Psychiatry and the media: from pitfalls to possibilities

In war, truth is said to be the first casualty. Something similar may be said for psychiatry. The ability of the media to distort public understanding of mental illness is well described (Wahl, 1995; Philo et al, 1994). Psychiatric disorders, their treatments and those who provide them are all subject to overwhelmingly negative portrayals in the print and broadcast media (Hyler et al, 1991). Dehumanisation, inaccuracy and sensationalism seem to be the media's stock-in-trade. Media professionals make no apology for this, citing the provision of impartial, emotionally-neutral accounts as one of their least pressing concerns (Salter & Byrne, 2000). They also reject the notion that they are responsible for the perpetuation of harmful stereotypes, claiming instead that they merely mirror the values and beliefs of our society (Bolton, 2000). This distorting mirror is of great relevance to psychiatry. It is probably no exaggeration to state that the celebrated cases of Christopher Clunis and Ben Silcock have done more to change the practice of community psychiatry than any College President or Secretary of State over the past 5 decades.

From within the profession, the call to improve relationships with the media, or at least make better use of it, has remained muted (Persaud, 2000b ). Many view the media and the few psychiatrists who work within it with suspicion and, possibly, envy (Tamber, 1996). It is seen as uncertain ground, where only the foolhardy or the talented dare to tread. What is certain, however, is that mental illness will generate raw news material indefinitely. If psychiatry is to exert a humanising influence upon the journalistic processing of this material, it must develop a far greater understanding of the discourse of the media professions and incorporate this understanding into its practice.

The power of the stereotype

The way in which media portrayals of mental illness alter beliefs and behaviours is poorly understood. Philo et al (1994) noted that people are not passive consumers of information. Rather, they actively engage with media stories, integrating them with previous stories, images or personal experiences. The meaning that any individual gives to new ‘facts’ about mental illness depends crucially upon their pre-existing framework of knowledge about the world. There is strong evidence that humans organise their knowledge into familiar categories or stereotypes (Hamilton, 1979). People prefer certainty to knowledge; the use of stereotypes is an effective cognitive strategy that reduces the uncertainty accompanying any novel stimulus.

An analysis of the content of media output identifies the stereotypes currently available to us. Wahl (1992) found dangerousness to be the most consistent feature. Wilson et al (1999) analysed prime-time television drama over a 1-year period and identified 10 themes, of which nine were negative; dangerousness and unpredictability were most common. Nairn et al (2001) analysed a collection of 50 published items relating to a single news event. They identified four major themes: human rights; vulnerability; risk of dangerousness; and the entity ‘psychiatric patient’.

The predominance of dangerousness in these studies is striking. It is possible that portrayals of mental illness as being dangerous fulfil a fundamental human need to build distressing images into familiar narratives, regardless of their objective truth, in order to reduce the uncertainty that they provoke (Salter, 2001). Allen and Nairn (1997) demonstrate how the media exploits the pre-existing common sense of the consumer to construct such narratives, reaffirming established beliefs.

Motives of the media

A fundamental difference between the media and psychiatric professions lies in the emphasis of form as opposed to content. For the media, the content of all accounts of mental illness, even those with an explicit educational intent, are subsidiary to another question: is it interesting? Far more than medicine, media is a business. Its output is driven by an overriding need to gain and sustain attention. Information is a raw product that must be processed into a form to achieve this end. Psychiatrists who, unlike their media colleagues, try to abide by the principles of confidentiality, accuracy and honesty, often misunderstand this process. Instead, media professionals are bound by three other constraints: recency, conflict and clarity. Stories are thus repackaged into forms already familiar to the target audience.

Media myths and methods

Our daily exposure to the media familiarises us with various conventions of form, in words and pictures. Philo et al (1994) noted how people are able to reproduce the styles of accounts of mental illness with surprising accuracy. Media accounts of mental illness place facts within these conventions, creating a sense of clarity. These may be simply grammatical, for example using a noun phrase as an adjective as in ‘community care knife-man’, or metaphorical, such as ‘politicians act to sweep mentally ill off the streets’. Alternatively, they may occur at a narrative level. Nairn et al (2001) show how a lengthy legal judgement of an offence related to mental illness was clarified into news. The original information acquired new meanings as it was placed into a novel framework chosen in accord with convention. The discussion of rights originally related to both the perpetrator and the victim, but was ascribed only to the latter in the final article. The theme of dangerousness was moved to the head of the article, as if ‘setting the scene’ for the tragedy about to unfold. Many accounts of serious incidents use this device to create a sense of unfolding narrative where none existed previously (Maden, 1995).

Journalists do not confine themselves to a shift of emphasis. They may actively rearrange words, quotes, facts or even the chronological sequence of events, in order to create a meaning that was absent from the original event. Persaud (2002) describes how truth does not need to obstruct pursuit of formal clarity. A lawyer's comments on a psychiatric report were first misattributed to the assessing psychiatrist and then reapplied to a completely different event, thus portraying the psychiatrist as incompetent. Placing the account within a conventional scapegoat narrative necessarily precluded mention of the accuracy of the psychiatrist's original assessment.

Apart from being inherently newsworthy, conflict creates an impression of clarity in all media. Typically, a proponent of any given view is placed directly against an opponent. This often creates an engaging discussion, which, while apparently meaningful, rarely departs from unhelpful dipoles, ‘asylum v. community’ or ‘drugs v. talking’. The complexity that psychiatry sees as central is sacrificed for the interest generated by polemicism.

Media professionals are also aware of the importance of recency. Public interest is notoriously fickle and the short period during which an issue remains in the news defines a crucial time frame for the media. Media workers regard a prompt response to an enquiry as essential and will return repeatedly to consult an ‘expert’, even if that expert's reputation for alacrity and fluency far exceeds his or her impartiality or knowledge. This accounts for much of the success now enjoyed by many mental health lobbying groups, all of which have devoted considerable effort to the development of a coherent media strategy. Recent events of an unusual nature also enable the media to resell the banal, by linking it to the event. It pays to be aware of the daily headlines; a psychiatrist responding to an innocent enquiry about adolescent substance misuse may find the quote being used in reference to the child of a senior politician. Media workers will always place information into their own context; one that emphasises entertainment or newsworthiness.

The role of the College

The extent to which the College should court the media remains a matter of debate (Hart & Phillipson, 2000). Other mental health organisations devote a higher proportion of their budget to media relations and so enjoy a higher media profile. These organisations can afford to be dogmatic in the way that the College cannot. The range and complexity of issues upon which the College may be called to express a view is so large as to render the notion of consensus meaningless. As the current controversy over antidepressant drugs illustrates (Meek, 2002), facts about mental illness accumulate so swiftly that any policy statement or guidelines — themselves fashionable conventions of form — soon becomes obsolete. Rather, the College could improve its ability to anticipate and provide prompt, measured responses to issues, as they arise. There are many ways to achieve this, from the top downwards. With few notable exceptions, successive Presidents of the College have kept a low media profile. Media experience rarely features in material presented in presidential hustings. In future, the media skills of presidential candidates could become a more decisive voting issue. Similarly, at divisional level, College Public Education Officers (PEO) could play a more active role (Khoosal, 2001).

The College would also benefit from enlarging its External Relations Department. At present, the small team deals admirably with a bewildering array of tasks (Hart, 2001), ranging from the triage of all media enquiries and dissemination of information through to formal media training of College members. Among the broader College membership, the opportunities for change are even greater.

Friendly journalists: grow your own

Many people listen to local radio and read local newspapers. All local media have a member of staff interested in health issues. The inherently newsworthy nature of our work all but guarantees a chance for regular communication. Taking this initiative reduces the odds of conflict and creates a chance to provide your regular contact with background information. Even if this goes unpublished, it can expand the context within which the story is constructed. Such dialogue also allows the writer's view of an event to be influenced, so that at least some control over the final output is retained. A media link, once established, often lasts beyond the life of the matter at hand and enhances the quality of future coverage.

Build your own media centre

Many units have a shelf where news cuttings, serious incident reports and similar documents gather. At home, most people have video cassette and radio cassette recorders. Encouraging staff to monitor the media and contribute tapes and articles to a departmental archive creates a resource that forms a lively topic for teaching, clinical meetings or journal clubs. Presentations might involve a general discussion of the report's content, identify specific journalistic devices and presentational styles, or use the more formal methods of social psychology to explore how context can alter the meaning of language (see Nairn, 1999).

Four cheap pieces of equipment can transform a resource into a training centre: a tripod, a microphone, a video camera and a television. With these, set-piece exercises can provide enjoyable, useful insights into the media process. Take an item from your resource and study its form and content. Who has the dominant voice? How do they achieve this? For how long does any person speak? What are the messages? Use these findings to inform a game of journalist and psychiatrist. Take turns behind the camera. Ask questions based on recency, stereotypic clarity and conflict. Confidentiality allowing, the game might relate to a current clinical dilemma or to more general controversy. Here the participants' imagination, or sense of mischief, can have free reign: Why is electroconvulsive therapy (ECT) barbaric? How did Prozac make me a subway bomber? Is there a difference between a psychiatrist and a psychologist? Despite initial fears, many people discover a natural fluency, providing the session is conducted in a relaxed, non-judgemental manner. Talented communicators should contact their Divisional PEO or the External Relations Department of the College for more formal training.

Hijack a soap opera

Popular television dramas have the capacity to reach more people than any other media format. Because they purport to depict ‘ordinary’ life, they provide a chance to expand the context within which mental illness may be understood. There have been several successful examples of this to date, with various aims. Reveley (1997) provides an account of a fruitful collaboration with the Eastenders team, which resulted in the presentation, to over 10 million people, of the idea that schizophrenia is a treatable illness that affects normal people. Expert opinion in these programmes is usually sought informally. Each inaccurate portrayal of mental illness offers a chance to contact the programme makers and offer to advise on the next series.

The future

A large part of psychiatric training in the latter half of the 20th Century stressed the importance of the psycho-social dimension of the patient's life alongside the biological. In the 21st Century, as new media technologies exert an increasing influence on our society, it appears that the socio-political dimension will be just as important — an influence not ignored by fundholders and politicians. It is difficult to envisage how our profession will change over the next 100 years (Persaud, 2000a ) but it is certain that technology will play a central role. Increasingly, the argument that media awareness is an irrelevant distraction from the business of helping sick people seems short-sighted. A better understanding of our innate capacity to communicate in symbolic and narrative terms is becoming crucial to psychiatry. The role of the media in this process is an issue that we cannot afford to ignore.

Declaration of interest

None.