From Resistance to Recovery

Promoting effective messaging • Sticking with it

The numbers show why public health officials are declaring a global mental health crisis. At least 970 million people worldwide are living an anxiety and depressive disorder, according to the World Health Organization. And according to a recent longitudinal study, nearly half of adults worldwide will develop a mental disorder in their lifetime (McGrath et al., 2023).  

Researchers, advocates, and care providers have made progress over the past few decades in increasing the number of people receiving appropriate mental health care. Yet most people with mental disorders receive no treatment, and lack of access to care is only part of the problem. Psychological researchers have documented social and cultural misconceptions and prejudices that discourage help-seeking among people with mental and substance use disorders (Corrigan, et al., 2014; Krendl & Perry, 2023).  

In a 2014 report in Psychological Science in the Public Interest (PSPI), researchers led by Patrick W. Corrigan of the Illinois Institute of Technology noted that stigma arises from a variety of sources, including 

• stereotypes and cultural factors that mark people with mental illness as being dangerous and responsible for their illness; 
• people with mental disorders believing the negative public perceptions and viewing themselves as incurable, or therapy as ineffective; 
• structural discrimination that excludes people with these conditions from job, educational, and social opportunities. 

Scientists are investigating techniques and strategies that can break through the stigma barrier and encourage people to seek help from professionals and loved ones.  

Promoting effective messaging 

In their PSPI report, Corrigan and colleagues identified approaches that can help increase care-seeking, including promoting personal stories of recovery and developing public-education campaigns.  

But the messaging can be challenging. Mental health care advocates have tried mass communication to encourage people with depression to seek help, but studies have shown that messages can actually reinforce negative stereotypes about mental health care.

Psychology researcher Jason T. Siegel at Claremont Graduate University has demonstrated the use of mistargeted communication— messages that are directed at a target individual but are ostensibly aimed at someone else— as a way to sway individuals with depression into considering treatment. In an online study, the researchers asked 335 participants to complete the Beck Depression Inventory-II to gauge their symptoms of depression over the previous 2 weeks. Some of the participants then saw a direct message (e.g., “Are you feeling distressed? Feeling hopeless?”), while others saw a mistargeted message (“Do you know someone who is distressed? Feeling hopeless?”). They were also asked about their attitudes toward help-seeking for mental illness.  

Among participants who received the direct message, those with higher depression scores generally reported lower intentions to seek help from loved ones. But that relationship didn’t hold for participants who received a mistargeted message. 

The findings indicate that the mistargeted message was more effective at promoting help-seeking than the direct message, Siegel and colleagues said.  

A second online study—in which researchers gave 1,152 participants the same depression inventory and then presented them, by video, with a direct message, a mistargeted message, or a control video featuring falling leaves—yielded similar results to the earlier study. 

“Simply put, although a poorly developed [depression-related public service announcement] can cause harm, a well-developed message can possibly save lives,” the researchers wrote (Siegel et al., 2014). 

Scientists are also testing outreach efforts aimed at people who have a culturally based resistance to mental health treatment. For instance, University of Chicago researchers found that bilingual people from cultures that treat mental health as a taboo topic may be more likely to support treatment when they hear information in their second language. 

Related content: Presenting Information About Mental Health in a Second Language Could Help Counter Cultural Norms Against Treatment

The research team, which included APS Fellow Boaz Keysar, conducted this research with 1,120 native Mandarin speakers living in China and the United States who spoke English as a second language. Bilingual natives of China utilize mental health services less than other groups in the United States, the authors noted. 

In the first of four studies, the researchers presented 201 participants in the United States with a vignette—written in either Mandarin or English—about a person with depression. The participants then read four follow-up descriptions of the individual’s progressive decline in functioning, which ultimately led to a job dismissal.  

After each description, participants rated how strongly they would recommend the depressed person go to a therapist for help. The participants were significantly more likely to recommend therapy when they received information about the individual’s condition in English versus Mandarin, though participants’ responses in both conditions became more similar when the person’s functioning declined enough for them to be fired.  

In their second study, the researchers presented 195 bilingual participants in China with a pair of vignettes about a person’s declining mental or physical health and surveyed them about their beliefs related to mental illness. Unlike in the previous study, participants’ treatment recommendations did not vary with the language in which the vignettes and survey were presented. But when participants were asked about mental health stigma in Mandarin, they were more likely to blame the person for their depression compared to when they were surveyed in English. Participants surveyed in either language reported feelings of anger, fear, and aversion related to the depressed individual.  

In a follow-up study of 392 bilingual people in China, participants again were more likely to recommend mental health treatment for the person when they read the vignette in English. The result suggests that an individual may be subject to this language effect even when not culturally immersed in an English-speaking country, the researchers noted.  

Finally, the research team surveyed 323 participants in China about their cultural values and found, as in most of their previous studies, that participants recommended therapy more strongly when they read the mental health vignette in English versus Mandarin. Participants who reported having more traditional Asian values, including placing a high value on social reputation, emotional control, self-reliance, and collectivism, were also less likely to recommend treatment when they completed the study in Mandarin. When participants completed the study in English, however, their endorsement of traditional Asian cultural values did not influence their recommendations, leading them to be more supportive of mental health treatment.  

Future research could explore how these findings might apply to other bilingual populations and how they can be used to craft outreach initiatives, the researchers said (Heller et al., 2023).  

Messaging can also affect individuals’ willingness to seek help for substance abuse treatment, research finds. A team that included APS Fellow Crystal Hoyt of the University of Richmond found that people who read a message about addiction behaviors being subject to change were more likely to report being open to treatment compared with people who read about addiction as a disease.  

For their study, the researchers enrolled 214 men and women who screened positive for substance abuse. Some participants received a message about multiple ways that people can address their addiction (a growth-mindset condition), while others read about changes in the brain that occur during addiction. All the participants then completed a survey in which they reported how much they blamed themselves for their addiction, how confident they were in changing their substance use, and how likely they were to seek treatment.  

The two groups showed no difference in the amount of blame they placed on themselves for their addiction, nor in their willingness to seek pharmacological treatment. But participants who received the growth-mindset message reported stronger intentions to seek counseling or cognitive behavioral therapy compared with the participants who received the disease message (Burnette et al., 2019).  

Sticking with it 

Getting someone to see a therapist is only the first step. Researchers are also exploring factors that encourage people to stick with treatment once they start it.  

A study in Germany, for example, demonstrated the role that therapists’ traits play in keeping patients engaged. As reported in Clinical Psychological Science, Anna Seewald and Winfried Rief, clinical researchers at the Philipps University of Marburg, found that therapists who demonstrate both competence (e.g., using a clear, confident tone, taking notes, demonstrating expertise) and warmth (e.g., smiling, nodding, making an effort to understand the patient) can inspire patients to develop positive beliefs about the effectiveness of treatment. 

Practitioners with these qualities may also boost patients’ willingness to continue therapeutic treatment, strengthen the therapeutic alliance between patients and practitioners, and even improve clinical results, the authors suggested. 

In their study, Seewald and Rief recruited 187 participants who had not been diagnosed with a mental health condition and were not currently receiving psychological treatment. They invited the participants to imagine attending therapy themselves. 

At the beginning of the study, participants listened to an audio recording of a patient telling their therapist about job-related stress. In a second recording, designed to lower participants’ expectations of the effectiveness of psychotherapy, the patient described a negative experience with therapy. 

In the last part of the study, participants were randomly assigned to view one of four videos of the fictional therapist addressing possible treatments for stress. In these videos, the therapist demonstrated either low competence/low warmth, low competence/high warmth, high competence/low warmth, or high warmth/high competence.  

At this point, participants rated the therapist’s warmth and competence and reported how they perceived the therapist’s proposed treatment. The high warmth/high competence scenario inspired the most positive expectations, the most motivation to start psychotherapy with this hypothetical practitioner, and the most comfort with the therapeutic alliance. The researchers called for investigations into the effect that therapist warmth and competence have on the attitudes of people with specific disorders (Seewald & Rief, 2023).  

Other researchers have delved into the specific strengths and weaknesses that therapists bring to the alliance with patients. In a double-blind, randomized control trial led by clinical psychology researcher Michael Constantino of the University of Massachusetts Amherst, patients had better outcomes when they were matched with therapists who had a track record of effectively treating the patients’ primary problem. Patients who had the most severe problems and those who identified as racial or ethnic minorities appeared to benefit most from this type of match.  

The study involved 48 therapists and 218 outpatients at community clinics in Cleveland, Ohio. Constantino and colleagues assigned some patients to a provider using a matching algorithm and others through conventional means. Therapists and patients were not told how they’d been matched.  

“Notably, the good fit in this study came not from changing what the therapists did in their treatment, but rather who they treated,” Constantino and colleagues reported in JAMA Psychiatry (Boswell et al., 2022). 

Clinical scientists emphasize that findings from research on attitudes about mental illness can help shift those views and erode the psychological, social, and cultural factors that keep people from getting treatment. 

As Corrigan wrote in his book, Challenging the Stigma of Mental Illness: Lessons for Therapists and Advocates, the stigma is “first and foremost a social justice issue.” 

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