'That's Just Crazy Talk': Using theatre to address mental illness stigma


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That’s Just Crazy Talk Is a thoughtful and funny on-woman play that looks at both the light and dark side of living with bipolar disorder, anxiety and psychosis. It is the product of a research study in bipolar disorder exploring the impacts of a ‘lived experience’ theatrical performance on attitudes and understandings of mental health issues.

The research is part of a two-year, knowledge exchange project funded by the Canadian Institutes for Health Research in 2009 to the principal investigators, Drs. Erin Michalak and Sagar V. Parikh with the Collaborative RESearch Team to study Bipolar Disorder (CREST.BD), the Canadian Network for Mood and Anxiety Treatments (CANMAT).
In this presentation, Dr. Erin Michalak provides an overview of this translational research project, including highlights from preliminary findings. Originally presented in January 2012 in Victoria, BC.

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  • The KTA project consists of three parts, addressing the topics of stigma, quality of life, and wellness strategies in people with BD. The first component, will be a one woman show performed by Victoria Maxwell (mental health educator) on the topic of stigma. The second component, will be a teaching event facilitated by the study investigators on how to apply and interpret the QoL.BD scale (the Quality of Life in Bipolar Disorder scale) to both consumers and clinicians. The third component, will be disseminating results from the first two components by using a variety of KT strategies. We’re still in the process of developing these methods of dissemination, e.g. postings on the website, workshops in the community, newspaper articles, pro-d events for clinicians. Each part will use tailored KT strategies to share information with two target groups: people with BD and BD healthcare providers. The research will be conducted at two primary sites, Vancouver and Toronto. QoL defined by the WHO as “Individuals’ perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns.”
  • Day’s Mental Illness Stigma Scale (DMISS) is a self-report measure of stigmatizing attitudes toward mental illness (Day, Edgren, & Eshleman, 2007). The DMISS consists of 28 items and contains seven subscales: interpersonal anxiety, relationship disturbance, hygiene, visibility, treatability, professional efficacy, and recovery. In this study, we substituted the word ‘mental illness’ with ‘bipolar disorder’. For each item, participants are asked to rate their level of agreement using a seven-point scale ranging from completely disagree (1) to completely agree (7). We also modified the scoring procedures by reverse-coding five items (1, 7, 9, 23, and 28) to ensure that higher scores were consistently indicative of greater levels of stigma across all items and subscales.
  • Self-stigma was measured on the Internalized Stigma of Mental Illness (ISMI) scale. The ISMI is a self-report questionnaire that is designed to measure the internalized,subjective experiences of stigma for people living with mental illness (Ritsher, Otilingam, & Grajales, 2003). The ISMI consists of 29 items and contains five subscales: alienation, stereotype endorsement, discrimination experience, social withdrawal, and stigma resistance. For each item, participants are asked to rate their level of agreement using an anchored four-point scale that ranges from strongly disagree (1) to strongly agree (4). Subscale scores and a total score are calculated by averaging the respondents’ ratings, with higher scores indicating higher levels of self-stigma.  
  • Clinician attitudes The Mental Illness: Clinicians’ Attitudes Scale – Version 4 (MICA-4) is a self-report measure of health care professionals’ attitudes toward people with mental illness (Kassam, Glozier, Leese, Henderson, & Thornicroft, 2010). The MICA-4 poses 16 statements for which participants are asked to rate their level of agreement using an anchored six-point scale ranging from strongly agree (1) to strongly disagree (6). Reverse-coding was performed on ten items. The scores for each item were summed to produce a single overall score. Higher DMISS overall scores indicate greater levels of stigmatizing attitudes toward mental illness.
  • 'That's Just Crazy Talk': Using theatre to address mental illness stigma

    1. 1. Thats Just Crazy Talk: Using theatre to address mental illness stigma Dr. Erin Michalak1, Dr. Sagar Parikh2, Dr. Jamie Livingston3, Victoria Maxwell41University of British Columbia, 2University of Toronto3BC Mental Health and Addiction Services, 4Crazy for Life Co.
    2. 2. Objectives1. To discuss mental illness stigma, in particular relating to BD2. To share findings from a CIHR-funded study exploring the use of theatre to reduce stigma in both people with BD and health care providers
    3. 3. i. Humaniv. & v. Labeled difference ispersons distinguishedexperience status and labeledloss anddiscrimination ii. Dominant cultural beliefs link persons to “It takes undesirable power to characteristics stigmatize” iii. Persons are placed in distinct categories to separate “us” from “them”
    4. 4. In Their Own Words a label that when people destroys your treat you like whole reputation a dog something that’s directed at you a cloud being royally maliciously over you screwed "prejudice" in a more specific sense rejection a deformity the injustice and unaccountability of being called derogatory psychiatrists names by educated professionals being haunted a character by the past defect when people bad look at someonemouth me about my and they say “oh, mental illness hes crazy" negative mark when people on someone look down on you when people think being treated the mentally ill are an anchor that unfairly by weird or you need to people dangerous carry around
    5. 5. 3 Levels of StigmaSelf StigmaCharacterized by negativefeelings (about self),maladaptive behaviour,identity transformation, orstereotype endorsementresulting from an individual’sexperiences, perceptions, oranticipation of negative socialreactions on the basis of astigmatized social status orhealth condition.Livingston & Boyd. (2010). Social Science & Medicine, 71: 2150.
    6. 6. 3 Levels of StigmaSocial StigmaDescribes thephenomenon of largesocial groups endorsingstereotypes about andacting against astigmatized group.Corrigan et al. (2005). Applied and Preventive Psychology, 11: 179 .
    7. 7. 3 Levels of StigmaStructural StigmaRefers to the rules,policies, and proceduresof social institutions thatrestrict the rights andopportunities formembers of stigmatizedgroups.Corrigan et al. (2011). Challenging the Stigma of Mental Illness:Lessons for Therapists and Advocates. John Wiley & Sons.
    8. 8. Swine Flu Stigma
    9. 9. The spectrum of bipolar disorder Mania Hypomania Normal Depression Severe Depression Normal Cyclothymic Cyclothymic Bipolar II Unipolar Bipolar I Mood Personality Disorder Disorder Mania Disorder VariationGoodwin FK, Jamison KR. Manic-Depressive Illness; 1990.
    10. 10. Stigma and BD• BD – the orphan child?• Are some symptoms of BD particularly stigmatizing? • Hyper-religiosity • Hyper-sexuality • Psychosis • Instability
    11. 11. How do we reduce stigma?
    12. 12. Knowledge to Action Quality of Life, Stigma, and BD: A Collaboration for ChangeThree study components: Theatrical performance targeting1. Stigma internalised stigma2. QoL assessment That’s Just3. Wellness strategies Crazy Talk KnowledgeTwo target groups: Exchange1. People with BD2. BD healthcare providers QoL.BD scale Development ofTwo main research sites: Development of KE tools for findings on KE tools for new BD QoL scale wellness strategies for BD1. Vancouver2. Toronto Wellness study team
    13. 13. Theatrical – basedperformance
    14. 14. Specific Objectives To exchange knowledge with people with BD and healthcare providers about how to recognize internalized stigma, how to deal with it, and how to recognize and respond to public stigma.To provide a compelling theatrical presentation that will engage people with BD and healthcare providers simultaneously to reinforce mutual understanding.
    15. 15. Methods – (I)• People will watch and evaluate a new play by established playwright and actress Victoria Maxwell, as well as participate (optional) in post-screening discussions• Deliberately, people with BD, healthcare providers, and the general public will watch at the same time – building a shared experience and also allowing for sharing of question and answer period following play• Play creation, performance, and evaluation all product of CIHR grant
    16. 16. Methods (II) Evaluation StrategiesSatisfaction scales and standardized Stigma scales (MICA-4, Day Scale, ISMI) Assessment scales administered at 3 time points: (T1) prior to the theatrical intervention (T2) immediately after the intervention (T3) 3 months post intervention.Telephone interviews at 3 months post-play to elicitnarratives regarding reflections and impact of the performance
    17. 17. Day’s MentalIllness Stigma Scale
    18. 18. Day Scale 
    19. 19. Internalized Stigma of Mental Illness Scale (ISMI)
    20. 20. Internalized Stigma of Mental Illness (ISMI) Scale  
    21. 21. Mental Illness:Clinician’s Attitudes Scale (MICA)
    22. 22. Mental Illness: Clinician’s Attitudes (MICA) Scale  
    23. 23. Performances• 3 research events (Vancouver & Toronto)• 2 public events (Toronto and Victoria )Participants• 89 health care providers• 81 people with BD• 3 individuals indentifying as both• Over 270 general public
    24. 24. Results: feedback• TJCT is valid, receiving positive feedback across people with BD, healthcare providers and general audience members • 98% of participants described the event as ‘good’ or ‘excellent’• TJCT observed to have the potential to affect stigma • 85% of healthcare providers and 67% people with BD thought the play could ‘change public acceptance of BD
    25. 25. Healthcare Providers Effect PRE POST Size N M SD N M SD t df P dStigma (DMISS)( =0.87)Treatability 84 1.74 0.76 84 1.52 0.54 2.94 83 .004 0.32Relationshipdisturbance* 84 2.38 0.99 84 2.06 0.94 4.35 83 .000 0.48Hygiene** 84 1.93 0.99 84 1.67 0.87 3.42 83 .001 0.37Anxiety* 84 1.72 0.89 84 1.60 0.82 2.14 83 .035 0.24Visibility* 84 3.40 0.84 84 3.40 0.83 0.01 83 .990 0.00Recovery* 84 2.55 1.31 84 2.20 1.38 2.44 83 .017 0.27ProfessionalEfficacy 84 2.74 1.35 84 2.53 1.32 1.78 83 .079 0.20Total*** 84 2.26 0.63 84 2.07 0.61 5.55 83 .000 0.58Stigma amongClinicians(MICA) ( =0.66)Total 82 30.61 6.52 82 29.77 6.65 1.56 81 .123 0.17 *p<.05, 2-tailed; **p<.01, 2-tailed; ***p<.001, 2-tailed
    26. 26. Healthcare provider results: headline• Significant improvement on DMISS domains: • ‘relationship disturbance’ (concerns about BD-related disruptions to normal, meaningful relationships) • ‘hygiene’ (negative beliefs about the appearance and physical self-care of people with BD) • ‘recovery’ (negative beliefs about the potential for recovery from BD) • ‘anxiety’ (affective feelings of anxiousness, nervousness, uneasiness, and fear of physical harm when around someone with BD) • ‘treatability (negative beliefs about the treatability of a person with BD)
    27. 27. People with BD Effect PRE POST Size N M SD N M SD t df P dStigma (DMISS)( =0.88)Relationshipdisturbance* 80 3.22 1.23 80 3.00 1.22 2.42 79 .018 0.27Self-Stigma(ISMI) ( =0.94)Alienation* 78 2.35 0.70 78 2.23 0.77 2.61 77 .011 0.31Stereotypeendorsement 77 1.55 0.45 77 1.56 0.45 -0.48 76 .635 0.04Discriminationexperience 75 2.20 0.63 75 2.24 0.72 -0.61 74 .542 0.08Socialwithdrawal 79 2.04 0.68 79 2.05 0.75 -0.32 78 .751 0.02Stigmaresistance 77 2.02 0.61 77 1.93 0.58 1.14 76 .259 0.14Total 75 2.01 0.49 75 1.98 0.55 1.00 74 .319 0.13 *p<.05, 2-tailed; **p<.01, 2-tailed; ***p<.001, 2-tailed
    28. 28. People with BD results: headline• In people with BD, significant improvement on ISMI ‘alienation’ domain• Floor effect at play
    29. 29. Next Steps• Performances scheduled: • Toronto, ON- CME Congress, June 2012 • Boston, Mass – Nat’l Society of Genetic Counsellors Conference, October 2012 • Distribution of DVD • March 2012 • 1000 in production
    30. 30. erin.michalak@ubc.cawww.crestbd.cawww.facebook.com/#!/CRESTBDBipolarResearch