Behaviour Change

PROPAGANDA FOR CHANGE is a project created by the students of Behaviour Change (ps359) and Professor Thomas Hills @thomhills at the Psychology Department of the University of Warwick. This work was supported by funding from Warwick's Institute for Advanced Teaching and Learning.

Thursday, February 28, 2019

MENTALLY ILL AT UNI

The Problem 

Mental health is an uncomfortable topic for many people. Unlike a physical illness or injury, you can’t readily see or even understand the cause for mental illnesses and this causes people to feel uncertain and afraid. As one comedian and mental health advocate, Kevin Breel, put it: 

"We live in a world where if you break your arm, everyone runs over to sign your cast, but if you tell people you're depressed, everyone runs the other way".

This sad state of affairs is caused by stigmas - negative characteristics or attributes associated with mental illnesses. Stigmas are a lot like stereotypes and are often widely applied to cover a whole range of very different mental health issues. This, sadly, has a lot of far reaching impacts on the people affected, from feeling socially excluded, to being unable to find work due to their mental health history.
Take a look at pop culture for instance. Films like Split, Psycho, Wonderland, Shutter Island, Silver Linings Playbook, The Visit, and especially TV shows like The Simpsons and The Big Bang Theory, all involve some form of mental illness or neuroatypical characters, and sadly these characters are often over the top caricatures of what people believe a person with mental illness behaves like. For example, it is commonly accepted that Sheldon from The Big Bang theory is autistic, yet his symptoms are played for jokes and mocked excessively. 

Take Split, a film about a man suffering from Dissociative Identity Disorder (more commonly thought of as ‘Split Personality Disorder’, hence the title). In patients actually dealing with this condition, the person often lives with two or more distinct personality states (alters). They may suffer from memory loss, often have to cope with other mental health problems like depression, and have little control over which alter is dominating at a time (American Psychiatric Association, 2013). In Split, the main antagonist suffers from DID and is later portrayed as a supervillain. The character has around 20 or so different personalities, with one particularly vilified personality referred to as ‘The Beast’. Now whilst a lot of how the disorder presents in patients was accurate in the film, the portrayal of someone with DID as violent, unstable and down right creepy at times has only increased the negative stigma surrounding the illness. Unfortunately, this negative effect isn’t limited only to the mental illness portrayed, but can be generalised to mental illness as a whole.

In the 90’s and 00’s, and still to this day, common insults or derogatory slang terms used by adults and children were terms like ‘spastic’ or ‘retarded’. These words originally came from the medical terms used to diagnose people on the autistic spectrum, however they fell into common use as insults designed to label someone as slow or strange, often used to imply that if you were ‘retarded’ then there was something wrong with you, you were sub-human. It’s a sad truth that the misuse of these terms can still be found in today’s society, and it is propagated by a lack of understanding about what the terms actually mean, a lack of education and willingness to talk about people who are neuroatypical. It is this lack of understanding and interest in being open about mental illness that we hope to address.

Why is this problem important?

The stigma arising from lack of education and exposure to real life mentally ill people has profound effects on those who are mentally ill. Citizens are less likely to hire someone who is mentally ill, less likely to rent them housing and more likely to press false charges for violent crimes (Bordieri & Drehmer, 1986; Page, 1977; Sosowsky, 1980). Experience of mental illness stigma is also associated with reduced help seeking (Rafal, Gatto & Debate, 2018), low self esteem, less willingness to disclose their mental illness, avoidance of social opportunities, lower trust in others, and persistence of symptoms (Wahl, 1999). This highlights the importance of countering stigma in daily life; it has real and damaging effects on those who struggle with mental illness. 

Who is our target audience?

Our target audience was those who may not be educated on mental illness, and hold stigmatised views. This is in the hopes that they would hold less stigmatised views and understand mental illness more, and therefore be more supportive of mentally ill people they more interact with, and possibly be more likely to seek help themselves if they experience mental health problems. Therefore, our project was designed so as many people from the general population would be exposed to our intervention as possible.

The Intervention

We considered an open platform project to encourage our target audience’s curiosity, so we ran the project with a stall outside of Warwick University’s library. This spot was strategic as many students would have to walk past us to access the library or move between lectures, exposing us to a large group of people throughout the day. Our idea was based on the social norm of reciprocity (Whatley, Webster, Smith, & Rhodes, 1999) with the prospect of an exchange: we planned to give out biscuits and chocolate, to encourage passerbys to stop and talk to us. This seemed like a fair bargain to us - all the audience had to do was start a polite conversation, and they would get a free snack. We specifically encouraged our audience to ask us any question they wished about mental illness - as stated on our banner: “we are mentally ill, ask us anything”. We placed posters around campus during the weeks before we ran our stall so people were aware that we would be there in advance and be aware of the prospect of free food. We also created a facebook event to which all added contacts were invited.

One of our posters up outside of the library

The poster

The event on facebook

We ran the project on a Tuesday and Wednesday during week 7. Our aim was to have three volunteers on the stand per session to give us room to take toilet breaks or breathing space where needed. It was an imperative for us, from the onset, to ensure that those who volunteer would be kept safe and reminded of their autonomy to answer questions however they wanted (if at all). We ran the stall for 5 hours a day on both Tuesday and Wednesday. On the stall were flyers providing links to resources available, flyers for the well being department, a disclaimer saying we had the right to not answer a question if we choose, and the snacks. Tapped across the tables was the banner, clearly visible to anyone who walked past, and from a distance. We also decided to tally those who approached our stall to ask a question, and to note down questions of interest, in the knowledge that some people would ask the great unknown, and that some may just have wanted small talk.

The stall, with the banner on the front

We contacted the university Wellbeing Service representatives for additional guidance, and we were given some helpful insight into ensuring ethical standards and to create the most welcoming space for both those who would volunteer for us, and those who would stop at the stall and ask us a question. The Wellbeing Service provided accountability for us, such as questioning: Who would be ‘talking’?  Would people be ‘identified’ as having mental health problems? If so, how would we do this? The service also emphasised how It is important that those talking/running the stand feel OK to talk about their story and are not overwhelmed. Similarly, how would we handle the situation if a student discloses something very painful/serious about themselves? To manage this, we ensured that all volunteers at the stall were fully aware of what the project involved, our aims, and their right to decline answering questions or withdrawing at any point. We ensured all participants had formally diagnosed mental health problems and/or are participating in a counselling or therapy service, and/or taking medication for mental health issues. We also gave links and resources available to the following: counselling service on campus, wellbeing service on campus, Samaritans, the University Health Centre, and the IAPT counselling service. We ensured all volunteers were aware that they could only share their own experiences if they wished, and were not able to give advice or suggest treatment. We additionally contacted the admin team in the Psychology department to help us with supplies. 

Persuasion Techniques 

There are several reasons why we carried out our project in the way we did: from the general principle, to the details. 

Firstly the general idea of going out into a public space to interact with others and answer their questions in return for a snack; the core of this was based on exposure. There is a significant body of research that demonstrates that one of the best ways to reduce stigma towards a group is exposure, and interaction with, members of this group (see Pettigrew & Tropp, 2006 for an overview). Several pieces of research demonstrate that this does also apply to the reduction of mental illness stigma (Sadow, Ryder & Webster, 2002; Rüsch, Angermeyer & Corrigan, 2005), including specifically with undergraduates (Kolodziej & Johnson, 1996), whom were our target group. This research is based off intergroup contact theory (Allport, 1954), which suggests that interactions between groups can lead to improved intergroup attitudes. In fact, it has been directly found that those of the general population who meet and interact with people with mental illnesses are more likely to lessen their levels of prejudice (Corrigan, 2005). 

In terms of specific details, Rüsch, Angermeyer and Corrigan (2005) outlined a number of factors that help create the right environment for interpersonal contact and stigma reduction, and we aimed to fit all of these factors. Firstly, equal status among targets. This is part of why we targeted the general student population, as students ourselves. This creates both this equal status, and highlights the similarity between us and them - hence why are posters and banner were titled “mentally ill at uni”, to highlight that we are all students. As shown in previous research, similarity breeds both liking and compliance (Burger et al., 2001), hopefully making it more likely that people would approach. Next, cooperative interaction. The conversations in our project were all 2 way; they ask a question, we answer, and in almost all cases conversation began. This is one of the reasons why we chose this method, rather than an educational seminar, which would involve a one-way depositing of information. Cooperation is also supported by the reciprocal relationship of “ask us anything, and get a free snack”. Finally, institutional support. For this, we added the Propaganda for Change logo to our posters, and the Wellbeing Service at the university provided us with several of their handouts to place on their stall, showing their approval of our intervention. They also suggest that it is important for some of the minority members that the majority interacts with to seem to mildly disconfirm the stereotypes surrounding the minority, likely in part because research suggests that ingroup members are viewed as diverse, and out-group embers are soon as less diverse (the outgroup homogeneity effect, Walch et al., 2012), and this aims to counter that. The main stereotypes around the mentally ill are that we are to be feared, irresponsible, and childlike (Rüsch, Angermeyer & Corrigan, 2005). We have designed our project to contradict all of these: by holding pleasant conversations and being approachable we show we are not to be feared, by showing we have organised this project effectively we show we are responsible, and by answering questions clearly and seriously (some of which were fairly complex questions about the nature of mental health) we show we are not childlike. Allport (1954), also proposed the Contact Hypothesis, that states that groups will reduce prejudice under 6 conditions, several of which we achieved within our intervention. Firstly, mutual interdependence was achieved as we relied on each other to get what we wanted: to get food had to ask us something, and for them to ask us something we had to give them food. Secondly, equal status. As stated previously, we highlighted the fact that we were all students. Thirdly, informal personal contact. The conversations were kept friendly and informal - we avoiding putting any pressure on our audience, and emphasised that this was not a study, and that we didn’t expect them to act any specific way. 

A member of the group enjoys painting in their spare time, so jumped at the chance to design the banner, with their choice of colour and motif deliberate. They consciously applied the persuasion techniques of the MINDSPACE mnemonic (Dolan et al, 2012) for marketing purposes. Our banner calls the audience in an assertive black Sharpie to ‘ask us anything’, as an incentive. For the audience, they had the opportunity to detach the apprehension or hesitance they may have concerning bringing up mental illness into conversation. In our experience, many people are uncomfortable and ask for assurance to talk about or ask about mental health. We understand that and are grateful for asking for our consent to discuss this, but those tentative social niceties are not necessary in this space we have designed: the banner says ‘yes, it is okay to ask me anything’, an incentive for the audience to approach us where there is no risk involved in hesitation of saying the wrong thing and any resulting negative consequences. Appealing to salience was important during design: the colours used were bold poster paint, in warm colours to signify approachableness and kindness, such as orange, pink and beige (Grieve, 1991), which may also act as a priming agent for approach and kindness in our audience. The hope for painting an open envelope with love hearts emerging, was a priming effect: before speaking to us, those who see the banner can notice that this is an open space with our aim to express more love and compassion, towards ourselves and others, those who are mentally ill and those who are not. Those who see this banner would make a commitment to their identity: we enjoy thinking of ourselves as warm and loving beings, and this was meant to be reinforced through the painting on the banner, also connecting to ego - people want to act in ways that make them feel better about themselves. 

As noted previously, there is a reason we chose this method for our project, rather than an education seminar or leaflets. Education is associated with lessened stigmatising attitudes (e.g. Herek & Capitanio, 1995; Pinfold, Toulmin, Thornicroft, Huxley, Farmer & Graham, 2003; Tanaka, Ogawa, Inadomi, Kikuchi & Ohta, 2003; Esters, Cooker & Ittenbach, 1998), which is why we included the education aspect of answering questions about mental health, rather than just simply interacting with people. However, education programmes tend to only reach those who already agree with the message (Devine, 1995), so it was likely if we held an educational seminar or handed out leaflets, only those who hold less stigmatising views of the mentally ill, or were passionate in reducing stigma themselves, would engage with it, and we would not engage with our target audience.

A persuasive method we utilized was the The Pique Technique. These technique relies on the idea that if a request is specific or strange, people are more likely to comply as these requests more mindful cognitions about the appeal, leading to the person entertaining in their mind what would happen if they did comply. The effect is more impactful the less the person has accountered the request/question before. This is why our banner clearly stated “we are mentally ill, ask us anything”. It is rare for people to be so forward about their mental health, let alone be so open to questions regarding this. We hope that the novelty of this question led people to entertain in their heads what question they would ask us, making it more likely for them to approach us to ask us their question. In fact, many people approached us to ask us why we were doing this, which we then used to lead into educating them and facilitation the asking of more questions.

Finally, the core technique of this project was the norm of reciprocity. The basic idea of this is that if you do something for someone, they feel obligated to do something in return. Therefore, we decided that if we wanted people to behave in a way that we wanted (to ask us questions about mental health and allow us to educate them), we would need to provide them with something. We had some people come up to take some food, and then see the nature of our stall, so they felt obligated to ask us something in return. It is also possible that some people viewed us answering their questions and educating them as us doing something for them, leading to them wanting to do more in return, such as asking another question, allowing us to provide them with even more information. We often found that by answering a question, people would then disclose more personal details in their next question, similar to Cunningham, Strassberg and Haan’s (1986) finding that we self-disclose to those who have disclosed themselves to us. 

Future Directions

Whilst we feel we utilized these techniques effectively, if we were to repeat this project we would make some small changes. Firstly, as we were sat at our stall, it meant people had to approach us to take the free food, which people may be unwilling to do. It may have been more effective to approach people with a plate of free food and offer it to them, and after they take it to ask them to ask us a question - much like the Hare Krishna Movement, where the sales force would approach people and give them a flower. Furthermore, it may have been useful to provide more information of why we wanted people to ask us questions. As demonstrated in Langer, Blank and Chanowitz’s (1978) study, the more information you provide a person within a request, the more likely they are to comply. This additional information could perhaps take the form of “we’re mentally ill, ask us anything to help combat stigma!”. 

Notable outcomes

To close off, we would like to note some notable outcomes of our project. We had a several people inform us that they were unaware that the university provided a counselling service, and that they were likely to seek it out in the future. We also had several people who were mentally ill themselves tell us that they were glad to see people being so openly mentally ill, and that it takes “guts” to put ourselves out here like this. We hope that from this, other mentally ill people are more willing to be open about their mental health, and possibly be more likely to seek the treatment they need. We also had two people talk to us about how within the culture, mental illness is rarely spoken about, and that people are expected to keep it hidden and private. Hopefully by us showing that mental illness isn’t something to be ashamed of, they can bring that idea to others within their culture and work towards changing attitudes within their group. In total, 56 people approached us and asked us a question about mental health. These questions ranged from “what is mental illness?”, “what are you diagnosed with?”, to “how does religion and mental illness interact?”.

What stuck out the most was when a man approached us and told us that he had in the past said that he didn’t believe that mental illness was “real”, and proceed to ask us questions in order to better educate himself and avoiding making holding such stigmatising and negative views of mental health again, which was exactly what we aimed to do with this project.  

References


Allport, G. W. (1954). The nature of prejudice. Cambridge, MA: Addison‐Wesley.

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Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614-625.

Cunningham, J. A. , Strassberg, D. S. , & Haan, B. (1986). Effects of intimacy and sex-role congruency on self-disclosure. Journal of Social and Clinical Psychology, 4, 393-401. 

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Walch, S. E., Sinkkanen, K. A., Swain, E. M., Francisco, J., Breaux, C. A., & Sjoberg, M. D. (2012). Using Intergroup Contact Theory to Reduce Stigma Against Transgender Individuals: Impact of a Transgender Speaker Panel Presentation. Journal of Applied Social Psychology, 42(10), 2583-2605.

Webster, J. M., Smith, R. H., Rhodes, A., & Whatley, M. A. (1999). The Effect of a Favor on Public and Private Compliance: How Internalized is the Norm of Reciprocity? Basic and Applied Social Psychology, 21(3), 251-259.

Whatley, M. A., Webster, J. M., Smith, R. H., & Rhodes, A. (1999). The effect of a favor on public and private compliance: How internalised is the norm of reciprocity? Basic and Applied Social Psychology, 21(3), 251-259.



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