In the Summer 2022 edition of Behavioral Health News, my colleague, Jayden Carr, BS, and I wrote an article reviewing the most common forms of stigmatization and their negative effects on people with mental illness and substance use disorders (MI/SUD). The term “stigmatization” rather than “stigma” is used because stigma focuses on and views the person(s) experiencing the discrimination as tainted, while addressing stigmatization focuses on dismantling the harmful behavior of the perpetrator(s) of discrimination (Bowleg, 2022). The article highlights the importance of acknowledging the social injustices that can create and maintain both MI/SUD stigmatization and the inequities in accessing and receiving treatment for MI/SUD (Shim & Vinson, 2021). Three years later, it remains crucial to address stigmatization through an intersectional lens. Recent data (NYC Epi Data Brief, 2024) show that while overdose deaths decreased among White New Yorkers, they continued to increase among Black residents of New York and remain high among Latinx individuals. Rates of overdose deaths also differ by gender, as indicated by a decrease in men’s overdose death rate and an increase in women’s deaths (no data was available on non-binary or intersex New Yorkers). Among adults in NYC, those who identify as lesbian, gay, or bisexual report more psychological distress than straight individuals and people who identify as non-binary, transgender, or another gender identity are two- to three- times more likely to report psychological distress than cisgender New Yorkers (NYC Epi Data Brief, 2025). This underscores the need for organizations to intentionally attend to LGBTQ+-affirming care.
From my work with health care agencies and hospitals over the past decade, what I perceive to be the biggest barrier to addressing stigmatization that causes health inequities is resistance to implementing current best practices for dismantling structural stigmatization. The Mental Health Commission of Canada (MHCC) (2023) has an excellent implementation guide that includes a summary of the key principles for dismantling structural stigmatization. These research-backed principles include acknowledging the intersectional nature of structural stigmatization; avoiding performative actions and tokenism; modeling change from within to spread influence; centering the voices of people with lived experience; embedding change and sustainable results via policy and ongoing training; and redistributing power relationships. There are three additional key principles in the guide that I suggest organizations reflect upon first as they consider strategies to effectively address stigmatization:
- Get Explicit Support From Senior Leadership
Effectively dismantling stigmatization requires commitment from leadership and a multi-level approach (Knaak et al., 2017) because, as Sievwright et al. (2022) state, “systems of power perpetuate intersectional stigma.” This difficult work of addressing institutional and policy-level stigmatization requires organizations to assess connections between identity, experiences, and systems of power among staff, recipients of services, and community members (Rehman et al., 2023). A lack of ongoing involvement and commitment from leadership prevents this process from happening. Freyd’s work researching institutional courage (2022) – “an institution’s commitment to seek the truth and engage in moral action, despite unpleasantness, risk, and short-term cost,” – emphasizes the importance of including leadership in efforts to educate the organization on the need to “transform institutions into more accountable, equitable, effective places for everyone.” I’ve seen organizations effectively involve leadership in a variety of ways, including:
- leadership attendance at trainings about stigmatization (this allows them to learn about best practices for reducing stigmatization and signals to employees the importance of the topic),
- the CEO attending all onboarding for new employees and discussing the agency’s commitment to providing an equity-driven workplace and services,
- adding an ongoing agenda item related to stigmatization at executive meetings, and
- including the board of directors in these efforts (sharing outcomes related to destigmatization work with them and inviting them to trainings).
- Evaluate Outcomes Through Monitoring and Measurement
Validated self-stigma assessments should be used with clients/patients, and stigma assessments and interventions should be included throughout clinical treatment and programming (O’Toole et al., 2016). It is also important to assess staff members to identify which types of stigmatizations are most in need of addressing and to track the effectiveness over time of the new interventions and policy changes (Modgill et al., 2014). Several of the validated assessments I use with sites are available at the NYS Office of Mental Health (OMH)-funded website. A limitation of most stigma assessments is that they only measure attitudes, so I also encourage the ongoing use of assessment tools that provide ways to track behaviors related to organizations’ responses to reports of intersectional forms of stigmatization (The Center for Institutional Courage has several of those assessment tools that can be accessed). I’ve also seen organizations add specific questions about experiencing discrimination to their quarterly client/patient surveys, which is an easy way to get behavioral feedback related to staff. Regardless of what outcome measures are tracked, sharing the results with staff, service recipients, and the community is an excellent way to show that an organization is committed to transparency and accountability.
- Grow Through Tension and Dissonance
Organizations working on the structural and clinical changes needed to address stigmatization must plan for resistance and backlash because it will happen. Sukhera & Knaak’s research (2022) emphasizes that dismantling structural stigmatization is “only possible through interventions that were accepting of, and proactively managed disruption as part of their intervention.” What causes pushback? The MHCC (2023) states, “In many cases, resistance comes from people in power who feel unmoored or even threatened when their perspectives are no longer the top (or only) priority,” and emphasize that it is important to acknowledge that this response makes sense and then “work to support those people through conversations rooted in empathy and curiosity.” One community mental health center I worked with that was very successful in addressing structural stigmatization started the process with an email from their CEO to all staff. The message explained the need for change, how certain outcomes would be tracked, and it included a link to an anonymous survey asking for feedback about the topic and any concerns or suggestions staff had for the upcoming changes. We got over a 90% response rate from 300 staff members and were able to share the results with the staff. That data helped guide much-needed discussions about potential changes and helped to identify specific training needs for the organization.
Continuing This Work in Challenging Times
Last week, I attended a conference addressing strategies for embracing change related to mental health and substance use services in New York in challenging times. Both the directors of Office of Addiction Services and Supports (OASAS) and the Office of Mental Health (OMH) presented at the conference and made themselves available to answer questions about their strategic plans and guiding principles. They embodied several of the key principles to dismantling structural stigmatization described above: leadership guiding change talk, discussion of strategies for evaluation of strategic plan goals (e.g. OASAS goal of reducing racism and stigma surrounding substance use disorder) and responding to the current challenges related to new federal-level policies that may cause conflict with state-level policies. I left the conference feeling more hopeful about this work than I had in several months precisely because it felt like the content of the day was driven by the key principles needed to dismantle the practices and policies that cause harm to New Yorkers who experience MI/SUD, to those who care about them, and sometimes to those of us who provide services in health care settings. It is my hope that these principles will be embraced by all healthcare leadership in the diverse communities of New York and result in equitable care for anyone in need of services.
Gretchen Grappone (she/her), LICSW, is a New York City–based training consultant and can be reached at grappone@ggrappone.org.
References
Bowleg, L. (2022). The Problem with Intersectional Stigma and HIV Equity Research, American Journal of Public Health, 112, S4, S344-S346.
Freyd, J. (2022). Center for Institutional Courage institutionalcourage.org
Grappone, G. & Carr, J. (2022). Acknowledging the effects of intersectional stigmatization. Behavioral Health News, Vol. 10, Number 1, 33.
Mental Health Commission of Canada. (2023). Dismantling structural stigma in health care. An implementation guide to making real change for and with people living with mental health problems or illnesses and/or substance use concerns. Ottawa, Canada. https://mentalhealthcommission.ca/wp-content/uploads/2023/12/MHCC_22-187_DSS_report_e_ACC.pdf
Modgill, G., et al. (2014). Opening Minds Stigma Scale for Health Care Providers (OMS-HC): examination of psychometric properties and responsiveness. BMC Psychiatry, 14, 1-10.
NYC Epi Data Brief (October, 2024): nyc.gov/assets/doh/downloads/pdf/epi/databrief142.pdf
NYC Epi Data Brief (March, 2025): nyc.gov/assets/doh/downloads/pdf/epi/databrief145.pdf
O’Toole, T., et al. (2016). The Veterans Health Administration’s “Homeless Patient Aligned Care Team” Program. Preventing Chronic Disease, 13:150567.
Shim, R. S., & Vinson, S. Y. (2021). Social (in)justice and mental health. First edition. Washington, DC: American Psychiatric Association Publishing.
Sievwright, K. et al., (2022). An Expanded Definition of Intersectional Stigma for Public Health Research and Praxis. Am J Public Health, 112: S356-S361.
Sukhera, J. & Knaak, S. (2022). A realist review of interventions to dismantle mental health and substance use-related structural stigma in healthcare settings. SSM – Mental Health. 2. sciencedirect.com/science/article/pii/S2666560322001104.
