February 5 opened the latest round of applications for the annual Rosalynn Carter Fellowships for Mental Health Journalism. Established in 1996, the nonresident fellowships—an initiative of the Carter Center’s Mental Health Program—support journalists in the US, UAE, Latin America, and Qatar, training them on “effective mental health reporting … as they report on a mental health topic of their choice.” Their goal: “strengthen reporting, drive change in their communities, and help reduce stigma through storytelling.”
Recipients receive a $10,000 stipend, access to mental health and journalism resources and experts including a mentor from the Center’s fellowship advisory board, and mandatory pre- and post-fellowship training sessions. They are promised total journalistic independence, required only to disclose their Center funding, “report accurately,” and “use appropriate language for reporting on mental health.”
Selected by the board and a committee of current and former journalists and mental health experts, the 2019 award-winners’ projects focused on important topics such as “college students forced to take mental health leaves of absence from school” and “PTSD and its resurgence among immigrants and asylum seekers amid harsher immigration policies.” Since the fellowship was established, the website boasts, the 200+ recipients have produced more than 1,500 mental health-related articles and other works during and after their fellowship year, some of which have garnered Pulitzer Prize nominations and have resulted in “changes to local, state and/or national behavioral health policies or programs.”
This all seems very positive, and it is easy to see that the Center is encouraging journalists to report stories that tell of abuse of people diagnosed with psychiatric disorders, and within a “human rights” context. It also regularly discourages journalists from falling into the “mentally ill are violent” storyline that so regularly pops up whenever there is a mass killing.
Yet, at the same time, one of the center’s key resources, the Journalism Resource Guide on Behavioral Health, is a manual for docile journalism.
There is no encouragement to be skeptical of the powerful in the field of psychiatry. Rather, the guide provides reporters with a template to follow that, for the most part, reifies conventional wisdom, offering a message similar to what the American Psychiatric Association has sounded for years. As such, even while individual stories written by journalists who’ve been at the Carter Center may be quite good and important, the Center—as an institution—is serving to sustain a narrative that has arguably done great harm to our society.
The Center’s Journalism Guide
The Cater Center is upfront about its vision of the role a better-informed press can play in advancing its Mental Health Program’s agenda of “improv[ing] access to care” for people dealing with “mental illness” and helping them and society to “overcome stigma.” That role, according to the Center’s website, is to “ensure the public gets reliable information about mental illnesses” that can “influence peers and important stakeholders” and “shape debate and trends with the words and pictures they convey.” As Rosalynn Carter put it in a 2016 Center webcast, the idea is to [refute] “myths and misconceptions” to “encourage people to seek support and treatment when they are in need.”
The Journalism Resource Guide on Behavioral Health codifies these and other lessons. Designed for use by newsrooms and provided to fellows to help them think and write about mental health and substance-use issues “in ways that shed light on a topic too often misunderstood,” the guide was developed over two years with funding from the Substance Abuse and Mental Health Services Administration and released in 2015.
In addition to specifying what type of words to use (and avoid), the guide features cheat-sheets on “mental illnesses” and symptoms, along with a list of “Credible Resources.” It also describes specific messages it says good reporting on mental health should convey.
According to Kari Cobham, Senior Associate Director of The Rosalynn Carter Fellowships for Mental Health Journalism and Media, the guide is unique in that it is the first of its kind in the U.S. and offers “an encapsulated overview” of the nuts and bolts of reporting on the broad subject of behavioral health as opposed to “niche” guides on covering specific topics such as suicide.
The Carter Center’s Template for “Good Mental Health Journalism”
The Role of the Journalist
The Center’s guide for mental health journalists informs reporters that they need to understand that “behavioral health conditions impact everyone.” In the webcast mentioned above (a simulcast of a panel for fellows on appropriate language use), reporters are told that mental health is a costly “serious public health issue” affecting one in four Americans in their lifetime. In opening the panel, Thomas Bornemann, director of the Center’s Mental Health Program, quotes the Lancet as calling mental illness “just as much a global health threat as infectious disease.”
Thus the Center’s guide, under the heading “Fair and Accurate Coverage Matters,” emphasizes the power of the news media to educate the public and “help create a society where people feel supported and are willing to seek and receive help for behavioral health problems. Encouraging help-seeking behavior can help resolve some of our nation’s most complex issues through prevention and intervention.”
In other words, reporters are told to write that behavioral health conditions are quite common, and to inform the public that prevention and intervention efforts are effective and helpful. This is the same message that the American Psychiatric Association has been promoting in its “educational” efforts ever since it published the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, and the Carter Center is informing journalists that in order to provide “fair and accurate” coverage, they need to promote that message.
Having set forth this standard for “fair and accurate coverage,” the Center’s guide then provides journalists with a “paint by numbers” script for reporting on mental health.
1. Consider Three Important Questions
Reporters are asked to begin by “consider[ing] three important questions,” which were developed by the Entertainment Industries Council, a group that encourages more realistic and sympathetic depictions of characters with mental illness and substance-use issues in fictional TV and movie programs. Namely: 1. Whether mental health or substance use is relevant to the story, and if so, 2. What is the source of the subjects’ diagnosis? (ask a health professional, not a neighbor) and 3. What is the most accurate language to use? (get a precise diagnosis and describe specific behaviors).
Aside from the oddness of applying guidelines for Hollywood scriptwriters to journalism, this section simultaneously reminds reporters not to overemphasize or make assumptions about a newsworthy subject’s mental state—and yet to make sure to pin down exactly what a professional says is wrong with the subject and use that information to characterize a person’s mental state.
2. Words Matter
The program and guide emphasize that journalists should know and use appropriate language when reporting on behavioral health, as this is said to help break down stereotypes about mental illnesses and people diagnosed with them. (Casual use of “crazy,” for example, is verboten.) According to the guide, word choices can “create greater understanding” of these “disorders” and thereby “make it more likely people in need will seek help.” Besides focusing on person-first language (person living with schizophrenia vs. schizophrenic), reporters are cautioned to avoid derogatory terms such as “lunatic,” “psycho” “wacko” “loony” and “nuts.”
For the record, it is hard to find any mainstream journalists using terms such as “psycho” and “wacko” today. So this advice seems a bit superfluous. More notably, there is no encouragement for journalists to consider how people so diagnosed self-identify, including whether they accept their diagnostic label in the first place.
In addition, the Carter Center’s guide advises journalists to refer to someone with “accurate” clinical terms such as “paranoid” or “delusional.” But such words provide much the same message to the public that “lunatic,” “psycho,” and “loony” do. The clinical terms are stigmatizing too, just more polite.
3. Report Behavioral Health Facts
This section features a bulleted list of basic concepts for journalists to convey and statistics to use, drawn mostly from health agency websites and reports. Some of the “facts” journalists are urged to include:
- “Scientific research into the causes of and treatments for behavioral health conditions has led to important discoveries over the past decade and should be examined closely.”
- “Substance use disorders are diseases of the brain.”
- Ten million US adults “experienced a serious mental illness last year.”
- “Behavioral health conditions are an economic concern.”
All of this is part of the usual spiel, and it tells a story of scientific progress in which “important discoveries have been made.” The guide then continues with this explanation: “Although science has not found a specific cause for many mental health conditions, a complex interplay of genetic, neurobiological, behavioral, and environmental factors often contribute to these conditions.”
Carefully parsed, this sentence implies that despite the elusive etiology of mental health problems, progress is being made in understanding “genetic” and “neurobiological” factors. Yet, as Mad in America readers will know, that story of “progress,” which American psychiatry has been telling for decades, has collapsed.
- The chemical imbalance theory of mental disorders, which is a neurobiological explanation, has been publicly abandoned.
- The search for the “genetic” underpinnings of mental disorders has so far proven to be a barren pursuit.
- Research has shown that psychiatric drugs are not particularly effective even over the short term, and they appear to worsen long-term outcomes.
- The public health burden of mental disorders has grown dramatically in the past 35 years, even as the use of psychiatric drugs has exploded.
Reporters are not encouraged to report any of these facts, which tell of a lack of progress.
Meanwhile, the ten million “serious mental illness” number arises in part from the expansion of DSM diagnostic categories (such as bipolar illness), but reporters are also not encouraged to explore that fact.
There is one listed “fact” in the guide that will be familiar to Mad in America readers: “Previous traumatic experiences are strongly associated with mental and substance use disorders.” But that statement is also being embraced by mainstream providers today, and so the guide is not going to ruffle any feathers by stating this.
4. Discuss Prevention and Early Intervention
With such “facts” in mind, reporters are then urged to “reinforce that mental and substance use disorders, even many severe and chronic conditions, are serious but often preventable, similar to diabetes or hypertension” and that “early diagnosis and intervention matter.”
In terms of early diagnosis, the guide tells reporters that they should advise readers to be on the lookout for the “symptoms” of “mental health conditions” that “persist,” and that they turn to the APA’s Diagnostic and Statistical Manual of Mental Disorders 5 as a reliable guide for doing so. This will help “raise awareness” and create opportunities for “early intervention” because the “persistence (of symptoms) over a certain period of time is important for diagnosis.”
The “signs” of a mental health condition, reporters are advised, include “prolonged” depression (which, according to the DSM, is a mere two weeks), “excessive” fears, and “disordered” thinking. Signs of substance use disorders are said to include “sudden lack of motivation,” “financial problems” or “legal troubles.”
The guide also provides reporters with an alphabetical “Common Mental Health Condition Index” summarizing symptoms of eight major classes of disorder in the DSM, from ADHD to Schizophrenia.
Clearly the Center, through its guide, is telling journalists to see the DSM as a reliable and valid instrument for identifying psychiatric disorders. There is no mention of the fact that the DSM categories are created by consensus of a small group of APA members, nor that there are no objective blood or imaging tests for these diagnoses. The guide is also silent on the lack of validity of these diagnostic categories, which have long been challenged within and outside the profession.
Given this criticism of the DSM, the Carter Center might also want to encourage reporters to discuss how the “symptoms” of behavioral health conditions may be caused by a reaction to unbearable life events or linked to a medical problem such as Lyme disease, toxic exposure, nutritional deficiency, or a prescription drug reaction.
Moreover, the Carter Center states that one of its goals is to decrease stigma. Research has shown that the notion of a biological/genetic basis for “mental illness” and substance use actually increases stigma. Shouldn’t reporters be made aware of such findings?
5. Include Treatment Options
The American Psychiatric Association regularly sounds this theme: Psychiatric conditions regularly go undiagnosed and undertreated, and psychiatric treatment is effective. The Carter Center’s guide prompts reporters to echo this message.
The guide tells reporters to “consider reporting the following [three] facts to help minimize barriers to treatment.” Namely:
- “Treatment is effective
- Treatment is accessible and affordable
- People are supportive of those in treatment”
Let’s look at each of these three “facts.”
Treatment is effective
The guide states that “between 70 and 90 percent of individuals with a mental health condition experience a significant reduction in symptoms and improvement in quality of life after receiving treatment.” The source of this statistic is the National Alliance on Mental Illness, as opposed to any scientific journal.
As is well documented, it is common that people have to try several different “meds” to get symptom relief, and for two-thirds of those taking them, these drugs either don’t work or quit working, leading to the concept of allegedly “treatment-resistant” conditions. The drugs may also have intolerable or life-threatening side effects that make it difficult to partake in activities of daily life.
Moreover, several of the pieces published by Center fellows actually reveal harm from accessing existing services, including inappropriate care for women with post-partum crises.
But the guide doesn’t tell of this potential for harm from treatment; instead, it urges reporters to cite a “fact” from NAMI that certainly isn’t supported by any meta-analysis of the safety and efficacy of antidepressants, antipsychotics, and other psychotropic drugs.
Treatment is accessible and affordable
Although the guide refers to more than 8,000 and 14,500 treatment facilities for mental health conditions and substance-use treatment, stories in the Center’s Fellows Project Database regularly document the difficulty of obtaining timely services. This lack of access to treatment is faced by many populations in the United States.
Psychiatric care can also be expensive, running into hundreds and even thousands per month, especially for those without good health insurance. The guide cites the expanded benefits of the Affordable Care Act, which have since been gutted under the Trump Administration.
Support for people to get treatment
According to SAMHSA surveys, says the guide, fewer than one-fifth of Americans “say they would think less of a friend or relative in recovery from an addiction” and that “more than two-thirds agree that treatment and support can help people with mental health issues lead quality lives.” If this is true, then it’s hard to argue that stigma has been preventing people from seeking psychiatric help.
6. Highlight Recovery
This section recommends that journalists “help the public understand that people can and do recover” from “mental illness” and substance use problems, noting that “the path to recovery is unique to each individual.” Reporters are urged to “feature individuals in long-term recovery” and “suggest that recovery supports are often critical” to success, listing options such as housing, work, exercise, mutual aid, and medication.
While this advice may seem encouraging, given that psychiatry’s current model tends to define disorders as incurable and lifelong, it is telling reporters that they should emphasize the positive and avoid focusing on the failures of psychiatric care. Journalists aren’t being encouraged to tell the stories of those who have been harmed by conventional treatments; nor to write about the dependency that psychiatric drugs can cause or their many side effects; nor to report on how the current paradigm of care has fueled a soaring rise in the number of Americans disabled by “behavioral health” conditions.
7. Reference Credible Sources
The guide urges journalists to “reduce the prevalence of sensationalized, inaccurate information that fuels prejudice and discrimination.” To that end, the sourcing section lists sites where reporters can find resources and mental health data that will support the type of stories that they have been advised to tell.
As could be expected, most of the listed resources are ones that promote conventional wisdom about psychiatry and its treatments. The recommended resources include government health agencies such as SAMSHA, the CDC, mentalhealth.gov, NIMH, drugabuse.gov, and healthcare.gov, plus the nonprofit HelpGuide.org International and The Association of Recovery Community Organizations (for substance-use topics). While such government materials can provide helpful data, they are informed by the agenda, political priorities, and leadership of the agencies from whence they come.
The guide does not provide any resources for obtaining the perspectives of people with lived experience. A useful list might include grassroots organizations such as MindFreedom International or the Icarus Project, and also include organizations that seek to protect the rights of people who are deemed “mentally ill,” by society, such as the Bazelon Center for Mental Health Law.
The guide also does not provide any advice to journalists about how they should read articles that appear in scientific journals, and in that manner assess whether what the “experts” are telling them is true.
Thus, if reporters covering mental health follow the Carter Center guidelines, they will be prompted to contact government agencies for general information and data about mental health. There is no resource listed that would bring reporters into contact with an organization or user group that speaks critically of the conventional wisdom. The guide is subtly telling reporters that they can just ignore the fact that there is a rising debate in society about the merits of psychiatric care. Their job, it seems, is to be able promoters of the conventional narrative that psychiatry, as an institution, has been telling us for decades.
A Government Guide For Journalists
As everyone in journalism knows, reporters are supposed to remain independent of the government agencies, businesses, or organizations they cover. As such, a non-profit that is trying to foster good “mental health journalism” would not be expected to “partner” with a government agency in developing a guide for how journalists should go about covering mental health.
Yet, that is what happened in this case. Though the guide has a disclaimer stating it reflects only the views of the Carter Center, “SAMHSA took the lead role in developing the guide, and we worked together on refining content,” said Rennie Sloan, the Center’s Press Liaison to Health Programs, in an email to Mad in America.
In an interview with Carter Center spokesperson Kari Cobham, MIA asked about the concerns presented in this piece. She replied that one of the guide’s main goals is “harm reduction.”
“I don’t think it’s encouraging reporters to present prepackaged information as much as it is encouraging them to be responsible in their reporting,” she said. “ For example, when newsrooms are making decisions on how to report on suicide, you see more and more now that they are using best practices of saying ‘died by suicide’” instead of “committed suicide.”
She added, “I’m a former journalist, and journalists have a responsibility to think critically but also to be accurate in their reporting and to be thoughtful . . . and if the way that a certain community is viewed or a certain illness is viewed comes across in the reporting, that also has a very large impact on stigma.”
Cobham stated that the lack of science and first-person sources in the guide is because it is only intended to provide basic tools. The Fellows’ projects focus on different elements of the mental health beat, and so “we connect them to the resources so they can dig into the area that their fellowship project covers.”
She added that “we do involve service users in our programming and training, talk to fellows about getting that perspective. Last year we had a session on how to talk to people with lived experience, like trauma, on how not to retraumatize them in the course of reporting.”
While all that is fine and good, it doesn’t distract from the fact that there are no discernible “services users” or survivor groups on the Center’s two key advisory boards. The Center’s Mental Health Task Force is populated with psychiatrists and MPHs; its chair, former First Lady Rosalynn Carter, is an Honorary Fellow of the American Psychiatric Association. The Journalism Advisory Board—composed mostly of journalists—also leans toward MDs and health policy experts.
Thus, it is not surprising that the Center’s resource guide for journalists urges them to report in ways that will support conventional wisdom and practices. A government agency took a lead role” in spearheading the guide, and its advisory boards are populated by professionals who could be expected to urge journalists to write stories that reflect conventional beliefs.
The notion that a journalist might question those beliefs, and do so by reading articles published in scientific journals and listening to those with lived experience who may resist conventional care, is completely absent from the Carter Center’s guide for covering behavioral health issues.
Good Intentions Gone Awry
The Carter Center, with its focus on public health and human rights, is seeking to improve mental health journalism in this country (and abroad). The guide does speak about trauma as a factor that can lead to behavioral health problems, and the message to reporters is to respect those who experience them. And its alums have produced important stories on problems within the mental health system, their reports prompting local and state governments to respond.
But the very fact that the Carter Center is seen as a leader in training journalists on how to report on mental health just makes its failures all the more discouraging. Reporters are supposed to serve the public and be willing to challenge the powerful, not act as stenographers who repeat conventional dogma. Thus the Center should be training journalists to think critically and be skeptical in their coverage of mental health issues. Can they trust pharma-funded research? Does the American Psychiatric Association have guild interests that affect the story they tell to the public? Do reporters know how to read scientific reports and other source documents to see if they support the narrative they are being told?
Cobham, from the Carter Center, Cobham notes that the guide will be updated and is an evolving document. It would be extremely helpful if a revised guide prompted reporters to think critically of the very “facts” they are, in the current guide, expected to promote.