Future Directions in Mental Health Treatment with Stigmatized Youth

ABSTRACT

Stigma refers to societally-deemed inferiority associated with a circumstance, behavior, status, or identity. It manifests internally, interpersonally, and structurally. Decades of research indicate that all forms of stigma are associated with heightened risk for mental health problems (e.g., depression, PTSD, suicidality) in stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities, such as youth of Color and transgender youth). Notably, studies find that stigmatized youth living in places with high structural stigma – defined as laws/policies and norms/attitudes that hurt stigmatized people – have a harder time accessing mental health treatment and are less able to benefit from it. In order to reduce youth mental health inequities, it is imperative for our field to better understand, and ultimately address, stigma at each of these levels. To facilitate this endeavor, we briefly review research on stigma and youth mental health treatment, with an emphasis on structural stigma, and present three future directions for research in this area: (1) directly addressing stigma in treatment, (2) training therapists in culturally responsive care, and (3) structural interventions. We conclude with recommendations for best practices in broader mental health treatment research.

Now more than ever, stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities; e.g., youth of Color, girls, transgender youth) are in need of effective mental health treatment. Inequities in mental health problem severity, diagnosis, and treatment between stigmatized and privileged groups (e.g., youth of Color vs. White youth, lesbian, gay, bisexual, or other sexual minority vs. heterosexual youth) are longstanding (Alegria et al., 2010; Bui & Takeuchi, 1992; Connolly et al., 2016; Garland et al., 2005; Rodgers et al., 2022; Russell & Fish, 2016), and these gaps are widening in the ongoing pandemic (Banks & Hsu, 2021; Benton et al., 2022; Bhogal et al., 2021; Fish et al., 2020; Hawke et al., 2021; Mpofu, 2022; Penner et al., 2021; Rothe et al., 2021; Saunders et al., 2021). These inequities are primarily attributable to these youth’s experiences of stigma at multiple levels: (1) internalized stigma (i.e., self-stigma), or one’s adoption of stigma-related beliefs resulting from exposure to stigmatizing environments or relationships (e.g., a girl believing that being assaulted was because of her physical attractiveness; Moses, 2009); (2) interpersonal stigma, which stigmatized individuals experience in interpersonal interactions (e.g., a peer saying “no homo”; sexual violence against girls; Fish, 2020; Jones & Neblett, 2017); and (3) structural stigma, or laws/policies (e.g., a state policy prohibiting gender-affirming care for transgender youth) and norms/attitudes (e.g., the belief that Black people will bring violence into neighborhoods they move into; Krieger et al., 2010) that negatively impact stigmatized people (Alvarez et al., 2021; Beccia et al., 2022; Castro-Ramirez et al., 2021; Hatzenbuehler, 2017).

Research consistently documents associations between internalized and interpersonal forms of stigma and mental health problems in multiple groups of stigmatized youth (e.g., youth of Color, girls, sexual minority youth; Bailey et al., 2022; Butler-Barnes et al., 2022; Chodzen et al., 2019; Price-Feeney et al., 2021; Reed et al., 2019; Rogers et al., 2022; Watson et al., 2019; Weeks & Sullivan, 2019). Relatively fewer studies with youth have examined structural stigma, but scholars have found associations between structural stigma and youth mental health (e.g., anxiety, depression, suicidality; Beccia et al., 2022; Duncan & Hatzenbuehler, 2014; Hatzenbuehler, 2011; Hatzenbuehler & Keyes, 2013; Saewyc et al., 2020; Torres et al., 2018) and behavioral health concerns (e.g., smoking, alcohol/substance use; Eisenberg et al., 2020; Hatzenbuehler et al., 2014, 2015; Watson et al., 2021, 2020). Studies also suggest that structural stigma may shape an array of cognitive (e.g., internalized stigma, rejection sensitivity; Pachankis, Hatzenbuehler et al., 2021; Pachankis et al., 2014), behavioral (e.g., identity concealment, social isolation; Pachankis & Bränström, 2018; Pachankis, Hatzenbuehler et al., 2021), biological (e.g., HPA-axis reactivity; Hatzenbuehler & McLaughlin, 2014), and developmental (e.g., neurodevelopment; Hatzenbuehler et al., 2021) processes in stigmatized young people.

Additionally, stigmatized youth in communities with higher (vs. lower) levels of structural stigma are more likely to experience interpersonal stigma (e.g., discrimination, bullying; Lessard et al., 2022; Renley et al., 2022; Van der Star et al., 2021; Watson et al., 2021), which may, in turn, increase their risk for internalized stigma (e.g., Boyes et al., 2020) and mental health difficulties (e.g., Seaton et al., 2022). Strikingly, emerging studies find that structural stigma is strongly associated with mental health treatment effectiveness (M. A. Price, McKetta et al., 2021; M. A. Price, Weisz et al., 2022) and access (Hollinsaid et al., 2022; Roulston et al., 2022) for stigmatized youth (see Figure 1 for a depiction of this multilevel mechanistic process). The present paper provides a brief overview of the scientific literature on structural stigma and youth mental health treatment, and details three future research directions we hope readers pursue. We conclude with recommendations for broader mental health treatment research to support further scientific progress in this area.

Figure 1. Multilevel model of stigma, its mechanisms, and mental health for stigmatized youth

Structural Stigma and Mental Health Treatment Efficacy and Access

Two recent meta-analyses found that higher structural stigma – specifically, sexist and racist attitudes (separately) aggregated to the state level – was associated with lower psychotherapy efficacy for girls (M. A. Price, McKetta et al., 2021) and Black youth (M. A. Price, Weisz et al., 2022), respectively. In other words, girls and Black youth fared worse in therapy when they lived in states with higher (vs. lower) levels of structural stigma. Although these studies were unable to test mechanisms that might explain why therapy efficacy was worse for stigmatized youth in high stigma states, M. A. Price et al. (2022) showed that Black youth’s treatment response was similar across states immediately after treatment ended, but significantly worse at follow-up (e.g., 6 months after ending treatment) in high (vs. low) racism states. In other words, this finding suggests that, once treatment ends, time spent living in a highly racist environment erodes treatment benefits for Black youth. Notably, this result was consistent with a similar spatial meta-analysis on anti-Black structural racism and HIV intervention efficacy, which found that efficacy also weakened over time in high racism communities (Reid et al., 2014). Taken together, these studies suggest that structural stigma may predict where and for whom youth mental treatment is effective. More specifically, the context in which treatments are tested, coupled with the identities of youth in treatment, are important and understudied sources of treatment-effect heterogeneity.

Emerging research also indicates that stigmatized youth may be less able to access mental health treatment if they live in high stigma environments (e.g., states with more restrictive laws/policies targeting transgender people’s rights), even when accounting for other structural factors (e.g., income inequality). In a large sample of sexual minority youth of Color, Roulston et al. (2022) found that structural homophobia and racism were strongly associated with treatment access, such that sexual minority youth of Color living in states with more homophobic and racist attitudes reported being less likely to access treatment, even when controlling for mental health provider availability. Likewise, Hollinsaid et al. (2022) documented substantially lower rates of mental health providers who specialize in providing services to transgender youth in states with more transphobic laws/policies while controlling for other state-level factors, such as political and religious conservatism. Similar studies have also identified a dearth of gender-affirming assessment materials (e.g., inclusive online intake forms; Holt et al., 2019, 2021), fewer referrals for gender-affirming services for transgender youth (Indremo et al., 2022), and less affirming services for sexual minority and transgender young people (Campbell & Mena, 2021) in places with high levels of structural stigma. In sum, research suggests that structural stigma not only increases stigmatized youth’s need for mental health treatment by worsening their mental health but also makes it harder for them to access and benefit from treatment.

In our increasingly diverse yet intolerant society, it is imperative to address the mental health needs of stigmatized youth. Doing so requires scientific progress resulting in improved youth mental health treatment efficacy and access. We propose three future directions to advance this research, each of which addresses stigma at all three levels (internalized, interpersonal, and structural). The first addresses treatment efficacy, and the final two address both treatment efficacy and access (see overview in Table 1):

1. Directly address stigma in youth mental health treatment

2. Train therapists in culturally responsive care

3. Develop, test, and implement structural interventions (i.e., changing the environment itself)

Table 1. Overview of future directions in mental health treatment with stigmatized youth.

Future Directions	Recommended Actionable Research Approaches
Directly Address Stigma in Treatment	1. Develop and test brief, scalable interventions addressing experiences of individual, interpersonal, and/or structural stigma. 2. Bring existing interventions targeting stigma to scale. 3. Identify the most effective components of these interventions (e.g., dismantling studies). 4. Test these treatments in high stigma settings. 5. Measure stigma-related factors (e.g., to test moderators and/or mediators of treatment efficacy) and report detailed location data.
Train Therapists in Culturally Responsive Practice	1. Develop trainings that are useful for a variety of therapists. 2. Use community-engaged methods. 3. Efficiently test and refine trainings. 4. Develop scalable (e.g., online) trainings. 5. Examine therapist and client outcomes. 6. Collect and utilize implementation data.
Structural Interventions	Schools
	1. Examine a variety of allyship programs (e.g., Black Student Unions). 2. Assess multiple outcomes (e.g., school-related, stigma-related). 3. Identify the most beneficial intervention formats and implementation strategies. 4. Test whether general anti-bullying interventions are helpful for stigmatized youth.
	Communities
	5. Identify effective intervention approaches in communities with limited resources and/or support for stigmatized youth. 6. Examine indicators of change in community attitudes and/or support.
	Laws/Policies
	7. Examine mental health treatment access outcomes. 8. Examine effects of laws/policies for understudied groups.
Recommendations for Broader Mental Health Treatment Research
1. Recruit stigmatized youth and inclusively assess a variety of identities (e.g., gender identity). 2. Publish detailed data to facilitate future spatial meta-analyses (e.g., intervention location data). 3. Study interventions in communities with low and high structural stigma. 4. Administer stigma-related measures relevant to multiple stigmatized groups (e.g., bullying exposure). 5. Pool intervention data to examine treatment-related outcomes and/or mechanisms in samples or subsamples of stigmatized youth in trials of existing treatments. 6. Identify protective factors that may enhance treatment efficacy for stigmatized youth in trials of existing treatments.

We provide exemplar studies within each future direction and specific suggestions that we hope enable researchers to conduct this much-needed research.

Future Direction #1: Directly Address Stigma in Treatment

Structural stigma is associated with a range of negative mental health problems in stigmatized youth (e.g., anxiety, depression, substance use; Hatzenbuehler, 2017), and research has uncovered individual (e.g., rejection sensitivity; Pachankis et al., 2014) and interpersonal (e.g., bullying, discrimination; Lessard et al., 2022; Watson et al., 2021) stigma processes, or mechanisms, by which structural stigma may increase risk for mental health problems (see Figure 1). Fortunately, there is growing evidence that mental health treatments can target some of these factors (e.g., Austin et al., 2018; Craig, Eaton et al., 2021; Pachankis et al., 2015), which may improve mental health outcomes for stigmatized youth. In fact, studies suggest that interventions that directly address experiences of internalized and/or interpersonal stigma may be more effective for those who experience more stigma (Lee et al., 2019; Pachankis et al., 2020). Accordingly, treatments that address stigma (at one or more levels) may be more efficacious in places with high structural stigma (Hatzenbuehler & Pachankis, 2021). In this section, we briefly review literature on treatments that directly target stigma and conclude with recommendations for future treatment research.

Treatments addressing client-level stigma range in scope (e.g., a self-administered brief online intervention, a multi-session treatment protocol) and focus (e.g., targeting internalized stigma vs. interpersonal skills). Though most treatments of this kind were developed for sexual minority and/or transgender clients (for a review, see Layland et al., 2020), promising interventions targeting internalized and interpersonal stigma related to race (e.g., Anderson et al., 2019), ethnicity (Kennard et al., 2020), and girl/woman identity (Bryant-Davis, 2019) have been developed more recently. Treatments in this category may be entirely novel treatment protocols (e.g., EMBRace; Anderson et al., 2019) or adapted from existing treatments (e.g., AFFIRM; Austin et al., 2018; Craig, Eaton et al., 2021; Craig, Leung et al., 2021; Craig & Austin, 2016; EQuIP; Pachankis et al., 2015).

These treatments are often rooted in minority stress theory (Brooks, 1981; Meyer, 2003), which posits that stigmatized individuals’ heightened risk for mental health concerns are attributable to chronic stigma-related stressors (e.g., discrimination, victimization) and stress processes (e.g., expectations of rejection). Examples of treatment components include psychoeducation on individual, interpersonal, and structural stigma and their mental health consequences (e.g., Craig & Austin, 2016), cognitive strategies to challenge internalized stigma (Austin et al., 2018), expressive writing and self-affirmation to address the effects of interpersonal stigma (e.g., family rejection, victimization; Pachankis et al., 2020), coping skills for actively attending to feelings during stigma encounters (e.g., mindfulness; Anderson et al., 2019), and assertiveness training for interpersonal stigma experiences (e.g., Pachankis et al., 2015).

Results from the relatively few pilot studies and randomized controlled trials (RCTs) of youth mental health treatments targeting stigma demonstrate promising effects (Anderson et al., 2018; Lucassen et al., 2015; Pachankis et al., 2020). Importantly, many of these interventions involve only minimal changes to existing evidence-based treatments (e.g., incorporating the minority stress model into a CBT module on psychoeducation), and they are often delivered digitally and/or in few sessions (Craig, Leung et al., 2021; Pachankis et al., 2020) – increasing their scalability. Practice-informed literature on longstanding treatments addressing stigma (e.g., feminist psychotherapy; Arczynski & Morrow, 2017; L. S. Brown, 2006; Conlin, 2017; Gorey et al., 2001) and methods of adapting common treatments to address stigma (e.g., DBT; Skerven et al., 2019) are also useful resources for clinicians and researchers.

We recommend that researchers interested in treatments targeting stigma focus their efforts in the following areas:

1. Develop and test brief and scalable interventions that address stigma. Doing so might involve the development of entirely new protocols or the adaptation of single-session online interventions to directly target stigma and its effects (Schleider et al., 2020). Such interventions may serve as effective standalone treatment options (e.g., Pachankis et al., 2020) or augment existing treatments.

2. Test (e.g., in RCTs) and quickly scale existing interventions targeting stigma, particularly in places with high structural stigma, given stigma’s likely role as a mechanism of mental health problems in stigmatized youth and their promising effects for young people with high levels of interpersonal and individual stigma (see Hatzenbuehler & Pachankis, 2021 for a review).

3. Identify the most effective elements of interventions that address stigma through dismantling studies (e.g., Resick et al., 2008), which can then be disseminated widely via therapist training programs and/or translated into single-session interventions.

4. Examine whether high structural stigma attenuates the effects of treatments targeting stigma (Hatzenbuehler & Pachankis, 2021). While spatial meta-analytic techniques may not yet be appropriate given the relatively few trials completed to date (i.e., meta-analyses may be under-powered if conducted in the near future), those conducting intervention trials should strategically recruit stigmatized youth living in communities with varying levels of structural stigma. This could be accomplished by conducting multisite intervention trials or online intervention trials with national samples (e.g., Schleider et al., 2022).

5. For researchers already developing and testing interventions targeting stigma, administer measures of targeted mechanisms (e.g., internalized stigma, social isolation) and factors that may hinder or bolster treatment progress (e.g., interpersonal stigma exposure, therapeutic alliance; Bailey et al., 2011; Birkett et al., 2015; Bockting et al., 2020; Hidalgo et al., 2019; M. A. Price, Hollinsaid et al., 2021; Williams et al., 2008). Collect and publish ample detail on the content of interventions (e.g., which elements were adapted) and the location of participants to facilitate subsequent spatial meta-analyses.

Future Direction #2: Train Therapists in Culturally Responsive Practice

While addressing stigma in treatment may enhance treatment benefits for stigmatized youth, such improvements will only be useful if stigmatized youth can access treatment from adequately trained therapists. Scholarship on culturally responsive practice (i.e., multicultural or cultural competence) emerged in the 1940s and proliferated in the 1990s and early 2000s (Singh et al., 2020; Sue et al., 1992). Though emphases on culturally responsive practice vary across helping professions, accrediting bodies (e.g., American Psychological Association, Council for Accreditation of Counseling and Related Educational Programs, National Association of Social Workers) overseeing therapist training programs require at least some education in “diversity” as it pertains to mental health treatment (Siegel et al., 2010). Such training varies widely across disciplines (e.g., social work, clinical psychology) and specific training programs (Devine & Ash, 2022; Galán et al., 2021; Gee et al., 2021; Najdowski et al., 2020; Pieterse et al., 2009). As a result, many therapists are under-prepared to meet the needs of youth with stigmatized identities (e.g., Abreu et al., 2020). For instance, studies suggest that few therapists have the knowledge and skills necessary to adequately support transgender youth and their families (M. A. Price, Bokhour et al., 2022; Strauss et al., 2021). Therapists’ lack of competency may increase their likelihood of discriminating against clients in the therapy room (e.g., microaggressions, stereotyping, misgendering) – a common treatment experience for stigmatized youth and adults (Compton & Morgan, 2022; Morris et al., 2020; Nadal et al., 2016; Yeo & Torres-Harding, 2021), including sexual minority and transgender youth (Chong et al., 2021; Forsythe et al., 2022; M. A. Price, Bokhour et al., 2022; Strauss et al., 2021) and youth of Color (Fadus et al., 2020; Fante-Coleman & Jackson-Best, 2020; Malone et al., 2021).

Taken together, this evidence suggests that existing training curricula in culturally responsive practice do not adequately address the mental health needs of stigmatized youth. This problem stems from both insufficient curricula (e.g., they are often developed solely by researchers, rather than by, or with, the client populations we seek to serve) and limited dissemination (i.e., the extent to which these curricula are distributed; Brownson et al., 2021; Lelutiu-Weinberger et al., 2022; Pachankis, Clark et al., 2021). Moreover, there is a dearth of research on the efficacy of such training. In other words, it is unclear whether training in culturally responsive care results in therapists using the practices they are taught, and the extent to which the use of those practices improves client experiences and mental health outcomes (Bettergarcia et al., 2021; Budge & Moradi, 2018; Chandler et al., 2022; Pachankis, 2018; E. G. Price et al., 2005). To address this gap, we recommend the following:

1. Develop therapist trainings that are useful to a variety of clinicians rather than specific to therapists who only use a particular treatment modality or work with a specific population (Pachankis et al., 2022). Doing so should involve teaching knowledge and skills that are applicable to a wide range of clients, such as directly addressing stigma in therapy (e.g., how to provide psychoeducation on internalized stigma).

2. Work closely with relevant community stakeholders using community-engaged methods (i.e., involving community members throughout the development, refinement, and testing of a new program) to develop therapist training programs (e.g., Allison et al., 2019). Doing so ensures that the trainings are designed to meet the needs of both clients and therapists, enhancing the likelihood that they are efficacious (i.e., likelihood of resulting in therapist behavior change and client satisfaction) and successfully implemented. Specifically, therapist training program development should involve the target client population (i.e., those who should ultimately benefit from being treated by trained therapists), the target therapist population (i.e., those most likely to work with the target population), and other relevant stakeholders (e.g., clients’ family members, clinic administrators, policymakers; M. A. Price, 2022).

3. Refine and test therapist training programs efficiently using methods designed to address and overcome implementation barriers, such as human-centered design (HCD; i.e., user centered design, design thinking), a method to develop and improve interventions by systematically incorporating input from key stakeholders and settings in which the interventions will ultimately be used (Lyon et al., 2020; Lyon & Koerner, 2016).

4. Create scalable therapist training programs by delivering them online or via apps (e.g., Lelutiu-Weinberger et al., 2022) to address widespread shortages in therapists with competency in culturally responsive care.

5. Assess the effects of training on both therapist and client outcomes to examine whether (or not) the target population benefits. While most studies of therapist training programs examine proximal effects on therapists (e.g., increased knowledge, attitudinal changes), very few studies assess whether or not clients experience any benefits (e.g., better mental health outcomes, stronger therapeutic alliance) from working with trained (vs. untrained) therapists. Assessing client outcomes among those working with trained therapists will provide information about the reach of the training program, and ultimately clarify whether the target population (e.g., stigmatized youth and their caregivers) truly benefits from therapist training efforts.

6. Examine and utilize implementation data throughout the development and testing process to facilitate later dissemination. In addition to examining effectiveness outcomes for therapists and clients (outlined above), we recommend collecting comprehensive implementation data (e.g., acceptability, appropriateness) from multiple stakeholders (e.g., clinicians, administrators) using multiple methods, such as self-report surveys, individual qualitative interviews, and objective measures (e.g., time spent interacting with online training app). These data should be analyzed and utilized to iteratively improve the training program throughout and after development (Dopp et al., 2019).

Future Direction #3: Structural Interventions

Targeting stigma in the environment will make treatments maximally effective for stigmatized youth (Blankenship et al., 2006; Hartog et al., 2020). Structural interventions aim to reduce stigma in institutions (e.g., schools), as well as in communities, states, or other geographic levels (Chaudoir et al., 2017; Cook et al., 2014). These interventions include efforts to change policies (e.g., implementing inclusive school/state anti-bullying policies; (Hatzenbuehler & Keyes, 2013; Kull et al., 2016), attitudes (e.g., increasing knowledge about stigmatized youth’s experiences to reduce prejudice; Grapin et al., 2019), physical spaces (e.g., building more accessible school playgrounds; D. M. Y. Brown et al., 2021), or access to resources (e.g., increasing the availability of sexual health services; Clermont et al., 2020). Structural interventions may have widespread and enduring benefits for stigmatized youth (Hartog et al., 2020) – improving mental health and perhaps even treatment access. In this section, we provide examples of structural interventions targeting stigma in schools, communities, and in the form of laws/policies, and recommend relevant research within each category.

Schools

Efforts to improve school climates for stigmatized youth are among the most common structural interventions, with many aimed at reducing stigma-based bullying (Earnshaw et al., 2018). These interventions can be universal (i.e., including the whole school) or targeted (e.g., focused solely on bullying victims; Fraguas et al., 2021), and often involve schoolwide discussions of anti-bullying policies, trainings on how to stop bullying (e.g., bystander interventions; Polanin et al., 2012), and education on stigmatized youth’s needs and experiences. Often, these interventions include contact between stigmatized and non-stigmatized individuals (e.g., through role-plays, presentations) and strategies to improve social or emotional skills (e.g., communication, self-control) for youth who bully others (Earnshaw et al., 2018). Other school-based interventions focus on reducing prejudicial attitudes among students and teachers through media (e.g., film; Burk et al., 2018; Sanz-Barbero et al., 2022). Substantial evidence suggests that school-based anti-bullying and anti-prejudice interventions decrease school bullying and foster more positive feelings toward stigmatized youth, including sexual minority and transgender youth (Burk et al., 2018), girls (Sanz-Barbero et al., 2022; Spinner et al., 2021), youth of Color (Aboud et al., 2012; Grapin et al., 2019), and refugee and migrant youth (Gabrielli et al., 2022).

Other school-based structural interventions provide stigmatized youth with sources of support and connectedness – whether through allyship with non-stigmatized youth or similarly stigmatized youth. For instance, starting a gender-sexuality alliance (GSA) may drastically improve school climate and support for sexual minority and transgender youth (e.g., Day et al., 2020). GSAs are consistently associated with reduced interpersonal stigma (e.g., victimization; Marx & Kettrey, 2016), better mental health (Baams & Russell, 2021; Poteat et al., 2020, 2021), and greater peer and teacher support (Day et al., 2020). Similarly, racial affinity groups offer students of Color a safe and supportive space to process experiences of racial discrimination and trauma (Oto & Chikkatur, 2019; Tauriac et al., 2013). Another example is the National Alliance on Mental Illness (NAMI) on Campus High School Clubs, which involve student-led efforts to increase mental health literacy and reduce mental health stigma in schools (National Alliance on Mental Illness [NAMI], 2021). However, relative to GSAs, the benefits of these programs have not been evaluated at the structural level, so it is unclear whether stigmatized youth who attend schools with vs. without such programs report better mental health. We recommend the following for research on school-based structural interventions:

1. Evaluate whether the presence of school allyship programs beyond GSAs (e.g., Black Student Unions) are effective in improving outcomes for stigmatized youth (e.g., mental health, rates of stigma-based bullying).

2. When evaluating school-based structural interventions, assess a wider range of outcomes, including school-related outcomes (e.g., attendance, grades) and covert stigma-related outcomes (e.g., microaggressions, cyberbullying).

3. Identify the most effective implementation strategies for, and components of, structural interventions in schools. For instance, researchers might consider questions such as: Who should these interventions target (e.g., students and staff, only students, only students who bully others) in order to be maximally effective? What is the optimal duration and frequency of these interventions? What are the most advantageous formats for delivering these interventions (e.g., classroom, school-wide assembly)?

4. Given recent efforts in some states to prohibit discussions of race, sexual, and/or gender identity in schools (e.g., “Don’t Say Gay” laws), it may be necessary to consider whether general anti-bullying interventions help stigmatized youth. Accordingly, we recommend examining whether general anti-bullying programs (i.e., focused on reducing school bullying regardless of motivation; Merrell et al., 2008) impact stigma-related outcomes (e.g., stigmatized youth’s mental health, rates of stigma-based bullying).

Communities

In high stigma communities, stigmatized youth may not have access to needed health services (Clermont et al., 2020) or support (e.g., family/peer support; Fish et al., 2019). Accordingly, many structural interventions aim to increase stigmatized youth’s access to community-based resources (e.g., sexual health services; Clermont et al., 2020; M. L. Ybarra et al., 2017, 2020; M. Ybarra et al., 2021) and support (e.g., LGBTQ community centers; Wilkerson et al., 2018). Other structural intervention focus on increasing access to physical spaces – for instance, by creating accessible play spaces for youth with disabilities (D. M. Y. Brown et al., 2021; Wenger et al., 2021) or by encouraging community members (e.g., business owners, health providers) to create and label supportive physical locations (e.g., safe spaces in healthcare settings; Evans, 2002; Finkel et al., 2003; Frye et al., 2017; Wheeler Black et al., 2012). Finally, a few interventions focus on changing community attitudes specific to stigmatized youth; those that do are most common outside the US (for reviews, see Hartog et al., 2020; Smythe et al., 2020). The following are recommendations for community-based structural interventions:

1. Determine how community-based structural interventions are best brought to scale – particularly in communities without supportive resources, or where interventions emphasizing intergroup contact may be invalidating or even harmful for stigmatized youth. Brief electronic social contact interventions (e.g., watching a two-minute video of a stigmatized youth sharing information on their identity and stigma experiences; Amsalem et al., 2022; Martin et al., 2022) represent one promising and readily scalable alternative, but they have yet to be tested at the community level.

2. To date, the effectiveness of community-based structural interventions has largely been assessed using self-report measures completed solely by those who completed the intervention (Michaels & Corrigan, 2013). To objectively assess change in attitudes in the larger community, scholars should analyze publicly available datasets such as Project Implicit – an ongoing, large-scale effort to assess individual explicit and implicit attitudes toward a variety of stigmatized identities (Xu et al., 2013). Project Implicit respondents include hundreds of thousands of individuals from communities across the US over decades, allowing researchers to measure community-level attitudes by aggregating data to the desired geographic level (e.g., county, city) and compare attitudes before and after the intervention.

Laws/Policies

Numerous structural interventions seek to change exclusionary laws/policies – most often at the state level. One of the most widely examined approaches is the passage of legislation extending rights to stigmatized groups (e.g., including gender identity in nondiscrimination laws/policies). In addition to the legal protections afforded by these policies, quasi-experimental research reveals that stigmatized youth experience myriad benefits from their passage, such as reduced mental health problems and treatment needs (McDowell et al., 2020). Alternatively, supportive state laws/policies can be adopted directly by voters through referendums. Although this approach is not as well studied as legislation, at least one study documented reductions in bullying for sexual minority youth following the approval of a same-gender marriage referendum in California (Hatzenbuehler et al., 2019). Because referendums often involve collective activism among stigmatized groups (e.g., engaging in demonstrations to raise awareness), they may have other benefits for stigmatized youth, such as increasing pride, self-efficacy, and connectedness (Flores et al., 2018). Litigation represents another promising strategy – with research showing that homophobic bullying decreased in California schools where students were successful in discrimination-related court cases (Hatzenbuehler et al., 2022). Future research in this area should:

1. Assess a wider array of structural intervention outcomes, including outcomes related to mental health treatment access. For example, researchers might consider: Does the implementation of more supportive institutional policies and practices (e.g., including pronouns on name badges for community health center staff) increase the number of stigmatized youth using services? Does the implementation of supportive state laws/policies increase help-seeking behaviors for stigmatized youth and/or the availability of specialty mental health providers? Alternatively, is it possible that enacting supportive state laws/policies may reduce the number of stigmatized youth needing treatment by reducing their mental health concerns?

2. Much of the extant research on the effects of laws/policies on youth mental health focuses on sexual minority and/or transgender youth. Future studies should examine the effects of law/policies relevant to other stigmatized groups. For example, researchers should use quasi-experimental methods to assess whether the mental health of youth of Color improves following changes in school and/or district policies that disproportionately affect them, such as school policing or exclusionary discipline practices (Nance, 2016). Additional examples of discriminatory policies/laws that may affect stigmatized youth’s mental health include state abortion bans, sexual misconduct policies, and policies banning Critical Race Theory.

Summary and Recommendations for Broader Mental Health Treatment Research

The current article summarizes innovative research on youth mental health treatment for stigmatized youth and provides a roadmap for researchers interested in furthering progress in this area. We outline three broad areas for future research: directly addressing stigma in treatment, training therapists in culturally responsive care, and structural interventions. Within each area, we recommend specific actionable research approaches (summarized in Table 1). We hope that the ideas outlined here inspire scientists to continue progressing toward a more equitable mental health treatment landscape for youth that ultimately serves to reduce mental health inequities. To improve our field’s ability to examine stigma in all intervention research, we conclude with recommendations for broader mental health treatment research:

1. To facilitate analyses of treatment outcomes for different stigmatized groups (e.g., Hollinsaid et al., 2020), recruit large and diverse samples of youth reflecting multiple stigmatized identities and comprehensively collect data on these identities (Kataoka et al., 2010; Lau et al., 2010; Santelli et al., 2003).

2. Publish data on participants’ identities (e.g., subsample sizes), intervention locations (e.g., zip code), and participant locations (e.g., the counties in which participants lived) in all intervention reports to enable researchers to conduct future spatial meta-analyses on structural stigma and mental health treatment efficacy (e.g., M. A. Price, McKetta et al., 2021; M. A. Price, Weisz et al., 2022).

3. Multisite intervention trials should be conducted in locations that are diverse with respect to structural stigma to facilitate research examining structural stigma as a moderator of treatment efficacy.

4. Administer measures of internalized stigma (e.g., Mak & Cheung, 2010), interpersonal stigma (e.g., identity-based bullying, discrimination; M. A. Price et al., 2019; Williams et al., 1997), and stigma-related processes (e.g., social isolation, rejection sensitivity) relevant to multiple groups to facilitate the identification of treatment-related moderators or mechanisms.

5. Examine whether treatment-related factors – such as therapeutic alliance, treatment duration, retention, and treatment satisfaction – are associated with treatment efficacy for stigmatized youth. For instance, researchers can use existing data from completed RCTs of traditional mental health interventions (i.e., that do not directly address stigma) with stigmatized youth subsamples or samples to explore differences in treatment experiences (e.g., Hollinsaid et al., 2020). Results may have implications for treatment development and testing and therapist training programs.

6. Stigmatized youth in low stigma (vs. high stigma) communities may respond more favorably to traditional mental health interventions. Identifying protective factors (e.g., family support, community connectedness) that predict treatment benefits for these youth (e.g., subsamples of youth of Color in ongoing RCTs) is another fruitful area of inquiry. Such work may reveal resources or strategies that – if made available to stigmatized youth in high stigma communities – may likewise improve their treatment response.

Acknowledgments

The authors thank Mr. Shuai (“Eddy”) Jiang for his help adding references and formatting this manuscript and Dr. Jonathan S. Jay for his thoughtful review and recommendations.

Disclosure Statement

Dr. Price has received grant or research support from the National Institute of Mental Health (NIMH), the American Psychological Foundation, the Boston College School of Social Work Center for Social Innovation, the Boston College Schiller Institute for Integrated Science and Society, the Boston College Office of the Provost, and the Pershing Square Fund for the Harvard Foundations of Human Behavior. Mr. Hollinsaid has received grant or research support from the Boston Area Research Initiative.

Additional information

Funding

This paper was not sponsored by a specific grant. However, Dr. Price’s time and effort is supported by NIMH under [Grant K23MH124670-01A1].