Annotated Bibliography

Review of Research

Whal et al. (2003)

The researchers suggest that the foundations of erroneous and harmful beliefs about mental illness are set in childhood, and therefore it is important to consider what children are learning from media about mental illness. The media of focus in this study was children’s films. 49 G and PG rated films are examined. Three independent raters per film were asked to judge if the film had a character with mental illness and answer questions about characters that did. At least 2 out of 3 raters had to agree that an aspect was present for it be counted. Questions were about the character’s demographics, attributes, and violent behaviors, as well as, the way other characters acted towards and treated the character.

33 of the films contained content about mental illness, 12 had one or more character(s) with mental illness, and 21 referenced mental illness. Of the references to mental illness, most were disparaging such as “certifiable,” “mental breakdown,” “driving me crazy,” and “nutcase.” A total of 14 mentally ill characters were identified and rated. The majority of characters with mental illness were white, adult males who were single or had an unknown marital status. Additionally, their illnesses were often identified using slang terms rather than formal diagnoses. 8 of the characters were shown as violent, and 67% were feared by others. All 8 of these characters were arrested rather than referred for treatment. Only 4 characters were actually shown recovering treatment, and it was helpful for just one. Some positive interactions were also shown where the characters got along with others, were helpful towards others, and/or were trusted by others.

The researchers found that there is a high concentration of mental illness related material in children’s films, and they concluded that the results confirm that children have ample opportunity to learn about mental illness from films directed at them. Though they cannot establish the direct impact of these depictions on child viewers from the data collected, it can be hypothesized that these often negative and denigrating portrayals contribute to the development of conceptions that people with mental illness should be feared, are less than, and should be referred to in demeaning ways. These conceptions can develop in childhood and extent into adulthood.

Lawson and Fouts (2004)

Lawson and Fouts studied the prevalence of verbalizations about mental illness in Disney animated films and discussed how exposure to these films can teach children mental illness labels and stereotypes. They reviewed Disney animated films for several reasons. They are popular and viewed by many children. Their length gives them more opportunity to develop characters than shorter T.V. shows, and feature-length movies often create feelings of family and identification with characters which may lead to the events and emotions having a greater impact of what children learn from the film. Also, Disney audiences span many generations, and the films are often viewed repeatedly and in a context that involves parental approval and enjoyment which may increase the impact of the film of children’s knowledge and attitudes. Lastly, research has shown that Disney films often present various stereotypes and legitimize social inequalities.

The researchers developed a coding system and reviewed 34 films that were released between 1937 and 2001. Both references by other characters and self-references were counted. A total of 64 words and 37 phrases referring to mental illness were obtained from past research literature and assigned numbers to use for frequency coding. Use of these words or phrases to refer to situations or negation of these words or phrases were not counted. References to thoughts, ideas, actions, and clothing were included. 85% of the films contained verbal references to mental illness, most of which were used in segregating and disparaging manner. Overall, there was an average of 4.6 mental illness references per film, and 21% of main characters were referred to as mentally ill. The 3 most prevalent words were “crazy,” “madness,” and “nutty,” which were all used to alienate characters and mark them as inferior. For example, Belle and Maurice are referred to as mentally ill in Beauty and the Beast. Maurice was taken away in a “lunacy wagon,” giving the impression that people with mental illness are dangerous and should be locked away.

The prevalence of verbal references to mental illness in Disney animated films was found to be higher than that found in children’s T.V. program and higher than the incidence of mental illness worldwide. The researchers suggested that these films can teach children prejudicial attitudes and discriminatory behavior towards people with mental illness, which could be exacerbated by children’s difficulty to distinguish fiction from reality. However, further research is needed to determine causal relationships. A limitation of the study is that only verbal and written references to mental illness were coded so the frequency of references codes may be lower than the number of all types of references. Another limitation is that references made when the character being referred to was on-screen and off-screen were coded, but their differing impact of viewers was not accounted for.

Butler and Hyler (2005)

Butler and Hyler are two practicing child and adolescent psychiatrists. Based on several films they viewed that depict mental illness and their own clinical experiences, they developed a list of 5 myths about child and adolescent psychiatry prevalent in film. The myths are (1) “a child with mental illness can be cured with enough love,” (2) “there is nothing to psychiatry; anything can be considered treatment and anyone a psychiatrist,” (3) “if you do not do what we want, you will be locked up forever,” (4) “mental illness is actually a gift; psychiatrists take that gift away,” and (5) “mental illness and evil overlap in their presentations.” They cite popular films that illustrate each of these myths and quotes from patient interviews. More about this study will be discussed in the Implications for Mental Health Treatment section on the next page.

Pirkis et al. (2006)

Pirkis et. al. reviewed literature to determine “the extent and nature of portrayals of mental illness in fictional films and television programs,” if there is evidence supporting the negative effects of these portrayals, and if there is evidence supporting positive effects of these portrayals. Most of the studies found were small-scale descriptive studies, anecdotal reports, and commentaries. There were some larger-scale descriptive studies and experimental studies on the harmful effects. There were very few studies on the positive effects. 

In answer to their first question regarding the extent and nature of portrayals of mental illness, the researchers found depictions of mental illness are widespread in both adult and children’s film. Additionally, the majority of these depictions are misconstrued and stereotypical in nature. The studies by Butler and Hyler (2006) and Lawson and Fouts (2004) were cited in the discussion of this question.

Concerning the second question about potential harmful effects of these portrayals, they found representations of mental illness in film often negatively impact public images of mental illness and perpetuate stigma. Several studies confirmed that people who cite film and television as their main source of information on the subject of mental illness, tend to have more negative and less tolerant views towards inflicted individuals. Granello et al. (2000) found a positive correlation between the amount of televisions and films viewed and the strength of negative attitudes, however, Lauber et. al. (2003) found that perceived realism mattered more than the amount of exposure. Philo (1996) held focus groups, and found that most people who held negative beliefs about people with mental illness referenced films and T.V. shows about mental illness in defending their beliefs. Clothier et. al. (2001) discovered that medical students held false beliefs about the use of ECT based on film depictions, despite having access to more accurate information. 

While exploring their third question about potential positive effects of portrayals of mental illness, Pirkis et al. discovered that some authors have argued that films can be an engaging education tool for mental health professionals. Other authors suggested that films can promote help-seeking behaviors, however, studies testing this have equivocal results. Lastly, some authors have commented on the potential benefits of using films as an adjunct to therapy and made lists of movies that could be utilized. There is no empirical evidence that this works, though.

Kimmerle and Cress (2013)

In part one of the Kimmerle and Cress (2013) study participants were asked about their media (TV and films) consumption in minutes per day. The participants’’ knowledge about major depressive disorder (MDD), obsessive compulsive disorder (OCD), and schizophrenia was gauged using a questionnaire where they were asked if given diagnosis criteria matched the illness stated. They could answer “correct,” “wrong,” or “I don’t know.” Perception of violence was measured by giving the participants statements about the violence levels associated with the three mental illness to which they could agree or disagree. The sub-hypothesis that the relationship between media consumption and knowledge and attitudes regarding MDD would be less significant than that with OCD and schizophrenia was supported by the results. However, conversely to previous research, there was no significant correlation between hours of media consumption and increased views of mentally ill people as violent. Additionally, the researchers found unexpected correlations between knowledge and views of violence. The more knowledge people had about MDD and OCD, the less they saw these individuals as violent. The more knowledge people had about schizophrenia, the more they saw these people as violent.

In the second part of the study, participants were given two knowledge tests. The first was before they watched a film, and the second was after. One group was shown a documentary on schizophrenia. The second was shown a fictional film. Participants in both groups indicated their emotions well watching the films and both groups took the same knowledge test after. People watching the fictional film expressed more negative emotions than people watching the documentary. Additionally, on average, the people who watched the documentary improved on the second knowledge test, while people who watched the fictional film did not. These results indicate that the type of film watched impacts viewer’s emotions and knowledge.

Perciful and Meyer (2016)

The researchers in this study examined the impact film depictions of schizophrenia have on people’s knowledge, attitudes, and behaviors towards individual with the illness. The study consisted of 106 participants who were asked to fill out a survey before and after watching a 45-minute film excerpt. The participants were divided into 4 groups: one watching an inaccurate-fear-based depiction, one watching an inaccurate-but-likeable depiction, one watching an accurate-educational depiction, and a control group. People in the inaccurate-fear-based group demonstrated significant increases in stigmatizing attitudes, and many agreed with that statements that people with schizophrenia are unpredictable, dependent, and dangerous. The results support the hypothesis that “negative, inaccurate portrayals of severe mental illness enhance stigmatizing attitudes.”

Perciful and Meyer began by reviewing the literature on public perceptions of, discrimination towards, and common negative portrayals of mental illness. Whal (2002) suggested that these stigmatizing attitudes towards the mentally ill develop during childhood. He found that children from first to ninth grade held beliefs that people with mental illness are violence and had unaccepting attitudes towards such people. Children’s acceptance of mentally ill people decreased with age (from first to ninth grade), while their acceptance of people with other disabilities increased. Sargent et al. (2002) looked at the top 10 most popular violent movies among adolescents at the time and found that 6 of them had (a) character(s) labeled as having a mental illness, and these characters were identified with derogatory terms. Coverdale and Narin (2006) showed that these negative attitudes likely remain constant or worsen in adulthood. Barry et al. (2013) conducted a national survey in which about 50% of people indicated that people with mental illness are more dangerous than the general population, and they would be unwilling to have a mentally ill person as a neighbor or coworker.

They also reviewed research showing that accurate depictions of mental illness in film can be educational and positively influence the attitudes of viewers. Penn et al. (2003) showed participants documentaries about people living with mental illness and found that they were more likely to believe in successful treatment after viewing the films. Kerby et al. (2008) showed two educational anti-stigma films to fourth-year medical students and discovered that students who watched the films demonstrated fewer stigmatizing attitudes than students in a control group.  

For the experimental study, the participant pool consisted of 106 undergraduate students at Wright State University who participated through the SONA system. The participants were asked demographic questions, questions about their level of contact with schizophrenia, and questions to gauge their knowledge about schizophrenia. Participants’ behavioral benevolence was measured by asking them to volunteer for 2 hours with people with schizophrenia and seeing how they complete a mock volunteer application for this. Questionnaires and mood-scales were used before and after viewing to measure the effects and immediate impacts on participants. The inaccurate-likeable film was Me, Myself, and Irene (2000). The fear-based-inaccurate film was Donnie Darko (2001). The accurate-educational film was The Brush, the Pen, and Recovery (2010), and the control film was What the Bleep Do We Know!? (2004). 

Results showed that participants who watched the fear-based film were “more likely to endure stigmatizing attitudes across emotional, cognitive, and behavior domains when compared to the accurate and control groups.” No significant changes were seen in the attitudes of participants in the accurate and control groups. Also, there was no significant increase or decrease in knowledge about schizophrenia in any of the groups. Participants in the fear-based group reported feeling nervous, upset, hostile, and afraid after watching the film. There was no difference in behavioral benevolence between groups as measured by participants’ willingness to “potentially” volunteer. The immediate impact scale used revealed that participants in both inaccurate groups believed that people with schizophrenia are unpredictable, unable to live independently, and dangerous. Overall the scale showed an increase in negative attitudes from the inaccurate groups and an increase in positive attitudes from the accurate group. Another interesting finding is that most people in the fear-based group believed that they viewed an accurate portrayal of schizophrenia. Limitations of this study include the limited participant population, the fact that only a 45-minute excerpt of each film was shown due to time constraints, and a lack of follow-up data. 

Smith et al. (2019)

In the study by Smith et al. (2019) characters were coded as having a mental illness if “a significant and/or persistent negative reaction was evidenced by internalizing or externalizing symptoms.” Out of 4,598 speaking characters in the films viewed, only 1.7% had a mental illness compared to 18.9% of the U.S. population that experiences mental illness. Additionally, men with mental illness were overrepresented and females, LGBTQ, racial minorities, and teenagers were underrepresented. 7% of the characters in the films with mental illness were teenagers, while 20% of teenagers in the U.S. experience mental illness. Not one LGBTQ character was depicted with a mental illness, despite the finding by the National Association of Mental Illness that “LGBTQ individuals are almost 3 times more likely than others to experience mental health conditions such as major depression or generalized anxiety disorders.”

The categories of the most commonly depicted mental illness in the films reviewed- addiction, anxiety/PTSD, mood disorders, suicide (ideation, attempt, and death), cognitive impairments, disturbances in thinking, spectrum disorders, and eating disorders – were established by the researchers and do not align exactly with DSM-5 classifications of mental illnesses. Sociopathy and antisocial personality disorders were not considered because the researchers wanted to analyze illnesses that are most common in the U.S. population. The representation of mood disorders was completely accounted for by depression, and it was far under that of actual occurrence in the U.S. The rate of comorbidity of depression and another mental illness, however, was accurately presented. Anxiety and PTSD were even more underrepresented. The greatest inaccuracy in regard to the depiction of suicide was the ratio of characters who thought about suicide versus the number who attempted suicide versus the number who died from suicide. Out of 13 characters who thought about or attempted suicide, 5 died. In reality the ratio of thoughts to attempts to death is 1000:100:1. Moreover, none of the 13 characters were teenagers, whereas according to the CDC, “1 in 5 American high school students have serious thoughts about suicide each year.”

The portrayal of characters with mental illness in the films reviewed was largely negative and included disparagement, use of the illness as humor, or concealment of the illness. Disparagement was considered as verbal and behavioral dehumanization and stigmatization of characters with mental illness and was considered whether it was self-directed of from someone else. 47% of the characters experienced disparagement, with 22% from their self. Common forms of disparagement were name-calling, being treated like a monster, being ignored or rejected, and isolation. Name-calling included “weird,” “crazy,” “psycho,” “freak,” “problem,” “unstable,” “ruined,” and “nuts.” 15% of characters tried to conceal their mental illnesses. Characters with mental illness were also portrayed as untrustworthy, violent, and/or a danger to society in several movies. 46% of the characters committed a violent act. For 22% of the characters, their mental illnesses was shown in a humorous context. Lastly, only 5% of characters were shown taking medication, 22% were in therapy, and 14% were hospitalized.

A limitation of this study is that they only looked at top rated films because they are the most wide-reaching; however, it is possible that mental illness is portrayed more accurately in less popular films. It is also possible that the inclusion of more films may have led to more accurate representations of the percentage of the population affected by mental illness. Another limitation is that only movies between 2016 and 2017 were viewed.