Since the inception of the big screen, film has been a cornerstone of American culture, as well as, many other cultures around the world. It has brought people together and torn people apart. It has greatly advanced that way we share information and ideas. Benzine says film sits at the intersection of art, industry, technology, and politics. “It is a universal language that lets us tell stories about our collective hopes and fears; to make sense of the world around us and the people around us.” It comes as no surprise, then, that film greatly impacts people’s knowledge and attitudes; especially regarding topics that they have little experience with in the real world. Several studies in the past three decades have found significant support for the concept that what people see on T.V. and in movies influences their perception of reality and plays a role in shaping their knowledge of the world including public opinions and societal perceptions (Kimmerle and Cress; Smith et al.). As film developed, both as a means to explore enigmatic concepts and to entertain, mental illness became a central theme. If mental illness is represented inaccurately in film, such can lead to harmful stereotypes, spreading of misinformation, negative attitudes towards the mentally ill, and barriers for people dealing with mental illness (Kimmerle and Cress; Smith et al.; Pirkis et al.).
I reviewed academic literature on the portrayal of mental health in films. I limited by review to publications since 2000, however, some of the papers I examined referenced research from before then. I found that depictions of mental illness are abundant in both children and adult films, and that such depictions are vastly negative. Many characters with mental illness are portrayed as violent, referred to with disparaging terms, or shown in a comical context that trivializes their illness. These negative portrayals can create or exacerbate harmful stereotypes and negative attitudes held by the public which further isolates individuals with mental illness and may contribute to lack of treatment seeking behavior. Inaccurate depictions seen by individuals with psychiatric disorders or their family members may, also, lead to unrealistic expectations for treatment. However, some positive depictions exist which have the potential of educating the public and being implicated into clinical practice. Overall, filmmakers need to work to make depictions of mental illness that are both entertaining and accurate, and mental health professionals need to be aware of the potential harm of media portrayals of mental illness so they can help patients overcome these stereotypes.
Impact of Negative Portrayals of Mental Illness
Despite significant changes in the understanding of mental health, “from the dark era of asylums and torture to the light of human rights and neurobiological interpretations,” much stigma surrounding mental illness remains in society (Das et al.). Decades of research have established that many people have inaccurate and negative beliefs about psychiatric disorders. For example, Jorm (2000) found that community attitudes towards people with mental illness are for the most part negative and heavily based on misinformed beliefs (cited in Pirkis et al.). Das et al. suggest that these adverse and amiss attitudes are in part because people’s true battles with mental illness are often shrouded from sight, leaving inaccurate and stereotypical depictions from media to dominate. Film is a major source of these depictions because filmmakers use the violence and sensationalism of stereotypic, yet misguided, presentations of psychiatric illness as a means to make money at the box office. “To popularize psychiatric themes among viewers-[filmmakers] largely focus on unipolar conflicts rather than taking an overall view,” (Das et al).
Portrayals of mental illness in film are often superficial, stigmatizing, and inaccurate. Many overemphasize stereotypical negative attributes such as violence, aggression, and bizarre behavior, as well as, rely on demeaning slang terms to refer to mentally ill individuals (Kimmerle and Cress; Smith et al.). Hyler et al. (1991) (cited in Pirkis et al.) classified stereotypical portrayals of individuals with mental illness in film. Their classifications were the aggressive and dangerous homicidal maniac, the eccentric and rebellious free spirit, the enlightened members of society capable of creating a utopia, the nymphomaniac and powerfully seductive female, the overprivileged narcissist, and the dehumanized crazy person. Two other negative stereotypes commonly portrayed are the irrational and confused simpleton character often used in comic ways, and the failure or victim who is unresponsive to treatment, unskilled, and unable to contribute to society (Pirkis et al.) One of the most prevalent stereotypes of mentally ill people exacerbated by film is that such individuals are violent. Despite weak evidence linking mental illness with violence, research shows that a large percentage of children and adults see mentally ill people as violent, dangerous, and unpredictable (Perciful and Meyer). Misconceptions about the violent tendencies of the mentally ill increase discrimination towards such individuals. This discrimination is seen in housing, employment, interpersonal relationships, and health treatment. Aside from the violent character, another stereotypical depiction a mentally ill person is the feeble-minded, developmentally delayed, and needy character. These characters are often inaccurately portrayed as a means of providing humor to the film. When mental illness is used for humor it is often hostile, belittling, and trivializing (Smith et al). Another falsehood feed by the film industry is that certain illnesses such as dissociative identity disorders, anterograde amnesia, and schizophrenia are more common than they actually are because they are popular illnesses used to creative melodramatic story lines (Pirkis et al.). Lastly, mental health treatment and professionals are often shown in an antagonistic or misleading manner. Pirkis et al. discuss three common types of doctors shown in films about mental illness- Dr. Dippy, Dr. Evil, and Dr. Wonderful. They say that overall, metal health professionals are ridiculed, feared, or treated with contempt. The portrayal of a sympathetic mental health profession is rare. Gabbard (2001) reviewed over 400 films and found only 3 with sympathetic mental health doctors. The researchers say that “only those treatments that serve a filmic purpose are depicted” (cited in Pirkis et al.). Psychotherapy is often shown because it allows the audience to know what is going on in the patient’s head. However, several of these sessions are unrealistic in that they show speedy recovery and lack of concern for medical ethics. Electroconvulsive therapy is commonly used for melodramatic purposes, and patients are often given this treatment without consent or anesthetic. It often results in the patient being zombie-like and very few films show positive results. Hardly any films show medication therapy as such is not as cinematically interesting (Pirkis et al.).
“Presenting mental health conditions as something to be feared, shunned, laughed at, or denigrated sends a dangerous message to audiences about how mental health conditions and the individuals who experience them should be treated both within and outside of the storytelling environment” (Smith et al.). Negative public attitudes towards psychiatric disorders can increase feelings of isolation, shame, and hopelessness in individuals suffering from these diseases (Perciful and Meyer). Considerable research has, also, demonstrated that pervasive negative beliefs about mental illness, which are significantly influenced by film, create an environment that deters treatment seeking and impedes recovery (Whal et al., Perciful and Meyer). Surveys by the U.S. Department of Health and Human Services have uncovered that negative attitudes towards mental illness increase harmful stigma and people’s unwillingness to seek help (cited in Pirkis et al.). Smith et al. say that such portrayals may “short circuit empathetic responding and heighten anti-social tendencies [towards those with mental illness.]”
Whal et al. (2003) and Lawson and Fouts (2004) determined that references to and depictions of mental illness are prevalent in children’s films as well as adult films. Both suggested that negative attitudes towards and erroneous beliefs about mental illness originate in childhood, and they are significantly impacted by the content of films directed at a young audience. Depictions in children’s films can influence how children think about and treat people with mental illness. Exposure to harmful mental illness stereotypes through film may lead children fear, distance themselves from, and act in a discriminatory manner towards individuals with mental illness (Lawson and Fouts). Weiss (1994) found that children displayed greater fear and distrust towards mentally ill people (cited in Lawson and Fouts). In discussion of the research, Whal et al. stated that depictions of mental illness in children’s film send two harmful messages- “first that psychiatric terminology is appropriately associated with behavior that is objectionable, foolish, devalued, etc., and second, that slag reference to mental illness is a common and acceptable part of conversational speech.” That such depictions of mental illness are common in films that target child is of particular concern because of how impressionable child are, and their difficulty distinguishing fiction from reality. They are constantly learning how to act from the environment around them, and what they learn in childhood lays the foundation of their knowledge, attitudes, beliefs, and behavior in adulthood. When harmful stereotypes and mistreatment towards the mentally ill is reinforced by characters children admire, it is likely that children will mimic these characters. Lawson and Fouts say “this combination of modeling and reinforcement is one of the most potent tools of socialization and has the potential to teach prejudicial attitudes and distancing behaviors towards individuals perceived as being mentally ill… [and] once these beliefs are formed, children continue them into adulthood.”
Impact of Positive Portrayals of Mental Illness
Despite the domination of negative stereotypes found in film, there is evidence that depictions have improved with time from the 1900s to the early 2000s (Pirkis et al.) Additionally, some movies, even if they still contain stereotypes, may overall have a positive impact on viewers. Films may help people relate to characters with mental illness who they look up to and feel more accepting of their own mental illnesses. A 17-year-old girl who was interviewed by Butler and Hyler said that Angelina Jolie in Girl Interrupted was empowering and helped her be more comfortable with her own bipolar and antisocial disorders. This idea was also noted by several of the students on the homework assignments about It’s Kind of a Funny Story. One student said in regard to the impact of movies on people’s attitudes, beliefs, and knowledge about mental illness, “I think it changes people’s attitudes a lot because they could see an actor that they like and look up to them. It might help mental illness patients get through their hard times.” These films might also encourage people who are struggling to get help (Pirkis et al.; Perciful and Meyer). I think that films can give individuals who are struggling the opportunity to see their illnesses outside of themselves. Especially for people who are in denial of their illness, this can help them realize their actions, the impact of such on themselves and others, possible roots of their illnesses, and how to seek help.
Certain films may also be educational and challenge stereotypes. “By authentically depicting the nuanced and complex way that mental health conditions intersect individuals’ lives, [film] can introduce audiences to new ways of thinking, ways to ask for help, and ultimately create necessary shifts in our cultural beliefs about mental health” (Smith et al.). Pirkis et al. discussed the possible use of film as an educational tool for mental health professionals. They may help explain symptoms of, treatment for, and stigmatization towards different illnesses. However, it is important that such is only supplementary to real-life clinical experience. Another potential use of film could be as an adjunct to therapy as discussed in the next section. I suggest also using films in school to teach about psychiatric illness and provide a productive environment in which to challenge stereotypes and misconceptions.
Implications for Mental Health Treatment
Obstacles to Treatment
As previously discussed, films influence audience’s perceptions and knowledge, and, thus, the way psychiatric disorders are portrayed in film can greatly influence the way people view these illnesses and treatment for them. Additionally, because more people are exposed to media representations of psychiatry than the real-life counterpart, majority of the public’s notions of psychiatry are from media rather than personal experience. If films paint skewed images of mental illness they could create a “significant obstacle to advancing knowledge and health behaviors related to mental health” (Smith et al.). Stigma is a major reason why people don’t seek treatment or comply with treatment, and this stigma is reinforced by films directed at children, adolescents, and adults (Perciful and Meyer). Moreover, incomplete, dramatic, and unrealistic depictions of mental health treatment in film can lead to treatment resistance and/or warped expectations of treatment (Butler and Hyler). Butler, an attending physiatrist on an adolescent inpatient unit, gives a narrative illustrating this problem. One of his patients, a 15-year-old boy, was scared that the doctors wanted to turn him into a zombie. When asked where he got that idea from, the boy answered “Nightmare on Elm Street.” The mother of the patient also held mistaken notions about psychiatric treatment and believed that her son needed to be locked up for at least a year, because she had seen in movies that children with mental illness are institutionalized for long periods of time. Butler and Hyler state that “successful confrontation of this imagery- mentally ill patients turned into zombies, psychiatrists with omnipotent control, indefinite hospitalization decided in a flash- would determine medication adherence, family support of treatment, and therapeutic alliance.” They believe that it is important for clinicians to know how mental illness and treatment are depicted in movies so they can counteract false conceptions patients and families might have.
Butler and Hyler’s Myths in Film about Child and Adolescent Physiatry
Throughout the history of film, child and adolescent psychiatrists have often been shown to “curb behavior that is unacceptable to society” rather than address the underlying emotional distress of the patient. Children and adolescents with mental illness were frequently shown as the juvenile delinquent in the early to mid-90s. In the late 90s, child and adolescent characters with genuine mental illnesses started to emerge, but unrealistic sociopathic and delinquent conditions continued to dominate, especially in horror movies. Additionally, some movies have characters who are clearly mentally ill to any psychiatrist, or other health professional, but never explicitly given a diagnosis or treatment. The portrayal of mental illness without diagnosis or treatment may distort the audience’s perception of what is ‘normal’. This may cause people to not recognize serious issues or to normalize unhealthy behaviors. An example given is the movie Thirteen (2003) which tells the story of a 13-year-old girl engaging in substance abuse, eating disorder behaviors, sexual promiscuity, and self-injury which is all painted as “normal” teenage behavior without a mention of possible mental illness. When asked about the movie, a 13-year-old year said that she has friends that do all that and worse, giving the impression that such behavior is normalized and even glamorized. The authors say that the most common distortion in movies and TV is showing the spectacular and omitting the mundane. This is why police officers are not shown doing desk jobs but rather solving dangerous crimes, and surgeons are shown performing impossible surgeries and not giving routine care. The same applies to depictions of psychiatry with only treatment of severe cases being presented. This might give a skewed idea of how serious a mental illness needs to be to get help. Also, showing extreme, invasive, and often involuntary treatment which is not the reality for most people with mental illness, may give the idea that treatment is a punishment or that one cannot voluntarily receive treatment.
Butler and Hyler discuss 5 Hollywood myths about how child psychiatry works. The first myth is that “a child with mental illness can be cured with enough love.” Sometimes the child with mental illness has neglectful parents and the psychiatrist takes on a parental role that cures the child as seen in Don’t Say a Word (2001), The Sixth Sense (1999), The Cell (2000), Silent Fall (1994), Don Juan de Marco (1995), and Antwone Fisher (2002). The presentation of this idea that love cures mental illness in children can have positive and negative consequences. On the positive side, it shows that stable and supportive relationships can help facilitate behavioral changes and mental wellbeing. On the negative side, it trivializes the importance of diagnosis and treatment. In movies with mentally ill children, there is often a competitive dynamic between the psychiatrist and parents. When love and care from the physiatrist ‘cures’ the child, it suggests that mental illness is caused by lack of love and support. This neglects the important biological factors at play and suggests that parents are to blame. This idea of blame might make parents reluctant to seek treatment for their child out of fear of condemnation or losing their child. Additionally, the degree to which love and support on the part of the clinician ‘cures’ the child is unrealistic and displays unachievable standards of self-sacrifice. Clinicians should be cautious of the role they take on with young patients and avoid invoking feelings of competition or displacement from the parents. I think this myth may also make children who have loving parents feel like they have no reason to be mentally ill. All the movies I watched about mental illness have either neglectful, or to a degree emotionally abusive, parents. Craig’s and Liv’s parents put a lot of pressure on them academically. Ellen’s mother is bipolar, her father left her, and all the adults in her life see her as a problem and the root of conflict in the family. Charlie’s father is in jail and his mother is caught up in her own depression. Susanna’s parents refuse to listen to what she wants in life and just label her as a problem. In The Skeleton Twins, the twins’ mother was absent for most of the childhood and only comes around when she wants something. Though it is true that neglectful, abusive, or similarly ignorant parents can be a trigger for mental illness, they, alone, are not the cause and do not need to be present for a child to suffer from mental illness.
The second myth discussed is that “there is nothing to psychiatry; anything can be considered treatment and anyone a psychiatrist.” Some movies like to show the ‘rebel’ doctor as the successful ones such as in Silent Fall where medication from the ‘accepted’ psychiatrist makes the child worse, but love from the ‘rebel’ one makes him better. These stories show that medication and typical psychiatric practices are not guaranteed, one-size-fits-all answers, and that other treatments may be useful. However, they might also encourage skepticism and cynicism towards psychiatric treatment, and it may even suggest that since there is no “real” treatment, there is no “real” disease.
The third myth is “If you do not do what we want, you will be locked up forever.” Popular movies that illustrate this belief are One Flew Over the Cuckoo’s Nest (1975), Silence of the Lambs (1991), and Nightmare on Elm Street 3: Dream Warriors (1987) which show prison-like mental hospitals, ECT, excessive medication, and harsh treatment of patients. These depictions of mental health treatment are most commonly seen in horror movies and are starkly different from modern mental health hospitals. An interviewee who had never been in a psychiatric hospital said that her impression of them is “rusty bed frames with striped mattresses, and that mystery room in the basement where they took you when you were bad or didn’t participate in group session.” The authors voice concern about the portrayal of psychiatrists as “jailers for nonconformists,” saying this might give adolescents the message that they can get their whole life can be taken away from them just by saying the wrong thing. It also paints physiatrists as the enemy. Movies that show psychiatrists in this unfavorable light give viewers a much different impression than movies that show psychiatrists who take on a parent role and ‘cure’ the child with love as discussed with myth one. I wonder how viewing both these types of movies would impact view’s beliefs about physiatrist and if one portrayal would seem more convincing.
Myth number four is that “mental illness is actually a gift; psychiatrists take that gift away.” This myth follows from the one that mental illness is “just a different way of seeing the world.” This is most commonly seen with autism. Other movies show children with hallucinations or special gifts. Where this concept is not completely inaccurate, movies that show such ‘gifts of mental illness’ often fail to take seriously the emotional and social toll these disorders take on the child. It may also give the idea that treatment has the purpose of striping an individual of that gift. On the other hand, such depictions can make mental illness diagnoses easier to accept and extend a sense of pride. I think it is important to see the positive traits of a person that might be contributing to their mental illness, well, also, understanding that they can reshape those traits to achieve better mental health without losing them.
The final myth is “mental illness and evil overlap in their presentations.” Movies that show people with mental illness as dangerous criminals, posed with evil spirits, or the like, give the message that mental illness should be feared, and people with mental illness should be locked away. Again, such depictions are most common in horror films. Examples of such movies are The Exorcist (1973), Gothika (2003), Heavenly Creatures (1994), Disturbing Behavior (1998), and Don’t Say a Word (2001).
Use of Film in Treatment
Movies can serve as therapeutic tools to aid discussion about patient’s fears and misconceptions, and work to amend these issues in a supportive environment. Butler and Hyler suggest that clinicians become knowledgeable about common distortions in film and address these with patients. Furthermore, they can use movies or clips to educate patients and families. Movies can be used to introduce patients and families to specific disorders, create therapeutic alliances, help patients reframe issues, give patients role models, offer hope, bring out emotion, help patients prioritize values, and facilitate communication (Pirkis et al.). Multiple authors have made lists of movies that might aid in therapy and how they can be used such as Hesley and Hesley (1998) and Wedding and Niemiec (2003). However, if therapists are going to use film, they need to consider the patient’s ability to handle the content, and they must be able to direct the use of the content in a constructive manner (Pirkis et al.).
I think using movies in the manner might seems less intimidating to patients and allows them to acknowledge their own misconceptions rather than just being told they are wrong. It might make therapy seem more approached and a clinician more relatable, as well. Overall, I think films can serves as springboards for open conversation when used in a therapeutic setting where distorted notions can be challenged, and emotions can be processed.
With the high rates of mental illness in America along with the stigma surrounding these illnesses, it is important to spread awareness and shine light on what mental illnesses are and how they can be treated. With the knowledge that film can greatly impact people’s understandings and opinions, and that many depictions of mental illness in film are negative, it is the responsibility of filmmakers, policy-makers, mental health professionals, individuals with mental illness, and the public to work towards more authentic, informational, and hopeful depictions of mental illness. I believe that everyone has a role in making this happen. Filmmakers will not change what is bringing in revenue without push from policymakers and the public, and they will not know how to depict mental illness in a truthful and educational manner without input from professionals and individuals with mental illness. Pirkis et al. confer that improving portrayals of mental illness in film needs to be a collaborative effort. They also say that individuals and organizations pushing for amelioration should acknowledge that the primary purpose of film is to entertain and produce profits. Therefore, advice for improvement should be reasonable and with the goal of educating while still entertaining.
Specify speaking to what filmmakers should do to improve portrayals of mental illness, Smith et al. give guidelines. They say that it is important to ask 5 questions when producing a film about mental illness. The questions are (1) “Why am I telling this story,” (2) “Is the mental health condition used as a plot device,” (3) “Is the mental health condition used for humor,” (4) “Is there unnecessary stigma depicted,” (5) “Is help-seeking depicted?” They also stress that it is important to give “authentic, nuanced, and safe portrayals” of suicide, making the point clear that most people who struggle with suicidal thoughts and attempts go on to live healthy lives. This was not accurately shown in the films viewed in their study where most people who attempted suicide died. Another important aspect of mental illness that is lacking in films is effective treatment and support. Filmmakers should consult professionals and individuals with personal experience when illustrating mental illness (Smith et al.).
In addition to changes in the film industry, more research on the topic of mental illness in film is needed. Smith et al. say that research must examine how the portrayal of mental illness impacts attitudes, behavior, and suicide risk/prevention. Contextual factors such as humor, stigma, and violence should be examined in experimental studies to see how such impacts viewers. Additionally, the means by which writers acquire their knowledge regarding mental illness should be examined so that interventions can be implemented to improve the accuracy of mental illness depictions. Lawson and Fouts advise examining the behaviors towards people who are labeled as mentally ill in movies, as well, as the emotional states of these characters. This would give a better idea of how these depictions influence viewers’ behaviors and emotions. I believe more research on the positive impacts of depicting mental illness in films is needed. Research about this could indicate what aspects of mental illness depictions are helpful which could be used to advise filmmakers on what specifically they should implement in films about mental illness. It could also open up new avenues for the use of film in treatment and education.
Benzine, C. (n.d.). Film History Preview. [Video file]. Retrieved from https://thecrashcourse.com/courses/film?page=2.
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Das, S & Doval, N & Mohammed, S & Dua, N & Chatterjee, S. (2017). Psychiatry and Cinema: What Can We Learn from the Magical Screen?. Shanghai Archives of Psychiatry, 29 (5), 310-313. DOI: http://dx.doi.org/10.11919/j.issn.1002-0829.217014.
Kimmerle, J & Cress, U. (2013). The Effects of TV and Film Exposure on Knowledge About and Attitudes Towards Mental Disorders. Journal of Community Psychology. 14, 931-943.
Perciful, M & Meyer, C. (2016). The Impact of Films on Viewer Attitudes towards People with Schizophrenia. Curr Psychol, 36, 483-493. DOI: 10.1007/s12144-016-9436-0.
Pirkis, J & Blood, W & Francis. C & McCallum, K. (2006). On-Screen Portrayals of Mental Illness: Extent, Nature, and Impacts. Journal of Health Communication, 11:5, 523-541. DOI: 10.1080/10810730600755889.
Smith, S & Choueiti, M & Choi, A & Pieper, K & Moutier, C. (2019). Mental Health Conditions in Film & TV: Portrayals that Dehumanize and Trivialize Characters [PDF file]. Retrived from http://assets.uscannenberg.org/docs/aii-study-mental-health-media_052019.pdf.
Whal, O & Wood, A & Zaveri, P & Drapalski, A & Mann, B. (2003). Mental Illness Depiction in Children’s Films. Journal of Community Psychology, 31, 553-560. DOI: 10.1002/jcop.10072.