Crac K ing U p Mental Illness and Stand Up Comedy: A Social Representations Approach to Anti-Stigma Resistance 17 August By Andi Cuddington As a requirement for a degree of Master of Science In the subject of Health, Community & Development 2009 At the Institute of Social Psychology, London School of Economics and Political Science Abstract! 4 Acknowledgments! 5 Chapter One! 6 1.0 Introduction! 6 1.1 Stand Up for Mental Health Program 7 1.2 Personal Motivation and Research Questions 8 Chapter Two! 9 2.1 Conceptual Framework! 9 2.1.1 Mental Health Stigma Research 9 2.1.2 Social Representations Theory 10 2.1.3 Social Identity Theory 11 2.1.4 Marginalization 12 2.1.5 The Possibility of Resistance 13 2.2 Literature Review! 14 2.2.1 Current Social Representations of Mental Illness 14 2.2.2 Positive Identities and the Arts 16 2.2.3 Humor 17 Chapter Three! 18 3.0 Methodology! 18 3.1 Sample 18 3.2 Data Collection 19 3.3 Analysis 20 Chapter Four! 22 4.0 Results and Findings! 22 4.1 Supportive Environment 22 Cracking Up | Cuddington (2009) | Page 2 4.2 Identity Renegotiation: Self Image 25 4.3 Identity Renegotiation: Re-evaluation of Group Membership 29 4.4 Contesting Meaning 32 Chapter Five! 37 5.0 Conclusion! 37 References! 40 Appendices! 46 Appendix I: Stand Up for Mental Health Video Appendix II: Participant Profile Table Appendix III: Interview Topic Guide Appendix IV: Research Consent Form Appendix V: Example Transcript Appendix VI: Codes and Textual Examples Appendix VII: Emerging Themes Appendix III: Thematic Maps Cracking Up | Cuddington (2009) | Page 3 Abstract Large scale attempts have been made to challenge continuing stigma towards mental illness without widespread changes in public attitude. From a social representations perspective, this qualitative study examines the potential role for creative approaches facilitate resistance against the negative representations that marginalize people with mental illness. Fourteen interviews were conducted with individuals from Stand Up for Mental Health, a stand up comedy program for people with mental illness. A thematic analysis elicited four global themes: supportive environment, renegotiation of self image, re-evaluation of group membership and contesting meaning. Results show the ways that the Stand Up for Mental Health program positioned individuals for active resistance against the negative representations of mental illness. The findings support previous suggestions that a proactive approach to social representations may have benefits in participatory health projects. While Stand Up for Mental Health is not a traditional health program its structure lends it to the same discussion. Keywords: Mental illness, stigma, social representations, comedy, identity Cracking Up | Cuddington (2009) | Page 4 Acknowledgments First, I would like to thank David Granirer at Stand Up for Mental Health for his assistance in making this project possible. I would also like to thank the performers who generously shared their experiences with me and provided many laughs along the way. My sincere gratitude goes out to my supervisors: Dr. Ama de Graft- Aikens, for her patience and understanding and genuine interest in the arts; and Dr. Caroline Howarth, for her rich theoretical contributions which serve as the backbone of this research. Thank you for your guidance that helped to cultivate my inner social scientist. I also extend my appreciation to Professor Cathy Campbell for opening my eyes to new possibilities. To my family, it goes without words that I could not have done this without your consistent support (both emotional and financial!) and encouragement. Above all, I would like to thank my friends. Because of you, I come away from this whirlwind year with amazing memories, a fresh perspective and a touch of sanity (though that may be debatable). Your compassion and good humor made this an incredible journey and I look forward to the adventures ahead! Cracking Up | Cuddington (2009) | Page 5 Chapter One 1.0 Introduction As Mark Twain once said, “against the assault of laughter nothing can stand”. Freud (1928) viewed humor as one of the healthiest defense mechanisms. He believed that humor allowed individuals to maintain a detached perspective in adverse situations, thus avoiding the depression, anxiety, and anger that might arise while maintaining a realistic view of oneself and the world. A novel and exciting program in Canada is exploring whether the cliche “laughter is the best medicine holds” true for the challenges of mental illness as well. Mental illness presents a dual challenge. On one hand, people with mental illness battle with symptoms and the side effects of treatment. On the other hand, they endure social challenges that result from the stereotypes and prejudice, fueled by ignorance and misconceptions about mental illness. Modern investigations of stigma began with Erving Goffman (1963) whose influential work Stigma: Notes on the Management of Spoiled Identity defined stigma as an “attribute that is deeply discrediting” and that reduces the bearer “from a whole and usual person to a tainted, discounted one” (p.3). While the field has evolved, stigma, beyond any limitation, conjures images of social judgement, intolerance and discrimination. The pernicious impacts of mental health stigma attacks on two levels: the psychological disposition as well as the interpersonal processes between individuals and groups. Public stigma is the reaction of the general public to people with mental illness that emerge in interpersonal interactions as well as stereotyping and negative images of mental illness in the media. With an arsenal of accompanying repercussions, ranging from health insurance and housing issues, to unemployment and decreased life satisfaction (Link & Phelan, 2001), stigma can prevent patients from receiving the best treatment, or at times stigma prevents individuals from seeking any treatment at all (Holmes & River, 1998). With stigmatization, there is also the possibility that an individual will internalize negative messages. Self-stigma manifests diverse responses. Coined as the “paradox of Cracking Up | Cuddington (2009) | Page 6 self-stigma” (Corrigan & Watson, 2002) some typical responses include decreased confidence, loss of self esteem and withdrawal; whereas individuals at the opposite extreme become energized by prejudice and express justifiable anger, feelings which are then channeled into activities such as activism and empowerment. While most anti-stigma campaigns are centered on mental health consumer movements, or “Mad Pride” campaigns, Stand Up for Mental Health provides a unique entry into mental health empowerment and advocacy. In this paper, I will explore the possible contribution of the arts in the creation of positive group identities that will help mobilize marginalized groups to engage in resistance against stigma, an exploration framed through the lens of social representations. 1.1 Stand Up for Mental Health Program “Most people think you have to be nuts to do stand up comedy. We offer it as a form of therapy” - slogan for Stand Up for Mental Health Stand Up For Mental Health (SMH) is a twelve month program that teaches stand up comedy to people with mental illness. This innovative program was created in 2004 by David Granirer, a counsellor and stand up comic who also has depression. The program’s mission is twofold: to empower participants and increase their confidence and to challenge public stigma towards mental illness. Each potential student undergoes a screening interview to make sure he or she meets the criteria for participation in Stand Up For Mental Health. Participants must: • Have a mental health illness or mental health issues • Have stable housing • A support system of both peers and professionals • Be stable on any medication they are taking • Have a reasonable command of written and spoken English • Have the motivation and desire to create healthy change • Have a desire to do stand up comedy The program consists of three phases. Following a brief screening interview, selected participants take an initial three month course in which students learn how to write, perform, structure and edit a comedy act lasting between 3-6 minutes. After three months of weekly classes, the students do their first “warm up” shows in venues Cracking Up | Cuddington (2009) | Page 7 selected because the audience is known to be supportive. After 2-3 warm up shows, the participants are featured at a debut performance gala at a local theatre. In the second phase, which last six months, classes are reduced from weekly to biweekly. The class focus now becomes honing comedy skills, learning advanced writing techniques and interactive comedy skills, and developing a whole new set for their Graduation Showcase. During this period, students perform regularly averaging 20-30 in various venues ranging from conferences and forums, treatment centers, university and college campuses, and other public events. Once students have finished their first year, they are invited to join the Alumni Program, the third phase. This group meets once every two weeks which allows students to continue writing and performing. Please take this opportunity to review Appendix I (the CD), which is a video compilation of a few performances designed to give a flavor of the program. This inspiring and creative program provided the impetus for the research presented in this dissertation, in attempt to tease apart the different elements and conceive a suitable theoretical explanation for the program’s effects. 1.2 Personal Motivation and Research Questions This research was borne out of my love of the arts, my appreciation of their role in well-being and finally my own experiences with stand up comedy. In 2006, I took a stand up comedy class, also taught by David Granirer, which is how I learnt about the SMH program. I was intrigued by how such an obscure activity such as stand up comedy could produce such radiating effects on confidence, self-esteem and self-efficacy. While not a traditional art form, stand up comedy is a unique performance skill. And unlike other artistic mediums such as dance, theatre or music, stand up comedy uses words, language and stories that are not only written but also performed by the same individual. Through my own experiences in stand up comedy, both as a comic and as an audience member of a SMH show, I became interested in studying the features of the program that enabled SMH to create empowering spaces as well as the program’s concurrent effect on public stigma. This curiosity led to the formation of two research topics. Using knowledge of community psychology, I sought to assess how the stand up comedy format used in the program created opportunities to negotiate new positive and Cracking Up | Cuddington (2009) | Page 8 empowering identities. Furthermore, I sought to explore how these newly created positive identities are complemented by dynamics of stand up comedy to fuel resistance against the negative social representations of mental illness. Chapter Two 2.1 Conceptual Framework In the section that follows I will describe the status of mental health stigma related research. I will continue by discussing the theoretical framework that will contextualize the program specifics and underpin my research questions. In the final section of Chapter 2, I will attempt to capture some of the literature specifically related to Stand Up for Mental Health, namely social representations of mental illness, the role of humor and a snapshot of the arts’ role in positive identity creation. 2.1.1 Mental Health Stigma Research Mental health stigma has been researched from multiple vantage points. Wahl (1999) investigated mental health consumers experiences of stigma whereas other’s have probed into the role anticipation of perception of stigma (Angermeyer, Beck, Dietrich, & Holzinger, 2004). Research has also illustrated the importance of considering subjective understandings of stigmatized conditions and societal reactions in order to understand the relationship between stigma and self esteem (Camp, Finlay, & Lyons, 2002). Other studies have explored how social support modifies perceived stigmatization (Mueller, Nordt, Lauber, Rueesch, Meyer & Roessier, 2006), the structural levels of mental health stigma (Corrigan, Markowitz, & Watson, 2004) and the potentially dehumanizing relationship with mental health professionals (Schulze, 2007). Building on various theoretical explanations of stigma, mental illness anti-stigma programs have attempted to reduce the impact on people’s lives through coping techniques and public campaigns to reduce the continued acceptance of prejudice toward mental illness. Although mental health research has explored at great length the Cracking Up | Cuddington (2009) | Page 9 impact of stigma, only recently has the research attempted to explore how best to confront stigma. Within this field, three approaches to confronting stigma have been developed (see Campbell & Deacon, 2007 for review). The first approach emphasizes individualistic explanations for stigma. It draws primarily on social cognition approaches which examine psychological attributes of perpetuators and targets and the interaction between them. As an example of this approach to mental health stigma, Corrigan et al. (2001) proposed a trinity of education, contact and protest grounded in social attributional theory as the most effective way to challenge stigma. The lack of widespread results arising from individual approaches has shifted the focus to macro-social inequalities. From this perspective, stigma is not an individual reaction but a social process linked to power, dominance and exclusion (Parker & Aggelton, 2003). Macro-social stigma interventions regarding mental health have included changes in legislation; however, despite these changes mental health stigma persists at an alarming rate. Link and Phelan (2001) adopt an approach that defines stigma in the relationship of several interrelated components, bridging the polarity between individual and macro- social approaches. In their conception, stigma exists when elements of labeling, stereotyping, separating, status loss, and discrimination co-occur in a consenting power situation. Building on this, Joffe (1999) accentuated that in the construction of stigma, individual and society are inseparably connected: a conception suited to an approach guided by Social Representations Theory. 2.1.2 Social Representations Theory The discipline of social psychology must embrace both the social and the psychological in its aim to study the relationships between the individual and society (Moscovici, 2000). To sufficiently understand mental health stigma, we need an approach that focuses on the dialogues between self and society, emphasizing the co- construction of reality. Hence the capacity of Social Representation Theory (SRT) to simultaneously conceptualize the power of society and the agency of individuals demonstrates its utility for stigma research (Howarth, 2006). Cracking Up | Cuddington (2009) | Page 10