The scale of the problem

Television, radio and newspapers play an essential role in the public perception of mental illness. While the media often perpetuate unhelpful stereotypes of mental illness (Reference ByrneByrne, 1997), if properly harnessed, they may also be used to challenge prejudice, inform and initiate debate and so help to combat the stigma experienced by people with mental illness and their carers. The media project of the College's ‘Changing Minds’ campaign recently gathered delegates from the College, the British press and television industry, in order to identify ways to achieve these goals.Footnote ¹

A baseline survey of public attitudes towards mental illness (n=1600) was commissioned by the College at the outset of the campaign. A significant majority believed that people with any mental illness were unpredictable, difficult to communicate with and felt differently from ‘the rest of us’. In addition, the scepticism faced by the originators of the campaign when attempting to persuade colleagues of its possible value, reminds us that the lay public are not the only group influenced by stigmatising beliefs.

The study also found that various mental illnesses attracted different types of prejudice, suggesting that the public have a sophisticated view of mental illness, at odds with the lumpen way that ‘the mentally ill’ are often described in media coverage. The media project of the campaign intends to use the power of ideas, words and images to further this sophistication, increasing understanding in order to alter attitudes and ultimately behaviour.

The rationale of the media project: every time we see a stereotype, go for it

Psychiatrists equipped with a working knowledge of the mechanisms of stigma, its imagery, and a basic understanding of the media professions are well placed to challenge stigma at many levels, from individual patients and their families to the wider community. The media project has created a powerpoint presentation designed for this purpose, which is freely available on the internet at: www.rcpsych.ac.uk. A database of 100 references to the stigmatisation of mental illness provides a flexible presentation that can be tailored to suit different target audiences. The matching of verbal and visual language to the target audience is essential if the presentation is to reach its recipients and thereby stimulate wider debate.

Understanding the press: it is not a branch of the Health Education Authority

Psychiatrists can increase their chances of expressing their ideas and opinions in print if they first understand the motives of the press and the work of the jobbing journalist. Health correspondents have the largest mail box in the news office, filled with ever more ingenious attempts to win a journalist's precious interest. Brass doorknobs symbolising patient care, silk brassieres highlighting breast cancer, countless ideas compete daily for the health journalist's attention. Thereafter, the writer must get the idea past the news desk. This process is poorly understood by doctors, who often have difficulty separating a ‘worthy’ story from a ‘newsworthy’ story. To a journalist, the latter is crucial. Their piece must stand out, with a striking headline, a powerful introduction and a good story. Credibility, accuracy and human relevance alone are insufficient to ensure passage into print.

If psychiatrists are to make better use of the press, they must cultivate their sense of what makes a good story. All health stories fall into one of four basic types: the scare story (e.g. ‘flesh-eating killer bug’); the cure story (e.g. ‘magic bullet drug breakthrough’); the money story (e.g. ‘Titanic NHS sinks after cash cuts’) and the human interest story (e.g. ‘my struggle with bulimia’). Such approaches can help attract the attention of a busy journalist, whose profession must be seen for what it is: a tough, competitive world, driven by a need to sell newspapers full of enjoyable stories to be read easily by busy people. This need - which the press contends unapologetically - fully justifies the use of powerful headlines which at times may cause concern to psychiatrists and their patients. Given that their primary objective is to gain access to readers' minds, the end justifies the means. A responsibility to educate and inform is only a secondary motive of the journalistic profession.

Psychiatrists wishing to correct imbalances in the press reporting of mental health issues need to take account of this.

Understanding television: have an angle, be short, sharp and interesting

Many senior employees of the British television industry candidly admit that theirs is an industry heavily influenced by egotism, disingenuity and an all important need to achieve ratings for programmes. Any psychiatrist hoping to use television to challenge the stigma of mental illness must, therefore, take account of the intense competition in the world of television. However much we object to the stereotypic portrayal of mental illness on television, these images are accepted by both programme-makers and viewers as common currency in our culture; images of madness and distress attract attention and boost ratings. To attempt to confront such images with simple complaint, therefore, is unlikely to alter thinking within the profession. Rather, stereotypes provide a useful way into dialogue with programme-makers. The recent Channel 4 series, Psychos provides an illustration. 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 - not to mention welcome publicity for the programme.

Television is also a blunt instrument, poorly suited to the subtleties of meaning which psychiatry regards as commonplace. For example, a Panorama programme on inner city psychiatric care was broadcast in the autumn of 1997. Originally conceived as a study of the complex issues surrounding discharge of vulnerable patients into the urban community, the programme evolved in the making into a scare-in-the-community piece. Many praised the programme for its honesty, while others were equally strident in condemnation. Such varied reactions illustrate both the strength and weakness of television as a tool for altering beliefs.

Many of the tenets of press journalism - an interesting idea told in a good story - apply equally to television, but some points are unique to broadcast media. Before any involvement with a broadcast, be familiar with the style of individual programmes and channels. Whenever possible, attempt to make live rather than pre-recorded broadcasts, as this limits the extent to which a message can be influenced by the editorial process. Total familiarity with one's subject matter is essential, as well as a degree of verbal fluency, in order to increase the chances of appearing concise and interesting. Daytime television is particularly suited to psychosocial issues and is currently much underused as a way of reaching an influential audience with useful messages about misunderstanding and mental illness.

The power of television to reach a large audience so swiftly challenges anyone seeking to alter public opinion about mental health. Psychiatry can only succeed by entering into greater dialogue with television. Given the nature of the industry, this will at first need to be on terms set by the television industry itself and may involve tactics not routinely used by clinicians. We will need to use all of our available wit, guile and knowledge of human nature to engage the industry more effectively. Resort to flattery if necessary. If a programme offends, contact the programme-maker, congratulate him or her on an excellent piece of thought provoking work and offer to act as advisor to the next series. Here, it is our ends that justify our means.

Watching the media: don't just sit there, do something

The spread of psychiatrists throughout the land and our daily contact with people from all walks of life, places us in a strategic position to identify some of the more egregious depictions of mental illness. Identification, however, is insufficient unless allied to complaint, and complaint is more likely to be effective if it is coordinated and on as large a scale as possible. The College's External Affairs Unit has described a practical way to achieve this (Reference Hart and PhillipsonHart & Phillipson, 1999) and further details are available on the College website: www.rcpsych.ac.uk. Written complaint is a skill in its own right; harness the heat of the moment by writing the first draft while the emotions are still fresh. Try to place this on a word processor within 24 hours. Check it at once for a sensible number of points, which link into a readable ‘chain’ of ideas. Thereafter, prune it to 200 words and sleep on it. The next day, ask a non-medical person to read it, and after a final revision, post it, fax it and e-mail it, before lunchtime, to the target ‘organ’. Your article should always contain your qualifications and your contact address.

The future: time to stand up and be counted

The current stance taken by College Members against the stigma of mental illness leaves much to be desired. In spite of the drastic way that stigma affects our work, the prevailing attitude of psychiatry towards it seems to be one of inertia and resignation. Stigma is mentioned in none of the main texts of psychiatry, nor does it feature in any meaningful way on the MRCPsych syllabus. With few notable exceptions, psychiatrists have taken a low profile in local and national debate or complaint about mental health issues, even though mental illness touches ‘every family in the land’. Jeremy Laurance, health correspondent for The Independent newspaper, wryly observed that in all his years as a health writer, he had received more letters from angry dentists than psychiatrists.

Psychiatrists should be wary of succumbing to such inevitable pessimism. The media can act as a powerful tool with which to confront our own inertia. 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. This may involve some members of the College being seen to risk abandoning the conservatism that many, rightly or wrongly, associate with the medical profession, but given the clear ability of the media to alter public opinion, this risk seems worthwhile. Once again, such important ends may be justified by unusual means.

There are countless ways in which psychiatry might use its experience to touch the opinions of viewers, listeners and readers. Some, such as introducing legislation to ban the use of pejorative terms for insanity, are clearly less workable than others, working mental health storylines into popular dramas, or targeting opinion formers in schools, theatres, advertising and industry. There is also the fascination of a secret revealed. The interest and attention that invariably attends the ‘coming out’ of a significant individual might harness the power of stigma to a useful end. Members of television industry and the press urged us to be aware of the power of a good story, harnessed to powerful images when trying to capture attention and alter opinion. Television, radio, newspapers and magazines are replete with disclosures of secrets, struggles, triumphs and failures. What is the daily work of the psychiatrist, if not about such fascinating human stories?

There is also a need to increase the emphasis placed on stigma in the training of psychiatrists and all doctors, from medical school onwards. Teaching on stigma could be easily incorporated into psychology and sociology modules of all medical courses, given commitment at local level. The regional arrangements of the College could conceivably take a lead in such an initiative. In this, and all other projects, local initiatives will be essential to success; psychiatrists who teach others about stigma will inevitably learn much about it themselves.

The task ahead of the psychiatric profession is clear. If we, as a professional body, are to do something about the terrible burden of stigma and discrimination that afflicts our patients, we must find ways to harness the emotional anger that comes from the countless tales told out in our ward rounds and clinics. This will involve our profession taking risks, and using unorthodox initiatives. Such ideas will only arise through far greater dialogue with people outside the profession, in the press, television, advertising, public relations and, especially, with our patients. It would be a sad irony if a medical discipline that prides itself on its ability to embrace the biological, psychological and social were to fail in this task. Responsibility for success, or lack of it, must remain with every Member of the College.