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Article

Mass media’s power to influence public perception, com- bined with frequent media exposure in today’s society, make mass media one of the most substantial influences in developed societies. It comprises the Saudi public’s primary source of information (De Choudhury, 2013) with 99% of households having televisions (Nationmaster. com, n.d.), 180 telephones per 100 residents (al-Arabiya. net, n.d.), 5 million Facebook accounts (Aljasir, Woodcock, & Harrison, 2012), and 2/3 of Saudi citizens having access to internet (saudiembassy.net, n.d.). However, when it comes to mental health, media tends to skew reality with inaccurate portrayal of mental health. For better or worse, media shapes our ideas and the way we understand those around us.

Prior research has uncovered a definitive link between how mental health problems are reported in media and the public’s incomplete, trivialized, or distorted percep- tions of mental health problems (De Choudhury, 2013). Klin and Lemish (2008) observed that media fabrications may lead to creation of false concepts and programs that do not accurately portray people with mental health prob- lems. Misunderstandings with considerable consequences

may arise due to inaccurate information from media about mental health problems, even when portrayals are discussed in a positive light such as Australian nonfic- tional media (Francis et al., 2004).

De Choudhury (2013) indicated that an inaccurate depiction of schizophrenia as multiple personality disor- der in drama has led to confusion, conflict, and treatment delays. This stigma may be self-directed (DeLuca & Clement, 2017) or originate from society at large. Watkins

855771 JAPXXX10.1177/1078390319855771Journal of the American Psychiatric Nurses AssociationAlyousef et al. research-article2019

1Seham Mansour Alyousef, PhD, King Saud University, Riyadh, Saudi Arabia 2Sami Abdulrahman Alhamidi, PhD, King Saud University, Riyadh, Saudi Arabia 3Monirah Albloushi, PhD, King Saud University, Riyadh, Saudi Arabia 4Thurayya Abduwahid Eid, PhD, King Saud University, Riyadh, Saudi Arabia

Corresponding Author: Seham Mansour Alyousef, Department of Community and Psychiatric Mental Health, College of Nursing, King Saud University, Riyadh 54995, Saudi Arabia. Email: [email protected]

Perceptions of Media’s Contribution Toward Stigmatization of Mental Health by Saudi Arabian Nurses

Seham Mansour Alyousef1 , Sami Abdulrahman Alhamidi2, Monirah Albloushi3, and Thurayya Abduwahid Eid4

Abstract BACKGROUND: Public often obtains mental health information from mass media and Saudi Arabia is characterized by high media penetration. Fictional and nonfictional media dramatize, trivialize, and misrepresent characteristics and needs of clients who need mental health care and may create and reinforce existing stigma. This pattern of stigma may adversely affect mental health care clients, practitioners, education, and programs. Portrayal of mental illness and opportunities for care in Saudi Arabia need development. OBJECTIVE: This study examined Saudi graduate nurses’ perceptions of stigma created by mass media and influence on public perceptions of mental health issues and use of these views to formulate ways to effect changes in mental health care availability and delivery. METHOD: Participants included 18 graduate practicing female mental health nurses at King Saud University School of Nursing. Qualitative data were collected using individual interviews and analyzed using NVivo 10.1 software for thematic content analysis. RESULTS: The core theme that emerged was “stigma in media,” which in turn had five subthemes: (a) media portrayal, (b) mass media, (c) social stigma, and (d) mental health care services. CONCLUSION: This inquiry may be helpful in enabling development of stigma-reduction programs by shedding light on the role of mass media in forming normative behavior and attitudes toward mental illness in Saudi culture.

Keywords mental health, mass media, stigma, nurse, Saudi Arabia

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and Jacoby (2007) noted that people with mental health problems are often pushed to the fringes of society and experience societal exclusion. Hinshaw and Stier (2008) found that stigma of mental illness can lead to social iso- lation and decreased quality of life, including restriction of access to work opportunities, housing, and other basic needs.

Livingston and Boyd (2010) also found that people with mental health problems in New Zealand experience stigma due to influence of media. These depictions emphasize a link between mental health disorders, crimi- nality, and threat to the community. However, links between mental health care and more constructive phe- nomena (e.g., leadership, universities, or human rights) are given far less emphasis.

Goodwin, Savage, and Horgan (2016) suggested that mental health publications in the United Kingdom rarely include examples of direct engagement with those who have mental health problems (i.e., one study found that 6% of texts about mental health cited individuals). In a 9-week survey of U.K. newspapers, more than half of articles con- cerning mental health had a negative theme with 18.5% to the total citing violence (Chen & Lawrie, 2017).

Information about stigma related to mental health care in Saudi Arabia is largely anecdotal. Al-Qhatani and Salmon (2008) found that about half (50%) of primary care patients in Saudi Arabia blamed nerves, stress, and religious factors as causes for their physical symptoms. This suggests that the general population largely recog- nizes that there are mental and emotional factors in ill- ness. To date, no studies have yet attempted to explore levels of mental health stigma in Saudi Arabia, its sources, and how it affects the population as a whole, sufferers of mental health problems, and those who care for them.

It bears noting that mental health is not freely dis- cussed at a personal level in Saudi Arabia. Clients who are receiving care for mental health concerns do not gen- erally divulge this to those around them. Obeid, Abulaban, Al-Hantani, Al-Malki, and Al-Ghamdi (2012) found 40% of university graduate school teachers believed that the cause of epilepsy was possession by Jinn (spirits). Thus, it is possible that even immediate family members are unaware that clients are receiving mental health care due to fear of stigma.

The purpose of this study is to explore views of prac- ticing Saudi mental health nurses with a variety of experi- ence about how they feel portrayal of mental illness in media affects their practice, patients, and society. Findings of this work may be useful in illuminating how mental health nurses view media affect on mental health care delivery in Saudi Arabia. This outcome may enable plan- ning of specific steps to ameliorate effects of media-cre- ated stigma resulting in improved delivery of mental health care.

Method

An interpretive descriptive design was used to analyze nurses’ perceptions of effect of media on mental health stigma in Saudi population.

Setting and Participants

Creswell et al. (2016) assert that the optimal method for elucidating views of an individual is to conduct semis- tructured, face-to-face interviews with that person indi- vidually. Interviews in the current study took place at the College of Nursing of King Saud University, Riyadh. All 18 of the participating subjects were female, and they ranged in age from 25 to 37 years. Each participant had prior experience of delivering mental health care in a variety of clinical settings in Saudi Arabia (i.e., private and state-run hospitals) and at the time of interview, each subject was actively pursuing a master’s degree in mental health nursing.

Subjects had to meet several criteria for inclusion in the study. Individuals were included if they were fluent in English, had 5 or more years of practical experience, and were employed in a clinical mental health setting with direct contact with patients at the time of the study.

Data Collection Procedure

Eighteen participants were included in the study. Four were employed by private health care providers, and 14 were psychiatric nurses employed by the public sector. Interviews were conducted in the psychiatric department of the nursing college and lasted approximately 60 min- utes each.

Ethical Consideration

We sought and obtained permission from the ethics body of King Saud University Hospital to carry out the study and record interviews. Participants were recruited via e-mail and made arrangements for interviews by tele- phone. Prior to participating in interviews, participants signed a written consent form. Verbal and written consent for audio recordings of interviews was also obtained before interviews commenced. No financial incentive was provided and participants were assured that content of their interviews would be stored securely and remain confidential, and that opinions they expressed would not influence their academic standing or grades.

Rigor

We followed principles of interpretive epistemology rec- ommended by Savin-Baden and Major (2013). We made

Alyousef et al. 3

efforts to consider perspectives of the subjects and to avoid preconceived expectations and ideas. Member checking and peer review was employed. Dependability, credibility, confirmability, and transferability of the study were enhanced through these means.

Data, codes, and categories were reviewed by two separate researchers, who then reached a consensus on meaning, accuracy, and importance of data. Consensus was reached only after a separate review and joint discus- sion by two separate researchers.

Two open-ended questions were used as probes to open semi-structured interviews. Probes were employed to assess participants’ impressions of effects of mental ill- ness stigma encountered by their clients and contribution of mass media to this phenomenon. Subsequent questions were structured around participants’ responses to these probes.

Data Analysis

Recording common themes allows researchers to detect patterns and themes that are repeated, and to consider their participants’ perspectives fully in their data interpre- tation (Braun, Clarke, & Terry, 2014; Ritchie, Lewis, Nicholls, & Ormston, 2013) have suggested that follow- ing transcription of interviews and a subsequent read- through of completed narratives, we coded the transcripts and identified themes that were beginning to emerge. We used the data analysis approach recommended by Silver and Lewins (2014), assisted by thematic analytic soft- ware NVivo 10.1. We subsequently discussed the themes and subthemes that emerged with an expert peer. Appendix A displays codes that were extracted.

Results

Overview

Each statement was regarded as significant and as poten- tially relevant to the study objective. Statements were coded within the NVivo 10.1 program as free nodes with- out instruction or meaning.

“Stigma of mental illness” was the primary emerging theme, and as the subjects expanded their perspectives on this theme, five further subthemes emerged. These themes included (a) media portrayal, (b) mass media, (c) social stigma, and (d) mental health care services.

Thick Descriptions of Emergent Themes

Main Theme: Stigma of Mental Illness in Media. This main theme which emerged—Stigma of Mental Illness in Media—is the sum and total of categories emerging from the data. Fictional and nonfictional media are both

responsible for providing consumers with impressions of the nature of mental illness.

Entertainment focused media portrayal highlights emphasis on stereotypes of persons who are displaying bizarre, distressed, or disturbing behavior. These patterns have been provided to consumers as the hallmark of per- sons in need of mental health care without attention to disorders which do not provide overt signs to the lay observer.

Nonfictional media is scarce, often profit motivated, and focuses on directing the public toward seeking care for symptoms which conform with the stereotype of men- tal illness or physical disorders which may actually be related to mental distress. In this vein advertising for relief of stress, insomnia, muscular pains, headache, and marital discord are predominant.

Subtheme 1: Media Portrayal. In Saudi Arabia, media por- trayal is now the primary means by which people obtain information. Types of media used include all forms of mass communication (e.g., television, radio, newspapers, signage), all types of online social media (e.g., Twitter, Instagram, Snapchat, and to a lesser extent Facebook), and internet including heavy use of YouTube and sites such as Netflix as a source of entertainment.

This high level of use of various media sources has led to an increase in access to materials which may be implicated in fueling misconceptions and increase dis- crimination against people with mental health problems via propagation of false and inaccurate information. Of the participants, 14 felt that media could, and should, play a more responsible role in educating people about mental health issues and in breaking down stigma rather than providing inaccurate views that lead to negative attitudes.

Subtheme 2: Mass Media and Its Impact on Mental Health. Several participants commented on sources most used by the media in Saudi Arabia. The type of media which is growing very rapidly in popularity is based in the electronic domain including Twitter, Snapchat, Insta- gram, SMS, and Facebook. Because of the weakness of advertising in Saudi Arabia as an institution in the recent past, these platforms are becoming major sources of pro- motion of services and products in addition to social interaction, exchange of opinions, and expansion of a wide variety of information. These innovations are par- tially replacing traditional word-of-mouth communica- tion. Radio and newspapers continue to be popular sources of communications but are not as attractive to the public as the highly graphic television nor the individual- ized content available on social media. Signage in town, cities, and on highways are used for advertisement of commercial products and services.

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Participants discussed role of media in mental health awareness and its interaction with the Saudi community and the world. One participant indicated that, regardless of whether mental health issues were depicted in positive or negative ways, communications have a vital impact on Saudi society:

Media is an important source that conveys to us views of mental health on the positive or negative side, and it has a huge impact on the community. [It is] possible to benefit from it, and [it] must be exploited effectively by healthcare providers.

One participant also noted that Saudi television and radio do not provide nonfictional treatment of mental health issues, unlike other countries such as the United States, Australia, and the United Kingdom, which discuss psychological issues related to the community:

There are no special programs on media such as TV or radio that focus on mental health issues. . . . For example, in the USA and UK, channels are more focused on programs on mental health concerns. . . . Although the radio does not care much about promoting mental health issues in the Saudi culture, we need to be concerned with mental health awareness programs.

Another participant stressed that presenting and dis- cussing psychological and mental health issues was not being subjected to content censorship, which can lead to problems and risks for users of social media (especially adolescents). “In social media, sometimes, discussions of psychological and mental health problems are inaccurate, disorganized, and random and not based on scientific background. This is risky for our society, particularly when followers are teenagers.”

Subtheme 3: Social Stigma. Participants felt that media coverage directly contributes to the image of mental health issues in the community. Several participants noted that media often presented mental health problems using negative images. One cited an example of a televi- sion show depicting people with mental health problems as crazy and dangerous. This has led to social fears and increased negative perceptions and stereotypes:

The media reflects the image of a person with mental health problems on TV as a person who is crazy as well as an addict and who cannot be trusted even if he or she obtains treatment. He or she will continue to be a serious problem to his or her family and to society.

Another participant noted that stigmatization, includ- ing self-stigma and social stigma, led to incapacity of mental health patients to express themselves through multimedia:

Via any type of media, it is very difficult to express my feelings or my problems in relation to mental health problems or to search publicly for help and advice. Our society is ashamed and hesitant to seek help for mental health problems, especially through social media, because of fears of society’s views and impact.

Another participant discussed difficulty asking for assistance with mental health issues through the media. The participant noted that there is no normative way to seek help for mental health problems that avoids societal stigmatization: “There is no online or private way for the community to seek help for mental health cases in a social setting or via the media.”

Additionally, this participant highlighted some crimi- nal cases in the community. News coverage of these cases have affected people living with mental health problems:

Murder and criminal cases will always highlight the criminal as a mental patient, and this is the quickest excuse because if he/she is depicted as mentally ill, the community readily accepts this excuse.

Subtheme 4: Mental Health Care Services. Regarding health care services, participants indicated that it is pos- sible to spread awareness of mental health issues among patients during clinical appointments or employ educa- tional tools such as medical education posters or pam- phlets in waiting rooms or corridors.

Two participants noted the absence of an institutional- ized role of media in Saudi society and lack of influence on the mind-set of the public regarding mental health care and issues. They stated that there are no mental health awareness programs offered in various institutions such as hospitals and that the various media do not promote awareness of mental health issues:

There are no clear programs; no awareness; and no signs, for example, on the roads or in public settings; no clear education and advertisements are used to raise mental health awareness, or, for example, to create acceptance of people who are living with mental health problems.

Another participant noted:

There are no clear brochures or educational materials for patients or visitors in mental health clinics or other clinics or in waiting rooms. In waiting rooms, there are posters that offer medical advice on general medical problems, but [they] do not offer tips for psychological and mental health problem awareness.

One participant recommended: “In healthcare centers or hospitals, they must take advantage of the situation of patients and visitors by educating them and raising men- tal health awareness.”

Alyousef et al. 5

Another participant suggested creating awareness of psychological and mental health issues through educa- tional programs and announcements in diverse settings, especially among medical center staff and community members: “Emphasis should be placed on media and psy- chological education for employees and visitors in organi- zations, hospitals, healthcare centers, roads, and schools.”

Other participants stressed that it is vital to end self- imposed and social stigma associated with mental health problems that flourish on social media. Simultaneously, Twitter or Snapchat were considered effective avenues for mental health workers to provide information on criti- cal mental health topics to the community:

It is necessary to exploit social media to raise awareness of mental health concerns in Saudi culture and reduce negative perceptions of mental health problems or illness and urge people to seek treatment without shame because the negative perception of such people is strong, especially on Twitter and Snapchat. In Saudi Arabia, there is still reluctance to seek mental health help. Mental health communities in Saudi Arabia must contribute to raising awareness by social media about up-to-date treatment methods.

These themes which emerged during analysis of stigma of mental health and mental illness in media in Saudi Arabia are represented in a concept map in Appendix B.

Discussion

Participants identified problematic depictions of men- tal health issues in their core theme of “stigma in media.” They expanded their perspectives on this theme with subthemes of “mass media” and “media portrayal” leading to dramatization, stereotyping, and trivializa- tion thereby forming false concepts and approaches that do not meet the need for care of people with mental health problems. These findings are similar to those conducted in the United Kingdom in which a survey of newspapers found articles related to mental health were largely negative in tone of which 18.5% associated mental illness with violence (Chen & Lawrie, 2017). This problem was believed to exist at the personal and social levels and even among health care professionals. Stigma was linked to the media’s unfavorable coverage and poor depiction of those with mental health prob- lems, which supplemented cultural misconceptions. This is consistent with the findings of McGinty, Goldman, Pescosolido, and Barry (2015)—namely, that most of the public’s knowledge about mental health problems stems from media.

Another key subtheme was “social stigma,” which described how stigma can arise from media’s depiction of individuals living with mental health problems. These

findings are consistent with those of Hinshaw and Stier (2008) in the United Kingdom, where individuals felt stigmatized from the moment they were diagnosed with mental health problems, which they attributed to the media’s depiction of their condition.

The stigma due to negative media coverage was found to impede recovery, trigger discrimination and prejudice, and create barriers. Decent housing, employment, and educational opportunities were among the aspects of life affected thus influencing income and life choices (Clement et al., 2013; Vahabzadeh, Wittenauer, & Carr, 2011).

A review of mental health–related media coverage based on electronic database search evaluated news media, social media posts, and media interventions aimed to reduce stigma. It was found that there was a positive relation between the tenor of reporting of mental illness and stigma and that interventions in the press to increase positive attitudes were ineffective (Ross, Morgan, Jorm, & Reavley, 2019).

An emergent question concerns degree to which Saudi Arabian society is influential in creating stigma. Our findings indicated that people living with mental health problems become associated with criminality in the collective mind of the community. Consistently, Lorenc et al. (2012) found that even one image of vio- lence portrayed by media involving people with mental health problems increased fears among members of the public that people with mental illness are violent and criminal. In actuality, mental illness has not been found to predispose persons to violent behavior with empiri- cal findings suggesting that those suffering from mental illness are in fact more likely to become victims of vio- lence than perpetrators (McGinty et al., 2015; Vahabzadeh et al., 2011).

Finally, we noted the fourth subtheme of “mental health care services.” According to this theme, there is a need to address stigma on a societal level as well as through mental health professionals’ own practice. Subjects noted that a variety of information sources aimed at improving the nation’s outlook on mental illness are necessary. These sources could include existing forms of health education and health promotion structures, new programs for this purpose, and informed reports on mass and social media.

Despite negative views about people with mental ill- ness being propagated by media, Burns and Birrell (2014) noted that it still plays a vital role in changing these perceptions and can do so by sharing accurate and positive messages and stories about people with mental health problems. Corrigan, Druss, and Perlick (2014) also indicated that the media should cover stories related to the successful recovery of those with mental health problems to contribute to the elimination of

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stigma and discrimination. Clearly, stereotypes, whether deliberate or not, have significant adverse effects on the course of recovery of people experienc- ing mental health problems. Furthermore, social sup- port and community services are important for facilitating the recovery of people with mental health problems as it provides them with hope, and a sense belief and wellness, that their future will be better than their past.

Limitations

This study has some limitations. The sample included female nurses which may not represent views of male colleagues. Participants were health care workers who reside in the greater Riyadh urban area. Therefore, the results may have limited generalizability to other locales in Saudi Arabia and elsewhere. Furthermore, in future research, “mental health problems” should be opera- tionally defined with more precise terminology, and the effects of diverse media outlets should be examined individually.

Conclusion

This inquiry examined the stigma generated when media portrays people experiencing mental health problems in Saudi Arabia, including consistently misrepresenting, exaggerating, and misinforming the public about people with mental health problems through the eyes of practic- ing mental health nurses. The main theme is Stigma of Mental Illness in Media from which emerged subthemes Media Portrayal, Mass Media, Social Stigma, and Mental Health Services.

Implications for Future Research

We recommend that future research should involve par- ticipants from rural areas so that future service develop- ments in mental health care can be tailored to meet the needs of both urban and rural communities. Various researchers suggest that this is especially crucial in the development of effective and responsive community mental health services (Jameson & Blank, 2007; Thomas, Hyde, Karunaratne, Herbert, & Komesaroff, 2008; Watkins & Jacoby, 2007). An improved insight into stigma in Saudi Arabia may also emerge from gaining a clearer picture of the cultural differences between the many ethnic groups in the country and how they view and interact with the concept of mental illness and those who suffer from it.

Implications for Practice

Interaction with media and other stakeholders such as clients, their families, community leaders, health care professionals, and public role models in ways to improve the image of mental health care and auger for appropriate depiction of mental illness may be instrumental in reduc- ing the amount of stigma portrayed and providing a hopeful outlook of how media might assist in improving and adjusting the image of mental health care, care pro- viders, and consumers of that care. Reposition of mental health care within the health care delivery system by inclusion in the primary care process in line with the APNA Primary Care Position Paper recommendations may assist in creating an environment characterized by reduced stigma, higher treatment availability, and appro- priate utilization by members of the population (American Psychiatric Nurses Association, n.d.).

Appendix A

Primary Codes (All Listed Are Frequency of One Except When Otherwise Noted).

Crazy (2), insane, addict, mental illness, blame, image, murder, destruction, inaccurate, excuse to kill, criminality, dangerous (2), risky, violent, violence, fear, crime, imprisonment, reflect

Twitter (4), Instagram (4), Facebook, image, awareness (4), search, impact, information, positive, idea, false, negative (4), television

Positive, unconscious, softened, reason, study, UK, USA, benefit, no special program (2), education program (2), symposium (2), treatment, recovery, attendance, counselling, benefit

Not trusted, serious, family (3), society, hope, awareness, ashamed, hesitant, seek help, teenagers, awareness (5), image, isolating, poster (3), brochure, signs, educate patients, educate visitors, organizations, online, privacy (3)

Shame, reluctance to seek help, negative perception, avoids, acceptance

Alyousef et al. 7

Appendix B

Effect of media on mental health nurse practice in Saudi Arabia

Authors’ Roles

S. Alyousef, principal investigator; S. Alhamidi, data analysis, manuscript editor; M. Albloushi, data collection; T. Eid, data collection.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received the following financial support for the research, authorship, and/or publication of this article: The authors are grateful to the Deanship of Scientific Research, College of Nursing Research Centre at King Saud University for funding this research.

ORCID iD Seham Mansour Alyousef https://orcid.org/0000-0003

-3815-9722

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