Decades of societal and cultural misunderstanding leave mental health shrouded in judgement, infused with moral disapprobation, and in many ways generally viewed as a character failure. Despite substantial advances in our scientific understanding of mental health over the years, there remains a disconnect between evidence and public perception, a disconnect even between the science and clinicians. Efforts to normalize how mental health is seen in the public often take the form of public education campaigns aimed to destigmatize mental health, and attempt to usher in a new understanding of health, inclusive of mental health.

Stigma has been defined in two ways: public stigma and self-stigma. However, both essentially address the same phenomenon: negative thoughts attributed to mental health leading to a negative behavior (e.g. avoiding seeking care because of what people will think). Further, mental health stigma has been found to have a negative impact on such important areas like employment and health care costs. In response to these countless studies on the negative impact of stigma, public education and stigma reduction campaigns have been a major strategy. But like all things public health, this one too does not occur without some controversy and unintended consequence.

Stigma Reduction Efforts

Stigma and discrimination reduction campaigns around mental health have had mixed results. Stigma reduction may help normalize mental, emotional, and behavioral health problems. Many stigma reduction campaigns aim to improve knowledge of mental health, educate the audience about the biological basis for mental illness, and help people feel more comfortable interacting with those experiencing mental health problems. Often, attempts are made to make mental, emotional, and behavioral health analogous to physical health issues. Like high blood pressure, strep throat, and arthritis, there is no individual cause for one’s suffering. The person suffering mental illness, emotional distress, or behavioral health problems has done nothing to deserve their illness, nothing to cause their illness, and is not personally responsible for having acquired their illness.

While the impact of stigma reduction efforts on the life of those suffering mental illness is unclear, there is growing evidence that educational stigma reduction programs that focus on the biological basis for mental illness can create the belief that it is intractable or reinforce the belief that the illness or a behavior problem is “hard-wired” and not amenable to treatment. Others have found that, while participants may know more about mental illness, they acquire more negative attitudes towards those with mental illness, and are more likely to avoid those with mental and behavioral health problems.

Stigma reduction programs may be crowding out space in the conversation for prevention of mental, emotional, and behavioral health problems. The idea that mental illness is biologically based, “hard-wired,” genetic, suggests there may be nothing we can do to prevent it. However, prevention is possible.

Consider the 2009 report by the Institute of Medicine. In this report, there are concrete and actionable steps to help prevent mental, emotional, and behavioral problems in children. Examples include strategies on offering early intervention for families and individuals and promoting mental health treatment in schools and community programs. It is possible to prevent the illness as well as treat and minimize the dysfunction that may accompany mental illness.

How We Can Prevent Behavioral Health Problems

How might we actually prevent mental, emotional, and behavioral health problems? Alexander Leighton, in his ground-breaking work My Name Is Legion, on mental illness and the community, wrote that some mental, emotional, and behavioral health problems are associated with, and may be caused by human susceptibility to our community environment. It is not an individual’s fault they acquire a mental illness, nor is it always hard-wired into their DNA that they will manifest mental illness or emotional distress. Community factors may have more influence on mental illness than we currently appreciate.

Leighton described the concept of community “dis-integration” as a general failure of the community functioning such that almost everyone in the population is exposed to stress. Leighton found that communities that were suffering dis-integration had higher prevalence and incidence of mental, emotional, and behavioral health problems (MEBH), including increased incidence of chronic persistent mental illness. Efforts aimed at improving community integration resulted in lower incidence of MEBH.

And general population stress is on the rise. In their annual stress survey, the American Psychological Association found that 42 percent of respondents reported feeling nervous or anxious in the past month, up from 35 percent the year before, and 24 percent of respondents reported extreme levels of stress in the past year, up from 18 percent. Adults who received more emotional support reported lower stress levels. Increased levels of general stress may be seen in lower socioeconomic communities, ethnic groups, and immigrant populations leading to higher levels of mental, emotional, and behavioral health problems. Prevention efforts aimed at community integration may be a strategy for reducing health disparities.

Integrating primary care and behavioral health is a potent start at addressing mental health as an integral component of overall health care. However, every referral to an outside mental health center regardless of integration status in practice serves to perpetuate the disconnect between mind and body, increase stigma, and prolong practice and community dis-integration.

We support stigma reduction efforts aimed at helping the general population recognize that the human condition is one of oscillation along a continuum of mental, emotional, and behavioral health across a lifespan. Some, with the help of family, friends, neighbors, and communities, are able to cope with these oscillations, the ups and downs of life, depending on their magnitude. Others reach a point along the continuum requiring professional help and support, or medication.

Some people are more prone to one end of the continuum or the other. We are all on that continuum. No, people don’t deserve to get sick. Mental, emotional, and behavioral health problems are not the result of moral failure, neither are they caused by random bad luck. We can prevent some of the movement along the continuum representing overt mental illness and emotional distress. Not all of it, and not all the time. But in our efforts to eliminate all judgement and stigma from mental, emotional, and behavioral health conversations, we have crowded out the space to consider prevention.

As we develop ongoing efforts to integrate behavioral health into primary care and community, recognizing community assets that can support mental health and wellness is crucial to changing the overall perception of mental health. In fact, could it be that by better addressing prevention and integrating care we begin to redefine health? Could it be that mental health is just that, a part of health that does not warrant separate discrimination in prevention efforts, care delivery, payment, and policy?

We offer the following recommendations aimed at preventing mental, emotional, and behavioral health problems. As multiple stakeholders attempt to advance efforts on mental, emotional, and behavioral health (e.g., Congress, state policymakers), it is critical to consider the role of prevention. If we, as a society, are truly serious about decreasing our health care costs and improving our health outcomes, we must downsize who needs services in the first place. We must “shift the mean” in order to begin to address problems before they are catastrophic; to encourage people to seek help within their communities as soon as possible.

It’s time to clear up our faulty understanding of health; it’s time for the pieces to come together as a whole, to integrate mental, emotional, and behavioral health into health care and health services research. For this to occur it will not be a simple stigma education campaign — no, this is a cultural shift decades in the making. Let’s reintroduce prevention into our dialogue around mental, emotional, and behavioral health, engaging patients, providers, researchers, and policymakers in open and meaningful conversation. Let’s create an “upstreamist” culture of those who are committed to preventing problems before they start, pursuing research efforts and funding aimed at identifying successful strategies for preventing mental illness and emotional distress.

Now is the time to identify and support local assets aimed at prevention, treatment, and stigma reduction to build local communities of solution for mental, emotional, and behavioral health.

Let’s not just stand around waiting downstream to treat. Let’s forge our way upstream together.