1. WISE BASICS: Increasing Inclusion, Hope and Support
WISE offers insights, resources and support for stigma reduction by organizations
Welcome audience and thank them for inviting you to share the information that has motivated people from across the state to work together to increase inclusion, hope and support for those facing mental health and substance abuse challenges. Invite participants to consider what their experience has taught them about stigma and what the research presented might mean for their own work to reduce stigma.
WISE BASICS:
Increasing Inclusion, Hope and Support
Reversing the Stigma of Mental Illness

2. 1 in 4 47% in our lifetime They are us! schizophrenia
Drug and alcohol abuse
Depression
1 in 4
47% in our lifetime
trauma
eating disorders
Just a simple statistical reminder of why we dedicate ourselves to the reduction of the oppression related to mental illness. 1 in 4 in any given year will experience mental illness or substance use disorders. The CDC data is that 47% of people will have a diagnosable mental illness in their lifetime. It this is not about your personal experience of mental health challenges, it may be in the future or you may relate to it as a family member or friend. So how does stigma play a role in these numbers?
More recently the CDC reports 1 in 5 in a given year….

3. Stigma Definition Stereotype-ideas Prejudice-beliefs
Discrimination-actions
Types
Internalized Stigma
Public
Structural
Stigma can be described with three words- stereotypes (ideas), that lead to prejudice (beliefs), that leads to discrimination (action). In the context of a power differential, this is oppression. One might argue that there is a power differential in most relationships so we might simply say oppression instead of stigma.
It comes in the form of public, internalized shame for those experiencing mental health challenges, and structural (policies and processes that reinforce discrimination) stigma.

4. Stigmatizing Ideas and Beliefs
Sumi
Stereotypes- Ideas
People with mental health challenges are incapable, fragile, dangerous, cannot recover
Charles
Mark
Val
Prejudice- Beliefs
They are less than.
Linda and Nneka
Reflection questions for the audience:
At age 34, Mark was living under a bridge in the throes of alcohol addiction. What ideas about someone who is actively addicted and homeless do you carry? Where did these ideas come from?
Mike was driving home from work one evening and was pulled over for speeding. He was angry at himself for speeding. When the officer got to the window to speak with Mike, he noticed Mike’s hand jerking and asked if he was on medications. Mike said, “yes.” He told the officer that he had taken his medications that morning and that he was fine. The officer then asked what he takes medications for and Mike told him Schizo-Affective Disorder. At that point the officer stepped back and used his radio. Mike heard him say, “I need back up, I have a schizo here.” A second car arrived and with lights flashing, both police cars followed Mike to his home. Mike lived with his parents at the time and his mother was furious at this treatment. She went to the station the next morning and talked with the officer. He apologized and admitted to ignorance about mental illness. Mike’s mom was challenging the stereotype that was driving this officers discriminatory behavior.
Here you may wish to show videos located at RogersInHealth.org. As you show videos, consider the following questions:
What forms of stigma do you hear being reported?
What “gut” reactions did you have to the people/person sharing his/her/their story? What biases, if any, did you notice in yourself?
How might you expose yourself to experiences that will alter such biases? How do you monitor and uncover your own bias?
How do you suppose stigma may impact the people/person sharing his/her/their story from receiving support/treatment/services?
. What level of hope do they have around their illness? Can you share realistic hope? Do you know enough about recovery to share hope? What are your past experiences with mental illness and recovery?

5. Discrimination - Social
Stigmatizing Actions
Discrimination - Social
I don’t want them to live next door, be a co-worker, marry into my family
Paul
Discrimination - Structural
Institutional, organizational, governmental limits to:
-availability
-accessibility
-acceptability
Pastor Tim
Take a moment to reflect on how you have seen stereotypes and prejudice drive actions that are discriminatory.
Social examples: from slide
Structural examples: from slide
Denise faced both social and structural when she needed residential treatment for her eating disorder and her insurance refused to pay for it even thought the medical professionals on her treatment team felt her life was in danger without it. While Denise was in treatment, her family scraped together all they had and she found out that her church was doing a fundrasier to support her care. She was mortified that this illness that she felt shame for having was exposed.
Paul is a therapist who had a traumatic brain injury and left him in need of psychological services. His story of recovery includes a profound understanding of how stigma played out in his own health care. Paul is a better therapist as he takes this empathy into his work.
Pastor Tim attempted suicide in his college years and found support for his recovery in hi home church family. He now works within the faith community and provides pastoral leadership to increase understanding of mental illness and decrease the stigmatizing ideas, beliefs and actions particular to the religious sector.
WISE has two main focus areas- eliminating public stigma and self-stigma…
Here you may wish to show videos located at RogersInHealth.org – see previous slide for probing questions.
Denise

6. Avoidance, anger, apathy
Self and Public Stigma
I am not good
Self Esteem
I am unable
Efficacy
Public Stigma
Internalized shame is another way to refer to self-stigma and perhaps says it better.
Walk through the slide click by click. Last click is just the last arrow showing the cycle feeding upon itself.
Once again, when we explore what works to reduce stigma, you will see how reducing discriminatory behaviors and reducing internalized shame rely on the same approach.
Potential questions for audience:
1) How do you suppose internalized stigma or shame may impact people’s willingness to access support/care/treatment/services?
2) Since self-stigma usually comes from public stigma, what are some common or frequently occurring forms of self-limiting/hurtful self-beliefs? (e.g., I’ll never recovery, I’m a bad person). Note to facilitator: you can make this question generally applicable to mental health (e.g., I’ll never recover) or specific to issues you and your audience are focused on (e.g., for dual-diagnosis – I’ll always be an addict; for suicidality – I am a burden; for males with depression – Men never cry….)
Why try?
Avoidance, anger, apathy

7. OPPRESSION ALL IS CONNECTED Sexism Racism Heterosexism Ableism Ageism
Etc.
People are multi-dimensional and sometimes face stereotypes, prejudices and discrimination from more than one angle.
(YRBS= Youth Risk Behavior Survey, a national survey of youth about various health topics administered in high schools.)
Ask the audience if they have examples of co-occurring stigma.
Rogers InHealth website has a story of a woman, Debbie, who found her mental health recovery once she was able to step proudly into her identity as a person who is deaf.
Potential question for audience:
1) What are some ways that you see mental health stigma intersecting with other facets of identity in your community/region?

8. but isn’t it better lately?
Some of these images come from decades ago. Haven’t beliefs and behaviors improved
OK,
but isn’t it better lately?

9. The Ongoing Impact of Stigma
Worse healthcare
Lost employment
Sub-par housing
Diminished education opportunities
Alienated from faith community
These categories come from research with people who have a lived experience of mental illness. They report oppressive behaviors by people in these sectors as deterrents to their recovery. What one thinks about a person cannot be known for sure. One’s actions are concrete and observable. Regardless of intention, when the outcome of an action is a deterrent to another’s rights, we have a responsibility to bring that to the light and work together to create a positive communal response.
For example, for employment:
Past research has shown that most people with serious mental disorders are willing and able to work. [8,13] Yet, their unemployment rates remain inordinately high. For example, large-scale population surveys have consistently estimated the unemployment rate among people with mental disorders to be three to five times higher than their nondisabled counterparts. Sixty-one percent of working age adults with mental health disabilities are outside of the labor force, compared with only 20% of working-age adults in the general population. [14*] Unemployment rates also vary by diagnostic group from 40 to 60% for people reporting a major depressive disorder to 20-35% for those reporting an anxiety disorder. Unemployment rates for people with serious and persistent psychiatric disabilities (such as schizophrenia) are the highest, typically 80-90%. [15] As a result, people with serious mental disabilities constitute one of the largest groups of social security recipients. [16*,17**]
Oppression of people with mental illness in the work place is a deterrent to an individual’s recovery and to our community having access to valuable human input by those with mental health challenges. WISE works with organizations to implement effective practices to reduce workplace stigma.
Potential question for audience:
1) How do you see stigma manifest in your communities?

10. What Changes Stigma? Is education the best approach?
Patrick Corrigan, PhD – an international stigma researcher
Education, advocacy and contact are the ways people have tried to decrease stigma.
We will look at what research tells us about the impact on stigma.

11. Results from a Meta-analysis
Does Stigma Decrease as Knowledge Increases?
Knowledge: Causes of Mental Illness
Stigma: Acceptance
A meta-analysis is when a research team looks at many recent research outcomes from studies about a common theme to discover patterns in the outcomes. In this case, they looked for research on how knowing more about mental illness would impact the stigma of mental illness. The thought was that if someone knows more about mental illness and the causes (biologic and genetic), they will be more likely to accept a person with a mental illness in their home, community and workplace.
Source: Schomerus, Schwann, Holzinger, Corrigan, Grabe, Carta, & Angermeyer, 2011

12. Meta-analysis: Brain Disease as CAUSE
In the time period from 1990 to 2006, the general population improved their knowledge that mental illness is a brain disease. Same is true for the fact that it can be genetic. (the researchers looked at research related to depression and schizophrenia)
So, how did this impact stigma?

13. Meta-analysis: ACCEPTANCE of neighbor
Yet, in that same time acceptance of someone with schizophrenia got worse and depression did not improve. The same holds true for co-worker acceptance.

14. Hear their stories on Rogersinhealth.org
The Contact Approach
“I’d like you to meet Mark, Simone, Rosa, Linda, Nneka, Charles, Paul, Val, Dori, Sumi, and Denise.”
This is the third option organizations have tried to reduce the stigma of mental illness- CONTACT.
These are all people who have faced mental health and substance use disorder challenges and share their stories of living in recovery on the Rogers InHealth website. (You may find Paul’s story helpful from the health care provider perspective. He is a therapist who had to seek therapeutic care after a brain injury.)
(Choose one or two of the stories to summarize, someone likely to appeal to the audience. Find the full stories at rogersinhealth.org. You can copy/paste the picture from this slide to the next slide of the person whose story you will summarize in the next two slides.)
Hear their stories on Rogersinhealth.org

15. Resilience and Recovery
Resilience- the capacity of children and adults to succeed and thrive, despite experiencing trauma, mental illness and/or addiction.
Recovery- A process of change through which people improve their health and wellbeing, live a self-directed life, and strive to achieve their full potential.
Four dimensions of recovery (from SAMHSA):
My Health
A safe and supportive Home
A sense of Purpose in my life
Belonging to Community
When we use the term recovery, we are talking about it from a broader definition than you may be familiar with. We are talking about a full life and full inclusion!
So let’s look deeper at what research says about how well contact with people living in recovery with a mental illness or addiction works to reduce stigma.
Potential questions for audience:
How have these facets of recovery operated in your own life or the life of those you serve?
How can you connect with your reasons for being in your profession?
As a professional, how do you make decisions about if and how to disclose your own experiences with mental health challenges?
How can you act as an agent of change to reduce stigma in the environment in which you work?

16. Contact vs Education: AVOIDANCE
Corrigan, P.W., Rowan, D., Green, A., Lundin, R., River, P., Uphoff-Wasowski, K., White, K., & Kubiak, M.A. (2002). Challenging two mental illness stigmas: Personal responsibility and dangerousness. Schizophrenia Bulletin, 28,
Education groups received education on either 1) dangerousness: presenting the myths about people with mental illness being unpredictable or violent and the facts that contradict those myths. Or
2) responsibility presenting the myths about people with mental illness being to blame for their disorder contrasted to the facts about biological factors such as genetics and brain disorders.
The contact groups were people presenting their story of mental illness and life in recovery that either included a focus on 1) their non-violent behaviors or 2) the genetic connection for their illness.
You can see that people expressed less need to avoid someone with mental illness after the education and the contact experiences- with contact having a greater impact.
Source: Corrigan et al., 2002

17. Education vs Contact over time
What surprised the researchers was the one-month follow-up responses. Those who took part in the education groups showed an increase in their avoidance attitudes from the initial pretest!
What might have occurred to cause this “rebound” in the education groups? (the group will name media attention to violent crimes, etc.)
Why didn’t the contact group also have a rebound then? (take ideas)
Point to the fact that the brain makes deepest learning connections when the emotions are involved. Media is good at making us FEEL fear and hopelessness. The real stories of resilient people living lives of recovery with mental health challenges tap into our emotions AND our reason to provide the deeper pathways of learning.
CONTACT WORKS.

18. Goal? TLC4 Up to Me (a HOP program) Safe Person - Seven Promises
CAREFULLY create environments where all can speak up
TLC4
stigma reduction
Up to Me (a HOP program)
strategic disclosure
Safe Person - Seven Promises
supportive listening
Compassion Resilience
caregivers and providers
So the grand plan to eliminate stigma is … (read slide)
If getting to know someone living in recovery with a mental health challenge is the key to eliminating stigma then we must first and foremost consider how to support those with a story to share. WISE programs are designed with this in mind:
WISE Basics with the introduction of the TLC4 planning guide introduces people to what works to reduce stigma and provides some structure to their planning.
When you look at what works to reduce stigma, it is the connections that are made when stories of challenge and resilience are shared. For that to happen, we need 2 things: people who are able and ready to share their story for the purpose of stigma reduction and people who are able to listen.
Up to Me (formally HOP) is a decision making model for people to use as they consider if and when they will share aspects of their story – for multiple purposes from receiving support to reversing stigma. It is an important precursor to a stigma campaign so that we are more sure that the people who choose to share their stories have been supported in making that decision carefully.
Safe Person decal and the 7 Promises are a brief way to both help people to identify themselves as someone who wants to be a safe person for listening and support and also to promote just what being a safe person looks like.
Compassion resilience is for the helping professionals and caregivers who want to be stigma free and compassionate but often are overwhelmed with their efforts and do not realize the toll it takes on them and their ability to be compassionate to those they serve and care for.

19. TLC4 Targeted Local Credible Continuous Change-focused Contact
The model is known as the TLC4 model. As supported by research on stigma, the foundation of this framework is a belief that it is through meaningful contact with people who can share their stories of challenge, recovery, and hope that we can best eliminate stigma.

20. Who Should the TARGETS Be?
community, healthcare, government
home, work, school
individual
When you ask people who experience the stigma, they point to these sectors of our communities as where they have encountered stigma. While this list represents the priority sectors to focus stigma reduction efforts, your organization may have information about the experience of stigma in your community that points to a different target group.
Potential question for audience:
1) Who do you think ought to be the targets of our local/regional efforts and why? How do we determine the targets of focus?

21. Does it play in your environment?
What is LOCAL Contact?
Does it play in your environment?
Stigma reduction works best if it is designed locally to meet the characteristics of the local community.
Potential questions for audience:
What are potential local strengths to leverage/consider in this work?
What is unique about our local needs and capacity to influence change?

22. What is CREDIBLE Contact?
Contact with peer
Example-
Nurse to nurse
Pastor to pastor
Athlete to Athlete
We take in information and integrate it into our thinking, beliefs and behaviors most readily when it comes from someone we consider a peer- someone like us- who understands us and our lives.
Credible does NOT mean famous.
A Packer player talking about his experience of mental health challenges has less of an impact than someone like you.
You can see that the peer-support programs in our state are crucial to a cultural transformation around mental healthcare and self and public stigma.
Potential question for audience:
1) How do we determine who/what would be deemed credible among our target audience?

23. CONTINUOUS Contact Once is not enough And variety is needed
WISE can help with examples from around the state of diverse and multiple activities organizations include in their stigma reduction efforts over longer terms than the one-time event. This is about a culture shift and that takes dedication over a longer period of time.
Potential question for audience:
1) How will we ensure sustainability of efforts moving forward?

24. CHANGE-FOCUSED Contact
What do you want the target group to do differently as a result of the contact?
For example, you may want faith groups to consider hosting support groups as a sign that they do not discriminate against people with mental health or substance abuse challenges. In that case, you would want story tellers who can talk about the role of support groups in their recovery. For one community that targeted civic organizations and know that they had very little time with them, their goal was to have members of those civic groups invite them to their places of work and worship to share more stories and engage people at a deeper level. The story tellers told about the role that their congregation or work place played in their illness and recovery.
Potential question for audience:
1) Can you think of a change you would like to see in a particular group and a story that might engage that conversation?

25. TLC4
Targeted – to particular groups or settings where people have encountered stigma
Local – culture should drive program adaptations
Contact – with people who live it!
Credible – contact with someone who is similar to us
Change-focused – determine what you want the targeted group to do differently
Continuous – contact with a variety of people over time establishes a wide base for the shift
Potential question for audience:
1) How does this framework help narrow/mold/inform our scope and provide us with direction?

26. Reversing Self and Public Stigma
Inclusion and Self Directed Support
I am good
Self Esteem
I am able
Efficacy
Public Stigma
To put it visually…
I care for myself
and others
Motivated engagement

27. What YOU Can Do Today
Maintain recovery perspective on a daily basis- proactively seek out stories.
Reinforce & support resilience & recovery in others.
Create curiosity - be prepared to speak up.
Consider the story you can tell about recovery
Bring the conversation to your community – work, civic, faith, schools.
Go through slide regarding what individuals can do
Mini- TLC4 to identify group to credible contact, credible voices, continuous contact, change focused content, etc.

28. The WISE Approach Up to Me (a HOP program)
To reach our shared goal of increasing inclusion and support, learn about the other three prongs of the WISE approach at WISEWisconsin.org.
 TLC4
Stigma reduction
Up to Me (a HOP program)
strategic disclosure
Safe Person - Seven Promises
supportive listening
Compassion Resilience
caregivers and providers
handout the WISE One Page Description on how and why organizations would want to work with WISE.

29. Thanks for the work you do!
To request resources and/or facilitator training,
What thoughts/reactions do you have on what heard today and what all this might mean for your organization?