Mediating Mental Health

Contexts, Debates and Analysis

Michael Birch

• Publisher: Routledge
• Year: 2016
• Print ISBN:
  9781138260139
• eBook ISBN:
  9781317098522
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

The problem of media representations about mental health is now a global issue with health agencies expressing concern about produced stigma and its outcomes, specifically social exclusion. In many countries, the statistic of one in four people experiencing a mental health condition prevails, making it essential that more is known about how to improve media portrayals. With a globally projected increase in mental health conditions Mediating Mental Health offers a detailed critical analysis of media representations in two phases looking closely at genre form. The book looks across fictional and factual genres in film, television and radio examining media constructions of mental health identity. It also questions the opinions of journalists, mental healthcare professionals and people with conditions with regard to mediated mental health meanings. Finally, as a result of a production project, people with conditions develop new images making critical contrasts with dominant media portrayals. Thus, useful and practical recommendations for developing media practice ensue. As such, this book will appeal to mental health professionals, people with conditions, journalists, sociologists, students and scholars of media and cultural studies, practitioners in applied theatre, and anyone interested in media representations of social groups.

Chapter 1
Mediating Mental Health

Most mediation about mental health, including mediations about madness, is problematic because of the potential that exists for stigma production. Examining this problem, Greg Philo wisely points out not just the pertinence of history but also how pervasive stigma is:

The stigmatisation of those who are mentally distressed has a long history in our culture and obviously predates our contemporary media. It must also be said that the portrayal of mental illness in films, on television and in the press is not the only source of public information and understanding in this area. Nonetheless, media coverage does have an important influence. Our study in this volume of the content of press and television showed that two-thirds of media references to mental health related to violence and that these negative images tended to receive ‘headline’ treatment while more positive items were largely ‘back page’ in their profile, such as problem pages, letters or health columns. (Philo 1996: 112)

Stigma, as quoted above, has an extensive past but it is not only the mentally distressed that are affected by problematic mediations. bell hooks (1994) identifies how contemporary media usually show negative stereotypes of African-American women, seen as lazy and/or dishonest. In her work with students, she learnt what it meant to be poor in America. hooks notes that, ‘If to be poor in this society is everywhere represented in the language we use to talk about the poor, in the mass media, as synonymous with being nothing, then it is understandable that the poor learn to be nihilistic’ (1994: 169). For people to learn to be nihilistic, as hooks puts it, is to ‘drown in the image that a life is valueless’ (1994: 169), and a devaluation of self-identity. How others might see that identity is one thing, but how a person views their own self-identity is another; problems of identity formation are numerous for a range of minority groups.

David Morrison (1992) addresses identity formation issues about homosexuality in British broadcasts; the homosexual wants to be recognized by broadcasters rather than through the hostile definitions by which s/he usually is recognized. Morrison reports from empirical work within UK contemporary culture that the homosexual struggles to ‘define their own sexuality as legitimate in the face of hostile definitions of sexuality’ (1992: 91). Examples of this are cited by Susan Benson (1997) in her explorations of how representations of Aids/HIV have come to stigmatize the homosexual body when the heterosexual has in fact been more affected. The ensuing mobilization of moral panic over the fear of infection during the 1980s, following from health prevention advertisements the UK government thought necessary, only served to alienate the homosexual community. What was wished for by this community was to be able to ‘establish for themselves a sense of identity not infected by the imposition of ideas from the heterosexual world that distorted who or what they were’ (Morrison 1992: 91). The representations of race and sexuality have produced a range of problems for each cultural group. Mental health representations produce equally if not more serious issues for identity because, as this book proposes, obscure ideas about madness prevail.

Guiding Ideas and Areas

In the examination of variant ideas about mental health, key concepts include: stigma, reflexivity, identity and the politics of identity, myths and stereotypes generated by media representations and the issues of genre. All of these areas raise questions about representational differences and similarities with the identity politics found in new social movements around gender, race and sexuality. Furthermore, the ways in which drama as an ingredient in meaning making has intervened in contemporary mediations is another important point.

Identity Formation, Recognition and Stigma in Theory

Calhoun (1994) notes that the problem of identity formation operates in relation to recognition, both recognition by others and self-recognition. ‘Problems involving recognition – or nonrecognition – by others are integrally related to issues in personal self-recognition’ (1994: 20). Necessarily, problems of recognition and the politics of identity play a key role for people with a mental health condition, who may be portrayed through stigmatizing stereotypes. Trends in mediations show inaccurate portrayals of minority groups and also a tendency to stigmatize in a way which generates a ‘fear of shame-based humiliation’ (hooks 1994: 169). This stigmatizing-by-shame begs two questions about the problem of representing madness: What is stigma in theory? With stereotypes developing in concert with stigma, how may stigma impact people who have a condition?

Among the scholars who examine stigma theory, Erving Goffman’s famous study Stigma (1963) is notably complemented by two works: Social Stigma: The Psychology of Marked Relationships by Jones et al. (1984), and The Social Psychology of Stigma by Heatherton et al. (2000). All three begin by addressing the notion of a person being ‘marked’, of being devalued and ‘different’ in some way and all illuminate ideas about a person’s identity being spoiled. Goffman presents three categories of stigma: a) abominations or deformities of the body; b) blemishes of individual character and; c) tribal stigma of race, nation, religion which Goffman (1963: 4–5) extends to low class, especially in Britain. For Jones et al. there are six dimensions:

1. Concealability. Is the condition hidden or obvious? To what extent is its visibility controllable?

2. Course. What pattern of change over time is usually shown by the condition? What is the ultimate outcome?

3. Disruptiveness. Does it block or hamper interaction and communication?

4. Aesthetic qualities. To what extent does the mark make the possessor repellent, ugly, or upsetting?

5. Origin. Under what circumstances did the condition originate? Was anyone responsible for it and what was he or she trying to do?

6. Peril. What kind of danger is posed by the mark and how imminent and serious is it?

(Jones et al. 1984: 24)

Heatherton et al. (2000) critically explore Goffman, Jones et al. and a range of scholars but propose new ways of understanding and thinking about stigma, not just as a list of elements of functions but as a process. In view of this, their work is given more space for exploration as well as drawing from the other scholars across this and remaining chapters.

In Heatherton et al. (2000), Dividio, Major and Crocker confirm that stigma contests a person’s identity, challenging it as a deviant to an expected norm in a society. However, while the concept can be understood as negative, it can sometimes be seen in a positive light; the statement, ‘s/he’s filthy rich’ could serve as one example. But as stigma is closely connected to prejudice, the stigmatized person is usually subject to a practice with the consequence of negative intent, an attitude aimed at marginalizing identity. As Heatherton et al.’s introduction says; ‘Thus, the major negative impact of stigmatization normally resides not in the physical consequences of the mark, but rather in its social and psychological consequences’ (2000: 5). Such consequences implicate not just those stigmatized, termed as targets, but those who are the stigmatizers, perceivers. In any examination of stigma, both groups must be taken into consideration as well as, where possible, interactions which occur between them.

Examining Crocker et al.’s (1998) view, Dovidio et al. note ‘that “visibility” and “controllability” are the most important dimensions of stigma for the experience of both the stigmatizer and the stigmatized person’ (2000: 6). If a stigma is visible, it may provide the basic schema through which everything about an identity or group is known. The visibility of the stigma and reactions to the stigmatized are indicators as to how stigma can impact a person’s situation. It may determine how conscious a person is of the stigma but in the case of people with conditions that are invisible, concerns occur: how do people with conditions that are not outwardly apparent respond to stigma as a result of negative mediations? Keeping a condition invisible means a spoiled identity is being ‘managed’ in ways that consume time and energy in denying exposure of identity and avoidance of self-expression. Controllability of stigma is important for this group. While some groups such as people with obesity may be seen as ‘in control’, they will be disliked because they are seen as having responsibility for ‘maintaining or eliminating the mark’ (Heatherton et al. 2000: 7). In the situation of people with mental health conditions, where the perceived ability to control a condition might be questioned by people in the outside world, this may lead to serious consideration as to whether or not divulgence of their identity or condition is appropriate.

Stigma as a Process: Perceivers, Targets and Mental Health Identity

Heatherton et al. (2000) develop a conceptual framework around three fundamental dimensions which inform about stigma as processes. The dimensions are: ‘(1) “perceiver-target”, (2) “personal-group-based identity”, and (3) “affective-cognitive-behavioural response”’ (2000: 9) and show how mental health identity may be impacted. Conceding that their framework is not comprehensive, they identify its usefulness in a perspective, locating stigma as part of larger context of general social psychological perspectives; a context complementary to this study’s purpose of unveiling the nature of stigma for people with mental health conditions and other groups.

The perceiver-target dimension results in consequences for both groups: those who perceive stigma and those who are targeted by it. Each group has similar characteristics. While the division is not clear cut, perceivers are those deemed ‘normal’ or ‘non-stigmatized’, as those who exacerbate stigma. This said, a perceiver can be stigmatized. The English may stigmatize the French and vice-versa. As a dimension, it usefully differentiates the points of view of each group and also illuminates the stigmatizing situation of people with conditions. Each group has different ‘needs, goals, and motivations which can further shape how they perceive and interpret information in different ways’ which Heatherton et al. (2000: 11) confirm in accord with Deaux and Major (1987), and Swann (1987).

The second dimension concerns personal and group-based (social) identity. Personal and social identity can be that of the perceiver or target but in making distinctions between these two identity sets, we can understand how people make impressions about others. Fiske and Neuberg propose that, perceiver impressions of targets will be formed ‘through a variety of processes that lie on a continuum reflecting the extent to which the perceiver utilizes a target’s particular attributes’ (1990: 2). Perceivers do this by category-based responses in which category membership determines a target’s attributes with little attention given to individual attributes (Heatherton et al. 2000: 12). While this occurs at one end of the continuum, at the other end individuating responses play a significant role in which individual characteristics are attributed. For people with mental health conditions (the targets), self-categorization theory also lies along a continuum where individuals determine their own responses. Here, the distinction between personal and social identity is more critical. Following the trajectory offered by Tajfel and Turner (1979), Dovidio, Major and Crocker propose that:

when personal identity is salient, an individual’s needs, standards, beliefs, and motives primarily determine behaviour. In contrast, when people’s social identity is activated, ‘people come to perceive themselves more as interchangeable exemplars of a social category than as unique personalities defined by their individual differences from others’ (Turner et al. 1987: 50). Under these conditions, collective needs, goals, and standards are primary (Verkuyten and Hagendoorn 1998). (2000: 13)

Thus, the salience of personal or collective identity matters in shaping how the person ‘perceives, interprets, evaluates, and responds to situations and to others’ (2000: 13) and this makes identity a more complex project to understand, as the changeability of social identity makes it more fluid than unique.

The final dimension of ‘affective-cognitive-behavioral response’ to stigma shows that any of these three items can occur in any sequence with effects that are not necessarily independent. The affective system dominates reactions to stigma in a fast, primitive or fundamental way, while the cognitive system is a slower, goal-directed and deliberated reaction. Behavioural reactions may occur before or after affective and cognitive processes or may even result from the simultaneous effects of both. Affective reactions can be characterized as those that are negative responses to significant physical deformities; causing a quick emotive reaction culminating in a behavioural aversion to people with disfigurement. Yet, cognitive processes may teach specific people to react in more understanding or what Katz (1981) terms ‘ambivalent’ ways (for discussion about this see Jones et al. 1984), like nurses or doctors dealing with patients who have diseases associated with stigma. However, affective reactions may be secondary in some instances. This is the situation in the Philo study, when respondents draw on cultural memory to rewrite news stories about people with mental health conditions in the news and then reject the individual as ‘crazed’. Dovidio et al. suggest that collective responses to stigmas rather than individual ones may be more cognitive or cooler as these are ‘often associated with well-learned consensual stereotypes’. Connected to deeply entrenched schemas, they are spontaneously ready for response and according to Fiske and Taylor (1991: 122) will be cued to affect how we interpret what we see, hear and read. However, stigma is a damaging part of the complex problem mediations cause for the person with unwell mental health.

The Person with Unwell Mental Health and Stigma in Practice

Research about people living with a mental health condition evidences cultural marginalization through the requirement to negotiate stigma and raises concerns about the development of subjectivity. A phenomenological study by Barham and Hayward (1991) examined the subjective meanings that users of mental healthcare services gave to their experiences in the social world. They identified the following themes in people who had been patients: a) feelings of being excluded from participation in social life; b) burdened by a cultural freight they felt obliged to carry; and c) needing reorientation toward ‘coping’ with their vulnerabilities (see Pilgrim and Rogers 1993: 171–2). These qualities of stigma contributed to feelings of marginalization, making them feel reluctant to enter, or re-enter patienthood.

Dunn (1999) seeks solutions to stigma and the social exclusion of people with mental health conditions. After the collapse of mental institutions and the walls that were once its physical barriers, more evidence about the continuous exclusion of people with mental health problems reveals economic and social obstructions, hindering inclusion within the community. The key impediments to living a normal life include employment, economics and media. Two studies cited in Dunn (1999), when coupled, provide strong grounds for the fear people with a mental health condition recognize when seeking employment. Link et al. (1997) determined that 75% of people with a mental health condition considered that they would not tell a prospective employer about their health condition. Glozier (1998) found that employers were less likely to employ a prospective candidate with a mental health condition than someone with another disability such as diabetes. Insurance, both for health and other types (auto and/or travel etc.) in other parts of the world also become significant issues. People with mental health conditions are seen as a financial liability rather than as people who are in need of support.

If cultural practices and discourses marginalize people with mental health conditions, then issues of trust surface in prominent ways. In Philo’s (1996) study and a pilot study for this book (Birch 1996), and in Wahl (1999), evidence shows how mediated stigma can impact subjectivity nurturing distrust not just by people in general but also by medical professionals. In the Wahl study, participants discussed how they would not reveal the condition, keeping it secret and only revealing it to their closest friends, if they did at all. ‘I never reveal’ was the most common remark, offering credence to Goffman’s notion of ‘covering’ the identity spoiled by stigma. Wahl further says that the notion that the person practicing honesty sometimes becomes, against their will, dishonest as a result of stigma. The Link study reinforces this point about distrust as well as the resulting change in behaviour and the ways in which they bring feelings of social isolation into play.

In examining personal and media narratives of unwell mental health, Birch (1995) showed how participants operated careful social management in their everyday life. These narratives further illuminated issues of distrust and isolation. Examining a tabloid depiction about schizophrenia, one participant related: ‘I am not a person who inspires fear in others. I am well-liked by a number of elderly neighbours, though I have always been careful not to let them know of my diagnosis of schizophrenia’.

In the Wahl study, a woman experiencing a severe case of post-natal depression said that she felt terrified about revealing she had been in hospital. Another was alarmed at divulging she had been hospitalized, particularly as she worked in the field of psychology. One participant indicated that she felt both fear and anger. Considerable energy was employed in her dealings with work colleagues: ‘The people where I work and a lot of people I socialize with don’t know that I’ve had these problems. And I live in fear of them finding out because I know they will treat me differently’ (1999: 135).

Language and history often play a significant part in the ways in which stigma is generated. One respondent described where he had first encountered stigmatic knowledge about his condition.

When I was told I was schizophrenic, I was very intimidated by it – I thought I was some sort of monster. I didn’t actually feel like a monster, but when they said I was schizophrenic, I just couldn’t believe it. … It’s just such a hell of a word, you know and it’s got a hell of a stigma. … My window cleaner asked me ‘would you not hit me over the head with the hammer?’ – I had to reassure him that ‘look mate, I’m not violent’ and he was telling the neighbours. It rots you, it just rots you. … Jane Eyre was my mother’s favourite programme and I think I got it from her. We watched it faithfully everyday Saturday night. She [a character in the story] was insane and she ran around screaming and shouting and burnt the house down – that instilled real fear in me. … They’ll burn the house down, they’ll stab you, they’ll kill you – that’s what I thought myself until I realised I had a problem myself. (User of Services, Glasgow) (Philo 1996: 111)

The quotation at the beginning of chapter resonates with these users, the problem of cultural marginalization perpetuated in mediations through stigmatizing themes of dangerousness. If, as this evidence indicates, meanings of stigma produced in cultural and media discourses are deeply embedded in the lived experiences of people with admitted health conditions, then further questions are raised about how its pejorative power influences other people in the forming of their sense of self and identity; particularly people who suffer from anxiety (approximately 2.8 million in the UK) (Bird 1993: 11) or people with depressive conditions who account for one in six of the population (Bird 1999: 6). Also, anorexia nervosa, identified as the third most ‘chronic illness’ in teenage girls, is more likely to affect women rather than men by a factor of 12:1 and bulimia nervosa will affect 1–2% of women in the UK (Bird 1999: 6–8). These figures constitute major sections of the community. If concerns are raised about how these significant numbers of people with mental health conditions perceive their own identity in pejorative mediations, then, the need arises to seek out what these people make of mediations and to determine alternative ways in which mental health can be portrayed. Consequently, part of the purpose in undertaking a Media Reception-Production Study is to focus upon identity and the struggle by people with mental health conditions around it. It seeks out those discourses impacting the subject in his/her struggle to define individual identity and in the production process, look innovatively for new portrayals offering indicators about ways forward in mediating mental health.

Revealing that stigma is everywhere, and resident in nearly every society, Dovidio et al. (2000) say it produces existential anxiety in people. From this anxiety, perceptions of difference and deviance give rise to increased awareness about a person’s (i.e., a target’s) own vulnerability and exposure in society. Revelation of an identity as a perceived threat mobilizes people to reinforce their world view of difference about a social group an...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of Figures
• List of Tables
• Foreword
• Preface
• Acknowledgements
• A Note about Language and Mental Health
• Introduction
• 1 Mediating Mental Health
• 2 Critical Contexts
• 3 Historical Contexts for Popular Meanings of ‘Madness’
• An Outline of the Case Studies
• 4 Phase One, Genre Studies 1: Film
• 5 Phase One, Genre Studies 2: News and Documentary
• 6 Phase One, Genre Studies 3: Drama
• 7 Phase Two, Part 1: The Community Project: Reception Study
• 8 Phase Two, Part 2: The Community Project: Production Study Exploring Change: Approach, Alternative Images and Practices
• 9 Conclusion
• Bibliography
• Index