Time to Change
Time to Change is England's most ambitious programme to end discrimination faced by people who experience mental health problems. It is run by Mind and Rethink, and is funded by the Big Lottery Fund and Comic Relief. It is being evaluated by the Institute of Psychiatry at King's College, London.
The programme of 35 projects involves: local community projects; a national high-profile campaign; a mass-participation physical activity week; legal test cases; and training for student doctors and teachers.
The nationwide anti-stigma campaign, which this case study focuses on, includes national advertising, PR, social media, community engagement and information resources. The campaign focuses on changing behaviours towards people with mental health problems, rather than just raising awareness of mental health issues.
- 4 per cent decrease during 2009 to 2010 in the overall level of discrimination reported by people who experience a mental health problem
- 6 per cent reduction during 2009 to 2010 in the number of people who reported losing a job due to a mental health problem
- Over 117 organisations have run activities to support Time to Change
Over the last decade there have been huge advances in our understanding and treatment of mental health problems and increased investment in services. We are moving closer to a society where recovering a full and meaningful life from mental health problems is the norm rather than the exception.
However, people with mental health problems consistently identify discrimination as one of their biggest issues and almost 9 out of 10 people affected by mental health problems have experienced discrimination.
It is commonly reported that one in four of us will experience mental health problems at some point. Yet mental health charities Mind and Rethink were shocked by statistics that attested to the extent of the stigma and discrimination those one in four face:
- 49 per cent of people with mental health problems had been harassed or attacked
- One-third of people with mental health problems reported having been dismissed or forced to resign from their job, and 70 per cent of people with mental health problems had been put off applying for jobs, fearing unfair treatment
- 24 per cent of individuals with mental health problems had been refused by insurance or finance companies, making it hard to travel, own property, run a business and provide for oneself and family
Subsequently, Mind, Rethink and the Institute of Psychiatry at King’s College, London came together to plan an England-wide campaign to end discrimination around mental health. Using evidence from sister campaigns in New Zealand (‘Like Minds, Like Mine’) and Scotland (‘See Me’), plus Rethink’s two pilot campaigns in Norwich and Northern Ireland, they developed a plan and received funding of £16 million from the Big Lottery Fund and £4 million from Comic Relief for a four-year campaign.
As part of the funding application, the partner organisations needed to establish specific outcomes for the programme. To identify these, the organisations researched other behaviour change programmes to see what could be achievable over the set timeframe, alongside results from the sister campaigns and pilots to establish robust targets.
Subsequently, the following aims were established for the programme:
- Increase public awareness of mental health, reaching 30 million adults in England
- Achieve a 5 per cent positive shift in attitudes towards mental health problems by 2012 and a 5 per cent reduction in reported discrimination by 2012
- Increase the ability of 100,000 people with mental health problems to challenge discrimination
- Engage 250,000 people in mass participation physical activity events
- Improve the mental and physical wellbeing of over 24,500 people with mental health problems through local community projects
In England there had been some relatively small-scale, piecemeal attempts to challenge stigma and discrimination around mental health. However, there had not been a coordinated, long-term, well-funded approach to raise public awareness about good mental health, counter pervasive negative stereotypes and challenge discrimination. Time to Change sought to rectify this.
The scoping phase of the campaign took place between October 2007 and June 2008.
Research into the impact of discrimination and public attitudes towards mental health, including the Department of Health’s (DH’s) Attitudes to Mental Illness survey, helped shape the initial plans for the Time to Change campaign, as did learning from anti-discrimination campaigns in New Zealand and Scotland, and from Rethink’s two pilot campaigns in Norwich and Northern Ireland.
Between December 2007 and February 2008, Rethink carried out the largest ever survey (Stigma Shout) of people with direct experience of mental health problems (3,038 service users and 661 carers), and follow-on workshops with 100 people to explore where they experience stigma and discrimination, who they experience it from and what should be done.
The Stigma Shout survey and workshops asked people with direct experience of mental health problems who the campaign should target, where and how. Survey respondents prioritised the following four groups:
- Friends, neighbours and local community
- Work colleagues
- Health professionals
Data from DH’s Attitudes to Mental Health survey provided information on the attitudes of different age groups and socio-economic groups towards mental illness, as well as how much personal experience different groups said they had of mental health problems and how much communications they had seen about mental illness. This information was used to develop a clear criteria for deciding which target audience to explore further for the marketing campaign:
- Will targeting this group make a difference to people with mental health problems?
- Is this an influential group?
- Are any other areas of Time to Change targeting this group?
- Difference between what they say and how they behave?
- Is a marketing campaign the best way to change this group’s attitudes and behaviour?
- How ready is this group to change?
- Are any other organisations or government targeting this group?
Members of the general public aged between 18 and 50, from B, C1, C2, D and E socio-economic groups were recruited for focus groups. The sample consisted of an even split of men and women and people from different ethnic groups, across life stages (before and after having children) and with a range of experience of mental health (from those who said they did not know anyone with a mental health problem, to those who said a close member of their family had a mental illness).
This research helped to narrow the audience down to people in middle to lower socio-economic groups. With these groups there seemed to be a gap between an expressed perspective of ‘live and let live’, and what their language and behaviour actually revealed about their beliefs. These groups were very focused on their world and unlikely to be engaged with mental health issues beyond tabloid headlines and personal experiences forced on them.
The target age range is mid-20s to mid-40s, as there is greater potential to make a bigger impact on this group. Generally acceptance and empathy increases with age, as people amass more life experience (and are more likely to have come into contact with someone with mental health problems).
The campaign also primarily targets those who have some proximity to people with mental health problems, such as friends, colleagues, and wider family members. Close family members were not chosen as a primary target audience as they tend to have higher levels of knowledge, and different issues and experiences that drive their attitudes and behaviours. In some cases close family members may also be a carer for a relative with a mental health problem - results from Stigma Shout indicated that carers are also likely to experience stigma and discrimination themselves. This target audience became known as ‘subconscious stigmatisers’.
Other segments identified but not chosen as a target audience were:
- Active discriminators – Although the behaviour of this group is the most extreme, it is also experienced by fewer people. This group was not chosen as a target audience as they would be extremely hard to target and are unlikely to change. They are also in the minority, most likely because active and conscious discrimination is frowned upon by mainstream society.
- People who ‘don’t see’ mental illness – They would say they have never known anyone with a mental health problem – it is just not on their radar. They are not interested in finding out more as they do not see its relevance to them. The decision was made not to specifically target this group, as they would be reached to some extent through targeting the ‘subconscious stigmatisers’. They are also likely to be a smaller group.
In-depth interviews were held with the identified target audience to build up an understanding of this group, which revealed several insights about their attitudes, beliefs, knowledge and behaviours.
- ‘That’s sad, but it’s not me’ – Stigma is often subconscious and many people who know someone with a mental health problem do not believe they are stigmatising or discriminating against him or her
- ‘Discrimination? What’s that got to do with mental health?’ – Many individuals are familiar with discrimination based on, for example, race, sex and sexuality, but often do not realise that people face discrimination because of mental health problems
- Fear is the strongest driver of perceptions around mental health problems and is felt in two different ways – first is the sensationalist fear driven by the media and news headlines of violence displayed by people with mental health problems; second is the everyday fear of what they would do if they were affected by a mental health problem
- ‘There’s no connection between my life and mental health problems’ – Mental health is an invisible issue that is not talked about. This lack of visibility means even people who have a close personal connection with someone with a mental health problem do not necessarily see beyond the particular mental health problems of the person they know
- Lack of understanding and information – Results from the DH’s attitudinal survey suggested a link between a lack of knowledge about mental illness and stigmatising attitudes. However, people do not perceive this information gap as something they need or want to fill
- Walking on eggshells – Lack of knowledge around how to behave means that people do not know what to say or do around someone with a mental health problem and are worried about making things worse
- Friends are very important – The support of friends is extremely important to service users. People tend to want to support their friends through difficulties and are willing to learn more about mental illness in order to do so
Barriers and competition
The research helped identify a number of key perceptual and attitudinal barriers to reducing discrimination against those with mental health problems:
- Misperception that mental illness is uncommon
- Lack of awareness that those with mental illness are discriminated against
- Lack of awareness or denial that they could be contributing to negative stereotypes and discrimination of those with mental illness
- Fear of those with mental health problems
- Apathy and lack of personal relevance
- Belief that people with mental health problems are not productive members of society or in the workplace
Some key sources of competition were also identified, including: the pervasive negative stereotypes about people with mental health illness; negative, sensationalised news coverage of people affected by mental health problems; and other anti-discrimination and social issue campaigns that compete for the public’s time and attention.
While the marketing campaign is aimed at people who do not have mental health problems, the campaign needs to reflect the experiences of and give voice to people who are directly affected. To ensure user and carer needs are at the heart of Time to Change, a group of 12 people affected by mental health issues help to shape the overall programme. Known as the Lived Experience Advisory Panel (LEAP), these 12 people provide specific guidance on how the programme can involve and engage mental health users and carers across the programme. They also review progress and act as spokespeople and ambassadors for the programme.
The Time to Change team developed a range of interventions, of which the national anti-stigma campaign is one element. Other elements include:
28 local community projects
These projects aim to bring people with and without mental health problems together to take part in activities, ranging from wellbeing to horticultural, to anti-stigma and mental health promotion. Twenty-two projects are run by local Mind associations and six that are run by Rethink services and groups.
Get Moving week
A week of events is run by individuals and organisations across the country in October, to challenge stigma by bringing people with and without mental health problems together to get active for improved mental wellbeing. The Get Moving idea is based on the theory that through social contact people can get to know one another, challenge stereotypes and break down stigma around mental health problems. Physical activity has also been proven to boost mental wellbeing of everyone.
Time to Challenge
This enforces the legal rights of people with mental health problems and establishes a wider understanding that discrimination on the grounds of mental health is no longer acceptable. Mind’s National Legal Unit takes cases through the courts that concern points of law that have a public importance and relevance to all mental health service users. This could, for example, be a case where an employee has lost their job because of potential discrimination on mental health grounds.
Mind developed a grassroots anti-discrimination project based on the principle that talking about mental health is the best way to confront stereotypes and tackle prejudice. It links up people with experience of mental health problems so they can support each other to speak out about their experiences. Through the Open Up network, members can access support, advice, training and inspiration for their work challenging mental health discrimination.
Education Not Discrimination (END)
END provides training for professionals who have a significant impact on the lives of people with mental health problems. Specific target groups for this project include medical students, trainee teachers and head teachers, and school social inclusion officers. Social contact is a key ingredient of this project and training includes lectures, testimonies, role play and interactive performance.
Nationwide anti-stigma campaign
This campaign was developed to challenge attitudes and change behaviour around mental health problems. Focus groups and in-depth interviews with the target audience were used to test all campaign advertising and messaging materials. The campaign includes:
Mass media advertising
This includes TV and radio adverts that show how the stigma and discrimination surrounding mental health problems is impacting on the life of a man with a mental health problem. Print ads featuring well-known personalities with mental health problems were developed for national newspapers and magazines. Millions of myth/fact beer mats were produced for in pubs and clubs around the country, alongside ads on the back of washroom doors in pubs. Outdoor ads were developed for the London Underground network.
Time to Change website
The campaign website includes information from real people and celebrities to challenge myths, stories of people who have mental health problems, tips for what people can do, blogs, forums, film clips and resources to download or order.
Free campaign resources
These are available on the Time to Change website to help organisations run an anti-discrimination campaign locally. Resources include a toolkit containing ways of getting started, event ideas and tips for working with the media. Campaign posters, leaflets and postcards can also be ordered, as well as a personal action pack to help individuals to get involved and run their own activity.
Social media sites
Facebook, Twitter and YouTube are used to drive Time to Change advocates to action, recruit new people to groups, engage the audience and give them a way of showing their support by providing interactive content and applications.
Videos were produced to challenge misconceptions and stereotypes of people who experience mental health problems and highlight the importance of support from friends and family. ‘Schizo: The Movie’, filmed in the style of a horror movie trailer, relies on people’s fascination with the sinister to reconsider their attitudes. ‘Kids Party’ appears like real video footage and was designed to be seeded into video sharing sites, such as YouTube, with the title ‘Schizophrenic man terrifies kids at party’.
Events were held in 12 cities and towns across the country with branded Time to Change stalls, which aimed to spread the campaign’s message locally. Appearing at shopping centres, high streets and local events, the majority of roadshow events were delivered in partnership with organisations in touch with their local communities. Based on social contact theory, which posits that discriminatory attitudes and behaviours can be challenged by bringing people in direct contact with each other, people with direct experience of mental health problems were recruited to volunteer on the roadshows.
Additional one-off events were held across the country. For instance, one of the trams on the Sheffield Supertram network was converted into a padded cell to make the point that mental health problems are very common and people who have experienced these problems are typically getting on with life and travelling to work, just like everybody else. A giant boulder was also placed in the streets of Manchester and Canterbury to highlight the weight stigma can have on people's lives.
These highlight important questions around the issues of mental health discrimination and elements of the programme.
A Stakeholder Manager seconded from DH took responsibility for identifying and engaging relevant stakeholders. While these were initially mainly NHS organisations, which also have targets around stigma and discrimination, a host of other partners have lent their support to the campaign, including local councils, charities and corporations.
The Time to Change team provides a suite of free resources to its national and local partners to support them in delivering their own activities. It also sends regular communications, for example through newsletters and presentations, and runs events for stakeholders throughout the programme for them to find out about ongoing work, latest findings and learning, and opportunities available with Time to Change.
The nationwide anti-stigma campaign was launched in January 2009. There have been a number of bursts of campaign activity since, with more planned for 2011.
Implementation of the programme has required development of delivery, monitoring and reporting systems across the partners nationally and locally. Funding is given to Mind and Rethink to run the different projects. There is also funding for a central management team, comprising a communications manager, PR manager, head of programme management and programme director. They have responsibility for reporting, budget management, and working with stakeholders to create synergy across the programme. Projects run by local Mind associations and Rethink services report to regional managers, who regularly feed back to the central team.
“It’s a complicated structure in that there’s quite a lot of indirect management. Time to Change is set up so the projects are all embedded in Mind and Rethink, which means that the work is within the organisations, so we can learn from them, and them from us, and longer term the skills are shared within the organisations.” (Katherine Crawshaw, Social Marketing Manager)
Implementation of all elements of the nationwide anti-stigma campaign is continually monitored and tracked, which allows problems and successes to be easily identified so that elements can be adapted accordingly. The film ‘Schizo: The Movie’, released online during summer 2009, was shown to be very successful at communicating the key messages: 62 per cent of those who saw the film online took out the message that they should change their attitudes, compared to 56 per cent of people who saw press ads and 44 per cent who saw TV ads. Because of this success, it was decided the film should be rolled out further. In April 2010, the film was used as a movie trailer in more than 1,750 cinema screens nationwide. Some cinemas also had supporting advertising on site, such as posters in foyers, washroom panels and postcards.
As the campaign has rolled out, a key challenge has been the need to continually make sure the focus remains on ‘subconscious stigmatisers’. Especially with events, the Time to Change team often found they were attracting those with mental health illnesses and those very close to the issue. While this was great for getting these people involved and making them feel empowered to challenge discrimination, the team recognised they needed to ensure that activities were focused on those whose behaviour they sought to change, rather than those who were already on board with the ethos of the campaign.
During 2009 to 2010 the campaign focused on getting mental health on the agenda. In 2010 to 2011 the focus shifted to getting people to realise they are responsible for stigma and discrimination.
One way it sought to do this was through conducting a social experiment in July and August 2010. This involved seven volunteers placing ads on flat share websites and six volunteers placing ads on dating websites. Volunteers placed ads with and without disclosing their mental health problems and results were compared. Overall there were over 50 per cent fewer responses to the volunteers’ dating ads when they disclosed their mental health problems, and 68 per cent fewer responses to the flat share ads when the volunteers disclosed their mental health problems. The experiment was run a further time with one more volunteer who had his experiences filmed.
Alongside this experiment a national survey was run through YouGov, which asked a range of questions about attitudes to dating and flat shares with people with mental health problems. The results supported some of the findings from the social experiment:
- 57 per cent said if they were single and looking for love online they would not want to date someone with a mental illness
- 43 per cent admitted they would not want to go on a second date with someone if they disclosed their mental illness on the first date
- 60 per cent of people in England would not want to share a flat with someone who had a mental illness
However, 27 per cent said they would want to find out more about a new partner’s mental health problem if they revealed it to them. The results from the social experiment and YouGov survey were used as part of a PR and advertising campaign launched in September 2010.
In October 2010 Comic Relief boosted the Time to Change campaign with an additional £500,000 of funding, to help ensure that the spring 2011 burst of campaign activity reached as wide an audience as possible.
The evaluation is based on the approach that stigma consists of problems with knowledge, attitudes and behaviour. The Time to Change programme aims to improve all three in the general public, as well as promote the empowerment and wellbeing of people with experience of mental health problems.
Therefore, success of the programme is being assessed on these three elements that make up stigma:
To assess and track changes in knowledge about stigma surrounding mental health, both in the general population and in specified groups, the DH’s Attitudes to Mental Illness Survey is being used. In 2009 some new questions were added to the survey that will be repeated every year of Time to Change, to help identify changes relating to the work of the programme. The 2008 survey acts as the baseline for the programme, as it was carried out before the launch of the campaign. In addition, after every burst of the Time to Change campaign, a sample of the target audience are asked about their mental health knowledge.
The annual Attitudes to Mental Illness Survey also contains a range of questions on public attitudes. Again, the 2008 survey provided a picture of where attitudes were before the campaign was launched and is repeated on an annual basis between 2008 and 2011 to assess changes in attitudes over time. It is administered to targeted groups within the overall programme, including a sample of the target audience for the campaign.
To monitor changes in discriminatory behaviour, an annual Viewpoint survey is conducted with 1,000 people in contact with mental health services across England, looking at their experiences of discrimination and stigma.
In addition to surveying service users, ‘reported and intended behaviour’ towards people with mental health problems is measured among the target audiences for the campaign and END work, using the Institute of Psychiatry’s Reported and Intended Behaviour Scale.
Press coverage of mental health issues are analysed annually to establish whether there is a trend over the period of Time to Change towards more positive coverage.
Key results to date
Reducing discrimination that people experience in their daily lives
- 4 per cent decrease during 2009 to 2010 in the overall level of discrimination reported by people who experience a mental health problem
- 9 per cent decrease during 2009 to 2010 in the levels of discrimination people face when searching for a job
- 6 per cent reduction during 2009 to 2010 in the number of people who report losing a job due to a mental health problem
Improving public knowledge, attitudes and behaviour
- The campaign has reached over 34 million people through advertising and PR
- Since the campaign’s launch, there has been a 1.3 per cent positive improvement in public attitudes. Having seen the campaign is a significant predictor of someone having a higher score on mental health knowledge questions
- People who are aware of the campaign are 19 per cent more likely to agree that people with mental illness are far less dangerous than people suppose
- People who have seen the campaign are also likely to have a higher score relating to their reported and intended behaviour towards people with mental health problems
- 35 per cent of people who have attended a Time to Get Moving event left with a more positive impression of people with a mental health problem
Improving knowledge, attitudes and behaviour of key professional groups
- Trainee teachers who had participated in training through END had improved scores on knowledge, attitudes and reported and intended behaviours
Building a movement for change
- Over 117 organisations, including PCTs and Trusts, local councils, student unions, police forces and charities, have run activities to support Time to Change
- David Cameron, Nick Clegg and Gordon Brown all pledged their support in January 2009, along with 45 other MPs. 110 MPs (1 in 6) have signed an Early Day Motion supporting Time to Change and its aims
- More than 31,000 people are Facebook fans of Time to Change
- More than 11,000 people have individually pledged to help end mental health prejudice
- 27,000 people have taken part in Time to Get Moving events
- Celebrities, including Stephen Fry, Ruby Wax, Alastair Campbell, Patsy Palmer, Ulrika Jonsson, Frank Bruno, Trisha Goddard, Gok Wan, Mel C and Trevor Nelson, have supported the campaign
One of many benefits of Time to Change being embedded in the Mind and Rethink organisations is that learning is regularly shared through their networks. Evaluation results and findings are also regularly disseminated by the Institute of Psychiatry.
As projects begin to wrap up locally, workshops have been run to talk about how these organisations could join up through local networks and how key elements of the Time to Change campaign can be embedded into future projects at the grassroots level.
The programme is due to finish at the end of 2011, with evaluation running into 2012. Mind and Rethink are currently looking at potential funding models for the work to continue beyond this time. Lessons learned from the programme so far are being incorporated into future plans, which will ensure that the different national projects are not viewed individually, but are instead joined together further to make sure they are viewed holistically.
Allowing time for planning at the beginning of a project can establish a robust foundation for the work. While there can be a rush to be seen to be delivering on outcomes, planning and scoping will underpin the later successes of the project.
“I think when a lot of funding comes into an organisation there’s a big pressure to deliver something and be seen to be doing something straight away. Although it sounds like a long time - a year spent researching and planning - that’s been the foundation of everything we’ve done.” (Katherine Crawshaw, Social Marketing Manager)
Research and insight
Doing research and insight is particularly important when your target audience is not your internal audience. Often what organisations may think will work will not resonate with the target audience. Having a foundation of research and insight can provide robust evidence for stakeholders about why a certain approach should be followed.
Get your tone right
Research has shown that most people do not recognise their own stigmatising and discriminatory behaviour. A judgemental tone makes it easy for people to distance themselves. Rather than a campaign that judges in any way, the campaign needs to get people to ‘feel’ their own prejudice rather than lecturing.
There is a big appetite for tapping into Time to Change from organisations, groups and individuals who want to run their own local anti-discrimination/stigma activities. The campaign proactively supports these organisations in their activities, which will help to deliver the overall outcomes of the programme. The work by local organisations not only enables the campaign to reach more people than could be achieved nationally, but embeds this work and ensures the programme can be sustainable.
Ensure your project is flexible enough to adapt plans as new insights emerge and in accordance with results from your evaluation monitoring. Do not stick rigidly to plans which are not having the desired effect. Instead, adapt your work to change areas found to be lacking and build on areas that are proving successful.
“Adapt and change as you go along. We haven’t stuck rigidly to a plan. For every evaluation we get back we look at it, think about what we’re going to do next and amend and adapt accordingly.” (Katherine Crawshaw, Social Marketing Manager)