Abstract
Depictions of mental illness in print media are predominantly negative [1–6] and consistently link mental disorders with violence, failure and unpredictability. It has been shown that the public's primary source of information about mental illnesses is the media [7–9]. Consequently destigmatization efforts are mostly directed at providing more accurate information [10], [11]. The work we are reporting shows that there is a need to attend to the frameworks within which the presented information is given meaning.
In previous articles [12–15], we have argued that analysis of media materials must incorporate an appreciation of the production practices [16] of the medium analysed. Central to the materials discussed in this article are the ‘news values’ [17], [18] that editors and journalists rely on to recognize and produce newsworthy stories. Construction of a news story emphasizes recency, conflict, clarity (the ease with which a single meaning can be conveyed) and the perceived impact on or relevance to readers. Further, journalists are not researchers so they typically create balance in their stories by presenting two, or occasionally more, conflicting sides [19]. Failure to acknowledge the effect of these journalistic practices on the materials analysed is a significant limitation of earlier studies of mental illness depictions in print media [1], [3], [4].
One consequence of ignoring the production practices is that earlier research on media depictions of mental illness [1–4] has been confined to describing negative portrayals in published or broadcast materials. Articles have included occasional speculations about why negative depictions predominate [1],[20–22], but we could find no reports that investigated how the published materials were created from a source event. Such knowledge offers the potential for more effective advocacy for those with a mental illness with respect to their depiction in the media.
A further limitation of earlier research on media depictions of mental illness is the implicit assumption that readers are passive consumers of the content. There is a growing body of research grounded in the recognition that people engage actively with media stories. This work shows that stories are understood by relating them to past or present stories, images and events (‘intertextuality’), and to the reader's own experiences [6], [9],[12–15]. These interpretive processes can affect the information that the story provides, as factual content is recognized as factual only in relation to the reader's common sense about the world.
In this article we report an analysis of news stories, relating to a psychiatric patient, that received considerable national publicity. Using discourse analytic techniques [5], [6],[12–15],[23], we plotted how the transformation of the original (legal) source material to the distributed wire stories affected the depiction of the psychiatric patient. Our particular emphasis in this work was to identify the patterns or themes (clusters of mutually consistent discursive resources; words, images and storylines) in the construction of mental illness.
Method
As part of a prospective national study of media depiction of mental illness, a commercial clipping bureau was contracted to provide cuttings of all items with a mental health or illness aspect published throughout New Zealand between 3 February and 2 March 1997. The contract included items about mental health or mental illness, persons with a mental disorder, psychiatric patients, treatments or practitioners and mental health services. Also included were terms associated with mental illness (e.g. ‘mad’, ‘madness’, ‘insane’) and colloquial phrases (e.g. ‘out to lunch’, ‘go completely bananas’). Prior to the contract being placed, one of the authors (RN) corresponded with the bureau and provided detailed definitions of these inclusion criteria. The corpus of collected materials ran to several hundred items ranging from brief ‘fillers’ to full-page newspaper articles.
One of the more widely covered events during this period was indirectly related to an act of violence against a child by a former psychiatric patient. The story broke on 12 February 1997, when the Privacy Commissioner released his opinion [24] on the disclosure, nearly 3 years earlier, of a patient's health information by a psychiatric nurse Neil Pugmire. The patient, Barry Ryder (a.k.a. Steven Staynor), had been released from a secure inpatient unit under the Mental Health (Compulsory Assessment & Treatment) Act 1992. Pugmire had released health information to an Opposition Member of Parliament who had been seeking an inquiry on the release of potentially dangerous patients into the community. Following the disclosure, but prior to the publication of the Case Note, Ryder had kidnapped and attempted to sexually violate an 11-year-old.
Of the 50 newspaper items about this event, 30 were news articles and the remainder (n = 20) were opinion pieces, primarily editorials (n = 16). To these we added a copy of the Case Note as originally released, and the text of the three news stories relating to the Case Note that the New Zealand Press Association (NZPA) distributed to subscribing papers. Copies of these were obtained from NZPA and are referred to as NZPA1 (SJE. Psychiatric patient humiliated. Wellington: New Zealand Press Associaton, 11 February 1997), NZPA2 (NB. Mother outraged by privacy decision. Wellington: New Zealand Press Association, 12 February 1997), NZPA3 (Eden S. Messenger ‘shot’ says PSA. Wellington: New Zealand Press Association, 12 February 1997). On examination, 19 of the 30 printed articles were found to be reprints of one of these news stories; six of NZPA1, seven of NZPA2 and six of NZPA3. With only one exception, the remaining stories added elements of a broadcast interview with Neil Pugmire (nurse) and/or a media release from the MP (Phil Goff) to one of the wire stories. Of the 24 different papers reporting the story only six carried a second article.
The Case Note was an eight-page statement (estimated 4800 words) of the steps by which the Privacy Commissioner gathered and assessed the information from which he derived his (legal) opinion. To this small booklet were added notes on six other cases, a formal statement of the status of the Commissioner's opinions, and an embargo notice for Case Note 2049. The news stories and published articles derived from the Case Note were much briefer. NZPA1, which summarized the Commissioner's opinion, was an estimated 450 words. NZPA2 and NZPA3 added comments from various interested parties and were longer, around 750 and 850 words, respectively.
Our analysis required at least three critical readings of all relevant items by all members of the research team. These readings were discussed by the team, and where they diverged, we sought to reflect this diversity in our report. Initially, attention was paid to the vocabulary and grammar of the items [16]. Subsequent readings, when researchers were more familiar with the corpus of text, enabled us to identify themes [12], [23], [25], [26] (clusters of mutually consistent discursive resources: words, images and storylines) utilized in the depictions of mental illness. We then examined how the transformation of the Case Note to the news story affected each theme, and how these changes affected the depiction of mental illness.
In reporting our analyses, each theme is outlined, followed by a description of its use in the Case Note and news stories. We have then described the effect of changes in the use of the theme on the stigma of mental illness. For the results, we concentrate on the NZPA news stories because, as outlined above, the newspaper articles typically printed the NZPA stories word for word so the deployment of the themes was unchanged. Unless otherwise stated, our references to, and comments on, NZPA1, NZPA2 and NZPA3 apply equally to the published newspaper articles based on that wire story. Material from the news stories is designated by paragraph, for example NZPA1, 4 refers to the fourth paragraph of the first story. Case Note material is designated by page.
Results
We identified four major themes (human rights, vulnerability, risk of dangerousness and threat, and mental illness/psychiatric patient) in the Case Note and the NZPA wire stories.
Human rights
The human rights discourse assumes the existence of rights to which any person is entitled. Claiming these rights by, or on behalf of, an individual constitutes an implicit claim that the individual is such an ordinary person. As the Privacy Commissioner asserts Ryder's right to privacy, he is making the claim that Ryder should be regarded as an ordinary person who is also a patient. In summarizing his opinion [24], pp.7,8], the Privacy Commissioner stated, ‘the patient had been significantly humiliated’, ‘felt unnecessarily hurt and let down as a patient’ and justified these statements by reference to ‘comments provided to me by the aggrieved individual’. These are explicit assertions that Ryder is ordinary in his person and in his response to events. However, the humanizing potential of this discourse for Ryder (the patient) was largely unrealized in the Case Note because he was anonymous, being referred to as ‘the patient’ throughout, and because the theme is predominantly represented by technical elements: ‘health information’, ‘privacy’ and ‘disclosure’. So the text does not construct Ryder as a recognizably ordinary person.
In the first news story, the human rights theme becomes more prominent, partly because of the reduced volume of the story (approximately 4800 words to 450 words) and because the journalist quotes primarily from the Final Opinion [24], pp.7,8]. The opinion that ‘Ryder's privacy had been interfered with’ appeared in the second sentence. The assertion that he had been humiliated provided the basis for both the headline and the lead sentence: ‘A former psychiatric patient was “significantly humiliated” when details of his health records were disclosed’ [NZPA1, 1] and is repeated in the last third of the first news story [NZPA1, 12].
The second news story applies the human rights discourse not only to Ryder (patient) but also to the boy whom he had abducted. Under the headline ‘Mother outraged at privacy decision’, the boy's mother dismissed Slane's opinion as the Government being ‘more worried about offenders' rights than her son's’ [NZPA2, 9]. Her conclusion is substantiated for readers by the reported consequences of Ryder's attack on her son; ‘now 14, was still too scared to walk to school alone. “He will not go anywhere by himself”’ [NZPA2, 7]. Implicit in this statement is a strong claim that a 14-year-old boy is entitled to seek and enjoy increasing independence, and that the Government by condoning, or failing to prevent, Ryder's release, was party to the violation of her son's rights. ‘They (the Government) are wiping their hands of them (the patients). What would have happened if it had been one of (former health minister) Jenny Shipley's kids?’. [NZPA2, 8 insertions in original].
As reported, the mother argued that her son, who was the victim, was more deserving of his rights than was the offender. ‘Why worry about Staynor's privacy? They (the Government) should get their shit together and look after them (the victims).’ [NZPA2, 10, insertions in original]. The mother's vivid argument was carried verbatim in six newspapers, a further three replaced the phrase ‘their shit’.
As a consequence of her appropriation of the human rights theme on behalf of her son, repetition of Slane's opinion that Ryder had suffered significant humiliation [NZPA2, 15,16] seemed indefensible because it adhered to the letter of the law. Because of this, the Commissioner's opinion did not create a human construction of Ryder and his mental illness.
Vulnerability
We had previously identified a cluster of discursive resources that enabled the construction of personal helplessness, an inability to control or cope with one's life [12] somewhat akin to, but less pejorative than, the ‘narcissistic parasites’ described by Hyler et al. [2]. Patients, by definition, are subject to the actions of others and this sense of vulnerability and passivity dominates the depiction of the (psychiatric) patient (Ryder) in the Case Note. Further, Slane reports evidence that Ryder was more vulnerable than the typical patient. First, Pugmire is reported as saying that ‘some forensic psychiatrists’ agreed Ryder needed ‘intensive and long-term therapy and care specifically directed at the condition’, and that the patient had never received such treatment [24], p.4]. Second, Ryder's community nurse was reported as saying that ‘the patient could barely manage many day to day tasks’ [24], p.4]. However, as these personal inadequacies were not germane to the privacy issue, they were not further explored in the Case Note.
Within the first news story, references to the patient's need for extended therapy or support and his difficulties with day to day tasks were not mentioned. His release through a ‘loophole or error in the writing and functioning of the Mental Health Act’ [NZPA1, 9; NZPA2, 20; NZPA3, 8] presents both patient and community as vulnerable following the failure or incompetence of relevant authorities. Community vulnerability was elaborated in the second and third news stories in ways that made Ryder's ‘humiliation’ appear trivial. In NZPA2, the mother makes frequent references to her son's unexpected vulnerability; being kidnapped [NZPA2, 1,3], victimized [NZPA2, 2] and rendered dependent on her [NZPA2, 7]. In the third news story, the Public Service Association statement emphasized Pugmire's vulnerability as the messenger who was ‘shot’ because his message was distasteful [NZPA3, headline, 1,13].
Risk of dangerousness and threat
Within the Case Note, dangerousness was represented by the legal notion of ‘a serious and imminent threat to public safety’ because this is one of the grounds for justifying release of a patient's health information. The phrase occurred in full 12 times and in reduced form on 10 further occasions. Testing Pugmire's action against this criterion, Slane referred to Pugmire's ‘concern that the patient would re-offend’ [24], p.3], Pugmire's perception ‘that dangerous people were being released’ [24], p.3] and to other hospital staff ‘waiting for the patient to commit another offence.’ [24], p.3]. He also mentioned, in passing, that another patient, released in the same manner as Ryder, ‘sexually violated an infant’ [24], p.3], an event consistent with Pugmire's concerns. Although Ryder's subsequent act of violence is irrelevant to the privacy issues, the absence of any reference to it in the Case Note provoked considerable public comment and resentment [27].
All three news stories include a one-paragraph report of Ryder's criminal assault [NZPA1, 4; NZPA2, 3; NZPA3, 6]: In September 1994, Staynor [Ryder] kidnapped an 11-year-old boy and attempted to sexually violate him at knifepoint. He was jailed for nine years.
In all newspaper articles, this statement preceded reports of Pugmire's concern to prevent threats to the public's safety. Phrases from the letter he wrote are then cited as if they identify risk factors for such actions, ‘psychiatric situation and state of mind’ [NZPA1, 6], ‘allegations about earlier behaviour’ [NZPA2, 12], ‘warnings of danger to children’ [NZPA3, 12]. As reported, Ryder's agency in and responsibility for the criminal assault is foregrounded by making him the subject of the active (grammatical) voice, the only point in the stories where he is represented as an agent. This contrasts sharply with his depicted passivity as a patient, which is highlighted by presenting him as the object of other's actions in (grammatically) passive sentences (human rights, vulnerability themes). The contrast crystallizes a common understanding about mental illness, that in sufferers, personal incompetence and destructive violence coexist.
The threat to public safety just outlined was intensified in the second and third news stories by reporting Pugmire's claim that more patients like Ryder were being released into the community through a fault in the law. These were ‘potentially dangerous patients’ [NZPA2, 20] or, ‘about 15 particularly dangerous patients’ [NZPA3, 8]. In the light of the reported actions of Ryder and the other unnamed patient, readers had grounds for viewing these releases as a threat to their families, and as evidence that those responsible for ‘care in the community’ were not concerned about the risks their practices were creating [28]. The change of modality, ‘potentially’ to ‘particularly’, intensifies the threat each patient represents. Nominating an actual number could, at best, slightly moderate the sense of danger created by news of their unheralded release into communities anywhere in New Zealand.
Mental illness/psychiatric patient
In earlier articles [12–15], we argued that undifferentiated depictions imply that mental illness is a unitary condition, and encourage similar responses to anyone who suffers from such a disorder. In the Case Note, Ryder's status as patient was central, so his mental illness was conveyed by systemic elements of the theme such as ‘mental health legislation’, ‘secure unit of a psychiatric hospital’, ‘patient's psychiatric situation’, ‘state of mind’, ‘counselling’, and ‘the community nurse who was supporting the patient’.
Throughout the news stories, Ryder's mental illness continued to be constructed through systemic elements: ‘former psychiatric patient’ [NZPA1, headline, 1; NZPA2, 1; NZPA3, 2], ‘health records’ [NZPA1, 1], ‘patient's psychiatric situation and state of mind, references to his ability to cope’ [NZPA1, 6], ‘secure unit of Lake Alice Hospital’ [NZPA1, 3; NZPA2, 4; NZPA3, 3] and ‘National Director of Mental Health’ [NZPA1, 5; NZPA2, 5]. Such systemic elements cue writers and readers to make sense of the events by drawing on commonsense understandings that those who suffer from this condition (mental illness) are dangerous and unpredictable. Simultaneously, the reports of sexual assaults by two patients, and references to other ‘potentially’ [NZPA2, 20] or ‘particularly’ [NZPA3, 8] dangerous patients, confirm those commonsense understandings.
Discussion
Our analysis identified four themes or sets of discursive resources that, in the way they were utilized, produced a stigmatizing depiction of the former psychiatric patient and of others suffering from a mental illness. Two of these themes, human rights, and risk of dangerousness and threat, became more prominent in the news stories. The former was redirected from the rights of a patient to the rights of citizens and their traumatized children. Risk of dangerousness and threat was foregrounded in the news stories, both confirming the dangerousness of the patient and undermining the claim that he was a person whose privacy should be respected [29].
While a few studies [2], [8], [12] have identified some positive themes in portrayals of mental illness, the reports show that such themes are outnumbered by negative ones and their ameliorating effect swamped by the negativity of the majority of depictions [1–6],[12–14]. In this story, the human rights theme offered the possibility of a positive depiction that was not realized because of its fragmentation within the Case Note. Clearly, it takes more than the routine use of a potentially positive theme to achieve a positive portrayal of mental illness.
We have identified three further aspects of the process of creating the news story that also undermined the potential positivity of the human rights theme. First, the massive reduction of the Case Note to the first news story required the omission of both evidence and legal reasoning supporting the Commissioner's legal opinion. The effect of these omissions was intensified because, in constructing the news story, the Commissioner was transformed from an authoritative legal commentator to a participant presenting one side of the story.
Second, the foregrounding of Ryder's sexual assault and other elements of the risk of dangerousness and threat theme not only emphasized the risk that individuals like Ryder represented for the community but also undermined his entitlement to privacy [29]. Undermining Ryder's right in this way facilitated a redirection of the Human Rights theme to the assaulted child and the vulnerable public he symbolized. Underlying this redirection is the commonsense understanding that any person has the right to do whatever they like provided it does not infringe another's rights [30], an understanding that is more available to readers than the details of the Privacy Code.
Third, as we have already described, readers are recognized as interpreting media materials through perceived connections or associations with other texts, images or experiences – referred to as ‘intertextuality’ [13]. The news stories presented the event as a conflict between two incompatible images of the psychiatric patient encouraging readers to flesh out the views and assertions of the Commissioner and the nurse to achieve an understanding of the event. This made the ‘character’ of Ryder crucial. As a consequence of these presentation strategies, the lack of any reference to Ryder's violence by the Commissioner enables writers to present him as wilfully blind to the patient's ‘real’ nature [27]. As described previously, the violence undermines the patient's ordinariness, making the Commissioner's opinion appear unreasonable and legalistic. The construction of the Commissioner's position as legalistic is reinforced by opposing him to the nurse who is depicted as being more realistic about the patient's nature.
In these materials, the characterization of mental illness is sketchy and generic, largely because it is dominated by systemic elements of the mental illness/ psychiatric patient theme. Such sketchy depictions encourage readers to draw on commonsense about mental illness in understanding the story. A more differentiated portrayal of Ryder's condition was not germane to the privacy issues, a justification for the predominance of systemic elements of the theme in the Case Note. As outlined above, the personalization of the news stories focused attention on Ryder's ‘character’ and encouraged the association of his undifferentiated mental illness with his criminal assault. We would not argue that the press should have given less prominence to Ryder's invasive and violating action. Rather, we are claiming that the way in which the journalists shaped the story conjoins that action to the undifferentiated portrayal of his mental illness and invites the reader to generalize from Ryder to other persons with a mental illness.
Throughout the corpus of material, the themes and production practices we have described mutually reinforced and nuanced each other, consistently linking mental illness with violence and unpredictability. This interplay was well exemplified by the way in which ‘patient’ was used. In the Case Note and in parts of the first news story, ‘patient’ was strongly associated with vulnerability and passivity. When attention was redirected to the rights of citizens in the subsequent news stories, Ryder's status as patient was obscured by emphasizing his active criminality. This redirection appeared to encourage feelings of disgust, outrage or fear of the patient, and of the people and institutions responsible for his presence in the community.
There are a number of possible limitations on our findings. First, work grounded in New Zealand print media might not generalize. As our findings were obtained with materials that were not aggressively sensationalistic and are consistent with previously published work [3], [5], [6], [8], [20], we are confident that the patterns reported have broad implications. Second, a different research team might identify different findings. This is a common problem with qualitative procedures like discourse analysis which, for this report, we addressed in two distinct ways. We sought consensus in the interpretation process reporting those aspects of our critical reading on which we were in substantial agreement, and we checked the intelligibility of findings by presenting them to colleagues who found them credible and helpful. Finally, we have not provided an exhaustive discussion of the transformations of the Case Study into a news story because we wished to draw attention to the most important of these.
We believe that there are two particularly novel and important features of this research. These are the comprehensive national sample on which this analysis is based, and the inclusion of the source materials in the analysis. This enabled us to examine how the legal opinion was transformed into news stories and the way in which use of the themes changed during the process, providing a unique perspective on stigmatizing processes. While we found no inaccurate content in the reporting of the Privacy Commissioner's opinion, the transformation of the relatively neutral Case Note opinion into the news stories created a very negative depiction of the patient. We believe that the prominence given to the patient's criminal assault that exemplified his dangerousness, especially for children, was crucial in this change.
We have asserted that an adequate analysis of how such negative depictions of mental illness are created and utilized must be addressed in any effective destigmatization project. Here we have drawn attention to two elements, the way that information is given meaning by the frame within which it is presented, and the depersonalized, generic representation of mental illness. These have immediate implications for recommended steps to reduce stigma. First, when consumers are providing ‘direct contact’ with someone who has been helped for a mental illness [10], p.67] it is essential that they are supported in ways that authorize their challenge to generic, depersonalized stereotypes of mental illness. Second, where the mental health community – professionals, consumers and families – are working with media personnel to achieve more diverse and accurate portrayals of mental illnesses [11], p.22], there needs to be careful attention to the way in which information is framed in creating the news stories.