Guidance for Journalists
Why does schizophrenia get in the news?
Research has shown that more often than not stories about schizophrenia are bad news stories and are often related to the disturbed behaviours that some people with schizophrenia display when they are in crisis. That is not to say that sympathetic articles about schizophrenia never appear, simply that it is the adverse stories that usually make the headlines. And it is with reporting those stories that this information sheet will concern itself, because it is usually those sort of stories where mis-reporting can occur and where the many myths about schizophrenia that abound in society can be perpetuated and reinforced.
It is undoubtedly the case that there is much misunderstanding in the mind of the general public about schizophrenia and it is also probably true that that misunderstanding is often reflected in media reporting on the subject. Many people blame the journalists who create the news for this but in truth the reason is probably more complex as news is not just the creation of the journalist but of a complex dynamic involving the journalist who writes the story, the readers or viewers whose expectations the journalist tries to meet and the sources of the news who provide the journalists with their information. (Mental Health Today, 2005).
Recognising that the process of producing news is thus a complicated one it is necessary to provide some guidance from the other side of the street i.e. from the point of view of those people who are on the sharp end of this national public health issue that we call schizophrenia: the carers and relatives of people with schizophrenia and of course the sufferers themselves.
Use of the stigmatising terms such as “nutter” and “bonkers” are today infrequent and thankfully becoming rarer but it is still sadly possible to meet old school journalists who will stand by their right to describe people with schizophrenia as “psychos”. So there is still much to be done. No mainstream journalist would dare to use similarly perjorative terms in their reporting of race today and we should try to ensure that over time journalists can become as sensitive in reporting about schizophrenia as they are in reporting about racial issues.
But the task is much greater than simply identifying language which it would be better to avoid. Shelley Joffre was a reporter on the BBC current affairs TV programme, Panorama when they produced two controversial programmes about the antidepressant medicine Seroxat. Reflecting on her role in the programme she admitted to Mental Health Today journal in 2005, “If I’m perfectly honest we didn’t spend a great deal of time at all thinking about the people who took Seroxat while we were making that first film”. This kind of flaw may affect many journalists writing about mental illness: that in seeking to write a really good story, full of impact, they overlook the people suffering with mental illness themselves. And so how much more difficult must it be to write competently about schizophrenia with all of its bizarre and distressing manifestations. Journalists will not find the condition an easy one to understand and to educate their readers about.
What is schizophrenia?
In brief schizophrenia is an illness of the brain caused by physical or chemical changes within the brain cells. We have now been studying schizophrenia for over a hundred years and we know a great deal about it. That said, schizophrenia is a very complex condition being rooted in the brain which is after all the most sophisticated organ of the human body.
The symptoms of schizophrenia can include hallucinations such as hearing voices and which can in fact affect any of the senses, and delusions such as paranoia or strange beliefs. These are what the doctors call positive symptoms and it is these symptoms that will sometimes bring a sufferer to the attention of the courts and the media. However, there is also a group of negative symptoms such as apathy and social withdrawal which can often be just as disabling as the positive symptoms and are often at the root of suicide attempts. There is more detail about the symptoms of schizophrenia in our information sheet and if you need basic information see our page on Facts and Figures which contains all the essentials statistics about this condition.
Schizophrenia and dangerous behaviours
The link between schizophrenia and dangerous behaviour such as suicide and violence is well chronicled. (Walsh and Fahy, 2002) Understanding dangerous behaviour in schizophrenia is difficult and is complicated by the understandable reluctance of some people in the mental health field to discuss the issue for fear of promoting stigma and as a result their explanations are often incomplete and insufficient. But It is sadly the case that people suffering from schizophrenia are more prone to dangerous behaviours like suicide (Caldwell and Gottesman, 1990) and violence (Fazel et al, 2011) than their colleagues in the general population. However, it is important to remember that in our society today for every homicide by a person with schizophrenia there are 30 suicides. Over a thousand people with schizophrenia die by their own hand every year in the UK alone.
Whilst suicide makes up the larger part of the death toll in schizophrenia the other part is the much smaller but equally tragic number of homicides. Each year people with schizophrenia are responsible for between 20 and 30 homicides in the UK. And there are other types of dangerousness to which people with schizophrenia are more prone including sexual offending and medical self-neglect.
So we must ask why people with schizophrenia are sometimes involved in dangerous behaviour? The positive symptoms such as the hallucinations and delusions are probably responsible for much of the violent behaviour. If the person is convinced that they are being spied on and persecuted they may, in fear of their life, try to strike out against those they see as responsible for it which more often than not will be someone close to them but equally could be a total stranger. As far as suicide is concerned both the positive symptoms such as hallucinations and the negative symptoms such as social withdrawal have been implicated.
However, when discussing dangerous behaviour we cannot ignore the role that drugs and alcohol play in increasing the risk. US psychiatrist Edwin Fuller Torrey, has pointed out that a large proportion of people diagnosed with schizophrenia will have some form of drug or alcohol issue. The reasons for this are unclear but some doctors think that the profound feelings of hopelessness that often accompany a prolonged period of schizophrenia which may go on for years are the reason why so many sufferers turn to drink or drugs. But whatever the reason, we know that many street drugs will make positive symptoms worse and both drugs and alcohol will increase the risk of dangerousness.
What can be done about dangerousness?
Antipsychotic medicines are the mainstay of treatment in the NHS for the positive symptoms like hallucinations and delusions and are consequently the first line of defence against dangerousness. Amongst anti-psychiatrists there are many critics of antipsychotic medicines who claim that they are ineffective and even harmful and these views are often given space in some of the more liberal sections of the news media. It is important not to be seduced by these views. The evidence of hundreds of research scientists, thousands of doctors and hundreds of thousands of relatives of people with schizophrenia is that these medicines are effective in relieving the symptoms in the majority of people that are treated. Time after time in the court reports we hear about people with schizophrenia deteriorating after they stopped taking their medication and then ending up before the judge. This view is heavily supported by the research evidence that has found that about 70% of people with schizophrenia who take the antipsychotics will experience some relief in their positive symptoms. For comparison, this is about the same degree of effectiveness that we would expect to see when antibiotics are used to treat infections.
We also know that early intervention particularly in the first episode of schizophrenia symptoms is the most effective approach. This will lessen the severity of the symptoms in the first episode and reduce the number of subsequent relapses. Sadly, we see all too often in the mental health field professionals who prefer to take a wait-and -see approach and delay treatment until the positive symptoms have become more evident. Often this is too late and the damage has already been done. This thinking is not uncommon and has even in some areas been enshrined in policy-making with some local organisations establishing projects to “divert” patients away from psychiatric treatment: a misguided policy, that is as inhumane as it is dangerous.
If antipsychotic medication and early intervention provide us with two effective tools in our tool kit, early warning provides the third and if it works well can save lives. We know from our years of study of schizophrenia that there are three clear predictors to dangerous behaviour. The first of these is a previous history of dangerousness or threats. If the person says they are going to take their own life then it should be taken seriously. The second predictor is non-compliance with the antipsychotic medicines and the third is concurrent drug or alcohol abuse issues. If the system works well and the local mental health service have the staff to be able to monitor people in their care for these factors then many people can be saved from dangerous behaviours even before their crisis has begun. However, in many cases the services are under-staffed and under-funded and the resources simply do not exist to make this happen.
So what can journalists do differently?
First of all when you start to write about a case involving schizophrenia you will want to think about your audience and it is worth remembering here that a substantial number of your readers or viewers will be people who themselves are sufferers of schizophrenia or who have a close relation suffering with it. Schizophrenia is by no means a rare condition: today in the UK around 220,000 people are being treated for schizophrenia by the NHS (NICE 2014). So we can estimate that about a million people or about one in 40 of the adult population will have close contact with this illness and an even greater number will have some close personal knowledge of it. Those people are as much a part of your audience as the general population and you should write with their needs in mind as well.
Watch your language
Language is important but we should not become obsessed by the issue. You will naturally want to choose terms that give your story as much impact as possible but do be aware that some terms can be perjorative and convey overt or hidden negative meanings to the reader. Here are a few examples of the problems of language.
I recently heard the editor of a daily national tabloid newspaper trying to justify his use of the term “psycho” to describe people with schizophrenia. He was wrong both medically and ethically. People with schizophrenia are not psychopaths and use of terms that are deliberately intended to evoke hatred against a particular group of people involuntarily disabled by a disease of the brain is simply not right. We would not do that to any other group of disabled people and we should not do it to people with schizophrenia. Remember the National Union of Journalists Code of Conduct states that journalists should not produce any material that will lead to hatred or discrimination on the grounds of a person’s disability.
Please don’t describe detained mental health patients as “prisoners or inmates”. They have been detained in a mental health unit for medical care and they should be described as patients.
You may also like to think again about the current trend for describing schizophrenia as a “mental health problem”. Describing schizophrenia as a mental health problem is a bit like describing lung cancer as a chest problem and we wouldn’t do that would we? Schizophrenia is an illness that has a major life-changing (and all too often life-threatening) impact on the sufferer and on the lives of those close to them. Calling it a “problem” only minimises its impact and will do nothing to convey the enormous tragedy of schizophrenia to your readers. Schizophrenia can be better and more accurately described as a mental illness, mental ill health or a mental health condition and always prefixed by “serious” as there is no such thing as a mild case of schizophrenia.
However, whilst these sorts of changes to the terminology are helpful they are not critical. Studies have shown that changing terminology only has a partial effect on people’s attitudes to schizophrenia. In fact, in countries such as Japan where the term schizophrenia itself has been replaced by one considered less stigmatising it has only had a limited effect on public attitudes. (Maiorano et al, 2017)
When reporting crimes involving people with schizophrenia if there are no legal restrictions on the disclosure of their identity such as due to their age then the journalist will want to provide the reader with as much detail about the story as they can. However journalists and editors should seriously consider whether the disclosure of the schizophrenia sufferer’s name, address and photograph is really consistent with their lack of mental capacity and it can be strongly argued that there is a case for withholding these details from the public in order to help the process of psychiatric and social rehabilitation that will eventually see that person returning to their community.
There can be no doubt that disclosure of these details to the public will have an adverse effect on the treatment process which may lead to further offending in the future and journalists and editors need to weigh carefully their role in informing the public with their wider duties to safeguard local communities. Remember that there is a qualitative difference between a sane person committing a crime and someone with schizophrenia doing so and that is that the person with schizophrenia will, given high quality psychiatric care, be able to avoid the compulsion to offend in the future and return safely to their community. The same cannot be said of offenders who do not suffer from a mental illness and whose re-offending rates are frighteningly high.
In addition, editors should consider the enormous impact that disclosure will have on the relatives and carers of the sufferer who are already bearing the enormous burden of looking after a loved-one struck down by such a complex and difficult condition and being projected into the public eye by what is to them also often a traumatic event. Remember that the IPSOS Editor’s Code states clearly that everyone is entitled to respect for their privacy, family life and health.
Given these factors we think that there is a powerful public interest and ethical case for editors electing voluntarily to withhold personal details of people with schizophrenia accused or convicted of an offence for the greater good of the community that they serve.
Use of hidden filming
There have been a number of cases recently where television reporters have used secret filming techniques to record inside mental health in-patient treatment facilities. In these cases the journalists responsible understood that some of the patients there were suffering from paranoid delusions and it must have been clear to them that the patients’ symptoms would have been made worse by such filming. For people suffering from schizophrenia who are already experiencing paranoid delusions of being spied on, filming of this sort will inevitably lead to a worsening of their psychotic symptoms and may even precipitate dangerous suicidal behaviour even if techniques are used to prevent their identification in the film such as by pixellation.
That said there have also been cases where abuse by staff has been remedied only by the use of such techniques. Any decision to employ secret filming in the collection of material to be used for broadcast must balance the grave risks to the schizophrenia patients inherent in such filming with the potential benefits of the disclosure. Such a decision should not be taken lightly and, given in addition the legal and reputational implications, should be made only at the highest level in the news organisation and only when all other possible means of collecting the necessary information have been considered and discounted. The needs of the sufferers must in all cases be paramount.
Reporting violence and other crime
In all groups in our society fear of violence is the most common negative attitude towards people with mental ill health in general (Putman, 2008) and schizophrenia appears to have the worst reputation of any mental health condition. Unfortunately, this view does not accurately reflect the actual risks. Yes it is true that people with schizophrenia are more likely to engage in dangerous behaviour than their colleagues in the general population but this statement must be heavily qualified by the assertion that most people with schizophrenia are never dangerous and that when dangerous behaviour does occur it is overwhelmingly the sufferers themselves who are at risk. In fact, it has been calculated that the statistical chance of being attacked by someone with schizophrenia in the UK is roughly equal to being struck by lightning (Dickens, 2008).
Around 10% of people with schizophrenia will die by their own hand within ten years of their diagnosis. When reporting suicide it is vital not to report details of the method that the deceased person chose to end their life as we know now that such reporting often leads to copy-cat deaths by others. However, it is useful to report the devastating impact that such a loss can have on the relatives and friends of the deceased as this is often a powerful protective factor on people who are contemplating suicide. It is also helpful to stress the waste that such a death represents and to underscore the difference that high quality psychiatric care can make.
For suicides in schizophrenia it is helpful to report the connection between dangerous behaviours and the use of street drugs and alternatively that antipsychotic medicines are effective in helping to reduce the risk of suicide (Hawton, 2005). If inadequacies in the mental health care of the deceased person come to light then these should be reported but with some care. It is important not to vilify junior members of the mental health care team if the real culprit is local cuts to inpatient crisis beds or unrealistically heavy case-loads for the mental health workers.
Background is vital
When writing about schizophrenia, particularly if writing about cases of violence or suicide, please try to include some background in your piece to tell the readers a bit more about schizophrenia itself. Otherwise they will only know that schizophrenia causes dangerous behaviour and nothing else. We suggest something along these lines:
So what is schizophrenia? Schizophrenia is a serious mental illness caused by physical and chemical changes in the brain. It causes the person’s thoughts to become confused and distorted. About a quarter of a million people in the UK currently have the condition. It is still not fully understood but we know that it runs in families and that people who had a difficult birth or an older father are much more at risk. Although there is no cure yet we do have excellent medicines to treat schizophrenia symptoms which are effective in about 70% of people who take them. The majority of people with schizophrenia will make a good recovery provided they are well cared for and supervised by the Mental Health Service.
Blame the illness not the person
When a person with schizophrenia becomes dangerous it is easy to blame them for it and after all when there is a tragedy it is perfectly natural for the bereaved to look for someone to blame. However, what we know is that a person at the height of a full-blown schizophrenic episode can become so detached from reality that they no longer know right from wrong or have any appreciation of the impact of their actions. This is not their fault it is simply another cruel feature of this terrifying condition. When a person with schizophrenia acts dangerously that is precisely when their thoughts are most disturbed and so it is also when their suffering is greatest. This issue of mental capacity is one that is sadly lacking in many press articles about schizophrenia.
It is vital to appreciate that when things go wrong the person suffering with schizophrenia is also a victim. This is an important point often overlooked by journalists. Always remember that no one would voluntarily choose to suffer from this complex and intractable condition which is terrifying in its symptoms, destructive of ambitions and quality of life, socially isolating and often life-threatening. People with schizophrenia are victims of one of the cruellest of diseases known to man.
Perhaps here the journalists of a previous age can provide us with valuable lessons in how to approach this subject with compassion. When the famous Victorian artist Richard Dadd killed his father whilst suffering from schizophrenia here’s what some of the newspapers of the day said about him:
“No doubt can remain upon the mind of any person who witnessed the examination that the unfortunate prisoner is not morally responsible for his actions”. (London Evening Standard, 1844.)
“He has always been considered as a young man of a most mild disposition and had ever exhibited the warmest and most affectionate attachment to his father”. (Kentish Gazette, 1843).
Precautions against dangerous behaviours
Previously we have seen how there are distinct risk factors for dangerous behaviour in schizophrenia and there are a number of precautions that can be taken by the medical and criminal justice teams to try to reduce this risk. First of all when a person is arrested or appears before the courts and there is the slightest suspicion that they may be suffering from a mental disorder it is vital that the police or courts arrange for a proper psychiatric assessment. Although there is clear guidance on this in the various codes this is often not done in practice. If the accused person is suffering from schizophrenia and it is not identified and treated then the person will not stop their dangerous behaviours no matter what penalties the courts impose.
We have already mentioned the importance of early intervention with psychiatric care particularly in the first episode of schizophrenia. This will reduce the risk of dangerous behaviour and the severity of symptoms for the sufferer.
Then there are a number of measures that can be put in place to reduce risk. In cases where dangerous behaviour of any kind is a risk the sufferer should not be left to take their own medicine but medicine-taking should be supervised. There are a number of ways that this can be done. For instance, the sufferer can be visited at home by the mental health team and observed when they take the medicine. At this time the doctor may elect to use medicine in the form of syrup or tablets that dissolve as soon as they are in the mouth (called oral dispersible). Another option is to administer the medicine by long-acting injection (which can last up to one month) rather than pills.
If drug or alcohol abuse is suspected then the courts have the option to impose drug and alcohol treatment orders and the mental health team can employ drug testing to ensure that the sufferer is being compliant.
When writing about any case involving dangerous behaviour by someone with schizophrenia whether violence or suicide, the good journalist will ask whether any of these precautions were in place at the time and if not why not.
Be fair in apportioning responsibility
Be cautious before blaming the doctors. The Mental Health Service has traditionally been the poor relation in the NHS and, despite constant promises from the politicians, the situation today sadly is no better. We have lost over a quarter of our inpatient beds in the Mental Health Service since 2000 and community services have fared no better. When things go wrong and a person with schizophrenia becomes dangerous it is often because the resources were simply not available to provide the level of supervision that the patient needed. Blaming junior mental health workers on the ground may produce a good story but often ignores the pressures that they work under and lets the politicians and senior NHS mandarins who are responsible for mental health resourcing off the hook.
It is also the case that workers in the mental health field often feel under pressure from some of the small but highly vocal “survivor’s” groups who claim erroneously to represent patients and have campaigned vigorously for many years against psychiatric interventions. Despite being highly unrepresentative of the vast majority of people living with schizophrenia and their relatives these campaign groups have succeeded over time in shaping mental health policy at all levels and in influencing the day-to-day decisions that doctors and psychiatric nurses make when treating their patients. Sadly, this influence has led in some cases to decisions about whether to detain or not or whether to treat or not being clouded by anti-psychiatry ideology rather than being based on purely clinical considerations.
Talk to sufferers and their relatives
Panorama journalist, Shelley Jofre talks about how their research for the Seroxat programme tended to focus on the expert’s views and didn’t really listen at first to those at the sharp end: the sufferers and their relatives. As she put it: “probably lurking in the back of our minds was the suspicion that you can’t really trust the testimony of people who are depressed or suicidal”. People who have lived with schizophrenia either as sufferers or as carers have a deep understanding of the condition that many health professionals simply do not achieve. It is well worth cultivating contacts with service-user and patient groups in your area.
In the general medical field great progress has been made recently in challenging negative attitudes towards schizophrenia by employing sufferers themselves in helping to train medical professionals. Perhaps the news media could take a lead from that initiative and invite people living with schizophrenia themselves into the lecture rooms, CPD sessions and news-rooms to give journalists a fresh insight into this complex condition.
It is fair to say that schizophrenia does not get a good press in the UK and the burden of that problem lies heavily on the shoulders of journalists themselves. Currently it is the case that within the “fourth estate” sadly there are many who, through ignorance or immaturity present people with schizophrenia in the poorest light. However, there are also plenty of women and men of goodwill and tolerance who seek to report with fairness and objectivity. The news media plays an important role in moulding the perceptions and views of people in the general public as well those who hold important office and it must bear a responsibility to ensure that their reporting of this difficult and enigmatic condition always serves the general good.
For more detailed guidance on reporting of suicide the Samaritans Media Guidelines are very comprehensive.
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Copyright © May 2020 LWS (UK) CIC.