Transition Design as a Strategy to Address Mental Health Stigma
Let’s talk about mental health care. The COVID-19 pandemics brought various niche topics into the mainstream discussion — and mental wellbeing was one of them. According to OECD, the rates of anxiety and depression increased and even doubled in some countries with the COVID-19 outbreak. In spring 2020, more than 20% of adults experienced mental distress in countries like the United States, Canada, the United Kingdom, France, and Australia, among others. In the Czech Republic, a survey from 2021 shows that 75% of people experienced worse mental state due to the crisis. While only 10% of people would seek support in therapy in 2020, it was almost 25% in early 2021.
Similar to other health care domains, finding support in mental health became rather difficult during the pandemics. People were trapped in their homes, often without a reliable internet connection or enough personal space to attend online therapy. Technical difficulties were not the only thing keeping people from appropriate help — many wouldn’t seek mental health support because of the prevalent stigma. There seems to be something shameful about caring for one’s mental wellbeing, something shameful in going to therapy.
Mental health stigma unfolds on multiple levels. First, there is social stigma: seeking mental health support can be socially discrediting, and those struggling with mental health issues may face stereotypes, discrimination, and labeling. In practice, this leads to the typical “What would others think?”. When an individual agrees with social stigma or even reinforces it, they may experience self-stigma. Self-stigma makes people think that the stereotypes apply to them; for example, they might believe that seeking support is a sign of weakness and refuse to see themselves as weak. In other cases of self-stigma, they can experience very low self-esteem and feel like their mental health is not worth other people’s effort. Lastly, there is structural stigma that is embedded in our social structures and systems. It includes “societal-level conditions, cultural norms, and institutional practices that constrain the opportunities, resources, and wellbeing for stigmatized populations.”
All three kinds of stigma are complex and widespread among individuals, communities, nations, and cultures. Mental health stigma is rooted deep in our history and embedded within our systems, which makes it demanding to untangle its origins and foresee a path to its correction. Complex problems like mental health stigma are often called “wicked problems.” To address wicked problems, we need to adopt new methods and holistic thinking; and then we can envision a path to a future without mental health stigma.
“A wicked problem is a social or cultural problem that’s difficult or impossible to solve — normally because of its complex and interconnected nature. Wicked problems lack clarity in both their aims and solutions, and are subject to real-world constraints which hinder risk-free attempts to find a solution.”
The first time I pondered about a future without mental health stigma was back in October 2020 when I joined a mental health care start-up Terapie.cz. The team’s goal was to make mental health care more accessible by connecting people who want therapy to therapists who can help them. As we were getting to know our users (clients), we encountered three prevalent mindsets, two of which were strongly affected by the mental health stigma:
- They acknowledge they need/want help, and they seek it.
- They acknowledge they need/want help, but they won’t seek it. (Stigma may keep them from seeking help. They also may not know where to find help or struggle financially to afford it.)
- They don’t acknowledge they need help, but they need it. (Stigma may cause them to turn a blind eye to their mental health problems.)
There are several mental health care platforms on the Czech market, and more are emerging. It becomes easier to find a therapist or other kind of mental health support; however, a lot more needs to change before we reach the ‘ideal’ future of mental health care. (And what would that look like, anyway?)
In summary, the COVID-19 pandemics brought previously unseen attention to mental health care and laid out the ground for change. That gave rise to innovative services and digital tools that make mental health support more accessible. Despite the increase in accessibility of mental health care, many people still hesitate to ask for support — they are deterred by the stigma connected to mental health issues. To overcome mental health stigma and pursue a future of better mental health care, we need to adopt new approaches to design and strategy planning.
And this is when Transition Design comes in.
When Transition Design Comes In
As the founders of Transition Design say, wicked problems cannot be resolved using traditional design approaches because they “tend to frame problems within relatively narrow spatio-temporal contexts and do not offer a comprehensive approach for identifying all stakeholders and addressing their conflicts.” Wicked problems (like mental health stigma) are often rooted deep in our history and will take many years or decades to overcome. We need to recognize their complex nature and address them with a holistic approach.
Transition Design is a new design approach focused on systems-level change. It “refers to design-led societal transition toward more sustainable futures and the reconception of entire lifestyles. It is based upon an understanding of the interconnectedness and interdependency of social, economic, political and natural systems. […] Transition Design challenges existing paradigms, envisions new ones, and leads to radical, positive social and environmental change.”
Essentially, Transition Design offers a framework to deal with complex problems and move society towards better futures. It emphasizes a holistic approach and long-term visions and acknowledges that some problems cannot be entirely defined, or their definition changes as we address them.
Issues related to mental health care can be labeled as wicked problems, and as such, we can approach them with Transition Design methods. In the rest of this article, we will talk about the process of designing transitions, which includes:
- Mapping the problem and its stakeholders. What is wrong with current mental health care? What role does the stigma play? And who is affected by the problem?
- Mapping the evolution of the problem. Where does mental health stigma come from? What influenced how people perceived mental health throughout history? And how far into the past do we need to go to identify the roots of the problem?
- Visioning the future. Can we imagine a future with no mental health stigma? What would it look like?
- Backcasting. If we have a vision of a favorable future, can we go back and imagine what steps lead to such a future? What needs to happen on micro-, meso-, and macro-level to facilitate the transition?
Next, we would propose specific interventions on multiple levels (e.g., local, national) that would move us towards the vision. We would start implementing changes and monitor how the problem evolves. Transition Design emphasizes that we cannot fully anticipate how a system will react to our interventions — it is crucial to observe the evolution and be ready to change our plan.
Transition Design uses participatory methods: it’s not the designers who map the problem and design transitions; instead, representatives of diverse stakeholder groups are invited into the process, and the designers act more as guides through that process. Transition designing is not a job for one; therefore, the following part will merely outline how we might address mental health care issues (such as stigma) without delving into concrete definitions and visions.
Mapping Wicked Problem & Stakeholders
In the first activity, we would use PEST analysis to map the wicked problem. PEST stands for political, economic, social, and technological — four external factors that influence the problem. If we were dealing with a problem connected to ecology and the environment, we could use STEEP analysis instead: it includes the same four factors as PEST and adds an extra environmental factor.
The PEST analysis could include the following issues:
- Political: There is a lack of mental health support covered by common health insurance.
- Economic: Capitalism pushes people to work hard and ignore their personal needs. Therapy is expensive for many people so they don’t even consider going.
- Social: Lack of education about mental health causes people to view mental health issues as personal failure.
- Technology & Infrastructure: People in small towns don’t have many options for finding in-person mental health support.
Next, we would map the stakeholders. The goal is to identify as many stakeholder groups connected to the problem as possible and describe their conflicting needs and opinions.
In practice, mapping the problem and its stakeholders requires extensive qualitative research and continuous stakeholder involvement.
Mapping the Evolution of a Problem
The objective of this activity is to form a multi-level timeline of the problem’s evolution. It uses Geels’ Multi-Level Perspective framework, which distinguishes three system levels: the landscape (macro), the regime (meso), and the niche (micro). Essentially, the framework describes how socio-technical systems change on different levels and how the levels interact. For example, the COVID-19 pandemics (landscape event) put pressure on the ‘status quo’ of mental health care: more people needed help and were willing to use new tools to get it (change in the regime level). That required endorsement of innovation that only existed at the niche level before, such as online therapy or meditation apps.
Visioning the Future
In this step, we would develop long-term future visions at five different levels of scale: the household, the neighborhood, the city, the region, and the planet. According to the Transition Design Seminar at CMU, “the objective of this step is to try and envision a long-term future in which lifestyles are sustainable and place-based and in which relations among the levels of scale of everyday life are symbiotic and mutually reinforcing.”
For instance, we could envision the following:
- Household: Parents teach their kids mental hygiene like they would teach physical hygiene. The household has become a place of emotional safety and support.
- Neighborhood: Neighborhoods have centers that offer mental health support, workshops, and meditation sessions.
- City: Mental health support is available and affordable. Mental health is a part of the school curriculum. Businesses work with households and the city to provide high speed internet.
- Region: Cultural norms have changed; mental health is considered as important as physical health.
Backcasting
When we have long-term future visions, we can start looking back and imagine what interventions would lead to such a future. We would assess existing practices (Which should we keep and which should be left behind?) and suggest new ones that could emerge during the transition period.
Backcasting can take on many forms. The essential objective is to develop a pathway from now to the envisioned distant future and design specific interventions on that pathway.
Let’s look at the example of a city-level vision “Mental health is a part of the school curriculum.” What steps can we take to bring mental health care to schools? We could start with modern schools that are open to new approaches to learning. These schools could be the pioneers of mental health education. Next, we could offer them workshops by external mental health care professionals and later expand these workshops to all types of schools. Finally, this should lead to a change on the political level and mental health education should become a compulsory part of the school curriculum.
The pathway to an envisioned future is not straightforward; there are many steps to take and various ways of reaching the same result. It would, again, require stakeholder involvement and participative design methods to identify the interventions necessary for the transition.
Afterword
The COVID-19 outbreak caused a secondary outbreak of mental health issues and a decrease in mental wellbeing. It brought the topic of mental health into mainstream media and instigated a discussion about the future of mental health care. In the words of Transition Design, the landscape of mental health care is changing, and the regime is opening up to innovation.
One single innovation won’t change the status quo — but a series of interventions on multiple levels could lead us towards better mental health care. The Transition Design approach helps us specify the interventions and develop a strategy for transition.
After outlining the complex approach of Transition Design, I will leave you with a perhaps more straightforward question to ponder: How can mental health care services (products, apps) contribute to our transition pathway to a stigma-free future? And how can we contribute as individuals?
The process was inspired by the CMU Transition Design Seminar and Masaki Iwabuchi. For a practical case study, I highly recommend Masaki’s work on Adolescent Depression in Kyoto.
