Editorial: Farewell, thank you and the framing of mental health challenges

Citation

Perkins, R. and Repper, J. (2022), "Editorial: Farewell, thank you and the framing of mental health challenges", Mental Health and Social Inclusion, Vol. 26 No. 1, pp. 1-5. https://doi.org/10.1108/MHSI-02-2022-097

1. Farewell, thank you and the framing of mental health challenges

After six years of editing Mental Health and Social Inclusion, we have decided that it is time to pass on the baton, so this will be the last editorial we write.

In the time in which we have edited this journal, we have aimed to enable people living with mental challenges and people providing services to tell a different story about mental health and challenge existing narratives. We have not sought to minimise the challenges facing people diagnosed with mental health problems, but to replace narratives of tragedy, fading life chances, deficit, dysfunction and danger, with narratives of hope and possibility. To move away from catalogues of discrimination and disadvantage towards things that can be done to enable people to discover a meaningful, valued and satisfying life for themselves. To challenge a prevailing idea that “mental health” is simply the absence of “mental illness”, with the primary focus on access to treatment and therapy and “getting rid of problems”, to one of “recovering a life” and “living well.” Life changes, but life goes on and that life can be a good life.

Recently we attended an online event organised by London School of Economics International Inequalities Institute (2021) entitled “Changing the Story on Disability”[1]. At this event, Kate Stanley, Executive Director of FrameWorks UK, spoke about the importance of “framing” in creating an inclusive society. She described how 60 years of research shows that the way in which information is presented affects what people think, feel and do. Thinking and understanding are “frame” dependent: the way in which we frame issues has the power shape the way in which people understand them, their attitudes and support for solutions. As Lakoff (2004) described in the introduction to his ground-breaking book “Don’t think of an Elephant”

Frames are mental structures that shape the way we see the world. As a result they shape the goals we seek, the plans we make, the way we act, and what counts as a good or bad outcome of our actions (Lakoff, 2004, p. xv).

While Stanley’s (2021) presentation did not address directly mental health challenges and those who experience them, the principles she outlined resonated with much that we have been trying to do in promoting the social inclusion that is the raison d'être of MHSI. Stanley (2021) articulated six evidence-based “tips”, derived from over 20 years of communications research, that can usefully guide our endeavours to enhance the social inclusion and life chances of people experiencing mental health challenges: three things that evidence suggests we should avoid and three things to do.

2. Communication for inclusion: three things to avoid

2.1 Avoid unframed facts and numbers

Too often, communications rely on statistics, facts and numbers to describe and emphasise issues. This sort of “presentation of the facts” alone approach is problematic because people tend to frame the facts in terms of their existing narratives. So, for example, if we say that “Black Caribbean patients were significantly more likely to be compulsorily admitted to hospital compared with those in white ethnic groups (odds ratio 2.53, 95% CI 2.03–3.16, p <0.0001)” (Barnett et al., 2019), this may be understood in different ways. We may expect people to understand this as showing that Black Caribbean people have less access to early intervention or the range of talking therapies before they reach crisis point, or that they are more likely to experience discrimination and consequent disadvantages that make it more likely that anyone develops mental health problems. However, presenting the facts alone could equally be interpreted as “Black Caribbean people are more likely to get mental health problems than white people.” Facts and data are important, but they do not speak for themselves – we need to contextualise them – provide a narrative around them.

2.2 Don’t focus on rebutting other people’s stories

Those of you who are as old as we are may well remember President Nixon saying “I am not a crook” and “immediately, Americans coast-to-coast thought of him as a crook” (Lakoff, 2017, p. 1). As Stanley (2021) described, repeating misperceptions typically serves to reinforce them, even if you are repeating them to rebut them. If someone tells you, in the words of the title of Lakoff’s (2004), “Don’t think of an elephant” it is virtually impossible not to think about elephants! In the progressive mental health world such rebuttals are commonplace, yet when we say, for example, “people with mental health problems are not dangerous” we are actually reinforcing the very idea that we are trying to dispel by evoking the frame of “danger.” The biggest predictor of whether you believe something to be true is the number of times you have heard it, so the more times we repeat it (albeit to refute it) the more we reinforce it. We need to be telling the story that we want to tell, not refuting those that others have told.

2.3 Avoid crisis stories

Narratives of “crisis” tend to convey a message of the overwhelming extent of the problem. Although we may be hoping to emphasise the need for resources, policies and initiatives to address the problems, Stanley (2021) pointed out that research repeatedly shows that a “crisis” narrative tends to have the opposite effect and make people feel that the problems are so big that nothing can be done. In the mental health world, talk of “crisis” is commonplace: the crisis of lack of access to treatment, the crisis of unemployment, homelessness, poverty, loneliness facing those living with mental health challenges. Yes, it is important to shine a light on the discrimination and disadvantage that people experience to highlight the need for action, but we need to quickly pivot to a discussion of solutions rather than repeatedly and consistently using an alarmist approach.

In the papers published in MHSI, we have endeavoured to offer a story of hope and possibility rather than either rehearsing the plethora of problems that people face or simply refuting narratives of deficit, dysfunction and danger. We have tried to ensure that data presented is contextualised within a narrative of recovery and inclusion and moves beyond treatment, therapy and cure to enabling people to live well, do the things they value and pursue their priorities in life.

3. Communication for inclusion: three things to do

3.1 Balance urgency with efficacy

It is important to emphasise that something can be done to promote inclusion and enhance life chances. There is a need to offer data to emphasise the urgency of tackling the problem, but to balance this with a good dose of efficacy: what can be done. For example, in relation to the social isolation that many people with mental health challenges experience, we need not only to detail the scale of the problem to demonstrate urgency but also what can be done to decrease it. Over the years, papers published in MHSI have demonstrated many innovative examples of efficacious approaches to reducing isolation, like the Creative Minds initiative (Walters, 2015); the impact of Recovery Colleges (Somer et al., 2018; Thompson et al., 2021) and discussions of co-designed work to build dedicated support for social inclusion alongside mental health services (Holttum, 2019).

3.2 Talk about solutions

If we focus too much on the problems at the expense of articulating solutions, we risk reinforcing fatalistic attitudes: people are likely to conclude that the challenge of inclusion for people with mental health challenges is just too big to be solved and that life chances are inevitably reduced. It is important to provide a clear narrative that lays out the challenges and describes how a particular solution addresses them, and then goes on to detail the positive outcomes, both for individuals and our communities, that result. We need to convey a message that the issues are soluble; the story we tell is as important as the data, policies and interventions. So, for example, when we say that 92% of people with serious mental health challenges are unemployed, we need to quickly pivot to showing that with the right kind of support, people living with such challenges can gain and prosper in employment, and that this brings positive impacts for the individual, their family and the communities in which they live.

3.3 Explain how problems and their solutions actually work

We need to offer explanations, not just descriptions. There is a tendency to describe the characteristics of a population – like people with mental health challenges – and the challenges they encounter; however, we also need to explain how the problems and their solutions actually work. We have got to “join the dots” to enable people to understand the relationship between issues and their solutions.

In the papers published in MHSI, we have shown that there are things that we can do to enable people with mental health challenges to live well and prosper. These can be found in numerous accounts of innovative interventions and services to assist people to recover a valued, satisfying and contributing life and pursue their life priorities as valued members of their communities. However, there is much further work that we need to do to delve into what effective narratives and frameworks might best promote the social inclusion and citizenship of people with mental health challenges. This is a research question, and if we simply make assumptions about what framing is effective, we risk making some big mistakes.

Take, for example, the narrative that “mental illness is an illness like any other.” This has been the core message of many anti-stigma campaigns. The assumption is that if mental disorders are seen as illnesses – attributed to factors outside the person’s control – then reactions to people with such disorders will be less negative (Perkins and Repper, 2016). However, this assumption is not backed up by subsequent research. It was found that such a narrative increases negative stereotypes, prejudice and discrimination (Sayce, 2000, 2015; Phelan, 2005; Read et al., 2006; Pescosolido et al., 2010). This research showed that if people framed mental illness as an illness, they were more likely to see the person as dangerous and unpredictable, more likely to fear people with mental health challenges and more likely to desire social distance from them and avoid them. In addition, the desire for social distance from the person’s relatives also increased, especially close relationships like dating, marriage and having children. So, far from decreasing discrimination and exclusion (as had been the intention), the result of the “mental illness is an illness like any other” framing actually had the opposite effect and exacerbated exclusion.

The framing of mental health issues is central to the social inclusion and life chances of people facing such challenges, those who provide services to support them and the communities in which we live. We do need new narratives, new stories to tell, that can shift thinking and understanding. Stanley (2021) offered some useful general, research-based, guidelines, but we need more specific and targeted research into the narratives that are effective in creating inclusive communities for people with mental health challenges. We are sure that the pages of MHSI will continue to have an important role to play in shifting mindsets, developing new ways of thinking and new solutions to the challenges we face.

Meanwhile, we want to thank our contributors and readers for all their support over the years of our editorship and for making MHSI into the journal it is today. We will be handing over to two excellent new editors: Professor Jerome Carson, Professor of Psychology at the University of Bolton, who is well known for his contributions to MHSI, including his regular “Remarkable Lives” papers, and his colleague Dr Julie Prescott who is a Reader in Psychology at University of Bolton. We are sure that, under their leadership, MHSI will continue to thrive and grow.

Note

1. A video of this event can be found at https://www.youtube.com/watch?v=rWw9HDrhf_U