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CHAPTER SEVEN WORKING WITH OTHER STAKEHOLDERS

Introduction

7.1 One of 'see me''s objectives is to work collaboratively with people and organisations across Scotland at national and local levels and across sectors and communities of interest. To explore the extent to which the campaign has met this objective and to further contribute to a detailed account of the development of 'see me', this chapter draws on interviews, workshops and a survey of NHS Board areas to describe the nature and extent of joint working from the perspective of the other National Programme delivery vehicles, local areas and other stakeholders.

Working with other National Programme delivery vehicles

7.2 As part of the process of examining whether and in what ways the campaign has been integrated and co-ordinated with other elements of the National Programme, a combination of telephone and face-to-face interviews were undertaken with 11 representatives of eight of the delivery vehicles. The following is based on the perceptions of these interviewees.

7.3 In terms of integration of purpose, the different delivery vehicles saw 'see me' as broadly complementary to their own objectives. From the point of view of Choose Life , for example, reducing the stigma associated with mental health problems would encourage earlier help seeking and contribute to suicide prevention. Other delivery agencies acknowledged that they were all part of the same broad agenda, but had different emphases.

7.4 Structurally, representatives of the delivery vehicles were members of the different national co-ordinating bodies set up by the National Programme over this period: the National Programme Advisory Group, the National Programme Implementation Group, and subsequently the National Programme Executive Group. From the perspective of the different delivery vehicles, these fora were largely mechanisms for informing the national programme director. The comments made in the course of interviews suggest that outwith these umbrella bodies the different agencies may work relatively independently of each other: working relationships and links being largely informal or practical in nature.

7.5 Specifically in the context of links with 'see me' different delivery agencies were using their own networks to disseminate information about the anti-stigma campaign and/or distributing 'see me' materials in a public arena such as conferences. Agencies or individuals also took part in 'see me' focus groups, or discussions in relation to specific campaigns, or when different approaches were being tested. Those interviewed did not, however, feel they had a strong influence over the direction or focus of the different 'see me' campaign strands (nor vice versa in relation to 'see me''s influence over elements of their own work). The one area where there was perhaps greatest influence was in relation to the young people's strand, where concerns about ensuring people working with young people were forewarned and that there was a link to sources of information for young people were felt to have been taken on board by 'see me'.

7.6 Outwith these points of contact, the interviews with the representatives of the different delivery vehicles suggest that the degree of joint or integrated working between each of them and 'see me' was variable and could be comparatively limited. In fact, the interviews suggest three broad types of relationship had developed. First, a reciprocal working relationship, characteristic of the links between 'see me' and Choose Life . On the one hand, 'see me' trained and supported the media volunteers who supported the work of Choose Life, and on the other hand, 'see me' 'worked with Choose Life local co-ordinators in a number of areas to encourage local anti-stigma activities. 'see me' and Choose Life had also worked in collaboration to develop media guidelines on reporting suicide and mental health problems.

7.7 Other relationships were more asymmetrical and largely based on using 'see me' as a resource. The Scottish Centre for Healthy Working Lives, for example, drew on 'see me''s resources to develop the anti-stigma component of its mental health commendation award. NRCEMH had fewer direct links with 'see me', but the two agencies had each worked in support of the Greater Glasgow and Clyde NHS Board anti-stigma partnership to research and develop anti-stigma resources for black and minority ethnic communities.

7.8 The third set of relationships were those in which the delivery agency and 'see me' were perceived to be largely "ploughing their own furrows", aware of, but not working closely together or jointly.

7.9 Even where sharing a joint resource, such as the media volunteer programme set up and managed by 'see me' on behalf of the National Programme, there was a sense from the comments made by several delivery agency representatives that they had little input or control over the process and purpose of the media volunteer programme. In the words of one respondent, they felt they were presented with a "fait accompli", in a way that discouraged them from using the service more intensively (this process is discussed in Chapter 5).

7.10 It was suggested that workforce capacity may have limited the opportunities for greater joint working: each agency was working to fulfil its own agenda with little scope to pursue work in collaboration. Arguably, the combination of their own agenda and their relative independence and autonomy from each other may have worked against opening up the space for more integrated working. Indirectly, this may also discourage 'mainstreaming' in the sense that anti-stigma work is seen as the role, and expertise of 'see me' rather than of the individual delivery vehicles. Paraphrasing one respondent, "'see me' is quality-rated and valued, so I don't feel I have to put in more input, because they are doing a good job". This does suggest that there is a risk that activities to address the stigma experienced by people with mental health problems is seen as the sole responsibility of one agency, rather than an integral part of the work of all the delivery vehicles.

Working with local areas

7.11 To support the development of local activity, 'see me' set up a national anti-stigma network in 2003 and held a number of events. The network was subsequently discontinued following a review because "it proved difficult and resource-intensive to sustain the momentum once participants returned to their local areas" ('see me', 2006). The same documentary source refers to 'see me' putting more effort into supporting "local anti-stigma champions". Although little reference was made to this network by those interviewed in the course of the evaluation one person did refer to attending a "good two-day event" and regretted that this had not been repeated, and participants in a local area workshop did suggest there would be a value in reinstating the network to support learning from across local areas.

7.12 To map the extent and pattern of local anti-stigma activity across Scotland as it relates to people with mental health problems, and the nature of collaboration between 'see me' and local areas, a web survey of the 15 NHS Board areas in Scotland was undertaken as part of the evaluation. Following the survey, three local areas (Greater Glasgow and Clyde, Tayside and Western Isles) were selected to take part in workshops to obtain a more detailed picture of local implementation.

7.13 Thirteen of the 15 local areas responded to the NHS Board Area survey, 12 of whom gave examples of local anti-stigma activity involving 'see me'. Respondents were asked to indicate up to three activities undertaken with 'see me' input. Across the 12 areas a total of 28 activities were described (see Annex 5). Seven of the 12 areas were able to describe at least three activities. The most frequently cited types of anti-stigma activity were:

• General population awareness raising, through radio, advertising on buses, distributing materials, public anti-stigma Pledge signing, and stands at agricultural shows (6 activities)

• Promoting 'see me' anti-stigma messages through sporting events, football clubs and volleyball teams (5 activities)
• Anti-stigma work with children and young people, including attitude surveys, peer support, drama and awareness raising (4 activities).

7.14 Evidence from the workshops in three areas suggests that activities were pursued to reflect the contexts in which stigma was viewed as an issue locally. In one area, for example, the focus was on key services such as housing, benefits and health with the aim of ensuring that stigma did not become a barrier to access for people with mental health problems.

Nature of 'see me''s involvement

7.15 'see me' was invited by local areas to become involved in relation to 15 of the 28 identified activities; 12 activities were pursued following an initial approach by 'see me' (no information was provided by one respondent).

7.16 Asked about the nature of 'see me''s involvement in local activities, the most frequently cited input was the provision of materials including leaflets, T-shirts and football strips, surveys, radio advertisements and competition prizes (15 activities). 'see me' was involved in a more strategic, or advisory, capacity in seven activities. Advice and support given by 'see me' included how to respond to negative media reporting, support with research and communication skills development and advice on developing local campaign messages. In terms of PR and media input (in 5 activities), respondents described how 'see me' had arranged photo shoots, negotiated advertising space and prepared written responses to the Scottish media on local issues.

Local models of working

7.17 The NHS Board area survey and the workshops in three areas revealed different models of working within areas and between the local areas and 'see me'. These can be distinguished in terms of the range or focus of activities, partnership arrangements, relationships with 'see me', and the factors acting as barriers or facilitators to local anti-stigma activities (Boxes 7.1 a-c).

Box 7.1a Greater Glasgow and Clyde NHS Board area

Box 7.1b Tayside NHS Board area

Box 7.1c Western Isles NHS Board Area

7.18 Respondents to the survey listed a wide variety of partners with whom they had worked (in addition to 'see me') to develop and deliver local anti-stigma activities. Unsurprisingly, since most respondents worked within the NHS, NHS Boards were the most common partner listed, with 20 of the 28 activities noted involving statutory health professionals and agencies. Voluntary organisations and community groups were involved in just over one-third of the activities noted, six activities involved education (schools and colleges) and National Programme initiatives were also involved in six activities.

7.19 Mental Health service users were involved in over half (16) of the local activities described in the survey. In Tayside, Plus Perth, a user forum, had taken the lead on local 'see me' activities; a unique situation in Scotland. However, only just over one third of all activities described in the NHS Board survey (11) involved carers.

7.20 It was recognised both in the survey and the workshops that the success of local anti-stigma work relied on dedicated and motivated individuals as well as staff capacity. In one area, for example, staff shortages were held to be largely responsible for anti-stigma work "fizzling out".

7.21 In addition, good relationships between local organisations and interested parties had the potential to facilitate co-ordination and enhance sustainability. Within Glasgow, workshop participants felt that the local co-ordination role within the anti-stigma partnership was vital to the success of anti-stigma work. This role was described as bringing partners together, keeping momentum going, and acting as a champion for anti-stigma work.

7.22 Buy-in from management and those at a strategic level was also considered to be an important success factor for the development of local anti-stigma activities. In a context in which mental health service delivery was perceived to be stretched and under-funded, the view from one area was that without this strategic support anti-stigma campaigning would be given a low priority.

Funding for local activities

7.23 Survey respondents indicated that just over half of the activities (15) had received some form of funding from 'see me', NHS Boards provided funding for 11 activities, and Local Authorities for 5 activities. Other sources of funding referred to by respondents included Choose Life, local voluntary agencies, grant-making bodies and corporate donations. Some areas indicated that they had received funding from more than one source.

7.24 In one area, additional travel costs and lack of ring-fenced funding had acted as a barrier to developing anti-stigma activities, take-up of training opportunities, and capacity to attend conferences and events. In contrast, the funding arrangements in another area, where each partner committed resources, was felt by workshop participants to work well, facilitating greater buy-in and commitment to anti-stigma work.

7.25 Participants in all three workshops felt that future funding was crucial to maintaining local activity to tackle the stigma experienced by people with mental health problems. While there was widespread support and commitment to reducing stigma in local areas, money, it was felt, could guarantee a dedicated resource to develop anti-stigma activities.

Perceptions of the impact of local anti-stigma activities

7.26 Just over one third (10) of the local activities described in the NHS Board area survey had been subject to evaluation. Nonetheless respondents were able to describe the perceived outcomes for 23 of the 28 activities. These included:

• Raised profile of 'see me' campaign and messages (five activities)
• Increased awareness of mental health issues in local populations (four activities - anticipated outcome in two of these)
• Changed individuals' ( e.g. young people's) attitudes towards mental health (four activities)
• Raised profile of local mental health initiatives and organisations (three activities)
• Mental health benefits for users involved in activities (three activities).

7.27 Workshop participants were also able to describe the perceived impacts of local activities. In one area, for example, it was felt that being involved in designing and running anti-stigma activities had empowered and given confidence to service users. In another area workshop participants indicated that over 500 people had already taken part in mental health awareness workshops. It was also felt that mental health issues were becoming a more acceptable topic of conversation within BME communities as a result of the work of the local anti-stigma partnership.

7.28 In terms of the impact of 'see me' on local activities, all but one of the survey respondents felt that the national campaign had had a positive impact. Two-thirds stated that at least some of their activities would not have happened without input from 'see me', while over half (seven) suggested that 'see me' had helped them to progress with existing anti-stigma work.

7.29 Workshops participants too felt that 'see me' had raised the profile of stigma as it affected people with mental health problems to a level that would not have been possible on a local basis. The campaign had made anti-stigma messages visible, giving local activities a base to build upon. It was also recognised that the campaign had some "clout" with decision makers, so could be helpful in terms of building buy-in for local anti-stigma work. The flow had not, however, all been one way. Workshop participants felt that local activity had raised the profile of the national campaign and that 'see me' would not have been so successful without the local campaign activities.

7.30 Some of the comments made in the course of the local area workshops also suggested factors that were perceived to have tempered the impact of 'see me' locally. In one area, for example, participants described how a local mental health organisation had been reluctant to display 'see me' posters. Those taking part in the workshop suggested that the organisation had been concerned with the use of (diagnostic) 'labels' in the advertising material: a concern that it was suggested arose because of a lack of understanding of the message. It was also suggested in the workshops that elements of the campaign, such as Stigma Stop Watch were not well known in some local areas.

7.31 Workshop participants in two areas felt there was a need for the 'see me' team to have more active links and involvement with local areas. It was suggested that link workers could participate in local meetings to help build momentum for the work.

7.32 Reflecting more generally on the campaign, participants in two of the workshops suggested that by taking a general population approach there was a risk that stigmatising attitudes among, or experienced by particular groups could be missed or overlooked. The perceived stigma towards people with mental health problems among mental health professionals was suggested as one example. The view that the initial campaign materials were not appropriate for BME communities was another example. In Glasgow the anti-stigma partnership, together with 'see me' and NRCEMH, had subsequently worked with local BME communities to develop materials to ensure that these groups were not excluded from the campaign's messages.

Working with other stakeholders

7.33 As summarised in Chapter 3, a wide range of key stakeholder agencies and organisations were consulted across the three phases of the evaluation. This section focuses on the findings from interviews with two groups: public and private sector organisations who had worked with 'see me' to develop anti-stigma campaigns within their own organisations; and a sample of national and local organisations who either worked with or on behalf of people with mental health problems or worked with different 'equalities' groups ( e.g. those working with groups of people who were at risk of discrimination or stigma on the basis of some aspect of social identity or in others ways at risk of being socially excluded). The focus here is on their awareness of, and contact with 'see me'; the views of these and other stakeholder groups on the future direction of anti-stigma and discrimination work in Scotland as it relates to people with mental health problems are reported on in Chapter 11. A full list of the participating organisations is available in Annex 3.

Perceived relevance of the 'see me' campaign

7.34 For the organisations and agencies interviewed, anti-stigma work was of relevance to them either because their client group was at risk of stigma on the grounds of mental health problems or because they saw it as part of a wider mental health awareness agenda which was active within their organisation. Organisations working with different equalities groups or with groups at risk of social exclusion highlighted the complex nature of stigma and discrimination and the potential "double whammy" some people could experience of stigma due to a mental health problem together with other forms of prejudice and discrimination such as racism, ageism or homophobia. Furthermore, the effects of stigma may not only be felt by the individual themselves, but by members of their families.

7.35 There was also recognition of the importance of both mental health awareness and of stigma within a workplace context. On the one hand, the stigma surrounding mental health problems could act as a barrier to employment; on the other hand, for employers, supporting or handling stress or mental health problems among the workforce raised issues of mental health awareness. One private sector organisation had experienced two suicides within the workforce, which for them had been a call to action around mental health at work, including involving 'see me' in anti-stigma activities.

Organisations working with 'see me'

7.36 Interviews were held with representatives of four private and public sector organisations who had actively linked up with 'see me' to undertake specific anti-stigma activities.

The reasons these organisations gave for working with the campaign included:

• Wanting to raise their profile as a good employer and raise awareness about mental health amongst staff (and students)

• To give shape to ongoing mental health awareness work
• For specialist PR advice and support.

7.37 A range of activities had sprung out of this relationship, including mental health information days and conferences, internal promotions, sponsored events to raise awareness, 'see me' advertisements on company vehicles and input into lectures and student curricula.

7.38 Those interviewed felt that the process had raised the profile of mental health within their organisations and had improved staff confidence in talking about mental health issues. Getting involved with 'see me' could also lead on to other related activities such as undertaking the Scottish Centre for Healthy Working Lives commendation awards. Finally, working with 'see me' was believed to have brought about PR benefits, increasing an organisation's reputation as a good employer.

National and local organisations with a stake in anti-stigma and discrimination work

7.39 The links with 'see me' among the sample of national and local organisations who either worked with or on behalf of people with mental health problems or worked with different equalities groups consisted of displaying campaign materials and exchanging information. However, this did not mean that they were not participating in any activities which could be included under the banner of anti-stigma work. Policy developments such as social inclusion and stress at work policies, together with ongoing mental health awareness raising activities were all thought to contribute to challenging the stigma of mental health problems within organisational and community settings.

Perceptions of the impact of 'see me'

7.40 Across the different organisations interviewed it was acknowledged that without 'see me' there would be no one to drive forward anti-stigma work as it relates to mental health problems, across Scotland. However, it was also noted that 'see me' was not alone in working to change attitudes around mental health. Other initiatives such as the Scottish Centre for Healthy Working Lives and Choose Life were also thought to be part of a wider force for change.

7.41 While those interviewed felt that there had been some increased awareness of the stigma that people with mental health problems can experience as a result of 'see me', some participants were uncertain whether 'see me' had achieved any meaningful impact on attitudes and behaviours. Some also questioned whether the media were the most appropriate mechanism for achieving this change.

7.42 Concerns were also raised about how anti-stigma work could be maintained and mainstreamed within specific organisational settings. This could be an issue, even for mental health organisations when anti-stigma work was just one of many priorities.

Perceived strengths of 'see me''s approach

7.43 On the basis of the interviews with the range of different organisations, the expertise 'see me' had built up in terms of PR was thought to be one of the key strengths of the campaign's approach. One organisation had been able to benefit directly from PR advice, and others felt that the profile 'see me' had built was something that they could use and learn from to develop their own responses. It was also thought that there could be learning to take from 'see me''s PR experience to benefit other anti-discrimination campaigns.

Perceived limitations of 'see me''s approach

7.44 There was a perception among some of the organisations working with different equalities groups that the approaches 'see me' had developed did not acknowledge issues of diversity. It was felt, for example, that the materials were not always promoted within, or appropriate for, different communities such as BME or LGBT populations. With the maturation of the campaign this perceived lack of recognition of different groups within the general population was felt to be increasingly unacceptable.

7.45 However, it was also recognised that some potential target groups can be hard to reach ( e.g. people who were socially excluded or young men) and approaches aimed at them need to be handled carefully to ensure that any activities developed were not counterproductive and upheld rather than challenged generalisations and stereotypes.

Views on integration of anti-stigma / discrimination work

7.46 It was recognised by participants that individuals can experience multiple forms of stigma and discrimination based on a range of factors including sexual orientation, ethnicity, gender or disability, and therefore that there was potential for linking up some of these issues, and undertaking joint working to challenge them. At the same time, however, it was felt that each form of discrimination had unique dimensions that were at risk of being lost if all responses were "lumped together". Consequently it was suggested that joint approaches for tackling stigma and discrimination should be limited to those which promote a more equal and accepting society for all, rather than producing a "one size fits all" anti-discrimination campaign.

Key points

• 'see me' is one of a number of delivery vehicles represented on the different National Programme management bodies. These bodies have provided a forum for information sharing. Outwith these fora the relationships between 'see me' and the other vehicles ranged from reciprocal relationships involving an exchange of resources to more asymmetrical relationships, such as those where 'see me' provides materials or resources, through to more distant relationships characterised as each vehicle "ploughing their own furrow". Workforce capacity as well as the relative autonomy of the different delivery vehicles from each other may have worked against more integrated working.

• Local anti-stigma activity in partnership with 'see me' was evident across Scotland. The nature of 'see me''s involvement included the provision of promotional materials, advice and support and PR and media input.
• The data reveal different models of working within areas and between local areas and 'see me'. These models can be distinguished in terms of the range or focus of activities, local partnership arrangements, the relationships with 'see me' and the barriers and facilitators to local activity.
• Factors perceived to enhance the success of local anti-stigma activity included dedicated and motivated individuals, staff capacity, good relationships between organisations, buy-in from management and those at strategic levels and funding to develop and support anti-stigma work.
• Individual organisations who had run activities with support from 'see me' felt that the process had raised the profile of mental health, helped people feel more confident about talking about mental health issues and brought PR benefits to companies.
• The links with 'see me' among the sample of national and local organisations who either worked with or on behalf of people with mental health problems or worked with different equalities groups consisted of displaying campaign materials and exchanging information.
• In terms of 'see me''s overall approach a common theme across this set of interviews was a perception that a general population approach may risk overlooking the stigmatising attitudes among particular groups or experienced by particular groups.
• In terms of the way 'see me' has worked at local level and with individual organisations the involvement of the campaign was perceived to have had a positive impact both by enabling local areas to run anti-stigma activities and in terms of outcomes. The campaign's expertise, particularly in PR was highlighted as one of its strengths.

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