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Invisible Design for Societal Change: Mental Health

ChloĂŠ Fong 12837126 Module Leader: Dr Eddy Elton

Translated Findings

Primary Research

Secondary Research

Table of contents 02 03 05 06 07 08 09 10 11 12

Market Research

Literature Review


The Experts

People with Experience

General Public

Insights Summary

Mood Board



Introduction “People with mental illness die on average 15-20 years earlier than other people – one of the greatest health inequalities in England.” (Stevens, 2014) Mental health is a topical issue that affects communities on both a local and global scale. In recent years, the UK government has prioritised mental health care. Beginning with amending the Mental Health Act in 2007 (removing the need for a person’s problem to be deemed treatable to get treatment), they also proposed a “No health without mental health” strategy (2011). These aim to challenge the stigma, as well as recognise the importance of taking care of personal mental health and that of others. The Royal College of Psychiatrists (2013) published a paper containing recommendations to achieve a “parity of esteem”, putting mental health and physical health on the same level of importance. The cost of mental ill-health in UK is one of the contributing factors for the implementation of such policies (Department of Health, 2011). “The costs of mental health problems to the economy in England have recently been estimated at a massive £105 billion, and treatment costs are expected to double in the next 20 years.” This cost can be put into perspective when compared against that of cancer care. Oxford University (2012) estimated that the economic impact of cancer to the whole of the UK is around £15.8 billion. One of the reason for this disparity is due to the prevalence of mental health problems. 1 in 4 people in the UK experience at least one mental health disorder in the course of a lifetime. Furthermore, at any given time, 1 in 6 have a mental illness (Singleton et al, 2001). 2.5 million people are living with cancer (Maddams et al, 2012). 10.7 million people are living with a mental health problems (MHPs). The NHS expenditure on cancers and tumours in 2010/11 was £3.3bn. The NHS expenditure on mental health in 2010/11 was £6.7bn. (Harker, 2012) This equates to £1320 per head for cancer and £626 per head for mental health. Since then, mental health spending has dropped by 8%, making the problem even more severe. (McNicoll, 2015) The World Health Organisation (WHO) has published reports in recent years outlining the severity of the problem internationally. In their Call for Action Report (2001) they predict that by 2020, depression will become the “second leading cause of global disability burden”. In another report published a decade later, it states that by 2030, it will become the leading cause itself (WHO, 2011). The same report also highlights the lack of care provided to people with severe3 mental disorders. “…between 76% and 85% of people with severe mental disorders3 receive no treatment for their mental health problem in low- and middle-income countries; the corresponding range for high-income countries is also high: between 35% and 50%” We can see from the evidence above that mental health issues are not only prevalent, but also debilitating to communities in the UK, and also in a global context.

Glossary can be found on page 4. 1

Secondary Research


Market Research How common is mental illness? In a year, 25% of the population will experience mental illness, more than the amount of people that catch the flu. The figure below is a visual representation of the scale of the problem. (NB: The health conditions on the right are not mutually exclusive)

Mental Illness

Seasonal Flu




Heart Disease

Data above from: The migraine trust, 2014. Flu watch, 2011. Asthma UK, n.d. British Heart Foundation, 2015. Diabetes UK, 2015.

Anxiety + Depression 1 in 11


1 in 13



What are the chances of an average person developing the following mental health problems in their lifetime? (Data from: Haliwell et al, 2007, Royal College of Psychiatrists, 2012, Mental Health Foundation , n.d.)

Pers o Diso nality r 1 in 2 der 0

Dementia 1 in 5

(If you make it to 80)

OC 1 in D 40










h op hiz Sc n 100






ia rex Ano 200 1 in



Literature Review

Suspected depression/ anxiety

Current mental health system 2 weeks observation

GP assessment*

Return to GP for review 6 weeks wait time

Cognative Behavioural Therapy 12 weeks

Up to 12 weeks of talking therapy treatment

4 weeks per drug

Medication trial**

4-6 weeks wait time

Referral to CMHT * During the initial GP consultation, the doctor prescribes reading and advises on good sleep ** Antidepressants take around 4 weeks to take effect, and multiple drugs might need to be trialled in order to find the best one Fig. 1 NICE pathway for depression 3

Mental health problems are irrefutably widespread, and are classically divided into two types; neurotic1 and psychotic2. The most common are neurotic disorders, with mixed anxiety and depression being the most widespread, affecting 9% of the British population. (Halliwell et al, 2007). Goldberg and Huxley (1980) created the industry standard five-step pathway of psychiatric care: 300 people out of 1,000 will experience mental health problems every year. Of those 300, 230 will visit a GP, 102 will be diagnosed as having a mental health problem, 24 will be referred to a specialist psychiatric service and 6 will become inpatients in a psychiatric hospital. Currently, the NHS has a variety of approaches to dealing with people experiencing mental distress based on the Goldberg and Huxley model. According to the National Institute for Health and Care Excellence (NICE) guidelines (2014), the first point of contact for a person with suspected mild depression and anxiety is their general practitioner (GP). The pathway of care can be seen (see fig 1). If the condition is acute, where immediate danger to self or others is present (severe suicidal depression, acute violent psychosis, etc.), the pathway is more direct (see fig. 2) However, in 1980, when the model was made, the mental health system was very different from its present situation. Moreover, today, there is significant evidence proving the model is outdated. “90 per cent of people who die through suicide in the UK are experiencing mental distress” (Time to Change, 2008). Suicide is the leading cause of death for both men and women between the ages of 20-34 (Luoma et al., 2003). However, only 19% of people who have completed suicide4 had been in contact with mental health services in the previous year before death (Department of Health, 2001). According to the Goldberg and Huxley model, 76% (230 in 300) instead of the 19% would have sought help. The massive difference between the NHS model and reality is grossly evident in the case of suicide. It is known that only a small proportion of those affected seek help. NHS England

(accessed 2015) states itself that “only a quarter of all those with mental illness such as depression are in treatment.” Layard (2004) adds that the reasons are either because they have not seen their GP, or have been misdiagnosed or refused treatment. There is also extensive literature on specific conditions such as OCD, where it often takes 1015 years for people to seek treatment (Michael and Margraf, 2004). Singleton et al (2001) also found that only 85% of people experiencing psychosis, the most severe and debilitating symptom, receive treatment.

Factors affecting help seeking It is difficult to gain an objective grasp of the specific reasons as to why many people do not seek help. Nevertheless, experts have tried to find such driving factors. Bebbington et al. (2000) examined the number of people seeking help for neurotic disorders from different socioeconomic backgrounds. They found that there were no significant contributing factors of race, age, sex, employment status, and that the only major influence was on the severity of the disorder itself. They also concluded that “Even people suffering from high levels of psychotic symptoms very often [did] not have contact with professionals who might [have] help[ed] them.” Even if there are indicators of a serious mental health disorder, some find it hard to access the help they need. An article written by an ex-inpatient mental health nurse (Filer, 2014) documents the scarce availability of help. Before leaving the NHS in 2007 to go into research, his view of the ward was positive, stating that “[they] were able to offer full and extensive care packages, making a real difference to people’s lives.” However, when his friend fell ill 4 years later, he found it a struggle to get him the help he needed. First of all, Filer believes that the suicide attempt that lead his friend’s hospitalization could have been prevented. There had been many warning signs of health deterioration prior to the act. Filer made daily phone calls to his friend’s crisis team to no avail, as planned admission

to an inpatient ward was no longer a possibility due to lack of funding. It was not until his friend’s attempted suicide that he was admitted. When visiting his friend, Filer found his ex colleagues to be overworked, stressed and the ward was understaffed. Furthermore, there was a planned closure for the hospital during his friend’s stay. This lead to anxieties within the staff about job security, which in turn affected the level of care. Research has found that people are more likely to seek help from “lay people” (friends and family) than professionals (Biddle et al, 2004). It is also well known that women are more likely to report mental health symptoms (Oliver et al, 2005, Singleton and Lewis, 2001). This may be because it is less socially acceptable for men to show “emotions of weakness” (Timmer et al, 1998). A multitude of studies indicate that the stigma of mental illness plays a large part in help seeking behaviours. In particular, the stigma surrounding people with such health problems causes additional hardships on top of those relating to the disease (Barney et al, 2006, Link et al, 2001, Schomerus et al, 2009). It was found that stigma impacts self esteem negatively (Link et al, 2001), which can lead to a worsening of mental health symptoms in common disorders such as depression and general anxiety disorder. Bharadwaj et al (2015) found that many people under report their symptoms and prescription drug intake because they are embarrassed about their condition. Created to combat mental health stigma and discrimination, the charity Rethink has conducted numerous studies in the field. Stigma Shout (2008) consisted of a survey and workshops involving 4000 participants in different areas within the UK, aiming to gain a better understanding of the extent of stigma and its effects on

people with MHPs. It was found that 9 out of 10 people found stigma to have a negative impact on their lives, 2 out of 3 stopped everyday activities because of stigma. The detrimental effects of stigma reached many aspects of the respondents’ lives, with employment and relationships with professionals being affected the most. The study not only measured the impact, but showed the difference between the perceived (by the respondent) versus the actual stigma experienced. In the category “disclosure of mental illness”, the perceived stigma was nearly 4 times higher than the actual figure. This could explain the reasons for the lack of help seeking behaviour seen in the studies above.

Conclusion Mental health issues are not only prevalent but also costly. Measures have been taken by the government to improve services, but only time will tell if they are proven to be effective. It was found that the NHS’s mental health services

are based on a model which is out of date and inaccurate. As it is founded on the misconception that people find it easy to ask for help. In addition, the amount of funding for mental health is not sufficient; even people in critically ill health cannot get the help they need. However, it is hard from the NHS’s point of view to quantify the need of the population as there is a reluctance to seek help, so the true extent of the problem cannot be addressed. The system is not entirely to blame for the lack of care. Stigma and discrimination, actual or perceived, not only affects the life of people with MHPs, but also prevents people from reaching out to get the help they need. At this current time of austerity, it is quite hard to change policy and funding levels (Roberts et al, 2012). This does not mean the current state of the system is acceptable, but the change might not be immediate. Therefore, a focus on getting people to reach out for help in the first place is not only key to personal recovery, but is also essential to bring to light the full scale of the problem.

Police / Paramedics Accident + Emergency

Discharge to Crisis Team

Glossary: 1. Neurotic disorder: Sufferers experience extreme forms of normal emotions, such has depression (sadness) and anxiety (fear) (Halliwell et al, 2007)

Admit to hospital Voluntary Stay


Discharge to CMHT

2. Psychotic disorder: Sufferers perceive a distortion of reality; hallucinations (of sight, taste, smell and hearing), delusions (believing things that no one else does). 3. Severe mental disorder: A disorder normally involving psychosis.

Discharge to GP

Fig. 2 Pathway for mental health crises

4. Completed suicide: the verb to complete has replaced commit in medicine. 4

Primary Research


Methodology The aim of primary research was to gain a comprehensive view into multiple facets of mental health help seeking. Three distinct groups of people were identified in this process. Group 1, the experts – Mental health professionals, to whom help is sought from. Group 2 -People with experience seeking help, and group 3- members of the general public. Sampling of the general public was identified from secondary research; Biddle et al (2004)

states that people are more likely to seek help from their friend and family. As it is known that 1 in 4 people have mental health problems in their lifetime. It is therefore extremely probable that any member of the general population will come in direct contact to someone with mental illness. The following are the final chosen methods; initial plans had to be modified due to ethical and time restrictions. (See appendix A)

e nc

ex pe r

A Mental Health First Aid (MHFA) course was attended to understand the best practice of dealing with people with mental health issues.

l Pu b l ic

Follow up interviews were conducted, which allowed participants to expand on their timelines. A phenomenological interview method was used as it allows participants to describe their ‘lived experience’ from their point of view. (Waters, 2015)

Simulation: An activity was created using case studies from the MHFA Workbook (Bailey et al, 2007). The scenarios were made into cards, and were presented to groups. There were 7 scenarios, including a range of situations involving people displaying depressive, anxiety related, and psychotic individuals through direct and indirect contact. (See appendix D)

ra ne

Cultural probes: There were 2 activities within the pack; participants were first tasked to plot an emotion timeline (See appendix D), labelling appropriate external factors that contributed to help seeking. The second activity tasked participants with writing a letter to their previous selves, revealing the thoughts and behaviours of someone dealing with mental distress.



Gr o


eople with up 2: P hel ps Gro


Semi structured interviews were used to elicit expert knowledge from a psychologist, the method provided a framework to gain insights into specific areas, but also allows elaboration. Based on the Question + Probe + Probe approach, where the researcher starts with an open question and uses probes as follow up questions to gain further understanding of the topic.



ie er p x

hea lt h



Group 1: Mental

The groups had to discuss and present what they think they would do. Their results were compared against the MHFA model.

Sampling: Group 1 Sample size: 1 A research proposal was first submitted to the NHS in June 2015 for permission to recruit participants, however this was denied. Therefore, the sample size was limited in the time frame of the study. Convenience sampling was hence used to recruit participants. All consequent attempts at increasing the sample size were not successful.

Group 2 Sample size: 7 For safeguarding reasons only a limited sample could be chosen. Volunteers were first recruited through convenience sampling (see appendix C), and purposeful sampling was used to narrow down participants, this included both genders, different ethnicities, students and the employed. As the ethical restrictions impacted generalisability, an expert who has dealt with a larger sample of the population was recruited.

Group 3 Sample size: 9 Convience sampling was used. Due to the personality-revealing nature of the group work, participants that knew each other beforehand were chosen to increase validity (see page 9). Within the convenience sample, groups were purposefully selected to include a variety of ages, both genders, students and those in employment, and participants of different nationalities and ethnicities.



The Experts 1.To find out the “correct way� to deal the people experiencing MHPs. 3. To find out how stigma interferes with mental health treatment



Mental Health First Aid Training


The other course members were professionals working in the public mental health sector, which provided a deeper understanding of the day to day challenges faced by mental health professionals. The method taught was supported by the latest research, and has been proven to be successful.

Time consuming - the course was spanned over 2 full days, and was located in London. The learning outcomes of the course were predetermined, hence there was no room for further investigation to gain deeper insights within the area of interest.


The psychologist was found by personal connection. An email was sent to arrange a date and time for the interview (See appendix C). A funded place on a mental health first aid course was found from contacting member of the foundation. A 2-day course was attended at Sutton Salvation Army centre.

Expert Interviews Pros:

The psychologist interviewed worked as an inpatient psychologist in the Australian Medicare system (similar to the NHS), specialising in Eating Disorders. She has since moved to Hong Kong and has a private practice. She also lectures clinical psychology at the University of Hong Kong.

Allows in depth understanding beyond the existing knowledge of the researcher, permits elaboration, instant feedback if there is any misunderstanding. As there were only 2 participants in this study group, there is enough time to go into detail.



4. To find out, from an expert point of view, what would motivate people to seek help earlier.

Time consuming, leading to only a small sample size. Extensive research on interviewing skills had to be done for question formation and approaches. As psychologists are on busy schedules, the interview was done as a personal favour. As there was only one participant in this sample group, there was a potential for respondent bias. However, due to the factual nature of the interview this was limited.

need to toughen up

lack will power

De sti gm at is

are just lazy

g in

s nes l l i l ta en m

He lp se ek in g


Address misportrayal in the media

Ask them what they need

a ice dv


People with mental health problems


are not trying hard enough Awareness of the problem

are wasting time

Information on prevalence

Start with someone you trust

It’s no one’s fault


People will not go to treatment because

Assess their needs instead of doing it your way

It’s an illness not a weakness If nothing is done, it won’t go away.

Start the conversation

of stigma of long waiting times

Take a chance, make a brave move

it’s the nature of some illnesses to isolate

Realise it’s okay to have problems

lack of motivation

Not one model for helping someone

they think there is not point (hopelessness)

of misperceptions of treatment e.g.

past negative experiences

Myths cold professionals

dredging up the past

Mental Health First Aid guidelines: The ALGEE method of mental health first aid was taught to be used in a variety of situations involving people in mental distress.

The framework can be used on people showing symptoms of the following:

Compared to females, males are

• Depressive disorders ranging from mild to severely suicidal.

discouraged to reveal emotions not likely to seek help unless severe

less likely to talk to their friends

less emotionally aware Not equipped with the vocabulary to describe complex emotions

The way forward

The current situation

are attention seekers



ohb nelfnisj k wb ju

• Anxiety disorders including generalised anxiety disorder, post traumatic stress disorder, panic attacks and phobias • Eating disorders • Psychotic illness: bipolar disorder, schizophrenia etc.


ssess risk of suicide or self-harm

isten non-judgementally

ive reassurance and information

ncourage the person to get appropriate professional help

ncourage self-help strategies


Aims: How?

1. To find out factors that contributed to help seeking behaviour. 2. To find out if the perceived obstacles before help seeking were valid.

The initial idea was to conduct interviews with all of the participants to gain an in depth understanding, however due to ethical issues (see appendix C) a better course of action was devised.

A post was made on a closed Facebook group to recruit participants. Interested parties were instructed to message the researcher privately. To gain the interest of readers, a picture of panda cubs was attached to the post (see appendix C). As there were many volunteers, participants based in Brighton were prioritised due to time constraints. A follow up interview was proposed at the end of the cultural probe pack. Voice recording was initially planned, but during a pilot study, a mock participant brought up the fact that he would feel uneasy if he was to be recorded saying sensitive personal information.

Cultural probes can only examine responses within the constraints of the framework outlined by the activity, it does not allow deviation that might provide alternative insights that the researcher would otherwise not consider

Follow Up Interviews Pros:

Allows participants to do it in their own time; providing more thought out responses, it also reduces the reactive effect (Gibb, 2008), where the participants can be affected by the researcher (to avoid embarrassment or otherwise). According to Roulston (2010) are more likely to portray their “authentic self”, that is not normally publicly visible, when not alone.

Helps minimise research bias when analysing responses, it will allow participants to fully explain their answers. It also allowed the researcher pose further probing question in order to gain a more comprehensive understanding of the participants’ point of view.




Cultural Probe Pack

Time consuming for both the researcher and the participants. The reactive effect applies to face to face interviews. As the interview was unstructured interviews, the results were hard to quantify. Additionally, a person’s emotional experience can be interpreted in various ways, influenced by language, cultural and the perception of both researcher and participant.

People with Experience








0 %




14 %

Very severe







Severity of disorder at time of help-seeking

What helped?

The severity of the symptoms were measured against the NHS NICE guidelines (NICE, 2009). The very severe category was added for participants actively planning suicide at the time of help seeking.

Confiding in friends, family and or partner

Seeing a GP

















Consequences of not reaching out sooner

Reasons for the delay in help seeking


Alchohol + drugs


Fearful of judgement

Wanted to tackle it alone


Did not want to cause worry

Summary of trends in participant emotional timelines Time between self suspecting mental illness and help seeking

0 years Postive emotions

6 years

9 years 15 years

3 months

12 years

Contact with mental health professionals


ConďŹ ding in lay people

4 years

1.5 years 2 years

Condition very severe at time of contact Condition severe/ moderte at time of contact

Average time (excluding outliers): 3.4 years

Negative emotions

Trying to tackle it alone

With the help of others


The 9 participants were grouped into 3 groups of 2-4. One of the members of the group first read the card aloud, the group then discussed the best outcome. By working in groups, participants’ views could be captured. The discussions were videoed. As a simulation, participants were less like to be affected by the situations emotionally, hence minimising distress. Working in groups, their thoughts would be verbalised and the process of coming to a conclusion could be analysed.

7. Quick to rationalise emotions

9. Scared to make the person worse by saying the “wrong thing”

2. Focused on giving advice and not prioritising listening.

1. More likely to offer practical solutions.




1. To find out how the public would help someone going through a mental health crisis, and to assess their level of competency. 2. To reveal misconceptions surrounding helping someone with mental illness.


General Public Due to time restrictions, role-play based simulations were used to access public reaction in place of overt observations. In an ideal world, briefed actors would go into public places, act out the scenarios, and covert ethnographic videos would then be taken. Participants were more likely to portray their “ideal self” as opposed to their “real self” during a simulation (Boundless, 2015), which might have created false insights. Participants might have also influenced each other’s feedback.

11. Depression was quickly identified by many.

5. Avoid bringing up sensitive issues in fear of invading privacy.

8. No one tried to gauge potential self harm, suicide or intent to harm others

3. Will not direct to professionals unless very severe.

10. Would rather wait for escalation on non urgent cases.

6. If not in direct contact, prefers to advise others to approach the person.

12. Anxiety symptoms were less identifiable.

13. Cannot identify signs of psychosis.

4. Don’t know how do deal with psychosis.

14. Many people feared for their own safety when in contact with people showing signs of psychosis.

See appendix D4 for initial analysis.

Anxiety disorders were less likely to be picked up, and those who did only offered logical solutions. As emotions are irrational, providing practical solutions are not very helpful.

Participants were quick to identify depression, but cannot identify the severity of the illness, and did not assess risk of potential harm even when presented with suicidal people. This may be due to worry about aggravating the problem.

According to the mental health first aid guidelines, it is not recommended to give advice to a person, but rather to listen non-judgementally and direct them to appropriate profession help. Due to the rationalisation of emotions, many participants would rather give practical advice. 8 1

There is a knowledge gap in the public about psychosis. However, they are more likely to refer sufferers to professionals.

In the sample group, participants were likely to avoid the topic of mental distress. They would wait for escalation, due to the fear aggravating the situation. If they were not directly in faced with the person in distress, participants would rather not approach the person themselves.

Insight Summary Validity and Reliability People with MHPs- cultural probes & follow up interviews • The cultural probes were standardised, and each participant was given the same pack, however interpretation of the task varied, and some participants were not able to give sufficient information. (see appendix D2) • Problems with validity -Emotions cannot be quantified and measured, as the same event could affect people in different ways. • Researcher bias could have affected the validity, as emotions had to be standardised and put into categories for data analysis. • Participants may not have wanted to show the researcher their vulnerable side. This was minimised by sample selection; all participants had established a relationship with the researcher prior to the study. • Reporting of emotions are restricted by language, vocabulary, perception, culture and are completely subjective. Sad for one person might mean happy for another.

• Some events in participants’ timelines happened more than 20 years ago, participants might not be able to accurately recall their emotional states. • Follow up interviews were done in an unstructured format based on cultural probe results. Therefore, the questions could not be standardised affecting reliability. • Although notes were taken during the follow up interview, audio recording was not done to create a safe environment for the participants to confide, the researcher could have missed key information while note taking. • The small sample size and demographic limits the generalisability of the results. In an ideal world a larger sample would be taken, and participants would be of a wider age range and from different socioeconomic backgrounds.

General Population simulations • As the cards where standardised, the information given to each group was the same. However only one participant was asked to read each card, therefore the fluency of reading could have affected the other participants’ perception of the question. • For some groups, the researcher had to ask follow up question to promote debate. This depended on the direction of the group discussion and were not standardised. • Participants had a least one person in the group to whom they were familiar with so they could feel more comfortable giving response of what they would do, rather an projecting a version of what they think a person should do during the simulations. • Peer pressure could have influenced participants’ decisions in what they would do in a situation. • Dominant members could have driven the direction of the discussion. • It is impossible to predict exactly how someone would react until hypothetical situation becomes reality. • As MHPs are so common, some participants might have dealt with similar situations or have experienced it themselves, this could have influenced the group’s decision.

Expert interview • The expert has never worked for the NHS, and her understanding of the situation in the UK is limited. • However, as she has had many patients during her lifetime, her responses were more generalisable compared to results gathered by researcher. • Respondent bias could potentially be a problem with only one participant, but results could have been potentially be triangulated against secondary findings if there had been more time. 9

Males are less likely to seek help because they are less emotionally aware, and it is common in masculine culture not to talk about emotions.

People with mental health problems do not want to admit it to themselves or others due to the stigma associated with MHPs. A solution could be to de-stigmatise the problem. “Realistically, I would probably do nothing.” 57% of participants refused to accept they had a MHP even after discovering that they fit all they symptoms of mental illness.

Simulation Participant

9 out of 10 people with MHPs found stigma to have a negative impact on their lives (Rethink, 2008)

Stigma was one of the most important factors delaying treatment. Ways to destigmatise MHPs were suggested (page 6)

Male patients were found it harder to know the emotion they were experiencing. (page 6)

Help from the general public is essential for initial contact with mental health professionals. However, this is not common knowledge within the population.

People with MHPs are more likely to seek help from friends and family rather than professionals. (Biddle et al, 2004)

“If my parents hadn’t taken me to get help, I think I’d be dead.”

It is less socially acceptable for men to show “emotions of weakness” (Timmer et al., 1998)

Participants with MHPs did not seek professional help on their own accord, all of them were urged by their family, friends and or partners.

The waiting time to get treatment and is very long

Key From secondary research

Participant with MHPs

From expert interviews

Treatment outcomes were more favourable if patients had a strong support network.

100% or participants withdrew in some way from their family and friends.

From people with MHPs

Participants of the general public avoided the topic of mental distress, in fear of invading privacy

From general public simulations

Although proven to be effective, people with MHPs are reluctant to confide in their family and friends as they see mental illness as a personal weakness.

People with MHPs seek ways to isolate themselves which becomes a barrier to help seeking.

Patients will not go to treatment because it is the nature of some illnesses (including depression and anxiety) to isolate.

During follow up interviews, male were found to have limited vocabulary to describe emotions. In general, they needed more prompting and had to be given options to choose from.

“I would never say I was depressed to anyone.” Participant with MHPs

Common misconceptions of people the MHPs are that they are just lazy, lack will power, need to toughen up and are not trying hard enough. (page 6)

All participants with MHPs found confiding in friend and family to be helpful The average time taken to seek help from friends and family is 3.4 years

Translated Findings


Image Board This virtual reality (VR) image board has been designed to evoke emotions similar to those suffering depressive disorders.

VR has been used effectively to treat mental health disorders (Hoffman, 2004), and can evoke emotional responses. From a Christian point of view, cathedrals are scared places of worship, where every person’s inner thoughts can be seen by God. Hence this was used as a background. The floating statements in red are reported thoughts and feelings experienced by participants while they were struggling with their mental illnesses.

To view this experience the board in VR, please contact Chloe Fong. She can be reached by emailing c.fong1@uni.brighton.ac.uk.

The VR experience is strongly recommended. As a backup, the visuals can be found at http://goo.gl/39GuvN.


Persona Persona 1:


Name: Alfred Owen (Alfie) Age: 28




Location: East London Occupation: Journalist Shares a flat with his girlfriend

Persona 2:

Family relationship distant


Name: Ajay Kattan (Jay) Age: 28 Location: West London

Knowledge of MHPs

Occupation: Unemployed Lives with his parents and sister in their family home.


Alfie and Jay were flatmates at university and both graduated a year ago. They were close when they were living together, but as they now live an hour away from each other, they do not see each other often. Since graduation, Alfie has found a graduate job at a newspaper company, Jay has applied for many jobs but has lost motivation due to multiple rejections. Jay thinks he has depression, he has googled the symptoms and he fits all of them, but has not spoken to anyone about it. Recently, suicide has crossed his mind, but he doesn’t have a concrete plan.


in depth

A month ago, Alfie and Jay met up and Alfie noticed that Jay didn’t seem to be his usual self. He was very quiet and seemed to be in an irritable mood, he did not give it much thought at the time. Recently, a mutual friend has to Alfie that Jay has been drinking alone in his room every night and does not seem to want to socialise with anyone anymore. The Jay Alfie knew would never pass a chance to go to a club. Jay’s motto at university was - have fun now, worry about work later. The fold out page contains the thoughts of the two personas at the same point in time. Alfie is going home from work and Jay is outside his family home.

The world is better off without me anyway.

This is ridiculous, how long can a person mope for?

What would people do if I jumped off this building?

He’ll be fine, he just needs to get his act together and get a job.

If he really wants to talk about it, he’ll bring it up.

Everyone else can deal with it, why can’t I?

He just needs a good night out with the boys. I need to pull myself together .

He just needs to see the good things in life. He’ll get over it.

Should I give him a call? Nah, I haven’t spoken to him in a while. It might be awkward.

All my life I have let down my family. I’m a grown man with no purpose in life.

What will people think of me if I tell them I’m depressed?

You’re a man aren’t you? Why can’t you just get on with life?

Nobody likes me anyway. Let alone want to listen to me moan about life like a girl.

I might piss him off, don’t want to invade his privacy. I’m not going to get anywhere in life anyway. He has other people to talk to anyway, maybe his mum will talk to him. Plus, girls are better at that stuff anyway.

There’s no point in talking to anyone, no one can help me.



The product must equip the general public with the knowledge to assess degrees of mental health urgency in under 15 mins. • In the general population sample, none of the participants assessed the risk of suicide in multiple situations where the person affected was presenting with suicidal thoughts. (report p8)


The product must appeal to a wide range of audiences, regardless of gender, race, age or religion. • MHPs affect a quarter of the population (report p1-2) There are certain demographic factors which can further delay help seeking, such as those listed above (report p4).

• 15 mins: If a person has planned their suicide, delayed action could cause death. However, sufficient time has to be given for general public to make an informed choice.


At least 80% of both genders must agree that product and supporting marketing materials have gender neutral branding. • Males are discouraged by society to reveal emotions and are less likely to talk about them with their friends (report p6). The product must therefore facilitate help seeking in this demographic, as well as others.


The product should to allow the general public to access professional services available. • Referral to professional help is one of the steps outlined by mental health first aid guidelines (report p8).

The product must outline the symptoms of common mental health problems (MHPs) to the general public in a clear and universally accessible manner. • During simulations, participants could not identity symptoms of any illness other than depression. (appendix D5 video data) • They are many people with MHPs (report p 2-4) and their immediate communities may involve a diverse range of people.


The product must motivate the person with MHPs to reach out to the general population within 2 months of suspecting a MHP. • The average time for participants to seek help from the general population was 3.4 years, this must be dramatically reduced (report p7). • Participants did not want to deal with negative emotions and get on with daily life. However, it was these negative emotions that interfered with day to day life (report p7)


The product must be targeted towards people with MHPs and/or their immediate communities (of the general population). • All participants with MHPs only sought professional help after they were advised by their immediate communities. (report p7) • The expert noted that patients with a strong support network are more likely to have favourable treatment outcomes (appendix voice recording)


At least 70% of people with MHPs must agree that the product makes them more confident about themselves and not feel more stigmatised. • People affected think MHPs are a weakness and not an illness (report p7, appendix D2).

• However, the general public were focused trying to rationalise emotions, not realising that the MHPs cannot be cured by rational thought (report p8, video data).


The product should have accompanying public available supporting materials to educate all parties on the prevalence of MHPs and highlight the common misconceptions. • The expert concluded the destigmatising the community involves education on prevalence and to minimise misconceptions. (report P6) • The general public simulations indicate that the sample group do not have much knowledge of anxiety disorders and psychosis. (report P8)


The project could be backed by mental health charities. • Charities and coverage will reach more audiences


The product could provide a range of at least 10 different options for people with MHPs to verbalise their emotions. • Males are less emotionally aware of how they feel and may lack the vocabulary to describe complex emotions when compared to females. (report P6) • This was also experienced first hand when interviewing males with MHPs (report p9)

• The expert stated that her patients often think they need to toughen up (report p6).


Primary Requirement The product must be discrete, so as to not draw any unwanted attention to the user • While the community still holds a negative view of mental health problems (report p3-4) the product cannot single out those with MHPs

Secondary Requirement Optional Requirement

• The expert also agreed that MHPs are stigmatised 1


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Profile for Chloe Fong

Invisible: Design for mental wellbeing  

User centred research report on mental health help seeking in the UK

Invisible: Design for mental wellbeing  

User centred research report on mental health help seeking in the UK

Profile for clowster

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