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NEW RESEARCH
Empowering the Next Generation to End Stigma by
Starting the Conversation: Bring Change to Mind and
the College Toolbox Project
Bernice A. Pescosolido, PhD, Brea L. Perry, PhD, Anne C. Krendl, PhD
Objective: To examine outcomes in a 4-year college pilot program built on stigma change research. U Bring Change to Mind (UBC2M) was
developed and launched at Indiana University (IU) in 2014 as an institutionally supported, student-led organization to make campuses “safe and stigma-
free zones.”The accompanying College Toolbox Project (CTP) assessed change in student prejudice and discriminatory predispositions as well as
perceptions and behaviors at follow-up.
Method: All entering Class of 2019 students were invited to complete a Web-based survey (N ¼3,287; response rate ¼44.6%). In their third year,
students were sent a follow-up survey. Stigma indicators for 1,132 students completing both waves were analyzed using descriptive statistics and
multivariate regressions. Models controlled for social desirability, prior contact, socio-demographics, and self-reported mental illness. Participation was
examined for potential biases.
Results: Statistically significant positive changes in attitudes and behavioral predispositions emerged. Although fewer students with prior contact
endorsed stigma items initially, they reported significant reduction at follow-up. UBC2M active engagement was associated with lowering prejudice.
Both passive and active engagement predicted change in discriminatory predispositions as well as current inclusive behaviors and positive perceptions of
campus mental health culture.
Conclusion: A long-term, community-based, student empowerment approach with institutional supports is a promising avenue to reduce stigma on
college campuses, to develop the next generation of mental health leaders, and to potentially reduce societal levels of stigma in the long run. CTP
provides evidence that both contact and contextual visibility matter, and that UBC2M offers a nationally networked organizational strategy to reduce
stigma.
Key words: stigma, mental health, intervention, college, emerging adults
J Am Acad Child Adolesc Psychiatry 2019;-(-):-–-.
research resurgence over the past two decades
has provided a solid scientific foundation for
understanding possibilities and limits for stigma
reduction.
1
Recent reviews, including the National Acad-
emy of Sciences (NAS) report, Ending Discrimination
Against People with Mental Illness and Substance Use Disor-
ders: The Evidence for Stigma Change,
2
provide both
encouraging and discouraging conclusions.
3-8
On the pos-
itive side, concepts have been clarified, facilitating an un-
derstanding of the multilevel, complex nature of stigma
surrounding mental illness (MI), defined as the prejudice
and discrimination surrounding MI.
1,5,9
Efforts to reduce
the consequences of negative social labeling of MI have
clearer targets and goals. Furthermore, in Western nations,
most of the public tacitly endorses underlying neurobio-
logical causes of MI while rejecting older, morally based
etiologies (ie, weak character).
3,10
Intervention studies
demonstrate the ability to “move the needle,”reducing
damaging beliefs, perceptions, and behaviors.
11-13
Finally,
perhaps the biggest change since the 1950s, is the growing
willingness of individuals to talk to friends and relatives
about mental health problems.
14
Personified by high-profile
individuals disclosing mental health struggles across sports,
entertainment, literary, and even political spheres, “testi-
monies of service users”as active ingredients of stigma
reduction is promising.
15
Contrary evidence shades optimism. In the United
States, stigma has not dissipated as predicted after deinsti-
tutionalization.
3,16
As the foremost obstacle to recovery,
17
stigma continues to amplify the devastating effects of MI
on individuals, families, professions, and commu-
nities.
4,18,19
From years of life lost to continued high
A
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unemployment rates, stigma diminishes personal and soci-
etal productivity.
20
Despite becoming more sophisticated in
understanding MI, a near public majority expresses ani-
mosity and endorses exclusion.
6
The battle over parity in
insurance, research funding, and services continues.
21
Some
messages, once considered key (eg, “a disease like any
other”), have been shown to be ineffective at this point.
22
Many anti-stigma efforts, based on “myths”about stigma
reduction, are never tested for effectiveness.
5
Those tested
have been characterized as having weak study designs,
inadequate sample sizes, and effects that extinguish over
time. Interventions focus primarily on attitude, less critical
from consumers’viewpoints, rather than behaviors or
behavioral predispositions.
5,12,13
Even the utility of the
“contact hypothesis”as a change agent is up for debate.
11,23
Seasoned stigma researchers and providers recommend
abandoning “familiar but ineffective approaches”
5
(p. xx).
In response, Glenn Close, actor and activist, began
speaking about MI in the context of her family’s history,
building an advocacy organization centered on “conversa-
tion”as a mechanism to decrease stigma. In August 2009,
Bring Change to Mind (BC2M) aired its first public service
announcement (“Grand Central Terminal”) and formulated
its two organizational pillars: a scientific foundation, and
inclusion of family and friends in all efforts (https://
bringchange2mind.org). This article reports data on one
of BC2M’s three major programs: U(niversity) Bring
Change to Mind (UBC2M), a student-led, anti-stigma
effort designed to create “stigma-free zones”on college
campuses. As Sontag-Padilla et al.
24
recently documented,
peer-to-peer programming has now been recognized as a
potential solution in higher education.
College administrators have taken note of mental health
(MH) issues, given recent research that has documented
high levels of MH problems among college students and a
similar rate of untreated problems as seen in the general
population.
25-28
Students generally enter during the mean
age of MI onset (1524 years of age) and face critical life
course transitions, including an elevation of academic re-
sponsibilities, movement out of the family home, shake-up
in friendship and support networks, and multiple cross-
pressures from social, living, and academic arrange-
ments.
29
With pressure on college health centers to increase
MH services, parents, students, administrators have
changed the dialogue. New advocacy organizations formed:
in 2000, the JED Foundation (https://www.jedfoundation.
org); Active Minds in 2003 (https://www.activeminds.org/
about-us./our-story); the National Alliance on Mental Ill-
ness’s revamped college efforts in 2013 (https://www.nami.
org/About-NAMI/NAMI-News/2013/New-Semester-New-
NAMI-on-Campus-Clubs); and Mental Health America’s
Life on Campus Program (http://www.mentalhealthamerica.
net/whats-your-plan-college-mental-health-disorder). Many
colleges and universities assembled task forces to confront
these pressures and to discuss novel programing (eg,
McLean Hospital’s ICARE
25
Internet-based treatment for
depression in college students, now in clinical trials).
Until recently, there were no rigorous evaluations of
stigma reduction efforts in higher education.
24
Here, we
assess BC2M’s college program, UBC2M. We examine
change over time on multiple stigma dimensions. On the
individual level, we hypothesized that active engagement
with UBC2M (eg, attending events, seeking out informa-
tion through social media or coursework) will have short-
term (favorable normative beliefs, more openness in
discussing MH) and long-term (stigma reduction) benefits.
At the campus level, we hypothesized that passive exposure
to UBC2M (eg, the UBC2M logo, bus, or flyers around
campus) will have similar short-term and long-term bene-
fits. The fundamental rationale for the individual-level hy-
pothesis stems from classical theory of prejudice reduction
based on active contact among those of equal status in the
pursuit of common goals.
30
The contextual-level hypothesis
draws from two sources: first, the synthetic, dual-process
theory of culture that suggests that cultural worldviews
shape local network inclusion
31
; second, the theory that the
larger culture, defined as normative beliefs and shared
behavioral expectations in a particular place, affects in-
dividuals’attitudes and beliefs, especially among the newer
members.
32,33
By evaluating within-person change in atti-
tudes and behavioral predispositions alongside current be-
haviors and perceptions, the results offer promising
directions for stigma interventions.
METHOD
Study Design
The CTP Outcomes Assessment (IU-IRB Protocol
1407536121) is based on online surveys administered in 2
waves during Years 2 and 4. Year 1 involved human subject
approvals, specific Indiana University (IU) permissions,
pilot events and instrument testing. All Class of 2019 stu-
dents (N ¼7,376) were eligible to participate at baseline
(Time 1; T1). IU Research Technologies’data manager, not
the research team, provided access to the IU(Bloomington)
Data Vault by the IU Council of Data Stewards, allowing
confirmation of first year status. Students were invited to
the survey at Orientation. Later, the Strategic Planning and
Research group, Office of Enrollment Management, sent
survey invitation e-mails, queued confidential reminders to
nonrespondents, and provided limited socio-demographic
data for consented subjects. Students completing the
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survey (N ¼3,287; response rate ¼44.6%) received a
student-designed “swag bag”(eg, IU/BC2M tank top, fanny
pack, light backpack). Two years later, current Class of
2019 students were sent invitations to the follow-up survey
(Time 2; T2 N ¼1,832; response rate ¼27.6%). We focus
on 1,193 students who completed both waves. Missing data
on individual variables slightly reduce sample sizes. Intra-
individual comparison lessens response bias inherent in
comparing responses of all panel respondents. As part of a
separate research question investigating whether and how
language matters, the survey at both time points used four
forms, randomly assigned to students. The different forms
each used person-first language, but described the person as
having “mental illness,”“mental health problems,”“a his-
tory of mental illness,”or a “history of mental health
problems.”Analyses of covariance controlling for prior
contact with individuals with MI found no effects of lan-
guage, so data are collapsed across forms.
The IU undergraduate demographics were 51% female
respondents, 70.8% white, and 62.5% in-state students. In
addition, 58.1% of the students were between 18 and 21 years
old (mean age, 18.37 years; https://www.collegefactual.com/
colleges/indiana-university-bloomington/student-life/diversity/).
Women accounted for 70.7% of respondents, 82.2% were
white, 69.5% were in-state students, 17.3% reported a
current/past MI, and 24.3% had low socioeconomic status
(see Tables S1 and S2, available online).
The Program: UBC2M
The impetus for a college program came from three sources.
First, given small-to-modest changes documented in large-
scale public efforts and extinguishing effects in individual-
level interventions, BC2M searched for alternative theories
of change. Sociological research suggested that cultural
change does not happen so much as a result of changing
“hearts and minds”but because individuals with new atti-
tudes, values, and beliefs come to the fore in organizations
and society.
34-37
Variously referred to as cohort replacement
theory or the acquired disposition models of cultural
change, this approach posits that individuals’character and
beliefs stabilize in formative periods, remaining fairly stable
afterward. This pointed to younger cohorts as a longer-run
strategy, with the advantage of potentially creating a new
generation of medical, political, and social leadership in
mental illness, including stigma. At the same time, pio-
neering research on college student mental health, reports
from college counseling center directors, and Center for
Disease Control and Prevention (CDC) suicide reports
document a growing MH crisis among youth.
26,38-40
UBC2M marked the goal of making colleges and uni-
versities “safe and stigma-free zones,”focusing on public
stigma, that is, the campus cultural climate. It followed the
review by Yamaguchi et al.
12
of educational- based efforts
calling for longer-term follow-up of stigma efforts. The
Program Advisor for Cognitive Disorders (Banbury Center),
held a planning meeting April 1417, 2014, at Cold Spring
Harbor Laboratory. Eighteen IU undergraduate and grad-
uate students, national and international stigma researchers,
and founder and members of BC2M and youth MH pro-
grams spent 2 days developing the “bones”of a novel college
program. The result was a two-part effort to develop and to
assess a campus-based effort at IU, the academic home of
BC2M’s Chair of the Scientific Advisory Board (first
author). First, the College Toolbox Project (CTP) provided
institutional support, and an assessment carried out by an
interdisciplinary science, staff, and student team working
pro bono. The CTP synced with what would later become
the primary NAS report
2
recommendation: long-lasting
stigma change requires continuous efforts that attack all
levels of stigma and use all tools available. Faculty designed
and implemented the assessment, provided mentorship, and
worked with institutional officials to clear administrative
hurdles. Second, UBC2M, the “U”niversity arm of BC2M,
would be a student-led club planning and carrying out anti-
stigma activities, advocating for change in college policies,
and creating “safe and stigma-free zones.”
UBC2M’s foundation was based on five general prin-
ciples from stigma research (Table 1). UBC2M targets
college as “community,”but where specific events may
focus on different groups (eg, freshman, students of color,
faculty, the larger Bloomington community). Leadership,
based on a peer-to-peer model, is charged with designing
programs and policies that speak to stigma, including the
possibility of intersectional or multiple stigmas, and are
provided the resources to do so. The basis for UBC2M
efforts is scientific research, avoiding approaches known to
be ineffective, condescending, or narrowly pedantic. Leaders
leverage community resources for greater impact and to
integrate anti-stigma efforts into the life of the community,
not just those with or with an interest in MH. UBC2M
aims for an approach with flexibility to change, continually
drawing from community energy, and moving with socio-
demographic and cultural trends.
2,5
These five general principles translate into five working
principles. First, start early and often. Second, use primarily
a“by students, for students”approach with activities,
including formative research, designed and carried out by
students with staff/faculty mentoring. Third, use a “bait and
flip”model. Research suggests that previous contact is a
fairly robust correlate of lower stigma, a potentially powerful
change lever, and a characteristic of typical participants
(those “inside the choir”).
41
Yet, those who report not
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knowing persons with mental health issues (those “outside
the choir”) are less likely to participate, and more typically
endorse stigma. Engaging wide participation calls for
innovative events and participation incentives (class credits,
swag, fun, support for other clubs). Fourth, leverage existing
student organizations, relevant classes, and university re-
sources to weave MH into the campus fabric. Finally, view
UBC2M, from the outset, as a “living library”of experi-
ences, creating resources (eg, event “blueprints,”whether
successful or not) with the expectation that each student
cohort, and each UBC2M campus, would build ownership
by developing unique events and blueprints.
College students showed remarkable leadership and
enthusiasm, facing the logistic and institutional challenges
successfully. Over time, student leadership developed
normative standards or expectations for their semester ac-
tivities. These include: biweekly club meetings; activity at
New Student Orientation “Late Nite”(eg, IU belonging art
project, a mosaic of individually drawn cardboard tiles);
participation in the Sex, Drugs, and Rock’n’Roll “Welcome
Week”event (eg “Stigma can suck my popsicle”activity
with temporary tattoo and lime green popsicle give away),
Student Involvement Fair (table for recruitment), “First
Thursdays”Festival (eg, hands-on stigma activity with
TABLE 1 Summary of Selected Principles From Stigma Reduction Research (Panel A) Tailored for College/University Programs
(Panel B)
Panel A
Selected Underlying General Principles for
Anti-Stigma Programs Implication for Current Program
Target a Population, Clarify
Relevant Message
Do not target general, national population as a
whole, but groups likely to be open to change
and that are potential leaders
College students stand at a key transition
point; goal is inclusion and tolerance
Choose Leaders “of the
Community”and Provide
Resources
Institutional programs, especially if forced, are
less likely to be effective
Faculty and staff are less likely than students
to develop successful student programs
that target culture
Avoid Known, Ineffective
Approaches
Base the program in the research on effective
anti-stigma approaches
Mentoring for student club includes science;
go beyond classroom
Leverage existing resources Avoid common unwillingness among MH
organizations to work together and typical
tradition to “own”programs
Partner with existing student groups,
institutional events
Build in Change Flexibility is essential to continue efficacy as
communities undergo social change.
Detailed manualized programs inappropriate
for anti-stigma programs
Panel B
Tailored Principles for Anti-Stigma University
Programs Implication for Current Program
Start Young Within the college population, special focus on
entering students
Include all students in events, but target first-
year students for special emphasis
By Students, for Students Organic focus on the campus climate, not
institutional requirements or needs; awareness
remains in-scope
Education most effective with younger
groups; leave to faculty, administration
Employ “Bait and Flip”Model Consider first what will draw students in to
receive the messages and start conversations
Get “outside the choir”to be most effective
Infiltrate, Share, and Build
Resources
Events require resources often outside student
organization budget; get “outside the choir”
facilitated by co-branding and volunteering in
related events
Seek places, other student groups or college
offices with similar goals to pool resources
and introduce similarity of larger goals
Create Shareable Resources
That Build Larger Effort
Provide guides to failed and successful events;
this includes what it takes to do the event, how
to do it, where tailoring should be considered,
and engage students to do simple, summative
assessments included in materials
Create “living library”of each event that
includes blueprint and assessment, and
allows for other campuses to have
ownership and program to move with
higher education culture
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UBC2M giveaways); one major UBC2M event (eg, “Bring
in the Booty”scavenger hunt with MH activity stations);
one co-branded event (eg, Union Board’s“Love the Skin
You’re In”Fashion Show promoting body-type diversity
and inclusivity); annual campus anti-stigma campaign
competition; one academic event (eg dinner and panel on
“13 Reasons Why”TV series); “De-Stress”event (eg, finals
study-break activities such as massages, coloring, kinetic
sand, word searches, and snacks); campus bus wrap design
(eg, lime green skin with branding and stigma “story”line);
student speakers during annual BC2M gala and major
events; and other efforts, both small (eg, tabling events) and
large (eg, Kelley School of Business hosting Late Show
actor/comedy writer/alumnus Brian Stack to speak about
anxiety and depression).
Measures
Dependent Variables. With stigma research on college
experiences being relatively recent, items were chosen from
standard scales, college-specific measures were developed,
and standard social distance items were adapted.
10
A prin-
cipal components analysis (PCA) determined whether items
loaded together with acceptable eigenvalues (>1) and suf-
ficiently high Cronbach’s
a
for internal consistency. As
required, individual scale items were reverse scored so that
higher raw scores indicate more stigma. In each case, results
suggested a one-factor solution. Retained items had a factor
loading of 0.30 or above.
42
We adapted two sets of prejudice items with responses
ranging from 1 (strongly agree) to 4 (strongly disagree). First,
12 items tapping General Prejudice (eg, “I am frightened to
be around persons with a history of mental illness”) were
analyzed. PCA identified eight items with acceptable inter-
item reliability (Cronbach’s
a
>0.77) that loaded on the
first factor (loadings: 0.390.70). Remaining items were
discarded. Second, College-Specific Prejudice drew from 12
items (eg, “Students who have a history of mental illness
should not be admitted to IU”). Nine items loaded on one
factor (loadings: 0.500.76), with good inter-item reliability
(Cronbach’s
a
>0.85). Three items were discarded.
Discriminatory predispositions were measured using
adapted College-Specific Social Distance, comprising 11 items
on unwillingness to engage across different interactions (eg,
“have a student with mental illness in one of your classes,”“as
a roommate”). Responses were 1 (definitely willing) to 4
(definitely unwilling). All 11 items loaded on one factor
(loadings: 0.440.83), with high inter-item reliability
(Cronbach’s
a
>.91).
General and College-Specific Prejudice as well as
College-Specific Social Distance were measured at both
times. Current perceptions and behaviors were assessed only
at T2. Perceptions of Campus Mental Health (MH) Cul-
ture included six items (eg, “I feel more free to talk about
mental health problems and stigma issues”) with responses
from 1 (strongly agree) to 4 (strongly disagree). All six items
loaded on one factor (factor loadings: 0.680.85) with high
inter-item reliability (Cronbach’s
a
¼0.86). Behavior,
Number of MH Conversation Partners, was assessed
through a list asking the number of person types (ie, stu-
dents, faculty) with whom they had talked about mental
health or stigma in the past year, serving as an indicator of
discussion or disclosure disinhibition (Table 2).
Independent Variables. Contact occurred in two ways:
through UBC2M Active Engagement or UBC2M Passive
Engagement. Active was assessed in two ways: asking re-
spondents to check UBC2M-sponsored events that they
attended (Number of Events Attended), and identifying all
possible ways they were “in contact with or became aware of
UBC2M”from a list of eight possibilities: UBC2M website,
UBC2M Facebook page, UBC2M Twitter follower, ban-
ners, UBC2M events, UBC2M courses, UBC2M bus, or
no interaction (Number of Contact Types). Of the possible
contact types, 4 had endorsements from >10% of the total
respondents: banners (30.5%), UBC2M events (19.9%),
UBC2M bus (31.9%), and no interaction (30.1%). Bivar-
iate correlations were used to determine the association
between contact types and stigma change for any variables.
No significant effects emerged (all pvalues >.10). Active
contact types reflected different ways in which respondents
could have actively sought out UBC2M-related information
or activities. Overall Active Engagement combined the two.
UBC2M Passive Engagement was measured by asking re-
spondents to identify the correct UBC2M logo (Recognized
Logo) from four options, assessing exposure free from social
desirability or recall bias. Passive engagement was also was
measured by asking respondents “How did you hear about
UBC2M?”(flyers, social media, class, friends, students,
branded items, Number of Ways Student Heard about
UBC2M) with a “none”option. Passive UBC2M engage-
ment is distinguished from active contact because they
capture exposure without having sought out the informa-
tion. From these, Overall UBC2M Passive Engagement was
created.Support for active participation is widespread in
stigma research.
1
However, research also suggests that cul-
tural symbols affect individuals’evaluations. They assign
meaning, in this case positive, that individuals interpret.
43
Swidler
44
has argued that during unsettled times in in-
dividuals’lives (such as entering college), symbols, doctrine,
and ritual shape attitudes and behaviors. With professors,
friends and material symbols touting acceptance of differ-
ence in MH, even passive engagement holds potential.
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Although national stigma studies have documented
only inconsistent findings for socio-demographic variables,
college studies have found that younger, male, and poorer
respondents endorse stigma.
28
We control for those here.
Finally, studies have assessed the importance of prior con-
tact with individuals with MI and respondents’desires to
provide answers that they believe others would expect.
1,30,45
Although effects were found in face-to-face interviews only
(versus computer-assisted, like CTP), we control for social
desirability.
46
At the end of the survey, respondents pro-
vided demographic information: Sex (male or female), Age
(in years), Race (white or nonwhite), Ethnicity (Latinx/not),
Self-reported Mental Illness (yes or no), Childhood Socio-
economic Status (high or low), and In-state Status (yes or
no). For Prior Contact, respondents reported number of
individuals with MI that they knew at baseline. At T2 only,
respondents also completed seven true/false items from a
standard scale to assess Social Desirability (eg, “I have never
deliberately said something that hurt someone’s
feelings”).
47,48
Analytic Strategy
Paired ttests for T1/T2 measures assessed within-person
change over time. Dependent measures were converted to
difference scores between T1 and T2. Negative difference
scores indicate greater stigma reduction and fewer discrim-
inatory predispositions, since higher raw scores on each
measure indicate more stigma. The difference model ad-
dresses time-invariant omitted variables, including prior
experiences or static traits that might influence individuals’
engagement level. Replicated analyses using an alternative
specification for two repeated measures, the lagged depen-
dent variable model, produced identical patterns of signifi-
cance for engagement (on request). Separate models
determined whether active (Number of Events Attended,
Overall Active Engagement) or passive (Recognized Logo,
Overall Passive Engagement) engagement had long-term
benefits associated with stigma change (General Prejudice,
College-Specific Prejudice), discriminatory predisposition
(College-Specific Social Distance), and/or short-term ben-
efits associated with favorable, current campus culture per-
ceptions (Campus MH Culture), and current behavior
(Number of MH Conversation Partners). Each model
assessed whether a specific type of engagement predicted a
specific dependent variable, using ordinary least-squares
regressions (with OLS, linear, and/or nonlinear poly-
nomial terms) or Poisson regression analyses, as appropriate.
All regression models adjusted for Sex, Age, Race, Self-
reported MI, Childhood Socioeconomic Status, and In-
state Status. Additional sensitivity analyses examining
Ethnicity, Social Desirability, and Prior Contact revealed no
difference in substantive conclusions. These later variables
were dropped for parsimony. Models were successfully
replicated in the subsample self-reporting MI and in using
all available cases in T1 and T2.
OLS regression was used to determine whether re-
spondents’UBC2M active and passive engagement was
associated with changes in prejudice and discriminatory
predispositions. Because variables measuring active, but not
passive, engagement were skewed, we entered them as both
linear and nonlinear (polynomial) terms (simultaneously) in
their respective regression equations. The expectation with
such skewed data is that the effect of participating in no
events, as compared to one event, may be different from
between 4, 5, or 6 events, which mark the upper range of
the distribution. Polynomial terms are reported only when
significant. To examine whether UBC2M engagement was
associated with more favorable perceptions of Campus MH
TABLE 2 Descriptive Statistics (n, Means, SD) for Prejudice and Discriminatory Predispositions, Campus Mental Health (MH)
Culture, and U Bring Change to Mind (UBC2M) Engagement (Active, Passive), College Toolbox Project, Indiana University (IU),
20152018 (N ¼1,132)
Stigma Types Time Point n Mean (SD)
Attitudes and Beliefs about
Mental Illness
General Prejudice T1 975 15.69 (4.10)
T2 975 13.97 (3.57)
College-Specific Prejudice T1 933 14.81 (4.54)
T2 933 12.78 (3.78)
Discriminatory
Predispositions
College-Specific
Social Distance
T1 913 19.98 (6.28)
T2 913 17.27 (5.85)
Perceptions of Campus Culture Campus MH Culture T2 1,132 15.95 (7.36)
Behavior No. of MH Conversation Partners T2 1,132 2.55 (1.95)
Active UBC2M
Engagement
No. of Events Attended T2 1,132 0.88 (1.57)
No. of Contact Types T2 1,132 0.97 (1.09)
Passive UBC2M Engagement Recognized Logo T2 1,132 0.50 (.50)
No. of How Heard T2 1,132 15.95 (7.36)
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Culture and Number of Conversation MH Partners, a
simple count, not zero-inflated, was used with Poisson
regression analyses in Stata 15. Statistical significance was
set at
a
0.05, two-tailed test (for full results, see
Tables S3S6, available online).
RESULTS
Prejudice and Discriminatory Predispositions
Paired ttests for the stigma measures at T1/T2 revealed that
stigma was lower at T2 across all measures. Specifically,
General Prejudice decreased over time (mean
T1
¼15.67,
SD ¼4.10; mean
T2
¼13.97, SD ¼3.57; t(974) ¼13.05,
p<.001, 95% CI ¼1.46, 1.98), as did College-Specific
Prejudice (mean
T1
¼14.81, SD ¼4.54; mean
T2
¼
12.78, SD ¼3.74; t(932) ¼13.30, p<.001, 95% CI ¼
1.73, 2.32). College-Specific Social Distance (mean
T1
¼
19.98, SD ¼6.28; mean
T2
¼17.27, SD ¼5.85) also
decreased over time (t(912) ¼13.21, p<.001, 95% CI ¼
2.30, 3.11). This magnitude of change ranges from a 10.9%
to 13.8% decrease. Among controls, only older entering
students, women, and out-of-state students fairly consis-
tently reported passive changes.
Active Exposure
UBC2M Active Engagement had differential effects on
stigma. Specifically, Number of Events Attended was asso-
ciated with reductions in both General and College-Specific
Prejudice (respectively,
b
¼–0.06, SE ¼0.01, p<.001,
95% CI ¼–0.09, –0.03;
b
¼–0.05, SE ¼0.02, p¼.005,
95% CI ¼–0.08, –0.01) as well as College-Specific Social
Distance (
b
¼–0.05, SE ¼0.02, p¼.02, 95% CI ¼
–0.09, –0.01). However, all effects were nonlinear
(Figure 1). Stigma reduction was relatively small if re-
spondents attended only a few (one to three) events, but was
pronounced when respondents attended multiple (four or
more) events (Figure 1A). This does not support our initial
assumptions about non-inear effects. It does support a
“tipping point,”nonlinear effect. The Number of Events
Attended was linearly associated with increased favorable
perceptions about Campus MH Culture (
b
¼1.29, SE ¼
0.13, p<.001, 95% CI ¼1.03, 1.55), and Number of
MH Conversation Partners (ie, incidence rate ratio [IRR] ¼
1.08, 95% CI ¼1.06, 1.10) (Table 3).
Similarly, Number of Contact Types was associated
with stigma reduction, but only for General Prejudice (
b
¼
–0.15, SE ¼0.07, p¼.02, 95% CI ¼–0.28, –0.02) and
College-Specific Prejudice (
b
¼–0.22, SE ¼0.08, p¼
.004, 95% CI ¼–0.37, –0.07) (Table 3). In both cases,
relatively little contact was associated with minimal stigma
reduction, but multiple forms (three to four) of contact
were consequential, again suggesting a tipping point
(Figure 1B). Overall Number of Contact Types did not
affect College-Specific Social Distance, but was linearly
associated with increased favorable perceptions of Campus
MH Culture (
b
¼2.68, SE ¼0.18, p<.001, 95% CI ¼
2.32, 3.04]), and Number of MH Conversation Partners
(IRR ¼1.20, 95% CI ¼1.16, 1.23) (Table 3). Table S7,
available online, lists the number of respondents by number
of events attended and by number of contact types.
Passive Exposure
Passive UBC2M Exposure (Number of How Heard) was
not associated with either General or College-Specific
Prejudice (all
b
values <0.26, SEs >.12, pvalues >
.15). However, Number of How Heard was associated with
more favorable perceptions of Campus MH Culture (
b
¼
2.94, SE ¼0.17, p<.001, 95% CI ¼2.62, 3.27),and
Number of MH Conversation Partners (IRR ¼1.23, 95%
CI ¼1.19, 1.26) (Figures 2A and B, respectively; Table 3).
Table S8, available online, reports the number of re-
spondents by given number of exposures. Similarly,
Recognized Logo was not associated with any change (ie, all
b
values <0.24, SEs >0.27, pvalues >.44). However,
Recognized Logo was associated with more favorable
Campus MH Culture perceptions (
b
¼5.56, SE ¼0.40,
p<.001, 95% CI ¼4.78, 6.34),and Number of MH
Conversation Partners (IRR ¼1.43, 95% CI ¼1.32, 1.54)
(Table 3).
Replication in Self-Reported MI Subsample
UBC2M engagement, whether active or passive, was not
associated with stigma change among students self-
reporting MI (Table S8, available online). There is one
exception: Recognized Logo was associated with a signifi-
cant increase in College-Specific Social Distance (
b
¼
1.71, SE ¼0.83, p<.05). This may be an anomaly, may
reflect this subgroup’s lower stigma at outset, or may
suggest an unwillingness to be segregated only with others
identified as a “person with.”However, all UBC2M
engagement measures, whether active or passive, were
significantly positively related (p<.001) to more favorable
perceptions of Campus MH Culture and to Number of
MH Conversation Partners. Furthermore, self-reporting
MI was significantly associated with positive change on
all outcome measures.
DISCUSSION
Based on recent research and policy reports, we designed
and assessed a college-based program, UBC2M, to reduce
stigma. The assessment design included both formative
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assessments (conducted by students for each activity, not
reported here) and summative assessments (conducted by
faculty in a two-wave Internet survey).
Our data analyses indicated that the program had
long-term benefits, reduction in stigma—prejudice,
discriminatory predispositions—as well as short-term
benefits, positive changes in perceptions of a favorable
campus MH culture, and inclusive behaviors. Significant
changes occurred, on average, for about 11% to 14% of
the population. Although this may not be as dramatic as
some small-scale interventions have documented, several
key points are in order. First, given lower endorsements of
stigma by entering college students than the general pop-
ulation, we were pleased to see any change. Second, these
rates of change are nearly 5 times greater than national
efforts recorded over a 10-year period.
47
Third, this de-
scribes change among more than those who participated
heavily (ie, about 5% reported attending 4þevents), and
demonstrates the power of contact. Finally, our finding
that active and passive engagement predict more favorable
normative beliefs about MH (eg, perceptions of campus
MH culture, Number of MH conversation partners)
suggests that the program may also shift the larger campus
culture of MI. Because normative beliefs have a powerful
effect on individuals’attitudes and beliefs,
32,33
this shift
may lead to more widespread and potentially longer-lasting
stigma reduction.
We do not claim that IU is, at present, a “safe and
stigma-free zone,”but these results do suggest a positive
impact of UBC2M on the college context. This is not to say
that the CTP is without limitations. For an Internet-based
survey administered to an entire college cohort, the response
rate was high
48
; however, we cannot assess effects among
students who declined to participate. Indeed, participation
may have been nonrandom, as those who completed both
surveys had lower baseline stigma than did those not
completing the follow-up. This does suggest attrition bias in
our sample. Moreover, the overrepresentation of women
and white students, although commonly reported in
contemporary survey research, suggests that more tailored
research and anti-stigma activity are in order. Furthermore,
we did not have a control group. Although considered at
great length (eg, other Big Ten Universities), the research
team decided that scientific, logistic, and financial costs
FIGURE 1 Effect of Active U Bring Change to Mind (UBC2M) Engagement on General Prejudice, College-Specific Prejudice, and
College-Specific Social Distance
web 3C=FPO
Note: (A) Number of Events Attended, College Toolbox Project, 20152018 (N ¼1,132); (B) Number of Contact Types, College Toolbox Project, 20152018 (N ¼1,132).
Please note color figures are available online.
8www.jaacap.org Journal of the American Academy of Child & Adolescent Psychiatry
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TABLE 3 Results of Separate Multivariate Regressions of Student U Bring Change to Mind (UBC2M) Engagement (Active, Passive) on Prejudice, Discriminatory
Predisposition, Campus Mental Health Cultural Perceptions, and Behaviors,
a,b
College Toolbox Project, Indiana University (IU), 20152018 (N ¼1,132)
Attitudes
Behavioral
Predisposition
Perceptions of
Culture Behavior
Change in
General
Prejudice
c
Change in
College-Specific
Prejudice
c
Change in College-
Specific Social
Distance
c
Favorable
Campus MH
Culture
c
No. of MH
Conversation
Partners
d
b
SE
b
SE
b
SE
b
SE IRR 95% CI
Type of Engagement
With UBC2M
Active No. of events
attended
0.30* 0.14 0.27 0.16 0.27 0.22 1.29*** 0.13 1.08 1.06e1.10
No. of events
attended squared
e0.06*** 0.01 e0.05** 0.02 e0.05* 0.02 NS NS NS NS
Amount of contact 0.50* 0.26 e0.22** 0.08 e0.25 0.19 2.68*** 0.18 1.20 1.16e1.23
Amount of
contact squared
e0.15* 0.07 e0.22** 0.08 NS NS NS NS NS NS
Passive Correctly
recognized logo
0.05 0.27 e0.24 0.31 0.21 0.42 5.56 0.40 1.43 1.32e1.54
Types of exposure e0.05 0.12 0.03 0.13 e0.26 0.18 2.94*** 0.17 1.23 1.19e1.26
Note: IRR ¼incidence rate ratio; MH ¼Mental Health; NS ¼not significant; SE ¼standard error.
a
Separate regressions were conducted to assess whether each type of engagement (eg, number of events attended) predicted each specific dependent variable (eg, change in general
prejudice). Linear and polynomial terms for each engagement type were entered together in the same model. Polynomial terms are included where significant.
b
All models adjusted for sex (male or female), age (in years), race (white or nonwhite), self-reported mental illness (yes or no), childhood socioeconomic status (high or low), and in-state status
(yes or no).
c
Ordinary least-square regressions.
d
Poisson regressions.
*
p<.05; **p<.01; ***p<.001.
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were prohibitive. In lieu of this, we focused on intra-
individual change, which addresses time-invariant unob-
served heterogeneity to reduce concerns about confounding
effects. Although we cannot say with certainty that changes
were due only to the UBC2M program, the nonlinear
relationship between students’reports of awareness or
attendance at UBC2M events and change were reassuring.
It is also possible that passive exposure to UBC2M did not
directly influence respondents’perceptions of IU’s campus
culture; rather, respondents who correctly remembered
passive exposure to UBC2M might have been biased toward
identifying the logo because they were more aware of MH
issues. In contrast to that possibility, respondents who
correctly identified the UBC2M logo at T2 did not differ in
their baseline T1 prejudice. Again, this is reassuring but by
no means conclusive. Finally, even if UBC2M diffuses
stigma, it leaves out a critical group—those emerging adults
who do not or cannot attend higher education. That group
may be at even greater risk.
Social science theory and research offered a different
pathway to stigma reduction–cohort replacement focusing
on individuals in critical years of attitude and normative
formation. Stigma has proved to be a formidable, stubborn
aspect of contemporary US culture. Science has documented
only temporary and minor change in response to traditional
anti-stigma efforts. Colleges and universities, to a large
extent, enroll emerging adults at peak age-risk for the onset of
serious mental illnesses, where academic challenges and life
transitions are stressful, and where the outcomes of failing to
complete college has profound effects on the life course.
40,49
Yet, higher education not only holds the potential to disrupt
stigma and to produce future leaders to build a culture of
MH, but offers an immediate impetus for change as a by-
product of changing demand from parents and students.
On one hand, UBC2M may be seen as unique among
interventions because it is not “manualized.”That is pre-
cisely the point. The Toolbox created by UBC2M provides
ideas, protocols, scientific justification, and models of as-
sessments that can be performed by students. To be truly
effective, each college or university must tailor these pro-
totypes to their cultural context, providing more guides to
the living library. On the other hand, UBC2M may not be
seen as unique from other college club programs. UBC2M
is a “deep touch”program requiring participation, even if
tacit, from a range of faculty, staff, administrators, and a
national organization. This contact is critical to sustain-
ability and continuity.
UBC2M is only in the beginning stages, and it ad-
dresses only part of the problem. However, any anti-
stigma effort must first establish a reasonable target. For
UBC2M, issues of the nature, accessibility, or quality of
campus services were ruled out of scope. UBC2M was
designed to address the campus cultural climate in the
short run, and perhaps to serve as a pathway to larger
cultural change in the long run. Yet the NAS report
2
describes countries with successful stigma reduction ef-
forts as having built a nationally networked program (eg,
Australian Rotary Health engaged all local chapters; the
Time To Change Program was backed by government
funds). It is unlikely that this kind of public
FIGURE 2 Effect of Number of Ways in Which Respondents Heard About U Bring Change to Mind (UBC2M) on Students’
Assessment of Campus Culture of Mental Health and the Number of Types of People With Whom Respondent Talked About
Mental Illness and/or Stigma
web 3C=FPO
Note: (A) Campus Mental Health Culture, Number of How Heard, College Toolbox Project, 20152018 (N ¼1,132); (B) Number of Conversation Partners, Number of How
Heard, College Toolbox Project, 20152018 (N ¼1,132). Please note color figures are available online.
10 www.jaacap.org Journal of the American Academy of Child & Adolescent Psychiatry
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PESCOSOLIDO et al.
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governmental or private, nonprofit effort will take hold in
the United States. It has not, to date. However, as one of
its great treasures, America’s system of higher education,
despite its problems and patchwork of institutional types,
stands as a likely source for building such a national
change network. There can be no better time than now
with the Millennial generation’s outspoken views, greater
tolerance of difference, and energy directed toward
making the world a better place.
50
Accepted July 26, 2019.
Drs. Pescosolido, Perry, and Krendl are with Indiana University, Bloomington.
Dr. Pescosolido is also with Indiana Consortium for Mental Health Services
Research, Bloomington.
Funding for the student program and survey costs were provided by Bring
Change to Mind. All investigators provided research services pro bono, with
the exception of travel for the first author to BC2M meetings as required.
Dr. Perry served as the statistical expert for this research.
The authors thank Alex Capshew, MA, Academic Specialist, Indiana Con-
sortium for Mental Health Services Research, Indiana University, for her assis-
tance during the entire span of program development and assessment. They
also thank Susan Barnett Purrington, PhD, and Hannah Chiarella, BFA, who
ably filled the important role of UBC2M Project Manager at Indiana University
during the pilot period, and Markie Pasternak, MA, who served as graduate
advisor to the UBC2M student organization. Finally, they thank the Indiana
University student leaders of UBC2M, especially founders Rachel Green, BS,
Alexis Parrell, BA, and Rachel Martinez, BA, and more recent leaders, Geor-
gePatrick Hutchins, BS, Christine Ake, BS, Korie Rice, BA, and Margaret Ben-
son, BA for their dedication to mental illness issues.
Disclosure: Drs. Pescosolido, Perry, and Krendl have reported no biomedical
financial interests or potential conflicts of interest.
Correspondence to Bernice A. Pescosolido, 1022 East Third Street, Schuessler
Institute for Social Research, Bloomington, IN 47401; e-mail: pescosol@indiana.
edu
0890-8567/$36.00/ª2019 American Academy of Child and Adolescent
Psychiatry. Published by Elsevier Inc. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jaac.2019.06.016
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