Confronting and changing the Confronting and changing the stigma of mental illnessstigma of mental illness

Mental Health Planning Council Mental Health Planning Council San Francisco, CaliforniaSan Francisco, California

June 19, 2008June 19, 2008

Sarah Altman, MD, MPHSarah Altman, MD, MPHKaren Hopp, MD Karen Hopp, MD

“Who is Crazy?”

Sarah Altman, MD, MPHSarah Altman, MD, MPH Clinical Instructor, UCSF Clinical Instructor, UCSF Attending Inpatient Psychiatrist,Attending Inpatient Psychiatrist,

San Francisco General HospitalSan Francisco General Hospital

Karen Hopp, MDKaren Hopp, MD Private practicePrivate practice Psychiatry & primary care medicinePsychiatry & primary care medicine Woodland Healthcare, Woodland, CAWoodland Healthcare, Woodland, CA

Objectives Objectives

Describe stigma and its effects on individuals, Describe stigma and its effects on individuals, families & communitiesfamilies & communities

Understand selected models in anti-stigma Understand selected models in anti-stigma researchresearch

Summarize what is known about effective Summarize what is known about effective strategies to reduce stigma and discriminationstrategies to reduce stigma and discrimination

Provide information about available resourcesProvide information about available resources

A Letter From A Resident…A Letter From A Resident…

““Dear Dr. Fink, Dear Dr. Fink,

I am a PGY-4 resident in psychiatry. I I am a PGY-4 resident in psychiatry. I am also mentally ill. I am bipolar and a am also mentally ill. I am bipolar and a recovering alcoholic. It has been difficult recovering alcoholic. It has been difficult and trying at times. Sometimes I feel as and trying at times. Sometimes I feel as though it is too much and I should though it is too much and I should reevaluate my goals…..”reevaluate my goals…..”

What is STIGMA?What is STIGMA?

Word originally referred to the mark or Word originally referred to the mark or brand that was put on Greek slaves to brand that was put on Greek slaves to separate them from free menseparate them from free men

““A sign of disgrace or discredit which sets A sign of disgrace or discredit which sets a person apart from others.” – Goffman, a person apart from others.” – Goffman, 19631963

The The Experience Experience of Stigmaof Stigma

SHAMESHAME BlameBlame SecrecySecrecy The “black sheep of the family” roleThe “black sheep of the family” role IsolationIsolation Social exclusionSocial exclusion HopelessnessHopelessness

(Byrne, 2000)

Common themes: Common themes: The Concept of StigmaThe Concept of Stigma

STEREOTYPINGSTEREOTYPING (The neutral PERCEPTIONS of difference)(The neutral PERCEPTIONS of difference)

PREJUDICEPREJUDICE (Negative BELIEFS about this difference)(Negative BELIEFS about this difference)

DISCRIMINATIONDISCRIMINATION(Negative ACTIONS (Negative ACTIONS

taken)taken)

Adapted from work by Corrigan et al and Link and Phelan

““People with Mental Illness are…”People with Mental Illness are…”

DangerousDangerous therefore they should be therefore they should be feared and excludedfeared and excluded

IncompetentIncompetent therefore they should be therefore they should be controlled and should not be allowed to controlled and should not be allowed to make their own decisionsmake their own decisions

Lack willpowerLack willpower therefore they need to therefore they need to be cared for and should not be be cared for and should not be independentindependent

(Corrigan, 2004), (Byrne, 2000)

The Discrimination of Stigma The Discrimination of Stigma

Less likely to be hiredLess likely to be hired Less likely to have apartments rented to Less likely to have apartments rented to

themthem More likely to be rejected by friends and More likely to be rejected by friends and

familyfamily More likely to be falsely accused of a crimeMore likely to be falsely accused of a crime More likely to be arrested and spend more More likely to be arrested and spend more

time in jail that someone else similarly time in jail that someone else similarly chargedcharged

(Rusch, 2005) (Read, 2006)

Public vs. Self StigmaPublic vs. Self Stigma

Public stigma consists Public stigma consists of three elements of three elements stereotypes, stereotypes, prejudice, and prejudice, and discrimination, in the discrimination, in the Context of Context of POWERPOWER,, that leads that leads to negative treatment to negative treatment of the stigmatized of the stigmatized groupgroup

Self stigma occurs Self stigma occurs when members of the when members of the stigmatized group stigmatized group internalize the public internalize the public attitudes toward them, attitudes toward them, and leads to self-and leads to self-defeating beliefs and defeating beliefs and behaviors behaviors including including avoiding treatmentavoiding treatment

(Corrigan, 2004)

““They called me mad, and I called They called me mad, and I called them mad, and damn them they them mad, and damn them they

outvoted me”outvoted me”

– – Nathaniel Lee, Nathaniel Lee,

patient from England,patient from England,

1616thth century century

Public vs. Self StigmaPublic vs. Self Stigma

Public stigma consists Public stigma consists of three elements of three elements stereotypes, stereotypes, prejudice, and prejudice, and discrimination, in the discrimination, in the Context of Context of POWERPOWER, that leads , that leads to negative treatment to negative treatment of the stigmatized of the stigmatized groupgroup

Self stigmaSelf stigma occurs occurs when members of the when members of the stigmatized group stigmatized group internalize the public internalize the public attitudes toward them, attitudes toward them, and leads to self-and leads to self-defeating beliefs and defeating beliefs and behaviors behaviors including including avoiding treatmentavoiding treatment

(Corrigan, 2004)

The Double BindThe Double Bind

People suffering from a mental illness People suffering from a mental illness have to deal both with the consequences have to deal both with the consequences of the illness and the STIGMAof the illness and the STIGMA

The number one predictor of STIGMA is The number one predictor of STIGMA is having the LABEL of mental illness, having the LABEL of mental illness, causing people to avoid treatment (and the causing people to avoid treatment (and the label) as well as maintain secrecy in order label) as well as maintain secrecy in order to “pass” to “pass”

(Rusch, 2005) (Link, 1987)

Stigma also affects…Stigma also affects…

FamiliesFamilies – “courtesy stigma” leading to – “courtesy stigma” leading to lack of disclosure and support lack of disclosure and support

Mental Health FieldMental Health Field – within training – within training programs and work settings, also seen in programs and work settings, also seen in lower levels of funding for “mental” vs. lower levels of funding for “mental” vs. “physical” health care “physical” health care

(Corrigan, 2005)(Corrigan, 2005)

Why Stigma? Why Now?Why Stigma? Why Now?

Unfortunately, research suggests public Unfortunately, research suggests public stigma is getting worse over the last few stigma is getting worse over the last few decades….decades…. A U.S. sample population in 1996 was 2.5 A U.S. sample population in 1996 was 2.5

times more likely to endorse dangerousness times more likely to endorse dangerousness stigma than a comparable population in 1950stigma than a comparable population in 1950

This finding has been replicated on 4 other This finding has been replicated on 4 other continents. continents.

(Read, 2006)

A look at our own attitudes…A look at our own attitudes…

Would you…Would you… Be willing to start work with a person with mental Be willing to start work with a person with mental

illness?illness? Like to live next door to a person with mental Like to live next door to a person with mental

illness?illness? Make friends with a person with mental illness?Make friends with a person with mental illness? Rent a room to a person with mental illness?Rent a room to a person with mental illness? Like your child to marry someone with a mental Like your child to marry someone with a mental

illness?illness? Trust a person with mental illness to take care of Trust a person with mental illness to take care of

your child?your child?(Social Distance Scale, Link et al. 1987)

Definition of Social DistanceDefinition of Social Distance

Social distance isSocial distance is…… the relative the relative willingness of one person to participate in willingness of one person to participate in relationships of varying degrees of relationships of varying degrees of intimacy with a person who has a intimacy with a person who has a stigmatized identity (Bowman, 1987)stigmatized identity (Bowman, 1987)

INCREASED Social Distance means INCREASED Social Distance means LESS interpersonal involvementLESS interpersonal involvement

A Community SampleA Community Sample(n=844) (Lauber et al, 2004)(n=844) (Lauber et al, 2004)

Definitely Definitely unwillingunwilling

UnwillingUnwilling NeutralNeutral WillingWilling Definitely Definitely WillingWilling

Work with?Work with? 2.62.6 6.46.4 24.524.5 38.038.0 27.527.5

Move?Move? 1.91.9 10.110.1 26.5 26.5 36.136.1 25.125.1

Befriend?Befriend? 9.89.8 17.517.5 31.031.0 26.826.8 14.614.6

Rent to?Rent to? 11.511.5 22.922.9 34.734.7 22.022.0 8.68.6

Hire?Hire? 9.49.4 24.224.2 35.435.4 22.022.0 8.38.3

Marry your Marry your child?child?

13.313.3 25.625.6 32.832.8 17.817.8 7.97.9

Take care of Take care of your child?your child?

25.125.1 30.230.2 25.825.8 14.214.2 4.54.5

Research around Social DistanceResearch around Social Distance

Factors that Factors that increasedincreased social distance social distance:: Schizophrenia vs. depression diagnosisSchizophrenia vs. depression diagnosis Belief in the biomedical model of illnessBelief in the biomedical model of illness

Factors that Factors that decreaseddecreased social distance social distance:: Positive attitude to lay helping and to Positive attitude to lay helping and to community psychiatrycommunity psychiatry Contacts to persons with mental illnessContacts to persons with mental illness

(Lauber, 2004)

StigmaStigmaStrategies for ChangeStrategies for Change

What does the literature tell us?What does the literature tell us?

What can we do to change it?What can we do to change it?

““The recognition of the enormous personal, The recognition of the enormous personal, social, and still unmeasured economic toll social, and still unmeasured economic toll of stigma, and the absence of a of stigma, and the absence of a conceptual framework or an evidence conceptual framework or an evidence base for interventions, are driving a base for interventions, are driving a movement to reinvent a science of movement to reinvent a science of stigma.” stigma.”

Keusch, Wilentz and Kleinman, February 2006

The science of stigmais in its infancy.

Academic Psychiatry, Academic Psychiatry, 32:2, March-April 200832:2, March-April 2008

Special Issue:Special Issue:

Reaching Out to Reaching Out to Families and Families and Overcoming Overcoming

StigmaStigma

ChallengesChallenges

Social distance Social distance ≠≠ actual behavior. actual behavior.

People know what they People know what they shouldshould say, but say, but often act differently.often act differently.

Measuring opinions doesn’t give insight Measuring opinions doesn’t give insight into why people have these opinions.into why people have these opinions.

InterventionsInterventions

ProtestProtest

Corrigan, River et al., 2001Corrigan & Gelb, B, 2006

Rűsch et al., 2005

InterventionsInterventions

ProtestProtest

EducationEducation

Corrigan, River et al., 2001 Corrigan & Gelb, B, 2006

Rűsch et al., 2005

InterventionsInterventions

ProtestProtest

EducationEducation

ContactContact

Corrigan, River et al., 2001Corrigan & Gelb, B, 2006

Rűsch et al., 2005

Intervention trialsIntervention trials

Real-world experienceReal-world experience

Evidence for InterventionsEvidence for Interventions

Limitations of the research dataLimitations of the research data

Uncontrolled trialsUncontrolled trials

Very small controlled trials Very small controlled trials

Self-reported measuresSelf-reported measures

Surrogate markers.Surrogate markers.

Intervention TrialsIntervention Trials

Small: n = 90, 100, 150, 200, 500, 1500Small: n = 90, 100, 150, 200, 500, 1500 ShortShort

intervention hours = 1 or less, 2, 4, 8intervention hours = 1 or less, 2, 4, 8 one week-long full-time interventionone week-long full-time intervention

Pre-test & post-test measurementsPre-test & post-test measurements

Knowledge about mental illnessKnowledge about mental illness

Attitudes: Attitudes: Attribution scalesAttribution scales

Attitudes: Attitudes: Social distance scalesSocial distance scales

School Children & Police OfficersSchool Children & Police Officers Community College Students Community College Students

(as surrogates for the general public)(as surrogates for the general public)

6 Uncontrolled trials in England and USA6 Uncontrolled trials in England and USAPinfold V, et al., 2003 (England) - Pinfold V, et al., 2003 (England) - 3 trials3 trialsWatson A, et al., 2004 (USA) Watson A, et al., 2004 (USA) Warner, 2005 (Colorado)Warner, 2005 (Colorado)Spagnolo, Murphy, Librera, 2008 (New Jersey)Spagnolo, Murphy, Librera, 2008 (New Jersey)

1 Nonrandom controlled trial in Germany1 Nonrandom controlled trial in GermanySchulze B, et al., 2003Schulze B, et al., 2003

2 Randomized controlled trials in USA2 Randomized controlled trials in USACorrigan, River, et al., 2001Corrigan, River, et al., 2001Corrigan, Rowan, et al., 2002Corrigan, Rowan, et al., 2002

Anti-stigma Intervention StudiesAnti-stigma Intervention Studies

Protest Protest → →

No measurable effect on attitudesNo measurable effect on attitudes

Anti-stigma Intervention TrialsAnti-stigma Intervention TrialsResultsResults

Protest Protest → → no effectno effect EducationEducation → →

Positive effect on knowledgePositive effect on knowledge

Minimal effect on attitudes, perhaps Minimal effect on attitudes, perhaps greater in school childrengreater in school children

Less effect on social distanceLess effect on social distance

Longer interventions → more effectiveLonger interventions → more effective

Boulder Police Officers Boulder Police Officers Disappointing increase in knowledge.Disappointing increase in knowledge.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-test 82% Post-test 71%

holding at least onemistaken belief aboutschizophrenia

Warner, 2005 (Open the Doors)

English PoliceEnglish PoliceSmall Improvement in attitudesSmall Improvement in attitudes

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Pre-test 2.4 Post-test 2.3

Attitude mean of 5-pointLikert scales, p = 0.006

Pinfold V, et al., 2003 (Open the Doors)

American middle schoolersAmerican middle schoolers Small improvement in attitudes Small improvement in attitudes

0

5

10

15

20

25

30

35

40

Pre-test 22.57 Post-test 21.99

Attitude Mean of 9 items (7-ptLikert scales), p = 0.006

Watson et al. 2004

Anti-stigma Intervention TrialsAnti-stigma Intervention TrialsResultsResults

Protest Protest → → no effectno effect Education →Education → modest, limited effects modest, limited effects ContactContact → →

Greater impact on social distance than Greater impact on social distance than education alone.education alone.

Impact still very small.Impact still very small.

Significant changes in some attitudes:Significant changes in some attitudes: The depressed patient The depressed patient was held less responsible for was held less responsible for

being depressed.being depressed. Depression can improve with treatment.Depression can improve with treatment. Psychosis can improve with treatment.Psychosis can improve with treatment.

____________________________________________________________________

But not others:But not others: The psychotic patient was held no less responsible for The psychotic patient was held no less responsible for

having psychosis.having psychosis.

Contact Contact →→

Corrigan, River, et al., 2001

ContactContact

New JerseyNew Jersey n = 426 adolescentsn = 426 adolescents 1 hour informational session developed 1 hour informational session developed

and facilitated by consumers of mental and facilitated by consumers of mental health serviceshealth services

significantly less stigmatizing attributions significantly less stigmatizing attributions on 7 of 9 factorson 7 of 9 factors

Spagnolo, Murphy, Librera, 2008

Protest RevisitedProtest Revisited

Grassroots efforts directed at the mediaGrassroots efforts directed at the media

Reduce the presentation of negative Reduce the presentation of negative images about mental illness in the mediaimages about mental illness in the media

Increase the presentation of positive Increase the presentation of positive images about mental illness in the mediaimages about mental illness in the media

Short-lived ABC sitcomShort-lived ABC sitcom Only 5 episodes aired in 2006, though 13 Only 5 episodes aired in 2006, though 13

were filmed.were filmed. By the third episode of the show multiple By the third episode of the show multiple

sponsors had withdrawn there supportsponsors had withdrawn there support

Social MarketingSocial Marketing

Changing Minds Changing Minds campaign – campaign – United KingdomUnited KingdomRoyal College of PsychiatristsRoyal College of Psychiatrists

Elimination of BarriersElimination of Barriers initiative – initiative – USAUSASAMHSASAMHSA

Open the Doors Open the Doors – – Calgary,Calgary, CanadaCanada

Like Minds, Like MineLike Minds, Like Mine – – New ZealandNew ZealandNew Zealand Ministry of HealthNew Zealand Ministry of Health

Crisp, et al., 2004Akroyd & Wylie, 2002

Sartorius & Schulze, 2005Vaughan & Hansen, 2004

““Contact” via media portrayalContact” via media portrayal Asked: “Are you prepared to judge?”Asked: “Are you prepared to judge?” TV spots ran 1 wk on/3 wks off for 8 mosTV spots ran 1 wk on/3 wks off for 8 mos A Phase 2 strategy utilized more in-depth A Phase 2 strategy utilized more in-depth

60-second mini-documentaries60-second mini-documentaries Download from www.likeminds.govt.nzDownload from www.likeminds.govt.nz

““Like Minds, Like Mine”Like Minds, Like Mine”Mass Media ComponentMass Media Component

Vaughan & Hansen, 2004

New Zealand: New Zealand: % % agreeingagreeingMental illness…Mental illness…

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

early 2000 late 2000 early 2002 Fall 2002

can happen toanyone

can still lead anormal life

people arebecoming moreaccepting

adapted from Akroyd & Wylie, 2002

New Zealand: New Zealand: % % disagreeingdisagreeingPeople with mental illness are…People with mental illness are…

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

early 2000 late 2000 early 2002 Fall 2002

always unwell

never going tocontributemuch

more likely thanothers to bedangerous

adapted from Akroyd & Wylie, 2002

Social DistanceSocial Distance Willingness to accept “a person who has Willingness to accept “a person who has

had experience of had experience of mental illnessmental illness” as…” as…

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

early 2000 late 2000 early 2002 Fall 2002

work mate

living on yourstreet

next doorneighbor

babysitter

adapted from Akroyd & Wylie, 2002

Social Distance in Social Distance in schizophreniaschizophrenia: : Willingness to accept someone as…Willingness to accept someone as…

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

early 2000 late 2000 early 2002 Fall 2002

work mate

living on yourstreet

next doorneighbor

babysitter

adapted from Akroyd & Wylie, 2002

Experience of persons with mental Experience of persons with mental illness in New Zealandillness in New Zealand

from Akroyd & Wylie, 2003

lot less stigma little less stigma little more stigma lot more stigma

"One of the biggest barriers to recovery is "One of the biggest barriers to recovery is discrimination. That is why stopping discrimination. That is why stopping discrimination and championing respect, rights discrimination and championing respect, rights and equality for people with mental illness is just and equality for people with mental illness is just as important as providing the best treatments as important as providing the best treatments and therapies.”and therapies.”

Blueprint for Mental Health Services in New Blueprint for Mental Health Services in New Zealand, November 1998Zealand, November 1998

National Plan 2007 - 2013National Plan 2007 - 2013

Ministry of Health. 2007. Like Minds, Like Mine National Plan 2007-2013: Programme toCounter Stigma and Discrimination Associated with Mental Illness. Wellington: Ministry of Health.

Sponsors of Sponsors of U.S. Anti-Stigma EffortsU.S. Anti-Stigma Efforts

National Alliance on Mental IllnessNational Alliance on Mental Illness SAMHSA: SAMHSA:

Address Discrimination & Stigma (ADS) CenterAddress Discrimination & Stigma (ADS) Center Elimination of Barriers Initiative (EBI)Elimination of Barriers Initiative (EBI)

Active Minds on CampusActive Minds on Campus National Mental Health Awareness CampaignNational Mental Health Awareness Campaign Mental Health AmericaMental Health America Chicago Consortium for Stigma ResearchChicago Consortium for Stigma Research Open the DoorsOpen the Doors World Psychiatric Association World Psychiatric Association

National Alliance on Mental IllnessNational Alliance on Mental Illness

Protest- “Stigma Busters” Protest- “Stigma Busters”

Education- support groups & “Family to Family”Education- support groups & “Family to Family”

Contact- “In Our Own Voice”Contact- “In Our Own Voice”

www.NAMI.org

SAMHSASAMHSA

- highlights current anti-stigma programs- highlights current anti-stigma programs

- fact sheets, survey data, “how to” tips- fact sheets, survey data, “how to” tips

www.adscenter.org

Elimination of Barriers Elimination of Barriers

- Public Education Program- Public Education Program

- Launched in September 2003- Launched in September 2003

- Pilot projects in 8 states - Pilot projects in 8 states

(California, Florida, Massachusetts, Texas, (California, Florida, Massachusetts, Texas,

No. Carolina, Ohio, Pennsylvania, Wisconsin)No. Carolina, Ohio, Pennsylvania, Wisconsin)

www.allmentalhealth.samhsa.gov

Substance Abuse and Mental Health Services Administration. Developing aStigma Reduction Initiative. SAMHSA Pub No. SMA-4176. Rockville, MD:Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2006.

National Mental Health National Mental Health Awareness CampaignAwareness Campaign

Launched in 1999Launched in 1999

Youth OutreachYouth Outreach Mental Health Media PartnershipMental Health Media Partnership Roundtable DiscussionsRoundtable Discussions

www.nostigma.org

www.activemindsoncampus.org

Founded in 2001Founded in 2001 Focus: Mental Health needs of College Focus: Mental Health needs of College

StudentsStudents

Active Minds on Active Minds on CampusCampus

““Open the Doors”Open the Doors”

Project of the World Psychiatric Project of the World Psychiatric AssociationAssociation

Begun 1996Begun 1996 Focus: Reducing Stigma in SchizophreniaFocus: Reducing Stigma in Schizophrenia 5 continents5 continents 19 countries19 countries

•www.openthedoors.com/english

Efforts in Stigma ResearchEfforts in Stigma Research

-funded by NIMH-funded by NIMH

-principal investigator: Patrick Corrigan, PsyD-principal investigator: Patrick Corrigan, PsyD

www.stigmaresearch.org

Other Anti-Stigma ResourcesOther Anti-Stigma Resources(Prepared by: National Stigma Clearinghouse)(Prepared by: National Stigma Clearinghouse)

Aleppos Aleppos Center for Psychiatric Center for Psychiatric

Rehabilitation - Boston Rehabilitation - Boston University University

National Mental Health National Mental Health Information Center Information Center

Indiana Consortium for Indiana Consortium for Mental Health Services Mental Health Services Research Research

Institute for the Study of Institute for the Study of Human Resilience - Human Resilience - Courtenay Harding Courtenay Harding

MacArthur Research MacArthur Research Network on Mental Health Network on Mental Health and the Law and the Law

NIMH - National Institute of NIMH - National Institute of Mental Health Mental Health

On Our Own of Maryland On Our Own of Maryland Otto Wahl: Writings, Otto Wahl: Writings,

Research, Resource Lists Research, Resource Lists Pathways to Promise: Pathways to Promise:

Ministry and Mental Illness Ministry and Mental Illness People Who People Who Stamp Out Stigma Stamp Out Stigma Stigma of Cinemania: Media Stigma of Cinemania: Media

Ethics (David Gonzalez) Ethics (David Gonzalez) Surgeon General's Reports. Surgeon General's Reports.

See 1999 Report on Mental See 1999 Report on Mental Health, and others. Health, and others.

http:www.stigmanet.org/http:www.stigmanet.org/

Targeted Groups for ChangeTargeted Groups for Change Popular media: journalists and executivesPopular media: journalists and executives EmployersEmployers LandlordsLandlords Criminal justice officials & law enforcementCriminal justice officials & law enforcement Legislators regarding discriminatory lawsLegislators regarding discriminatory laws At risk populationsAt risk populations ConsumersConsumers Providers of health care Providers of health care Mental Health ProfessionalsMental Health Professionals

STIGMA STIGMA

Takes an enormous personal, social, Takes an enormous personal, social, and still unmeasured economic tolland still unmeasured economic toll..

Funding differential for mental healthFunding differential for mental health

Poor integration of consumer servicesPoor integration of consumer services

STIGMA STIGMA Interventions Interventions

Protest, Education, ContactProtest, Education, Contact

Protest against the mediaProtest against the media Face-to-face contactFace-to-face contact Social marketingSocial marketing

Specific interventions must be targetedSpecific interventions must be targeted

Consumer involvement – a mustConsumer involvement – a must

Requires a sustained effortRequires a sustained effort

Over the long term: multi-faceted effortOver the long term: multi-faceted effort

Much has already been done. Much has already been done. Resources are available.Resources are available.

STIGMA and DISCRIMINATIONSTIGMA and DISCRIMINATIONEffective intervention strategiesEffective intervention strategies

Thank youThank you

Good luckGood luck