Psychiatry Research 220 (2014) 1043–1050

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

The film festival “AUSNAHME|ZUSTAND” (State of Emergency)—Do

feature films and documentaries on mental health reduce stigma
and influence help-seeking attitudes?
Ines Conrad a,n, Beate Schulze a, Sandro Corrieri a, Dirk Heider b, Georg Schomerus c,d,
Steffi G. Riedel-Heller a
a
Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103 Leipzig, Germany
b
Department of Medical Sociology and Health Economics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
c
Department of Psychiatry, Ernst-Moritz-Arndt-University Greifswald, Germany
d
Helios Hanseklinikum Stralsund, Germany

art ic l e i nf o a b s t r a c t

Article history: The study aims at evaluating the impact of the Germany-wide film festival “AUSNAHME|ZUSTAND” on
Received 17 December 2013 social distance and help-seeking attitudes of the adolescent audience. The festival, on the subject of
Received in revised form mental health, was staged for the second time, aiming to give a podium to the topic mental health and to
4 September 2014
inform and entertain an adolescent audience that has not been in close contact with the subject before.
Accepted 11 September 2014
Available online 19 September 2014
A pre-post test was carried out to look for the effect of feature films and documentaries on social
distance of the audience towards people with mental illness and on the change in help-seeking attitudes.
Keywords: A total of 532 young people with a mean age of 15.6 were questioned during the film festival in Leipzig.
Stigmatization As the results show, the effect on the viewers' social distance and their help-seeking attitudes strongly
Social distance
depend on the content of the feature films and documentaries. Two films improved attitudes – one both
Mental health
social distance and help-seeking, one only help-seeking. One film increased social distance, and two
films did not affect either outcome. Age, gender, and knowing someone with mental health problems
also turned out to be decisive factors influencing the development of social distance and help-seeking
attitudes. Feature films or documentaries about mental illness can reduce social distance or influence
help-seeking attitudes, but effects strongly depend on the particular film.
& 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction power is a prerequisite for stigmatization to occur. Discrimination

of a stigmatized group can take place on three different levels: as
Several theoretical models have been developed to describe the individual stigmatization of a group member, as structural dis-
process of mental illness stigmatization (Corrigan, 1998; Link and crimination (e.g. exclusion via regulation, rules and laws), and as
Phelan, 2001). In a widely used sociological model of stigma, Link discrimination qua self-stigmatization (e.g. internalizing negative
and Phelan, (2001) describe stigma as a process consisting of five attitudes into the self-concept and consequently avoiding the
interrelated steps. First, a person is labeled as mentally ill. This is active pursuit of opportunities) (Pincus, 1996; Link and Phelan,
followed by stereotyping, through which those labeled are linked 2001; Rüsch et al., 2005; Schomerus, 2009; Schomerus et al., 2010;
to negative characteristics rooted in dominant cultural beliefs. Bahlmann et al., 2013; Schomerus and Angermeyer, 2013). Indivi-
Stereotypes applied trigger negative emotional reactions and serve dual discrimination is the one best studied in the field of mental
as a justification to place those labeled in a distinct category, illness. Social distance is one of the most commonly used concepts
aiming to separate “us” from “them”. This is followed by status loss in measuring mental illness stigma. It enquires the willingness of
and discrimination. Finally, access to social, economic and political respondents to enter a series of social relationships with members
of other, often disadvantaged groups and acts as a proxy for social
acceptance (Parrillo and Donoghue, 2005). In our study, the films'
n
Corresponding author. Tel.: þ 49 341 97 24 336; fax: þ 49 341 97 24 569. effect on audience attitudes were assessed using an established
E-mail addresses: [email protected] (I. Conrad), social distance measure, addressing relationship situations parti-
[email protected] (B. Schulze),
[email protected] (S. Corrieri), [email protected] (D. Heider),
cularly relevant for an adolescent population (Schulze et al., 2003).
[email protected] (G. Schomerus), Up to now, studies have shown that previous social contact with
Steffi[email protected] (S.G. Riedel-Heller). people who have had mental health problems has been shown to

http://dx.doi.org/10.1016/j.psychres.2014.09.006
0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.
1044 I. Conrad et al. / Psychiatry Research 220 (2014) 1043–1050

be negatively related to social distance. Thus, personal face-to-face analyses for each individual film and interpreting results in the
contact with mentally ill people has been found to reduce desire for light of the films' specific storylines. In doing so, we are aiming to
social distance (Schulze et al., 2003; Angermeyer and Dietrich, contribute to elucidating the optimal content of video-based
2006; Conrad et al., 2009). The present study inquires whether contact interventions, which, in turn, may inform the program-
watching a documentary or a feature film on mental illness – and ming of future mental health film festivals.
thus having video-based social contact – has a comparable effect on Specifically, we aimed at evaluating the film festival “AUS-
desire for social distance (Baumann et al., 2003). The study further NAHME|ZUSTAND – Verrückt nach Leben” (“State of Emergency –
investigated effects of the film festival on help-seeking attitudes. Crazy for Life”). The festival specifically seeks to attract young
Previous research has shown that filmed social contact can be audiences. This is motivated by the fact that mental health first
equally effective as live social contact in improving attitudes, becomes personally relevant in adolescence, a formative period in
emotional reactions and intended behaviors. Video-based contact life when young people start developing a sense of personal identity
may further offer a number of advantages including that filmed and may experience significant emotional upheaval (Mussen et al.,
interventions have the potential to reach large audiences, offer 1990). In addition, adolescence marks the onset of many mental
consistency, have less risk of harm to presenters and are more cost- disorders (de Girolamo et al., 2012; Klein et al., 2013). Addressing
effective (Clement et al., 2012). However, these findings are limited this particular age group may therefore render anti-stigma inter-
to nursing student populations and specifically produced educa- ventions particularly effective. For one, previous research has
tional materials. By contrast, our study seeks to assess the effec- shown that it is well worth targeting adolescents in order to
tiveness of indirect social contact opportunities in real life prevent negative stereotypes about mental health before they are
circumstances. formed or become reinforced (Schulze et al., 2003). Moreover, the
The arts, in particular film festivals combining the presentation frequent occurrence of emotional problems among teenagers high-
of films with interactive events engaging the wider community, lights the importance of proactive help-seeking attitudes. Help-
have been proposed as an effective strategy to reduce stigma seeking intentions, then, are shaped by attitudes toward mental
(Quinn et al., 2011). In particular, the arts can change negative illness and mental health services. Two mechanisms appear to play
attitudes through constructing shared meanings, engaging audi- a particularly important role in this regard. First, a personal desire
ences at an emotional level and diminish perceptions of “other- for social distance was found to significantly reduce willingness to
ness” through personal identification with characters or artists seek psychiatric help. In fact holding negative attitudes towards
(Chung et al., 2006; Quinn et al., 2011; Evans-Lacko et al., 2013). In mental health problems and those suffering from them was a far
doing so, participation in a film festival simultaneously acts at two stronger predictor of help-seeking barriers than fear of discrimina-
mechanisms of the stigma process (Link and Phelan, 2001); tion by others (Schomerus et al., 2009b). Second, an analysis of the
emotional reactions and the separation of “us” from “them”. Theory of Planned Behavior (TPB) at population model revealed that
Moreover, audiences may find appropriate role models for helpful attitudes towards the behavior, i.e. the appraisal of psychiatric help
strategies in dealing with mental health problems. as beneficial, wise or good, were most salient in predicting help-
A recent systematic review of 19 randomized controlled trials seeking intentions. Attitudes towards enlisting professional help, in
(n ¼3176) demonstrated that mass media interventions, including turn, depended most strongly on personal beliefs about the likely
film, may reduce prejudice (Clement et al., 2013). This being said, consequences or other attributes of the behavior. In addition,
authors criticize an excessive reliance on student populations and though to a lesser extent, normative beliefs that important to others
thus on the – rather artificial – classroom setting in testing media would appreciate seeing a psychiatrist contributed to shaping help-
effectiveness. Studying the effectiveness of a film festival in seeking attitudes (Schomerus et al., 2009a). Besides being a
reducing social distance and improving help-seeking may there- beneficial period in life to reduce or prevent social distance towards
fore enhance the ecological validity of findings. people with mental health problems, adolescence has proven to be
Previous research investigating the impact of films on stigma an appropriate time to facilitate positive changes in help-seeking
and discrimination has revealed conflicting results. While report- behavior (Offer et al., 1991; Chan et al., 2009).
ing positive effects of video-based contact overall, there are also The aim of the present study was to examine to what extent
indications of potential harm, in particular when it comes to watching the respective documentary or feature film affected
portrayals of mentally ill characters in fictional films (Baumann audiences' social distance towards people with mental illness, and
et al., 2003; Yamaguchi et al., 2013). Films, then, are multirefer- to survey any potential change in their help-seeking attitudes.
ential systems. Symbols conveyed through the story and charac- It was hypothesized that viewing positive portrayals of men-
ters are imbued with multiple meanings which are decoded on the tally ill persons would lead to reduced desire for social distance
part of audiences in the viewing process. Festival participants compared with stigmatizing images, and that participants would
hence are not passive recipients of the content presented. Rather, report fewer negative attitudes about mentally ill persons. For
they actively reproduce film content in light of their own attitudes example, the film “Bonkers” introduces the affected person as a
and experiences. Consequently, it is difficult to predict to what positive and pleasant character that is portrayed humorously.
extent and which direction the medium film will be capable of As another example, the film “A Hero's Welcome” explains the
effecting attitude change. On the other hand, films make available background and motivations of an initially aggressive, but chan-
symbols and images about mental health in the first place, ging character and creates an understanding in the audience.
facilitating personal examination of a topic that young people Regarding help-seeking attitudes it was hypothesized that viewing
typically do not actively seek information about (Gerhards and successful offers of help would lead to an improvement of help-
Klingler, 2001). Film content is likely to be a key component in seeking attitudes. As an example, the film “Proof of Life” presents
affecting the direction of viewers' interpretation. As could be physicians and psychiatric doctors as cooperative, empathic and
shown in the context of school-based interventions, information helpful. The film “Bonkers” shows teachers as supportive and
about symptoms and suffering in the absence of opportunities to encouraging possibility for help.
explore the experiences described through personal contact with a Participants were asked to report their age and gender as
person who has had mental health problems may lead to an control variables. We further enquired whether they personally
increase in negative stereotypes such as violence and unpredict- knew a mentally ill person. It was assumed that those knowing
ability (Meise et al., 2000). In the present study, we therefore someone who is mentally ill would report lower desire for social
placed particular emphasis on film content by conducting specific distance at baseline than participants who do not.
 I. Conrad et al. / Psychiatry Research 220 (2014) 1043–1050 1045

Table 1
List of films – content and characteristics of the audience.

Film Content Sample

Film 1 25-year-old David returns from a Bundeswehra mission in Afghanistan to his home village in the N ¼ 75
Nacht vor Augen Black Forest. His family welcomes him warmly but David is close-mouthed, brusque, and not the Male: n¼ 30/40.0%;
same man he was before the mission. Shortly after his return, the army informally honors him for female: n¼ 45/60.0%
A Hero's Welcome supposed heroism. He is said to have shot an Afghan assassin in self-defense, thereby saving the Age (n/%):
(D, 2008; 91 min) lives of his whole unit. But David cannot sleep at night. A little Afghan boy plagues his r14:5/6.7
Director:B. M. Bertele nightmares. His life gradually goes out of control. The film describes in a realistic and matter-of- 15:19/25.3
fact way a phenomenon that always exists after war: the dumbness of the repatriates and the 16:24/32.0
indifference of society. Despite a growing sensitivity, soldiers still fear stigmatization when 17–20:27/36.0
addressing mental issues

Film 2 What do you do when you have a mother who has ideas that are much crazier than yours? Who N ¼ 83
Übergeschnappt picks you up from school in her pajamas, orders five sundaes at once and believes that you can Male: n¼ 45/54.2%;
rear an elephant in your garden? Normally, 9-year-old Bonnie can cope with this, because she is female: n¼ 38/45.8%
Bonkers supported by her grandmother who cares for her, even when Bonnie's bipolar mother lies in bed Age (n/%):
(NL, 2005; 83 min) and refuses ever to get up again. When her grandmother dies in a car accident, Bonnie and her r14:83/100
Director:M. Koolhoven mother suddenly are on their own. The Dutch director Koolhoven created a tragicomedy that 15:–
addresses a difficult issue in a cheerful and unconventional way. How is life for children with 16:–
mentally ill parents? The film succeeds in showing the balance between laughing and crying, 17–20:–
lightness and consternation that is a daily struggle for the heroines

Film 3 Why do especially girls and young women hurt themselves with razor blades, shards or knives? N ¼ 170
Lebenszeichen Their cuts are a symbol for great inner distress for which they have no other emotional outlet. Male: n¼ 59/34.7%;
This documentary accompanies five girls aged 16–20 from different social classes on their way to female: n¼ 111/65.3%
Proof of Life break the cycle. They vividly describe how difficult it is to resist the temptation of self-harm and Age (n/%):
(D, 2007; 100 min) to reassume the responsibility for their lives. The extraordinary openness of the girls has a r14:3/1.8
Direction:Medienprojekt Wuppertal reason, namely that the adolescents produced the film themselves. The protagonists acted behind 15:24/14.1
and in front of the camera, scripted and directed. It is hard to escape from their professionally 16:48/28.2
made stories. The girls and young women take you along into a world that seems hard to 17–20:95/55.9
empathize with at first but if you follow them it encourages to openly approach the taboo of self-
harming behavior

Film 4 Abhaun!, D 2004, Christoph Wermke 10 min, feature film N ¼ 154

“… und plötzlich war alles anders” Etwas ich, D 2007, Konrad Kästner 16 min, documentary Male: n¼ 63/40.9%;
female: n¼ 91/59.1%
“…and suddenly everything was different” 11:31, D 2004, Medienprojekt Wuppertal, 7 min, feature film Age (n/%):
Short film program (70 min) Tougher Yet, D 2006, Felice Goetze, 15 min, feature film r14:17/11.0
Der zweite Bruder, D 2007, Stefan Schaller, 22 min, feature film 15:56/36.4
Puberty: a drastic break in the life of a young person. Searching for a new identity, having a desire 16:38/24.7
for intense emotions, being different at all costs… sometimes this is far too much! Those five 17–20:43/27.9
short films take a look at the difficult yet exciting time between infancy and adulthood when
everything can change from one moment to the next

Film 5 From child soldier to hip hop star – Emmanuel Jal's biography is almost unimaginable for most N ¼ 43
War Child people living in the heart of Europe. In his film Christian Karim Chrobog tells the story of this Male: n¼ 15/34.9%;
musician born in southern Sudan in 1980 who became a child soldier with just 7 years of age. In female: n¼ 28/65.1%
(USA, 2007; 100 min) 1991 he deserted – together with 400 other children. Only 12 of them survived. Jal was later Age (n/%):
Director:C. K. Chrobog adopted by a woman working for the children's relief organization “Street Kids”. In 2005 he r14:10/23.3
scored a hit in Kenya with “Gua” and now, Jal is a star in Africa. Jal sings in English, Arabic and 15:27/62.8
Swahili as well as in two Sudanese languages. His songs are about the civil war in Sudan and are 16:5/11.6
an appeal for peace and tolerance. Interspersing original interviews, live concerts, and rare 17–20:1/2.3
footage of Jal as a 7 year-old boy, War Child will make viewers cry, laugh, dance, and celebrate the
power of hope

a
The German Military.

2. Methods Federal Association for Relatives of Mentally Ill, the Umbrella Association for
Community Mental Health, and the Alliance against Depression. Following certain
films, participants were invited to join discussions with the director, protagonists,
2.1. Intervention
people with mental illness and experts thus adding a component of direct social
contact. The present study focuses on the Festival's edition in Leipzig.
The film festival “AUSNAHME|ZUSTAND – Verrückt nach Leben” (“State of
Emergency – Crazy for Life”; http://www.ausnahmezustand-filmfest.de/) took
place in 70 German cities from October 2008 to June 2010. Festival programming 2.2. Sample
focused on feature films and documentaries addressing mental health and well-
being in adolescents. Contributions included films that tell stories about the A pre-post-test was carried out in order to measure the influence of the
emotional and intellectual world of adolescents; their longing for love and support documentaries and feature films on the social distance of adolescents towards people
as well as their crises and their boundary experiences. An overview of all of the five with mental illness and to learn about potential changes in help-seeking attitudes.
films which were shown in Leipzig and selected by the organizers is presented in During the film festival, that took place in several cinemas across the city, spectators of
Table 1. All films were presented in German language. According to the organizers five different films (Table 1) were questioned before and immediately after watching
(the Leipzig association Irrsinnig Menschlich e.V., the media makers EYZ Media and the films. All spectators received the questionnaire (two identical pages) when
its distribution label BFILM from Berlin), the aim of the festival was to create a entering the cinema hall. Everyone was told to fill out the first page now (before
podium for the topic of mental illness as well as to inform and entertain. The local watching the film) and the second page immediately after the end of the film. This was
festival partners were support groups, associations, organizations and institutions repeated at the end of the film. All questionnaires were collected. The audience
active in the field of mental health care or mental health promotion, including the consisted solely of complete school classes that had not been subject to any mental
1046 I. Conrad et al. / Psychiatry Research 220 (2014) 1043–1050

health-related interventions and were invited to see the movies during school time. fall in love with someone who has mental health problems” (2.86),
After the post-test, discussions with affected people and experts were held. The
and the lowest for “If one of my friends had mental health
audience, of which 59.6% were female, had a mean age of 15.6 (range 10–20) and
included 64.1% who knew someone with mental health problems. The response rate problems I would pay him a visit in hospital” (1.61).
was 96.4% and altogether 532 questionnaires could be evaluated.

3.2. Effects of the films on social distance and help-seeking attitudes

2.3. Instruments

The pre-post test showed that the effect on social distance

Socio-demographic characteristics (age and gender) were recorded and the
adolescents were asked if they knew someone who has or had mental health towards people with mental health problems as well as the effect
problems. To measure social distance towards people with mental illness, an on help-seeking attitudes depended heavily on the respective film
abbreviated scale of seven items was adapted from a validated measure specifically or documentary (see Figs. 1 and 2, Tables 2 and 3). A reduction of
developed for measuring social distance among adolescents (Schulze et al. 2003). social distance as well as an increase or no change could be found.
Reliability analyses (Cronbach's alpha) of the short form showed a sufficient
reliability for the social distance scale (pretest: α ¼ 0.7040 / posttest α ¼ 0.7439);
The help-seeking attitudes of the audience were affected by four
test–retest reliability 0.668 (0.617–0.712) (intra-class correlation coefficient (95% out of five films. The direction of the changes clearly depended on
CI)). By means of hypothetical situations, the willingness of interacting with people the subject of the respective film. Hence, a separate observation of
with mental illness was assessed using a five-point Likert scale ranging from 1 the results of the pre-post test for each film is necessary.
“strongly disagree” to 5 “strongly agree”. A high scale value represents a higher
social distance. The following situations were inquired:
3.3. Effect of the films on social distance – sum score
1. I could imagine making friends with someone who has mental health problems
(scale recoded in statistic calculations).
3.3.1. Pre-test (baseline)
2. I would be embarrassed if my friends knew that someone in my family has
mental health problems. At pre-test (T0), significant differences between the single films
3. If one of my friends had mental health problems I would visit him in a hospital on the sum score of the social distance scale were found. On film 4
(scale recoded in statistic calculations). (“… and suddenly everything was different”) social distance was
4. I would not take someone with mental health problems to a meeting of my friends.
significantly larger (1.01) than the grand mean of all five films
5. I would never fall in love with someone who has mental health problems.
6. Someone who has mental health problems should by no means work together
which was at 16.77. On film 5 (“War Child”) social distance was
with children and adolescents. significantly lower (  1.86) than the grand mean (Table 4).
7. Someone with mental health problems should not attend a normal school.

20
Concerning help-seeking attitudes, seven items listed potential helping resources:
friend; family; teacher; psychologist, psychiatrist, or doctor; internet (someone
familiar); and internet (stranger, anonymous, e.g. forums, chats). Respondents were
asked to rate how likely they were to seek help from each of these groups when
Social Distance

18
experiencing mental health problems themselves. Response options ranged from 1
“definitely not” to 5 “definitely”. A high scale value represents a greater help-seeking.

2.4. Analyses 16

An evaluation of changes in social distance and help-seeking attitudes of

audiences before and after the films (t-test) was carried out for overall scores on 14
each outcome by using the grand mean (the mean of the means of the 5 films) as
reference category. 0 1
Finally, a multiple linear regression analysis, which was used for the whole Time
sample, analyzed the influence of different aspects on the social distance towards Grand Mean Film 1
people with mental health problems, and on changes in help-seeking attitudes. A Film 2 Film 3
random effects regression model considered the influence of sociodemographic Film 4 Film 5
factors (age and gender) and the fact of knowing someone with mental health
problems in relation to the consumed film and if the questionnaire was filled out Fig. 1. Time effects of the social distance scale for the five films based on random
before (pretest) or after watching (posttest). The regression model further considered effects regression model.
the interaction between the film and the time the film was watched. The variable
“time” was coded as follows: pretest¼ 0 and posttest¼1. The statistical analysis was
conducted using STATA 10.0 and PASW Statistics 18.
We consider the number of 532 participants taking part in the study as sufficiently
17.4
high to assume significance by applying a critical p value of r0.05 only. Regarding
missing values for the social distance measure there were just a few cases (n¼ 515). If
only one item of the social distance scale was missing, it was replaced by the mean of 17.2
the remaining six items. In case of more than one missing value, the case was excluded.
Help Seeking

The study received approval from the Institutional Review Board (University of Leipzig). 17

16.8
3. Results
16.6
3.1. Characterization of the festival audience
16.4
The hypothesis, that those knowing someone who is mentally
0 1
ill would report lower desire for social distance at baseline than
Time
participants who do not, was confirmed (mean sum scores 16.12
vs. 18.34; P ¼0.00). Grand Mean Film 1
The social distance of the festival audience was generally quite Film 2 Film 3
Film 4 Film 5
low with the highest distance for the items “Someone who has
mental health problems should by no means work together with Fig. 2. Time effects of the help-seeking scale for the five films based on random
children and adolescents” (mean score 2.96) and “I would never effects regression model.
 I. Conrad et al. / Psychiatry Research 220 (2014) 1043–1050 1047

3.3.2. Time-effect (pre-post) 3.4.2. Time-effect (pre-post)

Indicated by the interaction term between film 1 and the time Between pre- and post-test, the sum score of the help-seeking
effect between pre- and post-test, the social distance significantly scale did not change on the five films grand mean. A significantly
increased by an amount of 0.62 points on the grand mean, largest on larger increase of help-seeking than on the grand mean was
film 1 (“A Hero's Welcome”) (2.83). On films 2 (“Bonkers”) ( 1.47) observable only on film 2 (0.55) (Table 5) (Fig. 2).
and 3 (“Proof of Life”) ( 0.92), a significant decrease of social
distance was observed between pre- and post-test (Table 4) (Fig. 1). 3.5. Interaction effects between films and time controlled by age,
gender and the fact of “knowing someone with mental health
3.4. Effect of the films on help-seeking attitudes – sum score problems”

3.4.1. Pre-test (baseline) The sociodemographic diversity of the audience influenced

On pre-test, the only difference from the grand mean (16.90) social distance and help-seeking attitudes. At baseline, social
was observed on film 4 with a significantly higher (0.59) sum distance was negatively related to age, indicating that older
score of the help-seeking scale (Table 5). participants were slightly more willing to interact with people

Table 2
Means, standard deviation and frequencies concerning social distance.

Film Social distance pretest Social distance posttest Social distance total
Means, S.D., frequencies Means, S.D., frequencies Means, S.D., frequencies t-Value

Film 1 16.17 19.51 17.81  6.817

5.05 5.68 5.61
75 73 148
Film 2 19.82 18.82 19.33 1.681
4.68 4.42 4.47
85 83 168
Film 3 16.09 15.58 15.84 1.796
5.18 4.74 4.97
171 164 335
Film 4 17.57 18.61 18.08  3.391
5.23 5.25 5.26
157 154 311
Film 5 14.85 14.23 14.55 1.084
3.75 4.72 4.24
43 41 84
Total 17.04 17.46 17.24  2.400
5.19 5.29 5.24
531 515 1046

Film 1: A Hero's Welcome.

Film 2: Bonkers.
Film 3: Proof of Life.
Film 4: “… and suddenly everything was different”.
Film 5: War child.

Table 3
Means, standard deviation and frequencies concerning help-seeking.

Film Help-seeking pretest Help-seeking posttest Help-seeking total

Means, S.D., frequencies Means, S.D., frequencies Means, S.D., frequencies t-Value

Film 1 16.77 16.42 16.60 1.247

3.59 3.43 3.50
75 74 149
Film 2 16.23 16.69 16.46  0.245
3.27 3.87 3.58
82 82 164
Film 3 17.20 17.39 17.29  1.086
3.22 3.67 3.45
171 163 334
Film 4 17.51 17.15 17.33 1.626
2.87 3.18 3.03
155 153 308
Film 5 17.07 17.28 17.18  0.952
2.91 3.01 2.95
43 43 86
Total 17.07 17.06 17.06 0.414
3.18 3.48 3.33
526 515 1041

Film 1: A Hero's Welcome.

Film 2: Bonkers.
Film 3: Proof of Life.
Film 4: “… and suddenly everything was different”.
Film 5: War child.
1048 I. Conrad et al. / Psychiatry Research 220 (2014) 1043–1050

Table 4 Table 5
Random effects regression model: interaction effects between film (grand mean Random effects regression model: interaction effects between film (grand mean
coding) and time controlled by age (mean centered), gender and knowing someone coding) and time controlled by age (mean centered), gender and knowing someone
with mental health problems, concerning social distance (grand mean coding). with mental health problems, concerning help-seeking (grand mean coding age
o21).
Variable Sum score social distance scale (SE) p-Value
Variable Sum score help seeking scale (SE) p-Value
Film 1  0.02 (0.54) 0.975
Film 2 0.50 (0.72) 0.493 Film 1  0.04 (0.37) 0.911
Film 3 0.37 (0.51) 0.469 Film 2  0.62 (0.49) 0.206
Film 4 1.01a (0.41) 0.014 Film 3 0.13 (0.35) 0.697
Film 5  1.86nn (0.69) 0.007 Film 4 0.59a (0.28) 0.037
Time (pretesta) Film 5  0.06 (0.47) 0.903
posttest 0.62nn (0.22) 0.004 Time (pretesta)
Film 1  Time 2.83nnn (0.44) 0.000 posttest 0.11 (0.14) 0.451
Film 2  Time  1.47nnn (0.42) 0.000 Film 1  Time  0.44 (0.29) 0.122
Film 3  Time  0.92nn (0.34) 0.006 Film 2  Time 0.55a (0.28) 0.049
Film 4  Time 0.46 (0.34) 0.168 Film 3  Time 0.12 (0.22) 0.573
Film 5  Time  0.90 (0.58) 0.118 Film 4  Time  0.40 (0.22) 0.070
Age (mean centered)  0.53nnn (0.15) 0.001 Film 5  Time 0.17 (0.37) 0.643
Gender (malea)female  1.02a (0.42) 0.015 Age (mean centered)  0.01 (0.29) 0.895
“Not knowing somebody” 1.63nnn (0.44) 0.000 Gender (malea)
Constant 16.77nnn (0.40) 0.000 female  0.12 (0.30) 0.663
r2_w 0.12 “Not knowing somebody” 0.26 (0.10) 0.381
r2_b 0.16 Constant 16.90nnn (0.27) 0.000
r2_o 0.15 r2_w 0.02
N_g 480.00 r2_b 0.01
r2_o 0.01
Film 1: A Hero's Welcome. N_g 478.00
Film 2: Bonkers.
Film 3: Proof of Life. Film 1: A Hero's Welcome.
Film 4: “… and suddenly everything was different”. Film 2: Bonkers.
Film 5: War child. Film 3: Proof of Life.
n
p r 0.05, nnp r 0.01, nnnp r 0.001. Film 4: “… and suddenly everything was different”.
a
Reference category. Film 5: War child.
n
p r 0.05, nnp r 0.01, nnnp r 0.001.
a
Reference category.

with mental health problems prior to watching the film. No

significant age effect was found for help-seeking attitude (see
Tables 4 and 5). no significant changes in social distance towards people who have
Regarding gender, at baseline females showed significantly less mental health problems.
social distance compared to males. For help-seeking attitude, no Reasons for the decrease in social distance towards people with
significant difference was observed. Aspects of social distance mental illness after watching the documentary “Proof of Life”
were also influenced by the fact of knowing someone with mental could be related to the very close (self-)portrait of girls who hurt
health problems; participants not knowing a mentally ill person themselves. The results show that social distance was reduced as
revealed a significantly higher social distance than others. Overall, far as prejudices against self-harming adolescents could be
no significant effect on help-seeking could be established (see reduced and more respondents could imagine befriending some-
Tables 4 and 5). one with mental health problems. “Bonkers” is the second film
reporting decreasing values for social distance, likely due to the
likeable impression of a bipolar mother conveyed in this tragico-
medy that opposes the common negative image of mentally ill
4. Discussion persons. Watching the feature film “A Hero's Welcome” resulted in
an increase in social distance of the festival audience. A reason for
A large proportion of the public opinion is adopted through this could be the aggressiveness of the protagonist and the
mass media (Cuenca, 2001; Ferk et al., 2005). Media with its confirmation of the stereotype that people with mental health
richness of images are catchier and more emotionally charged problems are a danger to society, resulting in an increased
than ever before (Finzen, 2000). In most films, people with mental hesitation to befriend or fall in love with somebody like that.
illness are displayed as being dangerous and unpredictable. Thus, “A Hero's Welcome” exemplifies that not every film addres-
Several studies have shown that these portrayals become reflected sing mental health issue is per se appropriate for the purpose of
in the attitudes of the audience (Straub, 1997; Penn et al., 1999; reducing the social distance towards people with mental disor-
Condren and Byrne, 2000; Baumann et al., 2003). Once consoli- ders. On the other hand, after the film, and after the participants
dated, stereotypes have proven fairly resistant to change. To effect filled out the questionnaires, an intense discussion took place in
visible improvements, an alternative discourse to the dominant the cinema. One of the participants was a military pastor and
pattern of media reporting needs to be established. This requires Afghanistan veteran himself, sharing his experiences with a keenly
regular inputs of alternative portrayals over prolonged periods of interested audience. The film certainly captured the young peo-
time (Desforges et al., 1991; Pinfold et al., 2003; Gaebel and Priebe, ple's interest in the topic of post-traumatic stress disorder, not
2005; Altindag et al., 2006). least since Leipzig is the site of an important military base of the
The effect strongly depended on the subject matter of the German Federal Armed Forces, including a major recruitment
documentary or feature film. A reduction (“Bonkers” and “Proof of centre for missions abroad which actively promotes a military
Life”) and an increase (“A Hero's Welcome”) of social distance career in local schools. Thus going on a mission abroad with a
could be found. “War Child” and the short film program triggered potential risk for post-traumatic stress disorder as the protagonists
 I. Conrad et al. / Psychiatry Research 220 (2014) 1043–1050 1049

of the film “A hero's Welcome” (s. Table 1) could be a realistic dichotomous variable for whether the participants “knew some-
prospect and thus of great personal relevance for some members one with mental health problems” instead of using a variable
of the audience. The discussion, which facilitated direct personal measuring intensity or degree of personal familiarity. Another
contact, may well have affected adolescents' social distance. limitation of the study is the poor internal reliability of the help-
However, the panel discussions following the film could not be seeking attitudes scale. These limitations point to the challenges
included in the evaluation on this occasion. involved in matching the needs of artistic creativity (in filmmaking
The film “War Child”, however, did not change the social and festival programming), the goals of mental health promotion
distance of the respondents in any direction. Nevertheless, it was and anti-stigma programmes (education and attitude change), and
by far the most popular film of the festival according to the quality criteria for evidence-based evaluation (methodological
adolescent audience. A reason for the popularity of “War Child” is rigor). Programmes planners are therefore confronted with diffi-
the subject matter of an African rapper and the display of how cult choices and could benefit from evidence regarding the active
music can change a person's life. Especially during adolescents, ingredients of artistic content in affecting the desired festival
music plays an important role and could therefore be used as a outcomes in their programming and evaluation decisions. This
means of sensitizing adolescents for mental health problems. being said, our results suggest that investigating the effects of film
“Bonkers”, directed at a slightly younger audience, was the film content on attitude change is a promising avenue for future
that most strongly changed the view on mental issues. research. As a first step, films may be selected using a theory-
Regarding the effect of sociodemographics on attitudes, a based coding matrix and tested in an experimental setting.
reason for lower social distance with increasing age could be a Elements of content shown to be effective might then inform film
more experienced attitude towards mental health problems and selection decisions for educational purposes as well as mental
life in general. The mean age of persons knowing someone having health arts and film festivals in the future.
mental health problems is higher (16.7 years) than for those who In the present study, the focus was on assessing attitude
do not (15.2 years). Consolidated and lucid social networks, more changes through video-based social contact in a naturalistic
typical for older ages, could indicate a more empathic contact setting, i.e. the cinema during a regular film festival open to the
between their members. This may also explain why health-seeking general public. This is clearly a value of our research since the
attitudes are more stable with age thus less malleable through majority of RCTs on the effectiveness of anti-stigma interventions
additional information as provided in some of the films shown. were carried out in a laboratory or classroom setting, giving
The same may be true for knowing someone with mental health precedence to a more easily controlled research environment over
problems and the reduction of social distance associated with it. ecological validity (Clement et al., 2013). Our study further sup-
Knowing that mentally ill persons do not resemble the negative ports the contention that video-based social contact can lead to an
cliché often transported by mass media, openness, and willingness improvement of attitudes (Clement et al., 2012). However, we did
to help could be considered as the key experiences for the young not directly compare the effects of media-based vs. in vivo contact
people arising from video-based social contact through documen- interventions as part of this study. Experiencing the lively discus-
taries and features films. Concerning gender differences, females sions with protagonists of films following the screenings, we may
have proven to show less social distance than males (  1.03), well have missed out on a good opportunity to do so. Further
which could be traced to the stereotype of women being more research should therefore measure the effect of both the films and
empathic and caring than men. Alternatively, gender effects on related personal contact interventions in the framework of the
social distance may relate to the fact already that females in the festival. The combination of films and panel discussions was
audience constituted a higher percentage of knowing someone certainly well-received by participants. A further positive effect
having mental health problems than men (68% vs. 62%). could be noted as an increase in the number of telephone calls to
Overall, the film festival “AUSNAHME|ZUSTAND – Verrückt the local crisis helpline was observed after the festival – as the
nach Leben” (“State of Emergency – Crazy for Life”) showed a organizing association Irrsinnig Menschlich told us. While contact
positive effect on attendees' social distance and help-seeking is fundamental to changing public stigma, effects of one-time
attitudes, though specific effects differed by film. Examining contact are likely to dwindle over time (Corrigan, 2012). Festivals
specific hypotheses related to the content of each specific films should therefore be held on a regular basis, facilitating repeated
afforded new insights concerning the elements of film content contact at multiple times. To continually assess the quality of these
particularly beneficial for improving viewers' attitudes. Sympa- efforts, further studies should seek to follow participants across
thetic, yet realistic portrayals of people with health problems as different attendances. This may be enhanced by closely collabor-
well as of successful help-seeking attempts seem to be the key ating with local schools, making festival participation a regular
features in this regards. This information may support the orga- element of the curriculum.
nizers of future film festival in their program planning. In conclusion, films festivals clearly have the potential to
This being said, our study has several limitations. For one, only positively affect audiences' social distance and help-seeking atti-
a pre-post test was carried out and the study did not include a tudes. This effect, however, cannot be generalized for the festival
control group. Furthermore, respondents were not randomly as an event. Rather, benefits could be found for certain films, while
allocated to a particular film. The range of the sample sizes is others left attitudes unchanged or even worsened. This highlights
another limitation of our study (e.g. “War child” with the smallest the importance of careful programming for arts and film festivals
sample size of 43 adolescents). Since the festival comprised of five aiming at reducing social distance.
films that differed in many respects (with regard to content and
esthetics), our interpretation of film-specific effects remains to
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