International Review of Psychiatry, August 2014; 26(4): 423–429

Evaluation of a comedy intervention to improve coping and help-seeking

for mental health problems in a women’s prison

STEVE WRIGHT1, MAYA TWARDZICKI2, FABIO GOMEZ3 & CLAIRE HENDERSON1

1Health Service & Population Research Department, Institute of Psychiatry, King’s College London, Denmark Hill,

London, 2Public Health Directorate, NHS Surrey, Kingston Upon Thames, and 3Southside Partnership, London, UK

Abstract
Rates of mental illness and self-harm are very high among women prisoners. Questionnaires assessed prisoners’ knowledge
of and attitudes towards mental health problems, and relevant behavioural intentions before and after the intervention, to
evaluate the effectiveness of a comedy show in a women’s prison to reduce mental health stigma and improve coping and
help-seeking for mental health problems. The intervention appeared to have been successful in improving some aspects of
prisoners’ knowledge about the effectiveness of psychotherapy (Z   2.304, p  0.021) and likelihood of recovery from
mental health problems (Z   2.699, p  0.007). There were significant post-intervention increases in the proportion who
stated they would discuss or disclose mental health problems with all but one of the sources of help in the questionnaire,
which was consistent with the increases in the number of prisoners who rated themselves as likely to start using different
sources of help or prison activities. There was no improvement in intentions to associate with people with a mental health
problem. The intervention appeared effective in improving factors that might increase help-seeking and improve coping,
but not those that would change behaviour towards others with a mental health problem.

Introduction
The prison population has a very high level of men-
tal health need, with as many as 12–15% of prisoners
having four or five co-existing mental disorders, and
30% of all prisoners having a history of self-harm
(Brooker et al., 2003). A more recent review
(Sirdifield et al., 2009) found that the prevalence of
mental disorders, substance use, and suicide remain
high in prison populations around the world, and
reiterates findings that the incidence of mental dis-
order is often higher for women. While women
account for only approximately 5% of prisoners in
England and Wales (Ministry of Justice, 2009), they
have very high levels of mental health problems, for
example between 2004 and 2009; 20–24% of female
inmates self-harmed every year (Hawton et al., 2013).
Imprisonment is a stressful experience, and the levels
of psychosocial stress engendered by overcrowding
may exacerbate the distress of prisoners suffering
from mental health problems.
There is evidence that stigma and discrimination
can limit access to mental healthcare (Clement
et al., 2014). However, there is a lack of evidence
concerning the effects of multiple sources of stigma
(such as, for example, mental health problems,
coming from an ethnic minority, and criminality)
on help-seeking. A small-scale qualitative study of
male prisoners found a combination of high levels
of distrust towards authority and ‘the system’ in
general, a perception that healthcare professionals
(usually doctors) ‘just don’t care’, and high levels
of stigma surrounding mental problems (Howerton
et al., 2007). Most of the respondents reported
that they would not seek help from any healthcare
professional if experiencing mental distress, despite
the fact that many had considerable emotional
problems (indeed, a quarter of them were flagged
as being at risk of self-harm).
This paper reports the results of an evaluation of
a novel psychoeducational intervention, in which
prisoners watched a comedy performance (entitled
‘Cracking up’) which explored mental health and
race-related issues including mental health-related
stigma, and encouraged seeking and accessing well-
being and support services. Performing arts classes
and performances for both recreational and educa-
tional purposes are by no means uncommon in pris-
ons, and there is research interest in the effectiveness
of novel interventions in supporting mental health
in vulnerable populations (Shandley et al., 2010).
Our evaluation is based on a conceptual framework
that describes stigma as consisting of difficulties of

Correspondence: Dr Claire Henderson, Health Service & Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny
Park, Denmark Hill, London SE5 8AF, UK. Tel: 0207 848 5075. Fax: 0207 848 1462. E-mail: Claire.1.henderson@kcl.ac.uk
ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry
DOI: 10.3109/09540261.2014.924096
424 S. Wright et al.
knowledge (ignorance or misinformation), attitudes
(prejudice), and behaviour (discrimination)
( Thornicroft, 2006). We therefore hypothesized that
questionnaires completed post-performance would
show improved stigma-related mental health knowl-
edge, more positive attitudes to mental illness, and
more positive behavioural intentions in terms of
contact with people with mental health problems,
compared to pre-performance ratings. Because the
show addressed help-seeking directly as well as
stigma as a barrier to help-seeking, we also hypoth-
esized that intended help-seeking and use of other
positive coping strategies would be higher post-
performance.
Method
Site
The evaluation was conducted at a closed prison for
sentenced adult women prisoners in the south of
England, with an operational capacity of 358 pris-
oners. The ethnic minority population for prisons
in the county was approximately 55%, compared to
approximately 5% in the local general population.
Participants
The participants were adult sentenced prisoners who
had consented to take part in the evaluation.
Measures
A pre-performance evaluation questionnaire was
developed which collected socio-demographics,
degree of previous familiarity with people with men-
tal health problems, whom the participant would feel
comfortable disclosing and discussing mental health
problems with, participation in prison activities,
and help-seeking and coping in prison. In the pre-
performance questionnaire, participants were asked
to record whether or not they presently took part in
or used each of eight different activities, sources of
help, or methods of coping that were presented. In
the post-performance questionnaire, participants
were presented with the same list, and asked to indi-
cate whether they intended to start, stop, or do or
use each activity, source of help, or coping method
more or less frequently, or whether they had no
intention to change their current frequency of use or
involvement. Stigma-related mental health knowl-
edge items were taken from the Mental Health
Knowledge Schedule (MAKS) (Evans-Lacko et al.,
2010), with two additional items intended to reflect
research findings concerning ethnic differences in
the prevalence of some mental disorders and in pat-
terns of mental healthcare usage which consistently
emerge (Bhui & Bhugra, 2007). This was considered
necessary because of the over-representation of
people from ethnic minority backgrounds in the
prison population. Attitudes to mental illness were
assessed using items relevant to the intervention
content selected from the Community Attitudes
toward the Mentally Ill scale (CAMI) (Taylor &
Dear, 1981). Intended behaviour was assessed
by applying the concept of social distance to this
setting; we asked about the extent to which the
participant was willing to spend time with someone
with a mental health problem, in comparison with
people with other types of disorder. One of the
comparison items, People with cancer was included,
because cancer, like mental health problems, is a
stigmatized illness (Rosman, 2004).
In an effort to reduce participant burden and there-
fore improve response rates, the post-performance
questionnaire did not include the data concerning
closeness of relationship with people with mental
health problems, education, and ethnicity, as this
data would have been already collected in the pre-
performance questionnaire.
Intervention
The comedy performance (entitled ‘Cracking up’)
explored mental health and race-related issues,
and encouraged seeking and accessing well-being
and support services. In addition to the stand-up
comedian, there were contributions from two
inmates in the form of poetry they had written –
as social contact between people with experience
of mental health problems and those who have
not, is an effective way of promoting more posi-
tive attitudes and reducing stigma (Corrigan
et al., 2012). The key issues addressed in the per-
formance were why mental health problems and
race equality issues are important in prisons, the
nature of mental health problems and risk factors
for developing them, addressing myths and stigma
(for example, myths concerning mental health
problems and violence, recovery from mental
health problems, cultural beliefs concerning men-
tal health problems, and misperceptions around
cultural issues), protective factors, sources of
help, and coping.
Material for the performance was researched
via the comedian talking both to ex-offenders and
to inmates through focus groups in three adult pris-
ons (two of which were for male offenders, the
other being a women’s prison, where the interven-
tion was performed and evaluated). This prepara-
tory research explored inmates’ and ex-offenders’
experiences, knowledge of and attitudes towards
mental health issues, help-seeking, coping strategies
and stigma.

Data collection
The original intention was to use a repeated-
measures design, with prisoners who agreed to
participate in the evaluation completing question-
naires before and after viewing the performance.
However, after the prisoners had been informed
about the evaluation and consent had been given by
prisoners who wished to participate in it, and the
pre-performance questionnaires were completed,
it became necessary to postpone the performance
for five weeks. Given that the turnover of a prison
population can be higher than 10% per week,
this meant that most of the prisoners who had
completed the questionnaires were no longer there to
see the performance. It was therefore decided to
collect post-performance evaluation questionnaires
from prisoners after they had seen it, whether or
not they had completed the pre-performance
questionnaire.
Analysis
Because the data distributions for the pre- and post
performance groups were non-normal for knowl-
edge, attitudes, willingness to associate, and disclo-
sure and discussion of mental health problems,
the scores of the groups were compared using the
Mann-Whitney test, and median values are presented
in Tables 1, 2 and 3. Because the MAKS knowledge
items address different knowledge domains rather
than forming a scale, a correction for multiple testing
was not used.
Prison mental health intervention 425
The ratings for current use of activities, sources of
help, and coping methods in the pre-performance
group differed from those for planned future use of
activities, sources of help, and coping methods in the
post-performance group, so direct comparison using
a statistical test was not possible. Instead, the net
positive or negative effects of the performance on
intended future behaviours in the post-performance
group were calculated in the following way. The per-
centage of participants who rated themselves as using
or being involved with the listed activities and help-
seeking and coping methods in the pre-performance
questionnaire was considered to be a base rate, and
the percentage of participants who rated themselves
as planning to either start or already do or use more
of the item was added to this figure, while the per-
centage of participants rated as either planning to
stop or already do or use less of the item were sub-
tracted. If the resulting total was higher than the base
rate figure, then the performance was judged to have
had a positive effect for that item, and vice versa.
Ethics
Permission to run the intervention and evaluation
was given by the Ministry of Justice and the three
prisons where work was done to develop the inter-
vention, including the prison where the intervention
was delivered. The King’s College London Research
Ethics Committee deemed the evaluation exempt
from research ethics approval on the basis that it was
a service evaluation.

Table 1. Pre- and post-performance attitude and knowledge scores.

Pre-performance Post-performance
% agreeing strongly/ % agreeing strongly/
slightly (median) slightly (median) Z P

Knowledge items
Most people with mental health problems want to have paid 75% (2.0) 84% (2.0)  1.720 NS
employment
If a friend had a mental health problem, I know what advice to 78% (2.0) 82% (2.0)  0.561 NS
give them to get professional help
Medication can be an effective treatment for people with mental 71% (2.0) 86% (2.0)  1.110 NS
health problems
Psychotherapy (e.g. talking treatment or counselling) can be an 76% (2.0) 91% (1.0)  2.304 0.021
effective treatment for people with mental health problems
People with severe mental health problems can fully recover 46% (3.0) 84% (2.0)  2.699 0.007
Most people with mental health problems go to a healthcare 47% (2.0) 38% (2.0)  0.556 NS
professional to get help
Black people get worse mental healthcare than white people 20% (5.0) 50% (2.5)  3.013 0.003
Black people have more mental illness than white people 14% (5.0) 48% (3.0)  3.336 0.001
Attitude items
Virtually anyone can become mentally ill 91% (1.0) 100% (1.0)  1.480 NS
People with mental health problems are far less of a danger than 39% (3.0) 48% (3.0)  0.821 NS
most people suppose
People with mental health problems should not be given any 9% (4.5) 35% (4.0)  1.743 NS
responsibility
426 S. Wright et al.
Table 2. Pre-and post-performance ratings of willingness to associate, and comfort in disclosing and discussing mental health problems
with others.

Pre-performance % Post-performance %
very/moderately very/moderately
willing to associate willing to associate
(median) (median) Z P

Person with schizophrenia 78% (2.00) 86% (2.00) NS

Person with depression 93% (1.00) 96% (1.00) NS
Person with a learning disability 93% (1.00) 100% (1.00) NS
Person with cancer 94% (1.00) 100% (1.00) NS
Drug user 82% (2.00) 86% (2.00) NS

Pre-performance Post-performance
comfortable/slightly comfortable/slightly
comfortable rating comfortable rating
(median) (median)

Fellow prisoner 27% (3.00) 68% (2.00)  2.730 0.006

Samaritan Listener 28% (3.00) 59% (2.00)  1.924 0.054
Prison officer 24% (3.00) 59% (2.00)  2.530 0.011
Healthcare staff 23% (3.00) 77% (2.00)  4.626  0.001
Mental health inreach staff 22% (4.00) 77% (3.00)  5.164  0.001
Chaplain 17% (3.00) 77% (1.00)  5.120  0.001
Southside community development workers 18% (3.50) 77% (2.00)  4.949  0.001

Results
Seventy prisoners (20% of the prison’s operational
capacity) completed pre-performance questionnaires.
Mean pre-performance age was 32.6 years (range 18
to 63 years, standard deviation (SD) 11.4 years).
Regarding ethnicity, 47 participants (67%) were white
British, white Irish, or White other, 11 (16%) were
Black Caribbean, two (3%) were Black African, three
(4%) were Chinese or other south-east Asian, and
four (6%) were of mixed ethnicity. These totals give

Table 3. Pre- and post-performance ratings of current and planned future use of activities, sources of
help, and coping methods.

Current use of/involvement in activity/source of help/coping method (pre-performance)

Yes No

Gym or capoeira 57 (85%) 10 (15%)

Education 24 (36%) 43 (64%)
Work 26 (39%) 41 (61%)
Samaritans Listeners 38 (59%) 27 (42%)
Mental health services/counselling 38 (59%) 27 (42%)
Encourage others 25 (37%) 43 (63%)
Brood on problems 40 (59%) 28 (41%)
Distract oneself 25 (37%) 43 (63%)

Planned future use of/involvement in activity/source of help/coping method (post-performance)

Do/use Do/use No change

Start Stop more less planned

Gym or capoeira 9 (39%) 0 4 (17%) 0 10 (44%)

Education 1 (4%) 3 (13%) 2 (9%) 0 17 (74%)
Work 1 (4%) 0 5 (22%) 1 (4%) 16 (70%)
Samaritans Listeners 1 (4%) 0 2 (9%) 2 (9%) 18 (78%)
Mental health services/counselling 2 (9%) 2 (9%) 2 (9%) 0 17 (74%)
Encourage others 3 (13%) 1 (4%) 1 (4%) 0 16 (78%)
Brood on problems 5 (22%) 1 (4%) 2 (9%) 0 15 (65%)
Distract oneself 3 (14%) 5 (23%) 2 (9%) 1 (5%) 11 (50%)

summary figures of 47 white British, white Irish and
white other participants (67%), and 23 participants
from black or ethnic minority (BME) communities
(33%). Average age of the pre-performance group was
31.9 years (range 18 to 63 years, SD 11.09).
Fifteen participants (22%) who completed a
pre-performance questionnaire had no educational
qualifications, while 35 (50%) were educated to
‘A’ Level or above.
Regarding previous familiarity with people with
mental health problems, 49 participants (70%)
reported that they themselves or a partner, family
member or friend had previously experienced mental
health problems, while the remainder reported hav-
ing no experience of knowing anyone with mental
health problems, or knew no-one more close than an
acquaintance or colleague.
Twenty-four prisoners returned post-performance
questionnaires, nine of whom had previously com-
pleted a pre-performance questionnaire.
Pre- and post-performance knowledge and attitudes
The items and comparisons of the pre- and post-
performance ratings are summarized in Table 1.
The proportion of post-performance respondents
who agreed with the statements concerning know-
ledge about mental health problems was significantly
greater than the pre-performance respondents for the
MAKS items ‘People with severe mental health prob-
lems can fully recover’ (Z  2.699, p  0.007) and
‘Psychotherapy (e.g. talking treatment or counsel-
ling) can be an effective treatment for people with
mental health problems’ (Z  2.304, p  0.021).
Statistically significant differences were also detected
for both of the additional items ‘Black people get
worse mental healthcare than white people’
(Z  3.013, p  0.003) and ‘Black people have more
mental illness than white people’ (Z  3.336
p  0.001).
No statistically significant differences between pre-
and post-performance ratings were observed for any
of the three attitude items pre- performance willing-
ness to associate, post-performance willingness to
associate, and comfort with disclosure and discus-
sion of mental health problems
Table 2 summarizes data concerning pre- and
post-performance ratings of the degree to which par-
ticipants would be willing to voluntarily associate
with people with different mental health problems,
and would feel comfortable in disclosing or discuss-
ing mental health problems with different types of
people in the prison. Participants were asked to give
ratings of 1 (very willing), 2 (moderately willing) or
3 (not willing) to each condition. No significant dif-
ferences were detected between pre- and post-per-
formance ratings.
Prison mental health intervention 427
With regard to comfort in disclosing and discuss-
ing mental health problems, ratings ranged from 1
(extremely comfortable) to 5 (not at all uncomfort-
able). This data is also summarized in Table 2. Sig-
nificantly more participants rated their degree of
comfort more highly after the performance than the
pre-performance ratings for all types of people, with
the exception of Samaritans Listeners.
Pre- and post-performance participation in prison
activities, and help-seeking and coping in prison
Pre- and post-performance ratings are summarized
in Table 3. Post-performance changes were positive
for gym/capoeira sessions (66% increase), education
(8% increase), work (13% increase), Samaritans
Listeners (2% increase), mental health services/
counselling (12% increase), encourage others (27%
increase), and brooding on problems (42% increase),
while distracting oneself was decreased by 14%.
Discussion
The increase in the proportion of prisoners who
reported increased willingness to discuss or disclose
their mental health problems with all the sources of
help listed (except for the Samaritans Listeners)
might be accounted for by the statistically significant
increases in ratings for the knowledge items ‘Psycho-
therapy can be an effective treatment for people with
mental health problems’ and ‘People with severe
mental health problems can fully recover’. Surpris-
ingly, the largest difference between pre-and post-
performance ratings was for ‘Brooding on problems’,
which increased from 41% to 59% of responses.
Ruminating upon problems is not seen as an adaptive
coping strategy, as it inhibits engagement in poten-
tially more rewarding activities (Kuyken et al., 2009).
It could be that the term ‘Brooding on problems’ was
interpreted by the participants in terms of thinking
problems though to find a constructive solution,
rather than the maladaptive strategy that rumination
is considered to be by mental health professionals.
No significant differences were detected between
pre- and post-performance ratings on attitudes
towards people with mental health problems and
also willingness to associate with people with mental
health problems. An aim of the intervention was to
address myths and stigma associated with mental
health problems, and one might expect that, to the
extent that the intervention achieved this aim, then
attitudes would become more positive and willing-
ness to associate with people suffering from mental
health problems would increase. However, 70% of
the pre-performance sample reported that they
themselves or a partner, family member or friend
428 S. Wright et al.
had previously experienced mental health problems.
Research shows that direct personal contact with
people with mental health problems is the most
potent way to improve attitudes towards them
(Corrigan et al., 2012) and that women are less
stigmatized (Stickney et al., 2012), so it is possible
that a ceiling effect occurred. Furthermore, this was
a comparatively well-educated sample, and people
with higher levels of education have been found to
have more favourable attitudes towards people with
mental health problems (Thornicroft, 2006).
While these results appear encouraging, they must
be considered in relation to the limitations of the study.
The study was conducted in a women’s prison, so the
results cannot readily be generalized to male offenders
as there are clear gender differences in help-seeking
behaviour. Further, the pre-performance sample was
comparatively young, and predominantly white,
although non-white prisoners were highly represented,
making up 33% of the total. Just over one fifth of the
participants (22%) had no educational qualifications,
which is comparatively low, given the figure of 71% of
women prisoners with no qualifications (compared to
52% of male prisoners and 15% among the general
population) identified in a previous study by the Social
Exclusion Unit (2002), and half of the participants
were educated to at least ‘A’ level standard.
Our original intention was to obtain both pre- and
post-performance data from the prisoners who
attended the performance. Because it was impossible
to do this for operational reasons, the only other
option was to adopt a less robust method. However,
there is no evidence to suggest that the participants
who viewed the performance but had not completed
the pre-performance questionnaire were different
from those who completed a questionnaire but did
not attend. In any case, attempts at matching pre- and
post-performance groups would have been difficult,
given the high rate of prisoner turnover in any prison.
This rate would also make it difficult to collect actual
help-seeking data, leading to a further limitation, i.e.
the use of reported intentions to disclose problems or
use different coping methods or sources of help.
While the results suggest that the intervention
could have been successful in encouraging those who
received it to seek help for mental health problems,
other research (Friedrich et al., 2013) suggests that
the effects may only be short term. An intervention
such as this should therefore be integrated into other
work, for example improvements to services informed
by service user involvement (Ward & Bailey, 2013).
Acknowledgements
We gratefully acknowledge the assistance given by
Obinna Ugoala (Community Development Worker,
Southside Partnership), and by the Champion Vol-
unteer Inmates, who undertook the data collection
for the evaluation as part of their NVQ in Informa-
tion Advice and Guidance.
Declaration of interest: Funding for the interven-
tion and the evaluation was granted by the Transfor-
mational Fund of the Department of Business and
Enterprise. C.H and S.W. were supported by a grant
from Time to Change from the Big Lottery Fund and
Comic Relief and a grant from the Shift project. C.H.
is supported by a National Institute for Health
Research Applied Programme grant awarded to the
South London and Maudsley NHS Foundation
Trust. The authors alone are responsible for the con-
tent and writing of the paper.
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