Coverage of Posttraumatic Stress Disorder in the New York Times ...

Journal of Health Communication International Perspectives

ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcm20

Coverage of Posttraumatic Stress Disorder in the New York Times, 1950–2012 J. Brian Houston, Matthew L. Spialek & Mildred F. Perreault To cite this article: J. Brian Houston, Matthew L. Spialek & Mildred F. Perreault (2015): Coverage of Posttraumatic Stress Disorder in the New York Times, 1950–2012, Journal of Health Communication, DOI: 10.1080/10810730.2015.1058441 To link to this article: http://dx.doi.org/10.1080/10810730.2015.1058441

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Date: 31 December 2015, At: 10:17

Journal of Health Communication, 0:1–9, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print/1087-0415 online DOI: 10.1080/10810730.2015.1058441

Coverage of Posttraumatic Stress Disorder in the New York Times, 1950–2012 J. BRIAN HOUSTON1,2, MATTHEW L. SPIALEK1,2, and MILDRED F. PERREAULT2,3 1

Department of Communication, University of Missouri, Columbia, Missouri, USA Disaster and Community Crisis Center, University of Missouri, Columbia, Missouri, USA 3 School of Journalism, University of Missouri, Columbia, Missouri, USA

Downloaded by [University of Missouri-Columbia] at 10:17 31 December 2015

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Posttraumatic stress disorder (PTSD) is a mental health disorder that occurs for some individuals following a traumatic experience and that can cause significant health, mental health, and functioning problems. The concept of PTSD has multiple components (cause, reactions, and treatment), which provides for great variety in the experience of an individual with PTSD. Given this complexity, the news media’s construction of PTSD is likely an important influence in determining how the public understands PTSD, but research has yet to investigate how the news media depict PTSD. This study addresses that gap in the literature by examining New York Times coverage of PTSD from 1950 to 2012. Results indicate that the number of PTSD articles during this time period increased, with coverage spikes related to U.S. military conflicts and the September 11, 2001, terrorist attacks. Almost half (49.14%) of all PTSD articles included military service as a PTSD cause. Military PTSD articles were more likely than civilian PTSD articles to depict the disorder as causing anger=irritability=rage, homicide=violence=rape, suicide, substance abuse, and home=work= relationship problems. PTSD news stories were almost always (94.8%) situated in the current time and most frequently (46.6%) used a community frame. Implications for public understanding of PTSD are discussed.

Posttraumatic stress disorder (PTSD) is a mental health disorder that occurs for some individuals following a traumatic experience and that can cause significant health, mental health, and functioning problems (Kessler, 2000). It is estimated that 6.8% of all Americans will experience PTSD in their lifetimes, with 3.6% of men and 9.7% of women affected (Gradus, 2014; Kessler et al., 2005). In addition, although many individuals will not develop PTSD following a traumatic event, some of these individuals may still experience posttraumatic stress symptoms or subthreshold PTSD, which can be problematic (Marshall et al., 2001). Overall, then, PTSD constitutes a significant public health issue (Iribarren, Prolo, Neagos, & Chiappelli, 2005). The concept of PTSD has multiple components (cause, reactions, and treatment), which provides for great variety in the experience and recovery of an individual with PTSD. For example, a traumatic event may occur at a more individual level (e.g., an automobile accident) or societal level (e.g., war), and there are a variety of reactions an individual might exhibit following a traumatic event (e.g., reexperiencing the event, arousal, numbing). In addition, different treatment approaches for helping those affected by trauma are available (e.g., therapy, medicine, hospitalization; Foa & Cahill, 2006). Given this complexity, the news media’s construction of PTSD is likely an important influence in determining how Address correspondence to J. Brian Houston, Department of Communication, University of Missouri, 204 Switzler Hall, Columbia, MO 65211, USA. E-mail: [email protected]

the public understands PTSD. However, little research has investigated how the news media depict this disorder. This study addresses that gap in the literature.

PTSD The concept of psychological trauma is inherent to the clinical diagnosis of PTSD in that PTSD requires the experience of a psychologically traumatic event. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association [APA], 2013), describes a traumatic experience as ‘‘exposure to actual or threatened death, serious injury, or sexual violence.’’ PTSD has been found to interfere with an individual’s ability to work, to affect social and family relationships, and to be associated with a lower quality of life and an increased chance of attempted suicide (Kessler, 2000). Even individuals without a full diagnosis of PTSD (which is described below) may suffer, as research has found that an increase in the number of PTSD symptoms is related to impairment, depression, and suicidal ideation (Marshall et al., 2001). Although traumatic symptoms and reactions have been described following events such as war or catastrophes for centuries (Friedman, Resick, & Keane, 2007; Iribarren et al., 2005), the APA established the first official PTSD diagnosis in 1980. The establishment of the PTSD diagnosis largely followed observations and research related to the United States’ experience in the Vietnam War (Morris, 2015). Since the initial conceptualization of PTSD, the


2 criteria required for a diagnosis of the disorder have changed as APA’s Diagnostic and Statistical Manual of Mental Disorders has been periodically updated. Currently, eight criteria must be met before a person can be diagnosed as having PTSD (APA, 2013). These criteria include first being exposed to a traumatic event, followed by experiencing intrusion symptoms related to the event, persistently avoiding reminders of the event, experiencing negative alterations in cognitions and moods related to the event, and exhibiting marked alterations in arousal and reactivity associated with the event. Each of these symptoms must endure for more than 1 month, must impair functioning, and cannot be attributed to substance or medicine use (APA, 2013). Meeting some or many but not all of these criteria—although potentially problematic for the individual—will not result in a clinical diagnosis of PTSD. The types of events that may cause PTSD include interpersonal violence (e.g., rape or assault), accidents (e.g., automobile accidents), and disasters (e.g., tornados, terrorist attacks; Yehuda, 2002). Causes of PTSD can occur at the individual, family, community, or even societal levels. In a study of individuals with probable PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), the most upsetting traumas reported by men were being in combat (28.8%), witnessing someone being badly injured or killed (24.3%), and experiencing an accident (12.1%); the most upsetting traumas reported by women were rape (29.9%), molestation (19.1%), and physical abuse (8.2%). Treatment for PTSD typically includes counseling or therapy and=or medication (Foa & Cahill, 2006). In a review of epidemiologic research on trauma and PTSD, Norris and Slone (2007, p. 86) concluded that experiencing a traumatic event is ‘‘exceedingly common’’ in that ‘‘by the onset of adulthood, at least 25% of the population will have experienced such an event, and by the age of 45, most of the population will have experienced such an event.’’

News Coverage of PTSD How the news media construct PTSD is important because media depictions of health issues may influence how individuals think about that issue in general (Clarke, 1992; Ziporyn, 1988) and about what must be done to prevent or treat the illness or disease (Bardhan, 2002). Media depictions of mental health issues may also influence mental health stereotypes (Hoffner & Cohen, 2014). The public frequently turns to the news media to gain health information (Brodie, Hamel, Altman, Blendon, & Benson, 2003), and attention to news coverage of health issues is associated with health knowledge and behavior (Brodie et al., 2003; Miller, Augenbraun, Schulhof, & Kimmel, 2006; Pierce & Gilpin, 2001; Slater, Hayes, Reineke, Long, & Bettinghaus, 2009; Yanovitzky & Blitz, 2000). Although several previous research studies have explored how the news and mass media depict mental illness in general (Aragone`s, Lo´pez-Muntaner, Ceruelo, & Basora, 2014; Slopen, Watson, Gracia, & Corrigan, 2007; Wahl, 1992, 2003), only one previous study has examined media coverage of PTSD. Pollock, Gratale,

J. B. Houston et al. Anas, Kaithern, and Johnson (2014) analyzed coverage of U.S. veteran posttraumatic stress in 26 U.S. newspapers over a 10-year period, coding the articles primarily for posttraumatic stress treatment responsibility (government responsibility, societal responsibility, balanced=neutral), and found that coverage generally focused on government responsibility for the treatment of veterans’ posttraumatic stress. In terms of understanding media coverage of PTSD, however, research that examines PTSD in contexts beyond military veterans and that provides a more robust content analysis of media depictions of PTSD is needed. The current study seeks to fill this gap in the literature. Framing How a health issue is framed is an important consideration in understanding media depictions of health issues (Brown, 1995). Framing involves the selection of ‘‘some aspects of a perceived reality’’ that then makes those aspects more salient to a media consumer (Entman, 1993, p. 52). Gitlin (1980) wrote that framing is unavoidable because, at the institutional and individual journalist levels, framing is necessary to interpret, organize, and understand large amounts of information. Entman (1993, p. 52) suggested that framing functions to define problems, diagnose causes, make moral judgments, and suggest remedies. In the context of health risks, Roche and Muskavitch (2003) argued that proper framing addresses the magnitude of the health threat, the symptoms related to the health issue, and the actions that can reduce the chance that an individual will be affected by the threat. Guided by this framing literature and the previous review of PTSD, the current project examines media coverage of PTSD using frames that are novel to PTSD and frames that are general and have utility across different framing studies. Our novel frames focus on the core components of the PTSD construct as described previously: PTSD causes, PTSD reactions and consequences, and PTSD treatments. The general framing scheme we use in the current study is Chyi and McCombs’s (2004) space and time framing approach, which captures the space in which news happens and time that news occurs. Space and time framing has been applied primarily to events such as school shootings and natural disasters (Chyi & McCombs, 2004; Houston, Pfefferbaum, & Rosenholtz, 2012) but is intended to be applicable to a variety of news issues. In the present study we extend the use of space and time frames beyond event-focused news to news coverage of an ongoing health issue. In addition to examining novel and general frames, we also examine how these frames change over time, a process known as frame changing (Chyi & McCombs, 2004; Muschert & Carr, 2006). Although frame changing is often applied to events and issues that emerge in the news media agenda and then recede, we examine frame changing as it applies to a health issue that emerged formally in the psychiatric literature several decades ago, thus providing a novel application of the frame-changing lens. Overall, the following research questions guide the current study:

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News Coverage of PTSD Research Question 1: What (a) causes, (b) reactions and consequences, and (c) treatment are included in PTSD news articles? Research Question 2: How are PTSD news articles framed in terms of (a) space and (b) time? Research Question 3: How do PTSD news article frames change over time?


Method In order to answer these research questions, we conducted a content analysis of New York Times coverage of PTSD. We examined PTSD news stories beginning in 1950 so that we included several decades of news coverage prior to PTSD becoming an official diagnosis in 1980. We concluded our content analysis with articles published in 2012. The New York Times was selected as the content analysis source because of its importance as a U.S. news source and its accessibility. The New York Times is known as the ‘‘newspaper of record’’ in the United States (Friel & Falk, 2004), it has been found to influence the news coverage of other media sources (McCombs, 2004), it maintains a strong circulation (Coe & Bradshaw, 2014; Meeks, 2013), and it contains content that has been found to be similar to that of other U.S. newspapers and television news programs (Bradshaw, Coe, & Neumann, 2014; Gilens, Vavreck, & Cohen, 2007). In addition, the New York Times provides an accessible archive that allowed us to locate, retrieve, and analyze a population of PTSD news stories from one major U.S. news source. Data Collection We used the Lexis-Nexis database to access New York Times news articles appearing between January 1, 1950, and December 31, 2012, that included the terms PTSD or posttraumatic or traumatic stress. We also searched using a variety of traumatic stress terms that preceded PTSD becoming an official diagnosis (e.g., Vietnam veterans syndrome, shell shocked, war neurosis, combat exhaustion; Jones & Wessely, 2005). Only news articles were included for analysis (e.g., opinion essays, movie reviews, and obituaries were excluded). In addition, a few articles included our search terms but were not about a psychiatric diagnosis, such as articles that used the term shell shocked to describe the performance of a sports team. These non-PTSD stories were excluded from the analysis. Using these requirements for inclusion, we identified 930 articles for analysis. Coding Variables The individual article was the unit of analysis for this study. The date the story was published was coded for each article. Five additional variables that are described below were also coded for each article. PTSD Cause The cause of the PTSD in each news story was recorded. In a previous pilot study (Houston, 2011), a list of possible

causes of psychological trauma and PTSD was developed by reviewing newspaper articles and television news stories about psychological trauma and PTSD and by reviewing the PTSD literature. This approach to the development of a coding structure combined inductive and deductive approaches (Beaudoin, 2007), in that possible trauma and PTSD causes were identified both directly from PTSD news stories (inductive) and from the trauma and PTSD literature (deductive). Ultimately, 21 trauma and PTSD causes were identified in the pilot study, and these causes were used in the current study. A maximum of three PTSD causes were coded for each news article. See Table 1 for an overview of the most frequent PTSD causes in the current study.

Table 1. PTSD causes in PTSD news articles

Cause Military service Terrorism Rape=sexual assault=sexual harassment Murder=violence= shooting= robbery Genocide= dictatorship= torture Child abuse= family and domestic violence Civilian war experience Transportation or industrial accident Natural disaster No cause mentioned Death of someone else (e.g., family member) Recession= unemployment Illness or medical issue Immigration or refugee experience Other

Number of articles that included cause

Proportion (%) of all articles (N ¼ 930) that included cause

457 132 81

49.14 14.19 8.71

68

7.31

66

7.10

49

5.27

49

5.27

48

5.16

42 42

4.52 4.52

35

3.76

26

2.80

25

2.69

17

1.83

61

6.56

Note. Entries are frequency counts and percentages indicating how often each PTSD cause appeared in a PTSD news article. Each news article was coded for up to three PTSD causes. PTSD ¼ posttraumatic stress disorder.

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J. B. Houston et al.


PTSD Reactions and Consequences PTSD reactions and consequences in each news story were coded. This variable was initially intended to capture the PTSD symptoms described in each news story. The initial process of creating the list of PTSD symptoms was the same as the process used to develop the list of PTSD causes. However, during the review of news stories it became apparent that in addition to clinical symptoms, many news stories were describing PTSD reactions and consequences. For example, a news story might describe an individual suffering from PTSD who committed homicide, and the act of murder would be associated with or attributed to the PTSD. In such cases, murder was depicted as a consequence of or a reaction to PTSD, even though murder is not a clinical PTSD

Table 2. PTSD reactions and consequences in PTSD news articles Reaction or consequence Fear=anxiety=terror Sadness= depression=crying Nightmares=sleep problems Memories= flashbacks= reexperiencing No symptom mentioned Anger=irritability= acting out=rage Substance use and abuse=smoking Homicide=urge to kill=violence=rape Home and work problems= relationship issues Suicide Loneliness= isolation=avoiding others Guilt=shame= self-loathing Health issues Memory loss= difficulty concentrating Feeling numb=not feeling School problems Growth=empathy Other

Number of articles that included frame

Proportion (%) of all articles (N ¼ 930) that included frame

314 314

33.76 33.76

256

27.53

205

22.04

194

20.86

187

20.21

162

17.42

147

15.81

139

14.95

119 113

12.80 12.15

83

8.92

79 61

8.49 6.56

45

4.84

29 15 23

3.12 1.61 2.47

Note. Entries are frequency counts and percentages indicating how often each PTSD reaction or consequence appeared in a PTSD news article. Each news article was coded for up to seven PTSD reactions and consequences. PTSD ¼ posttraumatic stress disorder.

symptom (APA, 2013). Our coding category was thus broadened to include any PTSD symptom, reaction, or consequence and was renamed PTSD reactions and consequences. Twenty PTSD reactions were identified. A maximum of seven trauma reactions could be recorded per story. See Table 2. PTSD Treatment Treatment for the PTSD that appeared in a news story was coded. The process to develop a list of potential PTSD treatments was the same as the process used to develop the list of PTSD causes. Nine PTSD treatments were identified. Up to three trauma treatments were recorded for each news article. See Table 3. Article Space and Time Each PTSD news article was coded using Chyi and McCombs’s (2004) space and time variables. The space variable addressed the primary level that the news story focused on, and coding categories included (a) individual=family, (b) community, (c) state=regional, (d) national=societal, and (e) international The time variable concerned the primary time period that the news story addressed and included (a) past, (b) present, and (c) future. Coder Training Three coders analyzed all PTSD news articles. A preliminary coding instrument was provided on which the coders were trained. Following training, the coders separately coded a small portion of the content and made minor revisions to the instrument based on a discussion of their experiences. The coders then separately coded 10% of all content and Table 3. PTSD reactions and consequences for military and nonmilitary PTSD articles

Reaction or consequence Fear=anxiety=terror Sadness= depression=crying Anger=irritability= acting out=rage Homicide=urge to kill=violence=rape Suicide Substance use and abuse=smoking Home and work problems= relationship issues

Percentage Percentage of articles of articles that did not that include included military military service as a service as a PTSD cause PTSD cause (n ¼ 473) (n ¼ 457)

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p

27.79 27.13

39.53 40.17

14.34