One of the Integral Elements of the See Me Programme Is to Promote Evidence Based Strategies

What works?

Key findings Projects which are effective in tackling stigma and discrimination tend to combine a number of elements into a multi-faceted approach.

 Protest aims to challenge and reduce stigmatising messages regarding mental health such as negative reporting in newspapers. This reactive strategy appears to be effective in reducing the frequency of negative messages and the act of participating in a protest activity may be empowering for individuals. However, protest may result in the negative messages being reinforced in the public’s mind if they are not replaced with more positive messages.

 Education aims to increase knowledge and understanding of mental health problems at social, community and individual levels, thereby changing attitudes leading to behaviour change. While education programmes do appear to be effective in changing attitudes, little research has been carried out into whether effects are sustained in the longer term as behaviour change.

 Social contact aims to challenge stigmatizing attitudes through planned interactions between people who have experienced mental health problems and direct experience of stigma and discrimination, and members of targeted groups especially employers, educational professionals and healthcare workers. Social contact appears to be effective in changing attitudes even in those who hold the most stigmatising views and should be targeted, local, credible and continuous. Social contact is ineffective when a power imbalance exists between the members of the stigmatised and stigmatising groups.

 There is an ethical imperative to involve those people with lived experience of mental health stigma and discrimination in the planning and delivery of projects as they are the intended beneficiaries. Leadership or anti-stigma and discrimination work by people with lived experience can help to develop projects which target the specific contexts in which stigma and discrimination are experienced. This should increase the likelihood that these projects will make a discernible and positive difference to the experiences of those with mental health problems.

 Projects which target specific contexts where stigma and discrimination has been evidenced to be most problematic (eg. within health and social care or workplaces) are more likely to be able to show evidence of change than projects which target general attitudes across large populations.

 Identifying and challenging discriminatory behaviour may be more directly effective than improving attitudes alone in reducing instances of discrimination against those who experience mental health problems.

 Evidence suggests that involvement in anti-stigma programmes may contribute to a sense of empowerment among those with lived experience of mental health problems. People with mental health conditions who are more empowered tend to have lower self-stigma, greater life satisfaction and improved recovery outcomes.

 Building process and outcome evaluation into the design of programmes and projects can help to show evidence of change and contribute to the understanding of what works in challenging stigma and discrimination. This allows others to learn from and apply the most effective methods to their own context.

What works? programme tends to agree that protest, One of the integral elements of the See Me education and contact are most effectively Programme is to promote evidence based when combined. For example, Link (2001) strategies for reducing stigma and asserts that, in order to make an effective and discrimination. In order for this to be possible, sustainable change, anti-stigma work should an understanding of the current evidence be multi-faceted and multi-level. Sayce (2010) base of both the problem and what is known supports this point: and what works best to reduce it is essential. “There is no single solution to discrimination, Unfortunately, relatively few anti-stigma and but different elements to potential ‘solutions’ discrimination projects are rigorously exist. What is needed is to bring different evaluated or published meaning that evidence strands of work together.” of what works in practice and process is often lost. As a result, much of the knowledge A scoping review carried out by the National around what works is experiential, that is, Institute for Mental Health in England in 2004 held within the expertise of those who work identified six key elements of successful anti- directly in the area. Despite these limitations, stigma activities: a number of promising strategies for reducing stigma and discrimination can be found in 1. Involving users and carers throughout academic literature, grey literature and the design, delivery, monitoring and project reports. evaluation of anti-discrimination programmes Corrigan et al (2001) separate mental health anti-stigma work into three categories: 2. Programmes supporting local activity protest, education and contact. inclusion of 3. Addressing behaviour change using a “experts by experience”, i.e. those who have range of approaches direct experience of stigma and discrimination, in the planning and delivery of 4. Targeting and delivering clear anti-stigma interventions, targeting consistent messages to specific interventions towards specific groups and audiences behaviours and empowering people with lived experience have been identified as hallmarks 5. Long term planning and funding of successful projects and programmes. In the underpinning the programme’s review, the literature regarding each of these sustainability above elements will be discussed, followed by 6. Appropriate monitoring and some consideration of the practical evaluation implications of combining and implementing what works within a project. Building on this, Sayce (2010) asserts that anti-discrimination activity must seek to Literature which attempts to draw together a address the imbalance of power between blueprint for building a successful anti-stigma those exhibiting stigmatising and mainstream media response, both stores discriminating behaviour and those removed the products and issued apologies. experiencing it which lies at the heart of stigma. She argues that this is not possible However, there is very little research about without multi-level interventions which are the impact of protest on attitudes towards run alongside changes to legislation, stating mental health. Importantly, some research that “initiatives to reduce discrimination suggests that suppression of a negative should make use of the iron fist of law within attitude may actually result in more the velvet glove of persuasion” (page 631). stigmatising thoughts. Challenging However, while legislation is important in re- stigmatising coverage of mental illness may balancing power, it will not be effective unless serve to reconfirm the original message in an it as adopted into a culture in which those individual’s memory, making them more who are discriminated against are supported sensitised to negative attitudes towards to challenge the infringement of the rights mental illness and more likely to recall afforded to them by such legislation. negative messages (Corrigan et al, 2001). While protest may be effective in reducing the visibility of stigmatising language and images Effective elements in the media, it is unlikely to be effective in It is not expected that every project will promoting positive attitudes or behaviour include all of these elements all of the time, change (Rusch et al, 2005). However, it may but rather that some elements may be more be that the act of participating in protest is appropriate than others or can be combined empowering to individuals who experience in a tailored way to inform specific projects, mental health conditions and those who ensuring that they are rooted in the evidence advocace for an end to stigma and base. discrimination which may help to diminish self-stigma. Protest Protest can be defined as a reactive strategy Education which aims to challenge and repress negative Interventions which use education aim to attitudes towards mental illness when and reduce stigmatising attitudes and behaviour where they are expressed. Protest often takes by proving information which disconfirms place in response to negative or stigmatising stereotypes. This can be done using many coverage of mental health conditions in the forms such as leaflets, posters, books, media or advertisements based on evidence lectures, videos and teaching materials. that such coverage contributes to and Education as a strategy for reducing stigma perpetuates negative public attitudes towards and discrimination is based on the assumption people with mental health conditions (Rusch that negative and stigmatising attitudes and et al, 2005). Using social media, anti-stigma behaviour are rooted in ignorance of the facts programmes can quickly mobilise supporters about mental ill health. Pinfold et al (2003) to respond to negative coverage. One recent showed that a two-day educational workshop example is provided by the reaction to the for secondary school pupils had some short sale of “psycho” and “mental patient” term positive effects on mental health literacy Halloween costumes by Tesco and Asda in and stigmatising attitudes. However, this 2013. Following an overwhelming social and effect was not maintained at six-month follow up, which raises concerns about the long term effects of educational interventions. In empathy towards a member of a specific addition, education programmes which group and, by extension, towards that group emphasise the biological, genetic or in general, is central to intergroup contact neurological basis of mental illness may theory. Although usually applied to exacerbate any sense of separation between intercultural and race relations, intergroup those affected and unaffected by mental contact theory has recently been used in health problems. This may contribute to relation to schizophrenia. West, Hewstone stigmatising attitudes and behaviour. and Lolliot (2014) showed that prior contact Biological interpretations of the causes with people with schizophrenia predicted less mental illness may also diminish beliefs that desired avoidance and more positive attitudes those affected can recover (Rusch et al, 2005). towards people with schizophrenia. It has As anti-stigma interventions commonly been suggested that extended contact, that is combine educational and social contact observing members of one’s own group strategies, it is difficult to separate out these interacting positively with members of a elements and evaluate their individual effects. stigmatised group, can also improve attitudes towards that group (West and Turner, 2014). Social contact Some research has shown that even imagining One of the most effective elements in intergroup contact with people with producing a measurable change in attitudes schizophrenia reduced anxiety towards future towards people with mental health conditions interactions and reduced stereotyping (Stathi is social contact: that is “planned interactions et al, 2012). Critics of intergroup contact between people with mental illness and key theory have suggested that those who groups” (Corrigan, 2011: p 824). Certainly, interaction may only be of benefit to those familiarity and previous contact with people who already hold generally tolerant attitudes. who experience mental illness seems to be a However, Hodson (2011) provides evidence powerful predictor of positive attitudes that social contact is maximally effective towards mental health in general (Read and among those who hold intolerant views. Law, 1999; West et al, 2014). However, it may be that people who hold more stigmatising Corrigan (2011) suggests that, in order for attitudes are less likely to participate in or social contact initiatives to be optimally report contact with people who have effective, contact must be targeted, local, experienced mental ill health (Couture and credible and continuous. Corrigan (2011) Penn, 2003). argues that contact is most effective when it is targeted towards a specific group of people, It is unclear from the literature exactly which such as healthcare workers or employers, components of social contact are sufficient which holds power over the stigmatised and necessary for improvements to be made groups. Projects could also be targeted in attitudes towards people who experience towards a specific behaviour which is mental illness or even the mechanism by problematic such as the underrepresentation which these improvements occur. Some of people who experience mental illness in insights can be taken from the literature the workforce. Local contact can be defined which discusses intergroup contact theory, by geographical area but also by which states that contact is a powerful neighbourhoods of specific socioeconomic strategy for reducing conflict and prejudice status or shared interest groups. The between groups. The development of continuity of contact is also highlighted as being important in increasing its efficacy. constitutes a barrier to recovery and help Corrigan points out that, while a single seeking. It has been suggested that projects incidence of contact may have fleeting effects, which aim to promote recovery may then be repeated encounters in a variety of contacts effective in reducing stigma among the may consolidate these effects. participants (Link et al, 2001; Corrigan, 2004) Corrigan (2013) hypothesised that taking part Lived experience expertise in mutual support programmes would reduce It is generally agreed it that people with self-stigma and increase quality of life for experience of mental illness and direct those who took part. Formalised peer support experience of stigma and discrimination programmes within mental health services should be central to the design and settings employ people with lived experience development of new anti-stigma programmes of using mental health services to work with or support services. It can be argued that current service users to offer support and there is an ethical imperative to involve the share strategies for recovery. A review of the intended beneficiaries of a service in its literature regarding peer support found that development, often referred to the “nothing such programmes appear to be effective in about us without us” approach (Rose, 2014). promoting hope and belief in the possibility of Despite the importance assigned to placing recovery among service users (Repper and services users and people with lived Carter, 2011). experience of mental health problems at the heart of anti-stigma projects, there is very Targeted behaviour change little evidence to support the claim that Designing a project which specifically targets projects will be more effective or outcomes behaviour change in terms of stigma and will be different as a result of that discrimination is a relatively new concept and, involvement. Even less is known about the as such, there is very little academic evidence process of involvement and the effect that regarding it. However, relevant evidence can leadership by those with lived experience has be drawn from the literature surrounding on the process of developing an anti-stigma health behaviour change. This focus on and the effect that it may have on those behaviour change can help to refine projects involved. There is some evidence, however, as it requires that the project be targeted that suggests that people with experience of towards a specific problematic behaviour in a mental illness may recognise stigma in specific group or population. A highly targeted different ways from their family members and approach, alongside consistency of messages medical practitioners. Those with lived and strategies for changing discriminatory experience were found to assigning most behaviour is most likely to be effective in importance to stigma experienced within producing measurable change (Public Health interpersonal relationships while family England, 2004). When seeking to change members and medical practitioners tended to behaviour within a specific population, it is assign greater importance to structural important to consider any social, cultural or discrimination and public stigma, respectively contextual factors which may hinder changes (Schulze and Angermeyer, 2003). to behaviour. This may be of greatest importance when targeting discriminatory Recovery behaviours which are accepted as social The evidence suggests that stigma, whether norms (NICE, 2007) and may be particularly experienced, perceived or internalised, relevant in healthcare settings where stigma and discrimination has proved difficult to Corker, E., Hamilton, S., Henderson, C., reduce (Corker et al, 2013). Weeks, C., Pinfold, V., Rose, D., Williams, P., Flach, C., Gill, V., Lewis-Holmes, E., Empowerment Thornicroft, G. (2013) Experiences of While often seen as a side effect of discrimination among people using mental involvement in anti-stigma programmes, it health services in England 2008-2011. British has been suggested that empowerment in Journal of Psychiatry. those with lived experience of mental health conditions can contribute to higher self- Corrigan, P.W., River, P.L., Lundin, R.K., Penn, esteem, better recovery outcomes and lower D.L., Uphoff-Wasowski, K., Campion, J., self-stigma (Brohan et al, 2010; Corrigan et al, Mathisen, J., Gagnon, C., Bergman, M., 2013). Corrigan et al (2013) claim that Goldstein, H. and Kubiak, M.A. (2001) Three “coming out proud”, which in this context Strategies for Changing Attributions about refers to disclosing one’s mental health status Severe Mental Illness. Schizophrenia Bulletin in a supported environment, may contribute 27(2), pp 187-195. to increasing empowerment. The benefits of Corrigan, P.W., Sokol, K.A. and Rusch, N. involvement in anti-stigma work for those (2013) The Impact of Self-Stigma and Mutual with lived experience must not be overlooked Help Programmes on the Quality of Life of but are currently underexplored in the People With Mental Illnesses. Community evidence. Mental Health Journal 49(1), pp 1-6. Evaluation Patrick W. Corrigan, Kristin A. Kosyluk, and In order to contribute robust evidence which Nicolas Rüsch. (2013) Reducing Self-Stigma by can strengthen the evidence base regarding Coming Out Proud. American Journal of Public effective strategies for challenging stigma and Health: Vol. 103, No. 5, pp. 794-800 discrimination, it is imperative that evaluation makes up an integral part of the planning and Corrigan, P.W. (2011) Strategic Stigma Change delivery of projects. Effective evaluation (SSC) Five Principles for Social Marketing requires reflections on the assumptions which Campaigns to Reduce Stigma. Psychiatric have been made about the activities of the Services 62(8), pp 824-826. project and the intended outcomes. The evaluation of See Me is based on a Theory of Hodson, G. (2011) Do Ideologically Intolerant Change approach. A more detailed People Benefit From Intergroup Contact? explanation of the evaluation of See Me can Current Directions in Psychological Science 20, be found in the evaluation paper. pp 154-159. Link, B.G. (2001) Stigma: Many mechanism References srequire multi-faceted responses. Epidemiologia e Psichiatria Sociale 10, pp 8- Brohan, E., Elgie, R., Sartorius, N. and 11. Thornicroft, G. (2010) Self-stigma, empowerment and perceived discrimination National Institute for Mental Health in among people with schizophrenia in 14 England (2004) Scoping Review on Mental European countries: The GAMIAN-Europe Health Anti Stigma and Discrimination – study. Schizophrenia Research 122(1-3), pp Current Activities and What Works 232-238. NICE public health guidance 6 (2007) imperative and/or radical challenge? Journal Behaviour change: the principles for effective of Health Psychology 19, pp 149-158. interventions. Rusch, N., Angermeyer, M.C. and Corrigan, Pinfold, V., Toulmin, H., Thornicroft, G., P.W. (2005) Mental illness stigma: Concepts, Huxley, P., Farmer, P. and Graham, T. (2003) consequences and initiatives to reduce Reducing psychiatric stigma and stigma. European Psychiatry 20, pp 529-539. discrimination: evaluation of educational interventions in UK secondary schools. The Schulze, B. and Angermeyer, M.C. (2003) British Journal of Psychiatry 182, pp 342-346 Subjective experiences of stigma. A focus group of schizophrenic patients, their relatives Reid, J. and Reid, A. (1999) The Relationship of Causal Beliefs and Contact with Users of and mental health professionals. Social Mental Health Services To Attitudes To the Science and Medicine 56(2), pp 299-312 ‘Mentally Ill’. International Journal of Social West, K., Hewstone, M. and Lolliot, S. (2014) Psychiatry 45(3), pp 216-229 Intergroup Contact and Prejudice Against People With Schizophrenia. The Journal of Repper, J. and Carter, T. (20110 A review of Social Psychology 154(3), pp 217-232. the literature on peer support in mental health services. Journal of Mental Health West, K. and Turner, R. (2014) Using extended 20(4), pp 392-411. contact to improve physiological responses and behaviour toward people with Rose, D. (2014) Patient and public schizophrenia. Journal of Experimental Social involvement in health research: Ethical Psychology 50, pp 57-64.