Journal of Nursing Education

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Educational Innovations 

Looking Below the Surface: Developing Critical Literacy Skills to Reduce the Stigma of Mental Disorders

Margaret McAllister, EdD, RN

Abstract

Although clinicians and the public are more informed about the factors that give rise to mental disorders, stigmatization does not seem to be abating. This article argues for one solution: altering the way students are taught, moving beyond content toward a focus on enticing attitudinal shifts, such as empathy and personal commitment to social change. This article describes a strategy for learners to develop critical literacy skills and to acknowledge and develop their role in encouraging students to become critical agents who possess the knowledge and courage to struggle against despair and to embrace hope.

Abstract

Although clinicians and the public are more informed about the factors that give rise to mental disorders, stigmatization does not seem to be abating. This article argues for one solution: altering the way students are taught, moving beyond content toward a focus on enticing attitudinal shifts, such as empathy and personal commitment to social change. This article describes a strategy for learners to develop critical literacy skills and to acknowledge and develop their role in encouraging students to become critical agents who possess the knowledge and courage to struggle against despair and to embrace hope.

Dr. McAllister is Associate Professor, School of Health and Sports Science, University of the Sunshine Coast, Maroochydore, Queensland, Australia. At the time this article was written, Dr. McAllister was Associate Professor and Postgraduate Programs Coordinator, School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia.

The author thanks the second-year undergraduate nursing students enrolled in the Human Responses in Crisis course taught within the Bachelor of Nursing Program, Griffith University, Nathan Campus, in 2005 for their inspiration, their willingness to share their learning experiences, and their assistance in greater critical reflection on the author’s teaching practice.

Address correspondence to Margaret McAllister, EdD, RN, Associate Professor, School of Health and Sports Sciences, University of the Sunshine Coast, Maroochydore, 4558, Queensland, Australia; e-mail: mmcallis@usc.edu.au.

Received: March 23, 2006
Accepted: August 11, 2006

Mental disorders are significantly disabling, ranking second in the burden of disease in established market economies such as the United States and Australia (Murray & Lopez, 1996). This disability is made worse by a continuing stigmatization of people with mental disorders. Although there is evidence that the public now know more about mental disorders (Jorm, 2000), the increase in knowledge may not be defusing social stigma. Phelan, Link, Stueve, and Pescolido (1997) found that the perception of people with psychosis as being dangerous is stronger today than in the past. Link, Phelan, Bresnahan, Stueve, and Pescolido (1999) found that the American public of the 1990s, compared with the American public of the 1950s, desired greater social distance from people with serious mental disorders.

This ongoing stigma compounds people’s unwillingness to seek help, delaying and exacerbating the experience of mental disorders (Kessler et al., 1996). It also leads others to avoid living with, socializing with, working with, renting to, or employing people with mental disorders, especially severe disorders such as schizophrenia (Corrigan & Penn, 1999; Penn & Martin, 1998). It reduces access to resources and opportunities (i.e., housing, jobs) and leads to low self-esteem, isolation, and hopelessness. In its most overt form, stigma results in outright discrimination and abuse. It also deprives people of their dignity and interferes with their full participation in society (U.S. Department of Health and Human Services, 1999).

No single approach to the reduction of stigma is likely to be successful. Advocacy programs, public education, and contact with individuals with mental illness through schools and other societal institutions are all important innovations (Corrigan & Penn, 1999). This article suggests that undergraduate nursing education using a particular approach called critical literacy may constitute one additional weapon in the armory.

The argument is that clinicians need cultural and social skills to influence public opinion, enhance tolerance, deepen understanding, explode myths, and work to effect social change. Critical literacy is an important cognitive skill, effective in raising consciousness about inequity and injustice.

Critical Literacy

Critical literacy is a key skill for those committed to social change. Being literate means having the ability to fluently read a text. In the context of this activity, it refers to media texts that sometimes subtly convey meaning that shapes public conceptions. Too often, people are passive consumers of information and are not conscious of the ways media shape, construct, and constrain what we see and what we come to believe (Gee, 1999).

Becoming critically literate is essential for nurses because it may help us to participate more consciously and effectively in the social practices that affect mental health, as well as the nursing discipline. It helps to be alert to activities that might not be serving the interests of nursing or clients. Being aware of how language is used in powerful ways means nurses may be more likely to contest misconstrued or misleading mental health representations in policy documents, news stories, television, and film. Critical readers are those who are conscious of subtle messages and are therefore less likely to be manipulated by covert, subtle, and sometimes harmful constructions. For socially conscious nurses, there is an imperative to work to transform, not just replicate, existing social practices. By teaching critical literacy skills to mental health nursing students, they can appraise media messages and look below the surface to see how power, ideology, language, and dominant forces help to keep the situation from changing. This article will now describe one such teaching innovation that occurred in 2005 in a mental health course within a bachelor of nursing program at a major Australian university.

Method

The teaching strategy had four broad aims:

  • To encourage students to disrupt the commonplace by looking at the everyday practice of media-watching and seeing representations of mental health through a new lens.
  • To interrogate multiple viewpoints by encouraging students to examine a variety of different kinds of text to make differences in perception, meaning, and interpretations visible.
  • To use a sociopolitical lens by raising students’ consciousness about the historical representations of mental illness and how they have changed across time, and by encouraging students to critique social constructs, rather than simply focusing on psychosocial skills acquisition.
  • To activate students by moving them from being consumers of media stories to more active producers of knowledge, and by encouraging them to promote social justice by questioning practices of oppression and exclusion.

Approximately one third of the semester was spent engaged in this awareness raising and activating exercise. Two thirds of the semester then focused on conveying and developing knowledge and strategic helping skills for a range of mental disorders. In addition to a multiple-choice examination, an assignment was planned as the end point for this social justice learning, around which interactive lectures, tutorials, and readings were prepared. The aim was for students to be able to:

  • Participate in dialogue about prominent social issues in mental health.
  • Raise their consciousness about issues taken for granted.
  • Deconstruct conventional constructions.
  • Generate recommendations for ways to revise the conventional constructions.

Students were asked to write a report analyzing three kinds of text (Table 1). Over a period of 4 weeks, students were engaged in interactive lectures and tutorials that explored a range of topics, including a historical overview of mental health, wherein assumptions, theories, and practices related to treatment of mental disorders were examined for how they have or have not changed over time, and textual analysis theory and practice using examples from literary, artistic, musical, and film representations of mental illness. Students gained knowledge about cultural theory, critical literacy, and textual analysis, and they critically examined how concepts such as power, gender, language, and history are played out within mental illness texts. Students shared ideas of what messages were or were not being sent and what meanings could be made within a range of texts, including photographs, magazine covers, cartoons, and film stills.

Assignment

Table 1: Assignment

Discussion

The interactive nature of the teacher-student relationship was crucial throughout this learning process and cannot be underplayed. It is about attending just as much to process as to content. As Ayers (1998) explained:

Teaching transformatively demands a dialectical stance: One eye firmly fixed on the students—Who are they, what are their hopes, dreams, and aspirations? What are their passions and commitments? What skills, abilities, and capacities does each one bring to the classroom?—and the other eye looking unblinkingly at the concentric circles of context—historical flow, cultural surround, economic reality. (p. xvii)

In attending to process, a tone of informality and curiosity was set. An expectation of mutual respect was made explicit and also implicitly conveyed, whenever possible, by the teacher addressing the student by name, expecting silence when a person was speaking, and using peoplefirst language when discussing people with mental disorders or disabilities. Well-prepared Microsoft PowerPoint® presentations with interesting, engaging material about the life histories of artists, poets, musicians, and authors who experienced mental disorders helped students appreciate the complexity of the issue. As a contrast, stories of stigma and alienation were also provided, especially those conveyed in film and television media, with powerful effect, as one student wrote:

I very much enjoyed the lecture relating to mental illness in the arts and music. It really gave a perspective to the condition that I did not hold before. I had an understanding of mental illness in the context of a hospital admission but can now understand a little of what it can be like to live with it at home and in the community. People with mental illness can lead productive lives and in fact have given humanity some of their most prized jewels.

The teacher tried to model excitement with the subject matter and provide enthusiastic support when students offered fresh insights. This helped to induce hesitant students to speak. Thus, a deliberate, consistent effort from the teaching team was made to move away from the instrumental, or transmissional, stance to generate dialogue and show students how to practice critical literacy rather than passive acceptance. Throughout each lecture and tutorial, examples of representations were repeatedly offered, as well as how to critically review the text. Table 2 includes a series of questions designed to reflect, probe, deconstruct, and reveal alternatives to the way mental illness was being presented. Students were encouraged to use these questions as a guide for their own textual analyses.

Questions to Guide Critical Literacy Analysis

Table 2: Questions to Guide Critical Literacy Analysis

Critical literacy concepts important to advocating changing public attitudes toward mental health were also explained, applied, and discussed. For example, discourse was explicitly explained and applied to mental health as embodied in the personal narratives and stories people tell to explain the meaning, function, and roles of people with mental health problems; the work of clinicians; and the nature of mental illness in a culture. This discourse may be conveyed and reproduced in popular culture. It also has the power to influence educational policy and practice. For example, when The Snake Pit (Litvak & Zanuck, 1948) was released, it led to such a public outcry about inhumane conditions that funding for mental health services was increased, helping to support John F. Kennedy’s community health policy and paving the way for deinstitutionalization to begin in the United States (Satel, 2003).

The concept of myth—when a representation is particularly resonant with a culture, it evolves into a myth that allows members both inside and outside of the culture to understand the phenomenon it describes—was discussed. The literature reveals several common myths about mental illness (i.e., the mad as dangerous, unpredictable, not normal, and visibly different) (Hazelton, 1997; Hyler, Gabbard, & Schneider, 1991; Philo et al., 1997; Wilson, Nairn, Coverdale, & Panapa, 1999), as well as theories about the purpose these representations serve (Foucault, 1961/1973; Gilman, 1995). Students learned that one cannot dismiss popular culture as mindless entertainment because its representations of mental health shape our actual or expected mental health experiences. It may tend to reinforce fear toward people with problems, or it may reinforce stigma toward the mental health profession. However, representations that are more realistic may move people to feel compassion and even entice students to enter mental health professions.

Students learned to reveal, deconstruct, and attempt to revise popular culture’s mental health myths so that real learning and motivation to lead change is made possible (Grant, 2002). Some people, including young people with limited life experiences who one day will be influential clinicians, may only have experienced mental health through films. Excerpts from films such as Bedlam (Robson & Lewton, 1946), Psycho (Hitchcock, 1960), One Flew Over the Cuckoo’s Nest (Forman, 1975), Fatal Attraction (Lyne, 1987), A Beautiful Mind (Grazer, Howard, & Goldsman, 2002), and Good Will Hunting (Van Sant, 1997) are used to explore myths about mental illness, skilled caring, and social change.

Students learned that representations have shifted throughout the twentieth century, that they are not static, and that they are thus subject to change. For example, students examine Shine (Hicks, 1996), which is a story of hope for an individual experiencing a lifetime of distress, his loved ones, and the community. David Helfgott’s experience is portrayed as shaped by and shaping the world around him. His beauty, strengths, and shared humanity are emphasized and celebrated. Students also learned that although the text is contemporary, it does not automatically contain enlightened messages. Excerpts of television series such as Law and Order: Criminal Intent (Wolf, 2005) revealed lingering unhelpful myths, such as dangerousness and unpredictability.

All of these practices were what established the conditions necessary to give students the confidence to test their newly learned critical literacy skills, the opportunity to be active and move beyond the expected passive stance, and the encouragement to believe in, and extend, their own opinions and arguments. Many of the students were able to demonstrate these cognitive skills well. The following response from a student who analyzed the movie K-Pax (Softley, 2001) is evidence of this:

In this movie the director goes to great lengths to challenge the audience’s perceptions about what is sane and insane. The audience is led to conclude this is not an easy determination and that pre-judging either way can be highly detrimental to the individual. Throughout the entire film the audience is encouraged to believe the main character “Prot” is an alien. Significantly, Prot is first noticed by a cripple in a wheelchair, one of the so called “invisible” people in society. Prot is always portrayed as calm and honest, two things that distinguish him from the surrounding chaos.... The director illustrated how “difference” can make people fearful and insecure and that it doesn’t take the threat of physical violence to do this….

Overall, these representations… were helpful to the cause of the mentally ill. The film emphasized the folly in prejudging others and portrayed mental illness like any other illness, something with which anyone may be afflicted. The film portrayed an attitude of hope and possibilities of recovery.

Evaluation

Critical literacy skills have been shown to be useful in awakening peoples’ awareness of the way the media shapes dominant attitudes, and in giving people new skills in using and producing texts (Sartorius, 2004; Wadsworth & Thompson, 2005); but in terms of nursing and mental health, it is possible that these skills may have still more useful purposes.

A course evaluation completed immediately following the innovation previously outlined produced meaningful data. A limitation is that the online evaluation produced a disappointingly low response rate (30%, N = 43). However, in addition to these data, 11 students e-mailed me to provide details about their learning experience. The low response to course evaluation may be because many students, despite reminders, do not regularly access their university e-mail. Alternatively, it may be that only those students who felt strongly (positively or negatively) about the content bothered to respond. Thus, the data below may not be generalizable, but the insights are interesting.

The following student’s comment reveals that critical literacy skills can help in enhancing effectiveness within the clinical role. She wrote:

Rather than passively listening to patients [critical literacy] teaches me to pick up on the finer details, giving me a more thorough understanding of the patient and [his or her] background.

The critical thinking skills learned in one context may also be transferred to other contexts, as this student’s comment revealed:

I think the textual analysis activity will be so helpful in my future practice. For example, we need to be more sensitive to design brochures and leaflets in a hospital context.… By being sensitive and critical, we can reduce overall stigma and misrepresentation about people with mental disorder.

This also shows high-level critical thinking. Many students (n = 66) said they felt engaged and enlightened as a result of the teaching approach having used examples and explanations of the many ways sociocultural practices influence mental health and illness.

Conclusion

It is hoped that sharing this attempt to change practice through education may be a spur to action, and uptake of the strategy may help more clinicians to see the relevance of social involvement. Teachers of mental health are therefore encouraged to apply and adapt the educational content and process outlined in this article as an innovative antistigma practice. In mental health, the major change to be achieved is reduction in stigma because, as stated in “Reducing the Stigma of Mental Illness” (2001):

Although we might hope that mental illness may one day be considered to be no worse a label than heart disease, diabetes or multiple sclerosis, this argument has so far failed to convince the general public. (p. 1055)

References

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Assignment

The Mental Health Association Queensland has commissioned you to write a report (approximately 2,500 words) on how effectively mental illness is represented in a variety of text types to the Queensland public.
To complete this task, you will be required to:
  Select from a range of items recommended by the course convenor that will include fictional, news, and academic texts.
  Be active in tutorial and learn about the issues. Debate whether representations of mental illness simply reflect public opinion or shape attitudes and responses. To do this, you will need to be familiar with concepts of critical literacy and cultural theory.
  Come to tutorial ready to analyze the ways in which the three different types of texts you have selected support, complement, or contradict each other. To do this, you will need to examine textual analysis and media representations in the literature.
  Use tutorial time to make judgements about the ways in which audiences or readers might respond to these differing representations. To do this, you will need to examine the nature of stigma, adaptation, and recovery.
  Come to tutorial ready to suggest ways in which fictional and news representations could better reflect the reality of those with mental illness and contribute to greater acceptance of difference in our community.
  Produce a final report. To do this, you will need to be familiar with report writing.

Questions to Guide Critical Literacy Analysis

What is this text saying/showing? (its surface level meaning)
What is being foregrounded?
What meaning do you make of this text? (Look deeper and suggest ways that health/illness is being portrayed, what effects it has on this person and on others, how is the author conveying these messages?)
Is this reflective of contemporary practice? If yes, how? If not, why not?
How common do you think this way of presenting nursing is?
What opportunities for change do you suggest?
Authors

Dr. McAllister is Associate Professor, School of Health and Sports Science, University of the Sunshine Coast, Maroochydore, Queensland, Australia. At the time this article was written, Dr. McAllister was Associate Professor and Postgraduate Programs Coordinator, School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia.

Address correspondence to Margaret McAllister, EdD, RN, Associate Professor, School of Health and Sports Sciences, University of the Sunshine Coast, Maroochydore, 4558, Queensland, Australia; e-mail: .mmcallis@usc.edu.au

10.3928/01484834-20080901-06

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