摘要：In a historic effort to reduce the stigma of mental illness, California voters approved the Mental Health Services Act in 2004. The law funds a comprehensive statewide prevention initiative that places stigma and discrimination reduction at its center, with 25 projects providing interventions at the institutional, societal, and individual levels. Stakeholders selected specific strategies from the research-based California Strategic Plan on Reducing Stigma and Discrimination. Strategies range from social marketing to increase public knowledge to capacity building at the local level, including training that emphasizes participation by consumers of mental health services and cultural competence. Collectively, these strategies aim to foster permanent change in the public perception of mental illness and in the individual experience of stigma. We examined the context, planning, programming, and evaluation of this effort. MORE THAN A DECADE AGO, the US surgeon general identified the stigma of mental illness as the most formidable obstacle to progress in improving mental health. 1 Goffman refers to stigma as a spoiled identity. 2 In the case of mental illness, stigma includes negative beliefs (e.g., people with mental health problems are dangerous), prejudicial attitudes (e.g., desire to avoid interaction), and discrimination (e.g., failure to hire or rent property to such people). The desire to avoid labeling oneself negatively or to conceal one’s problems from others appears to cause treatment avoidance, increase dropping out, and reduce adherence. 3 Today, California is addressing this social injustice and improving the well-being of its communities through a comprehensive statewide initiative supported by Proposition 63, the Mental Health Services Act (MHSA). 4 Passed by California voters in 2004 amid calls for fundamental changes to mental health care, the MHSA begins to fulfill California’s 30-year-old promise to build a community-based mental health system as an alternative to institutionalization. 4 By imposing a 1% tax on personal income in excess of $1 million, the MHSA provides funding and a framework to transform California’s traditional community mental health system to one focused on prevention and wellness, while expanding services to underserved populations and California’s diverse communities. In several ways, the MHSA resembles a blueprint for fulfilling the transformative goals identified in the New Freedom Commission’s Achieving the Promise: Transforming Mental Health Care in America in 2003. 5 The MHSA provides resources to mend a fragmented service delivery system, invest in strategies that support recovery from symptoms, promote community integration rather than institutionalization, and empower clients of mental health services (consumers) and their families to direct their own care. Like the commission’s report, the MHSA makes an explicit commitment to reduce stigma and its negative consequences. Furthermore, following the surgeon general’s call to apply a public health approach to mental health, 1 the MHSA requires that 20% of all funds (which average $1 billion annually) must support a wide range of prevention and early intervention strategies, 6 including programs to reduce not only the stigma of mental health diagnosis and treatment but also discrimination against people with mental illness. 7 Efforts supported by the MHSA aim to improve knowledge, change attitudes, increase help-seeking behaviors, reduce stigma, and challenge discriminatory policies.
