actual disorders. When new strategies to change social norms are tried, he asserted, every funded intervention should have an evaluation/research component with clear and precise outcome measures. He argued that process evaluation is not enough and suggested that compil-

ing accumulated results from multiple efforts will lead to sets of effective principles and practices.

Leshner closed with some thoughts on the state of science in the United States today. He noted tensions at the intersection of society and science that stem from multiple factors, such as lack of understanding, tarnished image of/lack of trust in science, political or economic inconvenience, conflicts with popular or peer group beliefs, and conflicts with core societal values and beliefs. He suggested that the tense climate may influence the science that is conducted and that research on stigma will likely confront all of these tensions. Therefore, he urged the audience to recognize and acknowledge the partial truths and truths that overlay this field, to think about the complexity of the issue, and not to look for simple solutions. He underscored that the strategy employed must be as complex as the problem to be addressed, and that it is important to be extremely specific about interventions and their outcomes. Finally, he reiterated that campaigns should not be mounted without evaluation components.

In a brief discussion period, one audience member commented that change in social norms often appears to come from many strategies that build into social movements. This speaker suggested the need to think more about how to feed such movements to change the respective social norms.

Another audience member referred to the challenges of obtaining funding to conduct the comprehensive research Leshner had suggested in his talk and asked him how to fight that battle. In reply, Leshner suggested that researchers give funders results. Because treatments are not perfect and because people often are not restored to full functioning for the rest of their lives with no problems, he said, it is extremely difficult to convince society and funders that researchers know what they are doing. He added that the truth is that a very large number of people are helped, and the research community needs to find a way to tell that story.

Reflecting on work in the addiction field, another audience member called attention to issues related to how professionals in mental health and addiction treat each other and how inappropriate language (e.g., referring to people “bombing out of treatment” and “dirty drugs screens”) is used even among professionals. This same audience member also expressed concern about the challenges faced by providers in getting reimbursed for effective and evidence-based treatments and wondered whether this stems from stigma or discrimination. Leshner suggested that the burden is on people in the field to examine their thinking, acknowledge the limitations of treatments, and find a way to understand the concerns in order to move the field to accept the evidence and fund new treatments.

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