The current study investigated the effectiveness of the In Our Own Voice (lOOV) mental health education program in improving knovi/ledge and attitudes about.
HTIC L E
Evaluating the Effectiveness of a Consumer-Provided Mental Health Recovery Education Presentation V Amy L. Wood
George Mason University Otto F. Wahl
The current study investigated the effectiveness of the In Our Own Voice (lOOV) mental health education program in improving knovi/ledge and attitudes about mental illnesses. Undergraduate participants (ti = ii4) completed three pre-test
University of Hartford
measures of knowledge and attitudes, attended either an In Our Own Voice presentation or a control presentation about psychology careers, and repeated the three measures following the presentation. Results indicated that the tOOV group showed significant positive change across time, as well as significantly greater improvement than a control group in their knowledge and attitude scores on all measures. These pndings support the effectiveness of the lOOV program. Key words: stigma, mental illness, mental health education programs, contact hypothesis
r o r people with psychiatric disorders, dealing with mental illnesses is a multi-faceted process. The foremost and most obvious challenge is being able to recognize, find treatment for, and successfully manage distressing psychiatric symptoms, in order to maintain daily functioning and improve quality of life. This experience is similar to people learning to cope with the challenges of a serious physical illness, such as cancer. Beyond this enormous task, however, people with mental illnesses are faced with another major obstacle to overcome when coping with their condition—societal stigma. Over the years, research has revealed that society tends to hold negative atti-
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tudes and inaccurate beliefs about people with mental illnesses, perceiving this population as unattractive, dangerous, unproductive, and unpredictable (Farina, 1982; Fink & Tasman, 1991). There are numerous sources that likely fuel such stigmatizing cognitions and drive the discriminatory behaviors commonly associated with these negative attitudes. Stigma frequently stems from a lack of accurate knowledge about mental illnesses, as mental illness in general is a topic that is frequently not discussed and oftentimes not openly addressed. Limited opportunities for education and learning, then, allows the misunderstanding of mental illness to continue. Inaccurate
SUMMER 2006—VOLUME 30 NUMBER 1 ideas are often further perpetuated by stereotyped media images of people with mental Illnesses (Day, 1985; Fink &Tasman, 1991; Wahl, 1995). According to a 1990 DYG Incorporated survey given to a representative sample of the United States population, the mass media is the public's most common source of information about mental illnesses. Unfortunately, media images often portray people with mental illnesses as violent, dangerous, unemployed, and transient (Fink & Tasman, 1991; Wahl, 1995). Another factor that perpetuates the cycle of stigma is the social exclusion and discrimination that often occurs towards such feared populations. By keeping stigmatized groups at a distance, there is limited opportunity for negative stereotypes to be dispelled. Therefore, accurate information about individuals living with mental illness fails to be learned and the general negative attitudes are maintained. Mental illness stigma has serious consequences for people already faced with the task of understanding, accepting, and coping with their mental illnesses. It diminishes self-esteem, fuels discrimination, limits opportunity, and contributes to reluctance to seek needed treatment (Corrigan, 2004; Wahl, 1999). In his 1999 Report on Mental Health, in fact, the Surgeon General identified stigma as one of the foremost barriers to people seeking mental health treatment (U.S. Department of Health and Human Services, 1999). Since calling the nation's attention to the many problems associated with stigma, the Surgeon General has recommended that we identify effective anti-stigma campaigns (Brown & Bradley, 2002). A variety of methods to address stigma have been implemented over the years, including such strategies as protest, advocacy, posi-
tive media advertising, and more accurate portrayals of mental illness in movies/television. From a scientific perspective, Corrigan and Penn (1999) proposed that we implement what has been learned from social psychology research to diminish the impact of stigma on people with mental illnesses, specifically focusing on contact and education as two of the most effective interventions. Past research efforts have identified contact and education as useful strategies in reducing stigma across a variety of disability groups. Contact and Education
Gordon Allport (1954) took a sociological approach to understanding the roots of prejudice in his proposal of the contact hypothesis, which suggests that increased contact with a stigmatized group promotes improved, more positive attitudes toward that group. This theory has since been examined using a variety of stigmatized populations, including certain racial and ethnic groups, people with physical disabilities, people with homosexual orientations, and people with mental illnesses. Sigelman and Welch (1993), for example, found that personal contact between African-Americans and Caucasians was associated with positive racial attitudes. A related study reported that African-Americans with close white friends expressed more favorable views of Caucasians as compared to those without such friends (Ellison & Powers, 1994). Some experimental research designs have been implemented to study the effects of contact with people having mental handicaps. Nosse (1993) conducted a study using 68 university students, who were assigned to either a control group or an experimental group. The experimental group interacted with adults from L'arche communities, where mentally and physically impaired individuals live and work.
After several days of direct contact, involving living, eating, and engaging in recreational activities together, the experimental group rated individuals with these type of impairments as significantly more favorably following the contact as compared to their own precontact ratings. Herekand Capitanio (1996) conducted a two-part national telephone study, where participants were asked about their level of interpersonal contact with anyone who was homosexual and also completed the Attitudes Toward Gay Men (ATG) scale, which has been shown to be a reliable and valid measure. The findings indicated that contact with gay men was associated with significantly more favorable attitudes towards gay men. In regards to mental illness, a metaanalysis of 35 correlational studies noted that interpersonal contact with people having psychiatric disorders was significantly associated with more positive attitudes towards mental illness (Kolodziej & Johnson, 1996). Other researchers have reported findings supporting the useful role of education in dispelling stigma (e.g., Paykel, Hart, & Priest, 1998; Corrigan et al., 2001c). Mental health education has been attempted through such avenues as school programming and public service announcements. Corrigan and Penn (1999) describe several education efforts, including the National Mental Health Association's longstanding public education programs and the 1996 Rotary International campaign "Erase the Stigma," used to teach American business leaders about the facts and fictions of people living with mental illnesses. Cross-sectional studies have shown that members of the general public who have more knowledge about mental illness are less likely to endorse stigmatizing attitudes (Link &
PSYCHIATRIC REHABILITATION )OURNAL Cullen, 1986; Link, Cullen, Frank, & Wozniak, 1987). Such research suggests that both contact and education would be important elements to include in anti-stigma efforts. The In Our Own Voice Program
One anti-stigma program to employ both contact and education is the National Alliance for the Mentally Ill's (NAMI) program, "In Our Own Voice: Living With Mental Illness" (IOOV).The stated purpose of this program is to open minds, change attitudes, and educate the public about what it means to have a mental illness. The lOOV program was generated by mental health consumers and is presented by mental health consumers, typically in teams of two, to many different types of audiences, including other consumers, mental health professionals, students, and police officers. The central component of the lOOV presentation is an 11-minute video that is divided into segments with the following titles: Dark Days, Acceptance, Treatment, Coping, and Successes/Hopes/Dreams. The nine consumers shown on the video reflect a wide range of diagnoses, such as schizoaffective disorder, postpartum depression, and bipolar disorder, as well as diverse ages, gender, and ethnicities. During a typical lOOV presentation, each segment of the video is shown, followed by the personal stories of the presenters and an interactive discussion with audience members. This format allows the consumers to weave their own individual experiences into the messages presented In the video. In sharing their personal stories about living with mental illnesses, engaging the audience, and encouraging discussion, the consumers simultaneously act as storytellers, educators, models of people living with mental illnesses, and group facilitators. Their strategy
Evaluating the Effectiveness of a Mental Health Recovery Education Presentation
draws on the combined power of indirect contact (video portrayal of consumers), direct contact (presenters with mental illnesses), and education (included in both the video and in the interactive discussion). Thus, general social science research would lead one to expect that the lOOV program would be effective in achieving its goal of changing minds and reducing stigma. Like many, if not most, anti-stigma efforts, however, the specific impact of the lOOV program has not been empirically determined. The lOOV program does typically include an audience survey, completed at the end of the presentation. Most of the questions on this survey, however, assess audience reactions rather than change—e.g., asking how audience members judged the depth and scope of the presentation and which portions of the presentation were the most helpful. Only two of the questions address possible changes: "I see people with mental illnesses in a new light." "I see recovery as a real option for the first time ever." Wood, Wahl, & Adame (2003) examined the survey responses of over 2,200 students who had received the lOOV presentation, including the responses to these two questions. They found that over one third (37%) of the students reported that they saw people with mental illnesses in a new light. In addition, 15% said they saw recovery as a real option for the first time (this number being limited by the fact that 55% indicated that they had "always believed in the possibility of recovery"). Such results suggest that the program is having some impact on audience knowledge and attitudes. However, results say little about the range of knowledge and attitudes that may have changed, and the self-report and retrospective aspects of the survey limit conclusions about real (as opposed to
self-perceived) change. Without initial (pre-presentation) measures of specific knowledge and attitudes, conclusions about impact must remain tentative. The primary aim of the current research, then, was to conduct a more rigorously controlled investigation of the impact of the lOOV presentation on knowledge and attitudes related to mental illnesses, using both experimental and control groups and pre vs. post comparisons. It was hypothesized that exposure to the lOOV program would result in increased knowledge and improved attitudes about mental illnesses.
Method A total of 114 undergraduate students from George Mason University (GMU) served as participants. Participants were recruited through a university subject pool. This study was entitled "Presentations in Psychology" and included the following description: "Serve as an audience member for a presentation on a psychological topic, such as mental illness or careers in psychology. The presentation consists of a video and an interactive discussion with the presenters. You will also be asked to complete a number of questionnaires, collecting information about demographics, personal attitudes, traits, experiences, and knowledge." All of the participants who volunteered signed written consent forms and completed all measures. In addition, participants who were under the age of 18 brought completed parental consent forms to the session. Following their involvement, participants were provided with both an oral and written debriefing, which explained more fully the purpose of the research. The study sample was 76% female {n = 87) and 22% male (n = 25), while two
SUMMER 2006—VOLUME 30 NUMBER 1 Students did not report their gender. The mean age of the participants was 21.ZJ years (SD - 6.i), ranging from i646 years. Participants were randomly assigned to either the experimental condition (/V = 57), in which they served as an audience for In Our Own Voice, or the control condition (W = 57), in which they received a presentation about careers in psychology. The control group presentation paralleled the length and format of In Our Own Voice, but participants watched a short American Psychological Association video about careers in the field of psychology, followed by an interactive discussion about this topic led by the first author. Measures To assess knowledge and attitudes, three measures were utilized. To measure general attitudes towards people with mental illnesses, the Social Distance Scale was chosen. This is a frequently used measure of general attitudes toward particular groups that asks individuals to rate their willingness, on a 4-point Likert scale (from 0 = definitely unwilling to 3 = definitely willing), to engage in seven kinds of interactions with others (in this case, with a person with a mental illness). Items included ones such as the following: "How would you feel about renting a room in your home to a person with a mental illness?" "How would you feel about introducing someone with a mental illness to your friends?" Responses are summed across the seven items to yield a total score ranging from 0 to 21, with higher scores indicating greater willingness to tolerate/engage people with mental illnesses. The Social Distance Scale has been found to have excellent reliability and validity, with past internal consistency ratings ranging from .75 to .92 (Link et al. 1987; Penn et al., 1994; Corrigan et al. 2001a, 2001b).
It was felt that most existing measures of attitudes toward mental illnesses were not well suited to assess the impact of the specific messages of the lOOV program. Moreover, many existing "attitude" measures seem to combine knowledge items that ask for facts about mental illnesses (e.g., "Most people with mental illnesses are dangerous") with attitudinal items that tap emotional responses and opinions (e.g., "It is wise to avoid contact with people with mental illnesses"). Accordingly, two instruments were developed that focused separately on the specific facts presented in the lOOV program and the specific attitudes targeted by the lOOV presentation. The initial steps in developing these measures included a careful review of the lOOV video and training manual by the researchers, identification of the aims of the presentation, and development of an initial list of knowledge and attitude items based on the core messages conveyed to the audience. The items included explicit information from the video and discussion, as well as implicit messages from the presentation. The researchers then attended a two-day presenter training at NAMI and made additions and revisions to this list of items, with particular attention given to the elements that the presenters were instructed to emphasize when addressing student audiences. Finally, the researchers consulted with NAMI coordinators of the lOOV program to obtain feedback on how well the list of items captured the central messages of In Our Own Voice, a process that also served as a mechanism for determining the newly developed measures' face validity. After minor revisions were made, based on NAMI's review and feedback, the final measures were approved. The Knowledge measure consisted of 12 items reflecting the most centrally emphasized elements in the lOOV
presentation (e.g., "Mental illness can strike people from all walks of life" "People with a serious mental illness, such as schizophrenia, can recover and lead normal lives"). The Attitude measure also contained 12 items related to the attitudes encouraged by the lOOV presentation (e.g., "I believe that hope exists for people with mental illness" "I believe that keeping people with mental illnesses in the hospital makes the community a safer place"). Each of these measures called for participants to read the 12 statements and indicate their level of agreement with each, on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree). Each measure, then, yielded a total score, calculated by totaling the participant's responses on each of the 12 items, ranging from 12 to 84, with higher scores reflecting knowledge or attitudes more consistent with the program's messages. Participants in both the experimental and the control groups completed the identical set of written instruments before and after the presentation they received. In order to reduce the overt demand for changed responding and minimize the potential confusion for control participants being asked to complete measures seemingly unrelated to their presentation about psychology careers, participants were informed that they were being asked to participate in a variety of tasks. First, they would be serving as audience members for a presentation on a psychology-related topic and secondly, they would be completing a set of questionnaires that are being pilot tested, thereby framing the completion of instruments and the presentation as separate components. The true methodological connection between these components, however, was shared as part of the debriefing.
Evaluating the Effectiveness ofa Mental Health Recovery Education Presentation
PSYCHIATRIC REHABILITATION JOURNAL Overall, this selection of instruments and design allowed for a controlled investigation and methodology to empirically test the primary research question of interest: Will exposure to people successfully recovering from mental illnesses through this structured and interactive education program significantly improve public knowledge and attitudes about such people? Our hypothesis was that the experimental group would show greater positive change than the control group on all three measures of knowledge and attitudes. Data Analyses Using three 2x2 mixed factorial ANOVAs, the mean pretest total scores on the lOOV Knowledge measure, the lOOV Attitude measure, and the Social Distance Scale (completed prior to the presentation) were compared to the mean posttest total scores for these same three measures (completed after the presentation). This allowed for the assessment of main effects for time (pre vs. post) and group (experimental vs. control), as well as for an interaction between those independent variables. Post hoc examination of mean scores at pretest and posttest allowed for direct comparisons between groups and testings.
the means indicate that the lOOV group showed a significant increase in Knowledge scores from Pre-test (/M = 64.3) to Post-test {M = 70.6), (f = -7.89, p < .01), while the control group did not (Pre-test Mean = 64.4, Post-test Mean = 64.9), (f = -.79. P = •44)- Similarly, lOOV Attitude scores increased significantly more for students in the experimental group (f (1,112) = 10.56, p < .01), with the lOOV group showing a significant increase in attitude scores from Pre-test [M = 66.0) to Post-test {M = 70.1), (f = -5.59, p < .01) while the control group did not (Pre-test Mean = 64.4, Post-test Mean = 65.3), (f = -1.54, p = .13). Analysis of Social Distance scores revealed an identical pattern: The control group showed no significant improvement from Pre-test [M = 12.6) to Post-test (M = 12.7) while the
lOOV group improved significantly in their reported willingness to accept a person with a mental illness (Pre-test M = 12.9, Post-test /M = 15.1; f (1,112) = 32.30, p
