Structural Stigma: The Next Frontier for Stigma Research

​By Dr. Stephanie Knaak
​Journal of Mental Health and Addiction Nursing

Stigmatization towards mental illnesses and addictions is a problem with deep roots and slow solutions. For the last seven years, I have worked closely with the Mental Health Commission of Canada in a research consultant capacity, conducting evaluation projects and other research on how to address this problem, mostly as it pertains to healthcare environments. Through this work, I’ve come to believe that to truly tackle the problem of mental illness and addictions-related stigmatization within healthcare, it needs to be addressed at all levels and throughout all sectors of healthcare. Also, it needs to be understood first and foremost as a structural issue – as something that is embedded into the very fabric and culture of healthcare institutions. 

In Canada, we’ve learned much over the years about what contributes to and feeds stigma in healthcare environments, what evidence-based techniques and approaches exist to reduce stigma, why some interventions work better than others, and we’ve identified many ‘success-promoting’ strategies for planning, implementing and sustaining stigma reduction messaging and programming. While this research has certainly moved us positively along the stigma reduction path, it gets us only so far. This is because much of the academic and practical work directed towards stigma reduction in healthcare has to date, been focussed mainly at the level of public stigma – i.e., at the level of health providers themselves.

Measuring stigma reduction at the level of individual providers is important, yes, and this gives us valuable tools and interventions for improving attitudes, beliefs, and even behaviours. But it’s not enough. Indeed, most health providers are caring and compassionate professionals doing the best they can in a systemic environment that is, at its core, inherently inequitable towards people with mental health and/or addiction-related problems. In other words, stigma exists in the system itself -- in cultural norms and beliefs (e.g., ‘they don’t really belong here, there’s nothing we can do anyway,’ they are hard to work with), in inequitable and sometimes punitive policies and practices that negatively impact and constrain the quality of care provided to people with mental illnesses and addictions.

Thus, a need to focus on stigma as a structural problem. Tackling stigma at a system level means many things. It means examining equity of care and resource distribution – e.g., equity of access, equity of availability, and acceptability of care and services – as well as applying a stigma-informed critical lens to both formal and informal policies and practices. It also means directing attention at the level of healthcare culture, and in measuring change at that level. This will require us to think not only about interventions themselves, but making sure to place equal emphasis on implementation considerations – i.e., understanding how programs, policy changes, and other interventions can be delivered and implemented in such a way that culture change may be mobilized.

We can draw some preliminary lessons from recent research conducted with police organizations. The research to which I refer was a qualitative examination of organizational context as it pertained to the implementation of a workplace mental health and stigma reduction program called The Working Mind – First Responder in police organizations in Canada. What we learned from this research was that moving towards cultural change was indeed possible, but that there were key organizational and implementation factors that had to be in place. In this study, a central theme called ‘successful cultural uptake’ emerged as key to the program’s ability to facilitate broader culture change. ‘Successful cultural uptake’, in turn, was facilitated by a number of key organizational and implementation factors -- organizational readiness, strong leadership support, ensuring good group dynamics, the credibility of the trainers, implementing widely and thoroughly, and implementing the program as only one piece of a larger puzzle. With these organizational and implementation factors in place, successful cultural uptake could be achieved, creating movement towards broader cultural change within the organization – which in this case was described as a less stigmatizing and more supportive workplace culture, and organizational momentum for additional mental health programming and policy initiatives.

Applying a similar lens to healthcare contexts will be an important next step. It, along with the development of tools and guidelines for tackling mental illness and addictions-related stigma in healthcare, and working closely with various healthcare partners in implementing and evaluating initiatives with this focus in mind, is a key part of the Mental Health Commission of Canada’s work over the coming years, and it is research I feel proud to be involved with. Anyone interested in learning more, or in discussing partnership opportunities, should feel free to contact me at sknaak@mentalhealthcommission.ca

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Journal of Mental Health and Addiction Nursing editorial board member Dr. Stephanie Knaak holds a Ph.D. in Sociology from the University of Alberta, and is currently a Research Associate with Opening Minds at the Mental Health Commission of Canada. Dr Knaak specializes in research on mental illness stigma, including research on key ingredients and best practices associated with combatting stigma in health care environments and among youth.
Read more about Dr. Knaak here.