This paper does not represent an exhaustive literature review. The author has not explored the potential of popular music, video games, fiction, comic books, or plays, for instance, since those media have not yet been employed as entertainment-education vehicles. These media, and others such as glossy magazines and websites, no doubt influence attitudes, beliefs and behaviour, especially with some demographic groups, and are deserving of consideration. Unfortunately, they fall outside the immediate scope of this paper.

The ideas presented here are just that—ideas, which are not supported by empirical research. The ideas may suggest research, but until work is actually conducted, readers are well advised to keep this caution in mind.

By Jan Matthews

Although the media must bear some responsibility for the state of mental illness stigma, just as it can cause harm, it can also do a great deal of good. Writers, directors and producers who had gathered at a recent US workshop of Hollywood, Health & Society expressed a willingness to listen to the CDC’s ideas about how to portray health issues, but insist that they maintain creative control over stories. That is as it should be, but the education about the subject should be provided by external, reliable sources.

That essential connection between the people who tell the stories and the people who live them has been missing. It’s impossible to know whether the current state of affairs is driving stigma, the result of stigma, or both. Uniting “us” and “them” is essential to destigmatizing mental illness. Entertainment-education has the potential to do exactly that. That potential, however, will only be realized if the people who tell the stories can be persuaded to adopt a healthier perspective toward mental illness.

Print and broadcast media have not traditionally been allied with the mental health community in the struggle to destigmatize mental illness, although there have been and continue to be examples of positive work done by journalists and creative writers. On the whole, though, media is a prime source of stigma. For instance, Corrigan et al. (2005) in 2002 analyzed 3,353 news stories from 70 large American newspapers that included content about people with mental illness. The researchers found that 39% of the news stories focused on dangerousness and violence; those stories were generally in the front section of the newspaper.

As research has shown, however, media does have the potential to teach people to be healthy. Entertainment-education, a method that purposefully embeds storylines into fictional media stories in order to educate audiences, is proving to be an effective technique to change people’s beliefs, attitudes and behaviour. Entertainment-education is effective enough and holds such promise that leading American institutions such as the Centres for Disease Control and Johns Hopkins University have integrated it into their research and education programs. No institution or research group to date has tested the efficacy of entertainment-education as a technique to destigmatize mental illness.

However, even if entertainment-education could help destigmatize mental illness, will any benefits that come about be eradicated by the position of media generally in regard to mental illness? Although entertainment-education may have the potential to undo stigma, the very medium that it employs routinely broadcasts and publishes stories that increase stigma. This paradox needs to be addressed if entertainment-education is to be used to its full potential in destigmatizing mental illness.

Although there is a great deal of evidence suggesting that mental illness is portrayed negatively in newspapers, television and film—Angermeyer et al. (2005) cite 31 studies, for instance—until recently, research has not directly linked media consumption to levels of stigma. Angermeyer’s recent study in Germany, however, has done just that. In an extension of findings from research conducted with university students (Granello & Pauley, 2000), Angermeyer found that the more television programming people consume, the greater their desire for social distance from people with schizophrenia, hinting that programs are creating or reinforcing stigma.

The research team conducted 5,025 personal interviews with members of the general population 18 years of age and older. They measured a preference for social distance from people with schizophrenia, social distance being a widely accepted proxy measure for stigma; how many days per week the person watched television; which channels were watched most often; and if the person read the newspaper regularly. The team found that people’s desire for social distance—levels of stigma—rose with the amount of television consumed. Reading a newspaper had no influence on social distance, although tabloid readers and readers of regional newspapers had a greater preference for social distance compared with people who regularly read broadsheets and people who read no newspapers.

Emotional content seems to make a difference: television messages are more emotional than newspaper reports and so are likely to be better remembered (Sturm et al., 1972);  tabloid stories are often run with large photos and sensationalized content, which are also more emotional than standard newspaper fare (Angermeyer et al., 2005). Moreover, television may be a more emotional medium than print simply because television images move whereas print does not. Tannenbaum (1981) suggests that the human brain is biologically conditioned to pay closer attention to moving images than static ones.

Although it would seem that where attention goes, attitudes follow, Angermeyer et al. (2005) make the point that their study wasn’t able to determine whether people who desire social distance from people with schizophrenia are drawn to television or tabloid papers. The study looked at correlations and so can draw no causal connections.

Few studies have examined potential relationships between changes in stigma with levels of television viewing or newspaper and magazine reading. One such study comes from Domino (1983), who measured university students’ attitudes toward mental illness before watching the film One Flew Over the Cuckoo’s Nest, three months later, and finally eight months later. Domino found that, compared to students who hadn’t seen the film, students who did see it had significantly less positive attitudes toward mental illness. Even later watching a documentary to counterbalance the negative portrayal in the film did not reduce negative attitudes.

This is indeed troubling given the amount of time Canadians spend watching fictional portrayals of mental illness on television. At last count, Canadian were viewing, on average, 21.7 hours of television every week, or roughly three hours every day (Statistics Canada, 2005). Children up to age 12 watch slightly less--14 hours a week, of which researchers estimate two-thirds of that programming contains some material about mental illness (Wahl et al., 2003).

After analyzing 58 hours of children’s television programming in New Zealand, Wilson, Naim & Coverdale (2000) found that 48% of episodes included references to mental illness such as “crazy,” “deranged,” “wacko,” and “loony.” Characters who were identified as having a mental illness were often villains and frequently were portrayed as having rotting teeth, bad breath and unruly hair. In a 1995 study of Saturday morning children’s television programming, Signorielli, Gerbner & Morgan (1995) found that characters with mental illness were more likely than other characters to be killed, injured or exploited.

People with mental illnesses are depicted as violent or childlike, or as outcasts (Edney, 2004). The association between violence and criminal behaviour and mental illness has been prevalent for decades, with psychosis in particular being portrayed as threatening (Rose, 1998; Olstead, 2002). After studying prime-time television drama, Wilson, Naim, Coverdale & Panapa (1999) found that 43% of characters with mental illness “lacked comprehension of everyday adult roles and appeared lost and confused.” They are often depicted as speaking in a childish voice, as being helpless and disheveled, and often poor and homeless. As Day and Page (1986) make clear, when mental illness is linked with homelessness, but is not done in such a way as to elucidate the broader systemic issues surrounding mental illness that lead to homelessness, people believe that to be mentally ill is to be dependent on others. And many believe that to be mentally ill is to be an unproductive member of society (Wilson et al., 1999).

Such depictions are not limited to television. The Grinch in How the Grinch Stole Christmas refers to himself as a “psycho.” In a nod of affirmation, the narrator of the animated film says, “Grinch’s head wasn’t screwed on right.” A research team led by Wahl (Wahl, Wood, Zaveri, Drapalski & Mann, 2003) watched this children’s film, and 48 others, to get a sense of how mental illness was being depicted in films aimed specifically at children. They found that 33 of the films contained content about mental illness. Twelve films included characters with a stated mental illness; eight of the 12 portrayed that character as violent; approximately two-thirds of the other characters demonstrated fear of the mentally ill character. Generally, “mentally ill characters tend to be feared and disparaged,” the authors wrote (p. 553).

Not all portrayals are negative. As Wahl is careful to point out, many of the characters analyzed in his study were well groomed and were shown as socializing well with others, as safe, predictable, sympathetic, even heroic. Based on existing literature, it is difficult to draw conclusions about just how affected people are by any negative portrayals of mental illness and how many positive portrayals are required to negate the effects, or, indeed, whether that is even possible. Domino’s research (1983) into viewing of the film One Flew Over the Cuckoo’s Nest would suggest that one documentary in support of mental health does not undo the effects of one dramatic film that demonizes mental illness; whether one positive dramatic film—or many—might undo the effects of one negative dramatic film has not yet been researched.

Being ineffective, unemployed, and having few or no interactions with family and friends, living alone or in dilapidated apartments or on the street, being asocial, unable to control their own lives, subjected to harassment, false accusations, manipulation, victimized verbally or physically, as most media portray mental illness, is a very good way to model stigma for viewers. Sociologists Link and Phelan (2001) conceptualize stigma as a process that begins with labeling, goes on to stereotyping, continues to separation, then ends with status loss and discrimination. (A discussion follows.)

• Labeling –applying beliefs and labels that are specific to the culture.
• Stereotyping – the label links a person to a set of undesirable characteristics that become a stereotype.
• Separation – separating “us” from “them.” “They” may be so different that they’re no longer human.
•  Status loss and discrimination – the three components preceding this ultimate stage of the process, as Link and Phelan suggest, provide the rationale for devaluing, rejecting and excluding people.

Someone may believe that people with mental illness are dangerous, for example. Labeling someone as a “mental patient,” therefore, leads to stereotyping them as dangerous (Link, 1987). Other common stereotypes applied to mental illness are: incompetent, antisocial, not trustworthy, not intelligent. Stereotypes lead to separation: separating “us” from “them” can lead to a person becoming a label, as in, “Sheila is schizophrenic,” as opposed to “Sheila is a person who has schizophrenia.” The outcome is status loss and discrimination. Being devalued leads to inequality and unfair treatment. Responses can occur at the individual or group level and can include rejection or avoidance, murder (in extreme cases) (Heatherton, Kleck & Hebl, 2000). Structural discrimination refers to such indirect unfair treatment as fewer funds being directed toward research into schizophrenia, for example, or mental health treatment facilities being located in difficult-to-reach or disadvantaged neighbourhoods.

"The primary assumption behind [the CDC’s entertainment-education] initiative is that the mass media in general, and television in particular, provide enormous amounts of information about health through storylines in entertainment programming. This information may be correct or incorrect, peripheral or central to characters’ lives, planned or serendipitous; in any case, it is plentiful, and thus it has been important for CDC to work with industry representatives to enhance the nature and quality of health information disseminated through entertainment programs." (CDC, 2001; pp. 8-9)

Given that mass media is a dominant source of information about mental illness, as well as possessing the ability to alter attitudes and model behaviours, it would not seem to be stretching the point to suggest that mass media may have the potential to inform, shape and model more positive beliefs, attitudes and behaviour toward mental illness. The field of entertainment-education does in fact suggest that this is the case, although to date research and practice have focused on such health concerns as AIDS prevention, screening for syphilis and family planning.

Sometimes known as edutainment or infotainment, entertainment-education (EE) is the “process of purposely designing and implementing a media message to both entertain and educate, in order to increase audience members’ knowledge about an educational issue, create favorable attitudes, shift social norms, and change overt behaviour” (Singhal, Cody, Rogers & Sabido, 2004; p. 5). EE’s first formal use was in England in 1951. The country was suffering from food rationing, which had begun during World War II. The federal government needed to educate farmers about agriculture; when asked how they wanted to be educated, the farmers suggested a radio drama (Davin, 2003). In response, the BBC created The Archers, which is still running today as a television series, although its predominantly educational purpose ended in 1972 (BBC, 2005). Britain’s approach to entertainment retains its educational tone, though, with cooperative efforts being more commonplace than in the US or Canada. This is particularly true for daytime dramas (Davin, 2003).

A 1969 Peruvian telenovela (television soap opera) called Simplemente Maria (Simply Mary) had the effect on the Latin American populace of an entertainment-education program, although that was not its intent. Aired from 1969 to 1971, the 448-episode-long story is about a young woman from the country who goes to the city to find work. She is seduced by the wealthy young medical student in the home where she is working as a maid and gets pregnant. The young man, who has promised to marry Maria, abandons her. She is left to raise her son alone while continuing to work as a maid during the day. She enrolls in adult literacy classes at night. Maria eventually finds work in a local dress shop, where she learns to use a Singer sewing machine. Over time—the series spans four decades—Maria becomes a highly successful fashion designer and moves to Paris where she founds and operates a dress boutique.

Viewers so admired—and identified with—the characters that when Maria finally married, after being courted for 20 years by her first teacher, who later became her business manager, 5,000 people attended the wedding scene as it was filmed. They dressed in their finest, some fainting from the overwhelming emotions of the day (Singhal, Obregon & Rogers, 1994). This is a striking example of parasocial interaction, which other researchers have also identified as important (Papa et al., 2000; Sood, 2002). It seems to foster active message processing, which helps enhance retention of the message and therefore may lead to more behavioural change. This is likely largely a function of the actors’ ability to portray the characters convincingly, the writing, seeing a new episode every week for a long period of time, production values and so on.

Additional, unintended effects of the telenovela included young housemaids wanting to learn to sew; a sharp rise in enrollment in sewing classes; and a rise in sales of Singer sewing machines. Enrollment in adult literacy classes also rose (Singhal et al., 1994). In focus-group research conducted many years later, Singhal found that people who followed the telenovela identified such social themes as the liberation of migrant women, more just treatment for domestic maids, the value of hard work, class conflict, intergenerational differences, inter-ethnic romance, and adult literacy.

Mexican playwright and television producer Miguel Sabido noticed the effect on audiences (the telenovela was shown in Mexico as well). Sabido, called “the father of entertainment-education,” his sister and several colleagues spent four years analyzing the program. The team used the results of the analysis to create other educational radio and television dramas (CDC, 2001).

The Sabido approach, as it is now called, applies Bandura’s social cognitive theories of modeling, Jung’s theory of archetypes, MacLean’s psychoneurological theory, Fisher’s narrative theory, and Bentley’s dramatic theory to soap opera development (Singhal et al., 2004; CDC, 2001). In brief, characters become good and bad role models, with some characters serving as people with whom the audience can very easily identify. Good role models are rewarded, while bad role models are punished. Neutral characters are not consistently good or bad; these are the characters that viewers are meant to identify most with. These characters are influenced by good characters and bad characters; their attitudes and behaviour gradually change as a result, and they reach their ultimate goals. The change occurs over hundreds of episodes and is set within the complex issues that people in the audience must also confront.

Sabido put his ideas into practice in, among other programs, Let’s Go With the Times, a radio drama that aired twice a week for two years over Radio Tanzania. Its focus was reproductive health, family planning and HIV prevention. Compared to people in a city who did not have the opportunity to hear the radio drama, researchers found that program listeners had a greater commitment to family planning; a greater adoption rate of sexual and reproductive health practices to prevent HIV; and higher attendance at family planning clinics in the broadcast area (CDC, 2003a).

EE has since spread to India, Kenya and the rest of the world and includes such media as cartoons, photonovelas, and prime-time and daytime television drama. Entertainment-education has been employed primarily in developing countries and has focused on reproductive health, family planning, HIV-AIDS, and preventable diseases. Key players are the BBC in the UK, Population Communication International, the Centers for Disease Control (CDC), and Johns Hopkins University.

Audience involvement has proven to be crucial. Tinka Tinka Sukh (Happiness Lies in Small Things) was a radio program in India that ran from Feb. 19, 1996 to Feb. 15, 1997—104 episodes in total. The serial focused on promoting gender equality, empowerment for women, issues related to dowry, small family size, family harmony, environmental conservation, youth issues, community living, substance abuse, and HIV/AIDS prevention. Researchers (Storey, 1998) examining the effect of the program on listeners found that it promoted self-efficacy and collective efficacy, and it encouraged people to talk about the issues presented in the program. When people identified with the characters, they tended to relate the program to their own lives. When people thought about the messages, they became critically involved by suggesting plot changes. “Audience individuals construct, reconstruct, and deconstruct the messages contained in an entertainment-education intervention, thereby making it a part of their popular culture.” (Storey, 1998)

A group (Sypher, McKinley, Ventsam & Valdeavellao, 2002) working in the Peruvian Amazon has made similar observations. The research team produced and researched a radio program called Bienvenida Salud! (Welcome to Health) that was designed to help combat high infant and maternal mortality rates and high fertility rates. The producers wanted to increase everyone’s awareness of the conditions underlying poor reproductive health as well as to help women enhance their ability to plan families effectively. That meant creating new social norms that encouraged people to communicate and cooperate.

The program included live interviews, a sociodrama, popular music, contests and raffles, letters from listeners, recorded testimonials, and news reports from communities. Agents in the community created listener groups, bringing women together in groups to listen to the program and discuss it afterwards. The agents, who were women with leadership capacities who had been elected by their communities, also promoted the program. The agents were trained to produce the plays, the radio-novella scripts, manuals and the like, and to run workshops on reproductive health, safe motherhood, and domestic violence.

Researchers traveled into the project sites by speedboat, seaplane, canoe and ferry, since no roads went in to the villages. The field investigators found that people prized their battery-powered radios and that they did listen to the program in groups. Men and women did not listen to the program together, however; the genders segregated themselves. People talked to each other most about the educational advice and real-life stories, and shared the jokes. Just over half the sample practiced a form of family planning before hearing the program. After hearing the program, listeners used birth control pills most often, then injectables, then the calendar or rhythm methods. Nonlisteners, by comparison, used traditional, less reliable herbal contraceptives more often.

One event recorded by the researchers suggests that the program was directly responsible for changing social norms. One of the husbands smashed the prized radio, shouting, “Now let’s see what you do without this radio to inform yourselves! Things will have to go back to the way they were before.” Upon questioning, the husband, who was a respected teacher and community leader, said he had been ridiculed by his male peers for allowing his wife to participate in the educational activities and that he destroyed the radio in public to restore his masculinity. The field staff visited the family to help the couple through the conflict; the village raised enough money for another radio, and subsequent groups met in someone else’s home. “This reaction suggests a juxtapositioning of women’s empowerment and male-dominated communal control, in response to media-sparked social change,” wrote the authors (Sypher et al., 2002).

EE can indeed effect change, and numerous researchers have added their own empirical evidence to the findings (Sharf, Freimuth, Greenspon & Plotnick, 1996; Rogers et al., 1999; Papa et al., 2000; Brodie et al., 2001; Beck, 2004; Kennedy, O’Leary, Beck, Pollard & Simpson, 2004). Although much of the research to date has been done in developing countries, where cultures, norms and health issues are very different from the developed world, evidence suggests that EE maintains its effectiveness in wealthy countries.

The designated driver campaign, formally known as the Harvard Alcohol Project, is a leading example of EE’s effectiveness in wealthy countries (Harvard Alcohol Project, 2005). Beginning in 1988, the Harvard University School of Public Health worked with writers from Hollywood studios and NBC, ABC and CBS to integrate storylines about the designated driver into such programs as L.A. Law, The Cosby Show and Cheers. The cooperative effort, with writers of the shows retaining creative control, ran for four years. More than 160 programs worked the ideas into plots, subplots, scenes, and dialogue. The networks also regularly run public service announcements to encourage viewers to designate drivers. A third form of media coverage included newspaper stories, instigated by Harvard’s public relations department. The New York Times, for instance, ran a story about the campaign on its front page. Prominent people, agencies and organizations, sports teams, and corporations endorsed and promoted the ideas as well.

In a survey of 17,592 college students, DeJong & Winsten (1999) found that, among drinkers, 36% reported serving as a designated driver in the past 30 days and 37% said they had been driven by a designated driver during the same time period. Forty percent of students serving as the designated driver refrained from binge-drinking, with the majority abstaining completely or having only one drink. The researchers concluded that the designated driver program had become a well-established strategy to avoid impaired driving.

The objective of the campaign was to reduce traffic fatalities; over the four years of the program, fatalities dropped by 24%, compared to no change the three years before the campaign began. The decline leveled out at 30% in 1998. The campaign was not solely responsible, since new laws were also enacted during the timeframe and were strictly enforced. However, senior television executives were so impressed at the results, according to a story in The New York Times, that they embraced the idea of using the medium for sending messages (Harvard Alcohol Project, 2005).

The CDC has embraced the idea as well. It works with the Norman Lear Center of the University of Southern California to persuade producers and writers of American daytime and prime-time television dramas to embed health content in storylines in order to help prevent disease, and conducts research where possible. It has worked with producers and writers of As the World Turns, Guiding Light, Days of Our Lives, General Hospital, ER, The Young & the Restless, among others (Beck, 2004).

The Bold and the Beautiful included a subplot on HIV in two episodes of the daytime drama on Aug. 3, 2001, and Aug. 13, 2001 (Kennedy et al., 2004). In the first episode, an attractive young Hispanic male character was tested for HIV and learned he was HIV-positive. Viewers saw the character speak to his doctor about having consistently used condoms with recent sexual partners. In the second episode, the character informed recent partners as well as his fiancée about his status. The character encouraged all of his partners to be tested. The station broadcast a hotline contact-information public service announcement by the actor after each episode; the CDC tracked the number of calls and interviewed some of the callers.

The response was overwhelming. The day before the first episode, the hotline logged 88 calls. The day of the episode, it logged 1,426 calls. The next day, the number of calls logged dropped to 108. The same pattern held for the second episode: 94 calls the day before, 1,840 calls the day of, and 234 the day after. Of the 1,904 callers interviewed, 57% said they intended to make a change or take action after seeing the episode; 44% subsequently got tested, and 28% used condoms.

The researchers suspect that the second calling spike was higher in part because the focus of the second episode had shifted to the female character, who vowed to find out everything she could about HIV and AIDS. Since viewers are mostly female, this storyline may have promoted greater viewer identification (Kennedy et al., 2004).

Since people report that they obtain much of their medical information from television, the impact of ER in the US and Casualty in England has been the focus of several studies. Whittier, Kennedy & St. Lawrence (2005), for instance, studied the effect of two episodes of ER that included a storyline about an MSM (a male who has sex with males) who is diagnosed with syphilis. Researchers invited MSMs in Internet chat rooms to participate in the survey and found that MSMs who watched the episodes, compared to those who had not, reported significantly greater intentions to be tested for syphilis and to advise others to be tested.

The effectiveness of the embedded storylines may be due, at least in part, to the credibility of the stories themselves. Indeed, the producers of ER go to some lengths to ensure that the prime-time drama, which is broadcast is more than 30 countries, seems genuine (Davin, 2003). Medical doctors write the scripts and supervise the filming; the stories are based on real emergency cases reported by health professionals; the main actors are familiar with actual casualty procedures; the medical equipment is real; the steadycam camera work gives viewers the sense of actually being there. Some people equate ER with a documentary film and even rate it as more reliable than documentaries. Viewers have learned about physiology, symptoms, diseases, treatments, and the practice of medicine from ER (Davin, 2003).

Casualty, BBC1’s flagship medical drama with 12.8 million viewers, has had similar effects on audiences in England (Davin, 2003). Unfortunately, the program may be sending people unhealthy messages. An episode that aired in  November of 1996 included a storyline about an RAF pilot in his 30s who had been in an accidental crash that killed a colleague. The pilot was having difficulty returning to work. He was afraid he had epilepsy. In expected primetime drama fashion, he was drinking more than usual and his marriage was in trouble. Two days before being taken to the accident and emergency ward, the pilot had taken 50 paracetamol (Tylenol); he collapsed and was taken to hospital, where he vomited blood. The character died a short time later from severe liver damage and an inability to clot.

As expected, audiences gained information from the episode. They may, however, have gleaned more than that. O’Connor et al. (1999) found that, one week after the episode aired, 85% of viewers of the series correctly identified paracetamol as having hepatoxic effects. Approximately eight months later, 76% of viewers retained the knowledge. Hawton et al. (1999) also studied the episode, but the team looked at whether the storyline influenced self-poisoning in the population. The researchers knew when the episode would air (which is not always the case) and so were able to collect three weeks of data on self-poisoning before the episode and three weeks following. The number of people presenting at hospital for self-poisoning increased by 17% in the first week after the episode and 9% in the second week. Of 32 patients who had poisoned themselves and who had also watched the episode, 20% reported that seeing the storyline had influenced their decision to overdose. Seventeen percent said it had influenced their choice of drug. Every person who attempted to overdose on paracetamol had made a similar attempt in the past, suggesting that the episode may have prompted people to attempt an overdose again. Fortunately, no deaths from paracetamol overdose were recorded during the time period under study.

Media can have a profound effect on people’s beliefs, attitudes and behaviour; indeed, media is having a profound effect on the way in which people think about mental illness. Unfortunately, it could be argued that the effects are overwhelmingly negative. Mass media and the entertainment industry have been modeling how to stigmatize people with mental illness. Much can be learned from an examination of the ways in which other campaigns have been able to effect change in other health arenas, however. That may be particularly the case when those campaigns are considered from within the context of the media industry and how stigma develops.

Many people who develop a mental illness have learned that, within their culture, mental illness causes people to be rejected and so they expect to be stereotyped. One of the ways to begin to undo that process is to enhance people’s knowledge and understanding of mental health, so that they are less likely to apply labels that do not fit. Several countries have launched media campaigns to educate the public; however, if people continue to draw much of their health information from prime-time television drama, those media campaigns are unlikely to have a substantial impact.

Given the success with other health issues, integrating storylines about mental illness into entertainment vehicles would seem an obvious response. In the United States, groups advocate for messages about adolescent sexual health (The Media Project), anti-bullying and violence prevention (Mediascope), youth violence prevention (Squash It!), immunization (UCLA School of Public Health), terminal illness and death (The Last Acts Writers Project), HIV-AIDS awareness (Hollywood, Health & Society), but there appears to be no group advocating on behalf of healthy messages about mental illness in the entertainment industry. Nor to the best of this author’s knowledge is there any group doing so in Canada, although a working group has recently been formed in Nova Scotia to lobby for healthier messages in the print media. The author recommends that a Canadian coalition of concerned writers and mental health professionals be formed to begin meeting with and talking to screenwriters in Canada about more accurate depictions of mental illness. Screenwriters and producers should at the very least be made aware of how their portrayals effect what people believe about mental illness. This could be done through regular newsletters, workshops, seminars and meetings, much as the CDC now does with American producers and writers (Beck, 2004).

Cultivation theory, which comes from the communication literature, suggests that exposure to a consistent set of messages, however inaccurate, encourages people to incorporate the message into their worldview (Signorielli et al., 1995). The theory predicts the “Mean World” syndrome, which occurs when people who are heavy viewers of television begin to perceive the world as more violent than is actually the case (Greunke, 2000). Cultivation theorists have studied the effects of television and violence, as well as mass media and gender roles, age groups, ethnic groups, and political attitudes (Chandler, 2005). In a study of college students, for instance, Dominick (1990, p. 512) found that students who were heavy viewers of soap operas were more likely than light viewers to overestimate the number of married people who have had affairs and been divorced; the same trend was true for real-world perceptions of the number of women who had had abortions.

Cultivation theorists have been criticized for neglecting the influence of other sources of messages about one’s world (Chandler, 2005). However, given that people obtain most of their information about health from popular media, and given that popular media tends to portrays mental illness in a negative light, cultivation theory suggests that heavy use of popular media leads people to believe that people with mental illness are dangerous and so on. This suggests that if any progress is to be made in destigmatizing mental illness, the current negative media depictions should be ended, in addition to positive depictions being shown.

Ending negative depictions promises to be a highly complicated process, involving as it would the dismantling of writers,’ producers’ and directors’ beliefs about mental illness. Negative portrayals are not appearing in popular media by accident—though it may be happening without people’s full awareness. A qualitative study of the way in which writers, directors and producers craft, then portray mental illness, including not just how characters are written but how characters are dressed and made up, how scenes are shot and edited, the music that is chosen and so on, would help understand how the negative aspects of mental illness are being used in dramas and sitcoms, and why. Until the research is conducted and data is accrued, it will be difficult, if not impossible, to determine how best to undo the damage. The same kind of research should also be conducted on animated features and television series, since that is a particularly popular medium with children. Once the process is better understood, creative teams may be quite willing to generate storylines that do not exacerbate the stigma of mental illness.

Narrative analysts (Seale, 2003) say that stories work by creating, then exploiting, oppositions such as heroes and villains, pleasure and pain, safety and danger, disaster and repair, innocence and evil, and so on. One might add “us” versus “them” to the list, with “them” referring to people with mental illness, and “us” as everyone else (Olstead, 2002). Life and death is the main opposition-set in medical drama, with doctors playing the hero, for instance. As discussed earlier, characters with mental illness have been stereotyped as villains for many years (Rose, 1998; Schneider, 2003; Wahl et al., 2003); they have also been used to represent danger, and are often cast as the ugly person (rotting teeth and bad breath included) (Wilson et al., 2000). Understood within the framework of narrative analysis, these stereotypes present a ready opportunity for writers to create and exploit oppositions in order to make their stories work. Writers may be more willing to not employ mental illness in these very negative ways if good alternatives are suggested to them, particularly if the alternatives have strong narrative appeal. This presents another avenue of research worthy of exploration, one that might involve communication researchers and stigma specialists working with writers to test the efficacy of more factual aspects of mental illness, yet maintaining classic oppositions.

Anecdotal evidence suggests that entertainment-education is a viable method of destigmatizing mental illness. The BBC daytime soap opera Eastenders created a character with schizophrenia, with help from a Bethlem Royal Hospital psychiatrist (Reveley, 1997). Joe Wickes was a teenager whose sister had died and whose father appeared and suddenly disappeared. Joe’s initial diagnosis was psychotic depression; the diagnosis changed to schizophrenia. The show’s writers, directors and producers visited the wards and photographed them, and also spoke with nurses, patients and the pharmacy in order to get the details right. The consulting psychiatrist believes that the storyline did help destigmatize the disorder, but no research has been conducted to test this hypothesis.

If a prime-time drama were to be created, drawing on existing analyses would be of benefit in determining how best to proceed. When Singhal et al. (1994) analyzed Simplemente Maria in an attempt to understand why it was so successful, the researchers concluded that:

• The production team was topnotch;
• The timing was good, with themes reflecting relevant concerns for the audience;
• The actors were highly skilled;
• Audience members closely identified with characters in the story;
• People felt as if they knew the characters;
• Gossip. The telenovela became a favourite topic of conversation among viewers;
• The telenovela was novel;
• Multimedia coverage;
• Vague geography. Since there were no references to location, the story was easily transported into other Latin American regions.

All but one of these points could be replicated in a new prime-time drama dealing with mental illness. An excellent production team, including excellent actors, could be assembled; there is no shortage of talent. Themes for a new drama could include the oil crisis, massive personal debt, war, the advent of a U.S. police state, other political strife, and so on, all within the context of mental health. Identification with the characters could be accomplished by understanding the audience’s fears and experiences, again within the context of mental health, which would be possible with sufficient research. The CDC has begun this process by hosting information sessions with writers, producers, and people effected by mental illness (CDC, 2003a; CDC, 2003b), so that the people telling the primetime stories or making films can listen and speak to the people who have been challenged by, and recovered from mental illness. Having a clear idea of the struggle may go some way toward persuading writers to replace stereotypes and clichés with reliable and accurate portrayals. Should an organization begin such a collaboration, it would be interesting to conduct research before, during, and after information forums to understand whether the process is effective.

If a prime-time drama that focuses on mental illness could be created, then based on Singhal’s analysis, expanding the program to a multimedia format and launching a public relations campaign as well would be beneficial. A radio version of the Simplemente Maria story was aired during the same time period as the television program, with the same actors, and many newspaper and magazine stories appeared as well. “…a type of Simplemente Maria ‘fever’ raged in Peru and other Spanish-speaking Latin American countries in the late 1960s and 1970s,” wrote Singhal et al. (1994).

Given the decades of experience that viewers have had with television programming, the element of novelty cannot be replicated. However, the Internet is still somewhat unexplored; there may be tie-ins that could seem novel to audiences. An example is the American Express website, which has offered visitors a short fictional video featuring well-known comedian Jerry Seinfeld and an animated version of Superman. The “webisodes,” as they’re being called, have only been available on the website. The most recent video, launched March 29, 2004, attracted approximately 2.4 million visitors during the seven days following the launch. That represents an increase of 31% over the previous week (Mara, 2004). The concept might be employed to promote characters or concepts from the prime-time drama.

Although Singhal did not include this point in his analysis of Simplemente Maria, repetition of a message is key, as Brodie et al. (2001) found after researching the influence of ER on audiences. Members of the team interviewed two samples of regular viewers before and after an episode dealing with emergency contraception. Awareness rose immediately after by 17%, but two months later, knowledge levels dropped back to pre-episode levels. The same pattern emerged after an episode aired in which nurse Carol Hathaway explained to a teenage patient that cervical cancer can be related to the sexually transmitted disease human papilloma virus. Knowledge rose immediately after, but the gains were not sustained over time. Messages must be repeated. Repetition, of course, is part and parcel of long-running television or radio dramas.

Understanding the audience is vital if a drama is to be convincing. Audience research helps make that possible. For a radio drama in Tanzania called Twende na Wakiti (Let’s Go With the Times), developers conducted 4,800 personal interviews and 160 focus groups. They found that long-distance truck drivers, who engaged in sex with prostitutes along their routes, were a key vector for HIV infection. The primary negative role model in the drama became a long-distance trucker named Mkwaju, who was promiscuous and chauvinistic, contracted AIDS and lost his marriage. Being exposed to the program led more than 20% of the people interviewed at family planning clinics to adopt a family planning method. Condom distribution increased by 600% in treatment communities versus 140% in control regions (Rogers et al., 1999).

People’s attitudes and knowledge before the Tanzanian radio program aired were consistent with the message, which may mean that behavioural effects depend on existing attitudes that are consistent with the message being promoted. If additional research proved this out, then early audience research could point to attitudes that are at odds with the intended messages of a program. It would then fall to the program developers, researchers and educators to lay the groundwork for attitude change using methods other than EE before the program aired.

Drawing from the success of the Harvard Alcohol Project, a new prime-time drama would likely be more assured of success if it were part of a larger process of social change that incorporated support and promotion from major public figures, respected corporations and the like. Since researchers have demonstrated that holding informal discussion groups to review messages reinforces the content of the program, that would be a valuable adjunct as well.

Source: Matthews, Jan (2005). Media, mental illness and stigma: does entertainment-education have the potential to help destigmatize mental disorder? Independent study paper submitted for partial fulfillment of master of arts degree, Dalhousie University School of Health and Human Performance, Halifax, NS.

On this page, I'll be reviewing research evidence that relates to the cognitive and emotional effects of video games, television programs, news reports, narratives, social media and so on.