Training activist professionals against stigma toward people with psychiatric diagnoses: an chilean experience

Abstract

Introduction  It is necessary to train health and social science professionals to take action to reduce the negative effects of stigma, not only for those who are stigmatized, but especially for those who stigmatize.

Objective  The objective of this study is to analyze the learning that occupational therapy students develop regarding public stigma reduction when they engage in a socio-educational intervention with the general population, supported by peer tutors in a Chilean university.

Methodology  A qualitative methodology with a socio-constructionist approach to knowledge was adopted. Data were collected through online qualitative questionnaires completed by six teachers, six peer tutors, and 80 students in a private Chilean university. The data were subjected to a thematic content analysis.

Results  Six topics emerged: learning facilitators, construction of public stigma, stigma reduction, reconceptualization of the stigmatized person, effects of public stigma, and development of occupational awareness.

Conclusions  The combination of project-based learning and peer mentoring is a useful and efficient pedagogical strategy for students in health and social sciences, such as occupational therapy, to learn relevant aspects of public stigma, such as its causes, potential effects, and some socio-educational strategies for its reduction.

Keywords:
Social Stigma; Project-Based Learning; Paired-Associate Learning; Students; Human Rights

Resumen

Introducción  Es necesario formar a los profesionales de la salud y de las ciencias sociales para realizar acciones que reduzcan los efectos negativos del estigma, no solo con las personas que son estigmatizadas, sino que sobre todo con quienes estigmatizan.

Objetivo  El objetivo de este estudio es analizar los aprendizajes que desarrollan sobre la reducción del estigma público las y los estudiantes de terapia ocupacional, cuando realizan una intervención socioeducativa con población general apoyados por tutoras/es pares en una universidad chilena.

Metodología  Se adoptó una metodología cualitativa con un enfoque socio construccionista del conocimiento. La información se produce por medio de cuestionarios cualitativos on line que responden 6 docentes, 6 tutores pares y 80 estudiantes de una universidad privada en Chile. Los datos se someten a un análisis de contenido temático.

Resultados  Emergen 6 temas: facilitadores del aprendizaje, construcción del estigma público, reducción del estigma, reconceptualización de la persona estigmatizada, efectos del estigma público y desarrollo de la conciencia ocupacional.

Conclusiones  La combinación del aprendizaje basado en proyectos junto a la tutoría de pares es una estrategia pedagógica útil y eficiente para que estudiantes del área de la salud y las ciencias sociales, como es el caso de la terapia ocupacional, aprendan aspectos relevantes sobre el estigma público como sus causas, sus potenciales efectos y algunas estrategias socioeducativas para su reducción.

Palabras-clave:
Estigma Social; Aprendizaje por Asociación de Pares; Estudiantes; Derechos Humanos

Resumo

Introdução  Profissionais de saúde e ciências sociais precisam ser treinados para tomar medidas para reduzir os efeitos negativos do estigma, não apenas para aqueles que são estigmatizados, mas, especialmente, para aqueles que estigmatizam.

Objetivo  O objetivo deste estudo foi analisar a aprendizagem que estudantes de terapia ocupacional desenvolvem sobre a redução do estigma público quando realizam uma intervenção socioeducativa com a população em geral apoiada por tutores pares em uma universidade chilena.

Metodologia  Foi adotada uma metodologia qualitativa com uma abordagem socioconstrucionista do conhecimento. As informações foram geradas por meio de questionários qualitativos on-line respondidos por seis professores, seis tutores e 80 alunos de uma universidade privada chilena. Os dados foram submetidos a uma análise de conteúdo temática.

Resultados  Seis temas emergiram: facilitadores de aprendizagem, construção do estigma público, redução do estigma, reconceitualização da pessoa estigmatizada, efeitos do estigma público e desenvolvimento da consciência ocupacional.

Conclusões  A combinação de aprendizagem baseada em projetos e mentoria entre pares é uma estratégia pedagógica útil e eficiente para estudantes de ciências sociais e da saúde, como terapia ocupacional, aprenderem aspectos relevantes do estigma público, como suas causas, efeitos potenciais e estratégias socioeducacionais para reduzi-lo.

Palavras-chave:
Estigma Social; Aprendizagem por Associação de Pares; Alunos; Direitos Humanos

Introduction

Stigma is a sociocultural phenomenon based on the belief that certain people or social groups have attributes or characteristics that make them different and inferior to the rest of society or dominant groups (Michaels et al., 2017), for example, poor people, women, and older adults, among others. Stigmatization, on the other hand, is the process by which people materialize stigma toward those who are stigmatized through attitudes, feelings, beliefs, and behaviors that can lead to discrimination (Loubat et al., 2017); that is, discrimination is the result of the stigmatization process, which makes it difficult for stigmatized people to exercise their rights.

For the purposes of this study, the focus is on the stigma toward people with a psychiatric diagnosis, which is based on a lack of accurate knowledge and stereotypical beliefs about mental health problems (Grandón et al., 2018). At the same time, it is considered a direct consequence of the social perception surrounding mental illness, which has implications for the identity of those stigmatized (Correa-Urquiza et al., 2020). Stigmatization of this social group entails negative consequences such as unequal treatment, fewer opportunities to seek timely treatment, increased relapse, difficulties in pursuing work and education, and in establishing friendships or relationships (Mora-Ríos et al., 2013; Mascayano et al., 2015; Saavedra & Murvartian, 2021). That said, it is essential for social and healthcare professionals to carry out interventions with and for society as a whole, so that people can identify their own prejudices, educate themselves about them, and share their experiences. This could promote destigmatization, thereby advancing social inclusion and the full exercise of rights.

The presence of stigma toward people with psychiatric diagnoses among students of health and social science professions has been the subject of study. Specifically, in the field of stigma reduction education, a series of methodological strategies have been implemented that have enabled constructive learning in this regard. For example, experiential learning reduces the fear caused by contact with people with psychiatric diagnoses, while also fostering humanization in treatment and care (Fuentes, 2019). Moraleda et al. (2023) argue that there are two socio-educational strategies that reduce stigma: the first is the use of documentaries starring people with psychiatric diagnoses, complemented by talks by experienced care professionals; and the second is the use of the educational game Stigma Stop (available on PC software, a mobile app, and online at their website).

Other successful strategies for raising awareness about stigma among university students include the combination of methodologies such as clinical simulation with actors, direct contact with individuals diagnosed with psychiatric conditions, and project-based learning (Rodríguez-Rivas et al., 2021). The use of problem-based learning alongside case studies facilitates the acquisition of knowledge about mental health issues and, in turn, helps reduce negative attitudes (Ozamiz-Etxebarria et al., 2022). Notably, the strategy that appears to have the most sustainable long-term impact is direct contact with service users whose experiences are framed outside of biomedical explanations of mental health problems (Moraleda et al., 2023; Pursehouse, 2023; Van Liew et al., 2023). It is important to highlight, however, that most studies focus on reducing stigma among students themselves, rather than on the potential contribution they can make to reducing stigma toward people with psychiatric diagnoses in the broader population.

Despite some advances, research on university students’ learning about stigma remains limited (Querido et al., 2016; Masedo et al., 2021; Gajardo et al., 2022; Grandón et al., 2022). This topic is particularly relevant in the training of occupational therapists and other health professionals, who must be equipped not only to work with people who are stigmatized but also to address and challenge the stigmatizing behaviors of others. It is therefore essential that students are capable of identifying stigmatizing attitudes within the general population and of implementing socio-educational strategies to reduce stigma and its consequences. This issue takes on even greater importance in light of one of the key objectives of Chile’s National Health Strategy, which explicitly includes reducing stigma toward individuals with mental health problems (Chile, 2022).

This study delves into the most appropriate and meaningful learning strategies for students regarding this topic, which is so important for professional practice and for improving the quality of life through the full social inclusion of people with a psychiatric diagnosis. To this end, an educational innovation was implemented that combines a project-based learning methodology with the support of student-assistants as mediators of the learning process. These methods were referred to in this study as peer tutors.

These methodologies were chosen because project-based learning allows students to develop their autonomy, which encourages them to be the protagonists of their own learning, while simultaneously developing the ability to seek solutions to real-life problems (Bell, 2010; Botella & Ramos, 2019; Morales et al., 2022). According to MacLeod & van der Veen (2020), project-based learning offers students the opportunity to design a solution by collecting data and conducting additional consultations.

At the same time, peer tutoring is incorporated since, as Cardozo-Ortiz (2011) points out, this strategy contributes to comprehensive learning, allows for expanding mastery in other areas of knowledge, increases technical language, and improves the academic performance of the tutored students. For their part, Jawhari et al. (2021) propose that peer tutoring is an efficient strategy for developing learning, since it tends to generate a more welcoming and trusting environment between tutor and tutee; at the same time, it allows peer tutors to consolidate their knowledge. Finally, peers are recognized as positive role models, motivating learning among tutees, which allows for the development of leadership skills that are useful for the students' performance during the practical activities of their professional training (Larkin & Hitch, 2019).

Valderrama Núñez et al. (2024) encourage the study of learning processes related to stigma toward individuals with a psychiatric diagnosis when project-based learning is combined with peer mentoring. In our view, this approach not only involves acquiring knowledge about stigma but also fostering an inclusive teaching-learning environment where students feel safe to discuss and reflect on these issues—thereby gaining a deeper understanding of the impact of stigma on people's everyday lives. In this regard, the role of educators becomes a key factor in the effectiveness of stigma reduction. It is not sufficient to simply convey theoretical content about stigma; teachers must be prepared to act as facilitators of learning within its sociocultural dimensions, guiding reflective, dialogical, and transformative processes.

The objective of this study is to analyze the learning that third-year occupational therapy students at a Chilean university develop regarding public stigma through the combined use of project-based learning and peer tutoring, considering the perspectives of students, teachers, and peer tutors.

Background and context of the study

This study is part of the training process for occupational therapy students at a private university in Chile, with campuses located in three cities: Viña del Mar, Santiago, and Concepción. Specifically, it focuses on third-year students enrolled in the course Mental Health I. In the first unit of this course, over a total of 12 instructional hours, content is delivered with the aim of achieving the following expected learning outcome: to explain the relationship between stigma and the violation of rights, as well as the emergence of strategies to reduce the social consequences of this issue.

Given that socio-educational approaches are powerful tools in anti-stigma programs (Lien et al., 2021), and that mental health literacy supports the acquisition of knowledge aimed at preventing and reducing stigma (Casañas & Lalucat, 2018), a project was designed in which students—working in groups of 3 to 4—developed, implemented, and evaluated a socio-educational intervention to reduce stigma within various social groups. In parallel, each student group received pedagogical support from a peer tutor through a virtual tutorial format. Each peer tutor was trained and supervised by the course instructors to enhance their knowledge and ensure effective guidance of the students. Each tutor was responsible for supporting 4 to 5 student groups. These virtual tutorials were conducted synchronously, lasted approximately one hour, were mandatory, and were scheduled based on the specific support needs of each socio-educational project.

The instructors provided students with the activity guidelines, tutorial plan, and assessment tools during the first class session. A total of seven instructors, nine peer tutors, and 156 students participated in this project.

The project was carried out in four stages and lasted 16 weeks:

1. Assessment and/or diagnosis of the situation: Students carried out an assessment of a specific social group, selected by themselves from a list of potential groups provided by the teachers. To identify stigmatizing attitudes toward people with psychiatric diagnoses that might exist in this group, the Community Attitudes Questionnaire toward People with Mental Illness (CAMI), validated by Grandón Fernández et al. (2016) for the general population in Chile, was applied. This stage lasted approximately 3 weeks.

2. Design of the socio-educational intervention: Once the information was collected, the data was analyzed to design a socio-educational intervention aimed at reducing the identified stigmas. The proposed strategies had the following characteristics: attractiveness, clear language and content, and messages focused on promoting destigmatization and the recognition of human rights in different areas and spheres of daily and social life. This stage lasted 3 weeks.

3. Strategy implementation: Based on pedagogical principles, the intervention promoted active and participatory learning, emphasizing interaction, co-construction of knowledge, and critical reflection to foster destigmatization and autonomy. This phase lasted 5 weeks.

The socio-educational strategies developed by the students included animated videos explaining key concepts of mental health, stigma, and rights; infographics in the form of diptychs and/or triptychs summarizing concepts, common myths, and action guides; recreational activities such as games; use of social media; and informative talks with a question-and-answer session. The emphasis was placed on human rights, social participation, personal autonomy, and reducing prejudices associated with mental disorders, through messages contextualized in multiple settings (educational, community, family, and workplace). No strategy was mandatory or exclusive; complementarity was encouraged throughout the process to reach different groups and life stages.

The individuals who received the socio-educational intervention represented a valuable diversity of stakeholders: university students, people over 65, homemakers, community group members, professionals, high school students, and students' families, among others.

1. Evaluation of the results: Finally, the students employed a mixed data collection methodology to capture and analyze the scope, contributions, obstacles, and facilitators of the strategies used to reduce stigma among the participating population. This phase lasted five weeks. Some of the strategies implemented by the groups included:

• Reapplication of the CAMI to quantify the effects of the intervention.

• Individual and group interviews to identify discourses that promote rights and improve knowledge about psychiatric diagnoses, among others.

It is important to note that, given the objective of this study, the intervention results are not presented in detail, as this experience was conducted for pedagogical purposes and these results were assessed within the course in which the intervention took place.

Methodology

A qualitative phenomenological methodological strategy with a socio-constructionist approach to knowledge was used to develop this study, as the objective was to analyze the meanings that participants attributed to the educational experience (Di Silvestre, 2012). Data was generated through an online questionnaire, described below.

Study participants

Three key stakeholders were included: the teachers of the Mental Health I course, students acting as tutors, and tutees. Participation of the first two groups was determined through purposive sampling. The only inclusion criterion was that they had participated in the training experience in their assigned role. In both cases, a direct invitation was sent via email and WhatsApp.

In the case of the tutored students, a simple random sample was conducted with all students participating in the training experience (Otzen & Manterola, 2017). The invitation was sent via institutional email and announced by the course instructors on the institutional platform CANVAS. In addition, each classroom instructor encouraged students to participate, and the tutors shared the invitation through WhatsApp with each of the previously formed working groups.

Six tutors (one man and five women) participated in this study; for all of them, this was their first experience serving as peer tutors. Six course instructors (one man and five women) also took part simultaneously. The three locations where the study was conducted were represented.

A total of six instructors collaborated. All of them are occupational therapists with experience in mental health interventions. Two have taught the course for five years, two for four years, and two for two years. Four are regular professors in the program (formally employed by the university), and two are adjunct professors (providing services on an hourly basis).

Finally, 80 students participated, representing a response rate of 51.2%. Of these, 91% (n=73) were women and 8.8% (n=7) were men. Regarding campuses, 30% (n=24) were from Santiago, 25% (n=20) from Concepción, and 45% (n=36) from Viña del Mar.

Information production instruments

The production of the information required to evaluate the training experience was carried out through online questionnaires designed by the research team. Braun et al. (2021) argue that these facilitate the participation of a larger number of people, especially when geographically dispersed. In addition, they allow for open-ended questions. The entirety of the responses obtained provides a richness of data that deepens the analysis and, finally, ensures a sense of anonymity that allows for more reliable answers. All these reasons were considered relevant to this study and were taken into account in the decision to use this instrument.

The questionnaires were created using the Google Forms platform and distributed through the same digital media used for the call for participation. The questionnaire for peer tutors and teachers consisted of 12 open-ended questions: six focused on peer tutoring and the other six on project-based learning. In the case of the tutored students, a mixed-format questionnaire was administered, including five qualitative questions and 14 closed-ended questions; the latter were not included in this study.

The questions were designed to elicit reflective responses and were reviewed by experts, whose observations were incorporated into the final version. The topics addressed included the following: significant learning, an adequate learning environment, motivation, problem-solving, decision-making, reflective skills, collaborative learning, lessons learned about stigma, project improvements, unachieved learning about stigma, and the relationship between stigma and human rights.

Analysis procedure

The questionnaires remained open for completion from June to August 2023. After this period, the data were subjected to thematic content analysis of all questionnaire responses, following the six stages proposed by Braun & Clarke (2022):

• Data familiarization: Data were extracted verbatim from the Google Forms platform and exported to an Excel file for processing. At least two readings of the responses were carried out, simultaneously recording the thoughts generated and noting assumptions and perspectives during the reading.

• Systematic data coding: Codes were created by identifying relevant and pertinent characteristics of the data. As many potential themes as possible were coded, and all data were included.

• Generating initial categories from coded data: Code lists were reviewed, and tables were used to organize and generate potential categories. Codes and categories were subsequently reviewed and further developed for all data.

• Developing and revising themes: The data were examined to ensure consistency with the evident meaning of the entire dataset, and any additional data that might have been omitted were categorized. Specific categories that represented each theme were grouped together.

• Refining, defining, and naming themes: The data were set aside for two weeks; after this period, the codes and categories were reviewed and refined to ensure that the scope and content of the report accurately represented the dataset as a whole.

• Writing the report: During this stage, adjustments to theme terminology and supporting categories were made, while the originally coded dataset and supporting quotes were retained as references.

This analytical approach was chosen because it offers flexibility in handling data, particularly when derived from multiple stakeholders and instruments. To strengthen the reliability and consistency of the analysis, stakeholder triangulation was applied to generate the initial codes and categories (Okuda Benavides & Gómez-Restrepo, 2005). The resulting codes, subthemes, and themes were then analyzed and discussed by the research team in several group sessions.

Ethical considerations

In this research project, the voluntary nature, anonymity, and confidentiality of all participants were respected, in compliance with Decree 114 of 2010 of the Ministry of Health of the Government of Chile, which approves the regulations of Law 20.120 on scientific research involving human beings and their genomes and prohibits human cloning. Therefore, the names, workplaces, and/or study locations of the participants were not used. The recordings and transcripts will be stored on a drive accessible only to the research team. These files will be deleted two years after the end of the study.

There are no known or foreseeable risks to the participants in this research. All of these aspects, in addition to the study objectives, are contained in the informed consent (IC), which was signed by all participants.

For students, the IC was attached to the questionnaire, so that if the participant accepted its contents, they could access the instrument. If the participant did not accept, access was disabled. For teachers and peer tutors, a digital signature was requested via email to the principal investigator of this study.

Results

Below are the topics and subtopics that emerged from the analysis process described above. These topixs and subtopics are then described, highlighting the quotes that support them. To present the quotes, codes were established to identify the corresponding participant: for students, the letter (S), for teachers, the letter (T), and for tutors, the letters (TP). All of these codes are accompanied by a number automatically assigned by Google Forms according to the temporal order in which each participant submitted their response, as presented below in Figure 1.

Figure 1
Summary of emerging topics and subtopics. Source: Own elaboration.

Topic 1. Learning facilitators

The participants in this study state that the teaching-learning methodology implemented is an ideal platform for identifying, understanding, and addressing public stigma, as two fundamental conditions are met during the process. First, the project is implemented in the everyday contexts of the people involved, far removed from the clinical and/or biomedical settings where occupational therapy students typically train: "This is a positive experience, as the opportunity allows students to gain real-world experience" (TP4). This experiential learning is even more valuable when considering that it challenges the predominant theoretical understandings of the university world: "They learned that the information they deal with in academia is very different from what people deal with in everyday life" (T2).

Secondly, the fact that the socio-educational intervention is carried out with “ordinary people” and in their daily spaces is presented as favorable: “understanding the stigmas that exist in the population, in my case among older adults, towards people with a psychiatric diagnosis and how to use strategies to eliminate these stigmas” (S48).

Topic 2. Construction of public stigma

For the participants in this study, their lived experiences allowed them to identify at least two aspects considered to promote public stigma toward people with a psychiatric diagnosis. The first corresponds to the lack of scientific and formal knowledge about mental health problems, which generates stereotypes and reproduces prejudices in the general population: "I consider it valuable to know the level of misinformation out there, as this triggers different points of view that we need to know how to manage and deal with people, as it generates many prejudices" (S52).

Secondly, this experience enabled the students to identify the stigmatizing beliefs and attitudes held by the general population regarding psychiatric disorders or diagnoses, which are closer than they had imagined: "…they realized that those close to them generated stigmatizing actions and held beliefs that were contrary to theirs" (T5), "I find that this work helped us a lot to understand how people stigmatize people with mental health problems and that it is important to visualize this" (S59).

Simultaneously, their ability to recognize public stigma was heightened as they observed contradictions in the discourses of those who participated in the intervention regarding people with psychiatric diagnoses:

This is because, in the results of our research, people did not consider themselves stigmatizing individuals with psychiatric diagnoses (they knew they were not violent and claimed to be able to relate to them), but 50% believe they should be hospitalized, which is contradictory in practice (S4).

Topic 3. Stigma reduction

Participants emphasized that the use of appropriate diagnostic instruments is important for reducing public stigma. In this regard, they considered the instrument used in this project inadequate for this purpose. They identified the CAMI as decontextualized, repetitive, and imprecise, both for the students and for the population to whom it was administered: "Our participant group considered the questionnaire to be very archaic and inappropriate; as a group, we share this opinion" (S67), "In the CAMI, we should be more specific when referring to people with mental illnesses (specifically, which illnesses? That term is too broad)" (S71).

Obstacles to reducing public stigma include a lack of awareness regarding the actual contribution students make to this goal: "I think the difficulties arise from the students' lack of awareness about the intervention processes, since, at the end of the evaluation, they didn't consider the impact that talking about stigma had on people" (T4).

In this sense, the inability to systematically monitor the results of the intervention is identified as a problem in recognizing its scope:

I believe that the project contributes to the evaluation or diagnosis associated with the population they will work with, but I don't think they will be able to fully evaluate the strategy they implement or monitor it (T6).

The participants believe that the project's duration is insufficient for the proposed stages, raising doubts about the real impact of the intervention: "A 100% implementation of stigma reduction, with so few sessions, makes it difficult to have a significant impact on people. If the project were implemented long-term, it could be more successful" (S69).

For several participants, one of the most valuable lessons learned is directly related to the possibility of implementing anti-stigma practices. The implementation of micro-social socio-educational interventions to reduce stigma demonstrated that educating the general population about stigma helps transform society to be more accessible and inclusive of people with psychiatric diagnoses, allowing them to advance in exercising their rights as citizens: "The stigma itself generates separation and exclusion toward the people to whom it is applied. When this stigma changes, people's rights are fulfilled as they should be" (S56).

The above implies that those who carry out anti-stigma socio-educational interventions should be guided by a human rights perspective, since human rights are considered a tool to reduce stigma, insofar as they recognize people in their condition as citizens rather than defining them solely by their psychiatric diagnosis at some given point in life: "Human rights are fundamental when it comes to breaking down stigmas and prejudices, since by making them visible, a better understanding of the person can be achieved" (S37).

Topic 4. Reconceptualizing the stigmatized person

For the participants, this intervention project allowed them to reflect on the importance of recognizing and respecting people with a psychiatric diagnosis as rights holders: "People with a diagnosis are violated by society based on the prejudices and stigma placed against them, and due to ignorance, human rights help recognize them as rights holders" (S35).

The participants' reflection on the status of those stigmatized as rights holders is intensified by taking actions that reduce public stigma. By linking this topic to human rights, we move toward a conception of society in which people with a psychiatric diagnosis enjoy the same rights as any other individual, thus contributing to fostering respect for the diversity inherent in the human condition: "People with a psychiatric diagnosis have exactly the same rights as everyone else; they are no less for suffering from this; they deserve respect, understanding, and help" (S61).

Considering people with a psychiatric diagnosis as subjects of rights implies that they have the capacity and the right to fully participate in community life. Therefore, it is imperative to reduce public stigma, as this action fosters an environment conducive to healthy coexistence. By addressing and reducing stigma, the necessary foundations are laid for creating conditions that foster enriching and respectful coexistence for all: "Stigma can be said to influence discriminatory acts by people toward others in the same society, which affects their fundamental rights to live in a full society" (S31). The socio-educational intervention analyzed became an opportunity to promote more humanized social relationships and thus raise awareness among potentially stigmatizing individuals: "Humanization of bonds is developed throughout their evaluation and informed consent" (T4).

At the same time, for the participants, people with a psychiatric diagnosis are considered capable of making independent choices about their lives; that is, they possess functional and moral autonomy to decide the future of their lives without anyone hindering them: "I think it's important to understand people as beings worthy of living their lives as they see fit, without being judged" (S42).

Topic 5. Effects of public stigma

Although there are rights that seek equality among people while respecting their diversity, through this experience some participants point out that public stigma appears to be a dominant condition in today's society that limits the exercise of rights for those who are stigmatized: "People with psychiatric diagnoses continue to be subjects of rights, but unfortunately, society, with its many stigmas, takes away those rights without realizing it or caring" (S19). This situation, in the opinion of the participants, has an impact on the ability of people with a psychiatric diagnosis to exercise their social rights, promoting the social exclusion of this group:

That the stigma toward people with mental health diagnoses will generate prejudice within society and can be detrimental, as these people are often excluded from doing things that others have the right to do, such as work or education (S28).

The discrimination produced by public stigma is based, according to the participants, on the fact that people are indifferent and ignore the human qualities of people with psychiatric diagnoses: "By having an intervention group without a diagnosis, they realized that this population makes those misnamed crazy people invisible" (T5). To such an extent that for some, a society in which they do not actively participate in the community would be better, implying that they are not part of it because they lack the necessary human capacities for such participation: "The participants found it difficult to understand that people with mental health disorders can actively participate in the community and maintain social participation" (S39). "They gain a broader understanding of the situations of exclusion, marginalization, and discrimination experienced by people with a mental health condition and recognize that they are present in the community" (T6).

The participants' accounts show that to deepen knowledge about the public stigma toward people with psychiatric diagnoses, it is necessary to incorporate them into projects and to experience their realities firsthand, since they possess unique knowledge as experts by experience: "I believe that what they failed to learn is the reality of people with a psychiatric diagnosis facing these stigmas imposed by society" (TP5). This therefore entails integrating the subjective consequences of those who suffer from stigma into the notion of public stigma, that is, addressing self-stigma through first-person experiences and testimonies:

The personal impact of stigma, including its emotional and psychological aspects, can be challenging to fully capture without more direct interaction and personal testimonies. While the project provides a solid foundation for understanding stigma, these more subjective and contextualized aspects may require further exploration beyond its scope (S73).

Topic 6. Development of occupational awareness

This project enabled students to develop an understanding of their own stigmas toward people with psychiatric diagnoses, but, above all, to transform these erroneous beliefs into actions that contribute to stigma reduction in their roles as students and future professionals in the field of mental health.

This process, according to the participants, was shaped by the students' ability to identify the stereotypes and prejudices that underlie stigma, with the goal of disassociating themselves from these perceptions and, thus, becoming better equipped to provide adequate care to those facing mental health problems. This self-awareness exercise not only allows them to confront and overcome their own biases, but also equips them with the necessary skills to offer more comprehensive and effective support to people requiring mental health care: "It helped me a lot to overcome my prejudices and learn a little more about the topic, so I'm as prepared as possible for my clients" (S24). "They learned that they are the ones who must initially let go of the stigmas they have about psychiatric disorders" (T2).

For the participants, this experience fosters the development of social awareness among students regarding public stigma. The importance of reducing this stigma in people who experience it in their daily lives is highlighted, as its adverse effects negatively impact the social inclusion of people with a psychiatric diagnosis. By stressing the need to address and mitigate stigma, a more understanding and supportive environment is fostered, creating conditions that favor the full participation and integration of those affected into society:

More than anything, it is a change in the way we empathize with people with a mental health condition, who have in fact been greatly excluded by society, both before and now, and that this must change without fail (S54).

For the students, taking concrete actions to reduce public stigma with ordinary people became the impetus to develop skills that go beyond mere individual intervention. They also emphasized being protagonists in generating positive change and being activists to improve the lives of those who suffer: "We all have rights, and as therapists, we have to assert them. We are subjects of rights" (S42). "They are people first and foremost, and it is our duty, from our position, to help reduce their exclusion and stigmatization through education and information" (S46).

Discussion

Artaza et al. (2020) argue that training in social and health professions should aim to build social awareness among students and provide them with tools that allow them to assume a leading role as agents of transformation, committed to addressing people’s social problems. In this sense, Simó (2016) contends that the service-learning methodology is a teaching strategy that enables students to learn about social stigma in real contexts, to experience their own capacity to contribute to societal improvement, and to become aware of their social commitment.

The results of this study suggest that these competencies are also developed through the implementation of project-based learning aimed at reducing public stigma, since both methodologies share the characteristic of being carried out in contexts where people interact in their daily lives, far from clinical and/or academic environments that may distort how stigma toward people with a psychiatric diagnosis is truly manifested. Given the characteristics of the experience analyzed and the support provided by peers, students learned to recognize stigmatizing beliefs and attitudes, to identify some of the factors that produce and reproduce public stigma as well as its effects on the lives of those who experience it; to design and identify facilitators and obstacles in the implementation of socio-educational strategies to reduce stigma; and, to a lesser extent, to evaluate the results of their actions.

Project-based learning and peer teaching foster the transfer of knowledge presented in class and the development of critical thinking (Rodríguez-Sandoval et al., 2010; Estigmar, 2016). According to the findings of this study, the students acquired these competencies. First, they demonstrated the ability to reflect on the contradictions present in participants’ discourses and attitudes when theoretically addressing the notion of stigma with the general population. Second, they were able to constructively identify areas for improvement in socio-educational programs for stigma reduction. This includes considerations such as the adequacy of the evaluation instrument used, the duration of the project, and the need to implement more comprehensive mechanisms for assessing the impact of the intervention.

To reduce public stigma, it is necessary to build a respectful, supportive, and humanized society (Valderrama-Núñez & Zolezzi-Gorziglia, 2021). For this reason, it is essential that the academic world encourages students to recognize their own beliefs about people with mental health problems so that they can reduce stigmatizing attitudes both in themselves and in those around them (Pursehouse, 2023). The results of this study show that when educational settings are created in which students interact with potentially stigmatizing individuals, and they have the support of a peer to reflect on their experiences, they are able to identify and address the prejudices and stereotypes of others while simultaneously recognizing their own. In this way, they experience a personal process of de-stigmatization while carrying out the socio-educational intervention.

Occupational therapy students display fewer stigmatizing behaviors and ideas in the field of mental health compared to students of nursing, medicine, psychology, and other health-related programs (Querido et al., 2016; Masedo et al., 2021). These differences may be explained by the fact that this profession incorporates courses related to the social sciences more prominently than other health programs, which tend to promote a biomedical approach to mental health problems (Grandón et al., 2022). An example of this is that the curriculum in which this experience is situated defines human rights as one of its central axes, meaning that students receive training in this area from their first year. Based on the results obtained, it is possible to state that through project-based learning and peer tutoring, students are able to move beyond biomedical and functionalist perspectives to understand public stigma as a human rights issue. This is expressed in recognizing the stigmatized person as a subject of rights, above and beyond their health condition—an individual who produces valuable knowledge from which everyone can learn, who is capable of making their own decisions, and who must be respected and acknowledged as a citizen with the right to live in community, to work, and to study.

Valderrama (2020) points out that human rights education enhances the occupational awareness of students, as it enables them to recognize their own condition as social subjects—individuals who may either stigmatize or be stigmatized. Furthermore, in their role as future professionals, when they carry out socio-educational interventions with those who are potentially stigmatizing, and reflect on this experience with the support of peers, they become occupational activists (Álvarez & González, 2018). In other words, they become occupational therapists with greater awareness and a stronger commitment to transforming the social, cultural, and material conditions that produce injustice and exclusion among the social groups with whom they intervene—professionals who take a political stance against discrimination and whose actions are aimed at eliminating it.

The findings of this study highlight the importance of including people who experience stigma, as well as their families and close environments, in anti-stigma strategies, as suggested by Mascayano et al. (2015) and Cea Madrid (2023). As Valderrama-Núñez & Zolezzi-Gorziglia (2021) emphasize, when these individuals participate as educators and provide first-person testimonies, they foster greater sensitivity and awareness of stigma among those without psychiatric diagnoses. For this reason, in order to strengthen stigma reduction strategies, it would be essential for people with psychiatric diagnoses to participate collaboratively with students in socio-educational intervention projects, either as interveners and/or as tutors. In any case, this proposal requires further research into the learning outcomes that students may achieve when working alongside experts by experience.

While it is essential for future professionals to acquire knowledge about stigma and strategies to combat it, it is equally important that students learn through teaching methodologies that enable them to apply this knowledge effectively. As Narváez & Itovich (2024) note, education reduces stigma as students progress; therefore, teaching must be intentional, progressive, and grounded in real experiences in order to consolidate a comprehensive perspective on mental health and human rights. Within this framework, teaching is understood as a pedagogical practice that integrates knowledge, ethical sensitivity, and organizational skills to foster an inclusive, safe, and participatory learning environment in which all voices are heard and valued. Constructive feedback that emphasizes processes rather than solely outcomes is also crucial for promoting critical thinking and student self-efficacy.

Conclusions

The synergy between project-based learning and peer mentoring emerges as a highly valuable and effective pedagogical strategy for occupational therapy students, particularly at an intermediate stage of their training, to acquire a deeper understanding of key aspects related to public stigma. This includes the ability to identify some of its causes by engaging with individuals who may stigmatize them, to recognize its potential effects, and to design socio-educational strategies for its reduction. This study not only underscores the importance of training professionals in stigma reduction but also emphasizes the need to prepare teachers and tutors who will guide these future professionals. Effective teaching is therefore essential for transforming stigmatizing beliefs both within students and in the broader community.

Nonetheless, it is important to note that the timeframes allocated for the project’s implementation are constrained by the academic calendar of the higher education institution to which the participants belong. This limitation may restrict students from gaining deeper insight into the effects of the socio-educational interventions they carried out in collaboration with community members. It is therefore recommended that these activities be scheduled in a way that allows students to critically evaluate their actions, thereby fostering learning from both the successes achieved and the challenges encountered throughout these processes.

• How to cite:
  Valderrama Nuñez, C. M., Avendaño Cartes, J. E., & Puntareli Vicencio, B. (2025). Training activist professionals against stigma toward people with psychiatric diagnoses: an experience. Cadernos Brasileiros de Terapia Ocupacional, 33, e4079. https://doi.org/10.1590/2526-8910.cto415140792
• Data Availability
  The data supporting the findings of this study are available from the corresponding author upon reasonable request.
• Funding Source
  This research was funded by the Teaching Department of the Academic Vice-Rector's Office at Andrés Bello University, Chile.

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Edited by

• Section editor
  Prof. Dr. Daniela Edelvis Testa

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Publication Dates

• Publication in this collection
  08 Dec 2025
• Date of issue
  2025

History

• Received
  24 Mar 2025
• Reviewed
  14 Apr 2025
• Accepted
  18 Aug 2025