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Some time ago, a study was published showing that 6 out of 23 schizophrenia patients at a particular clinic had reported carrying a weapon during a psychotic episode. The next day, the local newspaper ran the story, “Armed and Dangerous: Public at Risk as Mental Patients Escape the Care Net” (reported by Ferriman; 1). Not the least bit constrained by the selected nature of the original sample, the journalist extrapolated that, in the local community, 1250 patients with mental illness were toting weapons and posed a “serious threat to public safety.” Such distortions have galvanized antistigma programs to target inaccurate and unbalanced reporting (1). The media, both factual and fictional, are primary sources of negative stereotypes about those with mental illness. In prime time television, for example, 1 show in 10 involves a mental health or psychological theme, making mental illness the most commonly depicted disability. Two percent of characters are portrayed as having mental illness. Often, they lack a social identity and are single, frequently unemployed, dangerous, and unpredictable (2). Similar images appear in movies (3). Media stereotyping of persons with mental illness begins young: stigmatizing references to mental illness occurred in about one-half of a sample of television programs targeting children under age 10 years. The characters suffering from mental illness were virtually devoid of positive attributes (4). In the news, “sensationalism sells” (5). News accounts often explicitly link mental illness to violence and criminality (6,7). In a recent analysis of print media in Australia, for example, negative portrayals predominated. Criminality and dangerousness to others appeared in one-half or more of the items. Positive themes, such as human rights issues or educational accomplishments, occurred in only about one-quarter of all stories (8). Newspaper editors respond to market forces. They use incidents involving people with mental illness to awaken fear in their readers and sell newspapers. Also, by showing that they understand their readers’ fears, they imply that they are connected to their reading public and actively campaigning on their behalf for a better local community (1). However, even balanced coverage of crimes by people with mental illnesses reinforces public perceptions that they are violent and pose a public risk. This is particularly true when the coverage is lurid, sensationalized, or incorrect (9). Angermeyer and Matschinger studied the effects of publicized assassination attempts on prominent people in Germany across 8 representative samples of the population (10). With each successive attack, the level of social distance expressed by the public toward people with schizophrenia significantly increased, and negative stereotypes characterizing persons with mental illness as violent and unpredictable were reinforced. Social distance decreased in the 2 years following the attacks but never returned to the original levels. These results show that highly publicized events linking violence and mental illness have an enduring impact. In the UK, hospital-bed closures and resettlement plans were halted in the wake of several highly publicized incidents (11). Given the paucity in print and other media of positive images of people with mental illness, antistigma programs may adopt several strategies. They may attempt to modify media biases directly, by engaging members of the media. There is some evidence that giving reporters appropriate background materials can improve the accuracy of reporting (6). Antistigma programs may also attempt to counteract media effects indirectly, through public education campaigns designed to improve public knowledge about the true nature and extent of mental illness in the community (12); however, generic campaigns are likely to have limited effects (13). Finally, antistigma programs may implement media-watch initiatives that comb through the news and lodge a series of complaints whenever an infraction occurs (1). There have been few attempts to evaluate the results of such initiatives systematically, so little is known about their relative effectiveness. Despite a propensity for inaccurate and unbalanced reporting, the media can also represent a potent vehicle for challenging stereotypes and disseminating accurate, positive messages about mental illness (14). This paper evaluates the effectiveness of an intervention designed to improve a local newspaper’s images of people with mental illness, particularly those with schizophrenia. The intervention aimed to engage local reporters directly and thereby increase positive stories about mental illness in the daily news. MethodsThe Setting The media project aimed to assess the extent to which print news about schizophrenia and mental illness could be directly influenced by providing reporters with more accurate background information and by helping them develop more positive story lines. One of 2 local newspapers was targeted, a senior editorial writer was recruited, and a series of articles on mental illness were negotiated. Newspaper columnists were invited to all local events associated with the larger Open the Doors program, and local mental health service providers acted as liaison people for background or expert opinions related to breaking stories. The specific objective was to increase the number of positive news stories about schizophrenia and mental illness, and their word count, by at least 10% over a 16-month period. Evaluation Design Once retrieved, stories were reviewed and content analyzed for major themes. Antistigma stories were defined as stories with positive themes about mental illness or schizophrenia. These included accurate descriptions of diagnoses or treatment, profiles of people with a mental illness, commentaries on the need for improved funding or programs, human interest stories, research advances, or stories portraying people with mental illness as victims rather than as perpetrators of crimes. Stigmatizing stories included stories linking mental illness to violence, profiles of violent criminals or crimes in which mental illness was explicitly cited as the cause of the violence or criminality, stories portraying mental illness as a means for criminals to avoid prosecution, or any other negative portrayal of mental illness or the mentally ill. Each story was classified on the basis of its major message. Once categorized, the number of stigma and antistigma stories, together with their length, were counted. Standard word-processing software was used to establish word counts. To account for the different time periods, results have been averaged per month across baseline and postintervention periods. Although provisions existed for double coding in cases of uncertainty, story themes were found to be overt and easily classified as stigmatizing or nonstigmatizing. ResultsTable 1 summarizes all stories identified, categorized by type of reference to mental illness. Close to one-half of the stories identified were intended to portray some aspect of mental illness to the reading public, and just over one-quarter focused on schizophrenia. Just over 1 in 10 were identified as “incidental mentions,” in which the main story had nothing to do with mental illness, but the issue was raised in conjunction with one of the main characters (reporting, for example, on a history of mental illness or substance abuse treatment). Close to 1 in 10 commented on related mental health issues, but the main intent of the story was elsewhere. For example, stories dealing with the lack of shelter spaces for the homeless often identified mental health or substance abuse problems as related issues. Finally, story slurs occurred when a reporter embedded a mental health term in the text but used it improperly or punitively to reflect or reinforce a negative stereotype—speaking, for example, of a “schizophrenic” stock market or football game, or a “psycho-killer” movie or character.
Table 2 compares story themes across baseline and postintervention periods. Positive stories outnumbered negative stories in both time periods by about 2 to 1. Table 2 also shows that positive stories about schizophrenia and (or) mental health issues increased by 33% in the postintervention period. However, negative stories increased as well—in the case of stories about schizophrenia, by 46%. This was more than any positive gains made.
The second item in Table 2 reports on word count. In both periods, the average number of words contained in positive news stories outnumbered that devoted to negative news. However, in the postintervention period, the gap had almost completely closed for stories about schizophrenia. Positive stories about schizophrenia dropped in length by almost 10%, while negative stories increased in length by over 200%. This was not the case for other mental illnesses, where story lengths increased at a roughly comparable pace. Consequently, schizophrenia appeared to be singled out as a topic for negative news. DiscussionResults showed that positive stories outnumbered negative stories by a factor of 2 in both pre- and postintervention periods. Positive mental health stories increased by 33% in the postintervention period, and their length increased by an average of 25%. Stories about schizophrenia also increased by 33%, but their length decreased by 10%. At the same time, negative stories increased by 25% in number and 100% in length. The greatest increase in negative news was in relation to schizophrenia. The number of stigmatizing stories about schizophrenia increased by 46%, and their length increased from 300 words to 1000 words per story per month. Negative news about schizophrenia sufferers—the target group for the antistigma program—increased at a faster pace than positive news. It also rivaled the column space dedicated to positive stories of people with schizophrenia. Depending on the perspective, then, the results of this study can be interpreted as either encouraging or discouraging. If one were to focus on the extent to which the project was able to create positive local news, the conclusion would be guardedly positive. Results suggest that direct interventions designed to improve reporters’ access to information do improve the quality and quantity of reporting about mental health issues. Viewed from the broader perspective of mental illness and violence, however, these results are also quite discouraging. A detailed review of negative content showed that local antistigma initiatives were overshadowed by newspaper coverage of highly charged cases involving public security and several grisly homicides—all linked to people with untreated schizophrenia. Although the printed news is not the most significant source of violent stereotypes (television and movies are), it belongs to a larger media communication process that reflects and reinforces social stereotypes painting people with mental illness as violent and unpredictable (15). Consequently, stories that may be balanced in print can be, and often are, augmented with television visuals that include gripping film footage. Thus reinforced with sensational visuals, even nonsensation- alized newspaper accounts could easily overwhelm efforts to promote balanced reporting and positive local news. Indeed, balanced print stories may even lend credibility to sensationalized television news. Thus, inability to control or even manage the “CNN effect” (as it came to be dubbed) was considered to be a major disadvantage of this locally targeted media intervention and a main reason for its limited impact. Paradoxically, however, the CNN effect also highlights the importance of having counterstrategies in place to deal with the media incidents described above. These might include 1) making accurate background briefs on the relation of mental illness to violence readily available to reporters through their own online library archives, 2) maintaining a list of local experts available for interview when such stories break, and 3) maintaining regular contact with key editorial staff to discuss mental health issues and generate story lines outside the context of specific events. In this regard, Mayer and Barry show how a violent incident was used to educate the public concerning the difficulties faced by people with a mental illness (12). Despite this intervention’s limited impact, print and other media stereotyping of people with mental illness remain worthy targets for antistigma interventions, because negative media images are among the most damaging stigma experiences reported by mental health service consumers and family members. A recent poll of advocacy group members in the UK showed that negative media images can have such direct effects on consumers as heightened psychological distress (34%), hostility from neighbours as a result of media reports (24%), and reluctance to apply for jobs or volunteer positions for fear of being stigmatized (33%). One-half of those responding to the survey indicated that media coverage had negatively affected their mental health (16). The impact of negative media images extends well beyond the interpersonal realm into broader sociostructural processes. A qualitative study of stigma experiences conducted in Germany revealed that people with schizophrenia felt most of their stigma experiences to be related to negative public images portrayed in the media, inequities in social and health policy, and limited access to social roles. Social stereotypes imposed a particular illness identity on them—one that shaped the way they were perceived by others and reduced their range of social contacts. The resulting social structural barriers impeded their life chances and reduced their overall quality of life (17). More than ever before, successful community programming depends on creating a favourable community climate. Negative community reactions have been one of the most important factors affecting community management of mental illness in the deinstitutionalized era. Not only do they limit the ability of those with mental illness to participate in community life, they also limit the placement and availability of community-based mental health programs (18–20). Public intolerance for community-based treatment and social rejection of people with mental illness often hinges on perceptions of dangerousness and unpredictability derived from the news and other media (21). A wary public will use negative images that are fuelled by and transmitted through news and other media as a rationale to support punitive legislation and discriminatory policies, and negative stereotypes also offer a rationale to lobby against mental health reforms involving community care or to deny adequate funding for services and research (11,22–24). Therefore, the creation and perpetuation of media images stigmatizing people with mental illness is a potent ingredient in a broader social process that denies social and legal entitlements through neglect, avoidance, and discrimination (25,26). To conclude, this paper contributes to the sparse evaluation literature focusing on the extent to which it is possible to promote a broader understanding of mental health issues as they are reported in local newspapers. Results were positive but meager, showing that local influences can have, at best, only limited effects on the broader social stereotypes emanating from various media sources. Given the scope of the problem and pervasive media bias, these results support the view that strong national and international antistigma alliances are needed to coordinate media intervention efforts globally—a first step to addressing this important problem. References1. Ferriman A. The stigma of schizophrenia. BMJ 2000;320:522. 2. Wahl OF. Mass media images of mental illness: a review of the literature. J Community Psychol 1992;20:343–52. 3. Wilson C, Nairn R, Coverdale J, Panapa A. Mental illness depictions in prime-time drama: identifying the discursive resources. Aust N Z J Psychiatry 1999;33:232–9. 4. Wilson C, Nairn R, Coverdale J, Panapa A. How mental illness is portrayed in children’s television: a prospective study. Br J Psychiatry 2000;176:440–3. 5. Matas M, el-Guebaly, Peterkin N, Green M, Harper D. Mental illness and the media: an assessment of attitudes and communication. Can J Psychiatry 1985;31:12–7. 6. Matas M, el-Guebaly, Harper D, Green M, Peterkin A. Mental illness in the media: Part II. Content analysis of press coverage of mental health topics. Can J Psychiatry 1986;31:431–3. 7. Williams M, Taylor J. Mental illness: media perpetuation of stigma. Contemp Nurse 1995;4(1):41–6. 8. Coverdale J, Nairn R, Claasen D. Depictions of mental illness in print media: a prospective national sample. Aust N Z J Psychiatry 2002;36:697–700. 9. Heginbotham C. UK mental health policy can alter the stigma of mental illness. Lancet 1998;352:1952–3. 10. Angermeyer MC, Matschinger H. Violent attacks on public figures by persons suffering from psychiatric disorders. Eur Arch Psychiatry Clin Neurosci 1995;245:159–64. 11. Wolff G. Attitudes and the media and the public. In: Leff J, editor. Care in the community: illusion or reality. Toronto: John Wiley and Sons; 1997. 12. Mayer A, Barry DD. Working with the media to destigmatize mental illness. Hosp Community Psychiatry 1992;43:77–8. 13. Stuart H. Stigma and stigma reduction: lessons learned. Santé mentale au Quebec. Forthcoming. 14. Lee S. The stigma of schizophrenia: a transcultural problem. Curr Opin Psychiatry 2002;15:37–41. 15. Byrne P. Psychiatric stigma: past, passing and to come. J R Soc Med 1997;90:618–21. 16. Mind. Counting the costs: Mental health in the media. The Daily Stigma; Wednesday, February 9; 2000. http://www.mind.org.uk 17. Schulze B. Angermeyer MC. Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives and mental health professionals. Soc Sci Med 2003;56:299–312. 18. Crocetti G, Spiro HR, Siassi I. Are the ranks closed? Attitudinal social distance and mental illness. Am J Psychiatry 1971;127:1121–7. 19. Segal SP, Baumohl J, Moyles EW. Neighborhood types and community reaction to the mentally ill: a paradox of intensity. J Health Soc Behav 1980;21:345–59. 20. Rabkin JG, Muhlin G, Cohen PW. What the neighbors think: community attitudes toward local psychiatric facilities. Community Ment Health J 1984;20:304–12. 21. Trute B, Teft B, Segall A. Social rejection of the mentally ill: a replication study of public attitude. Soc Psychiatry Psychiatr Epidemiol 1989;24:69–76. 22. Cutcliffe JR, Hannigan B. Mass media, ‘monsters’ and mental health clients: the need for increased lobbying. J Psychiatr Mental Health Nursing 2001;8:315–21. 23. Guimón J. Mass media and psychiatry. Curr Opin Psychiatry 2001;14:533–4. 24. Arboleda-Flórez J. The state of the evidence: stigmatization and human rights violations. In: World Health Organization. Mental health: a call for action by world health ministers. Geneva: Ministerial Round Tables, 54th World Health Assembly; 2001. 25. Angermeyer MC, Schulze B. Reducing the stigma of schizophrenia: understanding the process and options for interventions. Epidemiolgia e psichiatria sociale 2001;10:1–7. 26. Link BG, Phelan JC. Conceptualizing stigma. Annual Review of Sociology 2001;27:363–95. Author(s)Manuscript received and accepted August 2003. 1. Associate Professor, Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario. Address for correspondence: Dr H Stuart, Department of Community Health and Epidemiology, Abramsky Hall, Queen’s University, Kingston, ON K7L 3N6 e-mail: hh11@post.queensu.ca
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