5th Annual Forum
28th April 2010
Royal Hospital Kilmainham
‘Promoting Positive Mental Health
and Reducing Stigma’
Stigma Reduction and Mental Health Promotion
What Works?
Professor Margaret Barry
World Health Organisation Collaborating Centre for
Health Promotion Research
National University of Ireland, Galway
Ollscoil na hÉireann, Gaillimh
• Concepts of mental health and wellbeing
• Adopting a mental health promotion approach
– why stigma is important for mental health promotion
• Challenging stigma and its effects
– the effectiveness of anti-stigma interventions
– interventions in schools and workplaces
Barry NOSP April 2010
Concepts of mental health
• Concepts of mental health vary as a function of time,
place, culture and context
– changing and competing perspectives concerning the nature of mental
health and ill-health
• Mental health has been conceived as a medical,
psychological and sociological phenomenon
- disease entity approach
- normality and abnormality; ‘ideal self’
- social construct - ‘deviance’ and social causation - impact
of poverty, social position, poor housing, unemployment,
social stressors
• The merging of perspectives - biopsychosocial model
Barry NOSP April 2010
Concepts of mental health
• Relationship between mental health and mental disorder
continuum or separate entities?
• Population approach - continuous distribution of mental
health and mental disorder across the population
• Mental health is fundamental to good health and quality
of life
‘complete physical, mental and social well-being’
‘a resource for everyday life which enables us to manage our lives
• Mental health as an integral part of health and wellbeing
(Lancet series on Global Mental Health 2007)
– there is no health without mental health
Barry NOSP April 2010
Concepts of positive mental health
• Conceptualisations of positive mental health (Keyes,
2002; Huppert, 2005; Ryff et al., 2006)
– hedonic - subjective well-being and life satisfaction
– eudaimonic - positive functioning, engagement, fulfilment and
social well-being
• Keyes’ concept of optimal mental health or ‘flourishing’
– more than the absence of mental illness
• Measures of positive mental health at population level
Barry NOSP April 2010
Mental health and wellbeing
• Mental Health Action Plan for Europe (WHO, 2005)
– ‘mental health is an essential component of social cohesion, productivity
and peace and stability in the living environment, contributing to social
capital and economic development in societies”
• UK Foresight Project on Mental Capital and Wellbeing (2008)
“ A key message is that if we are to prosper and thrive in our changing society
and in an increasingly connected and competitive world, both our mental and
material resources will be vital. Encouraging and enabling everyone to realise
their potential throughout their lives will be crucial for our future prosperity
and wellbeing” (www.foresight.gov.uk)
Barry and Friedli (2008) determinants of positive mental health State-of-Science
Review: SR-B3
Barry NOSP April 2010
A policy focus on wellbeing
• Richard Layard (2005) ‘Happiness: Lessons from a New
Science?’ – the economics of wellbeing
• New Economics Foundation - A Well-being Manifesto
for a Flourishing Society
“What would politics look like if promoting people’s wellbeing was one of the government’s main aims?”
– integration of social, economic and ecological policies
• Wellbeing Indicators at country level
– National Accounts of Well-being (New Economics Foundation, 2008)
– Canadian Index of Wellbeing (2009)
Barry NOSP April 2010
Adopting a mental health
promotion approach
• Focus on promoting population mental health
- enhancing the strengths and competencies of individuals,
communities and society
- addressing the broader determinants of positive mental health
• Multidisciplinary - theories and methods
• Builds on the basic concepts and principles of health
• Where is mental health created?
- contexts and settings where we live our lives
Barry NOSP April 2010
Health Promotion
action areas
Build healthy public policy
Create supportive environments
Reorient health services
Strengthen community action
Develop personal skill
Health Promotion Model
(WHO Ottawa Charter)
The process of enabling
people to increase control
over their health and the
determinants of health
micro - macro
combined into Health
Promotion strategies
Health Promotion Principles (participation, empowerment, equity)
Barry NOSP April 2010
Barry NOSP April 2010
Strategies for
well-being &
quality of life
Barry NOSP April 2010
Barry, M.M. (2001) International Journal of Mental Health Promotion, 3(1) 25-34.
Determinants of mental health
• Healthy structures - economic, political, social and
cultural framework for developing and maintaining
positive mental health
• Citizenship - social support, sense of social integration
and inclusion
• Emotional resilience - self-esteem, coping , life skills,
sense of control
Barry NOSP April 2010
Adopting a mental health
promotion approach
• Growing international evidence base on the
effectiveness of mental health promotion practice
(Hosman & Jané-Llopis, 1999; WHO, 2004; Jané-Llopis et al., 2005;
Herrman et al., 2005; Keleher & Armstrong, 2005; Barry & Jenkins, 2007)
• Evidence sources
Health Evidence Canada
Cochrane database of systematic reviews
US Mental Health and Substance Abuse (SAMSHA)
UK NICE - evidence briefings
• There is sufficient knowledge to move evidence into
practice (Jané-Llopis, Barry, Hosman and Patel (IUHPE
Special Issue, 2005)
Barry NOSP April 2010
Adopting a mental health
promotion approach
• Feasibility of implementing effective mental health
promotion programmes across a range of diverse
population groups and settings (Barry & Jenkins, 2007)
• Generate multiple positive outcomes across social and
personal health domains (Herrman et al., 2005)
• Strong economic case for investment – interventions
that can be sustained at a reasonable cost (Friedli &
Parsonage, 2007; Knapp et al., 2008)
• International policy and practice developments
- dissemination and adoption of evidence-based practice
Barry NOSP April 2010
Findings from SLÁN 2007 study
(Barry et al., 2009)
• Mental health and social wellbeing of 10,364 Irish
• Positive and negative mental heath as part of the
national health survey
• Lower levels of loneliness and higher levels of social
support are associated with positive mental health
• Gender and social and economic factors
• Markers of social advantage - higher income, employed,
higher education - associated with better mental health
Barry NOSP April 2010
Positive Mental Health
Barry NOSP April 2010
Psychological Distress and Energy and
Vitality by Income
Barry NOSP April 2010
Psychological Distress and Energy and
Vitality by Social Support
Mean Scale Score
Social Support
Energy and Vitality Index (EVI)
Psychological Distress (MHI-5)
Barry NOSP April 2010
Flourishing by Health Behaviour
(%) 6
Self-rated health
Physical Activity
Barry NOSP April 2010
Never Smoked
Increased Risk
Low Risk
Determinants of mental health and
• Eurobarometer study (Lehtinen et al., 2005) –
2002 survey of positive mental health across 11
European countries
• Dolan et al., 2006 - review of causative factors
associated with subjective wellbeing (analysis of
British Household Panel Survey)
• Both studies identified relationships and social
support, income, health, and employment as being
positively associated with mental health and wellbeing
Barry NOSP April 2010
Adopting a mental health
promotion approach
• Individual level – identity, self-esteem, efficacy and life skills
• Social networks - social relationships, support, exchange, sense of
social belonging and inclusion
• Community level – community involvement, civic engagement,
leisure, membership of clubs etc., volunteering
• Societal level – cultural, economic and social policies
- role in wider society, work, citizenship, democratic participation,
• Access to resources and opportunities
» supportive relationships, education, employment, opportunities for
social inclusion
• Stigma and discrimination denies access to life opportunities and
Barry NOSP April 2010
• “the situation of the individual who is disqualified from full
acceptance”; “an attribute that is deeply discrediting and reduces
the bearer from a whole and usual person to a tainted, discounted
one” (Goffman, 1963)
• ‘a combination of stereotyped beliefs, prejudiced
attitudes and discriminatory behaviours toward
outgroups… resulting in reduced life opportunities for
those who are devalued’ (Hinshaw and Stier, 2008)
• Mental disorders are one of the most stigmatised
Barry NOSP April 2010
Impact of Stigma
• People with mental health problems consistently identify
stigma, discrimination and social exclusion as major
barriers to their health, well-being and quality of life
(Dunn & Crawford, 1999; Moving People, 2007)
limiting access to housing and employment
damaging social relationships and social participation
reducing self-esteem and dignity
lack of control and influence in how services are designed and
– contributes to the abuse of human rights
Barry NOSP April 2010
• Stigma and discrimination are identified as the single most
important barrier to overcome in the community (WHO, 2001)
• Reduce the likelihood of people contacting the services for help
due to fear of being labelled and discriminated
• Reduce the willingness of policymakers to invest in mental health
- low priority
• Importance of tackling stigma and raising greater public
awareness from a public health perspective
– enable people to engage with mental health in a more positive way
Barry NOSP April 2010
• Link and Phelan (2010) stigmatization model
Labelling – differentiate and label human variations
Stereotyping – prevailing cultural beliefs
Disconnection – ‘us’ and ‘them’
Status loss and discrimination – unequal
• Social process – socially shared beliefs,
perceptions and cultural norms
Barry NOSP April 2010
Challenging Stigma
• Different approaches
Mental health sector – treatment services and recovery
Public health sector – public beliefs and attitudes
Disability sector – disability inclusion processes
Human rights sector – rights-based approach
• Challenge self-stigmatization
• Reducing stigmatization in the community
• Legislation and policy changes against discrimination
Barry NOSP April 2010
Challenging Stigma
• Large body of international research on the nature and
extent of stigma and discrimination in mental health and
public perceptions and attitudes to mental disorder
• Public attitudes - dominated by negative stereotypes
• Influence of the media – reinforces myths, derogatory
language and discriminatory portrayal of mental health
– violence, crime, unpredictable, incurable
Barry NOSP April 2010
Challenging Stigma
• Both mental health and mental illness are still associated
with stigma in the mind of the public
• NOSP (2007) report ‘Mental Health in Ireland: Awareness
and Attitudes’
• SLAN (2009) – 52% agree/strongly agree that
– “if I was experiencing mental health problems, I wouldn’t want
people knowing about it”
– Scotland 2002 (50%), 2004 (45%), 2006 (41%) (Braunholtz et
al., 2007)
Barry NOSP April 2010
Stigma Reduction Strategies
• WPA Open the Doors – (2002.www.openthedoors.com)
• UK Mind out for Mental Health (www.mindout.net); Changing
Minds Campaign (www.rcpsych.ac.uk) Defeat Depression
• Scotland See Me campaign (www.seemescotland.org)
• New Zealand Like Minds Like Mine (www.likeminds.govt.nz)
• Australia – Stigma Watch (www.sane.org); beyondblue
• US National Stigma Clearinghouse (http://community2.webtv.net/stigmanet)
• Ireland – NOSP, Mental Health Ireland, AWARE, Schizophrenia
Barry NOSP April 2010
New Zealand Like Minds Like Mine
• National programme – mass media campaign
– regional programmes contracted out to local providers
• Mental health promotion approach
– influenced by recovery approaches - service user constituency
– human rights and disability inclusion – government policy
• Impacts of the national media campaign
– surveys monitoring public response to the campaign messages have shown
improvements over the last nine surveys
– strong message recall on the support/acceptance/not discriminate theme
– specific behaviours in the last 12 months
Barry NOSP April 2010
New Zealand Like Minds Like Mine
• Cost- benefit analysis (Vaithianathan, 2010)
– Costs to the health care system and the benefits of the
campaign to the population purely in terms of increased
employment costs
– for every dollar spent on Like Minds $13 of benefit was
generated over a five year period
– assumption that Like Minds generated only 30% of the change
in attitudes and 50% in changed behaviour the benefits still
exceed the costs by more than 4:1
– Anti-stigma programmes have potential to generate large
economic value – increased employment opportunities for
people with mental disorders
Barry NOSP April 2010
Scotland See Me Campaign
• National campaign launched in 2002 – National
Programme for Improving Mental Health and Wellbeing
– national level publicity campaign – social marketing coupled with a
community development approach
– targeted campaigns – work with specific groups, the media (Stigma Stop
Watch, volunteers), support for local activities
• Independent evaluation in 2006
– national surveys (2002-2006) positive shifts in mental health awareness
and attitudes towards people with mental health problems
– media reporting – change in use of negative story lines
– active involvement of users and carers
– evaluation of reach and recall
Barry NOSP April 2010
School-based interventions
• Mental health promotion in schools, when implemented
effectively, can produce long-term benefits for young
people, including emotional and social functioning and
improved academic performance
• Traditional topic based health education approaches are
of limited value (knowledge only programmes have
minimal effects on behaviour)
• Programmes adopting a whole school approach are more
successful and the most promising
Barry NOSP April 2010
Systematic Reviews of School-based
Mental Health Promotion Programmes
• Lister-Sharp et al. (1999)
• Wells, Barlow and Stewart-Brown (2001, 2003) HSRU,
University of Oxford
• Harden et al. (2001) EPPI- Centre
• Greenberg, Domitrovich & Bumbarger (2001)
• CASEL (2003)
• Tennant et al. (2007)
• Payton et al. (2008)
• US Mental Health and Substance Abuse (SAMHSA www.samhsa.gov)
Barry NOSP April 2010
Collaborative for Academic, Social
and Emotional Learning (CASEL)
Essential skills for social and emotional learning:
• Self-awareness - know yourself and others - identify feelings, be
responsible, recognize strengths
• Self-management - manage emotions, understand situations, set
goals and plans, solve problems creatively
• Social awareness - care for others - show empathy, appreciate
• Relationships skills - communicate effectively, build
relationships, negotiate fairly, refuse provocations, seek help
• Responsible decision making - act ethically, appropriate social
norms, respect others
Barry NOSP April 2010
Systematic Reviews of School-based
Mental Health Promotion Programmes
• Three scientific reviews - 317 studies involving
324,303 school children aged 5-13 years (Payton et al.,
• Strong and consistent support for the value of social and
emotional learning (SEL) programmes implemented by
school staff
• Improvement in multiple areas :
Social and emotional skills
Attitudes towards self, school and others
Positive social and classroom behaviours
Conduct problems - misbehaviour and aggression
Emotional distress - stress and depression
Academic performance - test scores and school grades
Barry NOSP April 2010
Sample Programmes
• Whole School Approach
- Australian MindMatters programme (adapted as MindOut
programme in Ireland- Byrne, Barry and Sheridan, 2004)
- Olweus’ Bullying Prevention programme
- UK Social and Emotional Aspects of Learning (SEAL)
• Targeted Programmes
- Clarke’s Coping with Stress Course - depression
- Gillham et al’s Penn Resiliency programme
- Resourceful Adolescent programme (Shochet et al, 2001)
- Incredible Years Programme (Webster-Stratton et al., 2001)
- Anti-stigma – Mental Health Matters, Beating the Blues
- Out of school - Spun Out, Reach Out, Headstrong
Barry NOSP
April 2010
Barry NOSP
April 2010
Zippy’s Friends Programme
Emotional Literacy Programme for young
children enabling them to:
• learn skills to deal with everyday problems
• develop a wide range of coping strategies
• identify and label feelings
• focus on positive strengths and abilities
• think for themselves
• work cooperatively as a class group
Barry NOSP April 2010
Stigma Reduction in the
• The role of work and paid employment
• Mental health impact of unemployment is well
– EU countries report 20-30% employment rates for people with
mental health problems
– Scotland – 57% concealed they had mental health problems when
applying for a job ; 43% had not gone ahead with a job
application for fear of disclosure
• Evidence-based interventions to facilitate job retention,
re-employment, supported employment
• Organizational approaches - regulatory measures and
economic incentives; management and social support
• Legislation on discrimination in the workplace
Barry NOSP April 2010
Effective Stigma Reduction
Underpinning principles (Link and Phelan, 2001; Pinfold
et al., 2003; Gale et al., 2004; McDaid, 2008)
• Multifaceted and multi-level - addressed at the individual, community,
organisational and societal level
• Services users and carers involvement in the design, delivery and
evaluation of programmes
• Clear consistent messages delivered in targeted ways to specific audiences
• Education approaches alone will not lead to behaviour change - must
address discriminatory actions
• Policy and legislation – social inclusion and empowerment strategies,
create an environment of intolerance to prejudice and discrimination
• Long-term planning and funding
• Appropriate monitoring and evaluation of interventions
Barry NOSP April 2010
Stigma Reduction Promotes
Mental Health
• Improves the social inclusion and quality of life of
people with mental disorders
• Greater openness about mental health problems and
willingness to seek appropriate help sources early
• Improves mental health literacy
• help people to have a greater understanding of their
emotional and social well-being
• the importance of mental health for overall health
• knowledge of protective and enhancing factors for positive
mental health
Barry NOSP April 2010
• Remove the stigma and discrimination
surrounding mental health in order to
address the social determinants of mental
health and promote positive mental health
• Engaging the political will to promote
mental health at every level of policy
• Mobilising a public demand for a mentally
healthy society
- concern with emotional and social wellbeing, social values,
culture, economic and social policies
Barry NOSP April 2010
5th Annual Forum
28th April 2010
Royal Hospital Kilmainham
‘Promoting Positive Mental Health
and Reducing Stigma’
National Office for
Suicide Prevention
Annual Forum 2010
Geoff Day
Young Peoples Mental
Health Awareness
 Encourage young people to know about positive
mental health
 To increase young peoples understanding of mental
health issues
 To provide information on mental health in a youth
friendly format
 To encourage young people to look after their own
mental health and support others close to them
 To encourage young people ask for help and to let
them know it is alright to ask for help
Young People & Mental
National Survey
Isolation is a key theme
Concern about the future
Bullying, drink, drugs and peer pressure
Good understanding of mental health
Family and friends are key networks
Use of online but not the only means of
providing information
Young People & Mental
Health - consultation
 Consulted with young people through
Dail na nÓg and the OMCYA
 Consulted with young people from
various voluntary organisations
 Focus groups with young people
 Ongoing discussions with young people
Creative ways to encourage young
people to access information & help
on website & Bebo page
Launch by Minister Moloney 12th Oct 2009
Youth appropriate TV advertising
Youth appropriate Cinema advertising
Outdoor advertising i.e. bus stops near schools
Wallet card
Irish student press advert (circulation 50,000
Secondary School students)
 Promotional pens
TV / Cinema Ad
30% of our target audience (185,820) of 15-24 year olds
saw the posters on average 16.4 times
Wallet card
Website & Bebo page
Young Peoples Mental
Health Awareness
Results of youth appropriate
Website Stats
 Total number of visits = 23,598
 Absolute unique visitors = 19,378
 Unique visitors January – April 2010 = 4,397
 Pageviews = 83,074
 Average time on site = 2:57 mins
The cinema ad ran for 6 weeks from 20th
November 2009 on nearly 300 screens
During this time visits to the website increased
from just over 200 per week to between 500/700
per week
Bebo social network site
 Total number of friends: 1,649
 Moderated by NOSP staff
Some comments left on Bebo
Our Partners
 13 Voluntary organisations
 16 Projects (original target 8)
 Timeline for project completion November 2009 to mid 2010
 Projects funded by HSE NOSP will
include advertising of
Crosscare Travellers Programme
Cluain Mhuire Mental Health Service (DETECT)
National Suicide Research Foundation
‘FREE’ student campaign
Pieta House
Gay, Lesbian, Equality Network
Teen-Line Ireland
BeLonG To
Co-branding projects
Results to date
 40,000 mental health information packs
distributed to students during college mental
health week November 2009
 Samaritans Christmas/New Year radio advert –
17% increase in callers
 50,000 LGBT mental health booklets
 Traveller poster competition
 Bodywhys connect/online chat room
Co-branding in 2010
In development:
Belong To Parents booklet
Traveller youth training manual
DETECT early intervention publicity
GROW resource for young people in recovery
Teenline video to assist volunteers
Plans for 2010
Participants at Dail na nÓg
Repeat TV/Cinema advertising
Distribute wallet cards
Advertise in Irish Student Press
Monitor results from co-branding projects
Undertake follow-up to baseline national
survey of young people & mental health
 Continue consultation with young people
Young Peoples Mental
Health Awareness
……..….. It will make a difference
[email protected]
5th Annual Forum
28th April 2010
Royal Hospital Kilmainham
‘Promoting Positive Mental Health
and Reducing Stigma’
Mental Health Awareness
Promoting Positive Mental Health in St.
Angela’s College, Sligo
Mike Rainsford HSE West Mental Health
Promotion / Suicide Resource Officer
Local Partnership with Health Promotion and
St. Angela’s College
Tom O’Grady – Post-Graduate Diploma in
Nursing Studies ( Community Mental Health)
Promoting Positive Mental Health and
Aim: to develop mental health promotion knowledge,
skills and confidence, including understanding the
contribution that mental health promotion makes to
a wide range of health and social outcomes.
Students will recognise the positive impact that
mental health promotion has at a community and
individual level. This module also aims to critically
investigate current debates about mental health and
well-being. It is envisaged that students will be able
to develop and apply acquired learning into practical
situations in their own personal lives, communities
and their workplaces.
Content includes:
Designing and evaluating a mental health
promotion initiative
Changing health behaviour
Recovery and Wellness tools
Measuring success
Positive Psychology
Debating the economic case for Mental
Health Promotion
Connecting content to local initiatives:
‘Walking Back To Happiness’
Zippy’s Friends
Further outcomes:
Develop module into blended (e-learning)
Positive Mental Health Policy
Tom O’ Grady 071 91 35624
[email protected]
5th Annual Forum
28th April 2010
Royal Hospital Kilmainham
‘Promoting Positive Mental Health
and Reducing Stigma’
SEE CHANGE is Ireland’s national programme
working positively to change social attitudes
and behaviour so that there is a reduction of
stigma and discrimination associated with
mental health problems and to ensure that
everyone enjoys the same rights on an equal
• While one in four of us will experience a
mental health problem at some time in our
lives – many of us are frightened of the idea of
mental health problems.
• The stigma associated with mental health
problems is, for some people, almost as
difficult to manage as the experience of being
• w A recent Irish study into mental health attitudes found
that while 85% of people in Ireland feel that mental health
problems can affect anyone, 62% would not want anyone to
know if they had a mental health problem.
('Your Mental Health' Awareness Campaign Research Report , HSE’s NOSP, 2007)
 w Increasing public understanding about mental health
problems requires action at every level of society.
How can we reduce stigma?
support and
Vision of See Change
Our vision is that of an Ireland where every
person has an open and positive attitude to
their own and others’ mental health.
Reduce stigma associated with mental health problems and
challenge discrimination;
Create an environment where people are more open and
positive in their attitudes and behaviour towards mental
Promote greater understanding and acceptance of, and
support for people with mental health problems; and
Empower individual people with experience of mental health
problems to gain equality, respect and rights.
and discrimination through:
• A media campaign, using national
organisations to promote the message.
1. National level
2. Local level
• A network of national and local organisations
across the country that will also carry the
message through local broadcasts, local print
media and a range of other activities.
• This will be managed on a county, provincial
and regional basis.
See Change Partners so far…
Actions to date…
• w Amnesty’s research to capture individuals’ reported
experiences of discrimination due to their mental health
problems – findings from this research will help to shape
See Change’s work
w See Change has commissioned research into public
attitudes to inform the campaign (commenced 14th April,
conducted by Millward Brown Lansdowne)
• w Video promo
• w
Website: www.seechange.ie
• w Follow us on:
Most importantly…
We want people to get involved from the beginning,
to engage with See Change and to help us design
the campaign. That is why we are launching the See
Change Ideas Competition.
See Change has been initiated by Minister
Moloney and supported by the Department of
Health and Children through a grant from the
National Lottery
 Additional funding has been raised from:
 w HSE National Office for Suicide Prevention
 w Mental Health Commission
 w St. Patrick’s University Hospital
See Change will work to raise further funds.
We invite you to become part of
See Change

Mental Health Promotion and Stigma Reduction