How Media & Movies Shape Our Perception Of Serious Mental ...

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How Media & Movies Shape Our Perception Of Serious Mental Illness

Georgia Stevens, PhD, APRN, PMHCNS-BCDirector, P.A.L. AssociatesPartners in Aging & Long-term CaregivingWashington, DC

Mary Ann Boyd, PhD, DNS, PMHCNS-BCProfessor EmeritaSouthern Illinois University EdwardsvilleEdwardsville, IL

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Georgia Stevens, PhD, APRN, PMHCNS-BCPosition: Dr. Stevens is the Director of P.A.L. Associates; Partners in Aging & Long-term Caregiving in Washington, DC. She also provides staff training and ongoing evaluation of adult and geriatric patients with serious psychiatric mental illness as a long term nurse educator & care consultant.

Education: Dr. Stevens earned an BS in nursing from Duke University (Durham, NC), an MSN in Psychiatric Nursing Gerontology from Catholic University of America (Washington, DC) and an PhD in Nursing from the University of Maryland (Baltimore, MD)

Speaker Profiles

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Mary Ann Boyd, PhD, DNS, PMHCNS-BCPosition: Dr. Boyd is the Director of Mental Health Consultants, LLC. She serves as Clinical Faculty for the School of Nursing at Saint Louis University in St. Louis, MO and as a Nurse Educator for the VA Medical Center in St. Louis. She is also Professor Emerita for the School of Nursing at Southern Illinois University Edwardsville (Edwardsville, IL)

Education: Dr. Boyd earned an BS in nursing from Indiana University (Bloomington, IN) followed by an MSN from Washington University (St. Louis, MO) a PhD from Saint Louis University and an DNS from Indiana University (Indianapolis, IN).


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• Review the trends of media coverage and cinematic portrayals of mental illness

• Discuss definitions of stigma within mental healthcare and impact on individuals living with mental health conditions

• Examine considerations for change in the stigmatized narrative of mental health in the media and provide examples of success

Objectives

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PORTRAYAL OF MENTAL ILLNESS IN THE MEDIA AND MOVIES

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What percentage of media coverage of individuals with serious mental illness do you find to be negative?

A. 0% to 25%B. 25% to 50%C. 50% to 75%D. > 75%

Polling Question

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1. McGinty EE, et al. Health Aff (Millwood). 2016;35(6):1121-1129. 2. Whitley R, Wang JW. Soc Psychiatr Epidemiol. 2017; 53(2):241-244.3. Whitley R, Wang JW. Can J of Psychiatr. 2017;62(4):278-285.

• United States: TV & Newspaper Coverage (1995-2014)1

– Most frequently mentioned: Violence (55%) and Type of Treatment (47%)• Only 14% described successful treatment/recovery

– 2005-2014: media descriptions of mass shootings by individuals with mental illness significantly increased

• Canada: TV Coverage (2013-2015)2

– Significant linear increase of positively-oriented coverage– Link of mental illness to violence significantly decreased

• Remained over 50% of coverage

• Canada: Newspaper Coverage (2005-2015)3

– Increase in articles with positive tone nearly doubled (18.9% to 34.8%)– Stigmatizing content reduced by a third (32.7 to 22.3%)

National Trends in Media Coverage of Mental Illness

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1. Murphy NA, et al. J Ment Health. 2013;22(3):271-282.2. Koike S, et al. Schizophr Bull. 2016;42(3):552-559.

• UK: Four UK national newspapers (1998-2008)1

– Increase in reporting on issues related to mental health/illness

– Pejorative terms (i.e. “schizophrenic”) were used, in a number of the articles, to describe the person with a mental health condition

– Both the words “violence” and “drugs” were linked to mental health/mental illness

• Japan: Newspaper & TV Coverage (1985-2013)2

– Articles for schizophrenia contained more negative words (e.g., criminal or violent) than depressive disorder or diabetes (31.5%, 16.0%, and 8.2%, respectively)

National Trends in Media Coverage of Mental Illness

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1. Duckworth K, et al. Psychiatr Serv. 2003;54(10):1402-1404.2. Reavley NJ, et al. Soc Psychiatry Psychiatr Epidemiol. 2016;51(9):1257-1264. 3. Vilhauer RP. Int J Soc Psychiatry. 2015;61(1):58-63.

• U.S. Newspaper Articles (N=1,802)1:– Use of the term “schizophrenia” used metaphorically in higher rates

(28%) compared to physical illness such as “cancer” (1%)1

• Australian Phone Interview (N=5,220)2:– Recall of media reports about a person with schizophrenia was

associated with beliefs about dangerousness– Effect mitigated by knowing someone with a mental health problem and

having higher education• Review of 181 US newspapers covering Auditory Visual Hallucinations

(AVH) suggested3:– Are not present in healthy individuals– Were a symptom of mental illness– Were associated with criminal behavior, violence, and suicidality

Media Coverage of “Schizophrenia”

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1. Owen, P. Psychiatr Serv. 2012;63:655-659.

• English-language movies (1990-2010) featuring at least one main character with schizophrenia analyzed for depictions of schizophrenia1:

– Most characters displayed positive symptoms of schizophrenia– Delusions were featured most frequently, followed by auditory and visual

hallucinations– A majority of characters displayed violent behavior toward themselves or others,

and nearly one-third of violent characters engaged in homicidal behavior.– About one-fourth of characters committed suicide

• Misinformation and negative portrayals of schizophrenia in contemporary movies are common

• This underscores the importance of determining how viewers interpret media messages and how these interpretations inform attitudes and beliefs

Cinematic Depictions of Schizophrenia May be Stereotypic and Misinformed

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1. Shapiro S, Rotter M. J Forensic Sci. 2016;61(6):1592-1595.

• 50 highest-selling video games in each year from 2011-20131

– 23 out of 96 video games depicted at least one character with mental illness

– 42 characters identified as portraying mental illness, with most characters classified under a “homicidal maniac” stereotype

Portrayals of Mental Illness in Video Games

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STIGMA IN THE MENTAL HEALTH CARE SETTING

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What percentage of your patients/clients experience or have internalized shame about their mental health condition?

A. 0% to 20%B. 20% to 40%C. 40% to 60%D. > 60%

Polling Question

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1. Hatzenbuehler M. Am Psychol. 2016;71(8):742-751.2. Corrigan P. Psychiatr Serv. 2015;66:1347-1349.3. Corrigan P, et al. J Ment Health. 2016;25(1):10-15. 4. Carrara B, et al. Arch Psychiatr Nurs. 2018;32(2):317-324.

• Structural Stigma1

– Discriminatory laws, policies and community attitudes toward a particular group (especially minority)

• Public Stigma2

– Discrimination when general public endorses negative stereotypes– Leads to loss of service and rights; rejection & social distance

• Self-Stigma2,3

– Person internalizes public attitudes & negative stereotypes (agree & apply to self) “Why try?”

– Leads to loss of self-esteem and self-efficacy• Consequences4

– Negative behaviors, emotional reactions that indirectly interfere in health care and serve as barriers to access and treatment

Stigma and Stigmatization

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1. Horsfall J, et al. Issues Ment Health Nurs. 2010;31(7):450–45.2. Dabby L, et al. Can J Psychiatry. 2015;60(10):451–459.

• Definitions of stigma overlap with the concepts of social exclusion and discrimination1

• Contemporary conceptualizations require 3 components1: 1. A mainstream negative stereotype1

• For example, people who have mental health conditions are weak, irrational, manipulative, dangerous

2. Evidence/signs that a person has a mental health condition1

• For example, diagnosis, uncommon behavior, or a suspicion3. Avoidance, mistreatment, or discrimination against the person1,2

• Can be intentional behaviors like friendliness, or subconscious nonverbal behavior such as eye contact

• Stigma is a dynamic social/interactional process1,2

– The stigmatized person is labeled as different, linked to negative stereotypes,

– Persons with stigmatizing beliefs may exhibit behaviors that forge a separation, and the recipient responds accordingly

The Evolution of Stigma in Mental Health

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1. Horsfall J, et al. Issues Ment Health Nurs. 2010;31(7):450–455.2. Schulze B. Int Rev Psychiatry. 2007;19(2):137–155.3. Dabby L, et al. Can J Psychiatry. 2015;60(10):451–459.4. Ngui EM, et al. Int Rev Psychiatry. 2010; 22(3): 235–244.5. Rao H, et al. J Psychiatr Ment Health Nurs. 2009;16(3):279–284. 6. Mårtensson G, et al. J Psychiatr Ment Health Nurs. 2014;21(9):782–788.

• Pessimistic views held by mental healthcare providers may be based on clinical experience with patients in the most distressed phase of mental illness and those who are challenging to treat1–3

– Stereotypical views in this population may invoke feelings of uselessness, helplessness, or hopelessness, which may impact both professional and patient1

• Without effective diagnosis and treatment options, mental disorders are seen as untreatable, resulting in patients being undervalued and perceived as not able to contribute to society4

• Studies have reported a greater degree of stigma towards enduring mental illness versus short-lived psychotic episodes5

– Greater negative attitudes from staff working in inpatient services versus those in outpatient services has also been reported6

Attitudes Among Mental Healthcare Professionals

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1. Schulze B. Int Rev Psychiatry. 2007;19(2):137–155.

• Attitudes/routine practices may be experienced as stigmatizing– Specifically, mental healthcare consumers have reported

feeling stigmatized by:

Mental Health Patient Perspectives on Stigma1

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A lack of interest in them and their mental health

history

Being held to a standard psychiatric

treatment

Being diagnosed in a way that conveys an expectation of

negative prognosis

Not being sufficiently informed

about and/or included in

treatment decisions

Receiving poor quality mental health

services

Image based on: Schulze; 20071



1. Mårtensson G, et al. J Psychiatr Ment Health Nurs. 2014;21(9):782–78.2. Dabby L, et al. Can J Psychiatry. 2015;60(10):451–459.3. Ross CA, Goldner EM. J Psychiatr Ment Health Nurs. 2009;16(6):558–567.4. Ngui EM, et al. Int Rev Psychiatry. 2010; 22(3): 235–244.5. Schulze B. Int Rev Psychiatry. 2007;19(2):137-55.

• For individuals living with mental health conditions, stigmatization forms a barrier to recovery and social integration1,2

– A major reason identified by consumers of mental healthcare for not seeking or continuing with treatment is the stigma that they encounter3

– The stigma, myths, and misconceptions surrounding mental illness contribute to the discrimination and human rights violations experienced by people living with mental health conditions4

• In addition to individuals living with mental health conditions, their families and mental health professionals can also be the targets of stigmatization5

• There is increasing recognition that clinicians play an important role in perpetuating or mitigating stigma in the health care setting2

– This is important, as evidence suggests that patients living with mental health conditions receive fewer physical and laboratory examinations, are provided with less preventative healthcare, and receive fewer therapeutic interventions2

• Psychiatry itself is an important target of anti-stigma initiatives5

Stigma: Effects and Perpetuations

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1. Depression and Bipolar Support Alliance (DBSA). 10 Ways to Combat Discrimination with Compassionate Language. DBSA Website. Available at: http://www.dbsalliance.org/site/PageServer?pagename=dbsa_language. Accessed September 2016.

10 Ways to Combat Discrimination With Compassionate Language1

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“The choice of what picture you will paint with words is

yours―we ask only that you consider altering your

color palette.”

Image from: DBSA Website1



10 Ways to Combat Discrimination With Compassionate Language (continued)1

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Defy DefinitionsUse of “mental illness” imply a perpetual state of abnormality whereas mental health conditions

often present episodic challenges

Choose ThoughtfullyMany negative phrases historically

associated with mental health have become part of the common vernacular but can be

harmful

Avoid DistancingUse language that references people or individuals, instead of “them”, “those”, or

“the mentally ill”

Don’t Make AssumptionsRefer to individuals as people living with (or

experiencing) mental health challenges

Separate the Person From the Condition

Avoid reducing an individual to their condition (for example, “he is bipolar”)


Image based on: DBSA Website1



10 Ways to Combat Discrimination With Compassionate Language (continued)1

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Allow for Personal ChoiceDBSA acknowledges the individual right to

terminology of choice, but encourages more wellness-focused language

Accept ResponsibilityChoose language that is accurate,

respectful, and caring

Portray People RealisticallyAvoid showing a person only in an acute

episode or in shock-value behavior. Represent the broad experience of people

living with mental health conditions

Avoid SensationalizingAvoid emphasizing the most shocking and

tragic aspects of a situation. Don’t use headlines designed to shock and evoke fear

Don’t Assume Mental Health Is a Factor in Violent Crime

For mass shootings, avoid insinuating/stating that a shooter has a mental health condition

when there is no or questionable substantiation


Image based on: DBSA Website1



ALTERING THE STIGMATIZED NARRATIVE ON MENTAL HEALTH IN THE MEDIA

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Do you believe media and movies can be used to better educate on conditions of serious mental illness?

A. YesB. NoC. Best left to the professionalsD. They are just entertainment

Polling Question

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1. Bosoni N, et al. Int J Soc Psychiatry. 2017;63(3):275-277.2. Thonon B et al. J Behav Ther Exp Psychiatry. 2016;50:196-200.3. Maiorano A, et al. Can J Pyschiatry. 2017;62(10):702-715.

• Pilot study to assess if brief anti-stigma intervention (TV report) may have long-term effects1

– Persistent impact on reducing discrimination

• After watching a documentary film on people with schizophrenia less stigmatization was reported versus the control group2

• Systematic review (27 studies) found anti-stigma interventions for media professionals have some effect in improving reporting style3

– Intervention examples: contact-based educational approaches and the provision of guidelines by authoritative institutions

• Need for more positive and recovery-oriented impressions through mass media, as well as the importance of realistic depictions of people with mental illness in media

Positive Impact: Media

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1. Tohid H. Trends Psychiatry Psychother. 2016;38(3):178-182.2. Fink D, et al. PLoS ONE 2018;13(2): e0191405.

• Case Study in the Media:– Renowned comedian and actor Robin Williams

suffered from severe depression, believed to be the leading contributor to his suicide1

– “As of the end of 2015, no other case study seemed to have addressed or explored the links between the cause (or causes) and events leading to…suicide.”1

• His case exemplifies four major risk factors for suicide: – Major depression – Substance abuse – Relationship troubles – Financial problems

• Increased number of US suicides beyond predictive trends following his death2

Positive Impact: Media Increased Awareness and Compassion for Individuals with Depression and Suicidality

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http://romancemeetslife.com/2014/08/robin-williams-dead-of-apparent-suicide.html?m=0




1. Tripathi M, et al. World Neurosurg. 2017;101:718-721.

• Since the first use of film in cinema, it has been considered a mirror that reflects society1

– One Flew Over the Cuckoo’s Nest• Provoked debates on the ethical aspects of the treatment of patients

with mental illness• The movie established a need to look at the entirety of a patient as

an individual and need for empathy from treatment team

– As Good As It Gets• Portrayed the minutiae of the complexities of OCD• Helped to increase the awareness of OCD with widespread media

coverage, helping those with the disorder to seek treatment

Positive Impact:Cinema

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OCD, Obsessive Compulsive Disorder

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1. Destination Dignity Coalition. March for Dignity and Change in Mental Health. Destination Dignity Website. 2016. Available at: http://www.destinationdignity.org/. Accessed September 2016.

“Dignity and rights for people affected by mental health conditions are the counterpoint to a legacy of stigma, shame and discrimination that has caused social isolation, chronic underfunding of services, unnecessary levels of disability, and unacceptable levels of premature death. Public awareness must be led by people who have experienced these impacts personally, along with their supporters, allies and related professionals.”- Destination Dignity Coalition

The Importance of Dignity and Rights in Mental Healthcare1

Image from: Destination Dignity; 20161

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DISCUSSION

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