Middle adolescence (corresponding to ages 14-18, when youth typically attend high school) is a potentially critical period for both the development of mental health conditions and targeting mental health stigma. Approximately 50% of all diagnosable mental health conditions develop in middle adolescence, and there is evidence that it is a crucial period for the crystallization of stigmatizing attitudes that can affect interactions with peers and discourage future help-seeking (see DeLuca, 2020, for a review). As a result, the past 5 years have seen increased interest in the importance of providing “mental health education” in schools to address stigma. In fact, following advocacy from the Mental Health Association in New York State, in 2018 the New York State Board of Regents mandated “school mental health education” in New York State schools to “help young people and their families and communities feel more comfortable seeking help” (http://www.nysed.gov/curriculum-instruction/mental-health).
Despite the growth of interest in addressing mental health literacy and stigma in middle adolescence, there is currently no standardized approach to addressing stigma in educational settings. As a result, it is possible that many schools will not offer any specific information that directly addresses negative stereotypes about mental illness and ways to be supportive toward peers who have been diagnosed. Further, it is unlikely that schools will incorporate the most consistently “evidence-based” approach to addressing stigma: contact with a person with lived experience of mental illness who is a both “local” (i.e., is reflective of the characteristics of the community being targeted) and “credible” (i.e., shares a relatable story about their experience with mental health conditions) (Corrigan, 2018). Identifying methods of bringing in “local” and “credible” contact experiences as part of mental health education is therefore essential. Ending the Silence (ETS), developed by the National Alliance on Mental Illness (NAMI), is freely available approach that shows promise as a stigma reduction initiative that is specifically targeted toward high school students (NAMI, 2015) and may therefore be considered as a viable option for New York State’s Mental Health Education initiative. ETS includes a 1-day, classroom-based presentation that lasts approximately 50 minutes, and includes an informational presentation and personal story from a trained presenter who is a young person with lived experience of mental illness, as well as time for discussion (see https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-Ending-the-Silence for more information on ETS).
Our own research aimed to determine if ETS showed evidence for addressing stigma in its many dimensions using the “gold standard” randomized controlled trial design. Prior to our research, Wahl, Rothman, Brister, and Thompson (2019) had conducted a study of ETS in five U.S. states, using a pre/post/follow-up (4 – 6 weeks) nonrandomized design, including a no intervention control group. They used an ETS survey rather than standardized measures of stigma. Their results indicated positive changes at the immediate follow-up for ETS, especially in being able to recognize the warning signs of mental health conditions, and knowledge of what to do to seek help if experiencing a mental health condition.
In our own research, we incorporated greater rigor by using a “cluster randomized controlled trial design” in which classrooms were assigned to ETS or an active control presentation on careers in psychology. We recruited a culturally diverse sample of 206 high school students in New York City. Students completed 4 surveys including validated measures of mental health stigma throughout the study (pre, immediate post-presentation, 4 weeks post, 8 weeks post). Prospective results (over 2 months) and qualitative feedback were analyzed. Analyses indicated significant effects in favor of the ETS group for reduced negative stereotypes, improved mental health knowledge, and less anticipated risk for disclosing to a counselor immediately following the intervention (these improvements decreased to some extent two months after the intervention, although they still remained superior to the control condition). There were also trends in favor of the ETS group for reductions in intended social distancing and negative affect, and improvements in help-seeking intentions. Qualitative feedback indicated positive impressions of ETS overall, but suggestions for more interactive activities and discussion.
Our study indicated that a relatively brief program such as ETS can be an effective way of reducing stigma among high school students, although there were some caveats. Although ETS participants showed clear reductions in negative stereotypes and mental health knowledge after the intervention, the fact that effects had dissipated 2 months later indicates that the intervention would benefit from a “booster” component, especially if formally incorporated into discussions with a teacher designated to facilitate mental health discussions. Regarding future work, NAMI has continued to expand the ETS program and now also offers ETS presentations specifically for parents and caregivers (e.g., https://namisouthdakota.org/support-and-education/presentations/nami-ending-the-silence) and school staff (e.g., https://naminycmetro.org/request-a-speaker/ending-the-silence/). Targeting individuals within a young person’s network is particularly important, given the high prevalence of mental health stigma among the general public and the influence that close adults can have on youth.
Furthermore, NAMI also now offers an online, self-paced version of ETS (https://ets.nami.org/), which is identical to the in-person talk in terms of lived experience videos and educational information. Based on prior research demonstrating the unique impact of in-person stigma reduction (e.g., Corrigan et al., 2012), it is likely that in-person ETS presentations are most powerful in reducing stigma and should be a “first-line” approach. However, the online version of ETS should certainly still be implemented if in-person presentations are not available or feasible.[1] Going forward, collaborations with diverse groups to design and implement culturally-sensitive programming will also be imperative.
In sum, adolescent mental health is a pressing issue and stigma remains common. Rates of mental health problems among youth were already on the rise pre-pandemic, and the pandemic has only exacerbated this trend. Programs such as NAMI’s ETS can help to start important conversations around mental health, reduce stigma, encourage help-seeking, and subsequently improve community inclusion and quality of life among young people living with mental health concerns. Complementary approaches to sustain such work—and foster adolescents’ autonomy and inclusion in such work—may include NAMI on Campus clubs in high schools and colleges (e.g., https://namica.org/nchs/), groups that typically provide outreach and host events. Overall, stigma, at its root, is a social problem and continued, multipronged efforts will be needed to tackle it.
Joseph S. DeLuca, PhD, is an Assistant Professor in the Department of Psychological and Brain Sciences at Fairfield University. He is also an Assistant Clinical Professor (voluntary track) at the Icahn School of Medicine at Mount Sinai, primarily working in the Psychosis Risk Program. Dr. DeLuca is a licensed psychologist with expertise in youth mental health, serious mental illness, and stigma. His research is aimed at understanding intersectional stigma and addressing equity issues in services for youth with psychosis-spectrum experiences, as well as targeting public stigma toward various minoritized groups. You may reach Dr. DeLuca at jdeluca@fairfield.edu.
Philip T. Yanos, Ph.D., is a professor of psychology at John Jay College and the Graduate Center, City University of New York. A researcher who focuses on stigma and how it interferes with recovery among people diagnosed with mental illnesses, he is the author of Written Off: Mental Health Stigma and the Loss of Human Potential (Cambridge University Press, 2018) and associate editor for the journal Stigma and Health. He is the co-developer of Narrative Enhancement and Cognitive Therapy, a group-based treatment which addresses the effects of self-stigma among people diagnosed with mental illnesses that has been translated into several languages. He is the author of more than 100 articles and book chapters and has been principal investigator on several federally-funded research projects. You may reach Dr. Yanos at pyanos@jjay.cuny.edu.
References
Corrigan, P. W. (2018). The stigma effect: Unintended consequences of mental health campaigns. New York: Columbia University Press.
Corrigan, P. W., Morris, S. B., Michaels, P. J., Rafacz, J. D., & Rüsch, N. (2012). Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatric Services, 63(10), 963-973.
DeLuca, J. S. (2020). Conceptualizing adolescent mental illness stigma: Youth stigma development and stigma reduction programs. Adolescent Research Review, 5, 153–171. http://dx.doi.org/10.1007/s40894-018-0106-3
DeLuca, J. S., Tang, J., Zoubaa, S., Dial, B., & Yanos, P. T. (2021). Reducing stigma in high school students: A cluster randomized controlled trial of the National Alliance on Mental Illness’ Ending the Silence intervention. Stigma and Health, 6, 228-242.
Wahl, O., Rothman, J., Brister, T., & Thompson, C. (2019). Changing student attitudes about mental health conditions: NAMI ending the silence. Stigma and Health, 4, 188 –195. https://psycnet.apa.org/doiLanding?doi=10.1037%2Fsah0000135
Note. NAMI offers an adult version of ETS, “In Our Own Voice,” which can be shown on college campuses, etc. (https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-In-Our-Own-Voice)
