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The College’s Anti-Stigma Campaign, 1998-2003

A shortened version of the concluding report

Royal College of Psychiatrists

In autumn 1996, under the Presidency of Dr Robert Kendell, the College decided to mount a campaign to tackle the stigmatisation of people with mental illnesses. In 1997, a working party proposed goals, content, process and a 5-year governance. Other campaigns, both here and abroad, have either generically addressed ‘mental health problems’ (e.g. Mind’s ‘Respect’ Campaign) or targeted a specific mental illness, e.g. the World Psychiatric Association’s anti-stigma campaign in respect of people with schizophrenia. Our working party decided that it might be timely to recognise the differences in public attitudes to the variety of mental illnesses. The campaign thus addressed six categories of mental illness: anxiety disorders, depressive disorders, schizophrenia, the dementias, eating disorders, and drug and alcohol misuse/addiction. Target populations were identified as doctors, children and adolescents, the workplace, the media and the general public. The working party had also secured funding and arranged for a survey, in July 1998, by the Office for National Statistics of opinions of the British public concerning people with these mental illnesses (Crisp et al, 2000). The Campaign started on 7 October 1998. Since that time, and drawing upon our survey findings within its initial literature review (Kelly, 1999) the Department of Health mounted its own anti-stigma campaign, ‘Mind Out for Mental Health’, which addressed a similar range of mental illnesses.

Staffing

From the outset, the College agreed to accommodate the Campaign; meet its office overheads, fund a campaign administrator 3 days per week and to dedicate 10% of staff time (Ms Deborah Hart, Mrs Jill Phillipson and, initially, Ms Chris Gear) to the task. All other personnel were to give their services voluntarily.

A Management Committee was set up immediately and, shortly thereafter, a number of working parties charged with generating projects. Over the following years, the Management Committee met a total of 31 times.

Fund-raising

This became the responsibility of the Campaign. Overall, over £1 million was raised.

Service users

The Management Committee and its working parties actively recruited service user members, to ensure that their experience and views were represented within the Campaign.

Products

The majority of products have been absorbed into the Campaign Took Kit. This kit has its own website, www.changingminds.co.uk. By the year 2000, the Management Committee realised that the Tool Kit should be the Campaign’s principal legacy to the College. Major elements include:

1. Council Report CR91 ‘Mental illness: Stigmatisation and discrimination within the medical profession’
Council Report CR91 is the product of a cooperative exercise, involving the British Medical Association and the Royal College of Physicians as partners, and with the collaboration of the Royal College of General Practitioners. Its final text was importantly shaped by service-user members of the working party. It has been widely distributed to all undergraduate and postgraduate medical educational bodies in the United Kingdom and has been well received. Guidelines on relevant post-graduate training have been sought by some Royal Colleges. A leaflet summarising the report has been sent on our behalf by the Department of Health to all doctors practising in the National Health Service in England. We have also drawn it to the attention of the College’s Scottish and Welsh Divisions and to the Irish College of Psychiatrists, inviting them to help in encouraging similar distributions.

2.‘1 in 4’cinema film
The 2-minute film ‘1 in 4’ was launched in London as part of World Mental Health Day 2000. It had its Press Première at the Warner Cinema in Leicester Square and was subsequently shown at Warner Village cinemas throughout the UK. It was thereafter adopted by the World Health Organization and shown throughout the world at film festivals and on television. Aimed at young adults aged 15-25, ‘1 in 4’ aims to challenge preconceptions about mental illness.

3.‘Every Family in the Land’
This 200 000-word book was published electronically in 2001 on its own website: www.stigma.org/everyfamily. It has also been published as a CD-Rom and in an updated form, as a book by the Royal Society of Medicine Press. Contributors included users and carers, well-known scholars, senior academics and clinicians. It has been well received and has created interest well beyond the UK.

4. Changing Minds: Our lives and mental illness
Published jointly by the Campaign and the West London Health Promotion Agency in December 2002, Changing Minds: Our lives and mental illness presents personal stories from people who have experienced mental health problems, with commentaries from professionals in the field. The book focuses on success stories about how people have coped with, and overcome, difficulties brought about by mental illnesses.

5.‘Tube cards’
In 2002, with funding and design support from a sponsor, the Campaign website was advertised for one month on London Underground trains. The website hit-rate increased six-fold during this period. Great efforts have been made to secure funding to display the tube cards more widely within the UK. Costings have been worked out for displays on buses and trams in major UK towns and cities.

6. A variety of booklets, statements, leaflets and the Campaign video
Important examples include:

• Declaration of Intent, signed by over 2500 members of the College, and subsequently endorsed by many well-known people including the leaders of the three main political parties;
  
• the campaign videos, ‘Stigma’ and ‘1 in 4’;
  
• ‘Headstuff’ - an especially popular and valued leaflet for 14-17-year-olds;
  
• the original booklets covering the range of mental illnesses;
  
• key statements about such problem areas as personality disorder, violence, suicide, and drug and alcohol misuse/dependence;
  
• a statement on the relationship between creativity and mental illness;
  
• ‘Caring Around the Clock’ - a booklet for young carers;
  
• an information booklet for journalists reporting on schizophrenia.
  

7. Changing Minds CD-Rom for 13-17-year-olds
‘Changing Minds - Mental health: What is it? What to do? Where to go?’ is a multi-media CD-Rom created for young people aged 13-17 years. Designed to be used by teachers as part of the personal, health and social education curriculum (key stage 3 and 4), it includes cartoons, interviews with young people, video clips (including the film ‘1 in 4’), music and quizzes. It contains practical information on how to seek help.

8. Reading Lights: four picture books for 4-7-year-olds
These have simple texts. They are designed to encourage respect for diversity. Each book has an animal as its central character. They are illustrated with bold, colourful pictures and are accompanied by a poster and resource sheets for teachers.

9. Articles published in the medical press
The Campaign has commissioned and encouraged numerous articles in the medical press on a variety of topics relating to the stigmatisation of people with mental illnesses. References to these articles, now numbering over 100, are listed within the Tool Kit.

The Campaign website has recently been redesigned and expanded. The new version was launched in October 2003.

Campaign roadshow

This aimed to take the Campaign message to doctors and employers. In 1999, pilot roadshows were held for general practitioners (GPs) and employers. In 2001, further funding was offered for a ‘Stigma Alert!’ fortnight. Briefing sessions were held for the psychiatrists and users who would be taking part, and materials were produced (including leaflets sent to every GP in the UK). In November 2001, a series of 12 roadshows was held for doctors throughout the UK. Roadshow materials and messages can in future be incorporated into postgraduate medical training programmes.

Global proliferation of the Campaign message

The Campaign has attracted attention throughout Europe and the USA. It was presented as the lead lecture at the 2003 World Health Organization European Commission Meeting on Mental Health, and had a strong presence at the first two global anti-stigma conferences.

Collaboration

Throughout the Campaign, strong links have been maintained with the Department of Health’s ‘Mind Out for Mental Health’ campaign and with the numerous voluntary bodies concerned with mental health and stigma. Collaborative meetings were arranged with organisations such as Mind and Rethink to discuss issues of mutual interest, and representatives of many voluntary organisations have been involved in the Campaign.

Residual projects

Several projects have been fully designed by Campaign Working Parties and endorsed by the Management Committee, but it has proved impossible so far to secure funding. These include:

• ‘Employing and maintaining effective employees’: A training package for employers to understand and deal with mental health problems in the workplace.
  
• ‘Treatment Works’: Promotion of drug and alcohol policies and guidelines in companies.
  
• Research project to assess the adequacy of substance misuse education in undergraduate medical education.
  
• ‘Healing the Hurt’: A programme to address the stigma experienced by those from ethnic communities who have mental illnesses.
  

The results of the nation-wide surveys of public opinions, 1998 and 2003

These surveys, 5 years apart, were designed by us in collaboration with and conducted by the Office for National Statistics.

The results showed:

1. The public’s ability to recognise the nature of and differences between the illnesses - revealed especially in its knowledge of outcomes.
   
2. The public’s sometimes exaggerated and overgeneralised negative reported perceptions.
   
3. The tendency for selective negative opinions concerning ‘dangerousness’ and ‘self-infliction’, and the more universal perceptions that people with mental illnesses are difficult to communicate and empathise with.
   
4. The small but sometimes significant reductions in reported negative opinions in the second (2003) survey, especially in respect of communication/empathy difficulties.
   

Further analyses of the 2003 and the combined 1998/2003 data are awaited.

Campaign effects

Attitude changes take time, and one of the Campaign’s main endeavours has been to establish a durable and effective Tool Kit to inform and empower the College and other groups and individuals.

Conclusions

1. It is generally agreed that there are instinctive and social forces that drive both the stigmatisation process and its activation in relation to people with mental illnesses. Powerful efforts to moderate these forces need to be continuous, and to come at the problem from several directions with the full panoply of ‘Protest’, ‘Education’ and ‘Contact’ (Corrigan & Watson, 2002)
   
2. A number of the groups and institutions concerned with mental health (including the Department of Health in England and the Scottish Executive Health Department) have recently turned their attention to the problems of stigmatisation of and discrimination against people with mental illnesses and have mounted their own campaigns.
   
3. As doctors, charged with the responsibilities of continuing to develop and apply the ‘medical model’ diagnostic approach to mental illness, and with maximising its usefulness, we need to also remain wary of its limitations and potential for stigmatisation of our patients. Recognition of, and respect for, individual uniqueness must accompany the search for such categorisation.
   
4. Specifically, in respect of the Campaign’s original goals, the Management Committee has recommended to the College that:
   
   1. It adopts the Campaign Tool Kit, delegating the future management of it and the Campaign website and their continued development to the External Affairs Department.
      
   2. This will only remain effective as a source of information and empowerment, if it is brought to public attention and kept in the public eye. Such tactics as deployment of the tube card, links with other relevant websites, and the securing of media coverage come to mind.
      
   3. It continues to encourage the relevant Scottish and Welsh authorities to distribute the CR91 précis, together with its covering letter, to all doctors practising in those areas of the UK, as has already happened in England. Also to draw it again to the attention of the Irish College of Psychiatrists, in case it may wish similarly to promote it in that country.
      
   4. It responds urgently to other Colleges and Training Committees that are seeking guidelines as to what, and how much, postgraduate training in psychiatry should be delivered within their own programmes. The relevant Recommendation in CR91, buttressed by the General Medical Council Recommendations on the Training of Specialists, focuses upon basic competence in psychiatric history-taking and examination of the mental state.
      
   5. The projects identified and still awaiting funding are sound. If undertaken they would add further strength to the Tool Kit. It is worthwhile to consider whether funding can still be secured and whether, under such circumstances, their administration might still be managed by the College, e.g. through its External Affairs Department. Any consequent additional resources needed for this administration should be incorporated into the search for funds.
      
   6. It remains important to collaborate with other relevant groups and bodies in the continuing task of tackling stigmatisation and discrimination to avoid duplication/competition. The National Institute for Mental Health have recently taken over the funding and administration of the government’s ‘Mind Out for Mental Health’ campaign. The College has been invited to join its Board of Advisers, together with representatives from the other main mental health charities. This will hopefully be an example of collaboration between the many bodies working to tackle stigmatisation.
      
   7. The nation-wide survey of public opinions regarding people with mental illnesses, be repeated every five years, using the same instruments and methodology as in 1998 and 2003. The cost is currently £30 000 per survey. Results will provide an unparalleled opportunity prospectively to chart public attitudes to people with the variety of mental illnesses, and possibly to begin to identify influences.
      
   
   

Finally, those of us who have worked on the Changing Minds Campaign are grateful to the College and to Council for the privilege of developing the Campaign and for Council’s great support throughout the 5 years. The Chairman wants especially to thank those people who, though not members of the College, have generously and freely given of their time and enthusiasm. They have added greatly to such success as we have had. The Campaign ended on 6 October 2003. This needs to be seen as ‘the end of the beginning’. It is hoped that members will continue to make use of the Tool Kit, along with other resources, in working to sustain and develop the College’s declared intent to eliminate the stigmatisation of people with mental illnesses.

Meanwhile, it is a source of great regret to the Chairman and the Management Committee that Dr Robert Kendell has died without enjoying the fruits of his initial inspiration and determination. He expressed his views in characteristic style in his foreword to our book Every Family in the Land (Crisp, 2004).

References

CORRIGAN, P. W. & WATSON, A. C. (2002) Understanding the impact of stigma on people with mental illness. Journal of World Psychiatry, 1, 6-19.

CRISP, A. H., GELDER. M. G., RIX, S., et al (2000) Stigmatisation of people with mental illnesses. British Journal of Psychiatry, 177, 4-7.[Abstract/Free Full Text]

CRISP, A. H. (ed.) (2004) Every Family in the Land. Understanding Prejudice and Discrimination Against People with Mental Illness (Revised Edition). London: The Royal Society of Medicine Press.

DEPARTMENT OF HEALTH (2003) Attitudes to mental illness. Prepared for the Department of Health by RSGB Omnibus.

KELLY, J. M. (1999) General public attitude to mental health/illness: a summary of existing research. Prepared for the Central Office of Information on Behalf of the Department of Health.

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