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eLetters: Electronic letters published:
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Public attitudes towards mental illness
- John M. Eagles (7 April 2009)
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Author Response to Professor John Eagles' Letter, 7th April 2009
- Nisha S Mehta, Aliya Kassam, Morven Leese, Georgia Butler, Graham Thornicroft (28 April 2009)
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Measuring Stigma Remains a Challenge
- Raj Persaud, Khalid Mirza (13 May 2009)
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John M. Eagles, Consultant Psychiatrist Royal Cornhill Hospital, Aberdeen
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john.eagles{at}nhs.net John M. Eagles
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Dear Sir It is tempting to accept the conclusion from the paper by Mehta et al1 that the Scottish anti-stigma campaign “See Me” has successfully influenced public attitudes north of the border. However, it is not clear that this is an appropriate conclusion from the data they present. They describe random sampling techniques whereby 2000 adults representative of the UK population were surveyed. One presumes that this would give rise to cohorts in England which were roughly ten times larger than those in Scotland. Comparing the year 2000 against 2003, they observed a deterioration for 17/25 stigma questionnaire items in England against only 4/25 in Scotland, and concluded that Scotland’s dubious distinction of having done less badly suggested that “See Me” had been effective. Can they assure us that this difference did not arise simply because the much larger samples in England would be more likely to show a statistically significant difference than smaller Scottish samples? Yours faithfully PROFESSOR JOHN M. EAGLES, Consultant Psychiatrist, Royal Cornhill Hospital, Cornhill Road, ABERDEEN, AB25 2ZH 1. Mehta N, Kassam A, Leese M et al. Public attitudes towards people with mental illness in England and Scotland, 1994-2003. Br J Psychiatry 2009; 194:278-284. |
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Nisha S Mehta, Visiting Research Associate Health Service and Population Research Department, Institute of Psychiatry, King's College, London, Aliya Kassam, Morven Leese, Georgia Butler, Graham Thornicroft
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nisha.s.mehta{at}kcl.ac.uk Nisha S Mehta, et al.
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Dear Sir, Professor Eagles writes to ask whether our conclusion from the paper is that the Scottish ‘see me’ anti stigma campaign has positively influenced public attitudes about mental illness in Scotland. He suggests that this conclusion may be inappropriate because the populations in Scotland and England produce different sample sizes, given that the population of England is roughly ten times that of Scotland. We are very grateful to Professor Eagles for his comments as they allow us to provide some more information on these surveys than we could include in the original paper (1). As he rightly says, direct evidence of the position in Scotland vis a vis England is not provided by comparison of only those significant changes within the two sites. We had hoped to pursue this question further with analysis of future surveys, which would have given us power to do make the comparisons between Scotland and England adequately, but unfortunately the wording of the Scottish survey has been changed so this will not be possible. The existing datasets do, however, show limited evidence in favour of Scotland when comparing their respective mean changes from immediately pre- to post- campaign periods (2000 v 2003). Of the 25 items, 6 differed between the sites at a nominal 0.1 significance level. One item (26, fear of downgrading residential areas) favoured England, at p=0.05. The others favoured Scotland: items 7- 9 at p=0.1 (to do with tolerance) and items 10 and 13 (the need to spend money and care for people with mental illness) at p=0.05. As we stated in our paper, the evidence may be consistent with an early positive effect of ‘see me’, but this possible association requires further investigation, although we accept that it is far from conclusive and needs further verification. Yours faithfully Nisha Mehta, Aliya Kassam, Morven Leese, Georgia Butler & Graham Thornicroft Institute of Psychiatry, King's College London Health Service and Population Research Department Box PO29 De Crespigny Park London SE5 8AF Reference List (1) Mehta N, Kassam A, Leese M, Butler G, Thornicroft G. Public attitudes towards people with mental illness in England and Scotland, 1994 -2003. Br J Psychiatry 2009 Mar;194(3):278-84. |
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Raj Persaud, psychiatrist surrey and borders nhs partnership foundation trust, Khalid Mirza
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raj.persaud{at}sabp.nhs.uk Raj Persaud, et al.
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If public attitudes towards those with mental illness are becoming less positive in recent times, as reported by Mehta et al1, this is indeed a significant and disturbing finding; particularly given stigma dogs psychiatry and psychiatrists in contrast to most other medical disciplines. However before this conclusion can be so firmly drawn, more consideration surely needs to be given to how stigma is scientifically measured, and the dynamic structure of this mind-set within the complex world of attitude measurement. Raskin et al2 have pioneered a novel approach in this regard with particular relevance to stigma research. This perspective highlights the notion that attitudes tend to fall into a so-called ‘golden section’ structure – two-thirds one way and a-third the opposite in terms of positive and negative respectively. This theory might therefore be considered to predict the ratio of roughly two thirds to one third changes in a negative direction for attitude statements that Mehta et al1 found. Raskin et al2 argue that all attitudes, inevitably, are a mixture of positive and negative towards targets and the key issue is not merely to add up levels of negativity and positivity (as Mehta et al’s1 approach leans towards) but instead to contrast ratios of positive to negative. They also urge consideration of the specific context of an attitude. For example, a positive attitude may appear particularly salient because in fact it’s being contrasted with a background default level of high negativity. Raskin et al2 have used their approach in studies of the stigmatised (including the mentally ill) and found that the ratio of negative to positive was an almost mirror reversal of what is found when the non- stigmatised are considered. The key finding is that for the stigmatised, negative qualities are assumed while positive ones stand out as striking and unique. The vital implication is that it’s not whether you view a quality as positive or not in another, but more how surprised you are by this. Or another way of putting this; it’s your attitude to your attitude that really matters. Therefore it’s quite possible to view a particular mentally ill person as not violent when asked by a researcher, yet in fact be surprised by this, so revealing that your normal expectation is to link violence with mental illness. The essential implication for stigma research and campaigns is that it might be fundamentally misguided to aim at replacing all negative attitudes with positive ones. Instead a more realistic approach would be for the stigmatised to resemble the non-stigmatised in the overall pattern or ratio of negative attitudes to positive. It follows comparison attitudes and control groups become vital and Mehta et al’s study, similar to many others in the field, lacked this. Another indispensable inference of this ratio or contextual view of attitudes is that most mental illness behaviour is likely to be highly salient to the general public as it will be relatively rare in contrast to non-mental illness behaviour. It’s this salience that renders it particularly difficult to shift public attitudes. This attempt is always going to battle against a background of assumptions about normal everyday behaviour. 1 Mehta N, Kassam A, Leese M, Butler G, Thornicroft G. Public attitudes towards people with mental illness in England and Scotland, 1994–2003. Brit J Psychiat 2009; 194: 278-284. 2 Raskin JD, Harasym MT, Mercuri MA., Widrick RM.Construing stigmatized identities: A golden section study. Psychology and. Psychotherapy: Theory, Research and Practice 2008; 81:285-296 Raj Persaud, Khalid Mirza Surrey and Borders NHS Partnership Foundation Trust. |
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