Help us Win the Fight!

The most comprehensive review, to date, of the representation of psychiatric illness in the British media was conducted by sociologist Greg Philo in collaboration with colleagues in the Glasgow Media Group¹⁹ from 1993 to 1996. They applied systematic content analysis to local and national newspapers, popular magazines, children’s literature, television news reports and fictional television programmes including soap operas and medical dramas. References to mental illness were grouped into five major categories: comic images; violence to others; violence to self/suicide; prescriptions for treatment/advice and critical representations. The findings were remarkably consistent across all media formats. Violence to others was by far the most common category, outnumbering the next most frequent category (either comic or treatment/advice) by a factor of at least four-to-one. The authors conclude "the bulk of media content situates mental illness in a context of violence or harm and presents the public as potential victims of random mania".

Having identified a strong negative bias in media representations of mental illness, Philo and colleagues embarked upon the ambitious task of examining the links between media content and audience beliefs. For this they used six focus groups, containing an average of ten people. Each group was configured so as to be representative of a particular residential area. The content of the sessions was determined by an experimental design previously developed by the Glasgow Media Group for analysing the impact of particular types of media output. The focus groups produced powerful evidence for the influence that the media can exert over audiences but also demonstrated that people are not simply blank slates on which media messages are written. The authors conclude "the media are part of a very complex cultural nexus", they act as "a crucial variable, not merely for reinforcement, but as a powerful influence in the development of beliefs, attitudes and emotional responses". One rather worrying finding emerged from the focus groups. In previous studies using the same technique (to examine beliefs about physical health, politics etc.), researchers found that personal experience was a much stronger influence on belief than media content. This pattern was reversed in the mental illness study. In 21% of the sample, non-violent personal experience was overlaid by media influences. For example, one woman who lived close to a psychiatric hospital and mixed with patients during jumble sales and other local gatherings said, "the actual people I met weren’t violent – that I think they are violent, that comes from television, from plays and things."

Given the overwhelming evidence that newspapers, magazines and television contribute to prejudice by misrepresenting the mentally ill, it would be tempting for psychiatry to condemn these media as purveyors of prejudice. It would be quite understandable if psychiatry refused to have anything to do with the media. However, such an approach would not change anything and would certainly not help our patients. In a recent editorial in Psychiatric Bulletin entitled, "The stigma of mental illness: how you can use the media to reduce it"²⁰, Mark Salter and Peter Byrne point out that the press "is not a branch of the Health Education Authority". They argue that all health stories fall into one of four categories: the ‘scare story’; the ‘cure story’; the ‘money story’ and the ‘human interest story’. The primary motive of the newspaper journalist is to sell more newspapers by writing enjoyable articles that are easily read by busy people. The responsibility to educate and inform is very much secondary. Journalists work to deadlines. They are under pressure to produce stories that are ‘newsworthy’ not ‘worthy’.

Addressing television, Salter and Byrne argue that it is "a blunt instrument, poorly suited to the subtleties of meaning which psychiatry regards as commonplace." They acknowledge that programme-makers are driven by the need to maximise viewer numbers and that images of madness, violence and distress boost ratings. Within the culture of television, stereotypical portrayals of mental illness are accepted as common currency (by programme-makers and viewers alike). Simply complaining about such misrepresentations is unlikely to alter this way of thinking. Raj Persaud²¹, arguably Britain’s most media-aware psychiatrist, echoes Salter and Byrne’s comments, "psychiatry is a complex subject, and the pressure of deadlines means that the background and context of a story tends to be neglected. This is always likely to work to psychiatry’s disadvantage."

Can Psychiatrists Influence the Media?

The premise behind Salter and Byrne’s editorial²⁰ is that psychiatrists could reduce media bias against the mentally ill by becoming more closely involved with journalists and programme-makers. Although the editorial does not contain any research references, there is a small literature in support of this idea.

In 1992, an account of the impact of the Mecklenburg Mental Illness Coalition for Awareness (MMICA) upon the reporting of psychiatric issues in the city of Charlotte, Mecklenburg County, North Carolina was published in Hospital and Community Psychiatry²². MMICA brings together 24 mental health organisations for the stated purpose of improving public understanding of mental illness. It aims to foster relationships with a variety of local agencies, including the media, through an annual breakfast and by providing regular briefings and timely and accurate responses to media enquiries. Although the published account is anecdotal, the authors comment, "the good relationships and the credibility of the mental health community converted potential media sensationalism into a positive, balanced story that educated viewers through informative coverage."

A more formal scientific approach is outlined in a study by New Zealand psychiatrist Raymond Nairn²³. Seven articles, published in a local newspaper as a "Special Report on Mental Health" series, were identified. All seven were written by the same journalists and each consisted of a case report followed by commentary. Four of the items were derived from lay sources and three from psychiatrists. Discourse analysis of the text revealed that, when presented with depictions of mental illness that did not conform to common stereotypes, the journalists tended to weaken these depictions. However, in articles where the source was a psychiatrist, there was less journalistic manipulation, (e.g. 65% of sentences were attributed to the source compared with only 30% where the source was a lay person). Nairn concludes, "articles using psychiatric sources presented mental illness less negatively than those using lay sources" but warns, "if psychiatrists are to have a positive effect on how media depict mental illness, they will have to develop closer relationships with journalists and a better appreciation of media priorities and practices."

My Experience in Television.

The studies described above support the idea that, by ‘getting involved’, psychiatrists can have a positive influence upon the portrayal of mental illness on television news and in the printed press. However, the focus group work by Philo¹⁹ and colleagues suggests that film and television drama are the most important media in relation to negative public perception of the mentally ill. Although not aware of any studies examining the role of psychiatrists in these media, I do have some personal experience to draw upon.

In 1995 I was working as a psychiatric SHO. During the Christmas break I caught up with an old school and university friend, David Wolstencroft, who was struggling to establish himself as a script-writer for film and television. We had a few drinks and, in a relaxed social setting, we discussed, amongst much else, our respective jobs. I enthused about my experiences as a trainee psychiatrist and encouraged David to persevere with script-writing, convinced that he possessed the necessary talent and that patience would be rewarded. A couple of weeks later David sent me a script for a sit-com he had written in which the central characters were trainee psychiatrists; the working title was "Psychos" – an intended (ironic) reference to the professionals, not the patients. He asked me to correct any errors in psychiatric procedure and to contribute to the medical dialogue. After several re-drafts, the script was passed to an agent for distribution. I was delighted to help my friend out but assumed that, in the unlikely event of the programme reaching production, a ‘proper’ psychiatric adviser would be found. Two years later, head of drama at Channel 4 felt the need for a ‘challenging’ new drama series and "Psychos" became one of three entries considered for commissioning. David re-drafted the script as a forty-five minute drama and prepared treatments for a further five episodes. I offered technical advice. The proposal was submitted and a few weeks later we heard that it had been chosen.

At this point a series producer was appointed. She immediately started looking for additional psychiatric advisers. She approached two established ‘media-friendly’ psychiatrists without success. I suggested a few further names but each politely declined. She then turned to the Royal College of Psychiatrists who felt unable (or unwilling?) to help. Eventually, she identified a junior SHO working in London, who was keen to be involved with television, and a rather more reluctant consultant from Scotland, who agreed to help "if nobody else could be found".

David was given two months to "research" the subject. On my advice he read the Oxford Textbook of Psychiatry from cover to cover and this was supplemented with selected lecture notes. He was shown around a number of psychiatric hospitals and met with nursing staff, social workers, patient advocates and patients’ council members. He also shadowed a psychiatric SHO and a consultant psychiatrist. The deadline for the start of filming was tight and ghost-writers were employed to help David complete the scripts on time but he found that, because of their lack of psychiatric knowledge, rewriting their efforts took longer than starting from scratch. I was closely involved with the drafting of the scripts. David and I spent whole evenings on the telephone thrashing out details of plot and dialogue. Eventually six scripts emerged (as I recall, only two were completed by the day filming started). In their editorial, Salter and Byrne²⁰ identify the pressure of deadlines as an important factor in the way in which newspaper journalists deal with psychiatric issues. My experience is that television scrip-writers work under similar pressures.

The location chosen for filming was a recently abandoned psychiatric hospital in the South of England. None of the psychiatric advisers was able to commit the time required to be present during the filming. Fortunately, one of the actors had worked for many years as a psychiatric nurse and was able to prevent major misrepresentations. The post-filming production was conducted without any input from the psychiatric advisers and with minimal input from David.

When I was sent an early draft of the first episode, what I saw shocked me. I had absolutely no prior experience of drama production and could not understand how the witty, rather benign script I had helped to draft had been transformed into the angry, subversive images the text now conjured up. I realised that I had been totally out of my depth. With production entering the final stages, I was invited to London for lunch with the production team. Without any television experience, I had no concept of what changes were feasible at this late stage, nor did I know who would be responsible for implementing them. When the owner of the production company asked me "is there anything that members of you profession will criticise?" I jumped at the chance to make my main point "the title" I replied, "you can’t call it ‘Psychos’, the word is too offensive and the ironic humour too obscure. It is certain to attract attention but of the wrong sort. It will give potential viewers an excuse not to watch the programme and critics an easy stick to beat us with." I invited the team to come up with alternatives and reiterated my earlier suggestions of "Psyches" or "Trick Cyclists". When the first episode was screened in April 1999, I discovered that a handful of psychiatric inaccuracies had been introduced in the cutting room and, unsurprisingly, my advice regarding the title had gone unheeded.

The series was spectacularly well received by television critics. It was one of only four drama series that year to be nominated for a BAFTA. The reception in the wider press was mixed but I was pleased to see that it precipitated a flurry of review articles on mental health issues largely positive in tone²⁴. The response from the medical press was vitriolic²⁵.