Schizophrenia

The schizophrenia stigma and mass media: a search for news published by wide circulation media in Brazil

Francisco Bevilacqua Guarniero, Ruth Helena Bellinghini and Wagner Farid Gattaz

Departamento e Instituto de Psiquiatria do Hospital das Cl�ınicas da Faculdade de Medicina da Universidade de S~ao Paulo (IPq-HCFMUSP), S~ao Paulo, Brazil

ABSTRACT Schizophrenia is the most common illness used today as a metaphor in the media and routinely appears associated with crime and violence with no medical or scientific rigor, reinforcing the stigma against this disorder. Evaluation of the presence of structural stigma in the Brazilian media by means of a survey of printed news and the Internet using the term schizophrenia and its correlates under three aspects: (a) medical and scientific uses, (b) assigning a diagnosis of schizophrenia to crime suspects with little or no medical or scientific rigor, and (c) the metaphor- ical use. The study was conducted in three stages: search for publications, classification of items found and analysis of the context in which they were published. The survey was conducted in two periods: 2008 and 2011, the first being restricted to the newspaper Folha de S. Paulo and the second extended to the homepage of the main Brazilian print media. We found 229 texts, distributed as follows: 89 (39%) records as science and health, with a tendency to impersonality; 62 (27%) records as crime and violence, in which the ‘diagnosis’ of schizophrenia is given by lay people and ‘supported’ by an archeology of the life of the suspect which enlists all sorts of non- standard behavior; and 78 (34%) records of metaphorical use, always with a negative meaning. Most of the texts found (a) does not give voice to people with schizophrenia and their suffering, (b) trivializes the use of this psychiatric illness out of context to describe contradictory or of dubious character political and economic decisions, and (c) reinforces the stigma that lays over the bearer of schizophrenia individualizing them only in rare violent cases with a supposed diagnosis.

KEYWORDS Social stigma; schizophrenia; prejudice; social communication; press

Introduction

The stigma associated to mental illness is the main barrier for people in need to seek for professional help. This problem’s lack of visibility makes govern- ment in general to put little resources into mental health, and patients face social isolation and difficul- ties to find housing and work. Furthermore, this population receives worse healthcare (World Health Organization, 2001), once clinicians tend to credit their physical symptoms to ‘products of disturbed minds’ (Druss, Bradford, Rosenheck, Radford, & Krumholz, 2001). Within Psychiatry, schizophrenia presents a high level of stigma, which motivates favor- able campaigns for the patients and against the improper usage of the term in several countries (Jamison, 2006; World Psychiatric Association, 2002). Through History, common language has used medical diagnoses and distorted them, in many occasion as a way to segregate and to mark an ‘undesirable’ part of

society. The word ‘mongolism’ was used as a synonym to Down’s Syndrome until the Popular Republic of Mongolia made a formal request for the medical authorities to drop it. Politics has successively appro- priated the terms syphilis, tuberculosis, cancer, and more recently, schizophrenia, as a current expression, and nowadays schizophrenia is the most common negative metaphor used by the media (Corrigan et al., 2005). This inappropriate usage reinforces the stigma against patients. In ‘Illness as Metaphor’, Susan Sontag states about cancer that death is now an aggressively senseless event, so that a disease widely regarded as synonymous with death is regarded as something to hide (Sontag, 1978). The menace over the Psychiatric patient and their family is not of phys- ical death, but one of exclusion, a social death. Sociology describes a form of prejudice and discrimin- ation called structural stigma (Hill, 1988), object of the present discussion. It is a kind of stigma formed by well determined social or political forces, and is

This is an updated English version of the paper: Guarniero, F.B; Bellinghini, R.H; Gattaz, W.F. (2012). O estigma da esquizofrenia na m�ıdia: um levanta- mento de not�ıcias publicadas em ve�ıculos brasileiros de grande circulaç~ao. The schizophrenia stigma and mass media: a search for news published by wide circulation media in Brazil. Rev Psiquiatr Cl�ın. vol. 39 no. 3: 80–84. � 2017 Institute of Psychiatry and Johns Hopkins University

INTERNATIONAL REVIEW OF PSYCHIATRY, 2017 VOL. 29, NO. 3, 241–247 http://dx.doi.org/10.1080/09540261.2017.1285976

ARTICLE

represented in the actions and messages from private or public institutions that limit the opportunities for the stigmatized group. One example were the civil limi- tations imposed over people from the African contin- ent, like the inability to vote in different Western nations in the period after the abolition of slavery. In the very same way, it is what occur when an institution, instead of an individual, promotes stereotypical, preju- dicial and/or discriminatory messages against mental illness and its patients. The media today is a strong and prevalent institution, and the analysis of the published news about mental illness is a measure of the structural stigma present in this type of media (Corrigan et al., 2005). The medical literature has observed the presence of structural stigma, especially against schizophrenia, in mass media all over the globe (Byrne, 1997), verifying two different aspects: in one hand, the attribution of the psychiatric diagnosis with no or very little medical or scientific consistency – a diagnostic made by lay authorities, neighbors or family of persons from real stories; on the other hand, the recurrent metaphoric usage of the term ‘schizophrenia’ with derogatory meanings, such as contradictory, insane, incomprehen- sible (Corrigan et al., 2005; Wahl, Wood, & Richards, 2002). Moreover, current researches show the low fre- quency of positive stories about schizophrenia in the news, whereas there is a high prevalence of stories relating mental illness to violence (Nairn & Coverdale, 2005). It was observed, furthermore, the lack of a deeper discussion with professionals from the mental health area, and impersonal characteristics of the so called scientific news, like the ones about new treat- ments. Although the numerous studies from abroad, there is little attention to the matter in the biggest Portuguese speaking nation in the world, Brazil. With a low cost and a simple execution, the digital evaluation of the press in the Brazilian territory may give a por- trait of the nation’s structural stigma. Schizophrenia is the mental disorder of choice, because despite political changes towards mental health, schizophrenia patients have to live with the double challenge of disabilities and fighting unfair stereotypes and prejudice (Corrigan & Watson, 2002). As a consequence, this population is doomed to a vicious circle of marginalization, alien- ation, poverty and social exclusion (Thornicroft, Rose, Kassam, & Sartorius, 2007).

Methods

The present research was done in three steps: news survey, classification and published context.

News survey

The news survey was done in two phases: the first one was restricted to the national newspaper ‘Folha de S. Paulo’, selected for its first position as the most distributed newspaper nationwide, as evaluated by an external institution. A period of 12 months was randomly assigned from January 1st to December 31st 2008 (Folha e Uol, 2011). All dupli- cated items or news that were too short to be clas- sified were excluded. This news survey was presented as a dissertation for the Journalism Department of the School of Communications and Arts from the University of S~ao Paulo (Guarniero, 2009). In the second phase, through a simple inter- net search, all news, editorials, blog and articles that had the word ‘schizophrenia’ and/or ‘schizophrenic’ were collected, from the random assigned period between January 1st and December 31st 2011. The search included the following news sites: ‘Folha de S. Paulo’ (Folha), ‘O Estado de S. Paulo’ (Estad~ao), ‘O Globo’ (Globo), ‘Veja’, and ‘Epoca’ (Estad~ao, 2011; Folha e Uol, 2011; O Globo, 2011; Revista �Epoca, 2011; Veja, 2011).

Classification of items

Eligible items were divided as the following, in accordance to their analyses (Corrigan et al., 2005; Wahl et al., 2002): (i) Science & Health; (ii) Crime & Violence; and (iii) Metaphor. For this investigation, Science & Health was further divided into: Etiology, with or without a strong scientific basis, including biological and environmental etiology, investigation, diagnosis, patient and family ‘guilty’ in the disease development; Treatment & Recovery, including advances in treatment, recovery and rehabilitation; Affirmative Action, including the need of public pol- icy to improve the quality of life of people with schizophrenia, and actions to fight prejudice and dis- crimination; Other: several other notes, news, reports etc. e.g. a preview of a movie with a character with schizophrenia and all other items that were not pos- sible to be otherwise classified. The Metaphor classifi- cation was divided in terms of meaning: positive or negative/prejudiced.

Context analysis

After the classification, all items were analyzed for their context of publication.

242 F. BEVILACQUA GUARNIERO ET AL.

Results

News survey & classification

In the Folha online search engine, it was found 56 published items, from which 45 could be included in the analysis, including news report, interviews, articles, notes, editorials. All the items were classified as the following: 20 items as Science & Health (44.5%); 6 items, as Crime & Violence (13.3%); and 19 items, as Metaphor (42.2%). Amongst the ones that refer to schizophrenia as the mental illness, 11 were about Etiology (55%); 2, Treatment & Recovery (10%); 7, other (35%). No item found was about Affirmative Action. All the 19 items found as Metaphor were of negative and/or prejudiced nature. When the other media described was included, 184 items were found. Of these, 69 (37.5%) belonged to the category of Science & Health; 56 (30.4%) fitted the records of Crime & Violence, and 59 (32.6%) used schizophrenia as a Metaphor. Of these 184 texts,

only 13 (7%) presented the patient in a neutral or positive way. A summary of the findings of both sur- veys is shown in Table 1.

Context analysis

Examples taken from the vehicles analyzed for context analysis are shown in Box 1. The analysis was then subdivided according to the proposed classification.

Science & health

News about genes, stem cell studies, and neuroscience advances that are somehow associated with diseases such as schizophrenia are prevalent in the media, but excel at impersonality and most often belong to the realms of basic science. In the period from January to December 2011, we highlighted 6 items that explored the relationship between Cannabis and schizophrenia.

Table 1. Frequency of publications eligible for analysis concerning the term ‘schizophrenia’ and correlates, accordingly to their classification.

2008 2011

Classification Folha N ¼ 45 % Folha N ¼ 61 % Total N ¼ 184 % Science & Health 20 44.5 32 52.5 69 37.5 Crime & Violence 6 13.3 15 24.6 56 30.4 As a negative metaphora 19 42.2 14 22.9 59 32.6 aMeaning contradictory, insane, inexplicable.

Box 1. Context examples of the use of the term ‘schizophrenia. and/or its correlates (free translation from the Portuguese and bold by the authors). Context Example Media

Crime & Violence – the notorious case denominated in the media as ‘Realengo Massacre’

‘Wellington acted alone, says the police. Despite the disconnected references about religion, and an attraction for the fundamental- ism, he was no more than an idiot who decided to transform a life of social rejection into brutality.’

Veja (7th Apr 2011) In this case, the news report uses the diagnosis of schizophrenia sev- eral times before these 2 examples

‘Since being lonely is not equal to being unique, the connections and aspirations that collaborated with his deteriorated and diabol- ical criminal mind cannot be overlooked.’

‘Revealing the troubled mind of Wellington, Fant�astico clarifies that he lived a confusion between 2 religions: Jehovah's Witness and Islamism ( … ) it is not yet known if it is the product of an illness like schizophrenia.’

�Epoca online, blog ‘O Filtro’ (11th Apr 2011)

Crime & Violence – other cases ‘The defendant said he suffered from mental illness and that he had also previously received death threats. Relatives and neighbors confirmed that the defendant was mentally ill and used to take medicine for schizophrenia treatment.’

Folha (30th Dec 2008)

‘She [the child] was nothing like me. I wanted to get rid of her. I think I am schizophrenic.’

Folha (2nd Jul 2008) In this case, the headline was: “Mother arrested accused of throw- ing her 8-month-baby from the 6th

floor in Curitiba”

Negative metaphoric use ‘There is a schizophrenia within the city administration. The same mayor who demands the vehicular inspection does not invest in road work to aid the cars.’

Folha (5th Jun 2011)

‘Brazil’s foreign exchange policy is going schizophrenic. The Brazilian Federal Reserve keeps saying they do not have a foreign exchange target.’

Estad~ao (11th Jan 2011)

INTERNATIONAL REVIEW OF PSYCHIATRY 243

Crime & violence

In the Folha news survey during the year 2008, the 6 reports of violence and crime are sporadic cases, refer- ring to an alleged diagnosis of schizophrenia for sus- pects of crimes, as well as to the use of such a diagnosis as a legal defense; the ‘diagnosis’ was assumed as such solely on the basis of testimony from lay persons or from the person accused of the crime. Comparing only the Folha findings, the number jumped from 6 in 2008 to 15 in 2011, a 150% change. In the total media survey of 2011, 56 records were found, of which only 9 were sporadic cases; the remaining 47 were on well-known cases of the national and international press, namely: Wellington Oliveira case (‘the Realengo massacre’), with 31 occur- rences (55.35%); Glauco case, 9 occurrences (16.09%); Behring Breivik case (‘the Norwegian sniper’), 6 occurrences (10.71%); Jared Lee Loughner case (the Tucson shooter), 1 occurrence (1.78%).

Metaphor

The metaphorical use of the word ‘schizophrenia’, and especially ‘schizophrenic’, in the sense of ‘absurd’, ‘incoherent’ and ‘contradictory’, is recurrent in the political section (government, judiciary, The United States, Great Britain and even the European Community are branded as ‘schizophrenics’ by differ- ent authors and editorialists), economy section (exchange rate policy, economic policy, financial ‘schizophrenia’), but mainly in the publishing of arts and shows. It was considered ‘schizophrenic’ the Gramado Film Festival; the Cyndi Lauper show (that goes from ‘classics to pop platitudes’); the rhythm of the musical Evita; Batman; the actor (who strips off himself to dress a character according to the actress Bruna Lombardi); the unhappiness of today (according to the filmmaker and columnist Arnaldo Jabor); Rose, the neighbor of the character Charlie Harper in the series Two and a Half Man; the singer Madonna (who in adolescence did not decide between being a nun and popstar, according to herself); and the New York Times (charge for online access, but distribute free content on social networks). No items with positive metaphorical use were found.

Discussion

Most of the texts found: (a) do not give voice to peo- ple with schizophrenia and its suffering; (b) trivialize the psychiatric illness by employing it out of context to characterize contradictory political or economic

decisions or of doubtful character; and (c) reinforces the stigma that weighs on people with schizophrenia by personalizing it only in the sporadic cases of vio- lence in which this psychiatric diagnosis is supposed to be present. It is in the context of violence and crime that the most intense stigmatization of the schizophrenia occurs. As much as mental health experts strive to assert that this patient is rarely vio- lent (Gattaz, 1998), only after the occurrence of bar- baric crime, of the commotion caused by the killing of children in school, or of adolescents on an idyllic island in the Nordic summer, is that psychiatrists are heard to talk about this patient, namely, the rare schizophrenic sufferer who commits a violent act (Hodgins, Mednick, Brennan, Schulsinger, & Engberg, 1996). The impact of a notorious violent fact shows a significant link in the increase of the use of the term ‘schizophrenia’ in the context of Violence & Crime, as observed in the present study in the case of the ‘Folha de S. Paulo’ newspaper after the so-called ‘Realengo massacre’. This case also highlights what can be called an ‘archeology’ of the supposedly schizophrenic killer, in which behaviors are considered ‘aberrant’ (he did not drink, did not smoke, did not play ball, did not wear shorts, did not date, was religious, passed a long time on the internet, liked violent games) as if they were predictive, isolated, or in their entirety, of a vio- lent profile and possible diagnosis of schizophrenia. Another notable feature of the texts dealing with these crimes is the transformation of the binomial mental- intelligence disorder into a veiled contradiction. Breivik, the Norwegian sniper, writes ‘in perfect English’ and seems ‘intelligent and aware of his actions’; Oliveira is described as ‘cold and calculating’ in the planning of his violent act. It is important to emphasize a peculiarity in the Wellington Oliveira case: the episode occurs when the media persistently debates cases of bullying inside and outside the Brazil, and there is a clear attempt in the news to force a cause-effect relationship (bullying in childhood equals murder of children as a form of revenge). An import- ant problem is whether journalistic coverage simply relates to crime statistics or not, and if not, whether it is acting on the public’s perception of associating vio- lence with mental disorders. Perhaps the long western tradition of violence and criminality linked to mental disorders has created the basis for stereotypes of dan- gerousness against this population (Joyal, Dubrecq, Grendon, & Millaud, 2007; Thornicroft, 2006). However, although the literature reports an associ- ation between violent behavior and schizophrenia, with a risk of two to six times greater risk in

244 F. BEVILACQUA GUARNIERO ET AL.

individuals with this disorder than in the general non- affected population, there are studies in the opposite direction (Thornicroft, 2006). In addition, the litera- ture shows that violent crimes occur mainly among patients with schizophrenia who are substance abusers and are without appropriate treatment (Fazel, Langstrom, Hjern, Grann, & Lichtenstein, 2009). That is, adequate medical treatment would reduce the vio- lence of psychotic patients. More complex analyses demonstrate that mental disorders are predictors more weakly associated with violence than age, gen- der, or ethnicity, but the public tends to see more often people with mental disorders as a danger to their safety (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). Therefore, we could argue that the cul- tural environment, and including journalistic cover- age, is a social factor that favors this negative view about mental disorders in general and schizophrenia in particular, and that is not in accordance to the data available in the medical literature.

The texts found by both specialists and journalists are in short supply. Psychiatrists because, when called upon to give their specialized opinion – usually amidst the commotion provoked by a crime – they unravel jargon and technical classifications without the least concern in explaining the concepts involved, as if he and his interlocutor shared knowledge. In addition, a recent study has shown that Brazilian psy- chiatrists stigmatize schizophrenia patients, especially regarding the attribution of stereotypes, such as dan- gerousness, even though they do so with less intensity than their colleagues from developed countries (Hengartner et al., 2012; Loch et al., 2011). On the journalists’ side, there is a tendency to generalize iso- lated cases, but there is a caveat. Unlike experts, these practitioners do not go beyond their specialist degrees in politics, sports, health or arts, but they learn in daily practice when this is possible. Moreover, in extensive coverages such as those following national commotion crimes or the long illness of a politician or artist, it is not always the health reporter who is displaced to keep up with the facts. Therefore, most of the time, what the specialist has in front of him at the time of an interview is as professional a layman as the average spectator, with the same prejudices and stereotypes about the psychiatric patient as the popu- lation in general. And perhaps one of those prejudices is that the person with schizophrenia does not read newspapers, does not listen to the radio, and does not watch television, and that if they do, they are unable to perceive that he or she is talking about themselves.

Internationally, media seems unwilling to analyze its role in perpetuating the stigma that weighs on schizophrenia. A meeting held in Britain to discuss the subject was frustrated by the complete absence of the major newspapers – who declined the invitation on the grounds that they had nothing to add to the debate – but it showed the thinking of much of the press, in the words of Steve Hewlett, director of pro- gramming at Carlton Television. After claiming to know that the news of violent acts perpetrated by psy- chiatric patients arouses fear in the public, Hewlett continued: ‘It is much easier to reinforce the views of your viewers than to go against them. Newspaper edi- tors try to connect to their readers by showing they understand them. It’s easy for them to say: We under- stand your fear; we know it’s full of crazy people out there ready to attack. We are here to change these things and protect you’ (Ferriman, 2000). The imper- sonality of the science and health editorials is preva- lent - it’s all about schizophrenia, never about the patient with schizophrenia. At least, these findings have shown significant progress in portraying the causes of the disorder by failing to attribute ‘guilt’ in an erroneous and random manner. In this sense, the vehicles analyzed are in keeping up with the latest sci- entific publications on neuropsychiatry, even when the subject is approached by non-specialist columnists in the area. However, they do not include the charac- ter or give the patient a voice. The highlight here is for genetics, chemistry, the patient’s cell, which is depersonalized. There are few reports with positive examples in which the patient with schizophrenia is shown under treatment or recovery. There are few reports about the access to specialized treatment (there is an exception in the news about the Realengo case) or that portray the suffering of patients and their families. Records of affirmative actions are lack- ing, that is, the need for public policies to improve the quality of life of people with schizophrenia and to combat prejudice and discrimination.

Linguistics can provide evidence of stigma about certain groups, such as patients, since feared diseases are used as negative metaphors, such as tuberculosis in the nineteenth century or cancer in the twentieth century. Further studies on cancer indicate that the development of scientific knowledge of this disease has been accompanied by a reduction in negative per- ceptions about it (Clow, 2001). The same was true for AIDS, and the terms ‘cancerous’ and ‘aids’ were banned from journalistic texts other than Health & Science; however, media still abuses the metaphorical

INTERNATIONAL REVIEW OF PSYCHIATRY 245

use of schizophrenia and the terms ‘addicted’ and ‘drugged’ to indicate the substance dependent. The improper use of these metaphors is a reflection of the currents beliefs in society regarding stigmatized groups, and diseases shrouded in mystery would be more susceptible to this type of use, i.e. the metaphor- ical one. By this reasoning, mental disorders today would be more likely to appear as metaphors in the mass media, both because of the stigma they carry and because of the lesser understanding that Medicine has about them in relation to their other objects of study. In a broad analysis of American journals, it was observed that schizophrenia replaced cancer as a metaphor in the vehicles studied and that such improper use contributes to the perpetuation of stigma and lack of understanding about this psychotic disorder (Duckworth, Halpern, Schutt, & Gillespie, 2003).

In the current analysis, it was possible to observe the non-medical use of the term schizophrenia in a derogatory recurrent way in the two steps of the news survey. It is present in both the interviewees’ speeches and the journalists’ team of the analyzed vehicle, with- out concern for possible deleterious effects. If there was concern about their negative effects, the same could be avoided. If we see progress in the use of the terms ‘cancer’ and ‘AIDS’, they seem to have been replaced by ‘schizophrenia’, in agreement with studies published in newspapers of countries of the Northern hemisphere (Corrigan et al., 2005). Today, it is a con- sensus among psychiatrists who study the stigma of mental disorders that the metaphorical use of schizo- phrenia is needless and reinforces stereotypes and prejudices (World Psychiatric Association, 2002). Understanding the concept of schizophrenia inad- equately hinders its social acceptance and contributes to the reluctance of a considerable portion of its patients to seek help for their condition. The media played a decisive role in both the dissemination of information on cancer and AIDS, and thus contrib- uted to the prevention and early detection of these diseases. It may have the same participation in fight- ing the stigma that weighs on the psychiatric patient, and especially on the patient with schizophrenia. Given this scenario, it is necessary to mobilize, espe- cially mental health professionals, to reduce the stig- matization of psychiatry and mental disorders, particularly schizophrenia, in a global perspective (Stuart, 2003; World Psychiatric Association, 2002). A basic requirement of such programs is to focus on the multiplicity and versatility of interventions in order to reach out to the most diverse cultural sectors

of society and to sensitize as many people as possible. Educational interventions and the provision of mental health resources in a generalized and continuous nature, in order that it becomes part of the culture and practices in public health. If isolated, short-term interventions have shown limited effect in the fight against the historically rooted social habit of stigma- tizing those with mental disorders. In the case of the mass media, the Canadian experience is an example to be known. With a strategy focused on the most popular local newspapers, its objective was to increase the number of positive reports about schizophrenia, as well as its size, and for that were offered: national awards for reports on schizophrenia; conferences and events to clarify the press; prompts suggestions dir- ectly to reporters and editors. Participants in the intervention were available to the press as consultants to serve as a source of rapid information to reporters. On average, the number of positive reports increased by 33% and their word count by 22% per report; however, the number of negative stories also grew by 25%, and their word count doubled. These findings have shown that the intervention committee was able to influence the local news positively, but not the glo- bal news: notorious cases from abroad came to the newsrooms from international sources that attributed the diagnosis of schizophrenia to those accused of acts of violence (Stuart, 2003).

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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