This article was downloaded by: [University of North Texas] On: 12 November 2014, At: 20:30 Publisher: Taylor & Francis Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Journal of Health Communication: International Perspectives Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcm20 Mental Disorders Stigma in the Media: Review of Studies on Production, Content, and Influences a Anat Klin & Dafna Lemish b a School of Public Health, Haifa University and Department of Communication, Western Galilee Academic College , Haifa, Israel b Department of Communication , Tel Aviv University , Ramat Aviv, Tel Aviv, Israel Published online: 25 Jul 2008. To cite this article: Anat Klin & Dafna Lemish (2008) Mental Disorders Stigma in the Media: Review of Studies on Production, Content, and Influences, Journal of Health Communication: International Perspectives, 13:5, 434-449, DOI: 10.1080/10810730802198813 To link to this article: http://dx.doi.org/10.1080/10810730802198813 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions Journal of Health Communication, 13:434–449, 2008 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print/1087-0415 online DOI: 10.1080/10810730802198813 Mental Disorders Stigma in the Media: Review of Studies on Production, Content, and Influences ANAT KLIN Downloaded by [University of North Texas] at 20:30 12 November 2014 School of Public Health, Haifa University and Department of Communication, Western Galilee Academic College, Haifa, Israel DAFNA LEMISH Department of Communication, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel This article analyzes two decades of research regarding the mass media’s role in shaping, perpetuating, and reducing the stigma of mental illness. It concentrates on three broad areas common in media inquiry: production, representation, and audiences. The analysis reveals that descriptions of mental illness and the mentally ill are distorted due to inaccuracies, exaggerations, or misinformation. The ill are presented not only as peculiar and different, but also as dangerous. Thus, the media perpetuate misconceptions and stigma. Especially prominent is the absence of agreed-upon definitions of ‘‘mental illness,’’ as well as the lack of research on the inter-relationships in audience studies between portrayals in the media and social perceptions. The analysis concludes with suggestions for further research on mass media’s inter-relationships with mental illness. Negative social attitudes toward those suffering from psychiatric disorders that derive from misperceptions and stigmas are a key mental health and social problem (Corrigan & Penn, 1999). These attitudes interfere with the social integration of those who suffer from mental disorders (MDs); violate their civic rights, self-image, and family life; and could be a cause for employment and housing discrimination. One of the explanations for the low percentage of persons suffering from MD who seek professional assistance is fear of stigmas and their negative consequences, and the fear of being the target of disparaging laughter (Arboleda-Florez, 2002; Brown & Bradely, 2002; Crisp, Gelder, Rix, Meltzer, & Ravlands, 2000; Hayward & Bright, 1997; Link et al., 1999; Miller & Major, 2000). The mass media are an important source of information about mental health and have an important role in cultivating perceptions and stigma (Wahl, 2004). Assuming that a negative framing of MDs in the media (Sieff, 2003) contributes to misperceptions and myths associated with and hostile attitudes toward the The authors thank Professor Itzhak Levav from the research unit, Mental Health Services of the Israeli Ministry of Health, for his enthusiastic support and important psychiatric insights; and to Dr. Peter Lemish for his excellent editorial contributions. Thanks also to the Western Galilee Academic College for the financial support. Address correspondence to Dr. Anat Klin, Haifa University, P.O. Box 7430, Haifa 31074, Israel. E-mail: [email protected] 434 Downloaded by [University of North Texas] at 20:30 12 November 2014 Mental Disorders Stigma in the Media 435 mentally ill and their caregivers, then positive framing may well influence development of positive perceptions, reduce stigma, and contribute to a change in public attitudes. This is all the more important today given growing support for policies that integrate the mentally ill into the community. This policy shift involves changing the mental health care model from the institutionalization of individuals suffering from mental disorders to a community care approach, one that involves their integration into the community while using its health care system (World Health Organization [WHO], 2001). The success of such a process requires an enlightened public. This article analyzes studies of three broad areas common in media inquiry— production, representation, and audience reception (see McQuail, 2006) of MDs. All three areas focus on media involvement and their impact in fostering, perpetuating, or in reducing MDs stigma. Production studies focus on the nature of the influence exerted by governments, professional organizations, and business interests on those responsible for producing mental health related messages. Representation studies involve analysis of media messages themselves—analysis of the portrayals of MDs, the mentally ill, and those of their caregivers. Audience studies involve the analysis of perceptions, attitudes, and behavior of different media audiences in response to media messages about MDs and the mentally ill. The article concludes with suggestions for additional research that may advance our understanding of the roles the media play in regard to the mentally ill. Stigma and Mental Disorders Between 20–25% of the population of every country in the world suffer from an MD or a neuropsychiatric disorder during their lifetime (WHO, 2001). In countries where citizens are exposed to repeated traumatic stress (e.g., wars or terrorism), these security situations have additional impact and consequences for mental health. Often residents of such societies are forced to confront post-traumatic disorders many years after the traumatic incident (Neriya et al., 1998; U.S. Department of Health=Human Services, 2002). Even though conventional treatments of MDs are efficient and not expensive, only 20–35% of those afflicted seek professional assistance (Brown & Bradley, 2002; Wedding & Boyd, 1999). Prejudice and fear of stigma are among the principal factors for the fact that many people who suffer with MD do not seek or postpone seeking assistance (Jorm, 2000; Lipczynska, 2005; Philo & Secker, 1999). Thus, stigmatization harms attempts to reduce the suicide rate (Philo, 1996), because a direct connection has been proven to exist between depression and suicide (Beautrais, 2000; Wilkinson, 1994). The primary conclusions of these studies support the view that mental illness continues to be stigmatized and that large portions of communities hold highly prejudiced and hostile attitudes toward people with MDs (Bagley & King, 2005; Dahaf Survey, 1997). The common perception is that those afflicted with MDs (not just those who suffer from schizophrenia but also those with severe depression) are dangerous; developmentally disabled, of low intelligence, have communication disorders, or all of these; are dysfunctional; and do not contribute as workers as they lack desire or are lazy (Arboleda-Florez, 2002; Crisp et al., 2000). Even some psychiatrists hold negative attitudes of those afflicted with MDs—possibly even more negative than those held by the public at large (Chaplin, 2000; Sartorius, 2002). Labeling Downloaded by [University of North Texas] at 20:30 12 November 2014 436 A. Klin and D. Lemish attitudes of those who suffer from MDs also have been found also among some policymakers (Gureje & Alem, 2000; Sartorius, 1999). Labeling attitudes directed toward professionals causes persons who suffer from depression to feel embarrassed to seek their advice, primarily for fear that they will be perceived to be imbalanced or neurotic (Priest et al., 1996). In this regard, the public image of psychiatrists is less positive than that associated with other doctors as they often are considered to be cruel. In addition, images associated with psychotherapists, psychologists, and psychiatrists as being crazed, lacking in understanding of the patient, and involved in unethical sexual behavior are detrimental, especially in instilling trust in those in need of their assistance (Von Sydow & Reimer, 1998). There is limited evidence in the literature in regard to the source of stigma. Some claim that the tendency to label (stigmatization) is actually a survival strategy since it involves identifying and expelling scapegoats (Gilman, 1988, 1995; Haghighat, 2000; Shakespeare, 1994; Stangor & Crandall, 2000; Wedding & Boyd, 1999). Serving as a central source of information, the mass media not only reflect public attitudes and values in relation to disabilities and illnesses, but also take part in shaping them, both unintentionally by means of news coverage and entertainment shows, as well as intentionally, through advertising and information campaigns (Hafferty & Foster, 1994; Klin, 2001). Further, the media serve as socializing agents who influence both by cultivating the construction and perpetuation of perceptions (Gerbner, Gross, Morgan, Signorelli, & Shanahan, 2002) and learned behaviors (Bandura, 2002). Framing (Entman, 1993; Goffman, 1986), or the ways in which references to the mentally ill are constructed, organized, presented, and interpreted in the media, has a decisive impact on the way in which the public thinks about them (Sieff, 2003). Similarly, the frequency and prominence of the mentally ill in the media impacts attitudes toward them and the social agenda regarding mental health issues, as argued by advocates of the theory of agenda setting (Dearing & Rogers, 1996; McCombs, 1994, 1997). Methodological Note In order to complete a thorough review of the existing literature in the field, 325 articles and books published between 1985 and 2005 were collected from key databases (e.g., Sociological Abstracts, Medline, Psychinfo) by means of keyword searches (e.g., mental health, mental illness, psychiatric disorders, mental disorders, stigma, prejudice, media, television, newspaper, magazines, Internet, World Wide Web). This produced a research corpus that included empirical studies, theoretical essays, and reviews. News items, editorials, articles regarding eating disorders, and nonEnglish articles were excluded. Due to many replications of similar studies by the same authors, or other researchers who found similar results, we have chosen to highlight in this review about 100 items of the corpus as illustrations of the available literature. Production Studies of Messages of Mental Disorders Production studies examine processes through which reporters, editors, and producers of news and entertainment programs produce messages related to mental health Downloaded by [University of North Texas] at 20:30 12 November 2014 Mental Disorders Stigma in the Media 437 topics. Such studies might examine the sources of information provided producers, their personal attitudes, and their influence on the messages that they create (Glasgow University Media Group, 1976; Schudson, 1989) in relation to mental health subjects. This area of research is also interested in the nature of the influence exerted by governments, professional organizations, and business interests on those responsible for producing various media; how pharmaceutical companies influence magazine editors through paying for advertising; how journalists relate to their sources and decide on what counts as a good story; and how health groups use the web to distribute information. Very few production studies are present in the research corpus. For example, an isolated study found that print news editors’ attitudes toward persons with MD are more positive that those held by the public-at-large. This having been said, they too rejected employing them in media institutions (Greirson & Scot, 1995). This research did not examine, however, the influence on newspaper coverage of the journalists who hold such positive attitudes. Taking a broader view, production studies could assist us to understand if additional factors—such as pressures for profits resulting in sensationalized products—contribute to the distorted images and stereotypes of MDs presented in the mass media. Another study (Stuart, 2003) describes attempts to provide reporters with accurate background by assisting them in the preparation of positive accounts about MDs, but it did not take into account or examine other sources of information that could influence the coverage of MDs, or analyze how journalists relate to their sources, including health pressure groups, and how they decide on what counts as a good story. Another limited case study examined production values that lead the producers to determine the story plot of a popular soap opera (Henderson, 1996). Studies of Mental Disorder Representations Representation studies involve analysis of the content and form of media messages. Most of representation studies in the research corpus seek ideological biases or the discursive dominance of particular themes and constructions that result in what is perceived as being distorted coverage. Some studies are concerned with whether messages are likely to promote or damage health. For example, how a medical soap opera portrays the mentally ill and their health care providers, how murderers are depicted in the press, what messages about personal versus societal responsibility for health are conveyed in the advice columns of magazines, how the press portray mentally ill males in comparison with females, and which political analyses of the problems of health care systems receive more coverage. Representation studies demonstrate, on the one hand, that MDs most frequently are described in the broadcast media and films among all forms of disability; on the other hand, the amount of coverage devoted to them in print media is less than that of physical disabilities (Byrd & Elliot, 1998). And, generally, negative stereotyping of MD images is more frequent than those of physical disability (Seale, 2004, p. 109). Distortion of Images of the Mentally Ill. A primary claim made by many researchers who conducted content analysis studies is that the negative framing of MDs in different genres of the media contributes to perpetuation of the public’s negative attitudes toward those afflicted (Sieff, 2003). Downloaded by [University of North Texas] at 20:30 12 November 2014 438 A. Klin and D. Lemish Content analysis studies suggest that news reports often are sensationalized, including dramatic descriptions of violent attacks and murders committed intentionally by persons with MDs. For example, the criminal may be presented as suspected of psychosis, paranoia, depression, or schizophrenia (Hillert et al., 1999; Wahl, 2003a). News coverage focuses on description of legal cases that center on a violent sub group (Angermeyer & Schulze, 2001). Different from other MDs in which the print news media stress the motive, in the case of depression, in particular, they emphsasize the need to protect the afflicted from self-destruction (Rowe, Tilbury, Rapley, & O’Ferrall, 2003). Selective coverage by journalists of attacks by persons with schizophrenia reinforces the connection between violence and schizophrenia that labels the entire MD population as dangerous and unpredictable (Angermeyer & Matschinger, 1996; Philo, 1997; Wahl, 1995, 2004). Distorted descriptions of the connection of schizophrenics to violence were found even in drug advertisements in medical journals (McKay, 2000). Indeed, MD are among the causes for the rise in violence among children and youth (Colon-de-Marti & Marti-Calzamilia, 2000). The media do not make it clear to the public, however, that only a minority of those afflicted with MDs commit severe crimes and that the percentage of general violence associated with MD is low, indeed not above 14% (Angermeyer & Schulze, 2001; Arboleda-Florez, 1998; Monaham, 1997). Stereotypes and labeling of these disorders even in children’s films and television programs, especially in animated caricatures, point to the trend toward stigmatization (Lawson & Fouts, 2004; Wahl, 2003b; Wilson, Nairn, Coverdale, & Panapa, 2000). Very common in television dramas or films are depictions of persons afflicted with MD as violent and unpredictable, as victims, or as incapable of holding down a job (Bryne, 1998; Diefenbach, 1997; Hillert et al., 1999; Hyler, Gabbard, & Schneider, 1991; Kerson, Kerson, & Kerson, 2000; Signorielli, 1989; Wilson et al., 1999). What is prominent in television programs is not only the connection of violence with people afflicted with MDs, but also the tendency to place responsibility for scandals and tragedies associated with them on the policy that supports deinstitutionalization and community-based services (Rose, 1998). Gender Bias. Another type of mass media distortion of MDs is evident in the sexist stance applied to them. Content analysis of women’s magazines points to portrayals that lessened the severity of women’s mental problems, in comparison with those of others, especially their partners, and of ignoring solutions that will heal them. Prominent is the focus on ‘‘stress’’ and fear of open spaces (agoraphobia) as female mental disabilities, while ignoring more severe MDs such as schizophrenia and bipolar disorder (Beal & Gardner, 2000). Men were over-represented as having mental illness and as exemplars of health problems in popular magazines and in discussions about psychoses, personality disorders, and childhood problems. In contrast, women were over-represented with problems and models of sexual dysfunction, neuroses, and so on (Doherty & Young, 1978). Gender bias, too was found in direct-to-consumer advertising of antidepressants that frames depression as a female condition. In doing so, it perpetuates the stereotype of females as biologically depressive (Grow, Park, & Han, 2006). Discrimination of women is apparent, too, in the higher proportion of male experts portrayed in the mass media as involved in the mental health field than is Mental Disorders Stigma in the Media 439 Downloaded by [University of North Texas] at 20:30 12 November 2014 the case in reality. Women in the field—in contrast to men—are described as their failures as women: in lacking femininity and professional power (Von Sydow & Reimer, 1998). Gender bias even was found in advertisements for psychotropic medications in medical journals. Here, in the majority of cases, a male psychiatrist is portrayed as he actively observes a passive female client, even though many psychiatrists are women (Metzl, 2004). Distortion of Images of Professionals and Health Care Services. Films not only stigmatize MDs, but also male psychiatrists. They are portrayed as crazed (Walter, 1989), weird jesters, evildoers, sexually depraved, lustful, oppressive, and vindictive. In comparison, female psychiatrists are portrayed as persons deprived of love and satisfaction (Gabbard & Gabbard, 1992). Psychotherapists are presented in films and other media as people who abuse their power and violate the privacy of others (Von Sydow & Reimer, 1998). Researchers point, too, to the contribution of psychotropic drugs advertisements to the distorted images of the psychiatrists by emphasizing the psychiatrists’ power over patients’ subservient status and their control of patients by means of these drugs (Metzl, 2004). In addition, Berlin (1991) found that television news focuses solely on failures of psychiatric rehabilitation. Distortion of the Causes of Mental Disorders and Their Treatments. Biases in descriptions of causes of MDs and their treatment also have been documented. Conrad (2001) found that in coverage of the discovery of the genes associated with schizophrenia and manic depression there was a marked tendency to genetic determinism and overoptimism in regard to the genetic causes of MDs and their cure. He claimed that such descriptions could foster a public perception of genetic research as involved in a moral problem because of its comparison with eugenics. Prozac—the most famous antidepressant drug of the class (SSRIs—selective serotonin reuptake inhibitors) is another such example of distortion. This class of antidepressants has become a model of cosmetic psychopharmacology, due in part to the cultivating power of the mass media (Montagne, 2001). The press proclaimed Prozac to be a miracle drug for treating depression, despite the fact that the SSRI class of drugs has not proven to be much more effective in alleviating the symptoms of depression than the preceding generation of drugs (Montagne, p. 1268). Such coverage is problematic as it can cultivate unjustified expectations and hopes among those afflicted. The rise in sales of Prozac may be considered to be evidence of the enormous impact of the mass media in fostering perceptions regarding the influence, advantages, and safety of antidepressant medicines. The pharmaceutical industry used a marketing strategy that exploited the cultural image of the scientist who discovers biological causes of disease and scientific ways of healing (Sayce, 2000). An additional distortion was found in descriptions of post-partum depression and related mood disturbances. This distortion adopts the biomedical model of emotional disorders following childbirth and fails to provide accurate information regarding psychological aspects of this period. Further, there is contradictory information regarding the phenomenon’s definition and its frequency, onset, duration, causes, symptoms, and treatment (Martinez, Johnston-Robledo, Ulsh, & Chrisler, 2000). Similarly, direct-to-consumer advertising of antidepressants frames depression narrowly within a biomedical model of causation and privileges benefits over risks (Grow et al., 2006). 440 A. Klin and D. Lemish Studies of the Impact of Messages on Mental Disorders on Audiences Downloaded by [University of North Texas] at 20:30 12 November 2014 The studies that examined audience responses to depictions of MDs can be divided into two groups: studies that look for unintentional media influences, and those that look for intentional influences, following interventional antistigma media campaigns. The unintentional effects of the media can be divided into those that effect the public and those that effect policymakers; studies following unintentional effects on the public trace negative effects, while studies of intentional effects focus on antistigma interventions. Unintentional Media Influences. Most studies that report on misperceptions and negative attitudes of those afflicted with MD do not provide data about the sources of such perceptions (Crisp et al., 2000; Jorm, 2000). Overall, one of the primary sources is relatives or friends of the afflicted; however, the mass media and principally television may well have a decisive role in providing information to the public-at-large (Jorm, 2000; Sayce, 2000; Wahl, 2004). Although the images of MDs in the mass media are not synonymous with public attitudes, the idea of moral contamination—that arises from the mass media—is prominent in findings of public opinion studies (Sayce, 2000), and it is more widespread among the young than among adults (Bolton, 2000). Media images are considered to be primary contributors to all mental illness stigmas, to negative attitudes toward people with MDs, and to the perception that such persons are dangerous and should be kept at a distance from the community by means of hospitalization (Glasson, 1996; Wahl, 1999). In particular, stereotypes add to, reinforce, and foster beliefs and prejudices as well as perpetuate the image of the schizophrenic as a violent person (McKay, 2000). Selective coverage by journalists of attacks by persons with schizophrenia reinforces the connection between violence and schizophrenia that labels the entire MD population as dangerous and unpredictable, leads to negative attitudes, and distances the public from them (Angermeyer & Matschinger, 1996; Philo, 1997; Wahl, 2004; Wahl & Lefkowits, 1989). The focus on legal cases in news coverage and descriptions that center on a violent subgroup do influence public attitudes toward the mentally ill and undermine attempts of mental health advocates to deny the connection between MDs and violence in their attempts to reduce the stigma associated with these diseases (Angermeyer & Schulze, 2001). In addition, depictions of persons afflicted with MDs in television dramas or films as violent and unpredictable, as victims, or as incapable of holding down a job contribute to negative stereotypes (Byrne, 1998; Diefenbach, 1997; Hillert et al., 1999; Hyler et al., 1991; Kerson et al., 2000; Signorielli, 1989; Wilson et al., 1999). Mass media also were found to be among the primary contributors to both knowledge about, as well as the negative attitudes of medical students toward the use of electric shock treatment for persons with MDs and its perception as being cruel and painful, as a cause of brain damage, and its use solely as punishment for persons with MD who are violent or uncooperative (Andrade & Rao, 1996). Rose (1998), who reported a study of U.K. television’s treatment of MD and community care, argued that the fear of and hostility toward mentally ill people fueled by media imagery has a significant effect on policies of community care. Mental Disorders Stigma in the Media 441 Downloaded by [University of North Texas] at 20:30 12 November 2014 Although many studies have examined the public’s perceptions of mental illness and related stigmas, in fact, only a minority of the studies reviewed were oriented to the study of the influence of the mental health message in the mass media on public perceptions. Unusual, then, is the empirical study conducted by the Glasgow group who examined the perceptions and attitudes toward persons with MD in response to exposure to different genres in different mass media (Philo, 1999). The study found that not only news stories in newspapers and magazines, but also fictional stories in genres such as soap operas, films, and dramas, clearly have a very strong influence on the beliefs and attitudes of viewers and readers toward the mentally ill. The majority connected MDs to violence, expressed fear of those afflicted, and cited the mass media as the source of their beliefs. Intentional Media Influences. Just as the mass media perpetuate stereotypes of MD, they also are capable of promoting mental health and contributing to the social struggle against mental illness stigma. This can be accomplished through promoting information campaigns, by exposing and opposing cases of prejudices, and by initiating public discussion (Salter & Byrne, 2000). Attempts to provide reporters with accurate background by assisting them in the preparation of positive accounts about MDs have met with limited success along with the rise in the number of positive stories about MDs and increase in their length, however, there was also a rise in the number and length of negative stories, especially in regard to schizophrenia (Heater, 2003). Similarly, the long-term influences of such interventions are not clear, since only the immediate influences were examined during an intervention that took place over a 16-month period. Having extensive knowledge regarding MDs does not necessarily lead to greater openness to those afflicted with these disorders (Link et al., 1999). Further, even if there is success in changing attitudes toward persons afflicted with MDs, as well as in changing laws and policies, it is impossible to assume that this will necessarily result in a change in behavior toward them. Repper and colleagues (1997) claimed that the most effective education of the public involves integration of educational messages with approaches that bring the afflicted with MD in contact with the community and their acceptance by it. Thus, for example, while a documentary film did lead to a decrease in viewers’ perception of schizophrenics as guilty for their disease, it did not change their perception regarding their inherent risk or their willingness to be in contact with them (Penn, Chamberline, & Mueser, 2003). The involvement of celebrities who actually had experienced MD—in campaigns against stigmas and discrimination—raised interest in and awareness of those afflicted and improved the publics’ attitudes toward them when accompanied by community education campaigns (Vaughan & Hansen, 2004). While information campaigns did produce limited influence, they also led to decreased fear of persons with MDs and increased willingness to engage in social contact with them (Wolff et al., 1999). Another study found that an information campaign with high school pupils led to increased readiness to seek professional assistance (Battaglia, Coverdale, & Bushony, 1990; Esters, Cooker, & Ittenbach, 1998). The print media was found to be effective in reducing mental illness stigma and in promoting the acceptance of the mentally ill in the community (Hickling, 1992). Radio broadcasts were found to be the most efficient and inexpensive way to transmit messages about mental health to large population groups, while the print media were efficient but more expensive (Austin & Husted, 1998). Some Downloaded by [University of North Texas] at 20:30 12 November 2014 442 A. Klin and D. Lemish scholars argue that information campaigns are not effective among minorities or educated population (Jorm, 2000) groups and therefore intervention should focus on specific target groups, such as high school pupils and clinical workers (Corrigan & Penn, 1999). Some claim that in order for a campaign related to MDs to have an effect, it is not sufficient to present facts; rather, initiatives that arouse strong feelings or humor should be integrated in order to prevent boredom and to provide a compelling counter response to fear of a ‘‘crazed murderer’’ or to humor aimed at ‘‘crazy persons’’ (Wahl, 1995). This having been said, we need to acknowledge that some studies have found that there is a connection between active psychosis and an increase in risk of violence. Thus, we cannot claim that those afflicted with MDs are not more violent than anyone else. Accordingly, a more promising approach to earning the public’s trust is transmission of a clear message that those afflicted with MDs are only responsible for a small percentage of violent crimes (Sayce, 2000). While many studies have examined public perceptions of MD and prejudices associated with them, very few have studied the perceptions of those assisted by mental health services. Unusual, then, is the recent study by Bagley and King (2005) that found that only a minority among those who use these services seek actively to oppose these stigmas. This suggests that the effects of campaigns against stigmas need to be examined among the mentally ill as well. The expanding use of new media in the medical profession has lead to an interest in their potential role in attitude change regarding MDs as well. A review analyzing 63 studies concerning telepsychiatry examined, among others, ethical and legal themes and patients’ and caregivers’ satisfaction with the new communication technologies. The researchers claimed that only few of these studies can be considered methodologically reliable (Monnier, Knapp, & Frueh, 2003), for example, a study that focused on the impact of new media such as the videophone or the telemedicine system on the relationship between physician and patients with anxiety and depression as well as on the therapeutic potential of this technology. It found that this technology was rejected and resisted in a determined way by the psychiatrists because of the limited interaction with patients involved (May et al., 2001). Another study examined the role of virtual reality for treating people with specific phobias, pointing to its therapeutic potential (Davidson & Smith, 2003). In addition, two dissertations dealt with on-line mental health services: Efern-Fernnando (2003) stressed that Internet service insures confidentially in providing on-line information about mental illness services, while Slavich (2004) discussed the potential advantages of counseling and treatment services on the websites. While both studies indicate the potential advantages of the new media for persons who express fear of stigma, they too did not examine their impact on reducing mental illness stigmas. An initial effort in this area is a review that examined four Internet sites developed especially to support patients who suffer from stigmas and to provide information to their relatives as well as to educate the public regarding MDs (Lipczynska, 2005). The review examined their quality in relation to the assistance provided to the afflicted; the information on their rights and on the policies influence them; the presence or absence of online support; and the presence or absence of campaigns demolishing popular myths about mental illness. The review concluded that although all of the sites provide answers for the people involved with sufferers—from their friends and relatives to employers—only two combine online support with an awareness of public policy and the rights of individuals. Mental Disorders Stigma in the Media 443 Downloaded by [University of North Texas] at 20:30 12 November 2014 One prominent deficiency of many audience studies is that they rely on college students as their research subjects, as is often the case, and, as a result, it is not possible to generalize about the entire population. Furthermore, very few studies of persons afflicted with MDs have attempted to understand how they themselves perceive their images in the mass media. Such studies have great importance since more than 40% of the schizophrenics in one study reported that they had been harmed frequently by such messages (Dickerson, Sommerville, Origoni, Ringel, & Parente, 2002). An additional methodological disadvantage is that the few studies that examined the influences on people exposed to media messages did not document their attitudes prior to the exposure. Similarly, most studies are of only one medium and focused solely on its contents, types of coverage, or its short-term influence. Summary and Future Research Directions Although the public perception in relation to what is thought to be an MD has changed over time and now also includes depression and anxiety (Phelan, Link, Stueve, & Pescosolido, 2000), most of the studies described above do not focus on a specific MD, such as schizophrenia, nor do they define what is considered to be an MD in media representations. Therefore, it is not possible to make comparisons between studies or to generalize from them. In addition, most of the studies described above focused on representations and images of MDs and those afflicted in the mass media. Content analyses of the messages revealed different sets of distortions: exaggerated, distorted, or inaccurate information in the presentation of MDs; descriptions of the mentally ill as violent and dangerous portrayals of the nature of MDs and their causes; as well as descriptions of mental health services and caregivers. These consistent findings support the claim that the images used by the mass media may be contributing to the perpetuation of stigmas of mental illness, the mentally ill, mental health services, and caregivers. One of the early representation studies that was conducted by Signorielli (1989) concluded that these images are ‘‘likely to contribute to . . . ignorance and neglect, . . . perpetuate unwarranted views about mental illness, . . . and frustrate efforts at health education and integration of those who recovered from mental illness’’ (1989, p. 330). Prominently absent is research that examined the representation of subjects relating to policies and preferences for budget allocations, coverage of policies regarding integration of the mentally ill into society, as well as studies that focus on coverage of new technologies including new drugs. Also absent are representation studies about the appearance of persons with MDs in commercials, an action that violates professional ethical codes that seek to prevent potential harm to persons with disabilities, including those with MDs (Elfent-Lafler, 2003). In comparison with the many representation studies that deal with images of MDs and those afflicted in the conventional mass media, there is an absence of studies that focus on MDs’ images in the ‘‘new’’ mass media and especially the Internet, as well as studies that focus on the impact of new mass media on perceptions and stigmas of mental illness and the mentally ill. This could be attributed to, among other things, methodological difficulties, including the need to develop new sampling and analyzing methods. Internet studies also pose the new challenge of the blurring of the boundary between sender and receiver, producer and audience. Downloaded by [University of North Texas] at 20:30 12 November 2014 444 A. Klin and D. Lemish Our literature search has found very few production studies in the research corpus. The relationships between mass media descriptions and public perceptions, although informed by studies about the mass media’s role in cultivating social perceptions in other fields, remains theoretical and speculative at this stage. This may well be the most important gap in the existing literature and is a result of the fact that very few studies were conducted on the influence of the mass media on the public’s perceptions, although many studies have examined the public’s perceptions of mental illness and related stigmas. Most insightful are studies that include an analysis of the process of image production, the messages contained in these images, and their effects on a variety of audiences. In doing so, they illustrate the assumed relationship between production to creation of misinformation and stigma or the relationships between production of media interventions and their effects on reducing stigma (Philo, 1996; Philo, 1999; Philo & Secker, 1999). Clearly, in order to maximize the use of mass media with the goal of reducing stigmatization, we should enrich our knowledge on the topic. To this end, it is important, initially, to define explicitly what is included in the term mental disorder. This will allow researchers to make relevant comparisons between different studies. Furthermore, systematic studies should be conducted on different media simultaneously, while examining the contents and framing of the subject of mental health and their long-term influence, even after a period in which there is a lack of exposure. The variety of genres of mass media, too, should be examined as well as the channels that have specific influence on particular audiences, under certain circumstances, such as children and adolescents or the mentally ill themselves. The importance of research on MDs lies in its potential contribution to understanding the mechanisms that create and reinforce mental illness stigmas as well as their contribution to their reduction. Reduction of stigmas will encourage the ill to request assistance that may ease their suffering, assist their integration into society, prevent harm to their self-image and family life, and prevent economic damage to health and employment systems. Similarly, a thorough and consistent discussion of mental health policy issues may influence decision makers in the allocation of appropriate resources. References Andrade, C., & Rao, N. S. (1996). Medical students toward electroconvulsive: An Indian perspective. Convulsive Therapy, 12(2), 86–90. Angermeyer, M. C., & Matschinger, H. (1996). The effect of violent attacks by schizophrenic persons on the attitude of the public towards the mentally Ill. Social Science and Medicine, 43(12), 1721–1728. Angermeyer, M. C., & Schulze, B. (2001). Reinforcing stereotypes: How the focus on forensic cases in news reporting may influence public attitudes towards the mentally ill. International Journal of Law and Psychiatry, 24(4–5), 469–486. Arboleda-Florez, J. (1998). Mental illness and violence: An epidemiological appraisal, of the evidence. Canadian Journal of Psychiatry, 43, 989–996. Arboleda-Florez, J. (2002). The state of the evidence. Stigmatization and human rights violations. Mental Health: A Call for Action. Austin, L. S., & Husted, K. (1998). Cost-effectiveness of television, radio and print media programs for public mental health education. Psychiatric Services, 49, 808–811. Downloaded by [University of North Texas] at 20:30 12 November 2014 Mental Disorders Stigma in the Media 445 Bagley, C., & King, M. (2005). Exploration of three stigma scales in 83 users of mental health services: Implications for campaigns to reduce stigma. Journal of Mental Health, 2005, 14(4), 343–355. Bandura, A. (2002). Social cognitive theory of mass communication. In J. Bryant & D. Zillmann (Eds.), Media effects (pp. 121–154). Mahwah, NJ: Lawrence Erlbaum Associates. Battaglia, J., Coverdale, J. H., & Bushong, C. P. (1990). Evaluation of mental illness awareness week program in public schools. American Journal of Psychiatry, 147, 324–329. Beal, B. A., & Gardner, C. B. (2000). Gendered advice and mental health practices. Perspectives on Social Problems, 12, 203–216. Beautrais, A. L. (2000). Risk factors for suicide and attempted suicide among young people. Australian and New Zealand Journal of Psychiatry, 34(3), 420–436. Berlin, F. S. (1991). Media distortion of the public’s perception of recidivism and psychiatric rehabilitation. The American Journal of Psychiatry, 148(11), 1572–1576. Bolton, J. (2000). Mental illness in the media: The 13th royal college Christmas lecture for young people. Psychiatric Bulletin, 24(9), 345–346. Brown, K., & Bradley, L. (2002). Reducing the stigma of mental illness. Journal of Mental Health Counseling, 24(1), 81–87. Byrd, E. K., & Elliot, T. R. (1988). Disability in full-length feature films: Frequency and quality of films over!! year span. International Journal of Rehabilitation Research, 11(2), 143–148. Byrne, P. (1998). Fall and rise of the movie ‘‘Psycho-killer.’’ Psychiatric Bulletin, 22(3), 174–176. Chaplin, R. (2000). Psychiatrists can cause stigma too. British Journal of Psychiatry, 177, 467–470. Colon-de-Marti, L. N., & Marti-Calzamilia, L. F. (2000). Youth violence: Understanding and prevention. Puerto Rico Health Sciences Journal, 19(4), 369–374. Conrad, P. (2001). Framing genes and mental illness in the news. Culture, Medicine and Psychiatry, 25(2), 225–247. Corrigan, P. W., & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54(9), 765–776. Crisp, A. H., Gelder, M. G., Rix, S., Meltzer, H. I., & Rowlands, O. J. (2000). Stigmatisation of people with mental illnesses. The British Journal of Psychiatry, 177, 4–7. Dahaf Survey. (1997). Is disability contagious? Findings of an opinion survey. (In Hebrew). Yafo: Dahaf Institute. Davidson, J., & Smith, M. (2003). Bio-phobias-techno-philias: Virtual reality exposure as treatment for phobias of ‘‘Nature’’. Sociology of Health & Illness, 25(6), 644–661. Dearing, W. J., & Rogers, E. M. (1996). Agenda-setting. Thousand Oaks, CA: Sage. Dickerson, F. B., Sommerville, J., Origoni, A. E., Ringel, N. B., & Parente, F. (2002). Experiences of stigma among outpatients with schizophrenia. Schizophrenia Bulletin, 28(1), 143–156. Diefenbach, D. L. (1997). The portrayal of mental illness on prime-time television. Journal of Community Psychology, 25(3), 289–302. Doherty, E., & Young, R. (1978). Mental health problems in popular magazines over the past fifty years. Society for the Study of Social Problems. Efern-Fernnando, H. (2003). The construction of e-mind health.com: A mental health website. Dissertation Abstracts—Section A: Humanities and Social Sciences, 64(5-A), 1612. Elfent-Lafler, N. (2003). The presentation of handicapped persons. Jerusalem: Strategy & Research, The Second Television & Radio Authority. Entman, R. M. (1993). Framing: Towards clarification of a fractured paradigm. Journal of Communication, 43(4), 54–58. Esters, L. G., Cooker, P. G., & Ittenbach, R. F. (1998). Effects of a unit of instruction in mental health on rural adolescents’ conceptions of mental illness and attitudes about seeking help. Adolescence, 33, 469–476. Downloaded by [University of North Texas] at 20:30 12 November 2014 446 A. Klin and D. Lemish Gabbard, G. O., & Gabbard, K. (1992). Cinematic stereotypes contributing to the stigmatization of psychiatrist. In P. J. Fink & A. Tasman (Eds.), Stigma and mental illness. Washington, DC: American Psychiatric Press. Gerbner, G., Gross, L., Morgan, M., Signorieli, N., & Shanahan, J. (2002). Growing up with television: Cultivation processes. In J. Bryant & D. Zillmann (Eds.), Media effects (pp. 43–68). Mahwah, NJ: Lawrence Erlbaum Associates. Gilman, S. (1988). Disease and representation. Ithaca & London: Cornell University Press. Gilman, S. (1995). Picturing health and illness. Baltimore & London: John Hopkins University Press. Glasgow University Media Group. (1976). More bad news. London: Routledge and Kegan Paul. Glasson, J. (1996). The public image of the mentally ill and community care. British Journal of Nursing, 5(10), 615–617. Goffman, E. (1986). Frame analysis: An essay on the organization of experience. Boston: Northeastern University Press. Greirson, D., & Scot, R. (1995). Comparison of attitudes of editors and public toward mental illness. Newspaper Research Journal, 16(1), 95–102. Grow, J. M., Park, J. S., & Han, X. (2006). ‘‘Your life is waiting!’’ Symbolic meanings in direct-to-consumer antidepressant advertising. Journal of Communication Inquiry, 30(2), 163–188. Gureje, O., & Alem, A. (2000). Mental health policy development in Africa. Bulletin of the WHO, 78(4), 475–482. Hafferty, F. W., & Foster, S. (1994). Decontextualizing disability in the crime mystery genre: The case of the invisible handicap. Disability & Society, 9(2), 185–206. Haghighat, R. (2000). A unitary theory of stigmatization. British Journal of Psychiatry, 177, 207–215. Hayward, P., & Bright, J. A. (1997). Stigma and mental illness: A review and critique. Journal of Mental Health, 6, 345–354. Henderson, L. (1996). Selling suffering: Mental illness and media values. In G. Philo (Ed.), Media and mental distress (pp. 18–36). Harlow: Addison Wesley and Longman. Hickling, F. W. (1992). Radio psychiatry and community mental health. Hospital and Community Psychiatry, 43, 739–741. Hillert, A., Sandmann, J., Ehming, S. C., et al. (1999). The general public’s cognitive and emotional perception of mental illnesses: An alternative to attitude-research. In J. Guimon, W. Fischer & N. Sartorius (Eds.), The image of madness: The public facing mental illness and psychiatric treatment (pp. 56–71). Basel: Karger. Hyler, S. F., Gabbard, G. O., & Schnieder, I. (1991). Homicidal maniacs and narcissistic parasites: Stigmatization of mentally ill persons in the movies. Hospital and Community Psychiatry, 42(10), 1044–1048. Jorm, A. F. (2000). Mental health literacy. British Medical Journal, 177, 396–401. Kerson, T. S., Kerson, J. F., & Kerson, L. A. (2000). She can have a seizure maybe; then we can watch: The portrayal of epilepsy in film. Social Work in Health Care, 30(3), 95–110. Klin, A. (2001). Crime and punishment? The AIDS narrative in the daily press in Israel, 1981–1995 as a cultural construction of a disease. Ph.D. dissertation. The Hebrew University of Jerusalem. Lawson, A., & Fouts, G. (2004). Mental illness in disney animated films. Canadian Journal of Psychiatry, 49(5), 310–314. Link, B. G., Phelan, J. C., Bresnahan, M., et al. (1999). Public conceptions of mental illness: Labels, causes, dangerousness and social distance. American Journal of Public Health, 89, 1328–1333. Lipczynska, S. (2005). Stigma web review. Journal of Mental Health, 14(4), 423–425. Downloaded by [University of North Texas] at 20:30 12 November 2014 Mental Disorders Stigma in the Media 447 Martinez, R., Johnston-Robledo, I., Ulsh, H. M., & Chrisler, J. C. (2000). Singing ‘‘The baby blues’’: A concept analysis of popular press about post-partum affective disturbances, Women Health, 31(2–3), 37–56. May, C., Gask, L., Atkinson, T., Ellis, N., Mair, F. & Esmail, A. (2001). Resisting and promoting new technologies in clinical practice: The case of tele-psychiatry. Social Science & Medicine, 52, 1889–1901. McCombs, M. (1997). Building consensus: The news media’s agenda-setting roles. Political Communication, 14, 422–443. McCombs, M. (1994). News influence on our pictures of the world. In Bryant, Jennings, Zillmann, Dolf (Eds.). Media effects (pp. 1–16). Mahwah, NJ: Lawernce Erlbaum Associates Publishers. McKay, D. (2000). Stigmatising pharmaceutical advertisements, British Journal of Psychiatry, 177, 467–468. McQuail, D. (2006). McQuail’s mass communication theory (5th ed.), London: Sage. Metzl, J. M. (2004). The pharmaceutical gaze. Psychiatry, scopophilia and psychotropic medication advertising, 1964–1984. In L. D. Friedman (Ed.), Cultural sutures. Medicine and media (pp. 15–35). Durkheim, NC: Duke University Press. Miller, C. T. & Major, B. (2000). Coping with stigma and prejudice. In T. F. Heatherton, R. E. Kleck, M. R. Hebl, & J. G. Hull, The social psychology of stigma, New York: The Guilford Press. Monaham, J. (1997). Clinical and atuarial predictions of violence, In D. Faugman, D. Kaye, M. Saks, & H. Sanders (Eds.), Modern scientific evidence: The law and science of expert testimony, Chicago: University of Chicago Press. Monnier, J., Knapp, R. G., & Frueh, B. C. (2003). Recent advances in telepsychiatry: An updated review. Psychiatric Services, 54(12), 1604–1609. Montagne, M. (2001). Mass media representations as drug information for patients: The Prozac phenomenon. Substance Use & Misuse, 36(9–10), 1261–1274. Neriya, I., Solomon, I., Ginzburg, K., Dekel, R., Anoch, D., & Uri, A. (1998). Wars and their mental cost: Different aspects of mental trauma among soldiers and civilians in Israeli society. Society & Welfare, 18(1), 125–139. (In Hebrew). Penn, D., Chamberline, C., & Mueser, K. (2003). Effects of documentary film about schizophrenia on psychiatric stigma. Schizophrenia Bulletin, 29(2), 383–391. Phelan, J. C., Link, B. G., Stueve, A., & Pescosolido, B. A. (2000). Public conceptions of mental illness in 1950 and 1996: What is mental illness and is it to be feared? Journal of Health and Social Behavior, 41, 188–207. Philo, G. (Ed.). (1996). Media and mental distress. London & New York: Longman. Philo, G. (Ed.). (1997). Changing media representations of mental health. Psychiatric Bulletin, 21, 171–172. Philo, G. (Ed.). (1999). Media and mental illness. In G. Philo (Ed.), Message received: Glasgow media group research 1993–1998 (pp. 54–61). Harlo: Addison Wesley Longman. Philo, G., & Secker, J. (1999). Media and mental health. In B. Franklin, (Ed.), Social policy, the media and misrepresentation (pp. 135–145). London: Routledge. Priest, R. G., Vize, C., Roberts, A., et al. (1996). Lay people’s attitudes to treatment of depression: Results of opinion poll for defeat depression Campaign just before its launch. British Medical Journal, 313, 858–859. Repper, J., Sayce, L., Strong, S., Willmot, J., & Haines, M. (1997). Tall Stories from back yard. A survey of Nimby opposition to community mental health facilities experienced by key service providers in England and Wales. London: Mind. Rose, D. (1998). Television, madness and community care. Journal of Community & Applied Social Psychology, 8(3), 213–228. Rowe, R., Tilbury, F., Rapley, M., & O’Ferrall, I. (2003). ‘‘About a year before the breakdown I was having symptoms’’: Sadness, pathology and the Australian newspaper media. Sociology of Health & Illness, 25(6), 680–696. Downloaded by [University of North Texas] at 20:30 12 November 2014 448 A. Klin and D. Lemish Salter, M., & Byrne, P. (2000). The stigma of mental illness: How you can use the media to reduce it. Psychiatric Bulletin, 24, 281–283. Sartorius, N. (1999). One of the last obstacles to better mental health care: The stigma of mental illness. In J. Guimon, N. Fischer, & N. Sartorious (Eds.), The image of madness. Basel: Karger. Sartorius, N. (2002). Iatrogenic stigma of mental illness begins with behavior and attitudes of medical professionals, especially psychiatrists. British Medical Journal, 324, 1470–1471. Sayce, L. (2000). From psychiatric patient to citizen. London: Macmillan Press. Schudson, M. (1989). The sociology of news production. Media, Culture and Society, 11(3), 263–282. Seale, C. (2004). Villains and freaks. In C. Seale (Ed.), Media & health (pp. 102–109). London: Sage Publications. Shakespeare, T. (1994). Cultural representations of disabled people: Dustbins for disavowal. Disability and Society, 9(3), 2813–2831. Sieff, E. M. (2003). Media frames of mental illnesses: The potential impact of negative frames. Journal of Mental Health, 12(3), 259–269. Signorielli, N. (1989). The stigma of mental illness on television. Journal of Broadcasting and Electronic Media, 3, 325–331. Slavich, S. (2004). The status of online mental health services. Dissertation Abstracts—International: Section B: The Sciences and Engineering, 64(7-B), 3542. Stangor, C., & Crandall, C. S. (2000). Threat and the social construction of stigma. In T. F. Heatherton, R. E. Kleck, R. Michelle, & J. G. Hull (Eds.), The social psychology of stigma (pp. 62–87). New York: The Guilford Press. Stuart, H. (2003). Stigma and the daily news: Evaluation of a newspaper intervention. Canadian Journal of Psychiatry, 48(10), 651–656. U.S. Dept of Health & Human Services. (2002). The Surgeon General Report on mental health. (chap. 5). Washington, DC. Vaughan, G. H., & Hansen, C. (2004). ‘Like minds, like mine’: A New Zealand project to counter the stigma and discrimination associated with mental illness. Australian Psychiatry, 12(2), 113–117. Von Sydow, K., & Reimer, C. (1998). Attitudes toward psychotherapists, psychologists, psychiatrists and psychoanalysts: A meta-content analysis of 60 studies published between 1948 and 1995. American Journal of Psychotherapy, 52(4), 463–488. Wahl, O. F. (1995). Media madness. Public images of mental illness. NJ: Rutgers University Press. Wahl, O. F. (1999). Mental health consumers’ experience of stigma. Schizophrenia Bulletin, 25(3), 467–478. Wahl, O. F. (2003a). News media portrayal of mental illness. American Behaviorist, 46(12), 1594–1600. Wahl, O. F. (2003b). Depictions of mental illnesses in children’s media. Journal of Mental Health, 12(3), 249–258. Wahl, O. F. (2004). Stop the presses. Journalistic treatment of mental illness. In L. D. Friedman (Ed.), Cultural sutures. Medicine and media (pp. 55–69). Durkheim, NC: Duke University Press. Wahl, O. F., & Lefkowits, J. (1989). Impact of a television film on attitudes towards mental illness. American Journal of Community Psychology, 17(4), 521–528. Walter, G. (1989). The stereotype of the mad psychiatrist. The Australian and New Zealand Journal of Psychiatry, 23(4), 547–554. Wedding, D., & Boyd, M. A. (1999). Movies and mental illness using films to understand psychopathology. Boston: McGraw-Hill . Wilkinson, G. (1994). Can suicide be prevented? British Medical Journal, 309, 860–869. Mental Disorders Stigma in the Media 449 Downloaded by [University of North Texas] at 20:30 12 November 2014 Wilson, C., Nairn, R., Coverdale, J., et al. (1999). Mental illness depictions in prime-time drama: Identifying the discursive resources. Australian and New Zealand Journal of Psychiatry, 33, 232–239. Wilson, C., Nairn, R., Coverdale, J., & Panapa, A. (2000). How mental illness is portrayed in children’s television: A prospective study. British Journal of Psychiatry, 176, 440–443. Wolff, G., Pathare, S., Craig, T., et al. (1999). Public education for community care: A new approach. In J. Guimon, W. Fischer, & N. Sartorius (Eds.), The image of madness: The public facing mental illness and psychiatric treatment (pp. 56–71). Basel: Karger. World Health Organization (WHO). (2001). Outline of the World Health Report (chap. 2). Geneva, Switzerland: Author.