Television and the Press: Purveyors of Prejudice or Slayers of Stigma?

"Stigma is the single most serious obstacle to progress in the field of psychiatry". This is not the impulsive outburst of some misguided crank but the considered opinion of Professor Norman Sartorius, President of the World Psychiatric Association and respected elder statesman of the profession.

At the Annual Meeting of the Royal College of Psychiatrists in Edinburgh, Professor Sartorius presented his argument that stigma works at two levels: the level of the individual and the broader societal level. Whilst clinicians are often sensitive to the effects of stigma upon an individual patient and his or her family, as a profession we are guilty of turning a blind eye to the prejudicial attitude towards the mentally ill that pervades all strata of society. Professor Sartorius contends that in most developed countries there is enough money to help those with mental illness but that it is not made available because of the mind-set of political decision makers¹. He argues that attitudes within the higher echelons of society, where important financial decisions are made, reflect opinions prevalent amongst the wider public. As a result, the funding of health care for patients with mental illness compares poorly with the provision of services for patients with physical illness of similar severity². The same argument holds for research funding and, consequently impacts on scientific progress.

Professor Sartorius’ assertion that stigma is seen as a problem for the individual rather than for society is reflected in the definition of the word itself. The Oxford English Dictionary³ defines stigma as "a mark of disgrace or infamy; a sign of severe censure or condemnation, regarded as impressed on a person or thing; a ‘brand’". The eminent sociologist Erving Goffman⁴ offers an alternative definition: "any bodily sign designed to expose something unusual or bad about the moral status of the signifier". Goffman goes on to argue that when we encounter an individual who displays such a ‘bodily sign’ we "construct a ‘stigma theory’, an ideology to explain his inferiority and account for the danger he represents, sometimes rationalising an animosity based on other differences". Although Goffman defines stigma in relation to the individual, he argues that the ‘stigma theory’ constructed by the observer is inexorably linked to sociological factors. Not only is an individual’s personal ‘stigma theory’ strongly influenced by the society in which he lives but the collective effect of individuals’ beliefs acting together determines the attitude of society as a whole towards groups it identifies as different.

The Scale of the Problem.

Recently published surveys of stigma have shed light upon the day-to-day personal experiences of people suffering from mental illnesses. In 1996 Read and Baker⁵ surveyed over 700 ‘Mindlink’ members on behalf of the mental health charity ‘Mind’ and found that 47% had been abused or harassed in public, 26% had moved out of their homes to escape harassment and 14% had been physically assaulted. Last year the Mental Health Foundation⁶ conducted a postal survey of over 500 people with mental health problems. Fifty-six percent reported discrimination from within the family, 51% from friends and 44% from general practitioners. Despite their lack of scientific rigour, such surveys do provide an insight into the sources and consequences of stigma experienced by people with mental illnesses and their families.

In 1998 the Royal College of Psychiatrists⁷ set out to determine the opinions of the British adult population concerning the mentally ill as a baseline for their current ‘Changing Minds: Every Family in the Land’ anti-stigma campaign. Their well conducted survey of a representative sample of over 1700 members of the general public revealed that stigmatising opinions about people with psychiatric disorders are widely held and that these opinions vary in nature and frequency for different mental disorders. Of the seven disorders considered, schizophrenia, alcoholism and drug addiction elicited the most negative responses. Approximately 70% of respondents rated people with these conditions as "dangerous to others" and about 80% rated them as "unpredictable". These data suggest that the majority of people hold opinions about the mentally ill that are consistent with Goffman’s concept of a ‘stigma theory’.

A number of authors have highlighted unhelpful effects of the adverse public perception of the mentally ill upon the provision of psychiatric services. Byrne⁸ argues that the stigma of psychiatric illness is a negative factor in its presentation, detection and treatment. He cites research in support of his idea that fear of becoming stigmatised represents a hurdle at every stage of psychiatric care: it leads to people denying their symptoms; failing to present themselves to general practitioners; declining psychiatric referral; refusing hospital admission and declining or failing to comply with treatment. Byrne also expresses concern about poor recruitment to psychiatry and, echoing Sartorius, he highlights the low levels of funding for psychiatric research.

The Origins of Prejudice.

The surveys described above support Professor Sartorius’ assertion that a prejudicial attitude towards the mentally ill pervades society, however, they tell us little about the likely origins of this prejudice. Medical historians such as Porter⁹, reviewing the evidence over many centuries, document the scapegoating of persons suffering from a variety of ailments including leprosy, syphilis and ‘lunacy’. Most of these conditions are characterised by easily identifiable visible abnormalities or ‘stigmata’ which, as the American historian Sandler Gilman¹⁰ explains "trigger the deep-seated psychological tendency to construct us-and-them schemata, in which self-identity is strengthened through pathologising those who are different and potentially dangerous. Sustaining the fantasy that we are whole by setting the sick apart from ‘us’." Yet the physical stigmata of psychiatric illnesses are not easily identifiable and the factors that trigger the construction of us-and-them schema (or ‘stigma theories’) are manifestly more subtle. Surveys such as those conducted for Mind⁵ suggest that in contemporary society it may be the diagnostic label itself, (or the act of attending a psychiatric clinic or of being prescribed psychotropic medication) which is the ‘easily identifiable abnormality’. As Allison-Bolger¹¹ has pointed out, the stigma associated with mental illness has become self-perpetuating "mental illness is by definition bad, so to be diagnosed as mentally ill is to be defined as bad". Summerfield¹² takes this argument a stage further. In a recent personal paper in the Journal of the Royal Society of Medicine he blames psychiatry for validating negative stereotypes and exclusion, "stigma may be age-old, but aspects of its modern form are a by product of the medicalisation of society."

The authors of the Royal College Survey concluded that, whilst some of the negative opinions expressed by the British public may have been accurate, they were invariably amplified and over-generalised. For example, although it is undeniable that a few people with schizophrenia behave at times in ways that are dangerous to others, over 70% of respondents recorded "dangerous to others" as a general opinion about people with schizophrenia. Understanding the factors that drive this tendency to exaggeration and stereotyping is, in my view, central to the challenge of reducing the prejudice faced by the mentally ill in our society.

Mental Illness in the Media.

Previous authors have pointed the finger at biased and inaccurate representations of the mentally ill in the media. A number of studies have been designed to evaluate the extent to which the media misrepresent mental illness, whilst others have attempted to establish a causal relationship between misrepresentations in the media and misconceptions in the mind of the general public.

A recent study of nine daily newspapers in the UK¹³ identified 47 articles relating to psychiatry during a one month observation period. Sixty-four percent were critical in tone, 25% neutral and only 11% positive. The authors compared coverage of psychiatry with that of general medicine and found that stories relating to psychiatry were four times more likely to be framed in negative terms. Furthermore, the authors gained the impression that negative articles about psychiatry tended to criticise patients whilst negative articles about other medical specialties tended to criticise doctors. Other studies of newspapers have produced similar results. A Canadian study in 1986¹⁴ reported 42% of psychiatric stories as negative, whilst a Royal College survey in the UK in 1998¹⁵ found this applied to 54%.

Although newspapers are undoubtedly an important source of information, television - in particular soap operas and dramas - reach a far wider audience. A recent survey of the portrayal of mental illness on prime-time television in the USA¹⁶ found a high correlation between mental illness and violent crime. The mentally ill characters were ten times more violent than the general population of television characters. Furthermore, extrapolation from statistics relating to actual levels of violence perpetrated by the mentally ill in the USA revealed that each mentally ill character committed 10-20 years’ worth of violence during the two week observation period.

A group in New Zealand¹⁷ took a different approach. They followed fourteen television dramas for a full year. Ten of these originated in Britain (e.g. "Casualty" and "The Bill"). In total, they incorporated twenty mentally ill characters, whose portrayal was analysed systematically. They found that 15 of the 20 characters were depicted as physically violent towards self or others. Characters were also commonly depicted as simple, lost, unpredictable, unproductive, asocial, vulnerable, dangerously incompetent, untrustworthy and social outcasts. On the positive side, the characters were, at times, portrayed as caring and empathic. The authors concluded that television drama associates mental illness with "dangerous, unattractive, less than human persons and encourages viewers to shun psychiatric patients and oppose psychiatric facilities".

The same group of researchers have subsequently published a study of children’s television¹⁸. They objectively rated portrayals of mentally ill characters and references to mental illness in programmes specifically scheduled for viewers under 10 years of age screened on two New Zealand television channels over a two week period. The majority of programmes originated in the USA (e.g. ‘Loony Toons’ cartoons). Many others originated in the UK. They found that 68% of cartoons and 26% of real life programmes contained references to mental illness and they identified six consistently mentally ill characters. Three served a comic role and three were portrayed as evil villains. The characters were continuously engaged in illogical and irrational actions such as hitting their head with a hammer. All six were almost entirely devoid of admirable attributes and served as objects of amusement, derision or fear. They found frequent and casual use of fundamentally disrespectful vocabulary such as ‘crazy’, ‘mad’, ‘nuts’, ‘wacko’ and ‘looney’.

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.

Whilst "Psychos" delivered a more acerbic and less positive image of psychiatric hospitals and their inhabitants than I had hoped, there are certain scenes of which I am proud. The remarkably accurate depiction of ECT being administered and a sympathetically scripted, brilliantly acted portrayal of schizophrenia are perhaps the best examples. On balance, my opinion of the series is a positive one. I believe that it offered the viewer a deeper insight into the world of psychiatrists and their patients than any previous television drama and that, with a few notable exceptions, it succeeded in avoiding psychiatric stereotypes. I often wonder whether "Psychos" has helped to break down the stigma associated with mental illness or whether it has made things worse. The programme was certainly not a party political broadcast on behalf or the Royal College of Psychiatrists and in many ways it was politically incorrect, if not downright offensive. My hope is that it has helped to demystify the world of psychiatry and perhaps rendered psychiatrists more approachable. The portrayal of mental illness was inevitably distorted by the constraints of the format and the requirement for dramatic content. David and I were very careful to avoid reinforcing the myth that psychiatric illness equates to violence. Our efforts were somewhat undermined by the hard, edgy style adopted by the directors. I had hoped that the series would generate sufficient interest to spawn documentary-type programmes designed primarily to inform rather than to entertain but this did not happen.

Working on "Psychos" taught me a number of lessons about the portrayal of the mentally ill in television drama. First, script-writers find writing about psychiatric issues extremely difficult. Most writers either shy away from mental illness or deal with it at the superficial level of stereotypes and clichés. David is exceptional in both his level of knowledge (I often joke that he could pass his Membership) and his willingness to accept a psychiatric agenda. Second, Nairn’s comments about newspapers²³ are equally applicable to television, "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 failure to exert any influence other than at the script-writing stage resulted from my rather distant relationship with the production team and from my lack of understanding of the process of programme production. Third, in order successfully to challenge television’s tendency to slip into stereotypical portrayals of the mentally ill, a psychiatric adviser needs to be involved at every stage of the programme-making process. In "Psychos", psychiatric advisers had no input during the filming and post-shoot production with inevitable results. Finally, whilst television producers desperately want guidance from experienced psychiatrists, the vast majority of psychiatrists are loath to become involved.

The Role of the Royal College.

The response of the Royal College of Psychiatrists to "Psychos" was interesting. When the series producer contacted the College press office, she was treated courteously and given a few names of potential advisers (each of whom subsequently declined to help). However, it was made clear to her that the College did not wish to be associated with the programme in any way. She gained the impression that the programme makers’ motives had been pre-judged. When the first episode was screened, the College released a statement saying, in effect, "we had nothing to do with this programme". In my opinion the College’s response was symptomatic of the defensive stance that the psychiatric profession has traditionally adopted in its dealings with the media. I believe that the College missed a valuable opportunity to be proactive in the battle to improve the portrayal of mental illness on television.

Salter and Byrne²⁰, in their Psychiatric Bulletin editorial, refer briefly to "Psychos" commenting, "the belief that the title and content of the programme could serve only to harm the interests of people with mental illness is the short-sighted and unimaginative view of a conservative profession. Instead, psychiatrists should try to view such programmes and the reaction that they generate as an important way of stimulating debate". Michael Howlett²⁶, director of the Zito Trust, in his invited response to the editorial says, "from the point of view of public relations, psychiatry has been poorly served by its own college". "Much as we all view the media with contempt at times, a dismissive attitude towards it is not a clever strategy." Whilst I feel that Howlett’s criticism of the College is rather unfair, my reading of the literature together with my first hand experience of working on a television series has led me to question the effectiveness of the College’s current media strategy.

Staff from the College’s press office were invited to respond²⁷ to Salter and Byrne’s editorial. Recalling the polite but firm "no thanks" which greeted the producer of "Psychos", I read their reply with interest - "we are keen to work positively with the media. We undertake a structured programme of media activity, which is sufficiently flexible to be proactive, reactive and also to take advantage of ad hoc developments." The staff also referred to their "database of more than a hundred members (many of whom have been media-trained) willing to work in a positive and constructive manner with the media". Perhaps most revealing were their responses to criticism – "the College is not, and never could be, a lobbying organisation" and "the College has never been seen as ‘rent-a-quote’ – quite the contrary. Some issues may be more relevant to psychology than to psychiatry; others may be too deep or complex for the College to be involved with, others may require consultation with relevant Members or Officers . . . sometimes the wisest counsel may be to remain silent." Their final paragraph begins "for many years psychiatry has been faced by a powerful anti-psychiatry lobby which has used the media very effectively" and suggests that other professions that are "in the firing line" may be able to learn from psychiatry’s experience. To my mind this suggests a press office on the defensive.

Whilst the College’s "Changing Minds" and "Defeat Depression" campaigns are undoubtedly serious and admirable attempts to address stigma, they have required a significant investment of both money and professional time. It would be reasonable to consider what impact the same resources might have made had they been channelled into fostering close working relationships with editors of newspapers and producers of television programmes.

Professor Arthur Crisp, the driving force behind the College campaigns has recently been instrumental in establishing a College media group with the stated aim of challenging stigma wherever it appears. It is clear that the College now recognises the potential of the media as a force for good, (indeed media liaison is one component of the "Changing Minds" campaign). The Salter and Byrne editorial²⁰, drawn from a meeting of the media group, suggests "by avoiding a ‘them and us’ situation with the media, and instead creating a working dialogue with media agents across the land, we can make a significant difference." I hope that the establishment of the media group represents a turning point in the relationship between the profession and the media.

In Summary.

In this essay I have attempted to examine the origins and consequences of the prejudice shown towards those people in our society who suffer from mental illness. I have looked at the research evidence in support of the everyday observation that the mentally ill are unfairly misrepresented in the media and that negative images in newspapers and on television add to the stigma they endure. I have argued that psychiatrists can make a difference by working proactively with their media colleagues and have used my own experience of working in television to illustrate some of the obstacles facing those who take up the challenge. Although our profession is instinctively defensive in its dealings with the media, I believe that it is beginning to recognise a powerful potential ally.

I have made no attempt to defend the role of media. In my view all elements, from broadsheet newspapers to children’s television have been guilty of persistently peddling prejudice. However, I believe there is one simple reason why the psychiatric community must forge closer links with the auld enemy. A single sympathetic portrayal of mental illness in a soap-opera character probably has a greater effect upon the lives of our patients than all the propaganda that the College and other interest groups can muster in a year.

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