In analyzing the data, the analytical team recognized diversity in target groups throughout the material. The ads and brochures were directed toward the general public, as well as more strategic target-groups, i.e. students, teachers, GPs, health- and social workers, etc. In addition, several changes in strategies were identified. We describe this diversity before we turn to the three themes found to constitute the meaning content: (1) Knowledge is key, (2) (Almost) an illness among illnesses and (3) We all have a responsibility.
Differentiated target group communications and changes over time
In the early phase of the information campaign (1996–1997), the information material was distributed to all households in the county of Rogaland. At the same time, a range of more demarcated target groups were addressed. This included at risk youth, persons who had already developed early signs of severe mental illness, as well as people who were likely to interact with them: friends/peers, parents, school counsellors/teachers, health- and social workers etc. The ads often had slightly different content depending on who the recipient was meant to be. An example of this is a quote from an ad directed at teachers: “It isn’t easy being a teacher when a student changes and you don’t know why” (1999). Another example is found in an ad directed at social workers: “Everyone who works at the social office will now and then meet clients with mental health problems” (1999).
The early ads (1996–1999) were directed both at people in general as well as people surrounding those who were vulnerable. More often than not, parents, or mothers in particular, appeared to be the most important target group. For example, in one of the ads the heading said, “He or she who meets them [the problems] face on will most easily put them behind them” (1998). The text in the ad continued: “Rarely will the person who is struggling with mental health problems be able to contact a doctor. Most of the time it is relatives, friends or coworkers who have to do it” and “You can get help in order to help”.
Another variation we discovered in the data material was that in the beginning (1996–1997) ads started out with an open invitation to contact the early detection team independent of their degree of concern. In time, the ads communicated a slightly more restrictive service—meaning that people should contact them according to the supposed degree of risk. For example, in several Facebook ads (2017) as well as the website (2018) three levels of danger were utilized: green, yellow and red—representing the severity of signs/symptoms. In addition, the later ads (approximately from 2009 to April 2018) also seemed less authoritative than the early ones, as they often used a more suggestive tone, e.g. “If you’re worried about yourself or someone else you can call TIPS” (2017).
Moreover, we found diversity in the way the concepts mental illness, serious mental illness and psychosis were utilized. In many ads, mental illness was used in the heading followed by a description of psychosis in the text. In some ads, both mental illness and serious mental illness were applied, while in others the term psychosis was used alone.
Three core categories, or themes, emerged when analyzing this diverse and dynamically changing pool of data for thematic content across ads, across time periods and across target groups. Here, a theme is understood as a basic pattern of communication across contexts. In the following, we present and detail the thematic structure that resulted from the outsiders’ analyses.
Themes
Knowledge is key
Throughout the information material, knowledge was presented as key to increasing public awareness and altering help-seeking behavior. It was communicated that the content provided in the information material may assist people in understanding what is going on. For example, one ad said: “Read and become wiser…” (1997). As such, knowledge was presented as something that professionals within the mental health services hold. This is also illustrated through a quotation from one of the ads: “Experienced professionals will tell you what you should do, how you can move forward to figure out the situation and how you can get the right treatment or assessment if that’s necessary” (1999). This knowledge was often depicted as specific and objective. An example from one brochure pointed out: “Good treatment is based on solid knowledge and not just viewpoints and ideological beliefs” (1999). In one of the brochures (1999), the right treatment was described as consisting of mainly three parts: consulting a doctor, psychiatrist or psychologist (psychotherapy), combined with family-oriented therapy and medical treatment. At the same time, it was underlined that one type of treatment does not fit all. Hence, treatment has to be individually tailored.
Furthermore, it is not sufficient that the mental health system holds knowledge. One of the main messages in the information material was that people who meet persons at risk of developing psychosis should know what to look for. Through the information provided, people were told to attain a position in which they are able to help others, illustrated by the following quotation from one of the ads: “The more you know about them [mental illnesses] the easier it is to help the one affected” (1997). It was communicated that the reason why people do not act, is that they lack or do not have the right knowledge. In consequence, a core challenge is to get the information out to the public. An ad stated that “TIPS has a goal of increasing knowledge about mental illnesses so that more people contact health care services earlier and get treatment before the patient develops a serious psychosis” (1999).
Symptoms or signs of psychosis were presented as information that should be an essential part of common knowledge. Almost every ad in the data material listed signs to be aware of. They were presented as early signs of psychosis, serious mental illness (particularly the early ads) and mental health problems, or simply listed without any label. People were told to be alert if a person withdrew from his or her family, friends and colleagues, or if he or she isolated him- or herself. Other signs to look out for were if he or she slept poorly and ate little, stopped taking care of themselves, spoke or wrote about meaningless stuff or expressed inappropriate emotional reactions (e.g. laughing when hearing about sad news). Furthermore, reasons to be on guard included if the person became expressionless or did not react at all, felt persecuted, controlled by voices from outside or believed they had magical capabilities.
Symptoms and diagnoses were also presented on Facebook through a Christmas calendar (2016–2017). Each day, knowledge about one mental health issue was presented, starting with milder symptoms at day one, and gradually increasing the level of severity in the signs presented, e.g. day nine presented hallucinations. An excerpt from the accompanying text stated: “Hallucinations are perceptions which aren’t caused by outer sensations”. The calendar ends with psychosis on day 22—followed by early intervention and prognosis on day 23 and 24. The calendar can be interpreted as a gift to the public, comprising of knowledge as well as hope portrayed through the possibility of improving the prognosis through early intervention.
In the early ads (1996–1997), knowledge was also seen as key to breaking down old myths about mental health services. References to (and pictures from) the movie “One Flew Over the Cuckoo’s Nest” were, for example, used to illustrate the stigma and myths surrounding mental health institutions. One of the ads expressed: “A lot has happened in treatment of mental illness the last decades, but old myths still endure” (1996) (Additional file 1: Figure S1).
(Almost) an illness among illnesses
Many ads communicated that severe mental illnesses had a lot in common with physical illnesses. In this sense, it was communicated that psychosis has to be understood and treated in similar ways to physical illnesses. Several ads explicitly expressed: “Mental illnesses are like other illnesses…” (1996–1997). Occasionally, ads shed light on diagnostic labels, for example “bipolar disorder” or “schizophrenia” (1996–1997). Furthermore, in one of the ads a metaphor of a particular type of cancer, melanoma, was used. This is a type of cancer which the public knew little about and, consequently, many died from. After applying campaigns that raised public awareness of what to look for, experts were able to save many lives because people now sought treatment at an earlier stage. The same rationale seemed to be applied to psychosis, with the exception that the latter is said to be even more difficult to detect. As such, public awareness needs to be raised so that early intervention can be successful.
In the same way as with cancer/melanoma, psychosis was seen as developing in stages. One brochure said, “We see the psychosis as a process, where the psychotic breakthrough or breakdown is a stage of the illness’ development” (1999). As such, psychosis appears to be understood as developing from an early sense of anxiety, with a risk of converting to psychosis if not detected and treated at an early stage. Timely intervention can, however, impede this development. For instance, one ad expressed that: “Psychotic episodes can be prevented” (2015). In addition, psychosis was in part described as a breakdown in rationality and meaning, e.g. one of the signs of psychosis listed in the ads was to “talks and writes about meaningless things” (1998).
However, some ads had a slightly different twist. Instead of comparing mental and physical illness, overlap between these was highlighted at just one point—the need for early intervention. For instance, one ad showed a picture of a bandaged thumb pointing upwards, followed by the heading: “At one point, mental illnesses are just like other illnesses—when the help is provided early there is a greater chance of getting healthy” (1997) (Additional file 2: Figure S2).
Simultaneously, psychosis was also defined as something different from physical illnesses. For instance, one ad communicated how psychosis or mental illnesses are valued differently than physical illness: “Mental illnesses don’t have the same « status » [as physical illnesses]” (2000–2001), and the same ad stated: “Still, they’re hard to talk about” (2000–2001), which seems to point to the stronger stigma related to mental illnesses.
In addition, it was communicated that psychosis was seen as something other than physical illness, as there is a fine line between psychosis and problematic, yet normal behavior or feelings, e.g. a quote from one ad said: “That teenagers change is natural. When teenagers change noticeably over a short period of time- parents often worry. If teenagers isolate themselves, are silent or seem depressed, it is natural to be on guard” (2012). As such, natural emotions and behavior were expressed as something worrisome if they lasted over a period of time. Accordingly, signs of illness may also be signs of normality, as mental illness is more complicated to uncover than many physical illnesses.
We all have a responsibility
A vital message throughout the information material was the importance of reducing the duration of untreated psychosis. Many of the ads emphasized that treatment is often delayed. This was pointed out in the following quotation from one of the ads: “One of the biggest problems in treatment of serious mental illnesses- psychoses-is that the patients come to treatment too late” (1997). As a consequence, we all have a responsibility to detect people with, or at high risk of developing, psychosis, and help them get in contact with mental health services. By doing so, they can receive the treatment they need to get well. In the material, this task was not communicated as a responsibility only for mental health services. Psychosis, or mental illness, was presented as something that concerns everyone. In one of the brochures it said, “All Norwegians know someone with mental health problems” and “Every 15th Norwegian has a serious mental illness” (1998). This underlined a personal as well as a societal responsibility. Both caring for the people who are affected, as well as saving costs for society were presented as justification for the broad approach and its urgency claims. In this line of communication, mental health is not a private issue, it affects us all—mothers, fathers, friends and health workers. Everyone has to play a role to help prevent and alleviate mental health suffering, albeit with different role instructions. The societal responsibility was demonstrated through the next two quotations from one of the ads: “If the sick get help earlier there is a greater chance of getting healthy and they need less time at the hospital” (1998) and “It saves the society money and the affected will have a better life” (1998).
In our analysis, we developed four subthemes to summarize how we have a shared responsibility (a) to respond quickly; (b) to step in; (c) to provide an answer and (d) to tag along.
a. To respond quickly. Responsible: All
It was held forth as a fundamental problem that those it may concern rarely contact the mental health services themselves, e.g. as expressed in the following quotation from one ad: “The person affected is rarely able to contact a doctor themselves. That’s why it’s often someone close to the person who has to do it. That can feel hard and difficult, but it’s important to act quickly” (1998). A perpetuating message was conveyed saying that one should contact early detection services promptly if symptoms or signs of psychosis are observed. For instance, several ads used the sentence: “Seek help as soon as possible, that’s when you have the greatest chance of getting healthy” (1996–1997). The call for instant action underscored that it is possible to prevent, relieve or delay the onset of serious mental disorders, and that early treatment will be more effective.
In some ads, psychosis was presented as something that evolves gradually and almost unnoticeable. In a sense, it creeps up on you. As a consequence, the ads tell people to be on guard, and that there is a need for constant vigilance. What might seem like normal behavior does not have to be. This is articulated in one of the ads: “Serious mental illnesses often begin innocently. The person affected acts a little strange, but that can be temporary. It’s the recurrence which signals danger” (1996–1997).
Another way of communicating the need to respond quickly is to stress the negative consequences of delayed action. Such effects were illustrated in several ads using metaphors from children’s songs/plays expressing the poor outcomes of late responses, e.g. “Snip, snap, snout, this tale’s told out” (2000). By using single lines from children’s songs literally, and thus juxtaposing mental images of innocent children playing and severe mental health suffering, the ads employed poignant rhetorical strategies toward immediate action. Another example of possible negative consequences if people do not respond quickly can be found in an ad presenting a picture of domino tiles that have begun falling. Once the domino tiles have started to topple over, one thing leads to another in a downward spiral. Both images stressed the need for early detection and treatment, as well as the need for public awareness and response (Additional file 3: Figure S3).
b. To step in. Responsible: all
This is closely related to the previous subtheme. However, while the former refers to the need for understanding what one observes, being vigilant regarding signs of mental illness and swift action when such signs are observed, this subtheme assigns the responsibility to act even in ways you would not normally do in regards to another person’s health. This seemed to indicate that some young adults being at risk or suffering from psychosis are hesitant to contact services and sometimes even refuse, thus others need to cross boundaries they otherwise would not to step in. For example, one of the ads stated: “That’s when it’s important that others take responsibility and seek help” (2000). A central message in the ads is that people have a moral obligation as citizens to step in. This is illustrated through the following quotation from one of the ads: “If you know somebody who is affected by mental health problems, do as you would with other illnesses, contact a doctor, psychologist or the emergency room (ER) if you need advice” (1996–1997).
In many ads, this responsibility is more directly placed on people’s close relatives. For example, one ad stated: “This year many will worry about friends and family developing mental health problems… make sure the worry passes as soon as possible (2000). In this way, the commitment to take action is placed on the reader. As such, the messages conveyed through this strategy seem to suggest that one should go further than one ordinarily would with a young adult. One possible implication of this strategy is that many with mental illnesses are unable to take proper care of themselves, needing others to step in and make good choices for them. The legitimization for this breach of autonomy boundaries seems related to the images presented with regard to the roles of the suffering person and the responsible other.
Attention seems to be given to the importance of early intervention and that people around should step in, while the person’s own preferences at this stage are secondary. To lower the limit for contacting the services anonymous calls was presented as an option, e.g. from one of the ads: “You can get help in order to help… call TIPS, feel free to do it anonymously…” (1998) (Additional file 4: Figure S4).
c. To provide an answer. Responsible: the mental health professionals
Most of the ads described the ED team as a resource to the problems concerning youth at risk of developing a severe mental illness, as such the services readiness to help and to provide proper treatment and/or advice was highlighted. This was illustrated through the following quotation found in one of the brochures: “Everyone has specialized education/training and knows what should be done when a mental illness is developing” (1999). In the same way as with physical illness, mental health professionals seem to be regarded as experts who can provide knowledge. E.g. from one of the brochures: “We have created a brochure which talks about mental illnesses, what it is and how they are treated” (1999). This expert position was particularly emphasized in the early ads (1996–1999), for example it was said that: “… we will give a true picture of today’s options”, or in one of the brochures: “The patients get help quickly and are offered the help that is considered the best” (1999). Moreover, it was expressed that mental health issues can be severe and that people should take them seriously. One of the ads underscored that several hundred people have already called and received help and advice (1998). Accordingly, it was communicated that the early detection and intervention services are successful in their mission and that people can count on them. In some ads and brochures, photos and professional titles seemed to serve as a way of putting a face to mental health workers (1996–1999) (Additional file 5: Figure S5).
d. To tag along. Responsible: patients
An indirect message expressed in the ads was that people with, or at risk of developing, psychosis should seek help and follow professional advice. It was underlined that if someone feels uneasy or confused, they should contact health professionals. In one ad they say: “When you feel like something is wrong, you go to the doctor” (1996–1997). As such, their own interpretations or meaning-making capabilities were toned down, especially in the early ads (1996–1999). The main responsibility of the patient is therefore to go along with the treatment offered by professionals when in crisis and extreme distress, in order to get well and be able to continue on with their lives (Additional file 6: Figure S6).
The mental health professionals are not able to provide appropriate help unless patients share detailed information about their problems, as expressed in one ad: “We need your help to get where we want” (1996–1997). If potential patients (or others around them) do not contact the services and tell them about their afflictions, there is, in fact, nothing the mental health services can do. In this way, responsibility was also given to the patient.
In some of the later ads, home visits were proposed as an option. Here, mental health services are stepping out of their territory and into the context of people’s everyday life. Moreover, the language seemed less authoritative as the importance of following the professionals’ advice is toned down. A quotation from one of the Facebook ads illustrates this: “If you experience that challenges are larger than what can be solved in a confidential conversation you can ask us for help” (2017).
Insiders’ reflections on the findings
A tentative report of the outsiders’ findings was sent to J.O.J., I.J. and S.D. from TIPS to obtain the insiders´ perspectives and viewpoints on the findings. This provided us with an opportunity to utilize elements of discourse while maintaining multiple perspectives. Involving the researchers from TIPS in this process, helped clarify the intentions behind the data material, and it became clear that the outsiders’ interpretation of the material at times diverged from TIPS’ purpose and plan.
For example, the outsiders interpreted the message that psychosis is an illness in line with physical illnesses. However, the insiders wanted to underscore the same need for early intervention in mental illnesses as in physical illnesses. The insiders stressed that they did not have a “strict/traditional bio-medical” understanding, but rather a dimensional understanding of psychosis (a process, developing in stages). They also pointed out that they wanted to tone down the significance of genes or heritage as important causal factors of psychosis.
Secondly, the insiders stressed the need to consider the context when understanding the information material. E.g. in relation to the subtheme “to respond quickly”, they underscored that the mental health system in 1996/1997, before TIPS initiated low threshold and easy access, had been less accessible to people. Therefore, it was vital to change people’s attitudes towards the system by pointing out that they were welcome to seek help—which was a totally new signal from the mental health services at that time. They further pointed out that the outsiders’ understanding about negative consequences (e.g. domino) of not responding promptly differed from the insiders’ conception of psychosis as gradually developing in stages—and intervention could hinder worsening at any stage—not just the first. It should also be noted that at that time, psychosis (schizophrenia) was seen as an illness without hope of recovery.
A third remark was related to the subtheme “To step in”. The insiders pointed out that sometimes people lacked insight into their own condition/situation, meaning it could be unethical not to act against someone’s will. Finally, the outsiders’ depiction of mental health professionals’ expert position in the subtheme “To provide an answer” was incongruent with the insiders’ aspiration to convey hope and readiness to help.