Impact case study database

1) The quality and accessibility of mental healthcare professional services have been improved in terms of service delivery (A) and service user experience (B)

(1A) Leading national mental health services have adopted more collaborative delivery of support services and revised elements of their client-centred service delivery

Mental health care provision has been improved, through changing how practitioners understand mental disorders that involve hearing voices, unusual beliefs and distorted memories (as in schizophrenia and dementia, affecting up to 10% of the population). Specifically, service providers accepted the argument for the continuity between delusional and non-delusional thinking [O1] which contributed to reducing stigma and misconceptions around mental health [O6] and breaking down barriers between medical practitioners and people with lived experience.

This change is attested to in a number of organisations:

• Training resources for staff and volunteers were revised based on Bortolotti’s project PERFECT findings at the mental health charity Mind in Camden and the leading national support group for hearing voices campaigners and activists Hearing Voices Network. This change in training enabled practitioners to reframe their understanding of the association between mental health and irrationality [O5]. They did this by participating in and supporting a six-session programme of Mental Health Philosophy Workshops (MHPW) proposed, organised and delivered by Bortolotti’s team, which ran in 2016 and 2017. The MHPW systematically addressed stigma, enabling a more collaborative approach involving service users, service providers, and caregivers, where participants’ voices could be heard and shape the provision. The Hearing Voices Project Manager confirms that they have changed their practice and adopted new, more collaborative, approaches: “The training created a shared learning experience where both personal and professional insights into paranoia and unusual beliefs could be discussed.” [E1]

• The mental health charity the Mental Health Foundation for England and Wales (MHF) used insights from Bortolotti’s project PERFECT’s research in 2016 to revise its advice and guidance for external organisations on supporting the needs of voice hearers. [O1–O5] The Director of MHF said, “PERFECT has helped inform work around reasonable accommodations for voice hearers in workplace settings with workshops and writing facilitating an understanding between HR practitioners, line managers, and voice hearers in creating shared understandings of practical responses to varying cognitions and perceptions.” [E2] This revision was flagged in MHF’s 2016 annual report.

• Further changes to training, at other mental health organisations, were informed through intensive versions of the MHPW series being delivered, e.g. at Inside Out Australia, Australia’s national body for clinical excellence in eating disorder treatment, and at professional development events for healthcare professionals such as a session on “Clinical decision making in a mental health setting” at Harplands Hospital. Inside Out’s Director and Co-Founder said that their organisation will incorporate further opportunities for these valuable conversations, “both by promoting the Philosophy of Mind open access workshop material and by offering future events and workshops.” [E10] In 2019, Inside Out Australia circulated the MHPW resources to their 1,035 members and 776 health professionals in their newsletter.

(1B) Vulnerable service users have been empowered, leading to improved social inclusion, and access to services and public discourse

• Participants in the initial MHPW series reported they would take the new approach to mental health and advocate for the adoption of this approach elsewhere in the community. This is attested to by their feedback, recorded as part of a podcast for Camden Community Radio nine months after the end of the activity. For instance, one participant said they would “use the resources on the many committees they were a member of e.g. the Royal College of Psychiatrists Mental Health Act Review” and another wrote that they would introduce “the resources to student mental health services at the college where they were registered as a mature student.” [E3]

• By reframing symptoms as not solely negative, the personal development and empowerment of mental health service users who took part in MHPW series has been facilitated, helping them to advocate for themselves in mental health contexts [O6] and influencing their practice as activists. This change was transformative. Three participants felt the MHPW series benefitted them to such an extent they sent additional feedback and updates to Bortolotti. Service User 1 said they were empowered to “engage in a potentially more productive conversation with healthcare professionals, in a way that is not confrontational but collaborative.” [E3] Service User 2 testified that the techniques learnt meant that they were able to question conventional wisdom and apply them to their familial and social interactions which “opened up new ways of looking into the mental and conceptual world.” [E3] Service User 3 noted “much more confidence in the validity of my particular viewpoint, and a stronger sense that it might actually count for something.” [E3] These testimonies are representative of the 25 collected following the MHPW series, with 90% indicating a sense of empowerment and increased confidence in social and professional settings. This is a significant outcome given that voice hearers are a hard-to-reach vulnerable group with only one in every three receiving diagnosis and staying in treatment.

• Thanks to the MHPW resources being available open access complete with instructions for facilitators, the Occupational Therapy Assistant at HMP Pentonville in London delivered material from the workshop series during encounters with a vulnerable and hard-to-reach prisoner group [O6]. The aim was to fight mental health stigma via philosophical discussion and the outcome was a tangible and direct benefit judging from participants’ reports: detainees experienced a sense of empowerment and a new understanding of mental health. The series has been repeated since with considerable success: “The workshop content of the groups provided practical communication advice but also provided ‘something other than prison to think about’ (to quote a group member), focusing group members on larger questions and abstract thinking. The sessions were very popular with several participants taking materials back to their cells to share with cellmates and associates”. The Occupational Therapy Assistant commented that the workshops “provided an important, safe space for service users and staff to discuss important topics together and learn from one another on an equal basis.” [E4] Due to excellent feedback from the workshops in HMP Pentonville, the workshops led to the introduction of weekly Philosophy Groups in the prison’s Wellbeing Centre programme [E1]. The workshop material is cited as a direct example of “creative and innovative thinking and practice on behalf of prison leadership”. [E1]

2. Informing attitudes and values related to mental health advocacy amongst policy makers (A) and the wider public (B)

(2A) Enabling policy makers to recognise the need for training reform in relation to Mental Capacity Assessments

• Policy makers understood the need to detach poor mental health from irrationality and failures of agency due to engagement with Bortolotti’s research [O1–O2]. This enhanced understanding was achieved by targeted policy briefings aimed at legislators. The risk of biases affecting the assessment of mental capacity in people with a psychiatric diagnosis was acknowledged. Project PERFECT’s aims outlined in the brief, ‘Mitigating the risk of assumptions and biases in assessments of mental capacity’, presented the need for training for staff involved in mental health capacity decisions across the country. The document, championed by service user groups and mental health organisations (e.g., RE:CREATE Psychiatry, National Survivor & User Network, and SureSearch), was presented to parliamentarians, mental health practitioners, advocacy groups, legal experts, and policy makers in a webinar in March 2020. The webinar was very well-attended, receiving 423 views. [E10]

• The brief has brought change in the way policy makers working on revisions to the Mental Capacity Act viewed the effects of mental health stigma, as attested by the comments on the brief. The Labour (Co-op) MP and Shadow Chancellor of the Exchequer recognised the contribution of Bortolotti’s project PERFECT research to this shift: “There is now quite widespread recognition of the biases which affect decision-making […] Yet our awareness of these biases does not seem to feed into our understanding of mental health, which often categorises people as ‘irrational’ in an unspecified way. This can be a political issue; I’ve been urged previously not to engage with people with mental ill-health on the grounds that they ‘would not be interested’. These issues surely need more consideration, which is why I was pleased to see the progress of the PERFECT research project.” Alex Rucks Keene, prominent barrister and educator, said: “This work responds at so many different levels to issues that I am encountering in lots of different contexts, from practice to policy development. It is really important, useful, and grounded.” [E5] There is evidence that the need for reform has since been recognised in parliament in the discussion about new training for prison practitioners performing mental health capacity assessments (House of Commons debate on the Prisoners — Disclosure of Information About Victims — Bill, May 2020). [E6]

• Bortolotti acted as expert witness on an 18-month topical inquiry run by the Mental Health Foundation (MHF) into truth telling in dementia. [O2] The report, published in December 2016, adopted Bortolotti’s recommendations about the acceptability of not challenging patients’ delusions and confabulations in some contexts. [E7] This work promoting a more compassionate approach to symptom management in dementia patients was discussed in a blog post by the Director of MHF (“Is it wrong to lie to a person with dementia?” December 2016) and in an article by Bortolotti in Aeon reaching 406,266 people and receiving global attention . This exposure resonated with first-line caregivers, e.g. one reported that her father suffering from Alzheimer’s “benefited from people validating his frequently delusional thoughts. It’s not patronising but caring for his wellbeing.” [E10]

(2B) Broadened the representation and debate around mental health in wider publics

• Bortolotti has shifted public understanding of mental health, challenging conventional narratives and reflecting on the benefits as well as costs of behaviours associated with poor mental health. A film, Out of Blue, for which Bortolotti was a consultant on, ran at the London Film Festival in 2018. It won the Platform Prize at the Toronto Film Festival, and was listed among the ten best films in 2019 by Mark Kermode in The Guardian. The film’s lead character Mike was influenced by Bortolotti’s work such that (and the director states) she was “essential” to the characterisation and “the representation of delusions in Out of Blue is a complex one that doesn’t rely on the usual cinematic clichés!” [E8]

• Bortolotti’s engagement with mental health service users via the art collective Radical Sabbatical and the Barber Institute of Fine Arts Art Recovery group has further increased participation and social inclusion. [O1–O6] Through events, including talks, film screenings and exhibitions (for the Arts and Science Festival 2014–2019), Bortolotti changed public perceptions. For example, participants commented with regard to a session on bipolar disorder that it was “A huge relief to me hearing that BD or some symptoms like BD happen to many people else”; and that “The session has given me a much more nuanced understanding of bipolar disorder in particular but also mental health more generally.” [E9]

• The reach of Bortolotti’s work is evidenced in her extensive national and international media coverage with audiences of several million. [E10] Examples include BBC Radio 4 ‘The Philosopher’s Arms’ in 2017 (reach 2,996,500); BBC Radio 5 ‘ Live Breakfast Show’ in 2019 (1,592,333); BBC World ‘The Forum’ in 2014 (2,996,500) . Bortolotti has been cited in, e.g. Radio Free Europe (Balkans) in 2020; The Guardian in 2019 (1,944,228); Corriere della Sera (Italy) in 2018; New Scientist in 2017 (126,230); Red Magazine (UK) in 2017; The Age (Australia) in 2017; Scientific American in 2016.

• Bortolotti’s team sought to create a more positive representation of mental health through participation in debates and presentations at festivals of ideas with large audiences [O3–O5] (e.g., HowTheLightGetsIn Global in 2020; Brain Awareness Week at Birmingham’s ThinkTank Museum in 2019; York Mediale in 2018; Hay Festival and TEDxBrum in 2017). They were also interviewed in podcasts for clinicians and the well-informed public (e.g., Association for Child and Adolescent Mental Health in 2018; Philosophy 24/7 in 2017; Philosofa in 2016). Citation from social media provide further evidence of reach. The Imperfect Cognitions blog (2014–2020) has had over a million unique views.