Over the past two decades, stigma for people with mental health problems has become an increasing concern for researchers, practitioners, service users and politicians. This has led to several international government funded campaigns to increase public awareness of the realities of mental health problems. In doing so, it is hoped to reduce stigma and discrimination against people living with these conditions.
The UK’s version is the publically funded Time to Change campaign, started in 2009, intending to reduce discrimination against people with mental health problems by 5%. There is evidence that the campaign has exceeded these expectations and has led both to a softening in public attitudes towards people with mental health problems and reduced reported discrimination by those accessing mental health services.
While these improvements are to be welcomed, in a recently published paper Ewen Speed and I examine the limitations of approaches such as ‘Time to Change’. This was not in order to dismiss their usefulness but instead to ask what gets left out by how mental health problems are constructed in anti-stigma campaigns.
The most obvious limitation is a categorical one. Public anti-stigma campaigns often take an ‘illness like any other’ approach to framing mental health problems which delineates between those of us who have mental health problems and those of who do not. ‘Time to Change’s’ campaign states that ‘1 in 4 people will experience a mental health problem this year’. This, of course, suggests that there is a neat line that can be drawn between the presence or absence of mental health problems. This issue has been challenged by another anti-stigma campaign Only Us, by taking a more dimensional view of mental distress to promote the idea that all of us have different levels of mental distress at various times.
However, there is a less visible, potentially more insidious problem with anti-stigma campaigns in mental health that has less to do with categorisation than questions about what causes mental health problems in the first place. There is evidence that common mental health problems are more likely to occur in poorer areas, which then also have worse treatment outcomes. For more severe mental health problems such as psychosis, there is a significantly elevated risk for developing these conditions for people exposed to significant levels of abuse and neglect in childhood. So from this perspective, the social, relational and material conditions that underpin and trigger mental health problems are more important than debates about how many of us may experience mental distress.
On the social and material factors that may trigger mental health issues, anti-stigma campaigns have much less to say. Certainly, in the case of ‘Time to Change’, this is not because the academics involved in its evaluation are blind to these underlying factors. Rather it is a reflection of what was politically possible at the beginning of our current era of austerity. Mental health campaigning has become a way for politicians to display their compassionate credentials while doing little materially to reduce the conditions leading to ill-health. As social scientists and mental health experts have pointed out, any sustainable solution to reduce health problems requires a fundamental examination of how power and resources are distributed. Whether the masking by politicians of the underlying social and material context is intentional or not is less important than the impact it has; associated stigmas such as poverty, homelessness and a history of abuse get sidelined by a narrative which is predetermined and bounded by existing psychiatric diagnoses.
Many of the campaigns to reduce stigma seem to be based on a particular theory of change – the power of social contact. This theory originates from Gordon Allport’s 1954 social psychology study, The Nature of Prejudice. Allport sees prejudice ultimately as a failure of reason, a series of misperceptions borne of ignorance that can be corrected by education and social contact. In this case, the education of learning the ‘facts’ about mental illness and maybe meeting people who ‘have’ these conditions. While this is a laudable agenda, it neglects the structural, discursive and cultural factors that maintain hierarchies of discrimination and can be preserved in spite of individual attitudinal change. We can see this in the current UK’s government’s welfare reform agenda. On the one hand, the UK government are happy to fund Time to Change to reduce stigma against people with mental health problems Yet in another part of Whitehall a hostile discourse is created where the same people are portrayed as ‘welfare scroungers’ whose right to social security is being brutally dismantled.
In writing this blog and the paper that preceded it, I have been very mindful of the positive stories that I have heard from colleagues, clients and friends who have had transformative experiences through their contact with anti-stigma campaigns. For many of these people, anti-stigma events were the first time they spoke publically about their mental health and this was the first step in their recovery. There is nothing to be gained by denying how important this is for them and wider society. However, I am also reminded of other conversations I have had with the same people whereby their ‘recovery story’ was the only one that anti-stigma campaigns wanted to hear. The messier stories of abuse, poverty, and relapse were toned down or edited out. Perhaps the challenge for anti-stigma campaigns, and public debate, is to be able to listen to these more complicated stories and to ask what more do we need to do to tackle stigma than merely change our minds?