Introduction
Stigma is a general term which includes problems of knowledge (ignorance and misinformation), attitudes (prejudice), and behaviour (discrimination) that affects the daily life of people with mental health problems in a number of domains, including social isolation, relationships, parenting, employment, housing, and healthcare (Maiorano et al., Reference Maiorano, Lasalvia, Sampogna, Pocai, Ruggeri and Henderson2017). Significantly, stigma regarding mental ill health represents a significant barrier to treatment seeking in mental health (Link Reference Link1987; Lebowitz Reference Lebowitz2016), whereby the internalisation of attitudes towards mental health difficulties generally, and towards some individual disorders (e.g. schizophrenia) in particular, can lead to avoidance of seeking diagnosis and treatment (Corrigan Reference Corrigan2004).
One of the most common ways of combatting stigma is through educational campaigns aiming to raise public awareness (Stuart Reference Stuart2016), and this has been associated with greater public awareness of mental health difficulties in recent decades (Schomerus et al., Reference Schomerus, Schwahn, Holzinger, Corrigan, Grabe, Carta and Angermeyer2012). However, in their 2012 systematic review, Schomerus et al. found that while public knowledge of mental disorders had increased over a period of 20 years, perceptions towards people with mental disorders have not become more positive and, in the case of schizophrenia, had in fact become more negative. Likewise Valery and Prouteau (Reference Valery and Prouteau2020) have found schizophrenia to continue to be among the most stigmatised mental illnesses. This likely reflects the multi-faceted nature of stigma whereby increased knowledge may lead changes in some attitudes (e.g. reducing blame towards someone), without changing others (e.g. a willing to have contact with the person).
Localising this to an Irish context, Mothersill and colleagues (Mothersill et al., Reference Mothersill, Loughnane, Grasso and Hargreaves2021) found that attitudes and behaviours towards schizophrenia in Ireland are more negative than when compared to autism or bipolar disorder. Additionally, they found that 54.8% of participants did not feel adequately informed about mental health by the Irish media.
Headline is Ireland’s national media programme for responsible reporting and representation of mental ill health and suicide (headline.ie). It was set up in 2007 by Shine Ireland, and is funded by the National Office for Suicide Prevention as part of the HSE’s Connecting for Life Strategy to reduce suicide. Informing their work to reduce stigma with members of the media, Headline maintain a database of media articles referencing mental health. Initially, Headline focused on reporting on suicidality and in 2019 the scope of their data collection was expanded to include reporting on wider mental illnesses. In 2019, this database was extended to include articles covering schizophrenia.
The aim of the present study was to provide a descriptive review of all articles published in the online print news media in Ireland that reference schizophrenia in 2021. A particular focus of this review was to collaboratively develop a set of criteria to assess the ‘stigma reinforcing’ versus ‘stigma challenging’ content of these articles. To do this, we constructed a valence rating scale to examine the balance of stigma challenging versus stigma reinforcing elements of each article.
Methods
Dataset
The dataset available was based on a curated list of online print news media articles provided by a third-party media monitoring service (truehawkmedia.ie). This monitoring service collated key printed online news media across Ireland, including daily and Sunday titles, regional titles, and trade and consumer press. Articles were considered online print news if they were published online in written word format. These publications were then curated by a Truehawk team member who identified and included relevant publications based on a list of keywords provided by Headline, as follows: ’schizophrenia’ OR ’schizophrenic’ OR ’schizoaffective’ OR ’schizo’ OR ‘psychosis’. For each relevant publication the following information was included in the excel dataset: keywords, publication name, date, time, media type, reach, visits, advertising value equivalent, currency, automatic sentiment, page, author, and headline of where the article appeared were recorded. This dataset of an initial total of 676 articles was imported into SPSS (version 26). After removing unarchived articles which were no longer accessible (10), and articles which did not contain a reference to schizophrenia, psychosis, or schizoaffective disorder (10), the total sample was 656.
Evaluation criteria development
This study represented a non-funded collaboration between the University of Galway and Headline. A working group was established to conceptualise research questions relevant for analysis. The initial meeting between the researchers and Headline focused on the targets of the research. It was agreed that Headline would provide data on reporting of schizophrenia in the media during the year 2021. It was emphasised that a key output of the research would be to inform journalists of current reporting practises which could highlight targets for improvement. In a following meeting these outputs were reviewed and it was decided to not just highlight bad practises, but also focus on what journalists are doing well. This would allow the results to provide targets for improvement, but also give positive feedback on current practises. It was agreed for Headline to create a list of criteria which they viewed as being best practises when reporting on mental health. The list was created in consultation with two Headline programme officers and the Headline programme lead with 15+ years’ experience working in media monitoring methodologies, live programming, documentary, and international news and using existing literature for good practises on reporting mental ill health in the media (Everymind 2020a, 2020b). These criteria were cross-referenced by the research team with research for reporting on mental illness in the media (Maiorano et al., Reference Maiorano, Lasalvia, Sampogna, Pocai, Ruggeri and Henderson2017; Rose et al., Reference Rose, Thornicroft, Pinfold and Kassam2007; Aragonès et al., Reference Aragonès, López-Muntaner, Ceruelo and Basora2014; Everymind 2020a, 2020b). As well as academic, professional, and research expertise being involved in the finalisation of the list, experiential expertise was included by a peer support worker on the team with lived experience. This led to a list of 10 criteria: 5 stigma reinforcing and 5 stigma challenging criteria. The final list was presented to Headline for approval. The full criteria list is given in Table 1.
Table 1. Good reporting criteria
Data analysis
Each article was analysed based on its adherence to each of the criteria of good practise. Ten percent of which were independently marked by a second member of the team to ensure adequate assessment reliability, and no inconsistencies were observed. Following this, frequencies were calculated for all articles based on each of the individual criterion of good practise.
Development of scale of good reporting practise
In order to evaluate the balance of stigma challenging versus stigma reinforcing elements of each article, a valence scale was constructed according to criteria of good reporting. The total sample was split between articles reporting on mental health and articles reporting on mental health and violence. This was due to some criteria only applying to the context of mental health and violence. For criteria designated as stigma reinforcing (negative), a score of −1 was given for each criterion that was present. For criteria designated as stigma challenging (positive), a score of +1 was given if that criterion was fulfilled, and 0 if it was not. The scale ranged from −4 to +4 for articles reporting on mental health and −5 to +5 for articles reporting on mental health and violence. Sum scores were calculated for each article on its adherence to the criteria. This single score was the articles valence on the scale of good practise.
Results
Sample description
Of the total sample of 656 articles, 364 (55.5%) were original articles and 292 (44.5%) were repeat articles. Repeat articles were defined as identical articles by the same journalist that appear in multiple publications. The total sample was analysed to describe the overall publication instances, not just unique events, in order to capture what is published and republished. Of these, 264 (40.2%) articles were about mental health, and 392 (59.8%) were about mental health and violence. The keywords mentioning schizophrenia related terms were 476 (73%) Schizophrenia, 34 (5%) Schizoaffective disorder, 4 (0.6%) Psychosis, and 142 (22%) used a combination of these terms. The types of articles were 305 (40.0%) court reports, 141 (21.5%) news reports, 104 (15.9%) arts and entertainment, 53 (8.1%) feature piece, 42 (6.4%) opinion piece, and 1 (.2%) advice column. Table 2 shows the adherence of the sample to each of the individual criterion of good practise.
Table 2. Frequency of features of good reporting
Articles were found to avoid many stigma reinforcing criteria, with 96.8% of articles avoiding pejorative language, 94.7% avoiding the use of schizophrenia out of context, 93.4% avoiding the use of inaccurate terms, 88.0% avoiding use of mental ill health as contributing factor to violence when it is not relevant, and 83.2% using recovery focused language. In summary, these data indicated that journalists are largely succeeding in avoiding many elements/criteria considered to reinforce stigma.
By contrast, considerably less evidence of stigma challenging features were observed. While 78.4% of articles did make use of person-first language, only 12.0% provided information that confronted stereotypes, and 2.6% including a contribution from a person with lived experience. For articles that reported on violent incidents, less than half (45.9%) avoided a narrative of mental ill health being the sole cause of violence. Somewhat surprisingly, and only 4.9% provided a signpost to a relevant support. Figure 1 shows the spread of the sample on the scale of good reporting practise.
Fig. 1. Valence scale of good reporting.
As described above, each article was rated on a valence scale representing the balance of negative and positive features appearing in each article (See Fig. 1). The scale ranged from −4 to +4 for articles focusing on mental health, and −5 to +5 for articles focusing on mental health and violence. For both those articles focusing on mental health and those focusing on mental health and violence, both were observed to score nominally above zero. Articles focusing on mental health had mean scores of 0.66 (SD = 1.11), while articles focusing on mental health and violence had mean scores of 0.71 (SD = 1.05).
Discussion
The purpose of this study was to carry out a review of all articles referencing schizophrenia or psychosis that appeared in the Irish online print news media in 2021, the most recent year for which full data was available. Reflecting the multi-component nature of stigma, the specific focus of the study was to establish the frequency of items that could be considered either ‘stigma reinforcing’ or ‘stigma challenging’. Based on a collaboration with the programme Headline we collaboratively developed a set of criteria to assess the ‘stigma reinforcing’ versus ‘stigma challenging’ content of these articles. Based on a review of 656 articles identified we found that while a majority of articles avoided stigma reinforcing criteria, very few articles contained features that could be considered stigma challenging. As well as providing an up-to-date assessment of current journalism practice in Ireland in reporting on mental health, this study also suggests several practical steps that journalists can address in this regard.
Developing the right assessment criteria
In developing a methodology by which to assess representation of schizophrenia in the print media, a key criterion was to consider mental health and stigma in a broad multi-component framework. As noted, our criteria were informed by previous research in the area (Maiorano et al., Reference Maiorano, Lasalvia, Sampogna, Pocai, Ruggeri and Henderson2017; Rose et al., Reference Rose, Thornicroft, Pinfold and Kassam2007; Aragonès et al., Reference Aragonès, López-Muntaner, Ceruelo and Basora2014; Everymind 2020a, 2020b). Notably, however, despite tacit agreement that the media may either reinforce or mitigate stigma, relatively little research has been undertaken to qualify or quantify either in the media. In iteratively developing such criteria with Headline, Ireland’s national programme for responsible reporting and representation of mental illness and suicide, we sought to operationalise characteristics of both stigma reinforcing and stigma challenging media representation. In doing so, we have endeavoured to include as many stigma associated characteristics as we could find evidence of.
Main findings
The main findings from the present study presents a picture of reporting practice that can be viewed as having both positive and negative aspects. The positive interpretation of our data is that journalists working in the Irish print media reflect a practice that avoids the use of pejorative language when describing the lived experience of psychosis. This extends to avoiding inaccuracies to a large extent. For schizophrenia specifically, perhaps above all other mental health disorders, this is particularly noteworthy given the frequent misunderstanding that surrounds the term. As noted in our introduction, schizophrenia as a term is not well understood and even when some aspects of the condition are accurately understood others are not, leading to an increase in stigma relative to other disorders (Mothersill et al Reference Mothersill, Loughnane, Grasso and Hargreaves2021), despite greater information (Schomerus et al., Reference Schomerus, Schwahn, Holzinger, Corrigan, Grabe, Carta and Angermeyer2012).
Given the challenges to addressing stigma associated with schizophrenia, a focus on stigma challenging information remains a key requirement for a greater public health understanding of schizophrenia and related psychosis. The finding that 59.8% of articles were in the context of mental health and violence highlights the need for as much harm reduction as possible on the part of news media. The identification of target areas for improvement that can the inform training for journalists is a key finding, as a recent study by Ross et al. (Reference Ross, Morgan, Wake, Jorm and Reavley2021a) has shown media training targeting best reporting practices can be effective (Ross et al., Reference Ross, Morgan, Wake, Jorm and Reavley2020; Ross et al., Reference Ross, Morgan, Wake, Jorm and Reavley2021b; Morgan et al., Reference Morgan, Ross, Wake, Jorm, Kashihara and Reavley2022). In this context, this study provides some clear guidelines about further steps to be taken in the media. Specifically, the fact that only a minority (12%) seek to confront the many stereotypes about schizophrenia and psychosis (e.g. the long held popular association with ’split personality’) highlights a practical step that can be taken by print news journalists. But perhaps above all, the finding that less than 3 in 100 articles include a contribution from a person with lived experience highlights the distance still needing to be travelled in de-stigmatising the experience of individuals with psychosis. Finally, we were surprised that less than 1 in 20 articles discussing schizophrenia and psychosis signposted relevant supports for readers. Given the context in which schizophrenia appears in these articles (59.8% in the context of violence), this finding is particularly noteworthy as an opportunity to inform readers and suggest resources for further information on schizophrenia.
Limitations & future direction
Although based on previous empirical research informed by theories about stigma, the criteria developed for use in this review remain to some extent subjective. While representing a dialogue between academics and a non-governmental agency targeting stigma in the media, and striving to be inclusive, in developing these criteria other important criteria may have been overlooked. Similarly, as these exact criteria have not been applied to print media representation of other mental health disorders it is not possible to make a direct comparison. Another consideration may be that not all criteria fit with each article type, for example it may be less reasonable to expect a court report type article to include a contribution from someone with lived experience. However, when court reports was removed from the analysis, we found little impact on our results, with the mean valence score of mental health articles (from μ = 0.66 to μ = 0.72 with court reports removed) and the mean valence score of mental health and violence articles (from μ = 0.86 to μ = 0.40 with court reports removed), which we interpreted as evidence that the criteria are applicable across article types. Additionally, the valence scale used to estimate the valence of each article on its use of good reporting is as of this study unvalidated, and therefore any interpretations taken from these results should take this into account. Future research that compares these results both against representations of other disorders, and over a longer publication period will shed further light on the utility of the criteria employed here.
Conclusions
The findings of this study provide insight into the good reporting practises of the Irish media while also highlighting targets for improvement. Many of the major stigma reinforcing elements are avoided, such as pejorative language, non-recovery focused language, and inaccurate terms. Areas which could improve the overall truth seeking and harm minimisation of the reporting include signposting, contributions of lived experience, and information which confronts stereotypes. Future training programmes for journalists reporting on mental health may consider including these harm reducing factors to better represent mental health in the media.
Acknowledgements
Research by EG and GD is generously funded by a HRB Leader’s Award to GD (HL-20-007).
Financial support
GD and EG are generously supported by a Health Research Board (Ireland) Research Leader’s award to GD (RL-20-007).
Conflict of interest
The author has no conflict of interest to declare.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that ethics committee approval was not required for publication of this study.
