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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'That's Just Crazy Talk': Using theatre to address mental illness stigma
1. 'That's Just Crazy Talk':
Using theatre to address
mental illness stigma
Dr. Erin Michalak1, Dr. Sagar Parikh2,
Dr. Jamie Livingston3, Victoria Maxwell4
1University
of British Columbia, 2University of Toronto
3BC Mental Health and Addiction Services, 4Crazy for Life Co.
2. Objectives
1. To discuss mental illness stigma, in particular relating to BD
2. 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. i. Human
iv. & v. Labeled difference is
persons distinguished
experience status and labeled
loss and
discrimination 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. 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 someone
mouth me about my and they say “oh,
mental illness he's 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. 3 Levels of Stigma
Self Stigma
Characterized by negative
feelings (about self),
maladaptive behaviour,
identity transformation, or
stereotype endorsement
resulting from an individual’s
experiences, perceptions, or
anticipation of negative social
reactions on the basis of a
stigmatized social status or
health condition.
Livingston & Boyd. (2010). Social Science & Medicine, 71: 2150.
6. 3 Levels of Stigma
Social Stigma
Describes the
phenomenon of large
social groups endorsing
stereotypes about and
acting against a
stigmatized group.
Corrigan et al. (2005). Applied and Preventive Psychology, 11: 179 .
7. 3 Levels of Stigma
Structural Stigma
Refers to the rules,
policies, and procedures
of social institutions that
restrict the rights and
opportunities for
members of stigmatized
groups.
Corrigan et al. (2011). Challenging the Stigma of Mental Illness:
Lessons for Therapists and Advocates. John Wiley & Sons.
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
Variation
Goodwin FK, Jamison KR. Manic-Depressive Illness; 1990.
10. Stigma and BD
• BD – the orphan child?
• Are some symptoms of BD particularly stigmatizing?
• Hyper-religiosity
• Hyper-sexuality
• Psychosis
• Instability
12. Knowledge to Action
Quality of Life, Stigma, and BD:
A Collaboration for Change
Three study components: Theatrical
performance
targeting
1. Stigma internalised
stigma
2. QoL assessment
That’s Just
3. Wellness strategies Crazy Talk
Knowledge
Two target groups: Exchange
1. People with BD
2. BD healthcare providers QoL.BD
scale
Development of
Two main research sites: Development of KE tools for
findings on
KE tools for new
BD QoL scale wellness
strategies for BD
1. Vancouver
2. Toronto
Wellness
study team
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. 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. Methods (II)
Evaluation Strategies
Satisfaction 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 elicit
narratives regarding reflections and impact of the
performance
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. 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
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. People with BD
Effect
PRE POST
Size
N M SD N M SD t df P d
Stigma (DMISS)
( =0.88)
Relationship
disturbance* 80 3.22 1.23 80 3.00 1.22 2.42 79 .018 0.27
Self-Stigma
(ISMI) ( =0.94)
Alienation*
78 2.35 0.70 78 2.23 0.77 2.61 77 .011 0.31
Stereotype
endorsement 77 1.55 0.45 77 1.56 0.45 -0.48 76 .635 0.04
Discrimination
experience 75 2.20 0.63 75 2.24 0.72 -0.61 74 .542 0.08
Social
withdrawal 79 2.04 0.68 79 2.05 0.75 -0.32 78 .751 0.02
Stigma
resistance 77 2.02 0.61 77 1.93 0.58 1.14 76 .259 0.14
Total 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. People with BD results: headline
• In people with BD, significant improvement on ISMI
‘alienation’ domain
• Floor effect at play
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
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.