All of us who work within or who use mental health services are well-aware of the stigma that continues to surround mental health conditions and how it affects patients and their carers, preventing them from accessing support, making it difficult for them to enter or re-enter the workforce and how it saps at quality of life in a way that can make the stigma around mental  illness almost as disabling, and perhaps at times worse, than the illness itself.

At the same time, we are facing austerity drives that are leading to cuts and closures to mental health services. There is a national adult inpatient crisis. Against this background, we have to ask whether the generously funded anti-stigma campaign ‘Time to Change’ is working and whether it is value for money. This is not a popular question to ask. However, the analysis that ‘Time to Change’ has been subject to makes it easier to address.

A relevant starting point might be to ask whether any anti-stigma campaign has ever worked in mental health. The history of systematic attempts to de-stigmatise mental illness goes back to the 1950s when a psychiatrist and sociologist couple attempted to change the views of the folk of a Canadian town by presenting information about mental illness - unfortunately rather than de-stigmatise the condition they found that their attempts attracted hostility. 25 years later - another research group found that attitudes towards the mentally ill in that town had not shifted in that time. The World Psychiatric Associated launched an anti-stigma campaign, ‘Open the Doors’ in the 1990s - again with Canada being a pilot site. They found that there was no change in attitudes even if knowledge about mental health conditions increased. More large-scale projects followed. In the UK, the Royal College of Psychiatrist’s Changing Minds campaign between 1997- 2003 didn’t lead to a change in attitudes and the Scottish ‘See Me….’ campaign of 2002 was difficult to evaluate.

A question that could be asked is if these studies were adequately funded and if their effects were properly analysed. ‘Time to Change’ is the largest ever programme in England that aims to reduce stigma and discrimination against people with mental illness. The first phase between 2008 and 2011 was relatively well funded - £21million pounds from the DH and Lottery funds, led by leading mental health charities and evaluated by the Institute of Psychiatry in London.

The evaluation of the first phase was reported in a British Journal of Psychiatry supplement in April 2013. My reading of this evaluation and the associated editorials is that the project has not been a success.

With regards to public knowledge and reported behaviour the evaluation showed that there was no change. Although mental health service users reported a reduction in discrimination, the target of a 5% reduction was not met, and the percentage of service users who responded to this question was low - around 9%- and White British and women were overrepresented in the respondents. There was no change in the attitudes of professionals and a short-term improvement of the attitudes of medical students didn’t last. The economic evaluation is uncertain with model-estimates ranging from a net-cost to a net benefit of £223 million!

In my, much closer to home, evaluation - on a day in Mid November 2013, not one of the 20 patients admitted on my inpatient ward had heard of the Time to Change campaign and only one member of staff had heard about it (out of about 10 who I asked). Indeed in the past 3 years, not a single patient or carer had ever mentioned the Time to Change campaign to me. The only person who did was a visiting politician.

I’m not sure that TTC had an underlying theory that underlined their campaign and informed their attempts to change attitudes and reduce discrimination. I haven't seen one published.

In a recent issue of the New Republic I came across the work of Daniel Kahneman, an American academic who has explored the process in which people distort knowledge to fit their world-view. Cultural cognition theory might explain why mental health stigma campaigns fail to shift attitudes. Culture shapes world views and just a cursory glance at what’s been happening in our world and how the media reports this demonstrates the scale of the challenge. Media portals of mental illness remain dominated by accounts of violence - the Sun’s recent headline of ‘1200 killed by mental patients’ is a good example of this. But also, a recent You Gov poll (October 2013) showed that the public consider the mentally ill as the most discriminated group in Britain. The dominant political narrative has been of ‘benefit scroungers’ and whether the mentally ill are portrayed as ‘deserving or un-deserving poor’ depends on which newspaper you choose to read. Around Halloween our largest supermarkets marketed costumes based on negative stereotypes of the mentally ill as deranged killers. Although the outcry that followed forced them to apologise - the fact that these products managed to hit the shelves shows how Time to Change message has failed to penetrate. There has been no perceptible shift in the cultural attitudes towards mental illness.

Time To Change isn't sufficiently nuanced - the public equate mental illness with severe depression and psychosis and that’s why the ‘1 in 4’ message that it has championed fails to resonate, indeed I wonder whether it alienates. Perhaps we need to be more specific about what we mean by ‘mental health conditions’ and more sophisticated in targeting the stigma that surrounds each condition rather than try and address all as one group.

Susan Sontag’s work around the myths and metaphors that surround illness is also instructive here - when better treatments for TB, Cancer and HIV became available and accessible the myths that surrounded these illnesses started to clear and stigma reduced.

Mass anti-stigma campaigns against mental illness don’t work. We need a more sophisticated approach, targeting particular illnesses. And more research into treatment; and into the support that works to ensure that people with these conditions are given a voice, enabled to enter work and take part in public life. Locally presented stories are far more powerful in capturing and changing minds than national campaigns. Treating people and helping them get better to pursue their goals might be a better use of available resources and a better advert for anti-stigma work.

Is it time to change how we think about anti-stigma campaigns?

 
The blog was based on arguments presented at a debate at the Royal College of Psychiatrists Trent Division Annual Conference on 20 November 2013.

Arun Chopra
Consultant Psychiatrist

@arun_chopra