Print media

Most professionals read and provide content for the (relatively) permanent print media of books, journals, periodicals, magazines and professional literature, together with numerous hybrid publications. By virtue of our psychiatric training, the nature of the media we consume is coloured by our professional standpoint. As doctors, we read classic literature, especially diverse actual and fictional accounts of mental illness (Reference Hudson JonesHudson Jones, 1997), in a different way from the general public (Reference SalinskySalinsky, 2002). From the beginnings of the speciality, psychiatrists have been fair game for artists of all disciplines, even across 50 years of published cartoons (Reference WalterWalter, 1992), and this fascination has continued into modern media. Defining where psychiatry ends and journalism begins has been made difficult by the growth of the self-help book industry, where mental health books are written for and marketed directly to the general public. As with everything else, we can blame Freud, who wrote directly for the public and whose case histories can be consumed as fiction. That said, there are many positive benefits (public education, higher standing for the speciality, potential for improved resources) when a ‘psychiatry book’ achieves a wider readership. Separating the influences of recreational from those of professional reading is also problematic, and academic journals such as the BMJ (http://bmj.com) are changing (evolving, rebranding, becoming more accessible or dumbing down – chose your own words) to become (in their own words) ‘closer to Cosmopolitan than Brain’ (Reference SmithSmith, 2002). Readership of journals remains high, with a circulation of about 13 500 for the British Journal of Psychiatry and Psychiatric Bulletin (http://rcpsych.ac.uk), comparing favourably with a BMJ print readership of about 110 000.

In general, most contributors to these publications are familiar with their style and content. By contrast, disposable print has a greater variety of style, tight deadlines and it feeds a public perceived to be hungry for news. Several themes reflecting the divergent priorities of permanent and disposable print media are mirrored in the professional differences given in Box 1. Psychiatrists (with few exceptions) are reluctant to comment on individuals or supply instant commentary in reaction to the latest headline. Psychobabble about presumed motivation could be called Steve Davis syndrome, after the famous snooker player – ‘as Steve prepares to pot this red ball, he'll be thinking about the blue one he missed in the third frame’. Yet it is usually newspapers that are the target of any catch-all complaint about ‘the media’ and they feed the perception of a hostile media in the minds of professionals. In a BMJ review of three UK newspapers over 21 years (Reference Ali, Theobe and AuvacheAli et al, 2001), the proportion of negative stories about doctors remained constant, but the space allocated increased by more than three times as total coverage of health matters rose. When Reference Williams, Cheyne and MacDonaldWilliams et al(2001) catalogued public ignorance of the work of psychiatrists, it could have been that neutral or positive stories failed to inform, were seldom read or soon forgotten. The Uses of Literacy (Reference HoggartHoggart, 1958) was written at the beginning of a surge in readership of UK newspapers (an increase of 50% for daily newspapers and of 100% for Sunday newspapers). By the 1980s, sales of daily and Sunday newspapers had fallen by 400 000 and 900 000, respectively, with tabloid titles outselling broadsheets: the public liked its newsprint ‘straight and simple’ (Reference DickinsonDickinson, 1990). Although only a minority of the public reads a newspaper each day, it is the newspapers that set the news agenda and provide television news with its stories and its key personnel. For the latest newspaper trends and reliable figures for newspaper sales, The Guardian continues to host the best website, at http://media.guardian.co.uk.

The power and influence of the media on suicidal behaviour have been a key subject of debate over many years. Public attitudes to suicide (decriminalisation of suicide and reduction of its taboo status) have become more empathic, and although suicide rates are falling, they remain high. Reference Yip, Chao and ChiuYip et al(2000) report that in England and Wales, 59 608 people took their own lives over a 15-year period. Although psychiatrists should encourage open discussion of suicide among individuals and in a wider media context, there are specific concerns when fictional and real suicides are represented in the media. Reference Schmidtke, Häfner, Diekstra, Maris and PlattSchmidtke & Häfner (1989), in an extensive review with 131 references, examined the influence of the mass media, predominantly news media, on suicidology. The evidence for imitation (with regard to explicit details of method and celebrity suicides) proved conclusive, thus retrospectively justifying the American Academy of Medicine's first proposal for press constraints in 1911 (Reference Schmidtke, Häfner, Diekstra, Maris and PlattSchmidtke & Häfner, 1989). Two subsequent studies have examined the relationships between print media and the choice of suicide method. Reference Etzersdorfer, Sonneck and Nagel-KuessEtzersdorfer et al(1992) showed how attempted and completed suicides on the Viennese underground railway have been reduced to single figures after the media were given guidelines for reporting suicide. The total number of completed suicides for the city has been cut by 13%. These local press guidelines did not ban suicide reports, but achieved shorter, non-sensational items, which were rarely placed on the front page (Reference Etzersdorfer, Sonneck and Nagel-KuessEtzersdorfer et al, 1992). Reference Marzuk, Tardiff and HirschMarzuk et al(1993) identified the direct influence of a suicide instruction manual on at least 14 out of 144 completed suicides in New York City – all with specificity of method (asphyxiation and poisoning). However, in response to concerns about links between irresponsible reporting of suicides and possible imitation, Reference Kessler, Downey and StippKessler et al(1989) examined 12 years of US network news but found no evidence of a ‘dose–response’ relationship. Either way, in omitting details of the suicide method and toning down previous excesses, the press now behaves responsibly, with rare lapses.

Reference LawrieLawrie (2000) reports that psychiatry in general gets a bad press in the UK, compared with medicine, with little difference found between broadsheet and tabloid coverage. However, where medicine has a ‘bad doctor’ focus, psychiatry has a ‘bad patient’ angle. There are codes of conduct in place for journalists, but these do not address difficulties that are unique to clinical practice (Reference WhiteWhite, 2002). Most initiatives, such as the UK Government's Mindout Guide to Open-Minded Coverage of Mental Health (http://mindout.net), are targeted at journalists and headline writers, usually subeditors. The language of mental illness is well-documented (Reference WalterWalter, 1992; Reference WahlWahl, 1995; Reference PhiloPhilo, 1996; Reference ByrneByrne, 2000b ) and it is a truism that if you want to change the culture, first you must change the language. The most effective way of achieving this is with consistent ‘people first’ language, e.g. ‘a man with schizophrenia’ rather than ‘a schizophrenic’ (Reference Penn and Nowlin-DrummondPenn & Nowlin-Drummond, 2001). Confusion about psychiatric terms is not always the fault of the journalist: former Home Secretary Jack Straw's comments on Osama bin Laden demonstrate that he did not understand the difference between psychosis and psychopathy, despite his claim, reported in an interview in the The Times (6 November 1002: p. 6), that he ‘was picking [his] words with care here because whenever you use the language of mental illness, you get letters from people’. His mistake was corrected on the same page by the paper's medical columnist, Dr Thomas Stuttaford. Unfortunately, coverage by other newspapers and most broadcasts of Straw's remarks failed to correct his mistake.

In many ways, as a profession, we get the media coverage that we deserve. The worst inventions of the media are paralleled by the history of bad ideas in psychiatry (Reference ByrneByrne, 2000b ), perpetuated by the perennial shyness that psychiatrists have of the media (Reference Salter and ByrneSalter & Byrne, 2000). Proactive approaches are successful. In Norway, a coordinated press campaign reduced the duration of untreated psychosis in Rogaland county from 118 to 26 weeks (http://tips-info.com).

Television and radio

In the film All About Eve(1960), when an actress tells Addison de Witt (George Sanders) that she is auditioning for television, he exclaims: ‘my dear, television is audition’. In the legal challenge to Lady Chatterly's Lover, the question was posed as to whether the book was ‘something you would allow your servants to read’, but soon afterwards, the television set had entered every affluent home as ‘something for the servants to watch’. Today, as television presenter David Frost has remarked, this ubiquitous device permits us to be entertained in our homes by people we would not want to have in our homes. More recently, ‘reality TV’ has advanced the phenomenon of people ‘famous for being famous’ into the realm of watching those ‘famous for wanting to be famous’, where caution regarding the human cost is rarely advocated (‘Big Brother sucks you up and spits you out’, Observer, 27 January 2002). The medium has elevated arguing from the specific to the general into an art form and boasts distraction techniques that are the envy of behavioural therapists. Television writes its own reviews and creates its own language. Television programmes are promoted as ‘must-see’, ‘zeitgeist’, ‘nostalgic’ – I love 1972, etc. (repeats) or ‘water-cooler’. Most television serves to fill the gaps between the commercials, and even non-commercial television (the British Broadcasting Corporation (BBC)) fills its schedules with buy-this ‘GMC’ (gardening, make-overs and cookery) programming, with multiple commercial tie-ins. One producer has recommended daytime television as a suitable forum for mental health issues (Reference Salter and ByrneSalter & Byrne, 2000). However, these confessional programmes tend to confer either freak or martyr status on their guests. Furthermore, no group which has successfully fought discrimination (on the basis of race, gender or sexual preference) has achieved equality by arousing pity. Therefore, television is the worst medium through which to consider exploring the complex biopsychosocial origins of mental illness and its treatment, and such programmes are (almost) all in the worst possible taste.

The evolution of television news is worth particular examination. Although the next section focuses on film and video, I would like to mention here two mainstream US films Network(1975) and Broadcast News(1987) that satirised this culture. Network showed the descent of a television newsreader (Peter Finch) into psychosis. However, its depiction of astrologist Cybil the Soothsayer on the nightly news pales alongside Channel 5's (cartoon) news bunny. Equally, in Broadcast News, the rapid promotion of ‘himbo’ (the male bimbo) non-journalist William Hurt – a fine example of the television newsroom's ‘hairspray ethics’ as described by Reference Postman and PowersPostman & Powers (1992) – now seems tame as the reality has overtaken the satire. Television news employs the ‘straight and simple’ tabloid style, where human interest is always the story (Box 2): ‘if it bleeds, it leads’. Rather than raise standards, 24-hour news (or ‘newsak’ as former UK Member of Parliament and journalist Martin Bell dubs it) has become background noise, a continuous bland selection of insubstantial hors d'oeuvres – as described in the tag line from television's Day Today, ‘news from telly to belly’. Reference Postman and PowersPostman & Powers (1992) saw these negative trends as unstoppable and concluded that we should watch substantially less news and scrutinise its language, politics and commercial interests. Some 15 years ago, Reference KarpfKarpf (1988) predicted the decline of science programming and its amalgamation into current affairs. Psychiatrists Reference Berlin and MalinBerlin & Malin (1991) described their experiences of trial by television, where confidentiality prevented them from engaging with a hostile local media. Noel Coward described television as something for appearing on not for watching, but in many instances, psychiatrists should do a careful risk-benefit analysis before appearing on television news (Box 3). The Glasgow Media Group quantified UK television news coverage of all mental health issues for April 1994 and found that 70% of this was associated with violence (Reference PhiloPhilo, 1996). In mental health promotion, television in general, and television news in particular, is a major reservoir of stigma.

Children in the USA watch television for at least 25 hours every week, or 30% of their waking time. This amounts to 19 000 hours by school-leaving age and compares with a total of 13 000 hours of schooling in a lifetime (Reference Postman and PowersPostman & Powers, 1992). In addition to investigating the physical effects of this sedentary behaviour and the emotional consequences of spending more time in televisual rather than human, even parental, company, many studies have examined links between programme content (manifest or latent) and behaviour. Reference Klein, Brown and ChildersKlein et al(1993) found an association between contact with the mass media and self-reported risk behaviours in 2760 US adolescents. The risk behaviours, which included stealing, substance misuse and sexual activity, correlated with total television and radio consumption – an average of 40 hours every week for each medium in this survey population of 14- to 16-year-olds – but causal links could not be proved (Reference Klein, Brown and ChildersKlein et al, 1993). Despite previous research claims, suicide rates are correlated not with television ownership, but with wealth (Reference LesterLester, 1994). Given the quantity and multiple forms of media contact, it is not surprising that the search for negative psychological outcomes following specific programmes has been largely fruitless. When a popular UK programme (BBC's Casualty, with 15.5 million viewers) featured a rapidly fatal paracetamol overdose, this had no impact on regional parasuicide trends (Reference Simkin, Hawton and WhiteheadSimkin et al, 1995). However, using similar methods, a later study found that national rates of paracetamol poisoning doubled when the same programme showed the serious consequences of paracetomol overdose in an RAF pilot (Reference Hawton, Simkin and DeeksHawton et al, 1999). There are further methodological problems in researching the effects of violence. The concept of children as vulnerable viewers has been accepted, and an association has been established between exposure to television and aggressive behaviours (Reference VillaniVillani, 2001). Reference Wilson, Nairn and CoverdaleWilson et al(1999) performed a content analysis of prime-time dramas and confirmed the perennial representation of mental illness as violence, although in percentage terms this was less common than in previous studies (Reference WahlWahl, 1995; Reference PhiloPhilo, 1996). Direct engagement between the service users and professionals and the programme makers behind the scenes has enormous potential benefits. Television can perform a major public service when care is taken: for example, characters such as Joey Rainbow in Australian TV's Home and Away (http://www.sane.org/stigmamediahomeaway.html) and Joe Wicks in BBC TV's Eastenders (http://news.bbc.co.uk/1/hi/health/430859.stm) give realistic representations of schizophrenia.

Radio is sometimes regarded as television's poor relation. Programmes are cheap to make and consume but have great flexibility. Although radio is less influential in developed than in developing countries, Western adolescents do listen to it more as they get older (Reference Klein, Brown and ChildersKlein et al, 1993). The availability of radio on the internet improves international access, and recent developments in digital radio could further boost the number of listeners. One review reported that radio is the most cost-effective way to promote mental health (Reference Austin and HustedAustin & Husted, 1998), and anti-stigma initiatives in Canada employed modular radio slots (http://www.camh.net/journal/journalv2n2/myth_schizophrenia.html). Radio is a perfect entry-level medium for the novice; it remains the easiest medium to understand and is especially conducive to the exploration of mental health issues. After a television interview, viewers will remember what you were wearing. With radio, listeners will recall what you said.

Reluctance by professionals to enter the media fray is not new. Sir William Osler warned colleagues in 1907 that:

Osler's advice is still relevant to those psychiatrists who seem unable to decline a media interview, either on the basis of knowledge or ability (Box 3), and television appearances are the best example of this. Radio, by contrast, is well within the abilities of us all and local radio is a highly effective way of modifying a centralised news agenda. Over the past 15 years members of the College who wish to gain access to the media have been supported by the College's External Affairs Department. The problem is that too few psychiatrists give interviews: genuine experts are always preferable to the ‘usual suspects’. We know the benefits of patient education and there are compelling reasons to extend these efforts to public education (Reference ByrneByrne, 2000b ). Box 3 provides a checklist for participation in an interview. Facts always help, and the Mental Health Foundation (1999) and government statistics (http://statistics.gov.uk) are good primary sources.

Film, video and beyond

Reports of the death of film have been greatly exaggerated. The medium has survived its lowly status of fairground attraction, censorship, the coming of sound, television and the complementary formats of videotape and digital versatile disk (DVD). Technical advances, for example low-cost digital video and the ability to project an entire film, Toy Story 2 (2000), by digital computer image rather than through celluloid, have regenerated interest in cinema. Unlike most television programmes, every film is an accessible stand-alone work and a useful study, whether in its own right or in the context of a group (genre) of films. Cinematic images outweigh the power of the printed word and exert a powerful influence, directly or indirectly, through other media. For example, Reference PhiloPhilo (1996) traced the evolution of a television ‘soap’ storyline back to two contemporaneous films. Hitchcock remarked that what he called ‘stealing from’, the French have labelled ‘homage to’. After cowboys, soldiers, and cops and robbers, film-makers like looking at doctors. They love surgeons and country doctors (Reference DansDans, 2000) but, apart from a brief golden age, they don't like psychiatrists (Reference Gabbard and GabbardGabbard & Gabbard, 1999). Film studies blend cultural archaeology – both books catalogue historical trends with reference to professional developments – with technical knowledge, aesthetics and ideologies. Cinema at its best is artistic collaboration to achieve a seamless blend of form and content. The Conformist(1970), a film based on Alberto Moravia's (1968) book, photographed by Vittorio Storaro with impeccable production design under the direction of Bernardo Bertolucci, is foregrounded by extraordinary performances and intriguing dialogue:

These words, experienced within that film's reality, hint at the potential of the medium. Is this Plato's Cave, a cinema metaphor or more? Freudian, and latterly Lacanian, theory runs like a computer virus through cinema itself and retains the dominant role within film studies (Reference TurnerTurner, 1992).

Cinema frequently gets it right when it portrays the experiences of alcohol and substance misuse, grief, difficulties in relationships, autism and dissociative identity disorder. Many mental health training courses in the USA have film clubs, in which trainees are shown popular films as discussion points and some authors advocate cinema as a teaching aid for psychopathology (Reference Wedding and BoydWedding & Boyd, 1999). Open discussion of films that fail to reach the psychiatric quality mark provides opportunities to examine all aspects of our clinical practice and the ways in which we are perceived from outside.

There is a dearth of research into the use of films in therapeutic settings and we should be cautious of the latest US trend of ‘therapeutic films’, which are ‘prescribed’ for certain populations of patients (Reference Hesley and HesleyHesley & Hesley, 1998). When cinema gets it wrong, it not only offends the sensibilities of psychiatrists but also propagates stereotypes of mental illness that range from fakers and narcissistic parasites (Reference Gabbard and GabbardGabbard & Gabbard, 1999) through the comedic to psychokillers (Reference WahlWahl, 1995). The potential learning exercise here goes beyond lessons in complaining to a broader understanding of the medium and its processes. Equally important is the wider context of film distribution. The Omen(1976) had a marketing budget ($6 million) that was double its production costs (Reference TurnerTurner, 1992), and the studios spent $30 million promoting Godfather Part III(1990). Even a tasteless film like Me, Myself and Irene(2000) generated a wide debate about schizophrenia and resulted in enduring alliances with service-user groups (Reference ByrneByrne, 2000a ). In 2002, two films, Iris and A Beautiful Mind, resulted in valuable free publicity for psychiatry's two most neglected illnesses, Alzheimer's disease and schizophrenia. They will provide useful teaching aids for years to come because of their critical and commercial success coupled with their release on video. The College now includes film sessions at its annual meetings and owns the copyright to the anti-stigma film 1 in 4 (http://rcpsych.ac.uk/campaigns/cminds/oneinfour.htm), recently adopted by the World Health Organization for screening in 52 countries.

New media

Have the numerous website links that I have given illuminated or irritated you? Assume that this article is essential to your professional activity and you are required to review and update it by tomorrow. These links are immediately accessible and lead to other sites and sources of information beyond the scope of this few thousand words. If you are reading this piece online, this information is only a click away. The complex interrelationships between art and the art of medicine are frequently examined in Journal of Medical Ethics: Medical Humanities (http://jme.bmjjournals.com/). Most newspapers are available online, with free downloads for handheld computers (http://avantgo.com). A College handbook advising members on media contacts will soon be posted on the College's website (http://rcpsych.ac.uk). Film scholars can search for details by title, actor or subject matter (http://imdb.com). Given the time it takes to prepare and publish a journal article, this piece (written in January 2002, revised August 2002) is already out of date. Try typing the two keywords of the title into a search engine (e.g. http://google.com) and look at the resulting reference lists and content. You might find Martyn (2001) at http://bmj.com/cgi/content/full/323/7316/814/a, which comments on doctors in the media and will give you forward links to a public poll of perceptions regarding whether professionals are telling the truth or lying (doctors come out better than any other group), a similar US poll (also favourable) and our behaviour in restaurants as guests of the pharmaceutical industry (not so good). There is open public access to Medline (http://nlm.nih.gov) and the Cochrane database (http://cochrane.org) in the same way as to the BMJ. Most institutions receive e-journals (http://athens.nhs.uk) and the choice of publication (to read or submit articles to) can be informed using the citation index (http://isinet.com/isi/products/citation/jcr/jcrweb/index). These developments have now had an impact on research, teaching and journalism (Reference PatelPatel, 2001). Examination modules and results are already available online and virtual continuing professional development (CPD) points cannot be too far away. The proliferation of computer- and internet-based therapy techniques would seem most suited to cognitive–behavioural interventions (Reference White, Jones and McGarryWhite et al, 2000). Reference KileyKiley (1999) provides an introduction to this area in a book with an accompanying CD–ROM.

Because of the ease of publication, the internet can be a source of misleading information. Reference Lissman and BoehnleinLissman & Boehnlein (2001) found poor-quality information and bias on 178 depression-related sites. Similar findings on the lack of quality assurance produced a protracted correspondence in the BMJ (http://bmj.com/cgi/eletters/321/7275/1511). The internet is a combination of the best and the worst of print media (imagine a newspaper without an editor to scrutinise items or a readers’ editor to correct errors) and it includes images and sounds. Opportunities abound for obfuscation and pseudoscientific research (Reference PatelPatel, 2001). Imagine, too, a library where the librarian happily accepts every book and pamphlet, neglects to assign them to any particular section and is incapable of throwing the worthless, the outdated and the obscure texts in the bin. It is an instructive exercise to sample the range of antipsychiatry sites, not least those sponsored by scientology (http://scientology.org/reform/new/75psych.htm). Given the variety and democracy of the internet, you can also read how scientology is hoisted with its own petard (http://demon.co.uk/castle/media). Inevitably, there have been case reports of internet addiction, anecdotes of kidnappings and worse. New media will repeat the mistakes of their predecessors but, by any standards, they provide the fastest and cheapest way of mass communication. Our profession needs to be aware of the concerns of allied organisations (Box 4) and the quality of information online.

Recommendations

What have the media ever done for psychiatry? Not much in comparison with all the material travelling in the other direction. Get angry or get even? Here is a Top Ten:

1. • Once a week, acquire and read a paper you would never usually buy. Does it have a new-media section? Compare different styles across news and feature articles with those in your regular paper. If you enjoy journalists slagging off other journalists, read Private Eye.

2. • Listen to more radio programmes. Make notes. Think about the way in which ideas are communicated and consider contacting the programme makers. Once you have taken part in a live radio show, presenting to colleagues will never scare you again.

3. • Acquire the habit of searching the internet, beginning with the websites of user groups (Box 4), and e-mail others with your findings and bookmarks. Remember that patients, relatives and journalists will use the internet as their ‘second opinion’ on key clinical issues. Try to keep up to date. Decide which are the best newsletter groups for you; join NAMI StigmaBusters (http://nami.org/campaign/stigmabust.html).

4. • Watch The Simpsons. It aims its humour at religion, the media, professionals and other hypocrites. Even stigmatising language is given added irony in the cartoon, usually through the mouth of Chief of Police, Clancy Wiggam. Balance the praise for the programme by the Archbishop of Canterbury (‘One of the most subtle pieces of propaganda in the cause of sense, humility and virtue’) with the comment of the cartoon character Ned Flanders, ‘We don't judge you, Marge, we have a vengeful God who does that’. Spot the film references and enjoy the respect of children.

5. • Support a user, friend or professional – perhaps someone who is all three – and encourage them to undertake media interviews. While doing this, remember ‘see one, do one, teach one’. Try timing any interview and conducting a local ‘media watch’ of how the issue concerned and other mental health issues are represented over a set time period. This will quickly clarify the challenges.

6. • Get some media training and persuade your trust to provide training for service users as well. Agree a joint media project with local users; support and criticise each other. Celebrate the difference between a media psychiatrist and a psychiatrist with an interest in the media.

7. • Start a film club for trainees. Once this is up and running, be generous with films and invitations.

8. • Find out what your trust is doing to promote mental health. Did your locality meet the March 2002 deadline to implement National Service Framework Standard 1 (reducing stigma and discrimination)? The College's anti-stigma campaign (http://changingminds.co.uk) ends in 2003. Are there parts of this which you could adapt locally?

9. • The major challenge is the violence link, ‘scare in the community’, perpetuated by the Government's risk agenda. Change the emphasis: make the statistics and the stories real. More people are killed in the UK every year by speeding police cars than by people who have mental illness. Get the community to care.

10. • Why not actually read this article? Admit it, top-ten lists in bullet points are infinitely more interesting than text. Presentation is everything, but content helps.