Challenging Dogma

Sunday, May 6, 2012

Reducing the Stigma of Mental Illness: A Critique of the “What a Difference” Campaign and a New Perspective — Erin Anderson

Introduction to the “What a Difference” campaign
Considering the devastating impact of psychiatric disorders on individuals as well the large financial burden of mental illness on the economy (1), it is appropriate that government agencies focus their efforts on addressing this public health concern. One of the main barriers to seeking treatment for mental illnesses is stigma (2). Stigma is defined as having “some attribute or characteristic that conveys a social identity that is devalued in a particular social context” (3), which makes a person tainted or discounted in the eyes of the rest of society (4). Perhaps out of this fear of being labeled as tainted, those with mental illness are less likely to confide in family and friends about their conditions (5), reducing the level of available social support that has been shown to be critical in the healing process (2). Stigma also has direct negative effects on self-esteem and physical health. (5-7). To address these problems, the Substance Abuse and Mental Health Services Administration, partnered with the Ad Council, created a campaign called “What a Difference” which was designed to reduce stigma through increased social acceptance. This paper examines three areas of weakness in the “What a Difference Campaign” and proposes an expanded intervention designed to address these flaws.
            The stated objective of the “What a Difference” campaign is to “encourage, educate, and inspire” (8) 18-25 year olds to be supportive of friends who they know to be experiencing a mental illness. Educational material is distributed through state health departments, television and radio spots, and print ads. Materials consist of brochures and pamphlets with information about mental illness and techniques to support a mentally ill friend, as well as several webcasts. All materials direct consumers to the “What a Difference” website (8), which is the primary method through which the campaign’s message is delivered. The campaign’s website includes information about the intervention, and three main sections: “Learn,” “Support,” and “Listen.” In the first section, myths and facts about mental illness are addressed. The site highlights the fact that with treatment, those with mental illness can lead happy and productive lives. The site provides a brief description of common mental illnesses such as depression, anxiety, and bipolar disorder, among others, and provides resources to learn more about mental illness. The second section, “Support,” focuses on teaching individuals how to provide emotional support for a loved one with a mental illness. This section includes an interactive video that models a scene between two individuals and their friend with bipolar disorder. The video offers the viewer periodic choices as to how the individuals will proceed- asking the viewer to choose between an emotionally supportive response and a response that is less supportive. The last section, “Listen,” offers testimonials from those who have struggled with mental illness themselves and from friends and loved ones. This section emphasizes the positive difference that can be made with emotional support and acceptance. The “What a Difference” website also includes an interactive forum, where users can post and respond to topics related to mental illness and social support. The campaign includes several televised PSAs that direct viewers to the website and all include the phrase “What do if your friend is dealing with mental health problems? Everything you’ve already been doing.” In addition, the campaign recently featured a video essay contest called “Always Be There,” which called for stories of support and care from friends of a mentally ill person. The campaign also includes a multicultural component, with targeted cultural resources for African Americans and Native Americans and translation of the material into Chinese and Spanish.
Flaws in the individualistic nature of the model
The first domain of weakness that this paper will address is the individualistic nature of this campaign. “What a Difference” aims to increase the number of those who the stigma model refers to as those who are “wise”(4) to the condition in question, believing that additional supporters will reduce stigma. However, the campaign fails to acknowledge that stigma is a group level phenomenon. It errs in its assumption that a collection of supportive friends will translate to an entire society that is accepting of mental illness. It makes the assumption that individuals will make the connection between their friend with mental illness and mental illness in others. Although research on the attitudes of young people about those with mental illness (2) is cited, SAMHSA makes no mention of young people’s attitudes about people who they actually know who have a mental illness. There is a marked difference between demonstrating acceptance to one individual who is an intimate friend and being accepting of mental illness in the general population. Youth may feel accepting and positive about their friend with mental illness and come to view them as a person with a mental illness rather than someone who is inherently mentally ill. However, the tendency to commit the fundamental attribution error may prevent young people from being accepting of those they do not know. To be truly effective, the “What a Difference” campaign would require every young person to emotionally support someone with each of the common types of mental illness, which is unlikely. The campaign lacks an understanding of the differences between individual awareness and group understanding.
The individualistic focus of the health-belief model may also be inappropriate in this campaign because it encourages “victim-blaming.” “What a Difference” puts the onus on the individual to eliminate the stigma that pervades all of society. This may overstate the role that individuals play and may lead to victim-blaming attitudes (9) that if stigma associated with mental illness fails to decrease, young people are failing to be supportive enough as friends. In addition, this individualistic focus may highlight and reinforce the current state of stigmatization. Young people are called on to show compassion and support despite the climate of negativity around mental illness, which reinforces the norms that those with a mental illness are people to be pitied, are weaker than “normal” people, and cannot function in society on their own. The campaign focuses on the individual in a way that may lead to blaming those with mental illness and their friends, rather than to a significant change.
Failure to reach the target audience
            The “What a Difference” campaign fails to reach its target audience, which is the 18-25 year old demographic in the United States. A presentation by the Director of Consumer Affairs for SAMHSA (10), states that the website has had 1.5 million total visits since its launch. However, the number of visits per month has been steadily declining, and the evaluation goes on to state that “awareness, attitudes and behaviors towards mental health have remained steady since the launch of the campaign” (10). Additionally, the number of registered users on the website’s interactive forums and the total number of views of the campaign’s online materials can be used as a basis for evaluating impact. Eighteen percent of American youth struggle mental illness (2), meaning that the number of young people with friends who have mental illnesses is likely even higher. However, the online forums of the website (8) only have a total of 984 registered users who can post on the discussion boards. There are only 47 users who are considered “active” by the site. There are 698 posts on the entire forum. These numbers suggest that American youth are not participating in the discussion mental illness in the way that SAMHSA had hoped. Additionally, under the “What is Mental Health” forum, of forty total topics, three of the discussions pertain to weight loss/fitness, one describes the health benefits of fruit, and one is titled “best dog food.” A great many of the topics are posted by those with mental health problems who are themselves seeking help. Although this may be a useful venue for that conversation to begin, it does not fulfill the stated purpose of the forum, which is described as “an online community for friends of those living with mental health problems” (8). The winning entry of the campaign’s “Always Be There” video essay contest (11) has a mere 4,561 views on SAMHSA’s YouTube page, where the video was posted. And because the ages of the users are not reported, it is likely that some viewers were not members of the target age group. The most popular of SAMHSA’s videos on this social media site is their “Dude Got Back” PSA (12), a video about continuing to support friends through times of mental illness. Although this video has roughly twice as many (8030) views as the “Always Be There” essay, all four of the comments on the page are negative and critique the video as “annoying,” “pointless,” and a “nice waste of tax payer money.” While this paper cannot speak to the impact of the PSAs when they were aired on television, the YouTube page can be viewed as an additional and worthwhile metric for evaluating impact. More encouraging is the fact that SAMHSA has 15,255 members who “like” their group on Facebook (13) and has 15,125 followers on Twitter (14); however, these cannot be viewed as a direct evaluation of the reach of this campaign, but rather of the impact of SAMHSA’s general presence in social media. Although not a precise measure of impact, the quantity and quality of posts in the online forum and the number of YouTube views of SAMHSA’s online materials suggest that “What a Difference” is not reaching its target audience in large enough proportions.
            In addition, the format of the “What a Difference” campaign creates a selection bias that hinders its ability to reach its target audience. Research (15) has shown that those who seek health information online are more likely to demonstrate pro-health behaviors. It is likely that anyone who found this campaign by searching mental health topics would already have positive attitudes and behaviors towards those with mental illnesses. Additionally, in its materials that are distributed to the general public, the campaign relies heavily on the website and asks users to visit the page for more information. This means that youth who benefit from the educational materials are active seekers of this kind of information, and again are likely already demonstrating the desired socially accepting behaviors. There is an additional selection bias because the youth who can benefit from the site are only those who know that they in fact have a friend with a mental illness. However, because of the stigma associated with disclosing this information, it is possible that the youth may not be aware of the problem of their friend. The “What a Difference” campaign is actually hindered by the problem it intends to solve and is failing to reach its target audience due to a selection bias.
Wrong message, wrong promise
            This paper argues that the basic message of the “What a Difference” campaign is not salient to its target audience and may in fact be creating psychological reactance. By calling on young people to be more socially accepting of their friends, this campaign is implying that young people are not already socially accepting. By including instructions on how to be supportive of a friend in need, this campaign implies that young people do not know how to support their friends. The skills of empathy and compassion are not domain-specific, and the website implies that either young people do not know how to transfer these skills to friends with mental illness or that young people do not possess these skills at all. The interactive video (8), which models the supportive behavior it hopes young people will adopt, asks the viewer to choose a response that is compassionate. If viewers choose the incorrect response, one of the actors appears to lecture the viewer on why the other response might be better. The message of this campaign may be condescending to those who already view themselves as a good friend. It is unlikely that most viewers would be open to the message that they needed to improve as a friend.
            The message of the campaign may also be called into question due to the identity of the messenger. The “What a Difference” campaign is a government sponsored public health intervention. Psychological reactance to the message of the campaign is increased when the source is seen as “dominant,” or seen as being in a position of power over the recipient of the message. The “” ending of the website for this campaign immediately suggests to the viewer that the source of the message is in a dominant position. Research (16) has shown that young people respond better to a messenger who is similar in age, gender, and other traits. Youth are unlikely to react well to the messenger of the “What a Difference” campaign, who they might see as a distant and dominant messenger.
            According to advertising theory, a promise of salient benefits is needed for a successful campaign (17). The first promise of this campaign is that youth will become more supportive as friends. This promise is not relevant to young people. As discussed above, it is unlikely that the promise of being a better friend will appeal to young people. The second promise of this campaign is that the stigma of mental illness will be reduced. It is well documented that health is not a strong motivating factor for change (17). If personal health it not a sufficient motivation for change, it is doubtful that the well-being of other people would be a strong motivation, and this promise will also not appeal to youth.
Introduction to the expanded campaign
            The expanded campaign proposed here addresses the three major weaknesses reviewed above. In this new approach, the stigma associated with mental illness will be reduced through a social norms rather than individualistic approach. The target audience will be addressed more appropriately through a focus on both the mentally ill and their friends and through a more engaging youth-oriented structure. The message of this campaign will be altered to be more positive and dynamic, and the campaign will promise more exciting and immediate benefits to its target audience. Because the expanded campaign will focus in large part in having a strong youth involvement from the outset, the rest of this paper will describe the general changes that need to be made for a new campaign to be successful. However, this paper will not create a title or logo or enumerate all details of the new campaign because one of the fundamental assumptions presented in this work is that only a youth-driven campaign will produce positive results. The extended campaign will require extensive formative research and a clear youth voice in the development of the intervention.
Focus on social norms
Rather than targeting individuals as the medium of change, the new intervention will broaden its impact by changing social norms about mental illness. Past campaigns targeting social norms have been effective in creating change. A campaign to reduce energy usage succeeded not by providing information about the benefits for the consumer or for the environment, but by encouraging home owners to use no more than their neighbors used (18). One campaign that successfully impacted a public health issue was the designated driver campaign (19) created by the Harvard School of Public Health. This campaign changed norms by partnering with primetime TV to display characters on popular television shows always choosing a designated driver when alcohol consumption was depicted on the show. These efforts successfully reduced the amount of drinking-related auto fatalities (19).  A similar intervention should be implemented for characters portrayed as having mental illnesses: although only 3% of those with mental illness are characterized as “dangerous,” 77% of characters with mental illness on primetime television are depicted as being dangerous (20).  Changing the social norms displayed on television will have a significant and positive impact on society’s views of mental illness. Focusing on social norms has been a successful intervention model in the past, and can be successful for the new campaign.
The expanded campaign will focus on descriptive norms, or the perceptions about how prevalent mental illness is. The new intervention will change descriptive norms by highlighting the fact that mental illnesses are common; in fact, more common in 18-25 year olds than in adults 25 and up (2). According to stigma theory (6), something can only be stigmatized if it is seen as belonging to an outside group. Changing descriptive norms and demonstrating that mental illness affects a large portion of society would reduce the “us” vs. “them” perspective. The Massachusetts based  “84” campaign (21), serves as an example of a successful intervention that enacted change through the reframing of descriptive norms. The campaign spreads the message that youths who do not smoke are in the majority, in the 84% of smoke-free young people. This campaign has involved more than 700,000 young people in Massachusetts since 2007 (21) and can serve as a model for the “What a Difference” campaign. The 84 campaign holds “Drop Dead” sessions in which twenty-four youths in a crowded community setting all drop to the floor at once, representing the twenty-four deaths per day due to smoking in Massachusetts. The same thing can be done with statistics about the prevalence of mental illness in youth. This would be a dynamic and memorable way to change the descriptive norms about mental illness.
Additionally, affective norms can be useful in reducing the stigma of mental illness. Stigma can only exist when a quality is seen as undesirable (4), therefore changing the way people feel about mental illness is a necessary step. It is already a semi-common practice to highlight famous people who are affected by mental illness, and this should be an aspect of the new intervention, with even greater celebrity participation. A recent ad by Bring Change 2 Mind (22) shows an effective demonstration of a celebrity changing affective norms by showing mental illness as something you have rather than something you are. Affective norms can also be changed through effective ads without the use of celebrities. One ad for marriage equality (23) is an ideal model for changing perceptions of mental illness. Ads in the new intervention will show young people in a positive light: creating works of art, acting nervous before a date, running a marathon, in a humorous light with friends- and will reveal phrases such as “I AM NOT depressed/bipolar/schizophrenic- I HAVE depression/bipolar disorder/schizophrenia. And 1 in 5 young adults are just like me.” Ads can also focus on the positive aspect and highlight the fact that many young adults do choose to seek treatment. The focus on changing social norms in the expanded campaign will reduce the amount of stigma towards mental illness by removing the “us vs. them” component and the undesirable taint of mental illness.
Real youth involvement
            The expanded intervention will address the campaign’s failure to reach its target audience by placing a focus on real youth involvement. The very successful “Truth” anti-smoking campaign in Florida cited heavy youth involvement as one of the reasons for the positive results (24). Youth were interviewed and their opinions were valued. In developing a new campaign, qualitative interviews with 18-25 year olds will be conducted, and the results will play a large role in informing the intervention. Additionally, youth must feel engagement in the intervention for it to succeed. One study (25) designed to evaluate the effectiveness of pro-mental health programs found that programs were most effective when they got kids to participate in an active way, when there was a component of experiential learning, and when the message was integrated into multiple aspects of the school’s curriculum. Social media efforts will be expanded so that the campaign has a real presence online and reaches young people in a way that television and radio do not. The new campaign must include media that goes beyond traditional media and is truly interactive. The new campaign will include a component modeled after the “Operation Beautiful” project (26), which encourages women to leave post-its with positive messages that promote a healthy body image in public places. The new campaign will call upon young people to leave post-its in bathrooms, subways, and especially in areas of high youth residency, such as college dorms. Messages can be from the perspective of those with a mental illness, or those who know someone with a psychiatric disorder. Messages will focus on the idea that you are not alone. The “What a Difference” campaign will expand its current partnership with Active Minds, a college-based group which promotes opening a dialogue about mental health. It will support the “Post Secret U” (27) project and expand these efforts to reach young people not part of the college population. This involvement will not only help reduce stigma by creating awareness of the pervasiveness of mental illness, but will also have positive mental health benefits for youth with a disorder: Research (5) has shown that being a part of an advocacy movement to reduce stigma helps those with mental illness cope and increases their self-esteem. This effort to encourage true engagement of the target demographic will promote self-efficacy and inspire young people to become involved. By engaging youth in a real and dynamic way, the new campaign will be able to reach its target audience.
An engaging message, an exciting promise
            The expanded intervention will address the flaws with the message and the promise of the original campaign. The new message of the campaign will be to have fun and to create a positive change in the world. SAMHSA already reports (2) that many youth do not think people with mental illness are difficult to talk to and that the majority of youth understand that treatment and emotional support are beneficial. The expanded campaign will respectfully acknowledge that youth are capable as friends and are ready and willing to be an agent for change. Instead of a message of youth having defects as friends, the new campaign will have the message that everyone belongs. The only stated goal of the current campaign is to reduce the stigma of mental illness. The new campaign will be more relevant to young people if there is a message with a core value that is more engaging.
The new campaign will be fun to be involved with, and it will promise young people the opportunity to make a difference and be a part of a movement. In the 84 Campaign, the guide for starting a new chapter (21) includes a list of the stated benefits for the new members. The first benefit is that members will make a difference. Also cited are new friendships, leadership opportunities, and creating connections with other talented youth. Fun is also a stated benefit, and the word “fun” is used 11 times in the explanation of how to run a chapter (21). The expanded program will focus on fun and create enjoyable ways to participate. By encouraging youth to put up post-its with supportive messages, young people have fun with this whimsical gesture, yet feel that they are part of a movement. The flash mobs, modeled after the “drop dead” series, will be another way to get young people active in the movement in an enjoyable and exciting way. Benefit concerts can be held as a way to bring young people together, and there can be special selections or performances by musicians struggling with mental illness to bring the message to the forefront. In addition, by changing the venues through which youth learn about the campaign, the problem of the inappropriate messenger will be resolved, since the sources will be the youth themselves or celebrities that the youth admire. The campaign will sell t-shirts and gear, branded with messages that are created by youth focus groups, which will be an opportunity for youth to spread the message of inclusion, as well as to make them feel ownership of the message. The message of the campaign will focus on engaging and exciting opportunities for youth to be a part of a movement for change.
By addressing the inappropriate nature of the individualistic approach, the failure to reach the target audience and the lack of salience of the message of the campaign, SAMHSA can create profound change. Only by focusing on social norms, by truly engaging the youth in the formulation and execution of the campaign, and by creating a more exciting promise which will attract members will this campaign be able to truly reduce the stigma associated with mental illness.

1. Insel TR. Assessing the economic costs of serious mental illness. The Journal of American Psychiatry. 2008;165:663-665.
2. US Department of Human and Health Services. Social acceptance is the key to mental health recovery. Accessed March, 2012.
3. Crocker J, Major B, Steele C. Social stigma. In Handbook of Social Psychology, ed. S. Fiske, D Gilbert, G Lindzey, 2003; vol. 2, pp. 504–53. Boston, MA: McGraw-Hill

4. Goffman, E. In Touchstone (Ed.), Stigma: Notes on the management of spoiled identity (First ed.) New York, NY: Simon & Schuster, Inc. 1963.

5. Wahl OF. Mental health consumers' experience of stigma. Schizophrenia Bulletin. 1999;25(3):467-478.
6. Link, B. G., & Phelan, J. C. (2006). Stigma and its public health implications. The

Lancet, 367(9509), 528.

7. Lai YM, Hong CPH, Chee CYI. Stigma of mental illness. Singapore Med J. 2000;42(3):111-114.

8. Substance Abuse and Mental Health Services Administration. What a difference a friend makes. Accessed April, 2012.
9. Marks DF. Health psychology in context. Journal of Health Psychology. 1996;1:7-21.
10. Substance Abuse and Mental Health Services Administration, Magellan Health Services, The College for Behavioral Leadership. Federal efforts to promote social inclusion. . April 22, 2010.
11. Substance Abuse and Mental Health Services Administration. Always be there. Web site. Updated 2010. Accessed March, 2012.
12. Substance Abuse and Mental Health Services Administration. Dude got back. Web site. Updated 2010. Accessed March, 2012.
13. Substance Abuse and Mental Health Services Administration. SAMHSA. Web site. Accessed March, 2012.
14. Substance Abuse and Mental Health Services Administration. SAMHSAGOV. Web site.!/samhsagov. Accessed March, 2012.
15. Dutta-Bergman MJ. Health attitudes, health cognitions, and health behaviors among internet health information seekers: Population-based survey. Journal of Medical Internet Research. 2004;6(2):15.
16. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology. 2005;27:277-284.
17. Siegel M, Doner Lotenberg L. Marketing public health: Strategies to promote social change. 2nd ed. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2007.
18. Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ, Vladas G. The constructive, destructive, and reconstructive power of social norms. Psychological Science. 2007;18(5):429-434.
19. Center for Health Communication. Harvard alcohol project. Harvard School of Public Health Web site. Accessed April, 2012.
20. Chapter 1: Effects of stigma on psychiatric patient. In: Fink P, Tasman A, eds. Stigma and mental illness. Washington DC: American Psychiatric Press; 1992.
21. The 84 Campaign. The 84 chapter guide. Web site. Accessed April, 2012.
22. Bring Change 2 Mind. Change a Ming About Mental Illness. Web site. Updated 2009. Accessed March, 2012.
23. Grindley, Lucas. Possibly the Most Beautiful Ad for Marriage Equality We’ve Seen. website. Accessed April, 2012.
24. Hicks JJ. The strategy behind florida's “truth” campaign. Tobacco Control. 2001;10:3-5.
25. Nind M, Weare K. Evidence and outcomes of school based programmes for promoting mental health in children and adolescents. European Conference on Educational Research, Vienna. 2009.
26. Operation Beautiful. website. Accessed April, 2012.
27. Active Minds. Post Secret U. Active Minds website. Accessed April, 2012.

Labels: , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home