Impact case study database

Widdows has 1. changed NGO practices and campaign messaging around lookism 2. stimulated policy debate, by direct collaboration with policy makers and through influence on the Nuffield Council on Bioethics’ programme of work and 3. changed public attitudes and understandings of the pressures to be perfect.

1. Lookism is becoming a recognised term for appearance discrimination, changing the practice of NGOs and shaping their campaigns.

Lookism and the #EverydayLookism campaign have been incorporated into NGO recommendations and practices and ‘lookism’ is increasingly being used to name appearance discrimination in activist circles. [R1] Widdows’ influence is particularly visible in two campaigns:

• The national anti-bullying charity Ditch the Label included a chapter on lookism in the Annual Bullying Survey for the first time in 2019. The report showed that the most prevalent form of bullying is appearance bullying, with 59% reporting that they had experienced bullying “attitudes towards my appearance” in the previous twelve months. Yet appearance bullying is taken less seriously than bullying based on race or gender because it is not recognised as discrimination. The report featured a supporting quote from Widdows: “We need to take this form of bullying very seriously or the epidemic of body image anxiety will spiral out of control. Lookism is discrimination, and in a world where appearance increasingly matters, a particularly devastating form of discrimination”. [S1]

• The Mental Health Foundation’s briefing paper ‘Image-editing Apps and Mental Health’ (September 2020) [S2], cited R1 directly and approached Widdows to be its spokesperson, resulting in prominent exposure by the BBC. [S8] The report has six recommendations of action. The first directly recommends that “organisations and individuals should engage with #EverydayLookism.” [S2] The report draws directly on Widdows’ framing of lookism and takes its wording from #EverydayLookism: “negative comments about other people’s bodies matter. When we shame bodies, we shame people. These are lookist comments. We no longer put up with sexist comments, we don’t need to keep putting up with lookist comments. Sharing your lookism stories shows how common lookism is, calls it out, and says it’s not ok.” [S2, directly quoting S9] Widdows’ comments in support of this briefing paper in particular were quoted in 264 outlets directly, reaching an audience of 11.6m. [S8]

1. Policy makers have changed how they regard the demands of beauty seeing it as a public health issue meriting communal and regulatory responses.

2.i. Policy makers have changed their attitudes with regard to the seriousness of the demands of beauty. Policy makers at all levels now recognise that beauty and body image raise public health issues which need communal responses and regulation. At the beginning of the impact period, appearance tended to be regarded as trivial, a matter for individuals to choose and not an issue of public concern, making regulation and communal responses unnecessary. That policy makers have changed their views is evidenced by their interventions. For example, following meetings with Nuffield Council on Bioethics executive, five parliamentary questions were asked (from Clive Lewis MP, Bambos Charalambous MP and Baroness Gould), showing a commitment to regulate. MP Luke Evans has produced draft legislation (Digitally Altered Body Images Bill 2019–2021) that requires advertisers, broadcasters and publishers to display a logo in cases where an image of a human body or body part has been digitally altered. That Widdows is influential is evidenced by Evans discussing the proposed legislation with her. Evans has agreed to participate in a series of Facebook Lives, arranged in December 2020, due to run in 2021. These are hosted by Widdows, with policy makers (MP Luke Evans, MP Bell Ribeiro-Addy, MP Chris Evans) and NGOs (Mental Health Foundation, Anti-Bullying Alliance, Face Equality International, Girlguiding), showcasing the position that body image concerns are public health issues. [R1, R5; S3] In addition, funding to research the impact of social media on body image was suggested as a matter of urgency by the Women and Equalities Committee’s inquiry into body image (September 2020). Widdows submitted a written response to this inquiry, which resulted in correspondence, and the sending of R1 to the Chair. In addition, Widdows was named and R1 cited directly in the oral evidence for the need for further funding: “That would be absolutely the first step, to get social media companies to fund research […] [F]rom a philosophical perspective, one thing that is really puzzling and interesting is to understand the connection between our real selves, who we are, and the imagined self, as Professor Heather Widdows puts it, that we present on social media.” [S4]

2.ii. The policy debate was stimulated by the intervention of the Nuffield Council on Bioethics (NCoB), which in 2017, produced a report, ‘Cosmetic Procedures: Ethical Issues’ (CP). [S5] Widdows was influential in the NCoB decision to consider this topic and, through collaboration with her AHRC Beauty Demands Network and the publication of The ‘Beauty Demands: Briefing Paper’ (BDBP) [S6], she directly and substantially influenced the content of the report.

The NCoB is the UK’s national ethics committee, and the UK’s equivalent to the President’s Council of Bioethics in the US or the German and French National Ethics committees. Since 1994, NCoB has been funded jointly by the Nuffield Foundation, Wellcome Trust and the Medical Research Council to produce recommendations that have a direct influence on policy debates, and what is seen as good ethical governance. NCoB has established itself as the main UK body that other countries and international bodies look to for guidance on bioethics.

That the NCoB considered cosmetic surgery at all can be traced to Widdows’ intervention. She influenced the decision as a member of the Council, as a member of the ‘Future Work’ subgroup, and through Nuffield’s formal partner status on the Beauty Demands (BD) project, on which Widdows was PI. Many of the topics and recommendations of the NCoB report were prefigured in the BD documents and the BDBP. [S6] The BDBP was co-authored by Widdows and the Deputy Director of the Nuffield Council, and launched at the Bedford Square Nuffield premises on 9 June 2016. That Widdows’ BD project was fundamental to the NCoB’s work is explicitly recognised in the acknowledgements of the CP. The acknowledgements are only two paragraphs and the second is wholly dedicated to BD and recognises the NCoB’s Working Party (WP) “benefited considerably” from the partnership with BD. [S5] The importance of BD is confirmed by the Deputy Director who reported to the AHRC that BD “provided both a helpful short-cut to important areas of debate and literature, and also facilitated contact with key individuals working in the field, who have subsequently engaged in the project either as Working Party members, or through providing direct evidence and input through the Working Party's consultative activities”. [S7] Nine of the twelve WP members were key contributors to BD. Widdows’ central role in the report is shown by the fact it was she who presented the Nuffield’s work on cosmetic procedures to the French and German ethics committees, at the biennial 2017 trilateral meeting. In addition to policy change, following the NCoB’s recommendation, the Advertising Standards Authority now considers how adverts can increase the demand for cosmetic procedures and, in September 2019, it sanctioned two beauty chains for adverts featuring celebrities.

1. Global public understanding and public attitudes are changing, and pressure to engage is increasingly taken seriously and not seen as trivial or individual.

That public attitudes are being shaped is shown by extensive media engagement. Widdows’ work has been discussed and cited by national and international print, radio, film, TV and social media. [S8] Widdows is the ‘go to’ expert for discussion of the rising demands of beauty and how they are impacting on individuals and changing culture. Widdows has been cited across all five continents with particular take up in the most dominant national papers in Australia, the UK and the US. To illustrate, a selection of news outlets includes: in the UK, BBC, The Daily Mail, The Guardian, The Irish Times, The New Statesman, The Sunday Times and The Telegraph; in the US, CNN, Time, The Atlantic, The Boston Globe, The Huffington Post, The New Yorker, The New York Times, Vogue and Women’s Health; and in Australia, Brisbane Times, The Age and The Sydney Morning Herald. Her recorded media reach since 2016, according to Kantar and Meltwater reports, is 28m. These citations capture Widdows’ mentions with her University affiliation and do not capture mentions that use her more popularly used title ‘British Philosopher Heather Widdows’. [S8] She has featured on numerous national radio shows, international podcasts, and TV programmes and documentaries. [S8] One documentary on ‘Future Beauty’ (VPRO Tegenlicht), after interviewing Widdows, was released as ‘Perfect Me’. To give details on another, Widdows’ appearance on the BBC4 Thinking Allowed has reached a total of 1.25m listeners to date, and her combined listener numbers in 2018 from numerous podcasts and radio programmes numbers are over 2.38m. She has also broken into ‘new media’, including appearing on the popular Vox.com documentary series ‘Explained’ which launched on YouTube and is now hosted on Netflix. Widdows was an invited expert in the 15-minute episode on plastic surgery, with the producer saying, “Perfect Me has been integral in shaping my views on the topic”. [S8] ‘Explained’ (9.1m subscribers) regularly reaches 1.66m views per episode on YouTube.

Widdows’ voice is unique in this space; that she is leading and changing the debate is shown by the way her work is considered transformative of the debate. This is well illustrated by the following examples:

• Perfect Me was listed as one of the best 19 books of 2018, by The Atlantic Magazine, which said it is “urgently relevant to the current cultural moment”. [S8]

• Vogue described Perfect Me as “groundbreaking” and Maclean’s as “a buzzed about book”.

• Edarabia listed Perfect Me as one of the 100 books to read in a lifetime. [S8]

• Bri Lee, Australian journalist and author of Beauty (2019) and the award-winning Eggshell Skull (2018), wrote that Perfect Me “freed me from years of accidentally accumulated bullshit thinking” in an article based on four Books That Changed Me. [S8]

Public understanding change is further evidenced by the way the public engage with Widdows’ work. The strongest evidence of the depth of the attitude change is shown by the engagement with Widdows’ #EverydayLookism campaign, which has been picked up by the media, has a successful Instagram account, and resonates with hundreds of people who have shared their very personal #EverydayLookism stories. [S9] In the three weeks following the launch, the campaign received 74,886 video views, 13,449 engagements and 1.03m saw the campaign. The stories are body shaming stories, deeply personal and full of feeling, and convey just how deeply lookism cuts. To give just two representative examples: “‘I can’t believe grandma spoilt you so much! You are so fat! You need to loose (sic) weight right now!’ said my mom as she put me on a diet when I was 6 years old. I battle food addiction to this day — I am 36.” (Story 530), and “My friends called me ‘finger toes’ when I wore sandals to an evening out. I never buy or wear open shoes because of that and it was 15 years ago” (Story 411). [S9] To date, the #EverydayLookism blogs have over 46,000 views and the campaign has received over 800 story submissions. The campaign produced the first anti-body shaming (#stopbodyshaming) GIPHY (with 523,987 views) and #EverydayLookism posts are regularly ‘top’ results for the Instagram #stopbodyshaming hashtag (with 171,000 posts), showing Widdows is leading the debate on this platform. [S8]

Pictured: A still image of the #EverydayLookism GIPHY. It depicts the words Stop Body Shaming next to a sketch of a red megaphone.

That the campaign is successful is shown in the take up of an anti-lookism mantel across a broad church of organisations and campaigners. For example, journalists and presenters from the Atlantic, Vogue and the BBC (Molly Forbes, Shahidha Bari, Melissa Seley, Clem Prendergast) and social media influencers (Love Disfigure and Anti Diet Riot Club) with a total public following of 279,761 on Instagram joined Widdows in a series of Instagram Lives which ran from the #EverydayLookism account. The mini-series ran for eight weeks and the #EverydayLookism Instagram now has over 300 posts, with up to 4,820 engagements per post. The #EverydayLookism campaign has been picked up by the ITV Central News, Birmingham Mail, Free Radio, Adrian Goldberg’s Talk Show and Body Cons podcast in media showing secondary reach. It is also being picked up by schools: sixth-formers at Hillcreast School agreed all body shamming should stop; Altrincham Grammar School for Girls have included the campaign in their Citizenship and PSHE classes; St Swithun’s sixth-form had a reading group on Perfect Me and tweeted that they were “filling in our examples of #EverydayLookism” [S8]; and a Year 12 student in Toronto was “inspired” to undertake a school project with her class and set up a YouTube channel. Since the #EverydayLookism campaign began in 2019, people from over 123 countries have taken Widdows’ MOOC. [S8] Over 3,000 people have attended over 20 public events on beauty, highlights of which include, Widdows appearing at the Hay Festival twice (2014 and 2018). [S8] Data collected from just four of Widdows’ talks, (to over 1,000 people in Birmingham, Oxford and Swindon) show that 81% of the attendees who filled out questionnaires agreed that the talk had changed their perception of beauty, and 78% agreed that beauty raises ethical and moral dilemmas. [S10]

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.