Changing stigma against mental illness: Evaluating the impact of a youth film program
Nicole Koziel, M.D., F.R.C.P.(C).Women’s College Hospital and Youthdale Treatment Centre; Ruderman, Carly, M.D. University of Toronto; Chowdhury, Priyanka, M.D., University of Toronto; Lawlor, Raymond, M.D., University of Toronto; Han, Mihan, M.D., University of Toronto
Corresponding Author: Dr. Nicole Koziel, Women’s CollegeHospital, 7th Floor, 76 Grenville Street, Toronto, ON. M5S 1B2. Email: . Telephone: 416-323-6230.
Word Count:
Abstract:250
Body Text:3427
Abstract
Objective:To evaluate the impact of a film-basedintervention, Rendezvous in the Classroom,on stigmaagainst mental illness in high school students.
Method: A pre- and post-test design was used to measure change in student’s self reported attitudes. Participants (172 students) were in grades 9-12 across 4 high schoolsin the Greater Toronto Area.
Results: Stigmatizing attitudes (P < 0.001) and ratings of social distance (P = 0.002) significantly improved following the film program.Ratings of social responsibility did not change(P = 0.44). Stigma was less prominent and the impact of the program was greater in students who reported knowing someone with mental illness. Qualitative data demonstrated an outcome of enhanced empathy and knowledge and desire for more information about mental illness and treatment.These results are contrasted to pilot data collected before an educational component was added to the program and which failed to show a reduction in stigma.
Conclusions:Rendezvous in the Classroom succeeded in reducing stigma in youth and increasing awareness of mental illness and its treatment.
Implications:
- This study replicated findings that contact, in person and through film, can reduce stigma against mental illness when paired with educational programming.
- Youths in Torontowant to learn more about the how to detect, treat, and help others with mental illness.
Limitations:
- The behavioral equivalent and long term effect ofattitudinal change is uncertain.
- Student self selection bias limits interpretation of the results.
Keywords: mental illness, adolescents, youth, stereotype, stigma, media, film
Background
People who suffer from mental illness endure a double set of burdens from their disease: the ill effects of the mental illness itself, and the intense stigma and prejudice that surround it.Stigma has been identified as one of the greatest obstacles by the World Health Organization in treating mental illness1. The stress associated with stigma not only leads to worse health outcomes, it also increases the reluctance of individuals to seek help and adhere to treatment2-7. Negative attitudes towards mental illness have been shown to be present in individuals from an early childhood age, and to increase with age, leading many researchers to believe that the roots of stigmatization towards mentally ill develop in childhood and youth8.
Though evaluations exist9-17, the development and assessment of interventions for reducing levels of stigma towards individuals with mental illness, particularly in youth, is a relatively recent and underdeveloped area of the literature. There is an identified need for further empirical work examining what format and content is most effective for initiatives aiming to reduce this stigma, since what is believed to reduce stigma may in fact not have that effect18.In youth, this is perhaps even more important, because interventions developed by adults who assume to capture the perspective of youth can miss the mark on impact19.
In Canada, the Mental Health Commission of Canada (MHCC) was created with a primary goal to reduce stigma against mental illness, with a particular interest of reaching youth20.Workman Arts is a Toronto-based, not-for-profit professional arts company affiliated with the Centre for Addiction and Mental Health (CAMH). Workman members are artists who receive treatment for mental health or addictions. The organization serves its members by assisting them to develop their artistic ability and improve their quality of life21, and serves the greater community by raising awareness about mental health issues22. Rendezvous in the Classroomis a program that Workman Arts developed for high school students. Itconsists of 4 short films selected to raise interest and awareness for important mental health issues, and it isfollowed by a panel discussion comprised by mental health clients and professionals and often a film maker. The program was initially developed in collaboration with high school students living with and without mental illness, and it has previously been shown to thousands of Toronto youth during Workman Arts’ annual Rendezvous with Maddness Film Festival, with school educators providing very favorable feedback.
We conducted a pilot study evaluating this program in 2009, but struggled to successfully recruit a representative sample, and in those who did participate, the program failed to reduce stigma and in some cases, reinforced undesirable attitudes. The students provided very helpful feedback in terms of what was lacking and unclear in the program and this feedback along with researcher input was applied by Workman Arts to revise the program and our study methodology.Study measurement instruments employed in the study were adapted from the MHCC youth stigma survey, which was still in development at the time,and which is based on the World Psychiatric Association’s evaluation of high school-based anti-stigma programs10. Questions were also drawn from a literature review of questionnaires used to measure stigma in youth11,12,14-16,23. Social distance and stigmatizing attitudes are evidence-based domains of questions generally asked in Likert format. We utilized these domains of questions and added a small domain of social responsibilityto explore more outward “socially appropriate” behaviors. Questions were modified to reflect the specific content of the program, as is typically done in other studies. We paired survey outcomes with focus group data and student written responses to assist in interpretting quantitative outcomes.
Methods
Program Development
The Rendezvous in the Classroom film program content was revised according to recommendations that came out of our pilot study. Certain films were withdrawn and others added to capture student areas of interest and address previous dissatisfaction. Final film content underwent researcher scrutiny to highlight salient themes as well as provokative and ambiguous content and Workman Arts used this feedback to develop didactic education content discussed by the panel and prepare a study guide for teachers to utilize in classrooms before and after the program.To accomplish this task, Workman Arts employed an individual experienced in developing educational programs for high school students. Since Workman Arts is fundamentally an arts organization, controversial themes and ambiguity were not avoided but rather welcomed as inherent aspects of a creative experience and as a means of stimulating interest. Therefore, one film that had been found to increase stigma because of its unrealistic portrayal of instant recovery was included in the revised program but with attention to this aspect so as to discuss inaccurate media portrayals.Ultimately, Workman Arts provided the final selection of films which was comprised of Elevator, a humorous short skit of two men, one a young man and another a business man, both with anxiety disorders trapped on an elevator;Tom Hits his Head, a short abstract film also with humor of a man who develops panic disorder and subsequently psychotic depression; Loonie, a serious film of a boy who reaches out to his mother who suffers from schizophrenia, refuses treatment, and lives on the streets; and Alice, a serious film of a young girl with anorexia nervosa.
Following the films, a panel discussedspecific film content, provided psycho-education, and offered students an opportunity to ask questions. The panelists consist of a moderator from Workman Arts, one or more individuals living with mental illness, a social worker from the Schizophrenia Society of Canada, a director of one of the films, and a liaison from a community eating disorder program. The panel was instructed to speak to specific topics highlighted in the films, offer their personal experience, and answer student questions.
Ethics Approval and Recruitment
The study protocol was approved by the research ethics boards of CAMH and of the Toronto District School Board (TDSB). High schools across the Greater Toronto Area were recruited for the film program by Workman Arts and informed about the opportunity to participate in this study. Interested schools were contacted by the research team for potential recruitment into the study. School principals and teachers of classrooms participating in the program were contacted and asked to provide written consent and assist in distributing and collecting parent consent forms and student program surveys. Surveys were collected up to 5 days prior to students viewing the program. Students were not required to participate in the study nor did they require parent consent to attend the film program, but did require parent consent to participate in the study. At each school, 10-15 students were also recruited on a self-selection, voluntary basis to participate in focus groups approximately 30 minutes in duration after the program.The number of students volunteering for focus groups did not exceed the target quota and so all who volunteered participated, providing that they had returned parental consent forms and themselves provided consent.
Measures
The studysurvey had 25 statements in total, with 12 items gauging stigmatizing attitudes (SA), 8 items assessing social distance (DS), and 3 items assessing social responsibility (ACT). 2 additional items assessed students’ reliance on media for beliefs about mental illness. Students rated each question using a 5-point Likert Scale (strongly agree, agree, neutral, disagree, strongly disagree). Pre- and post-test surveys were identical with the exception that post-test surveys had additional open ended questions asking students for basic demographic data, to elaborate on what they had learned, and to providetheir impressions about the presentation. Focus group questions were open ended and designed to expand on the themes addressed by the surveys.
Data Analysis
Each item on the survey was graded by assigning a numerical value to Likert options (1=strongly agree, 2=agree, 3=neutral, 4=disagree, and 5=strongly disagree) such thathigher scores indicated less stigma while lower scores indicated more stigma. Reversed-scoring was applied when appropriate. Scores for each statementwere aggregated to give each student raw scores for SA, DS, and ACT. When a question was not answered in the pre-test for an individual, the corresponding question on the post-test was disregarded, and vice versa to avoid error. Pre- and post-test responses in each domain were compared using the Wilcoxon signed-rank test, a non-parametric statistical test for comparing two linked samples. As the data was not normally distributed and the pre- and post-test responses are linked, this was the most appropriate statistical test24. Statistical significance was set at p0.05. Focus group data was analyzed qualitatively by three members of the team who reached consensus onrecurrent ideas which were grouped into overarching themes. Qualitative questionnaire data was similarly analyzed for recurrent comments and themes.
Results
Workman Arts identified 5 schools interested in the research component of the youth film program. All five schools provided consent to participate in the research, but only 4 had sufficient time to collect pre-program questionnaires and thereby participate in the study. Students from Grades 9-12 attended the film program. 172 completed packages were returned (including pre-questionnaires, post-questionnaires, and parental consent forms). The response rate from the four participating high schools was 45%. Survey completers were predominantly female (60%). 79% were either in grade 10 or 11, and the remainder were divided closely the same between grades 9 and 12.
Stigmatizing Attitudes, Social Distance and Social Responsibility
Of the three domains evaluated, two showed statistically significant shift in attitudes in a positive direction: stigmatizing attitudes(P <0.001), and social distance (P = 0.002). The social responsibility domain showed no significant shift in attitude (P = 0.44). Mean shifts in each domain are noted in Table 1. Students on average were neutral regarding their reliance on media for views of mental illness and were only slightly suspect of media’s portrayal of mental illness, though their skepticism increased following the program.
Post-Hoc Analyses:
Individual items were assessed using the Wilcoxon sign rank test to determine specific items capturing change. The results for individual questions are highlighted in Table2 with pre- and post-program mean values for each 5-point Likert question (reverse-scored as appropriate such that higher means represent less stigma). Of note, two items that captured the most stigmatizing attitudes in the pre-test: allowing someone with a treated mental illness baby-sit one’s children, and having someone with an anxiety disorder be one’s teacher, both showed significant positive shift. Items that had shown an increase in stigma prior to program quality improvement in 2009 were also compared to the current results to determine if implemented changes had been effective in revising the program.While the majority of items showed improvement, there remained no change in the belief that individuals with mental illness could “snap out of it if they wanted to.” This likely related to the ongoing inclusion of a film depicting such a scenario, despite didactic attempts to point out that this depiction was unrealistic, as supported by one student’sstatement, “I have no idea how he resolved his issue with such bad stuff going on. All of a sudden the next day he’s perfect.” Finally, overall positive shift in stigma was compared amongst students who reported knowing someone with mental illness and those who did not. Students who reported knowing someone with mental illness, prior to the intervention demonstrated less stigma (P = 0.01), and demonstrated a greater mean improvement in measures of stigma (0. 21 vs 0.15 mean improvement in Likert points averaged across questions) relative to students who did not know someone with mental illness.
Qualitative analysis
Recurring themes from both focus groups and written responses indicate that students learned from this program that mental illness can happen to anyone and can manifest in many different ways. That is, mental illness does not specifically target homeless, low-income, or uneducated individuals. Also, students learned that you cannot necessarily tell who has mental illness from their appearance, as captured by the quote, “Ialways thought people with mental disorders would have a certain look to them, but they can be normal looking people.” Approximately one quarter of all survey respondents indicated one of the above themes when asked what they learned from the program.
Students also reported developing an appreciation that there are treatments available for mental illness, that recovery is possible, but also that mental illness can be chronic and recovery only partial for some. Students commented on the seriousness of mental illness and that persons with mental illness should seek treatment. Furthermore, students demonstrated increased complexity in their appreciation of the factors that contribute to mental illness, which was elaborated in focus groups as a recurring lesson that it is not an individuals’ fault or choice if he or she develops a mental illness, as revealed by the reflection of one student, “before, I thought that a person’s mental health only depended on their view of things.” Other students’ insights included that individuals who suffer from anorexia nervosa do not necessarily choose not to eat because “they want to look thin” or “think that it looks good” and that people living with mental illness may have difficulty adhering to their medications because of fear of side effects, lack of insight, and paranoia. These comments suggest that some students lessened their placing of blame on individuals who are experiencing mental illness, as summarized by one student’s comment, “mental illness is serious, people suffer from it, but it’s not their fault, and they can get better.”However, other students commented on the choice that persons with mental illness have in seeking treatment, suggesting that in others, an increased awareness of treatment led to an increased expectation that persons with mental illness should take responsibilityfor seeking out treatment.
Finally, some students commented that for those not living with mental illness, it is essential to be supportive and non-judgmental, and offered statements indicating an intent to do so, such as,“People with mental illness should not be isolated; I know some people I have isolated because of this and I’m going to change that.” Nevertheless, students also continued to express concern that individuals with mental illness can be dangerous and unpredictable. How this belief impacts students’ intent to increase inclusion was not elicited in focus groups.
Overall, students found that the use of films effective in educating and provoking thought and discussion. They found this a more interesting medium than simply being taught the material in classrooms. Some students commented that they felt they could relate with the characters and get a better, more vivid sense of the concepts of mental illness through the use of films. Other students however, found the films too abstract and difficult to follow, and felt that the program lacked an overall apparent focus. Students greatly appreciated the presence and stories of panelists who had recovered from mental illness, particularly because they appeared “normal”. Students felt that the panel could have been more interactive with the audience, and could have been more youth-orientedby including youth panelists. Some students were uncomfortable asking questions during the panel in front of their peers and suggested that there be an anonymous question box available to avoid this problem.Students’ recommendations for improvement of the program include incorporating a small introduction before each film to alert to its main messages, as well as a brief discussion after each film to help students digest what was presented, rather than saving the discussion for the end. Students also expressed a desire for more practical information, such as how to detect mental illness in oneself or in others, and what to do if a friend is suspected of having mental illness.