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 College Hospital, 7th Floor, 76 Grenville
Street, Toronto, ON. M5S 1B2. Email: [email protected]. Telephone: 416-3236230.
Word Count:
Abstract: 250
Body Text: 3427
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Abstract
Objective: To evaluate the impact of a film-based intervention, Rendezvous in the Classroom,
on stigma against 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 schools in 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 Toronto want to learn more about the how to detect, treat, and help others with
mental illness.
Limitations:
2

The behavioral equivalent and long term effect of attitudinal change is uncertain.

Student self selection bias limits interpretation of the results.
Keywords: mental illness, adolescents, youth, stereotype, stigma, media, film
3
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 Classroom is a program that
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Workman Arts developed for high school students. It consists of 4 short films selected to raise
interest and awareness for important mental health issues, and it is followed 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 youth 11,12,14-16,23.
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 responsibility to 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
5
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 discussed specific 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
6
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 study survey 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
7
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 provide their 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 that higher scores indicated
less stigma while lower scores indicated more stigma. Reversed-scoring was applied when
appropriate. Scores for each statement were 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 nonparametric 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 p < 0.05. Focus group data was analyzed
qualitatively by three members of the team who reached consensus on recurrent 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.
8
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 Table 2 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
9
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’s statement, “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, “I always 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
10
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 responsibility for 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
11
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 youthoriented by 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.
Discussion
Previous studies evaluating film-based anti-stigma interventions for young people have shown a
reduction in stigma.10,11,16. However, the videos in those studies depicted real people recovering
from mental illness with the videos intended to be a surrogate for direct contact with people
suffering from mental illness. This study evaluated a combination of abstract and fictional films
of mental illness, selected for both their content and their artistic merit. The results from this
evaluation confirm that high school students do hold stigmatizing attitudes towards those with
mental illness. Rendezvous in the Classroom, by incorporating feedback from students who
viewed the program the previous year, was successful in reducing stigma in high school youth.
This study highlights the importance of capturing the impact on the target audience, in this case,
youth themselves, rather than relying on mere impressions of the non-target audience, i.e.,
12
teachers, to determine program effectiveness. Noteworthy, an attempt to continue to include a
film that demonstrates an individual suddenly becoming better while addressing the fallacy of
this depiction through didactics was not sufficient to alter the stigmatizing belief that individuals
with mental illness can “snap out of if” if they want to. Therefore, the inclusion of provocative
material, while stimulating interest, is risky when the goal is reducing stigma. Finally, students
bring into the program personal experience with persons with mental illness which significantly
alters their pre-program stigmatizing views, on average for the better, as well as their response to
anti-stigma interventions, a result which has been demonstrated previously by others25.
In terms of the current format and delivery of the program, the qualitative data indicates that the
program worked well at demonstrating that anyone can get mental illness, and that one cannot
infer mental illness by appearance. It fostered empathy towards those with mental illness and
their families, and created a greater appreciation of the role environmental stressors play in the
development of mental illness. Additionally, the program was successful at encouraging
curiosity about mental health, especially with regards to detection and treatments. Students also
wished for more opportunity to ask questions of the panel. Though a classroom study guide
accompanied the program, teacher utilization before and after the program is unclear. This
highlights the importance of building capacity within schools to incorporate programs such as
Rendezvous in the Classroom within an educational curriculum.
The response rate for this evaluation was 45%. The biggest factor in limiting our response rate
was the unreliability of students in returning parental consent forms. Many pre- and postquestionnaires were unusable because they did not have associated signed parent consent forms.
In the future, one way of addressing this difficulty would be to include parent consent forms in
the initial package that many schools send out to parents at the beginning of the school year.
13
Other factors likely also played a role in our low response rate, including cultural sensitivity to
the topic of mental illness which may have limited some students’ involvement. Feedback from
some teachers, particularly at schools with high proportions of new immigrant populations,
indicated that this was a taboo topic for certain of the ethno-cultural groups at the school, and
posed a barrier to involvement. Finally, while some teachers were strongly proactive in
supporting the research, and spent more time encouraging and reminding students to bring their
consent forms back, other teachers were less responsive which impacted study recruitment.
Many students who chose to participate in focus groups personally knew someone with a mental
health problem. This self-selection is clearly a bias in the study. Whether or not randomly
selected students would have reported the same favorable outcomes is unclear, however, focus
group responses were very consistent with written qualitative feedback provided overall by
students.
While Workman Arts can offer an avenue of stimulating interest and providing some knowledge
and reduction of stigma, further curriculum development is required in schools. Students
expressed a desire to learn more about how to identify symptoms, and how to help a friend who
may be struggling, as well as information on what treatment is available. Whether or not this
important and very practical information would reduce stigma is unclear, however, given that
mental illness often begins in childhood or adolescents – with about 50% of lifetime mental
illnesses developing by 14 years of age and 75% developing by 24 years of age26, it is important
that youths are provided with valuable information regarding mental health and illness.
Conclusion
Workman Arts’ Rendezvous in the Classroom effectively reduced stigmatizing attitudes and
social distance in students across four high schools in the Greater Toronto Area. The artistic
14
medium stimulated interest and was successful in reducing stigma when paired with a
thoughtfully selected and prepared panel group that discussed material highlighted in the films.
However, this program could further benefit by working more closely with schools to ensure that
mental health curriculum is implemented before and after the program. High school students
demonstrate an ability to appreciate the complexity of mental illness, and so rudimentary
screening instruments are best accompanied by qualitative measures that allow for student
impressions to be elaborated.
Funding and Support
The authors of this paper received no funding for this research and do not have any conflicts of
interest. This project was made possible through a research curriculum requirement as part of the
Determinants of Community Health course at the University of Toronto Medical School.
Acknowledgements
Special thanks to Dr. Elizabeth Lin who provided her expertise to the study development and to
Dr. Zaretsky who supported the application to CAMH and TDSB Ethics Review Boards.
15
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Tables and Figures
Category
Stigmatizing Attitudes (12)
Social Distance (8)
Social Responsibility (3)
Mean Pre-Score
3.76
3.48
4.07
Mean Post-Score
3.92
3.55
4.08
p value
p < 0.001
p = 0.002
p = 0.44
Table 1. Summary of Quantitative Data Analysis from 5-point Likert Scale Questions. Left column
shows the category domain with how many questions measuring that domain noted in brackets.
Mean Pre Likert scores before watching the program were compared to the Mean Post scores
following the program for each student using the Wilcoxon sign rank test.
Questions Related to Stigmatizing Attitudes
Pre
Post
P-value
Most people with a mental illness could snap out of it if they wanted to.
4.0
3.9
P = 0.98
People who have mental illness should be entitled to sick leave from work or school.
3.3
3.8
P < 0.001
There are effective treatments for mental illness.
3.6
3.8
P = 0.02
People with mental illnesses are dangerous and unpredictable, even if they are receiving
treatment.
3.4
3.5
P = 0.04
People with mental illnesses are untrustworthy.
3.8
3.8
P = 0.34
People with anorexia nervosa are vain.
3.6
3.7
P = 0.25
People with mental illness don’t try hard enough to get better.
4.1
4.0
P = 0.08
Children of people who have a mental illness are usually not normal.
3.8
3.9
P = 0.31
You can tell someone has mental illness by looking at them.
3.9
4.2
P = 0.005
People with mental illness usually exaggerate their symptoms to get out of work or school.
3.8
4.0
P = 0.002
Eating disorders are serious mental illnesses that require treatment.
3.8
4.3
P <0.001
I would go to a doctor if I thought I had a mental illness.
4.0
4.1
P = 0.15
Questions Related to Social Distance
I would be upset if someone with a mental illness sat next to me in class.
P-value
3.9
3.9
P = 0.36
18
If I was an employer, I would not give someone who had a past episode of mental illness a
job.
3.7
3.7
P = 0.55
I would let someone with a treated mental illness baby-sit my children.
2.6
2.9
P < 0.001
I would not want someone with an anxiety disorder to be a school teacher.
2.9
3.2
P= 0.004
I would not mind if someone with a mental illness lived next door to me.
3.7
3.7
P = 0.66
I would bring along someone who has a treated mental illness when I meet my friends.
3.5
3.7
P = 0.08
I would feel embarrassed or ashamed if my friends knew that someone in my family had a
mental illness
4.0
4.0
P = 0.90
I would make close friends with someone who has an anxiety disorder.
3.4
3.5
P = 0.11
Questions Related to Social Responsibility
P-value
I would visit a classmate in hospital if they had a mental illness.
4.1
4.2
P= 0.29
I would stick up for someone who had a mental illness if they were being teased.
3.4
3.5
P=0.49
I would volunteer my time to work in a program for people with mental illness.
4.1
4.2
P=0.36
Questions Related to Media Perceptions
Pre
Post
P-value
The media tends to portray mental illness correctly.
3.4
3.6
P<0.001
Most of what I know about mental illness is from television or movies.
3.1
3.1
P=0.81
Table 2. Item analysis of change in stigmatizing attitudes
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Abbreviations List
SA – stigmatizing attitudes
DS – social distance
ACT – social responsibility (action)
20