Challenging teenagers ideas about mental health

Discrimination is a major barrier to the social inclusion of people with mental health problems (Social Exclusion Unit, 2004). Teenagers are an important group to target since they appear to have less tolerant attitudes about mental health (Care Service Improvement Partnership, 2009) and may even harass mental health service users (Berzins et al., 2003). This is something which, sadly, has figured recently in the news with Fiona Pilkingon's killing of her daughter Francecca – who had a learning disability – and herself, apparently after years of harassment by local youths. Moreover, adolescence is a time when teenagers themselves may experience such problems and yet they find it more difficult to seek help than adults.

A recent longitudinal study has shown that attitudes towards people with mental health problems worsened in England – and to a lesser extent in Scotland – between 1994 and 2003 (Mehta et al., 2009). This is despite extensive campaigns (e.g. Crisp et al., 2000). One possible explanation for this is that campaigns to address discrimination against mental health service users have so far tended to be based on a biomedical model. Indeed, Angermeyer and Matschinger (2005) reported that the increased desire for social distance from people with a diagnosis of schizophrenia found in their surveys of the West German public between 1990 and 2001 was matched by a parallel increase in the tendency of the public to endorse biological causes. However, psychosocial explanations – where mental health problems are seen as caused by adverse life events – appear to be associated with more positive attitudes and behaviour (Read et al., 2006).

Compared with the research on adults, there has been relatively little investigation of young people's views of mental health. In an interesting qualitative study Lindley (2009) used photo vignettes to elicit accounts from 14- to 18-year-olds. She reported that teenagers found it easier to adopt non-discriminatory positions towards people with mental health problems when the cause of those problems was seen as lying in their life history – i.e. when a psychosocial explanatory framework was available.

Some recent studies have indicated that educational interventions based on psychosocial models of mental health may be more effective in bringing about positive attitude change. Schulze et al. (2003) developed a project week for German teenage school students during which they met a young person with a diagnosis of schizophrenia. They focused on similarities rather than differences, including the idea that life events (such as poverty, disability, violence, drugs and loneliness) were important determinants of well-being for everyone. The mental health service user discussed their experience of mental health difficulties and the experience of discrimination resulting from having a diagnosis of schizophrenia. The project took place over five days and all of the elements were interactive with issues being explored through guided group discussions. Measures of attitudes and behaviour indicated that there were positive changes both immediately and one month after the intervention with regard to both the stereotypes the young people held and their readiness to enter social relationships with people with a diagnosis of schizophrenia.

In a similar study carried out in the UK (Pinfold et al., 2003), secondary school students attended two mental health awareness workshops. Group 1 received two hour-long sessions on understanding mental health problems from a psychosocial perspective delivered by a mental health professional. Group 2 received the same content, but with sessions co-facilitated by a mental health service user. Positive attitude scores rose significantly following psychosocial education, in particular for female students, grammar school students and those who had had prior personal contact with people with mental health problems.

We designed an intervention aimed at challenging mental health discrimination and delivered it to a class of 25 13- to 14-year-old students in an inner London school (Sholl et al., 2009). They received four weekly sessions (each 50 minutes long) facilitated by Catherine (then a trainee clinical psychologist) and Juan (a mental health service user and clinical psychologist) – Dave's role was as Catherine's research supervisor. We took a collaborative approach whereby the group were encouraged to discuss their beliefs and reflect upon what they had learned and experienced within each session.

Our approach was underpinned by two assumptions:
I    The active participation of service users is important in challenging stereotypes (Pinfold et al., 2003).
I    Advocating a biomedical model is ineffective and may even maintain or increase negative attitudes towards people with mental health problems (Read et al., 2006). Instead we were influenced both by a psychosocial approach (Read et al., 2006) and by the disability inclusion model (Sayce, 2000). Here there is an emphasis on challenging discrimination in society and increasing empathy by viewing mental health problems as understandable responses to difficult life events.

The four sessions were as follows:
I    Session 1: An open, interactive (rather than didactic) discussion about the group's ideas about people with mental health problems.
I    Session 2: The group interviewed Juan about his life and experiences of distress.
I    Session 3: Understanding mental health distress – exploring what we need to live and be happy, and how we might respond if these things were not available.
I    Session 4: Presenting information to help challenge any myths that had been raised (e.g. that all people with mental health problems are dangerous).

Quantitative and qualitative analysis indicated that, following the intervention, the young people had more positive attitudes about mental health. The collaborative and respectful approach helped to facilitate change. Meeting a service user and hearing their story, not only in relation to mental health but also learning about them as a person (e.g. their work and hobbies) was important, as was receiving accurate information about mental health issues.

Open to change
Despite the rather negative picture painted by attitude surveys, it is clear that, under the right conditions, teenagers are open to changing their views about mental health problems. This project emphasises the need for effective teaching about mental health problems in schools. Such teaching would be an innovative way of meeting some of the aims of Every Child Matters like encouraging children to 'be healthy' and 'make a positive contribution'. Working alongside service users, psychologists could begin more proactive work aimed at reducing the mental health discrimination and inequality found in society (schools, employers, etc.). What is needed now is more extensive provision of this kind of intervention, properly evaluated, across UK schools. This would help us to develop our knowledge about effective anti-discrimination interventions. However, in order for this to occur, it is essential that there is better communication and more joint work, not only between health and education agencies but also involving mental health service users. Only then will we begin to see consistent progress in both addressing mental health discrimination and improving young people's well-being.

Commentary Juan Korkie, service user
Service users can often be made to feel that their involvement is tokenistic and that they are not seen as equals. However, this was avoided here because both Catherine and I were equally involved in the planning and negotiation of our respective roles. My dual perspective both as a service user and as a psychologist seemed to be helpful both in drawing out the students' stereotypes and in helping them to reflect on this process.

We aimed to help the young people to move from sympathy (which implies a level of social distance) to empathy. Stereotypes about people experiencing distress involve several layers of socialised reactions. Therefore part of the work was to help the young people to develop their general social skills – for example being open to difference. It was important for the teenagers to hear about other parts of my life and so realise that being a service user is not the sum total of my identity.

Obviously it was not possible for me to 'represent' the experience of all users of mental health services but I aimed to enable the young people to draw wider lessons from both my own unique experiences of distress and the ways in which services have responded to it.

Catherine Shol is a clinical psychologist with West London Mental Health Trust
[email protected]

Juan Korki is a service user and also a clinical psychologist with Central and North West London NHS Foundation Trust
[email protected]

Dave Harper is Reader in Clinical Psychology, University of East London  [email protected]

References

Angermeyer, M.C. & Matschinger, H. (2005). Causal beliefs and attitudes to people with schizophrenia. British Journal of Psychiatry, 186, 331–334.
Berzins, K. Petch, A. & Atkinson, J.M. (2003). Prevalence and experience of harassment of people with mental health problems living in the community. British Journal of Psychiatry, 183, 526–533.
Care Service Improvement Partnership (2009). Attitudes to mental illness 2009: Research report. London: Department of Health.
Crisp, A.H., Gelder, M.G., Rix, S. et al. (2000). Stigmatisation of people with mental illnesses. British Journal of Psychiatry, 177, 4–7.
Lindley, E. (2009). Gateways to mental illness discourse: Tools for talking with teenagers. International Journal of Mental Health Promotion, 11, 15–22.
Mehta, N., Kassam, A., Leese, M. et al. (2009). Public attitudes towards people with mental illness in England and Scotland, 1994–2003. British Journal of Psychiatry, 194, 278–284.
Pinfold, V., Toulmin, H., Thornicroft, G. et al. (2003). Reducing psychiatric stigma and discrimination. British Journal of Psychiatry, 182, 342–346.
Read, J., Haslam, N., Sayce, L. & Davies, E. (2006). Prejudice and schizophrenia: A review of the 'mental illness is an illness like any other' approach. Acta Psychiatrica Scandanavica, 114, 303–318.
Sayce, L. (2000). From psychiatric patient to citizen. New York: St Martin's Press.
Schulze, B., Richter-Werling, M., Matschinger, H., & Angermeyer, M.C. (2003). Crazy? So what! Effects of a school project on students' attitudes towards people with schizophrenia. Acta Psychiatrica Scandinavica, 107, 142–150.
Sholl, C., Korkie, J. & Harper, D. (2009). Working with young people to challenge discrimination against mental health service users. Clinical Psychology Forum, 196, 45–49. 
Social Exclusion Unit (2004). Mental health and social exclusion. London: Office of the Deputy Prime Minister.