Swedish Mental Health Nurses’ Experiences of Portrayals of Mental Illness in Public Media

Abstract

News reporting about mental illness lack perspectives of the mentally ill themselves and it is almost exclusively psychiatrists who are accessed when healthcare staff is consulted. The perspective of mental health nurses might contribute to the public understanding of mental illness. The purpose of this study was to describe mental health nurses’ experiences of how mental illness is portrayed in media. Eight semi-structured interviews were conducted with qualified mental health nurses. A qualitative content analysis resulted in three categories: Negative portrayals of mental illness, Inconclusive images of mental illness and Biased dissemination of different perspectives. The conclusion of this study is that mental health nurses experience media portrayals of mental illness as negative and misleading with too much emphasis on the medical perspective while a holistic mental health nursing perspective is heavily obscured. Mental health nurses need to take a more prominent role in public reporting on mental health to resolve the current lack of relevant facts regarding mental illness. Further research is needed regarding portrayals of mental illness in social media and how the current lack of perspectives affects public perceptions of mental illness. In addition, further studies regarding the viewpoints of journalists reporting on mental illness are required.

Background

The stigmatization of people diagnosed with mental illness is well documented, and schizophrenia is in particular a diagnosis that is commonly linked to stigmatization (Angermeyer, Matschinger, & Schomerus, 2013; Mestdagh & Hansen, 2014; Read, 2007; Read & Harré, 2001). People diagnosed with schizophrenia often experience fear of abandonment or exclusion due to their diagnosis and studies have shown that even healthcare staff in the mental health services discriminate against patients diagnosed with schizophrenia (Mestdagh & Hansen, 2014). People diagnosed with schizophrenia also run a greater risk of having their integrity and autonomy violated by healthcare staff (Jormfeldt & Hallén, 2016; Mestdagh & Hansen, 2014). Earlier studies have shown that a biological model for the explanation of the illness increases the public’s fear of mental illness (Angermeyer et al., 2013). This increase of fear has been linked to the interpretation that a biological model reduces the individual’s possibility for changing or preventing their symptoms of mental illness. This thus makes people with mental illness appear to be different and unpredictable and becomes an indication that anyone can be affected by severe mental illness (Angermeyer et al., 2013; Cross, 2004).

A review of studies on influences regarding stigma related to mental disorders in the media maintains that mental illness is the most common form of illness represented in TV and movies (Klin & Lemish, 2008). Mental illness was more commonly associated with negative stereotypes compared to somatic illness. News media, newspapers in particular, are a common source of inaccurate and negative information about mental illness and studies have shown that the portrayal of mental illness in news media does not differ from entertainment media in terms of inaccurate and negative information about mental illness (Stuart, 2006). An examination of 300 news articles, reporting on mental illness in the USA, found that the most common theme related to mental illness was dangerousness (Wahl, Wood, & Richards, 2002). As many as 26% of these news articles reported on violent crime or murder perpetrated by people suffering from mental illness. Similar results have been found among studies in other countries (Wahl, 2003). News media often include dramatic descriptions of crime and murder, where they characterize the suspected perpetrator as suffering from psychosis, paranoia or other forms of mental illness (Klin & Lemish, 2008). Previous studies have found that the selective reporting by journalists, of violent crimes committed by people diagnosed with schizophrenia, contributes to the view held by the general public that people diagnosed with mental illness are dangerous and erratic (Klin & Lemish, 2008). Studies have also described how the recurring connection between mental illness and violence in news media has the potential for maintaining and increasing stigmatization of people diagnosed with mental illness as dangerous, erratic and in need of monitoring and legislative measures (Stuart, 2006; Wahl, 2003). Studies (Klin & Lemish, 2008; Stuart, 2006; Wahl, 2003) have also highlighted that the lack of reporting about successful treatment methods for mental illness in news media leads to skepticism and pessimism towards mental healthcare and reduces the possibilities for treating and recovering from mental illness.

Two-three % of characters in fictional TV-shows from the USA, between the years 1965 and 1989 and the year 1994, were depicted as mentally ill (Stuart, 2006). Half of these characters hurt another character and a fourth killed another character. Stuart (2006) approximated that characters suffering from mental illness used violence ten times as often as other characters in the TV-shows studied. A qualitative content analysis of 116 Swedish crime novels published between 1998 and 2015 showed that the perpetrator in one third of the novels, often a killer, suffered from mental illness (Berglund, 2017). This author (2017) points out that this portrayal of mental illness and disease engenders a risk for further stigmatizing an already vulnerable group. It has been described in another study that the portrayal of people who have received mental health in-patient care as crazy, evil and dangerous in newspapers is closely related to the historical diagnosis of the Criminal Lunatic (Cross, 2004). Cross (2004) discusses whether the link between violence and mental illness is so ingrained in the media that it prevents other citizens from considering those with mental illness as ordinary people. The contemporary portrayal of mental illness in media is a continuation of the historical trend of trying to separate and isolate people with mental illness from ‘normal’ society by housing them in mental hospitals far from population centers (Cross, 2004; von Heydendorff, Meyer-Lindenberg, & Dressing, 2016).

Analyses of news have shown that the reporting of mental illness is often inaccurate, misleading and filled with exaggerations (Jormfeldt & Hallén, 2016; Klin & Lemish, 2008; Stuart, 2006; Wahl, 2003). The reporting about mental illness in the news often lacks the perspective of the mentally ill themselves and when healthcare staff are consulted it is almost exclusively psychiatrists who are accessed (Wahl, 2003). This leads to an unbalanced reporting with a focus on biological explanations and pharmaceutical treatments of mental illness (Wahl, 2003) thus increasing the stigmatization of mental illness (Read, 2007; Read & Harré, 2001). This inaccurate and unbalanced reporting may also maintain stigmatizing attitudes towards mental illness in healthcare systems, which thus may not distribute public resources in a way that can provide the most effective help for people with mental health issues (Jormfeldt & Hallén, 2016; Wahl, 2003).

The psychiatric nurse has an important role in shaping the culture and counteracting stigma (Doyle et al., 2018). Individuals are shaped by the culture they live and operate in (Eriksson, 2015) and when the culture and the individual perspective share the same content, the culture can be experienced as obvious or self-evident. If the individual is not aware of the factors that shape the culture, he/she will only propagate the culture without further reflection or contemplation about the thought patterns, habits and rules that forms its basis. Thus it is important in health care services to be aware of the basic assumptions of the culture of caring to be able to exercise the necessary contribution to the progress of the culture of caring (Eriksson, 2015). The psychiatric nurse has been educated to attain a holistic perspective, which allows them to see the links that exist between the individual with a mental illness, the surrounding culture and caregivers. Being as mental illness is mainly depicted from a biological perspective in the public media, the view of mental illness among the general public has been primarily based on biological explanations, and thus risk not attaining a holistic perspective of the individual. Greater prominence for the psychiatric nurses’ perspective of mental health and illness may contribute to a greater understanding of mental illness in society as a whole and in the mental health services in particular.

Purpose

The purpose of this study was to describe the experiences of psychiatric nurses of how mental illness is portrayed in public media.

Method

Design

This study has a qualitative design with an inductive approach (Graneheim, Lindgren, & Lundman, 2017). This approach was chosen as the intention was to explore the research question based solely on the participants’ experiences without predetermined theoretical perspectives.

Participants

A total of eight psychiatric nurses, geographically located in different parts of Sweden, were interviewed. The selection was strategical (Elo et al., 2014) and the psychiatric nurses were asked to participate through the auspices of the Swedish Association of Mental Health and Mental Health Nurses. The aim of the strategic selection was to include participants with sufficient professional proficiency in order to be able to reflect and discuss about the portrayal of mental illness in public media. An invitation to participate was sent to all the members of the board of the national organization and those that expressed interest in participation were provided with further information about the study and participation. The selection criteria was based primarily on the length of experience as a psychiatric nurse, as well as a broader experience of the nursing field, such as teaching experience at university level, research on psychiatric nursing or participation in improvement projects in mental health care. Participants with a broad experience of the nursing field were judged to possess a solid understanding of the phenomena investigated in actual study. All of the participants had several years’ experience of working as psychiatric nurses, five of whom were men and three were women. Four had experience as teachers in the nursing field, two had experiences of research in the field of nursing, two had participated in improvement projects in mental health services, one participant had experience as a manager in a mental health outpatient clinic as well as having a degree in nursing and one participant had a degree in another academic field.

Data collection

All the participants who were invited to take part were sent written information about the study and a consent form by e-post prior to the interviews. A written informed consent was obtained from each participant before the interviews were conducted. The data collection was conducted in semi-structured interviews with a prewritten interview guide including questions about the participant’s understanding of the origin of mental illness and the possibilities for recovery and their perceptions of how these issues are portrayed in public media. The recorded telephone interviews lasted between 30 and 60 minutes and were carried out by two of the authors (HJ) and (MH) in December 2015 and January 2016.

Data analysis

The interviews were transcribed in January–March 2018 by the first and second author (ML) and (SK). The transcriptions were coded and analyzed using qualitative content analysis inspired by Graneheim and Lundman (2004). First, the interviews were read several times to gain an understanding of the content as a whole. Meaning units related to the research question were then identified and condensed. The condensed meaning units were then abstracted and given a code. Descriptions of the contents were close to the original statements, rather than interpretations of the content. The codes with a similar content were sorted into subcategories and categories (see Table 1).

Table 1. Examples of data analysis.

Meaning unit	Condensed meaning unit	Code	Subcategory	Category
It is invectives, invectives we are talking about. It was in a fit of psychosis or… a psychotic person that killed someone, not like a cancer diseased person that killed someone, but it… yeah. You use it to describe… people.	Psychiatric diagnoses are used as invectives.	Psychiatric terms are misused	Stigmatizing reporting on mental illness	Negative portrayals of mental illness
Well, you see I would like to see more of fact based and experience based information. Not of the juicy, like.	Lack of facts in media reporting	Lack of facts	Flawed image of mental illness	Inconclusive images of mental illness
It is hardly ever you see an interview with an associate professor of mental health nursing in Swedish investigative television focused on social issues, where he or she is allowed to sit around, problematize, twist, and turn things with regard to his or her specific expertise to explain or understand human actions….	Nursing professionals are not invited as experts in public media	Invisible psychiatric nursing	Absence of mental health nursing perspective	Biased dissemination of different perspectives

Ethical considerations

All identification markers were removed from the interviews during the transcription process in order to prevent identification of the participants. Sound files and transcribed interviews were stored on a password-protected computer and copies of the interviews were saved on an encrypted USB memory stick that was kept in locked storage. All the participants were informed about the study and any risks associated with participation prior to signing a consent form for participation in the study, which is in accordance with the current Swedish legislation (SFS, 2003, p. 460). The most evident risk for the participants was moderate ethical or professional stress, as the interviews entailed topics that could be considered sensitive or controversial from a professional viewpoint. These risks were considered to be sufficiently prevented, as both interviews were experienced researchers, one of whom was also a qualified psychiatric nurse. The participants were informed that participation was voluntary and that they could terminate their participation at any time without having to give any reason. Furthermore, all the participants had long experience of their profession and had expressed an active desire to participate in the study. The study was approved by the local ethics committee at the Department of Health and Welfare at Halmstad University (Dnr. UI 2018/159).

Results

The analysis of the interviews resulted in three categories: Negative portrayals of mental illness, Inconclusive images of mental illness and Biased dissemination of different perspectives. In the category Negative portrayals of mental illness the subcategories were: Crimes being linked to mental illness and Stigmatizing reporting on mental illness. In the category Inconclusive images of mental illness the subcategories were: A more positive image of mental illness and Lack of facts in images of mental illness. In the category Biased dissemination of different perspectives the subcategories were: Biomedical mental health emphasis and Absence of psychiatric nursing perspective. An overview of categories and subcategories are presented in Table 2.

Table 2. Result categories and subcategories.

Category	Subcategory
Negative portrayals of mental illness	Crimes being linked to mental illness
	Stigmatizing reporting on mental illness
Inconclusive images of mental illness	A more positive image of mental illness
	Lack of facts in images of mental illness
Biased dissemination of different perspectives	Biomedical psychiatric emphasis
	Absence of mental health nursing perspective

Negative portrayals of mental illness

Crimes being linked to mental illness

The participants described experiences of the media linking crimes to mental illness. Participants spoke of the news media reporting on violent crimes and described experiences where the journalists used mental illness to explain why violent crimes were committed.

The participants talked of two perspectives regarding the reporting of crimes in media. The first perspective was that people experiencing mental illness were portrayed as dangerous and erratic. The second perspective was that mental illness was used as to explain why perpetrators committed violent crimes without presenting any further elucidation.

It is as if mental disorders in themselves are the thing that makes people commit… commit crimes. (Interview 4)

Stigmatizing reporting on mental illness

The participants described that the media, to a varying extent, reported on or portrayed mental illness in a stigmatizing way and spoke of experiences of mental health diagnosis and mental illness being used as invectives in the media.

A recurring experience was that the negative portrayal of mental illness in the media was perceived as being intended to label people with mental illness or otherwise group them together to make it easier to generalize about mental illness. The participants expressed that these generalizations of mental illness were negative and upsetting.

It is invectives, invectives we are talking about. It was in a fit of psychosis or… a psychotic person that killed someone, not like a cancer-diseased person that killed someone, but it… yeah. It is used to describe… people. (Interview 1)

Inconclusive images of mental illness

A more positive image of mental illness

The participants said that some media gave a relatively positive or unprejudiced image of mental illness. They also spoke of alternatives to the traditional media as contributing with information that was more positive. Examples of these alternatives were 1177.se (Swedish healthcare’s national information website), social media and the literature published by patient organizations.

The participants also talked of experiencing that the media had started to present a more positive image of mental illness, referring to TV-series as positive examples. They also spoke of the news media having started to improve their reporting on mental illness by doing so in a more nuanced manner.

I feel as if they are providing a more nuanced picture and that they are comprehensive when discussing mental illness today… and that they’ve even begun to take some responsibility for what they’re writing. (Interview 8)

Lack of facts in images of mental illness

Participants talked of experiences of the media presenting a misleading image of mental illness, in both news reporting and literature as well as in movies. The participants spoke of a lack of facts in the media portrayals of mental illness. This was primarily related to news reporting about mental illness, but was also described in relation to fictional literature and a lack of facts in reporting about what cure or help can be given for mental illness.

The participants talked of experiences of the media making false claims about mental illness, and how fictional literature and movies presented misleading images of mental illness. They also experienced that the mental health experts made statements about events or people in the media, despite not having been sufficiently knowledgeable about the individual case to be able to provide a fair picture.

Well, you are still talking about psychosis and those things I think are stigmatizing in themselves, instead of talking about what kind of vulnerability or what the person has experienced in life (Interview 8)

Biased dissemination of different perspectives

Biomedical mental health emphasis

The participating nurses talked of experiences of a predominantly biomedical perspective in the news media and that psychiatrists were the ones authorized to make statements about mental illness. The participants invariably described the psychiatrists’ superior role and the dominance of the biomedical perspective in public media as being destructive and incorrect. They also spoke about other professional perspectives having been neglected due to the medical focus in the media.

Somehow it is often… the psychiatrists who asked to be on the air, to talk and respond to this or that when something has happened. And then… you often end up with the biomedical perspective. (Interview 2)

Absence of mental health nursing perspective

The participants talked of a lack of a mental health nursing perspective in portrayals of mental illness in the media. The reasons for this were ascribed to the current hierarchy in the healthcare services where psychiatrists are seen as the authority. The participants also felt that nurses were bad at making themselves visible in the public media.

And in media I’ve never seen anyone bring up the perspective of mental health nursing. (Interview 5)

Another aspect that the participants talked of was the experience that mental health nursing had low status, both in relation to nursing in the medical field and among other nursing practitioners.

You hardly ever see an interview with an associate professor of mental health nursing in Swedish investigative television program focusing on social issues, where he or she is allowed to sit around, discuss and twist and turn things with regard to his or her specific expertise to explain or understand human actions…. (Interview 4)

Discussion

The results of this study show that psychiatric nurses experience the presentation of mental illness in public media as negative. The participants speak of the negative portrayal is partly done through the media linking mental illness to violent crimes and partly through the reporting of mental illness in a discriminating and stigmatizing manner. This result is in line with earlier studies about the reporting of mental illness in the public media (Klin & Lemish, 2008; Stuart, 2006; Wahl, 2003). Cross (2004) explains this negative media portrayal of mental illness in a historical context by pointing out that society has tried to isolate and block out phenomena that can be frightening and hard to understand, which has cemented the negative reporting of mental illness in the public media. When the media reports the presence of mental illness among violent criminals as being something abnormal and deviant, the individual consuming the media is able to rest easy knowing that they and their loved ones would not commit violent crimes, as the narrative of violence was focused on mental illness (Cross, 2004).

The negative portrayal of mental illness in the media is problematic in several ways. These include the media presenting a misleading picture of mental illness or presenting it as the cause of sensational events, despite the lack of available information (von Heydendorff et al., 2016). The media also contributes to stigma around people experiencing mental illness, something that causes these people stress and suffering (Stuart, 2006) and fear of discrimination and alienation (Mestdagh & Hansen, 2014). The current study indicates that it is possible that the media may fail in its objectivity in reporting on mental illness, with misleading reporting due to a lack of facts, such as the humanistic and holistic nursing perspectives of mental illness. This finding is partially supported by previous studies (Klin & Lemish, 2008; Wahl, 2003), but it appears as if previous studies have not differentiated between negative portrayals and false or made-up statements. One previous study showed that the creators of TV-shows were aware of the misleading picture of mental illness that their shows conveyed, but felt that their job was to provide good dramaturgy and entertainment, not to educate their viewers (Henderson, 2018). This indicates that the responsibility for the negative and misleading reporting of mental illness in the media is ambiguous and problematic and that changes are required in terms of how mental illness is approached in the public media.

The media is also in a position to provide positive images of mental illness and the results in this study showed that psychiatric nurses had experiences of the media providing nuanced reporting on mental illness. TV-shows could provide a positive image of mental illness and previous research has showed how TV-shows can fluctuate between positive and negative portrayals of mental illness based on the dramaturgical need of the show (Henderson, 2018). The findings show that social media sometimes provide positive portrayals of mental illness. A previous study has shown that people with mental illness have found that some types of social media provides them with possibilities for gaining social support and advice from other people with mental illness (Naslund, Grande, Aschbrenner, & Elwyn, 2014). Naslund et al. (2014) also found that social media might be able to reduce feelings of isolation and provide hope for people with mental illness. As the topic is relatively unexplored, more studies are needed in order to more clearly delineate the role of the social media in the forming of opinions and attitudes about mental illness in society.

The medical perspective dominates media reporting on mental illness. The nursing profession’s subordinated position compared to the medical profession is a well-known problem in healthcare. This is an historical imbalance that has progressively diminished but still remains today (Price, Doucet, & Hall, 2014). The results of the present study showed that psychiatric nurses still perceive that psychiatrists are the healthcare professionals most commonly visible in media, while the nursing perspective is absent. A part of this imbalance can be found in the difference in status between the professions, where medical professionals are given a higher status. Another result from the present study is that nurses are not usually invited to make their professional voices heard in public. This finding has some support in previous research, urging that nursing education historically has taught nursing students to be subordinate in relation to medical doctors (Price et al., 2014). The results showed that psychiatric nurses had vivid experiences of the imbalance between the professions. The dominant position of the medical perspective in the media regarding healthcare has thus been well documented (Price et al., 2014; Read, 2007; Wahl, 2003). Moreover, Nilsson (2009) problematizes the type of hegemony in knowledge and science that seems to exist particularly in relation to mental illness. When a specific perspective dominates it is not politically neutral, but brings with it classifications, dividing lines and perceptions about what delineates the field (Nilsson, 2009). This understanding of how the media represents science is in line with Eriksson (2015) who emphasizes the importance of embracing a multitude of perspectives to understand all dimensions of the whole. Previous studies on the influence of the media have shown that the perceptions and ideas of what constitutes scientific knowledge about human nature have consequences for the daily lives of people (Nilsson, 2009). Similar results have also been found in studies about how reporting of mental illness in the public media affects societal attitudes towards mental illness (Read, 2007). A theoretical explanation of this increase in stigmatization is that medical models primarily explain mental illness as abnormities in human brain and function, which creates fear and uncertainty among the public (Jormfeldt & Hallén, 2016). Studies have thus indicated that the medical model of explanation of mental illness increases stigmatization of mental illness (Jormfeldt & Hallén, 2016; Read, 2007). If the individual is considered unable to prevent or alter the development of mental illness or control the course of the disease without pharmacological treatment due to biological factors, mental illness is considered more frightening and unpredictable among the public than if mental illness is explained by a sociobiological model (Angermeyer et al., 2013). There seems to be a dearth of research on the absence of a nursing perspective in the public media, indicating a need for further studies on this topic. It is important to determine what effect an increase of a holistic nursing perspective in public media could have on stigmatization of mental illness in society. This study and previous studies on the topic show that the lack of other perspectives than the medical perspective in public media negatively affects how the public understands mental illness.

Methodological considerations

The views of psychiatric nurses on how mental illness is portrayed in the public media have rarely been investigated or described; an exploration of how psychiatric nurses perceive the portrayal of mental illness in the public media was thus considered essential to carry out. Qualitative content analysis was considered an adequate method for addressing the aim of the study, as it focuses on the experiences of the individual in regard to events and phenomena and creates a synthesis between the individual perspective and the broader context (Graneheim et al., 2017). The strength of the inductive approach is that the analysis is based on the available data, whereupon a theoretical understanding is reached based on the findings made in the data analysis (Graneheim et al., 2017). A potential risk exists, however, with the inductive approach in that it may not probe sufficiently deep.

The selection of participants strengthens the validity of the study, as there is a geographical distribution within Sweden, a wide range of professional experiences, practical experience of nursing and a fairly even gender distribution. The fact that the selection is limited to members of Swedish Association of Mental Health and Mental Health Nurses could be considered a strength, as a membership in the association displays an interest in and commitment to mental health nursing, which is the basis for thorough reflections on profession-related topics such as public portrayals of mental health and mental illness. A potential weakness in the selection is that none of the participants was new to the role of mental health nursing. As a broader range of experiences among participants can generate greater validity (Graneheim & Lundman, 2004), it cannot be disregarded that someone with less professional experience might have had different experiences in relation to a more experienced colleague. This, in part, because younger mental health nursing staff tend to have a more negative attitude towards people experiencing mental illness (Hansson, Jormfeldt, Svedberg, & Svensson, 2011).

A strength in the data analysis is that the material for each interview was rich and well substantiated, which made it possible to distinguish nuances during the analysis. The uniform content in the interviews affects the dependability and trustworthiness of the results (Graneheim & Lundman, 2004). Data collection was conducted during a short period of time, which minimized the risk of drift, such as changes to the questions or changed external circumstances, during the data collection.

The result is believed to have a good transference, as the strategic selection was tailored to involve participants, who possessed experiences relevant to the research question in the study. Transference is further strengthened by the fact that the results of this study confirm the findings of previous studies on how the media depicts mental illness.

Conclusion and implication

The findings show that nurses working in mental health services experience the reporting of mental illness in the public media as negative, misleading and stigmatizing. Mental health nurses experience that the medical perspective is given too much space in the public media and that the mental health nursing perspective is invisible. However, there are also positive portrayals of mental illness outside of the traditional media and mental health nurses experience that the traditional media are becoming better at reporting on mental illness in a more nuanced manner.

Further research is needed in regards to how mental illness is portrayed in social media and how the lack of perspectives other than the medical one affects the public perception of mental illness. Studies including younger psychiatric nurses with less experience of the professional role may yield more information about public opinion on mental illness. There is also a need to study the perspective of journalists who cover the field of mental illness. Further research in these areas can lead to an expanded understanding of the impact of public media on the perception of mental illness and the possibilities for improving the public perception and understanding of mental illness. Psychiatric nurses need to be more visible and take a larger role in media, to counteract the current one-sided reporting of mental illness. The awareness of a current lack of a holistic nursing perspective on mental illness and the possible consequences of bringing attention to a holistic perspective on mental illness in the public media needs to be addressed by psychiatric nurses, care organizations and journalists. The holistic nursing perspective should be at least as common in the public media as the narrower biomedical perspective of mental illness. An awareness of the existing shortage of a holistic perspective on mental illness in public media also needs to be introduced into the mental health nursing education and form the basis for discussions during the courses with mental health nursing students.

Disclosure statement

No potential conflict of interest was reported by the authors.