Empowerment, Disclosure, Group Identification: Reducing Self-Stigma, Discrimination and Enhancing Social Inclusion.

"Empowerment, Disclosure and Group Identification:
Reducing Self-Stigma, Discrimination and Enhancing Social Inclusion"’
Prepared by Neasa Martin 1/25 3/27/13

The National Network for Mental Health (NNMH) is the only non-diagnostic
consumer/survivor driven mental health organization in Canada that is national in scope. Its
purpose is to advocate, educate, and provide expertise and resources that benefit the
Canadian consumer/survivor community. Core to its mandate is a commitment to foster
networking, inclusion, partnerships, and mutually respectful alliances. Using a ‘grassroots’
approach to community development the NNMH helps bring individuals and organizations
together to share information and find common ground. By working collectively, consumers
are empowered to remove the barriers to full citizenship and achieve a healthy, connected
and good quality of life.
Over the decades, consumers across Canada have played a leading role in pursuing
systemic change and advancing important concepts of recovery, peer-support, cultural
safety and consumer-driven economic development and employment initiatives. 1, 2 , 3
Consumers have intuitively understood that the way to reduce stigma and discrimination is
through protesting inequality, advocating for equal treatment, educating influential people on
the human experience of mental health problems (not mental illnesses), along with
encouraging positive personal contact between peers and with the public. Consumers also
understand that to achieve sustained and meaningful change they must play a leadership
role. “Nothing about us without us” emerged from the social disability movement as a
rallying call to consumers to ensure partnership and not paternalism drives decision-making
on issues central to their lives. However, this consumer leadership role is undertaken almost
exclusively on a volunteer basis, with limited coordination and in an environment of unequal
power and influence. A lack of financial resources for consumer-focused organizations has
meant that this voice is muted and unable to participate as equal and active partners in
critical change processes. The ‘experiential expertise’ of consumers has not held equal
sway with policy planners in the face of professionally driven, peer-reviewed, evidence-
based research. 4 , 5
However, emerging research is increasingly confirming what
consumers have long known: that recovery is possible and is enhanced by peer support.
That peer support is an effective and efficient resource, which fosters recovery and protects
people from self-stigma, and that addressing self-stigma is critical to recovery. Consumer-
led support plays a contributing role in reducing self and public stigma, in supporting
disclosure, and empowering consumers through positive group identification.
A changing Canadian landscape
Canada is at a critical ‘tipping point’ on mental health issues. The establishment of the
Mental Health Commission of Canada has increased visibility and interest on mental health

issue across government and in the media. A national mental health strategy 'Towards
Recovery and Well-being: A Framework for a Mental Health Strategy for Canada’ and stigma
reduction strategy is in development that will provide a blue print for shaping mental health
policies of provincial governments and territories for decades to come. Consumers are
pleased that mental health issues are taking a more dominant place in the public discourse
and has ‘come out of the shadows at last’. Consumers want action that will improve access
to recovery-focused services (including consumer led supports), create a more inclusive
society, protect their human rights and build equal access to resources and support full
citizenship. In a national stakeholder survey, summarized in 'Towards Recovery and Well-
being: A Framework for a Mental Health Strategy for Canada’, 6
Canadians agree that
stigma is a critical issue and that consumers must play a leading role in program
development and delivery. However, concerns are also raised that the existing consumer
networks have yet to be engaged in any significant manner in the work of the Commission
and there is no strategic plan in place to ensure consumers play a leading role, particularly in
relationship to program development on stigma and discrimination on which they hold a high
stake and considerable expertise.
Based on emerging research, and the expert advice of international leaders, transformative
change begins with the robust engagement of people living with mental health problems/
service users in addressing stigma, discrimination, and promoting recovery. 7
, 8
, 9
The
NNMH seeks to build an evidence-base, built on existing research, to strengthen this
position and provide a rationale for consumers as partners in this change process. This
report provides a high level review on stigma research and summarizes the evidence on the
importance of peer support, empowerment, and group identification in reducing self-stigma,
discrimination, and enhancing social inclusion. 1
A review of the scientific peer-reviewed
journals and grey literature in the policy, program and practice realms informs this report.
1
A summary of this report is available as a poster board on the NNMH website.

UNDERSTANDING STIGMA & DISCRIMINATION
Stigma and discrimination is broadly recognized as a major issue for people with mental
health problems and is one of five key priorities for the MHCC. 10
According to Graham
Thornicroft stigma represent a mark of shame or degradation and is ‘any attribute, trait or
disorder that marks an individual as being unacceptably different from ‘normal’ people with
whom he or she routinely interacts, and that elicits some form of community sanction.’ 11
Jeff
Cheverton, Executive Director of the Queensland Alliance describes this further “stigma is at
its core the mark of difference of those things we associate in our society as ‘signifying
madness’. People who are trolling the garbage dumps, panhandling on the street or act
impulsively have come to be defined as ‘mad’. The business man walking down the street in
a suit is not identified as ‘mad’ although he may very well meet the defined criteria for a
mental illness. The result is that we hold a skewed understanding of what madness looks
like. Discrimination is the different way we treat people who we define as ‘mad’.” 12
It is
being marked as ‘other’ that drives many people towards secrecy in order to avoid being
identified as mad.
STIGMA’S IMPACT
Stigma’s sting is felt in terms of lost relationships, opportunities denied or peoples
unwillingness to pursue life’s goals for fear of rejection or failure. Stigma interferes with help
seeking through label avoidance, reduced adherence to treatment, diminishes hope and
impedes recovery. It is felt in the pessimistic attitudes of health care providers who are more
focused on deficits and disability than strengths and competencies. 13 , 14
Although widely
acknowledged as an issue of concern, stigma is rarely addressed with clients in the clinical
setting. It continues to be experienced long after symptoms of illness resolve suggesting
that stigma reduction through better treatment as too simplistic an approach. 15
Research shows that stigma leads to:
• High rates of unemployment and lower educational achievement; 16, 17
leading to
persistent poverty which increases the risk for mental health problems. 18
• NIMBYism – through denial of housing and rejection by neighbours. 19
•
Being the object of ridicule, derision, and being depicted within the media as violent,
impulsive, and incompetent. 20, 21, 22, 23
•
People with mental health problems are more likely to be the object of violence than its
perpetrator. The myth of violence persists despite evidence to the contrary. 24

•
Violation of human rights i.e. the use of seclusion, restraints, involuntary admissions,
and forced treatments, 25
denial of health, life and mortgage insurance, restrictions in
travel, on holding public office and the loss of personal and parental rights. 26
• People with mental health problems receive poorer health care, less diagnostic testing,
fewer medical procedures 27 ,
live with more chronic illnesses and have significantly
shortened life spans. 28, 29
• Stigma and discrimination is a barrier to recovery, results in a lack of choice and limited
access to community, rehabilitation, and treatment supports. 30, 31
• Reduced policy attention and low funding of services by governments despite
increased work and health related costs, which exceed cancer and cardio-vascular
disease. 32
, 33
•
Greater emphasis on ‘risk containment’ and the criminalization of people with mental
health problems. 34, 35, ,36, 37
• Worsens existing symptoms and lead to relapses in mental health problems and
increases the risk for suicide. 38, 39, 40
•
Harms caregivers’ health, economic, social, and emotional well-being. 41 , 42, 43
Beyond the personal impact of stigma, mental health problems have a broader social cost
making this a critical issue to address. It is considered the leading cause of 'healthy life' lost
due to disability. The World Health Organization recognizes psychiatric disability as the
fastest growing cost sector for occupational disability. A conservative estimate of the
economic cost of poor mental health is 3% - 4% of GDP in developed nations. 44
There are
significant economic losses identified due to absenteeism; reduce productivity or
‘presenteeism’, increased morbidity, and higher rates of mortality. The annual economic
cost in Canada of mental illness is estimated at $51 billion. 45
According to Corrigan stigma takes on many forms:
1) Public stigma: the harmful effects to people when the general population endorses the
prejudice and discrimination of mental illness.
2) Self-stigma: the harm that occurs when people internalize negative stereotypes impacting
self-esteem (“I am not worthy!”) and self-efficacy (“I am not able”) leading to self-blame,
hopelessness and helplessness.
3) Label avoidance: avoid stigma by not seeking mental health services from which labels

are often obtained. (“I am not going to see a psychiatrist; people are going to think I am
nuts!”). 46
4) Courtesy stigma: the devaluation by association experienced by caregivers and
professionals associated with people who have mental health problems. 47
Self-stigma is increasingly recognized in the research as a critical issue to address because
it results in people not pursuing opportunities, advocating for entitlements or accessing
mainstream activities. Self-stigma leads to social isolation and the breakdown in support
from family and friends. 48
Most promising is that those elements, which protect people
from self-stigma, are also the means by which stigma and discrimination is combated in the
public realm.
WHAT CAUSES PUBLIC STIGMA?
Stigma is found to arise from three inter-related problems:
1) A lack of knowledge of mental health problems leading to ignorance.
2) Ignorance leading to the formation of negative attitudes or prejudice and when knowledge
is replaced by myths.
3) Discrimination, is the behavioural result of prejudicial attitudes, results in people excluding
or avoiding contact with those who are identified as mentally ill.
Link and Phelan describes a four-step process for stigma formation. 1) Labeling: when key
personal characteristics are recognized by others as conveying difference; 2) Stereotyping:
there is a linkage of these differences to undesirable characteristics; 3) Separating: a
distinction is made between the ‘normal’ group and the labeled group; and 4) Status loss:
leading to discrimination, devaluing, rejecting, and excluding the labeled group.
Discrimination is ‘dependent on differences in ‘social, economic and political power’.49
The emerging trend internationally is to see discrimination as a human right issue not an
illness based phenomena. The goal of action is to achieve equal treatment and greater
access to service and resources and not to change attitudes.
THREE-PRONGED SOLUTION:
Research suggests that this negative cycle can be interrupted by: providing education on the
experience of having a mental health issue and sharing the personal experience of
discrimination – not education to improve knowledge of mental illness; by increasing positive

contact with competent, capable people who to challenge stereotypes attitudes; and by
promoting human rights and protesting against acts of discrimination. 50
1) Education - to build understanding
The research evidence supports that people with a lived experience of mental health
problems are the best agents for delivering education. However, information alone has not
been found to positively change attitudes or result in positive shifts in behaviour. Ignorance
of mental illness does not appear to drive negative public opinions. In fact, researchers have
found that the more educated the public was about mental illness the greater their desire for
social distance. 51
Research has also found that positive shifts in attitude are not necessarily
correlated to desired behavioural changes or improved quality of life. 52, 53, 54
However,
personal contact plus education can improve knowledge uptake. 55
Education is best when
it is multi-faceted and includes challenging common myths (dangerousness, incompetence,
impulsivity). 56, 57
Stories that touch the heart and mind of the listener increase positive
emotional connection and have a long-lasting effective when: they describe the challenges
encountered and discrimination faced; share ways difficulties were overcome and what
helps people to cope; and when hope and optimism of recovery are key messages. 58, 59
Education is best when it promotes respect, rights, and a shared responsibility of reducing
discrimination. In addressing stigma, there is no ‘general public’, and education is most
effective when it is targeted, segmented, delivered locally and the messages are audience-
specific (i.e. police, medical students). 60
The use of creative art, theatre, comedy, photo-
story, poetry, first person-narratives etc. helps to create a strong emotional response that
encourages reflection and helps shift public attitudes.
2) Positive contact
Direct contact is consistently identified as the most effective means of producing long-
lasting and sustained improvement in attitudes. Positive contact is found to increase
empathy, understanding, and leads to pro-social behaviour. 61
It is most effective when:
• There is a relationship of equal status (peer to peer);
• Contact occurs in a context of active cooperation and the pursuit of shared goals;
• There is opportunity for interaction and discussion;
• There is a coexisting relationship such as co-worker, friend, neighbour etc.;
• Both the message and messenger are culturally appropriate and relevant to the
audience;
• Contact disabuses people of common myths (dangerousness and impulsivity);

• The presenter is viewed as ‘credible’ and challenges stereotypes (incompetence and
incapacity). 62
3) Protest
Protesting inequalities and demanding equal rights and entitlements are also found to be
effective in reducing discrimination and promoting personal empowerment. Protest includes
challenging negative media and seeking systemic changes at a policy, practice, and
legislative level. Examples include: the use of ‘Media Watch’ programs, legal challenges,
and the use of human rights complaints mechanisms. Protest also builds a sense of group
identification, self-efficacy, and rightful entitlement core to enhancing personal and group
empowerment. However, protest can be a double edge sword and can increase public
stigma. When used to suppress negative thoughts can result in a rebound effect. For
example emphasizing mental illness is not connected to violent behaviour may inadvertently
strengthen the connection in the audience’s mind. 63
Taking a balanced approach of using
both rewards (awards, social marketing campaigns) and protest is found to achieve the best
outcome. Protest is felt to be most effective when it is incremental in nature, creates a
dialogue where education can take place with the target audience, seeking clear redress and
cessation of offending actions, and ultimately leads to the formation of an ongoing
partnership. 64
FRAMING MATTERS – “Illness like any other” approach hasn’t worked
A common approach to addressing public stigma has been educational efforts to increase
the publics’ understanding of ‘mental illness’ and bring it into closer alignment with medical
opinion. The underlying assumption is that this approach would lessen the perception of
personal responsibility for mental illness based on moral weakness or character failings. The
reasoning goes that if mental illness are seen to be caused by factors outside of the
individual’s control, then they are not responsible and a well-informed public would be more
accepting and understanding towards people with mental illnesses. At the same time the
use of direct marketing to customers by the pharmaceutical industry has also resulted in the
ubiquitous presence of ‘public education’ campaigns that promotes a bio-medical framing of
mental illnesses as a disease for which treatment - medications – are effective. However,
the “illness like any other” approach to reducing stigma has not worked as intended and has
been found to increase stigma and discrimination. Faming mental health problems as
biologically based, genetically influenced, chemically medicated diseases increases public
fears, and social withdrawal. A ‘disease model’ educational approach increases the belief
that people with mental health problems are incapable of exerting control, judgment, or

reason. 65
This approach has been found to strengthen the link between violence,
incompetence, and impulsivity. The result is a public more tolerant of coercive treatment, a
decreased belief in the capacity to recovery, and a desire for greater social distance. Stigma
is reduced when less emphasis is placed on limitations, disability, chronicity, morbidity, and
mortality. Less emphasis needs to be placed on medications, and hospitalization and
stigma is reduced when services are provided in the community. There is also more public
acceptance when there is government funding for supports and services. 66, 67, 68, 69, 70, 71
Conversely, there is less stigma when mental health problems are framed as part of our
shared humanity and the natural consequence of a certain set of circumstances. 72
, 73
Given
this emerging research caution is necessary in how mental illnesses are framed in both
public education and in clinical setting. 74, 75
Attention needs to focus on addressing the
stereotypes of unpredictability and dangerousness because these are most closely
associated with a desire for social distance. 76
TAKE A HUMAN RIGHTS FOCUS
The emerging international trend in stigma and discrimination programming is to focus more
on reducing discrimination that attempting to change public attitudes. Discrimination frames
the issue as a systemic, social, and political phenomenon and not as an individual health-
related issue. The historic focus on ‘stigma’ as the critical element of intervention is felt by
many to set the prejudice towards people with mental illness apart from other forms
discrimination like racism, homophobia, or sexism. 77
A focus on discrimination helps to
bring the prejudice towards mental illness into closer alignment with the approach of the
broader disability community. Disability in this context is not seen as the consequence of
the symptoms of illness but the barriers erected by the broader society that limit social
inclusion. The locus of change is then external to the individual and requires proactive steps
to remove barriers and create structural and policy enablers to support inclusion. 78
This does not mean that stigma, particularly self-stigma, is ignored. An approach focused
on discrimination makes clear that the ultimate endpoint of action is to attain equal treatment
and equitable access to services and resources. From a broader policy planning
perspective, applying a discrimination lens makes program goals and objectives more
measurable and strengthens the ability of researchers to clearly evaluate the outcomes of
interventions in ways that are meaningful to consumers. For example, it is not important to
assess whether an employer would hire someone with a mental health problem but whether
he or she actually does. 79
, 80
It provides policy makers with broader recommendations for
action including: addressing human rights; civil liberties; health and social service

transformation; policy; and legislative changes. Liz Saycer, a leading disability policy expert
states “Initiatives to reduce discrimination need to make use of the iron fist of law with the
velvet glove of persuasion. 81
Although legal redress is considered a blunt instrument,
legislation does serve as a powerful deterrent. Graham Thornicroft recommends drawing on
national Human Rights Acts, Disability Rights Legislation, the Universal Declaration of
Human Rights and existing covenants and charters to provide both a legal framework and
the moral authority for reducing discrimination. Government legislation can impose a public
sector duty to promote equality of opportunity. 82
Coordinated planning to improve the
protection of human rights can also be achieved by bringing together organizations with a
shared interest and responsibility for reducing discrimination, an approach recently
undertaken in New Zealand. 83
MANAGING SELF-STIGMA
There has been very little research undertaken to understand the mechanism by which self-
stigma is formed or its harm mitigated. Nor has self-stigma been a focus of attention within
the clinical setting. Given its significant impact on peoples lives it is becoming an area of
greater research focus. Those strategies that are found to have the greatest impact on
reducing public stigma (education, contact and protest) have also been found to play a
complimentary protective and healing role in addressing self-stigma. Empowerment,
inclusion in planning processes, group identification and making meaning
of challenging mental health experiences helps to prevent self-stigma, encourages
disclosure and supports recovery. Research and program experts agree that a robust anti-
stigma and discrimination reduction strategy needs to include mechanisms to foster
disclosure, nurture empowerment, support group identification, and encourage advocacy
and protest.
What is self-stigma?
Self-stigma is the way in which people internalize negative social stereotypes. People who
live in a culture that holds widespread negative beliefs about mental illness come to
anticipate, and accept attitudes that reflect devaluation and discrimination. Common
stereotypes include: being to blame for ones illness; incapacity and incompetence; and
dangerousness. 84
Research reveals that the more people are aware of these prejudicial
beliefs and cultural devaluation, and the more they agree and identify with them, the greater
the degree of self-stigma, emotional and psychological distress, depression and decreased
sense of well-being. 85, 86
Pat Corrigan describes three components in the formation of self-

stigma: 1) having an awareness of negative cultural beliefs; 2) agreement with these
stereotypes (“people mental illness are to blame for their illness, are incompetent or
impulsive”) and 3) the application of these stereotypes to oneself. (“I am responsible… I am
incompetent”). Self-stigma leads to self-limiting behaviour, which is negatively re-enforcing
(“Why try… I won’t succeed anyway…. I am a failure”). This negative cycle lessens self-
esteem and self-efficacy and is positively associated with a failure to pursue work or
independent living, lower quality of life and goal attainment. 87
, 88
Self-stigma results in a
fear of intimacy, feelings of deep shame, anxiety, and depression and increased self-blame.
It destroys hope, leads to distrust of ones self and others, feelings of worthlessness, retards
healing, and recovery, and results in a fear of exposure. Secrecy and an unwillingness to
self disclose leads to isolation and cuts people off from finding meaning and purpose in their
experience. 89
The most damaging stereotype appears to be the belief that people are
personally responsible for their illness. This leads others to feel a decrease in empathy and a
greater acceptance of structural discrimination.
90
Breaking the connection of personal
responsibility in ways which do not emphasize brain dysfunction is critical in shifting both
public attitudes and personal beliefs that lead to self-stigma.
Receiving a psychiatric diagnostic label and the pessimistic attitudes of health care
professionals have also been found to contribute to the formation of self-stigma by creating
a sense of “otherness”. What health care providers tell people about their condition has a
major impact of their confidence, belief in recovery and future aspirations. Addressing the
social, and vocational impact early on in treatment is critical to pre-empting self-stigma.
Waiting to get well or be symptom free before embarking on the journey of recovery is not
helpful. This includes efforts to return to work. Those people with a high level of illness
awareness and who identify strongly with their psychiatric diagnosis are found to have better
functional outcomes but also experience more self-stigma, lessened hope, pessimism
regarding recovery, and diminished self-esteem. 91
A high level of self-stigma is positively
associated with an increased risk of psychiatric hospitalization92
and self-stigma is found to
be higher amongst people who believed medications and therapy were not helpful. .
Some
researchers have found that those who disagree with discriminatory social attitudes may be
more likely to participate in counseling. 93
This apparent paradox requires a careful dance
between promoting the efficacy of treatment without placing an over emphasis on diagnostic
labeling. Participating in cognitive behavioural therapy may be helpful on an individual level
to challenge stigmatizing beliefs that are irrational or harmful. 94
Stigma is powerfully reinforced by culture and is not easily overcome at the individual level.
It is important to acknowledge this as a ‘social problem’ and not a problem of individual poor

adaptation. Many people with mental illness expect to be rejected leading them to become
secretive about their condition, limit, or withdraw entirely from, social interaction. Hiding
ones history of illness, social isolation and efforts to educate significant others about mental
illness are the most common coping strategies people employ, consume a lot of energy,
have not been found to reduce self-stigma and may do more harm than good. 95
What protects people from self-stigma?
Not everyone responds negatively to social stereotypes. Some people react with a sense of
righteous anger at the discrimination they face. This often leads to taking on roles of
advocate in pursing social and systemic system change. Others feel indifferent to the
negative stereotypes, which they reject as illegitimate. Those who reject the legitimacy of
common stereotypes have often experienced positive personal contact with others who
have mental health problems. 96
, 97
The New Zealand ‘Fighting Shadows’ research report on
self-stigma identified important ‘circuit-breakers’ to counter discrimination and negative
thought patterns which include: increasing visibility of people with mental illness, building
peer support networks, affirming human rights, challenging negative attitudes, and
encouraging mental health services to focus on recovery. 98
Additional protective factors identified in the research include:
• Having a high degree of peer group identification and sense of belonging.
Participation in peer support and self-help groups, which facilitate empowerment
and build self-esteem and self-efficacy. Peer leaders who act as role models. 99
• De-emphasizing the psychiatric diagnostic label.
• Access to rehabilitative and recovery focused supports and services.
• Disclosure has positive health and social benefits helping people to reframe the
negative experience of illness more positively. Peer support groups are felt to
provide a supportive environment where people can practice self-disclosure. 100, 101
• Holding an insiders perspective provides people with a “buffering life space” where
they can begin to make sense of their social world and reject the role of ‘victim’. 102
• Participation in anti-stigma campaigns, speaking out against discrimination,
becoming involved in reform and advocacy efforts helps people feel empowered and
cope with discrimination. 103
• Opportunities for choice within treatment planning, housing, and program
involvement and access to recovery oriented supports and services. A collaborative,

respectful, and inclusive relationship with professionals built on trust and mutual
respect. 104
• Strong sense of self-esteem and self-efficacy. Participation in the work-force and
support in returning to employment of school. Active engagement in the community
including volunteering, participation in arts and leisure, sports and recreation as well
as inclusion in mental health program design and service delivery. 105
• Empowerment and opportunities for choice and self-determination are critical.
Opportunities for defining self and their experience of illness. Understanding the
importance of interdependence.
THE IMPORTANCE OF PEER SUPPORT & EMPOWERMENT
Peer support and self help have deep roots within the consumer movement. For decades,
consumers have felt excluded from decision-making within treatment planning and program
development and the low expectation for recovery. Viewed through a less optimistic lens,
professional treatment centered on diagnosis, symptom management, disease containment,
and the treatment of psychopathology to prevent relapse and stave off deterioration in
function. In response, consumers they found ways to support each other building peer-
driven, self-help supports and services including economic development initiates. 106
Within
peer support groups people saw that the success was indeed possible and the concept of
‘recovery’ emerged creating a new sense of empowerment, optimism and hope.107
Consumer-focused recovery was/is seen as a challenge to treatment strategies, which are
too narrowly focused on symptom alleviation instead of addressing people's multiple
residential, social, vocational, and educational needs. 108, 109
, 110
Research, although limited, confirms the importance of peer support and it now identified as
a ‘best practice’ in mental health service provision. 111 , 112, 113
The WHO acknowledges that
informal self supports play a foundational role in mental health care in both prevention and
recovery. 114
In Canada peer support takes multiple forms including: running alternative
businesses, patient counsels, self-help supports, participation in education, advocacy and
research efforts, peer counselors and support workers, and delivering recreational, cultural
and artistic enterprises. Consumer-directed initiatives differ from mainstream services in
significant ways including: a changed power relationship with consumers providing
egalitarian control over decision-making; a spirit of advocacy; group identification through
reciprocal helping roles; a different understanding of mental health issues focused more on
holistic care, hope, recovery; moving away from the role of ‘patient’ towards greater self-
efficacy and control; and adoption of the advocates role in influencing systems. Research

reveals that peer support is highly valued by consumers. 115
Participation significantly
reduces hospitalizations (number & duration), decrease symptom distress, and the use of
emergency rooms, and other expensive medical services. It helps to ease the transition from
psychiatric hospitalization to community living. Peer support increases social contacts,
builds group identification, supportive networks, and enhances quality of life. It helps people
to re-frame distressing life experiences positively and to normalize the experience of mental
ill-health so that people feel less broken and different from fellow citizens. Programs also
help people learn self-management strategies, awareness of resources, how to navigate
professionally run services and in this way promotes recovery and increase self-esteem.116
Consumer-led economic development initiatives helps to affirm a persons capacity to work,
and reduces pessimism regarding recovery. Consumer employment (peer support workers
and counselors) working within mental health services is also found to reduce stigma and
discrimination amongst health care providers. 117, 118, 119, 120
A sense of group identification
and membership has also been found to improve the well-being of marginalized groups
including people living with mental health issues. 121
However, people who have suffered a
loss of self-esteem, because of stigma, may not experience a beneficial effect from peer
support. 122
Funding of Peer Support
Consumer Survivor Initiatives 2
and peer support programs remain poorly understood by
policy planners and mental health service providers. Despite their recognition as ‘best
practice’, demonstrated efficacy, and effectiveness, they are inadequately funded - if at all.
In Ontario, the province which provides the greatest financial support, consumer-led
services receive only 0.2% of mental health service budgets and less than 3% of the total
community mental health budget. 123
In an economic analysis of the cost savings associated
with utilizing peer support by patients transitioning from hospital to community living,
researchers calculated that peer support saved over $12 million dollars in shorter hospital
stays and emergency room usage - an average savings of $4,400 per person studied.
Additional benefits included: reduced loneliness, improved social skills, enhanced quality of
life, and feelings of well-being which contributed to better recovery outcomes. 124
This
funding neglect extends beyond peer support and is endemic across all mental health
treatment and support services. According to the Institute of Psychiatry, Kings College and
London School of Economics stigma plays a contributing role in the low funding priority
affording by governments to mental health problems relative to other health issues such as
2
CSI is the terms used to describe government funded consumer-directed services in Ontario

cancer or heart disease. This funding neglect is despite higher levels of morbidity and
mortality, which are worsened as a consequence of services not being available in a timely
or at an adequate level. 125
The failure of governments to fund this effective best practice
element of care is considered by many consumers as an expression of the systemic
discrimination.
Empowerment
SAMHSA’s National Consensus Statement of Recovery defines empowerment as:
“consumers have the authority to choose from a range of options and to participate in all
decisions—including the allocation of resources—that will affect their lives, and to be
educated and supported in so doing. Consumers have the ability to join with other
consumers to collectively and effectively speak for themselves about their needs, wants,
desires, and aspirations. Through empowerment, an individual gains control of his or her
own destiny and influences the organizational and societal structures in his or her life.” 126
Empowerment comes with taking responsibility for ones life and choices and through
restoring a sense of free will. 127
It is a positive mediator between self-stigma and personal
goal attainment. The empowerment journey includes having ones experience validated,
consciousness-raising, feeling a sense of righteous anger, defiance, and constructive
participation in advocating for personal and systemic changes. Participating in peer support
nurtures empowerment and empowerment is critical to leadership development, promotes
self-disclosure, which are powerful inoculants against self-stigma. Consumers feel
empowered when they are able to hold stakeholders accountable and participation in
systemic advocacy helps to identify solutions and supports systemic change. 128, 129, 130
INCLUSION IN RESEARCH
Research helps us understand the world we live in and shapes how we act within it. Power
comes from defining the research questions asked, participating in the asking and shaping
the research design. Consumers have not always faired well in the research enterprise and
throughout history, unwitting participants have experienced significant harm. 131
Consumers
are increasingly aware of their unique expertise and “owned knowledge” gained through the
production of personal narratives and collective wisdom. Although this experiential
knowledge is often devalued by professionals as anecdotal, lacking professional integrity
and authority, it is increasingly recognized as a valuable resource and is helping to shape
public policies and treatment practices. 132
Ministries of Health are increasingly requiring
that consumers be involved in planning, implementing, and evaluating services at every level.

Evidence is slowly emerging to support the importance of peer support and empowerment in
reducing self-stigma and discrimination. However people living with mental health issues
have not yet played a direct or prominent role in defining research priorities or participating
beyond being the objects of study.. 133, 134
Internationally, the expertise of consumers is being
recognized and incorporated into research design and program development. 135, 136
Like
many other marginalized groups consumers have also questioned the benefits of existing
methodologies used in research and fear that their concerns will be subsumed by the
researcher’s voice. 137
According to Glen White, the “golden rule” for ethical consumer
participation is that it must both benefit and empower participant.138
There are significant barriers to building consumer participation in research including funding
criteria and epistemological biases against qualitative, participatory action and emancipatory
research, and institutionally-based biases in the ethics review process, that create powerful
disincentives for consumer involvement. Some researchers feel that consumer involvement
can produce better and more ethical research and recommendations to policymakers to
build this approach into research practices is emerging. 139
Consumers in Canada have been
asking for more out-comes focused, action-oriented research on reducing stigma and
discrimination. 140
In 2008, the Mood Disorders Society of Canada held a research plenary
session including consumers, family members, researchers, policy planners and funders to
identify the critical research questions consumers and families want addressed. 141
It was
clear they felt the ‘right’ questions are not being asked, they want to play a more active role
in research design and want to see more action-oriented outcomes-driven research on
stigma and discrimination. There was a sense that traditional research methodology was
failing to get at the nub of consumer concerns, that publicly funded research findings are not
widely shared, or in a format from which people can derive meaning. Most importantly that
the outcomes of research was having little significant impact on reducing discrimination,
changing behaviour or improving quality of life. A subsequent review by the MDSC in 2009
revealed little has changed.142
The Mental Health Commission of Canada’s Scientific
Advisory Committee is in the early stages of supporting the development of a Canada-wide
consumer-led research group. While a promising start It is too early to determine if this will
help play a meaningful role in building the capacity of consumer researchers. 143
Summary of findings:
Stigma and discrimination is identified as a critical issue with far-reaching health, economic
and social consequences for people living with mental health issues. Engagement of
consumers as leaders is a critical ‘best practice’ in designing, delivering, and evaluation anti-

stigma and discrimination strategies. Research reveals that the most effective means of
combating public stigma and discrimination is through the use of education - to build a
shared understanding; positive contact - with people who have experienced mental health
issues; and protesting inequities and misrepresentations - particularly in the media.
Confronting myths of personal responsibility, incompetence, incapacity, and dangerousness
is critical. A robust anti stigma/discrimination reduction strategy includes adopting a human
rights approach to address systemic barriers and inequalities at a policy, practice, and legal
level. Framing mental health issues as genetic, biologically based illness, and chemically
mediated brain disorder increases stigma, the desire for social distance and tolerance for
coercive treatment. Stigma is diminished when illness is framed as part of our shared
humanity and by emphasizing equality goals and recovery. Self-stigma is a critical factor in
limiting people’s pursuit of life’s goals and needs to be includes as part of an anti-stigma
strategy. Group identification, empowerment, and peer support plays a critical healing and
protective role in preventing self-stigma. Participating in education, protest and system
advocacy reduces self-stigma and supports recovery. Peer support programs are a highly
valued, under funded and an effective means of support. Consumers and professionals
experience this funding neglect as discriminatory. Research is limited in large part because
consumers are not included as partners in research and their issues are unique supports are
under-evaluated creating further barriers to being funded as a ‘best practice’.
KEY MESSAGES FOR NNMH
‘Best practices’ in anti-stigma/discrimination programming must include:
 Robust involvement of consumers in stigma and discrimination programming.
 Mental ill-health framed as part of our shared humanity - not as a disease of the brain.
The use of an “Illness like any other” approach to education does not reduce but
increases stigma.
 Increasing the visibility of people living with mental health issues as competent, capable
‘citizens’ and not ‘problems’ to be solved.
 Conveying messages of hope, optimism, and recovery. Emphasizing disability,
morbidity and mortality increase stigma and discrimination.
 Addressing human rights through supporting policies, practices, and laws.
 Include all stakeholders to work in collaborative partnerships to remove systemic
barriers. This must be seen as a share responsibility.
 Improving quality of life, social inclusion, and full citizenship must be the outcomes of
programming. This includes improvements in:

• Housing, employment, education and training, income security, safety, improved health
& mental health, recovery-focused care, stop discrimination, supportive communities,
access to mainstream services…
Funding of empowerment / peer support programs is critical because:
• Peer-support is recognized in Canada and worldwide as a “best practice” in mental
health service delivery. It delivers results and is cost effectiveness.
• Peer support, group identification, and participation in education and advocacy efforts
is core to overcoming self-stigma and improving quality of life.
• Reducing self-stigma removes a barrier to pursuing treatment, work, and friendships
and supports recovery.
• Consumer leadership drives systemic transformation and peer-support builds
consumer leadership.
• Across Canada, peer-driven services are devalued and under-funded.
Building a research evidence-base is essential but…
• Must include action-oriented, outcomes focused research reflecting consumer
priorities.
• Publicly funded research must include participatory-action, qualitative and
empowerment research design.
• Consumers must be seen as partners NOT subjects in research delivery.
• Research must both benefit and empower consumers.
• Knowledge is shared in accessible and meaningful ways using user-friendly language.

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