Psychiatrists are reluctant to engage with the media. There is little understanding of why this is the case.
—Beth Chapman, psychiatrist (Ref. 1, p 464)
The degree to which society has allowed itself to accept misinformation as a norm has reached a critical point.
—Adam Chiara, Professor of Communication2
If you don't like what is being said, then change the conversation.
—Character Don Draper, Madmen, Television Drama3
It has been argued convincingly that the public's primary source of information about mental illness is the media: news, entertainment, and the echo chamber of social media.1,4,–,10 These depictions cue, frame, and otherwise guide our interpretive frameworks in both obvious and subtle ways. Visual media may be especially compelling and impactful in guiding social awareness, implicit beliefs, and change.11
If only by their relative ubiquity in the media, mental health and illness seem fascinating, confusing, and beguiling to the masses. These concepts are complicated (the latest iteration of our psychiatric nosology, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, runs over 900 pages) and complex because they are sensitive to and dependent on myriad individual and social conditions. It is no surprise that mental health concerns should have these qualities, given that the beliefs and values that emerge from the contested boundaries of what is deemed normal versus pathological are a defining feature of who we are. It is concerning, then, that media representations of mental illness consistently skew negative, overemphasizing unpredictability, violence (to self and others), and criminality.12,–,14
McGinty et al 14 took a random sample of 400 news stories involving mental illness across two decades, from 1995 to 2014. The most consistent theme across the period was violence (55%), and although 47 percent of the stories mentioned some type of treatment, only 14 percent spoke of successful treatment or recovery. The emphasis on interpersonal violence was deemed “highly disproportionate” to actual rates of violence among those with mental illness. This was even more pronounced than an earlier cross-sectional review, which found that 37 percent of stories focused on dangerousness and violence.15
Another study suggests that when the perpetrators of mass violence incidents are white men, they are disproportionately framed as mentally ill, “while Black and Latino men are treated as perpetually violent threats to the public” (Ref. 15, pp 766–7). Evoking mental illness when the perpetrator of violence is white is seen as a competing externalizing factor, which may mitigate societal views of culpability.16 These stigmatizing negative associations and attribution errors may serve interested third-party ends17 and have also been shown to influence resource allocation and policy response.18,19
Stigmatization occurs when persons living with mental illness are reduced to or primarily viewed through the lens of their being different, less desirable, and feared (e.g., unpredictable, dangerous). This may be the sharpest of thorny concerns involved in the sociocultural positioning of mental illness in media depictions, whether fictional or documentary. Yet another thorny concern, less discussed but increasingly relevant, is the conflicting interests of media ratings (or success) versus the desire to get the story right.
Fiction and Fact Geared to Ratings
As fundamentally commercial enterprises, fictional media prioritize populist appeal over verisimilitude. While popular television shows have been analyzed for prevailing tropes in medicine and their treatment of doctors,20 quantifiable elements highlight how they may, quite understandably, prioritize sensationalism over accuracy and honesty. Diem et al.21 looked at the outcome of cardiopulmonary resuscitation (CPR) in three medical programs between 1994 and 1995. They found that while the literature reported that CPR was effective for short-term survival about 40 percent of the time, television nearly doubled that figure to 77 percent. The long-term survival rates were more discordant, with 30 percent expected versus 67 percent when portrayed on television. One study found that 92 percent of patients over the age of 62 reported obtaining information about CPR from television.22 It is not surprising that patients often overestimate their chances of survival from CPR when they gather information about it from television.
Given the longer story arcs of movies and serialized television, new and competing perspectives have the potential to be explored and to provide nuances that are often overlooked in print media. Television series, however, due to limited resources, timelines, and competing interests, tend to depict mental illness on an individual level rather than include overarching systemic concerns or collective/institutional solutions. Even if commercial and artistic pressures are prioritized over verisimilitude, however, they may still be useful in initiating the conversation, such as advancing understandings of phenomenology, shared history, and social context in psychiatry.23
Outdated stereotypes and inaccurate beliefs are legion. A small sample of particularly rankling ones include the following:
Trauma triggers acute, new-onset psychosis;
Ridiculous (albeit entertaining) characters like Hannibal Lecter are found in psychiatric hospitals;
Whiplash fluctuations in mood are symptomatic of bipolar disorder;
While surgery is reliably depicted as a life-saving and often heroic intervention, electroconvulsive “shock” therapy is barbaric;
Locked inpatient wards are staffed by automaton-like orderlies who behave like heartless henchmen;
A court-accepted “insanity plea” means you “got away with it.”
One could not help but consider in some cases that the trend to report or mirror through fictional portrayal life's vicissitudes involving persons with mental illness is driven by sensationalism and a financial imperative for ratings and circulation.
Psychiatry Reluctant to Engage with Media
Just as we assume that the majority of psychiatrists are proponents of raising the quality of information produced about mental illness, including challenging public perceptions involving misinformation (explicit and implicit), we also assume that those who produce and write for fiction and nonfiction media have a desire for accuracy and a willingness to consult psychiatrists and other experts on medical, sociocultural, and political events that involve mental health and illness.
It has been observed, however, that psychiatrists have generally been reluctant to engage with the media.1,13,24 A British national news journalist stated, “I cannot name an expert in psychiatry or mental health research off the top of my head, but I could give you a long list of experts on stem cells or cardiology” (Ref. 13, p 83.) This sentiment is not uncommon, and it leaves journalists unsupported in understanding the involvement of mental illness in a story, as well as seeking out and interpreting research that may be relevant.
One study in the south of England found that only about 30 percent of mental health professionals (mostly psychiatrists) had had any contact with the media, and that about 13 percent had any media training.1 Interestingly, psychiatrists and media-content producers who had contact with each other felt more comfortable with the other group and experienced significantly less mistrust.1 Close collaboration between mental health experts and the entertainment industry has been shown to reduce negativity and stigma.9,25,26
Some topics in mental health care are sufficiently complex that a balanced narrative would demand lengthier, more complex, and perhaps less-compellingstorylines. A current, poignant example is the use of seclusion in correctional institutions. Although the use of seclusion rooms has been recognized as being detrimental to individuals with mental health concerns and inmates in general, a nonnegligible portion of this population remains in seclusion for lengthy periods because they have requested to be there or adamantly refuse to leave. A fictional depiction of this, with psychiatrist consultation, may shed a compassionate light on such institutional decisions, although it would be less evocative and compelling than the workings of heartless henchmen in an unjust system.
While other medical disciplines rely on technologies and tools that are not well understood to the public, and may in themselves connote expertise and allow for objective clarity, psychiatry is often represented by the increasingly rare psychoanalytic couch. If your electrocardiogram reading indicates a serious heart block, a pacemaker may be required. If a physical exam indicates that your liver is enlarged, a battery of testing will be pursued to figure out the cause. In mental health, however, the narrative is complex, language-based, and requires negotiation at all times. Simple prescriptive measures are hard to come by. Some words (e.g., depression, trauma, mania) have circumscribed clinical meanings to psychiatrists but are used by the public and media in markedly different ways, furthering confusion and semantic slippage.
Popular media can reach large audiences through television and movies, and collaborative involvement would ideally promote accuracy, honesty, and broader awareness in portrayals of the lives of those with mental illness. Perhaps the accuracy that engenders a more resonant and enduring impact on the audience will outweigh the loss of shock-factor sensationalism.
Barriers to Collaboration with Media
If collaboration between mental health professionals and the media appears beneficial, why are psychiatrist consultants so hard to come by? What is our duty to inform the wider public about what mental illness is, and what it is not? After all, the term “doctor” derives from the Latin word docere, meaning “to teach.” We argue that a mandated duty to society includes a circumscribed media collaboration.
There are many reasons for the hesitation that psychiatrists have with regard to engaging with media,27 but we are of the opinion that perhaps the most salient for psychiatrists in general, and forensic psychiatrists in particular, is that they are highly sensitized to running afoul of ethics principles and having their professionalism impugned. Although ethics guidelines are relatively clear about physicians' duties to patients (e.g., confidentiality, consent), and to themselves and the craft (e.g., professionalism, ethics, objectivity), they have a cautioning, if not downright ominous, nature regarding deviations from clinical practice pursuits. For example, the American Psychiatric Association ethics guidelines state that “a psychiatrist who regularly practices outside his or her area of professional competence should be considered unethical” (Ref. 28, Sec. 2.3).
For forensic psychiatrists, there are added considerations regarding ethical behavior toward an evaluee, where clinicians become third-party assessors not bound by the customs of a doctor–patient relationship, and toward third parties (e.g., courts, lawyers, insurance companies, professional bodies), where the clinician-experts are called upon to provide objective and nonpartisan opinion, bringing their knowledge of science and best practices to bear in addition to their clinical acumen.
As expert witnesses, it is a sacrosanct rule that we should function within the areas of our competence, speak carefully and circumspectly about what we know, and avoid comment on areas on which we are not fully briefed or studied. Speaking incorrectly or out of turn can be embarrassing and can harm the perception of our credibility.
Given their expertise in psychopathy, sadism, terrorism, severe personality disorders, violence, etc., forensic psychiatrists are uniquely sought on matters in the criminal justice system or by others who require independent mental health assessments. They are also sought in cases involving notoriety (high-profile or otherwise spotlighted media figures, celebrities, and politicians). So how best to proceed?
Toward a Circumscribed Collaboration
We argue that there is a clear mandate from several psychiatric professional bodies to thoughtfully engage and collaborate with those media that have a legitimate interest in public health. In 2009, the World Psychiatric Association set up a task force to suggest ways of reducing stigma associated with the psychiatric profession. One suggestion was the need to improve media collaboration.29 The American Medical Association's updated code of ethics states that physician mandates include “ensuring that the public is informed promptly and accurately about medical issues is a valuable objective” (Ref. 30, Chap. 3.1.5). The American Psychiatric Association mandates that “a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health” (Ref. 28, Sec. 7) and it is later clarified that “psychiatrists should foster the cooperation of those legitimately concerned with the medical, psychological, social, and legal aspects of mental health and illness” (Ref. 28, Sec. 7.1).
A vigorous academic and public debate is being held over the right for physicians to comment on the mental health of nonpatients in unique circumstances.31,–,35 Section 7.3, informally called the Goldwater Rule, states:
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement [Ref. 28, Sec. 7.3].
In other words, absent a sanctioned and trained capacity for diagnostic and prognostic acumen, citizens are free to comment on the mental health of their neighbor (or, say, a prominent politician), yet psychiatrists are ethics-bound to remain silent precisely because of these capacities, despite potential perceived risks to society for doing so. The American Psychiatric Association has further clarified their position and re-emphasized their commitment to this principle.36
Ethics guidelines are social documents, and thus they evolve. Academic challenges to such documents should be encouraged, and ignoring them may be an embarrassment to the individual and the profession. As a general rule, when interacting with the media, psychiatrists should always explicitly state when they have not conducted a personal examination, and they should endeavor to discuss areas of psychiatry in general rather than commenting with clinical precision on the specific person in the spotlight, for better or worse.
Achieving Collaboration
It would appear, then, that in regard to psychiatrists who have eschewed engagement with the media, it is to the detriment of both. While a spotlight has been pointed at the collaboration with media regarding nonfiction domains, it has not been directed at such collaborations in fictional storytelling.
Few outside of our discipline understand what we do, and fictional media depictions reflect that communication challenge. There has been no seminal television series or movie franchise that has done for psychiatry what “ER” did for emergency medicine. But when it inevitably arrives, what are the considerations for the consultant psychiatrist collaborator?
There is scant attention in the academic literature to describing the dynamics between mental health consultants and those involved in producing, writing, and filming television or fictional movies. Important considerations would include the power differentials during negotiations in the initial writing and editing of scripts, filming decisions, and postproduction editing. These negotiations may involve attention to labeling, background entertainment elements, medicalization, treatment, and recovery.
Having a mental health professional sign off on script or video legitimizes, to some degree, the efforts that the producers and others may have taken in striving for accuracy, and to some extent it may immunize them against accusations to the contrary.
One of the authors of this editorial (S.C.) was a consultant for the Canadian Broadcast Corporation television series “Cracked.”37 The serial drama was centered on the “Psych Crimes Unit” of an urban police force tasked with “solving crimes and resolving crises.” The lead characters were a detective, who had symptoms of posttraumatic stress disorder, and a forensic psychiatrist. The television writers and producers worked diligently to uphold their stated primary concern for the accurate and honest portrayal of mental illness. As the first season ended in what may be the standard internecine chaos of large productions, however, writers and producers changed, and along with their departure came some erosion of this devotion. S.C. came to suspect that the world of media production so familiar to its denizens is as baffling to psychiatric consultants as systems of mental health care provision are to those writing and producing medical dramas involving mental illness. Good work requires close collaboration, yet what are the professional considerations for such a psychiatrist consultant?
For forensic psychiatrists who provide expert testimony, just as their curriculum vitae and published academic work may be examined closely by the court, also fair game for scrutiny are television interviews, personal web pages, and media productions with which they have been associated as consultants. The psychiatrist's awareness of this potential added scrutiny may encourage distinguishing personal from professional opinion and may militate against exaggeration and overreach.
Even diligent and thoughtful collaboration, however, may have unintended echo-chamber effects that skew the original messaging. While journalists and storytellers are often, in their own rights, professionals with prescribed training, ethics standards, and some form of postproduction editing processes, this cannot be said of the growing wave of more peripheral, yet louder, media content producers.33 Independent bloggers, vloggers, and social media commentators may, through algorithms, targeting, disinformation, and amplification techniques such as bots (i.e., automated accounts impersonating humans) spread intentionally and strategically manipulated or altered news more effectively than ever before.8,38 Social media is a primary and growing source of news,10 and while this influence on the perception of mental health is not well understood, it is likely to degrade fidelity to professional and original sourcing.
It is foreboding that the term “post-truth” was Oxford Dictionary's 2016 word of the year.39 While misinformation campaigns date back millennia to the rhetorical arts of the Greeks, their amplification and impact today are unprecedented. In the post-truth era, this outer tier of content producers may increase its influence on how the public learns about mental disorders. The fundamental principles guiding psychiatrists and other health care professionals (e.g., beneficence, truth-telling, and respect of persons) risk being incrementally drowned out by less scrupulous epistemological competitors.
In the post-truth world, anonymity is not a flaw but a feature. The psychiatrist's voice, whether directly through nonfiction opinion, or indirectly through behind-the-scenes consultancy in news, television, or film, will increase the public's knowledge of mental health and illness, translate medical jargon, foster awareness of treatment resources and considerations, and continue the good fight against pernicious misconceptions.
Media is, in many ways, a powerful model of, and for, reality. As such, it both reflects and creates understandings of mental health. The most effective safeguards against the innocent or malicious creation and amplification of stigmatizing beliefs about those living with mental illness are now, seemingly more than ever, interdisciplinarity and collaborative. This should be actively fostered and encouraged.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2019 American Academy of Psychiatry and the Law
