"LIKE MINDS LIKE MINE" RESEARCH WITH MENTAL HEALTH SERVICE PROVIDERS

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1 8 Normanby Road, Mt Eden PO Box , Auckland Telephone Facsimile "LIKE MINDS LIKE MINE" RESEARCH WITH MENTAL HEALTH SERVICE PROVIDERS R E S E A R C H R E P O R T F O R November 2005 Authors Lisa Star Lara Mulgrew Shaun Akroyd Sinai Hemaloto Kathryn Goodman Allan Wyllie Ref: R4036v20.doc

2 CONTENTS EXECUTIVE SUMMARY RECOMMENDATIONS INTRODUCTION RESEARCH METHOD AND SAMPLE RESEARCH FINDINGS CULTURAL CONTEXT CHANGES IN ATTITUDES AND PRACTICES WITHIN MHS HOW DO MENTAL HEALTH SERVICES THINK THE PUBLIC PERCEIVE THEM? STIGMA AND DISCRIMINATION AND THE LMLM CAMPAIGN ISSUES RELATING TO THE MENTAL HEALTH SECTOR STANDARD ON STIGMA AND DISCRIMINATION (STD 18) PERCEPTIONS OF ALCOHOL AND OTHER DRUGS AND COMPULSIVE GAMBLING AS MENTAL ILLNESSES REFERENCES APPENDIX A... 52

3 ACKNOWLEDGEMENTS PHOENIX RESEARCH WOULD LIKE TO THANK PARTICIPANTS IN THIS RESEARCH. 1

4 EXECUTIVE SUMMARY INTRODUCTION This qualitative research was undertaken to inform the further development of the "Like Minds Like Mine" ( LMLM ) project, with a particular focus on how the project can work more effectively with Mental Health Services (MHS) and increase their support for addressing stigma and discrimination Qualitative research was undertaken with 30 MHS staff across varying sectors and varying work types. Seventeen were from District Health Boards (DHB) and thirteen were from the non-government or community sector (NGO). Ten were managers and 20 were other staff members The data collection was undertaken between late July and early October 2005 CHANGES IN ATTITUDES AND PRACTICES IN THE MENTAL HEALTH SERVICES MHS staff generally felt that there has been a gradual shift in attitudes and practices over the past five years for themselves and within the MHS. They identified the following as having facilitated change: De-institutionalisation; working more with people with experience of mental illness (PWEMI) within the community Younger workers coming into the services and helping to change entrenched attitudes and practices On-going training (both formal and workshops) - particularly consumer-led training where personal experiences of MHS are shared Adoption of strengths-based approaches and recovery-based models Consumer groups advocating for change Clients being active participants in their recovery, rather than passive recipients of a service MHS staff s personal experiences both of managing their own mental health and in their private lives of interacting with or having close relationships with people with mental health issues MHS staff having direct involvement with the LMLM campaign The "LMLM" TV ads, but they were not seen to be playing a major role in shifting attitudes within Mental Health Services. PERCEIVED PUBLIC PERCEPTIONS OF THE MENTAL HEALTH SERVICES MHS staff were divided as to the extent to which public perceptions of the mental health services have changed in the last five years: Those MHS staff spoken with believed the public generally know very little about the MHS unless they have had personal (or a family member has had) 2

5 dealings with the service MHS staff interviewed believed that the public see the MHS role is largely to keep the public safe from people who they perceive as threatening Public attitudes vary depending on the level of unwellness of PWEMI in the services Negative media coverage requires MHS to manage high risk situations and err on the side of risk averse practices, which increases stigma and discrimination. STIGMA AND DISCRIMINATION AND THE LMLM CAMPAIGN MHS staff interviewed generally acknowledged that attitudes within the MHS toward people with experience of mental illness have changed for the better, however they acknowledged that stigma and discrimination do still exist within the context of the MHS. For most staff, knowledge of LMLM was limited to the television ads, although: Some have LMLM staff on site Some have attended LMLM training Staff felt stigma and discrimination is perpetuated by: Staff not feeling valued Staff not valuing clients Organisational constraints around time, energy and resources The recovery model still being relatively new and not yet embedded within organisations Working in 'risk averse' ways Hospital-based MHS staff feeling discriminated against by other parts of the hospital The MHS staff suggestions for addressing stigma and discrimination formed the basis of the following recommendations in terms of target groups for LMLM working with MHS: Identify MHS staff with a personal interest in reducing stigma and discrimination, who can become champions for the cause within their MHS Support MHS staff who interact with clients, families and the community Work with 'Quality' personnel and standards as they are important in terms of policy documents Work with management, as they are important for providing leadership in this field Work with clinical staff, possibly with an emphasis on promoting the recovery model 3

6 STANDARD 18 Most MHS staff interviewed were not aware of the content of Standard 18, which is a tool to measure the way MHS can help reduce discriminatory practices, both within and outside their organisations Standard 18 can be lost in the plethora of paperwork Interviewees identified a range of ways to judge a destigmatising organisation, spanning consumer involvement, to treating people with respect, and having policies that can be readily actioned (not forgotten in a policy document) PERCEPTIONS OF ALCOHOL AND DRUG ADDICTIONS AND COMPULSIVE GAMBLING AS MENTAL ILLNESSES MHS staff interviewed did not generally perceive addictions as mental illnesses, because they are "knowable" and familiar However, staff who work in addictions did view addictions as mental illnesses RIGHTS MHS staff interviewed were continually balancing the rights of clients, families and community Interviewees perceived that the public's understanding of the rights of a PWEMI is that they have rights as long as they seem to make "reasonable" decisions and do not seem too unwell or threatening MHS staff interviewed felt that the Mental Health Act is helpful when used appropriately and continually reviewed The new changes to the Mental Health Act were perceived as positive, due to the increased requirement for staff accountability and client access to legal aid 4

7 1. RECOMMENDATIONS Support MHS staff who are already advocating for MHS clients, by resourcing them with pamphlets, DVDS, videos, that: Tell recovery stories Raise awareness of mental illness Tell families/whanau/government and community agencies how they can help in a positive manner Provide resources to assist in educating MHS staff, that focus on consumer experiences with mental health and MHS Raise the profile of "LMLM" and existing LMLM resources within all MHS: Needs to filter through all levels of organisations, especially in hospital based services Work with MHS and DHBs towards a goal of creating cultures of zero tolerance around stigma and discrimination, via: Achieving a critical mass of recovery-focused staff Recovery-focused leadership in services, and recovery advanced as more than just rhetoric Strong organisational procedures around complaints Medical leaders endorsing destigmatisation Empower clients: Continue the positive trend of increased consumer involvement within MHS Educate clients on their rights and complaints procedures Value MHS staff and the work that they do: Show them the positive stories in which they have assisted Acknowledge the difficulties, whilst emphasising the positive contribution they have made Provide staff with regular training that: Reflects staff experiences Is consumer led Provides follow-up within the clinical context Generate positive media stories, to counter negative media about mental illness and MHS Undertake further research to investigate the feasibility of developing an adaptation of Standard 18 that would be adopted by MHS staff as a working strategy 5

8 2. INTRODUCTION AUDIENCE FOR THIS REPORT This report was written for the Like Minds Like Mine project to assist its planning for how to more effectively work with MHS. It will also be of relevance to people in MHS, particularly those with an interest in reducing stigma and discrimination. BACKGROUND This research project was part of a broad programme of LMLM research initiatives seeking to understand how to decrease stigma and discrimination towards people with experience of mental illness. The qualitative research outlined here is one contributory project of a seven-year research programme that has included a range of methods with a broad range of audiences. Mental Health Services are important to LMLM for two key reasons: MHS staff are potentially key allies for LMLM: they are one of the few groups in the community who are likely to have sufficient interest in mental health issues to be motivated to advocate and work for reduced stigma and discrimination towards PWEMI, both in their work and in the wider community MHS have been identified as a source of stigma and discrimination experienced by PWEMI by a Mental Health Foundation survey conducted in 2004, entitled Respect Costs Nothing The Like Minds Like Mine ( LMLM ) Orientation Kit defines discrimination as "systematic unfair treatment of people because they are different," behaviour that says "You're not as good as us" or "You're not worth listening to", "You don't belong", "We don't want you here" or "You're not important". (Like Minds Like Mine Orientation Kit, 2004 p9). Stigma is something attached to a person which can mark them for life as unacceptable (ibid, p 8). Therefore, destigmatisation, phrased in positive terms, is about equality and inclusion. In Te Reo Maori the LMLM slogan is 'Whakaitia te whakawhiu i te tangata'. This whakaitia means to reduce, while stigma and discrimination is referred to as 'te Whakawhiu i te tangata' which can literally mean 'the putting down of people' or 'the throwing out of people'. Thus addressing stigma and discrimination is in the context of reducing the tendency to put people down, reject them or 'outcast' them. In 2002 Phoenix Research published a report as part of the LMLM research programme which was based on 458 self-completion questionnaires from MHS staff in five DHBs in the Northern and Midland region. Although over half said they had only 'a little' knowledge of LMLM, there were almost half who reported 'large' or 'moderate' changes in their behaviour to reduce stigma and discrimination 'as a result of the project'. A third reported similar levels of change in their organisations. A research study which has informed the current study was that produced by the Mental Health Foundation in 2004, entitled Respect Costs Nothing. This research 6

9 based on 785 people with experience of mental illness (PWEMI) explored their experiences of stigma and discrimination in a wide range of contexts. Research results showed that 34 percent of the 785 people who filled out a questionnaire had at some time felt discriminated against when using mental health services (MHS) 1. The current research also considered MHS perceptions of what the public think of mental illness and MHS. Information in the report allowing comparison with perceptions actually reported by the public comes from previous research undertaken by Phoenix Research. The report published earlier this year, Qualitative Research Of "Like Minds, Like Mine" Target Groups looked at the attitudes and behaviours around mental illness of members of the public aged years. The research identified shifts in public perceptions since the first such research was carried out by BRC in It also examined ways to continue to shift the public toward attitudes and behaviours that are non-stigmatising and nondiscriminatory to PWEMI. RESEARCH OBJECTIVES The objectives of the research were: To identify any shifts in attitudes and practices by MHS staff and services In their own attitudes In the attitudes of other MHS staff Within their organisation and Within other MHS To compare attitudes of MHS staff with those of the general public To examine the understanding that MHS staff have of stigma and discrimination within the context of MHS Ways in which they feel people with PWEMI are discriminated against or treated unfairly Awareness of behaviours that would reduce stigma and discrimination in MHS Support for and impediments to these behaviours To identify (further) changes they would like to see to reduce stigma and discrimination within MHS To explore how MHS staff/services could become more supportive of the LMLM campaign How individuals might be supported to become champions for the cause To identify the impediments to reducing stigma and discrimination in the MHS To ascertain awareness of and support for the LMLM campaign within MHS 1 The aim of the survey was to explore discrimination and anyone with experience of a mental illness was eligible to participate. The questionnaire was distributed via consumer networks and other sources and had a relatively low response rate. 7

10 Issues relating to the mental health sector standard on stigma and discrimination (STD 18) If MHS staff were to judge a mental health service against this standard, the sorts of things they would look for How MHS staff think the public perceive MHS Types of services provided and their roles Perceptions and attitudes towards community care versus institutionalisation Understanding of the issues facing the services Perceptions as to how well the needs of people with experience of mental illness are met by the services MHS staffs perceptions of alcohol/other drug addiction and compulsive gambling as mental illnesses and how these differ from other mental illnesses Support within MHS for the rights of people with experience of mental illness and understanding what the concept of rights means in this context 8

11 3. RESEARCH METHOD AND SAMPLE QUALITATIVE METHODS Qualitative research was the appropriate method to use for this study, as we wanted to allow people to tell us in their own words how they perceived the issues. Qualitative research also allowed for a deeper understanding of the attitudes, motivations, triggers and barriers among MHS staff around issues of stigma and discrimination. Qualitative research seeks to provide a neutral and stimulating environment in which to facilitate thinking and free discussion around a topic. ETHICS This research project received ethical approval from the Health Ethics Committee, which also necessitated gaining approval from each DHB and the Maori committees or representatives within each DHB. SAMPLE In-depth interviews were undertaken with 30 managers and staff working in the MHS: 10 Managers 20 Other staff The interviews were divided between DHBs and NGOs, with 17 of the 31 interviews in DHBs. The interviews were spread evenly over five DHBs: Waitemata, Counties Manukau, Bay of Plenty, Hutt Valley and Southland. The remaining 13 interviews were spread over NGOs in same areas as the DHBs. Maori and Pacific were included in the interviews, as shown in the tables below. MENTAL HEALTH SERVICE STAFF IN DHBS Total Maori Pacific Other Manager Psychiatrist Psychologist Psychiatric Nurse Social W orker Total

12 MENTAL HEALTH SERVICE STAFF IN NGOS Total Maori Pacific Other Manager Psychologist Psychiatric Nurse Social/Community/Support Worker Total The staff outlined above worked across a number of areas such as residential, alcohol and drug services, community and family support, adolescent MHS, personal development and hospital settings. Within each role, there were also varying levels of seniority and years of experience. This was especially so for community and support workers (the names used for these roles varied by organisation), which varied from supervisory /co-ordinating roles to hands on staff. DATA COLLECTION The interviews were undertaken between 25 July and 4 October District Health Boards (DHBs) and Non Government Organisations (NGOs) were identified via Ministry of Health and Mental Health Services Peak Organisation networks. The LMLM national co-ordinator personally contacted the MHS managers in all the selected DHBs to gain their support for the research prior to Phoenix Research contacting them. Once a contact person was established within each organisation, they were responsible for identifying participants, from the roles shown in the sample section above, who were willing to be interviewed. All the Maori interviews were undertaken, analysed and reported on by a Maori researcher and the Pacific (Tongan) researcher undertook a similar role with the Pacific Peoples interviews. The interviews were usually of one to one and a half hours in duration. Respondents were sent information sheets and consent forms prior to their interview. The interviews were taped with the respondent's consent, for listening back to during the analysis phase. Some interviews were transcribed. Each of the researchers working on this project has a different voice, so variations in reporting style and description are evident in this report, but the findings work in together to tell an insightful story. 10

13 4. RESEARCH FINDINGS CULTURAL CONTEXT MAORI Families Maori MHS staff interviewed noted that most Maori families find the service to be useful and helpful and they support the MHS staff. Workers mentioned a type of inclusiveness that Maori families extend toward them, which the workers described as whanaungatanga. Inclusiveness and holism Under both Maori and western medical models of MHS, staff care about the wellbeing of clients, and know the difference between empathy and sympathy. What might differ between the models is how inclusive and holistic the practice might be. For instance, Maori MHS staff interviewed mentioned that the western model might see the clinician only working with a young child (apart from the family), who then returns to the environment from which they came. The Maori perspective would be to work with the child and family within their environment, to enhance positive change for all. There was a feeling among Maori MHS staff in general that Maori (and non-maori) clients feel uncomfortable in western medical settings that expect a clinical detached relationship. This type of setting is said to reduce the mana of the client/guest, by implying that the clinician permanently and intrinsically has greater status, value and authority. By contrast, in Maori settings both parties are valued right from the beginning, as the marae way of life is applied to the interaction between client and clinician. Within this setting, hospitality and respect for guests and whanaungatanga is practised by staff, by which clients are made to feel welcome and relaxed, which increases the likelihood of trust between client and the service. Kaupapa Maori service delivery There was a feeling among Maori MHS staff interviewed that Maori-run services are at the forefront of reducing stigma and discrimination, which has a lot to do with the way kaupapa Maori services are being delivered. Some mentioned that this type of approach could be used in mental health services in general, to reduce stigma and discrimination, and to be more inclusive. The relationships between staff and clients in kaupapa Maori services can be more egalitarian, which is more friendly, relaxed and informal. Overall, these types of services are developed and delivered in the context of Maori cultural values such as whanaungatanga, manaakitanga, oranga wairua, which by demonstration reduce the likelihood of discrimination for clients. 11

14 Maori services now that are running their services around a holistic feeling and they are getting results, so yes, yes, yes! Great for the government for allowing that to happen and taking a risk and they do occasionally Shared values with clients Having shared values with Maori clients, Maori staff reported that they often relate more easily with Maori clients, tend to see them more as whanau, and be more sensitive to their needs. Maori MHS staff interviewed appeared also to be more likely to prefer to provide a mobile service. This would allow for interaction with the client within their own environment, reducing possible barriers to them accessing services. By being Maori, Maori MHS staff can also be more direct with Maori clients, although it was acknowledged that choosing the wrong time in which to engage the client in this manner could be counter-productive. Awareness of Maori health models Maori MHS staff were also more likely to be cognisant of Maori models of practice e.g. Te Whare Tapa Wha, especially relating to taha wairua (spiritual health aspects) and more likely to practice from or be informed by these models. Some Maori MHS staff practiced these models more overtly than others, depending on how accepted the models were within workers' respective organisations. MHS staff from within Maori services noted their use of these models to concentrate on assisting clients to achieve balanced wellbeing. This goal is enhanced by the organisations helping to address issues like employment, income, and housing, which might be barriers to clients wellness. PACIFIC PEOPLES Pacific MHS staff noted that most Pacific families find the services to be useful and the families support the mental health workers. Pacific MHS staff work very closely with the families of their clients, and in most families there is a sense of relief at having someone they can unload onto. In most families they look up to MHS staff with the same respect they would a doctor. From one Pacific social worker's point of view, there has been a shift in attitude with the Pacific people. Five to ten years ago if someone had a mental illness it would be said that it was a curse and it would be blamed on something a person had done or that their parents had done, but now you hear a lot of talk about drugs being the cause of the illness. Pacific MHS staff mentioned that sometimes the public can think that they also have a mental illness. 12

15 CHANGES IN ATTITUDES AND PRACTICES WITHIN MHS There was found to be a diversity in the practices within MHS workers, which included a range of theoretical models and skills that underpinned the work that they did. The length of time within MHS and general life experiences shaped the way in which they approached their tasks. Overall, MHS staff interviewed felt that there had been a gradual shift in attitude over the past five years. They noted this for themselves, other MHS staff, their organisations and other mental health services. They felt that some areas of mental health care were progressing with this faster than others, and that in all areas there was still a long way to go. MHS staff felt that these changes were evidenced by: Training staff in recovery based models and being cognisant of recovery methods, e.g. adherence to Ministry of Health Recovery Model competencies Using client pathway documents/plans to guide service delivery Change in language used within the service and with clients e.g. more about recovery goals than treatment plan Being less prescriptive when working with clients Interactions were more client focused and client led Encouraging client independence from services Collaborating with other health/mental health services in order to get the best service for clients e.g. involving support workers, relationship with GPs, links with Supporting Families, consumer advocates Working with families of clients Working with consumer advocates and family advocates Shorter hospital stays for acute admissions MHS as more flexible to access and where clients can leave or change services as their needs change FACTORS FACILITATING CHANGE In examining the change in attitudes both with staff and organisationally, MHS staff identified the following areas as having facilitated a positive shift in their attitudes and practices: De-institutionalisation Moving mental health care from institutionalisation to community based was mentioned by MHS staff as having had the greatest impact, as it began the journey 13

16 of integrating into the community people previously kept separate from society. This seemed to have had the effect of giving both staff and clients hope in recovery from mental illness, and decreased the paternalistic attitude that health care providers have toward consumers. MHS staff working in community based services felt that being community based allowed them to view clients differently and it highlighted the skills and abilities that clients with mental health issues have. This was contrasted with inpatient services, where it was felt (by those who currently did not work in these services), that practices and attitudes were perhaps a little more entrenched and coloured by the level of unwellness their client population experiences. "Having lived through the de-institutionalisation stages and all the rest of it, and having worked in a big psychiatric hospital as well, it's been quite an interesting journey really to follow that through. But I think that as a society we are quite intolerant of difference and of mental illness. It is getting better, but there's still heaps of a long way to go" Length of time in the service MHS staff felt that new, young workers coming into the services were helping to change the attitudes and dynamics within the services, particularly in areas that may have had more entrenched views around the care of people with mental health issues. Training MHS staff felt that on-going training had helped facilitate changes in attitudes and practice. This had been through a variety of training programmes and workshops. Of particular note were the positive effects training, which included large sections run by consumers, that gave staff first hand insights into how consumers experienced the services offered. Models of practice The strengths-based approaches and recovery-based models are viewed as instrumental in changing the way that clinicians work and relate to clients. "The strength perspective does look at the problems and their diagnoses, but that's not the focus. The focus is on the person's strengths, on what that person has done in the past, wants to do now, and can do in the future. So I believe personally that that focus completely changes the course of the treatment" "That they [clients] actually move through the service that we provide. Back then and certainly earlier it was that 'oh they'll be in this service long after I'm gone', you know you come to 14

17 mental health service, you're here for life. Now I think people more have an opportunity to use the service and then move out, come back when they need it" Consumer groups MHS staff felt that consumer advocates and groups have been facilitators for change. Consumer groups have over the years pushed for change and advocated for themselves. They have raised MHS staff awareness that clients need to be active participants in their own recovery, rather than passive recipients of a service. "I actually shared an office with the consumer advisers and family advisers. Now I just think that was just wonderful really. That was participation at its best really" Personal experiences Personal experience both of managing their own mental health, and in their private lives of having close relationships with people with mental health issues were described as having had a positive effect on MHS staff attitudes and practices. "Like Minds, Like Mine" MHS staff who have had direct involvement with the LMLM campaign felt that it had a positive effect on their attitudes and their practice. Also some MHS staff generally noted that the campaign was raising awareness within the community and making it easier to talk about mental health issues, which had a positive impact on staff. THE CHALLENGES Whilst many MHS staff reported positive changes in attitudes and practises within the mental health services, some MHS staff acknowledged that some challenges remain. Areas that they identified are outlined below. Service structures In some areas service structures could unwittingly continue a paternalistic approach. This could be seen in areas where MHS staff were working with very unwell clients. Reactive approaches to treatment also perpetuated the paternalistic approach, particularly when services had been involved in a tragedy. Services would sometimes take a blanket approach to managing risk, which negated the individuals needs, experiences and potential. 15

18 Models of practice The different models which staff used to understand mental illness could help to ensure that clients had an opportunity to work with a member of staff that may use a model that best fitted with their understanding of their needs. However if a service was fixed on one or two models this meant that clients were expected to adapt themselves to fit the services and modes of therapy offered by those services, rather than having the service adapt to their needs. Burn out High levels of stress created by the constant requirement of managing high levels of unwellness could led to what has been termed as staff burn out. Staff experiences of burn out highlighted feelings of anxiety, depression and frustration which lead to difficulties in MHS staff staying motivated and they were therefore often less able to provide client-centred care. "So I think hope amongst mental health professionals is really critical to how they do their jobs, and to give them that motivation and enthusiasm and ability to continue with the role really. If people lose that hope, then they become burnt out and it's just a job" Relationships with other mental health service and health service providers In some areas there seemed to be friction between different mental health services and health care providers. Some mental health services were critical of other mental health services. The focus on negative differences between the services could make it difficult for services to work together with the clients needs as the focus. This also appeared to be the case between physical health services and MHS. "Then I started to realise that actually professionals in mental health services and helping professions, a lot of them do this for the power, not knowing what you know about people. They underestimate the trust and how disappointing we can be if we are not worthy of the trust" "The community residential services need to be monitored, some of them are just in it for making money. Some of the staff are controlling and stand over the patients (when they come to see this psychiatrist) and don't let them talk" "So what happens is you have a couple of qualified people that are creative and want to be there for the clients and you get a whole lot of other people that are trying to cover their arses and protect themselves. So there's a great tension in the system and to get into the system there's such a level of gate keeping you cannot believe" 16

19 HOW DO MENTAL HEALTH SERVICES THINK THE PUBLIC PERCEIVE THEM? CONTEXT MHS staff do not exist in a vacuum. Their work is influenced by: society's attitudes, the organisations in which they work, their own background, training and day to day experiences. MHS staff have to balance the needs of the clients with the needs of the community, their agency, the funder, team dynamics, external agencies and their own personal needs. At any time one of these needs can outweigh the other, and cause an imbalance which therefore impinges on the way in which they relate to the client. MHS INVISIBLE TO THE PUBLIC - EXCEPT WHEN SOMETHING GOES WRONG Staff felt that most people would not even want to think about MHS existing, unless people had a direct relationship with someone who was a client of the services. There was also a feeling that people only take notice of the MHS when something goes wrong, and that this was perpetuated by the media only reporting negative issues rather than positive stories. "They don't care as long as it's not in their back yard. (But it might be in their own back yard without them ever even knowing)" PUBLIC PERCEPTIONS HAVE HUGE INFLUENCE OVER STIGMA AND DISCRIMINATION Overall, there was quite a strong feeling that the public didn't always value MHS and MHS staff. There was a very strong feeling that the public still believes that MHS should be provided to protect the community from PWEMI, and that the public is still quite fearful about PWEMI. They think that the service is here to help them [the community], to protect them, to keep them safe MHS staff interviewed were aware of public opinion and its potential to be stigmatising and discriminatory to themselves, their clients and the services. They felt public opinion is controlled by the media. They often felt powerless to influence the media or public opinion unless their organisation was active in doing so through public relations. "We hardly ever see any positive stories in the media about mental health services, and that would be really nice to see. They only report the big disasters like the XX incident" 17

20 "Public attitudes to MHS are changeable like the weather - sometimes getting better, sometimes appalling. We can't do anything about it because we're not mandated to speak out" There was a definite perception that negative public views of both mental health and MHS (such as the idea that MHS are likely to make mistakes in their processes) seemed to stem from unbalanced reporting in the media about mental health and MHS, especially in the case of tragedies or near tragedies. "You get the media-fired attitude that (MHS) don t do anything right and let dangerous people get out there on the streets, who commit crimes and things" PERCEPTIONS OF TYPES OF SERVICES PROVIDED AND THEIR ROLES Keeping the public safe versus getting people well While many staff thought that society sees MHS only as 'keeping the public safe', some staff feel that the public image of MHS is shifting towards a 'getting people well' role. MHS as a mystery There was a feeling that the public see MHS as mysterious and secret - that nobody knows what goes on 'behind closed doors' and that it could be anything from people lying on couches talking to someone, to the more ominous feeling that they could be like "One Flew over the Cuckoo's Nest". The public stereotypes extremes of services and confuse MHS and IHC There was a perception that the public had no idea about the range of services, but thought that services were only either one extreme or the other. There was a real feeling that the public confuse services for mental health with services for those with an intellectual disability. This was reflected in hearing the use of the word "mental" to describe both. Some MHS staff interviewed had the experience of the public thinking that the job of being a mental health worker is worse than it is, or is harder than what it really is or that they must be a saint' to do that work. 18

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