Abstract
As media are the public's primary source of information about mental illnesses [1–3], depictions of those suffering from these disorders contribute significantly to the stigma associated with mental illness. This contribution makes the negativity of media depictions [1],[4–8] a matter of great concern, and it has been argued [9–12] that these depictions would be more favourable if psychiatrists and other mental health professionals were more closely involved. To test this proposal, I compared the depictions of mental illness in stories based on interviews with lay sources and psychiatrists from a backgrounder on mental health.
In an earlier article [13], we argued that analyses of media depictions must take account of media practices and the present analysis is grounded in studies of the relationships between journalists and their sources [14],[15]. Analyses of journalistic practice [14–16] show that sources struggle, usually with little success, to sustain their preferred interpretation of the information they provide, as journalists and editors deploy it to construct a newsworthy story [14]. In practice, journalists organise their materials to present the appearance of objectivity [17], while giving priority to newsworthy elements understood to attract readers [14],[15],[18].
Central to the task of creating a credible, objective report is the authority of the sources quoted or referred to, achieved by reference to the status and authority of the source [19] or by identifying them as a participant. Participants speak primarily about what happened (primary information [20]), and how they experienced the event (tertiary information [20]). Experts, within their domain of expertise, provide explanations (secondary information [20]), evaluations (whether the event is good or bad) and recommendations.
Published studies of newspaper stories dealing with mental illness [5],[21],[22] do not report accounts or explanations provided by those with a mental disorder. This means that readers are informed about mental illnesses through stories from lay persons or professionals who have interacted with a sufferer. Yet this does not explain why the depictions are so negative [4–8] nor, more importantly, how these negative depictions are constructed [13],[23].
This article reports the results of discourse analysis [23],[24] informed by the understanding of media practices. In this work, the constructive role of language is fundamental, ‘social texts do not merely reflect or mirror objects, events and categories preexisting in the social and natural world. Rather they actively construct a version of those things’ [24, p.6]. Such analyses have added much to the understanding of the depictions of otherwise naturalised categories: race [25],[26], gender [27] and political identity [28], but have only recently been applied to portrayals of mental illness.
Method
The media sample for this study was a two-part ‘Special Report on Mental Health’ in the Auckland City Harbour News, 19 and 26 March 1993 [29], consisting of 12 articles on two double-page spreads (see Table 1). Under various local names, this free community newspaper has a circulation about 310 000 in the Auckland region. The work reported here is an analysis of four ‘case stories’ (items 1, 2, 4, 5; 19 March) and three interviews with individual psychiatrists (items 8, 9, 11; 26 March). The other items were excluded because they involved multiple sources that were not consistently distinguished and because these sources were not clearly lay or qualified mental health professionals.
Structure of the Special Report on Mental Health
On the left-hand page of the first double-page layout, there was a black band bearing, in white, the title; ‘Special report.mental health’. Below this the two journalists, Yvonne Martin and Pat Booth, are named and said to ‘present the evidence’ in relation to ‘the treatment of the mentally ill’.
Report items were read and re-read for three kinds of information: the sources; the kinds of information they provided; and how it was used in the depiction of mental illness. Information was only attributed to a source who was directly quoted or reported. All other information (unattributed) was assigned to the journalist irrespective of the probability that it was originally provided by the source (see Table 2).
Contributions from sources in items analysed
To examine the use of the sources' information, all sentences attributed to a source were decomposed into propositions [30] which were classified using the categories from Ericson et al. [20]: primary—what happened; secondary—why it happened; tertiary—what the experience was like; evaluation—is this good or bad; and recommendation—what should be done. As some sentences provided more than one kind of information, the totals for the proposition-based analysis, 183, referred to as information counts, differ from the tally of attributed sentences, 126.
To analyse the depictions of mental illness, all descriptions and characterisations of people with a mental disorder were noted, together with the associated verbs and their source. The place of these descriptors within the items and their contribution to the overall effect of the report were identified through these analytic readings. By these means, we are able to compare the depictions of mental illness in the case stories and the psychiatrist interviews.
Throughout, articles and sentences are numbered for reference; ‘1.14’ refers to article 1, sentence 14.
Methods
Use of sources: are the psychiatrists treated as experts?
Nine informants (sources) were identified in the seven items being analysed (Table 1). In the items analysed, the journalists treat the sources of the case stories and the psychiatrists they interviewed differently. First, each psychiatrist is named and their institutional position is given in either the first or second sentence. Sources for the case stories are not named, being identified, often quite late in the story, only as a neighbour, mother or father. Second, there is a marked difference in the amount of information attributed to two categories of informant (Table 2). In the case stories, 30% of the sentences are attributed to the source, for the psychiatrists 65% of the sentences are attributed to the source by direct quotation or reported speech.
The items also differ in the way in which they are presented to the reader. Case stories read as reports from the journalists, primarily constituted by the unattributed information, presented as if the writer had been an observer:
(4.14–4.16) He won't eat or sleep for days on end. He hears voices in his head and avoids certain colours, letters of the alphabet and numbers because of his schizophrenic superstitions. He speaks an apparently foreign language, using words but leaving out letters of the alphabet he feels are evil.
In contrast, psychiatrist interviews are arranged by the journalists but the unattributed information backgrounds or summarises what the psychiatrist says:
(9.12–9.14) ‘Over-tolerance by authorities will lead to sharp reaction from the public, demands that patients return to hospital, or for more restrictions, with every good reason.’ Historic cases of arson, rape, sodomy and even murder inflicted by patients have been horrific. Nurses had been beaten up, indecently assaulted and raped.
The kind of information provided
Table 3 summarises the differences between the two groups with respect to the kinds of attributed information that the journalists deployed within the items.
Categories of information attributed to sources
Lay sources spoke predominantly of what happened (49%) and what the experience was like (26%). Evaluations of their experiences (16%) focus, almost entirely, on failures of the mental health system to provide care for, or to protect the public from, its patients [31]. Five evaluations and two recommendations originated with authorities, police or doctors, and were recounted by the source.
In the psychiatrist interviews, explanations (34%) and evaluations (26%) were most common. Compared to the lay sources, psychiatrists provide less primary (49–24%) and tertiary (26–9%) information and, consistent with their status as experts, provide considerably higher rates of explanations (3–34%), evaluations (16–26%) and recommendations (5–15%). When providing primary information, the psychiatrists typically talk about general changes in practice and law rather than personal experiences.
Do psychiatrists provide a less negative depiction of mental illness?
As described previously, the case stories are primarily reportorial narratives with quotations from sources adding immediate, personal details that enhance the authenticity of the story [32]. This means that the depiction of mental illness in these items is primarily the journalist's. Typically, as in sentences 4.14–4.16 cited above, negative evaluations are woven into these narratives. In sentences 15–16, we are told that the patient's speech is rendered unintelligible, ‘apparently foreign language’ as a consequence of ‘schizophrenic superstitions’ in which some letters are evil. In contrast, each psychiatrist depicts mental illness in a manner consistent with their views about the new Mental Health Act 1992 [33] and associated practices.
Central to the case stories are the ‘relatively standard, predictable narratives, discourses and preferred images’ [23], the commonsense understanding that persons with a mental illness are unpredictable, threatening and violent [31]. Unpredictability may be asserted:
(4.19) His unpredictable behaviour has worsened.
Or implied by behaviour that is clearly unexpected:
(5.38) He wrote letters to Scotland Yard and the army and hand-delivered a letter to the Police Commissioner in Wellington.
In item 1 the journalist uses ‘threats’ or ‘threatening’ six times as well as describing disturbed behaviour that threatens others:
(1.9) …setting her unit floorboards on fire,…
Similarly in item 5:
(5.7) (parents act)…under a constant torrent of abuse from their son,…
Although the violence described is limited, the threat of escalation devastates ordinary people exposed to it (items 1, 2) and leads parents to fear for their son's life (items 4, 5).
The most violent depiction of mental illness comes in the interview with the retired superintendent of Oakley Psychiatric Hospital (item 9). He argues that patients must be strictly managed in the community otherwise: (9.7) It will discredit the system and cost the country money and cost someone else life and limb (see also 9.12–9.14, previously mentioned).
To justify strict management, he must present the consequences of failure to control as dangerous and the interview includes extensive references to violence; ‘sexual or paedophiliac component’ (9.9), ‘cases of arson, rape, sodomy and even murder’ (9.13), ‘(Nurses) beaten up, indecently assaulted and raped’ (9.14). As neither the frequency of such actions nor the patients perpetrating them are specified, this constitutes a general link between violence and ‘mental illness’.
Neither of the other psychiatrists (items 8,11) foregrounds risks or actual violence in this way. In his interview, the regional director of forensic services [8] argues that the vast, ‘80 percent’(8.6), majority of mental illness can and should be treated in the community. So he has to ‘normalize the way the community sees (mental illness)’ (8.11) and the item includes the unattributed sentences:
(8.29–8.30) Statistics had proven treated mentally ill patients were no more dangerous than ‘Mr and Mrs Citizen’ in the community. The untreated mentally ill were a different story.
As part of the normalising, he refers to people as being merely ‘odd or different’(8.2) and claims that we all know of people with ‘mental problems’(8.12). The kinds of behaviour described in the case stories become, implicitly, a matter for the police (8.4) but he acknowledges that a brittle ‘minority…needed asylum—a place of refuge’ (8.31) ‘for the rest of their lives’(8.34).
The clinical coordinator of the central mental health unit (item 11) similarly talks of patients who need the high degree of supervision available in an inpatient unit (11.27–11.8) for their own good. The unavailability of such long-term care and the resultant over-stayers who create a bed shortage (11.20–11.29) inform his discussion of the new Mental Health Act [33]. He emphasises that the new law gives explicit rights to patients, that they are using these rights, and that, in some cases, this compromises their care (11.17–11.18). In passing, he mentions that staff operating with a community treatment order would be unlikely to override a patient's order to ‘go away’ (11.1;11.10–11.12) confirming events described in items 1 and 2. The criteria for compulsory treatment; being dangerous to self or others, or being incapable of self-care are explicated in the context of a story of a patient (11.14–11.18) who exercised these rights to discharge herself from care.
Woven through the case stories is a commentary on treatments and a range of problem behaviours by those with mental disorders such as uninvited entry (1.12,2.24,5.13), noisiness (2.7), homelessness (4.3), and refusal to take medication (5.26). References to treatment are not positive, at times implying that it is only or barely custodial:
(4.11)…he spent six stints of up to three months each in Carrington.
As if in response the retired psychiatrist (item 9) speaks of control rather than cure:
(9.31–9.32) By chemical manipulation…produce an injection…which lasted for a fortnight,… I had a weapon you could control people with outside the hospital.
His colleagues discuss problems created by a shortage of beds (11.36–11.37), lack of services (8.19;36), and the necessity of providing inpatient facilities for a group of long-term patients (8.31–8.34; 11.27–11.28) but say little about effective treatment. As neither item (8 or 11) explicitly states that they are working with the small group who are most seriously affected by their condition, the depiction they provide confirms the understanding that mental illness is not curable.
Discussion
In the special report, the psychiatrists are clearly identified and treated as expert knowers in contrast to the lay sources who were invisible in the writer's story until summoned to add vivid and/or personal detail to the narrative. The status of the psychiatrists as expert knowers is acknowledged through their titles, the kinds of information they are seen to supply, and the extent to which their ideas appear in their own words. These acknowledgements impose two kinds of cost: first, they identify the speakers with the mental health service; and second, they distinguish their items from a report about events.
To elaborate, the regional director of forensic services (item 8) and the clinical coordinator (item 11) are both employees of the mental health system and, as such, might be expected to provide interested comments, whereas the retired psychiatrist apparently has no such stake in the present system. Also, in these interviews the journalist arranges the interviewee's words to present a position or argument rather than telling a story. Each psychiatrist emphasises a different aspect of mental health: ‘commonness of mental illness’ [8], ‘risks to the community’ [9] and ‘patient rights’ [11] and, on the issue of dangerousness, the items are inconsistent. One [9] strongly confirms the dangerousness of men with mental illnesses that played a central role in the case stories. The other two [8],[11], focused on practices and law, appear to overlook or play down such dangerousness, as might be expected of interested accounts. Both the latter interviews refer to patients who need asylum because of their mental illness and this sits uneasily with their main contention that mental illness can be appropriately treated in the community.
Two of the three psychiatrists interviewed depict mental illness in a less negative manner than the case stories which told brief accessible tales about deviant persons suffering from a mental disorder. These individuals with a mental illness are shown behaving in aggressive, threatening and unpredictable ways, that differ only in degree from media materials analysed in other reports [1],[4],[5],[22],[31]. The stories rely on com-monsense understandings about mental illness as unpredictable and violent [34] as the basis for a preferred or obvious reading [13] and the narrated parallels between the cases confirm these commonsense understandings while enhancing their acceptability as factual accounts. These case stories, presented as ‘the evidence’ with titles that imply selection from a larger pool of cases [13], are read the week before the interviews with the psychiatrists, creating the context into which the psychiatrists speak. Those psychiatrists who talk of treatment in the community by the system that had been depicted as unresponsive or ineffective in the case stories [31] appear to be presenting a party line. An outcome that is enhanced as the retired psychiatrist confirms the dangerousness of ‘completely uninhibited men’(9.16) and emphasises the need for control.
This analysis leads to the conclusion that the psychiatrists reported in these materials have made little positive difference to the negative depiction of mental illness and mental health services [31]. There are limitations to this conclusion as a consequence of the sample analysed and the absence of viewers' responses to the items analysed. First, the sample is small and a backgrounder rather than news but the parallels with previously published research suggests that it is reasonably typical. In a standard news report [30], the psychiatrist's statements would have been briefer but would still have been used very similarly to enhance the newsworthiness of the journalist's item. The extended nature of the backgrounder has allowed me to make the interplay between the content and the journalist's framing clearer. Second, and of greater significance, the reading of materials presented here has not been checked with a sample of readers. There is published work [34] against which to test my reading that suggests that such a sample would not differ significantly from my interpretation. With other members of the research team, I am seeking funding to undertake the required reception studies.
This work has implications for psychiatrists in their relations with the media. First, and most obvious, is the warning that whatever is said to a journalist will be appraised and utilised within a framework that emphasises newsworthiness. That can cause meanings to mutate as they are shaped by the journalist's priorities which emphasise conflict and deviance. There is evidence from media studies [14] and mental health workers [35] that the relationship between a journalist and a source can make a critical difference. Within a developed relationship there will be the possibility of asking for a fuller picture of the story as the journalist sees it and of providing critical material as not-to-be-reported background [14]. The use of the disagreement between the psychiatrists in this material is a reminder that professionals, like all interest groups, need to be constantly aware of the media belief that conflict is inherently newsworthy even if expertise is undermined as a result.
The second implication follows from the first. If psychiatrists and other mental health professionals are to work with media to establish more positive images of mental illness they will need to have both a sound appreciation of journalistic practices and priorities, and a media strategy. Like their colleagues producing entertainment [36], journalists do not accept that education about or public relations for mental health is part of their professional responsibility [37]. For mental health professionals to obtain more balanced coverage of events involving persons with a mental disorder they need to be able to convince the journalist that the story will be improved by being adequately contextualised. They will also need to develop the skills for generating usable positive news stories. These tasks require that a relatively high level of media skills is developed and maintained.
Conclusion
This analysis demonstrates that psychiatrists can present those with a mental disorder in a less negative manner than usually reported. However, journalistic practices, the temporal structure of the report, and the conflation of authority and opinion weaken these alternative depictions so they do not threaten the common stereotypes. The analysis has demonstrated how case studies and psychiatrist interviews have been assembled in ways that confirm commonsense understandings of mental illness and inadequacies of community care [13],[31]. Case studies are warranted as ‘evidence’ through standard journalistic practices, while the expertise of the psychiatrists is undermined by professional disagreement and the fabricated disjunction between their talk and the reality instantiated by the case stories. It is recommended that future research examines other journalistic work in similar detail and that readers' responses to such materials be an integral part of those analyses.
Footnotes
Acknowledgements
This work was supported by a Health Research Council grant (97/31) to Raymond Nairn and Associate Professor John Coverdale.