Caveat spectator

Film is art but it is also a ruthless commercial enterprise, driven by populism and low cunning: ‘follow the money’ is the first rule of movie psychiatry (Box 1). Producers include any element to give the public what they think they want, just as actors in search of acting awards ignore a poor-quality script to play someone with an intellectual disability or multiple personality disorder. We should not expect film-makers to be even-handed or knowledgeable in their choices of psychiatric representations. The key arguments here were first rehearsed by psychology professor and cineaste Franklin Fearing in 1946:

To these three observations is added the truism that film-makers learnt what they know about mental illness and its treatments at the cinema, not from books or in the clinic.

The second rule of cinema, artistic and commercial, is that film begets film: whether as inspiration for writers or an ‘in’ that helps the producer's pitch to the money men, every new genre film is based on what has gone before. Along with stereotypes (of doctors and patients), simplistic conceits of classic films depicting mental illness (Table 1) – for example, the repressed great dark secret that must be exposed to release the patient from misery – quickly became standard ingredients of the next generation of films. At its most extreme, the second rule allows for sequels and remakes, each more vacuously derivative than the last.

Group work

The opportunities to consume film have never been better (Table 2). From its early years as a fairground attraction, cinema was made to be consumed in groups. The modern book club (regular group meetings to discuss literature) becomes the culture club (film, play, music, exhibition). Excerpts or entire films are shown to medical undergraduates as ‘cinemeducation’ (e.g. Reference BhugraBhugra 2003; Reference Alexander, Lenahan and PavlovAlexander 2005). Table 1 lists 20 popular psychiatry films; they are all in the English language and are a mixture of comedy and drama. Representative of this genre, only one male psychiatrist breaks boundaries. Female movie psychiatrists always break professional rules with male patients and this has come to mean sexual liaisons. In the real world, where psychiatrists rarely sleep with their patients, men violate trust two to three times more often than women (Reference GharaibehGharaibeh 2005). Films containing elements of mental illness require group viewing to place them in context and to counter similar filmic conceits. Reference Gabbard and GabbardGabbard & Gabbard (1999) is the seminal work on screen psychiatrists, and Reference Flowers and FrizlerFlowers & Frizler (2004) have compiled a list of psychotherapists in 5000 films from the first century of cinema. Before psychiatrists' fall from grace (Reference Gabbard and GabbardGabbard 1999), key questions posed by a movie psychiatrist brought gravitas to a commercial film. The professional could share ‘deep thoughts’ not unlike the marketing of ‘psychological’ thrillers. Inevitably, screenwriters adapted mental illness as source material (Table 1), but even within fantastical plots, these films have interesting things to say about modern psychiatry. In the time-travel fantasy 12 Monkeys, the chief of psychiatry instructs her residents about new admissions: ‘evaluate, medicate and vacate’.

However, Table 1 is only the start of your journey: these are substantially hospital-based films and you need to get out more – into the community. Films about mental illness are niche films and usually make more revenue in ‘sell through’ sales (formerly video cassette but now DVD) than on brief cinematic release. The falling costs of film production have led to a burgeoning of releases, but hearing about them, let alone seeing them, is a challenge: the third rule is that skewed distribution hides more films than censorship ever did. As with previous innovations that presented a threat to film (television, video cassettes), the internet will feed the public's appetite for film. Take a group to the art house cinema (Table 2) – a partial antidote to rule 3 (Box 1).

A whole new world

Any good film takes viewers to another world, holding their attention within the rules of that world to say something, anything. This is as true for science fiction, western and horror as it is for films about mental illness. At one level, Table 1 is all you need to start a psychiatry film club, but you would be missing out on an enormous canon of films. At the time of writing (the first 2 months of 2008), five outstanding films have taken us to the Japanese occupation of Shanghai (Lust, Caution), a Texan manhunt (No Country for Old Men), locked-in syndrome (The Diving Bell and the Butterfly), teen pregnancy (Juno) and to the battle between capitalism and religion in pre-Depression America (There Will Be Blood). Films in which a mental health theme is a minor component stretch audiences beyond the confines of clinic-based psychiatry. We can't catch everything but as psychiatrists we should be familiar with what our patients and their families watch: astute clinicians explore people's preconceptions about psychiatric labels before imparting a new diagnosis. We all need cultural training and a major deficiency of the films in Table 1 is their lack of cultural variety – they are all US films. During the ‘money shot’, a stormy helicopter ride, in the French film Men, Women: A User's Manual (1996), Benoit (Bernard Tapie) remarks to his companion:

The point here is that world cinema, independent ‘small’ films, documentaries, shorts and unconventional forms such as animation – all absent from Table 1 – can explore differences in personal stories, cultures, countries and genres. Taking Jack Hodgins' idea of ‘lies that tell the truth’ (Reference HandcockHandcock 1979), film is fantasy. The global film village stretches beyond Hollywood. Colleagues have documented representations of mental illness in Greek (Reference Fountoulakis, Kogiopoulos and NimatoudisFountoulakis 1998) and Indian (Reference BhugraBhugra 2006) cinema. In watching world cinema, we must remember that just as film-makers (mis)learnt psychiatry through film, there are limitations in learning about other cultures through film alone.

Reference Rosen, Walter and PolitisRosen et al (1997) chart the rise of films from Australia and New Zealand that depict mental illness: beginning in 1994, they list 19 films in which central characters have become unwell. Collectively, these films have been dubbed the ‘company of eccentrics’ and represent a disproportionately high percentage of the region's cinema output. From a European perspective, this is the ‘cinema of the outsider’ who struggles to find his or her own voice. Many films (such as those discussed below, in ‘When cinema gets it (mostly) right’), can be used to teach psychopathology and the wider effects of the mental illness label. Rosen et al conclude that the films are: ‘encouraging, as are the messages of hope, resilience, rebellion, self-determination and triumph’. Not every aspect of these films is perfect. Their depiction of psychotropic medication has been examined in detail (Reference Walter and RosenWalter 1999). Positive messages (drugs taken under medical supervision are helpful when part of other therapies) are outweighed by actual negative (drugs can impair performance and are teratogenic) and inaccurate negative ones (high doses can anaesthetise from the neck up, non-adherence is always the patient's fault). Perhaps reflective of negative stereotypes of psychiatrists (see below), drugs are prescribed to control deviant behaviour, to impair enthusiasm (on the pretext that it is bipolar disorder) and in excessive doses by ‘heavy-handed’ clinicians (Reference Walter and RosenWalter 1999).

History lessons

For technical reasons and because of neglect, about 80% of silent films have been lost, with only stills and written descriptions remaining of them. Disproportionately more comedies and higher profile films have survived to the present day, but rare dramatic depictions stand out: Broken Blossoms (1919) and Page of Madness (1926) for psychopathy and psychosis, respectively. Reference Flowers and FrizlerFlowers & Frizler (2004) identified 462 films from the silent era (1899–1929) that feature a psychotherapist, but only 73 (15.8%) are available for viewing. Back then, role-play could cure mental illness: The Course of True Love (1905) and The Restoration (1909) are both silent films depicting talking therapy without a hint of irony. These films served as prototypes for the ‘psychiatrist as detective’ subgenre (Table 1), crystallised by Conflict (1945) in which a clever psychiatrist (Sidney Greenstreet) tricks the murderer (Humphrey Bogart) into implicating himself in his wife's murder.

Before censorship intervened – both ad hoc and self-censorship or formalised as the Hays Code in 1930 (www.classicmovies.org/articles/blhayscode.htm) – many films depicted the horrors of drug and alcohol misuse (Tables 3 & 4). In A Drunkard's Reformation (1909), director D. W. Griffith uses shot–countershot (showing the person, then showing that person's point of view, to establish the reality of a scenario) and parallel editing (two separate but related events are edited together to heighten drama and invite other meanings). In his reading of the film, Reference Gunning, Grievson and KrämerGunning (2004) argues that Griffith used these two technical innovations to create a moral contrast to soothe the authorities' moral panic in pre-Prohibition America. This film could also reflect its director's overdependence on alcohol in his life and in his films (the first seven films of Table 4): ‘projection’ has multiple meanings in film theory. Alcohol was also the first product to be advertised through film: Dewar's Scotch Whisky (1898). Reference MertonMerton (2007) sets out sophisticated comic representations of alcohol intoxication in silent comedy: the oft-copied Chaplin took the role of the drunk for himself – realising that's where the laughs were – in films such as The Clinic (1917).

Lambs of the silents

Dr Dippy's Sanitarium (1906) initiated the eponymous comedic psychiatrist stereotype (Reference Gabbard and GabbardGabbard 1999) – his only treatment is pies for his patients – although humour is more usually directed (as here) at people with mental illness in ‘lunatics on the loose’ chase films from Off to Bloomingdale's Asylum (1901) to Who's Looney Now? (1914) to The Dream Team (1989).

More frequent than the Dippy archetype came the evil mesmerist who uses the dark art of hypnosis to gain advantage. Out of 42 surviving ‘therapist’ films from the first two decades of cinema, 10 feature a hypnotist (Reference Flowers and FrizlerFlowers 2004). These films peaked with the German expressionist film The Cabinet of Dr Caligari (1919), inspiring Dr Mabuse the Gambler (1922), with six later reincarnations (sequels). Mabuse is the insane psychiatrist who commands a criminal empire; even after death, his ghost continues his dastardly work. Similar evil, mind-bending psychiatrists were unusual in talkies until reinvented as the ludicrous Dr Hannibal Lecter, who by Hannibal (2001) had acquired superhuman powers to stalk the land as a psychokiller. Given the second rule (films are derivative), copycat films turned on twists of convention (psychiatrist as patient, phoney psychiatrist, expert devoid of common sense, authority figure who can be corrupted), and Drs Dippy and Evil (Reference Gabbard and GabbardGabbard 1999) are merely flip sides of the idealised movie psychiatrist, Dr Wonderful. Reference MacFarlaneMacFarlane (2004) argued that contemporary excessively positive representations of psychiatrists and treatment benefits (11 films in Table 1) have unintended negative consequences for our patients: false hopes of a rapid and complete cure or expectations that therapists will bend the rules for them.

Medical models

As professionals, psychiatrists share many of the perceived core attributes of scientists:

1. • highly educated figures of authority, set aside from (or above) the rest of society

2. • employed directly by governments, making accountability seem remote

3. • their specialist subjects are difficult to understand and poorly explained

4. • use of empirical arguments drive a perception of reduced humanity.

In his study of scientists in cinema, Reference FraylingFrayling (2005) identifies several themes:

1. • the price of professional success is relationship and personal failures

2. • genius, where there is narrow pursuit of a goal, approaches madness

3. • coercive powers over others are frequently misused (‘for the greater good’)

4. • subjects reflect public concerns of the time: public dialogue about science began in film with poison gas, peaked with nuclear terrors and currently resides with human/genetic engineering.

Relevant to movie psychiatrists, ‘psychiatric fears’ include hypnosis (see above), brainwashing (The Manchurian Candidate 1962The Manchurian Candidate 2004; the Bourne trilogy 2002–07), unlawful incarceration (Table 1), torture-treatment (A Clockwork Orange 1972; Regeneration 1999; The Jacket 2005) and, combining all four, electroconvulsive therapy (ECT). The last has countless negative film representations (Reference McDonald and WatersMcDonald 2001) but these began positively with Autumn Leaves (1956) and Fear Strikes Out (1957). The only punitive psychiatric treatment, in A Beautiful Mind (2001), depicted insulin coma therapy; its psychiatric advisor was Professor Max Fink, an enthusiastic proponent of ECT. We can conclude that ECT will always get a rough cinematic ride or that we can potentially influence even powerful Hollywood studios: glass half-empty or glass half-full?

But it's the truth even if it didn't happen

The above subheading is the closing sentence of the first section of the novel One Flew Over the Cuckoo's Nest (Reference KeseyKesey 1962). The documentary Completely Cuckoo (Table 5) fails to recount the feature director Milos Forman's intention (as a Czech émigré) to depict the totalitarian state or the fact that real inmates of its asylum location were refused cameos in the film because they ‘didn't look odd enough’. Just as modern fiction films borrow documentary form, documentary frequently crosses the line into fiction or exaggerates (‘but it's almost true’) to attract audience interest: rule 1 of film (follow the money). Epileptic Seizures 1–9 (1905), nine one-reel films, were in effect the first mental health documentaries and, in their treatment of their subjects as objects, a taste of things to come. Made by a physician with good intentions, they became circus.

When cinema gets it (mostly) right

Reference CapeCape (2003) criticises films that depict alcohol and drug misuse as stigmatising, dividing them into four stereotypes: the tragic hero, rebellious free spirit, demonic/homicidal maniac and humorous/ comedic user. There are certainly recognisable types (rule 2: film begets film) but taken together, films about addiction (Tables 3 & 4), with occasional lapses, are brutally honest about the consequences (if not the causes) of addiction. Many films that initially trivialise substance misuse (Le Feu Follet 1963; Easy Rider 1969; Withnail and I 1987; Trainspotting 1996) proceed to depict serious consequences for the user. It would be a challenge to name an occupation not depicted on screen for which alcohol misuse leads to lost opportunities, career decline and worse. Some films depicting drug misuse (e.g. Requiem for a Dream 2000) could not be more harrowing about the terrible consequences of addiction even if made by health professionals. This is true of the messages in Trainspotting (dehumanising capitalist drug subculture that degrades its members), which seem conservative alongside those of mental health professionals (Reference ByrneByrne 1997).

One unintended consequence of censorship is the gap in films showing the horrors of addiction in the early talkies (Tables 3 & 4). Symptoms of drug misuse are highly filmic, as are the delusions and hallucinations of psychosis (first column, Table 6). Many of these films go beyond symptoms and signs to contextualise the experience of psychosis. The Madness of King George (1994) depicted highs and lows, whereas Mr Jones (1993) excised depression to allow more room for its star's exuberant behaviour in getting the girl (his psychiatrist of course).

There are three categories of ‘psychosis film’: rules 1–4 (Box 1) have moved the public perception of the disorder from the first into the second column of Table 6. The first column approaches verisimilitude, the second is about spectacle. Like Chekhov's gun (the gun seen in the First Act that must be fired in the Final Act; http://en.wikipedia.org/wiki/Chekhov's_gun), film-makers have focused not just on the 10% of people with psychosis who may become violent during their illness, but on the tiny proportion who kill (second column, Table 6). Either film-makers became bored with psychosis without homicide or they needed conflict, in its extreme forms, to heighten drama. Added to these, major actors and directors (James Cagney, Jack Nicholson, Stanley Kubrick, Robert De Niro, Martin Scorsese) influenced subsequent films: see rule 2 (film begets film).

Good/Bad = Ugly

Another line was crossed with the seminal Psycho (1960), by itself the originator of the psychokiller genre (third column, Table 6). This film conflates violence with mental illness, as it does schizophrenia with multiple personality disorder: both conceits are nailed down with the movie psychiatrist's epilogue explaining Norman's murderous acts. Equating ‘split personality’ with Jekyll/Hyde (that is, good/bad) initiated the dichotomy that continues to drive the public's worst perceptions of mental illness. Convention makes the killer a quiet man ‘who wouldn't even hurt a fly’ (Psycho) and who ‘flips’ from good to bad, suddenly and inexplicably. When portraying the extremes of bad behaviour, how else can amoral ‘psychos’ express themselves other than by violence and homicide? This is given life (and reincarnation) as the psychokiller, who kills initially for revenge, then for pleasure (Reference ByrneByrne 1998). Frequently more franchise than series, the many psychokiller films (Table 6) are so excessive we can easily dismiss them, but we cannot dismiss ‘realistic’ films linking psychosis and violence (second column, Table 6).

A variation on Chekhov's gun, rule 5 is ‘if it bleeds it leads’. This is the maxim of television news editors, who will always move up a story featuring injury and death, as examined in the pages of this journal (Reference ByrneByrne 2003). We are stuck with this – film audiences enjoy watching violence – and the madman who walks among us is as good a villain as any. This rule pulls decent film-makers from the first to the second column in Table 6 and exploitative ones from the second to the third. Violent psychosis is as strong in film folklore as are hard-drinking cops and hookers with hearts of gold, and even government ministers don't know the difference between psychopathic and psychotic, as I have noted before (Reference ByrneByrne 2003).

Good grief

The opening narrator in Field of Dreams (1989) sets up his own world:

The intense yearning and hallucinations of acute grief have spawned a subgenre (third column, Table 7) of bereavement films. At 20 films, the list is short but contains highly successful films, crossing mainstream genres with only three horror films. Were this list to include more horror, dozens of zombie films, including their comic variants, ‘zom coms’, would lengthen it. Despite a perception that cinema denies death (bullet-proof heroes, high body counts, the gift of eternal youth to actors from make-up and lighting departments), all of the 76 films in Table 7 portray the aftermath of a death. Some therapists advocate watching these films as part of psychotherapy but evidence is unlikely to justify prescribing films for individual patients: many could overwhelm.

Although Field of Dreams is not strictly a film about mental illness, aspects of its fantasy are useful to understand normal grief. There are various markers of pathological grief (phobic avoidance of people/places related to the deceased; extreme guilt and anger; total lack of grief; overidealisation of the deceased; physical illness; and recurring nightmares of the deceased) and it is also defined by longevity. Although fewer films depict this consistently, these films (third column, Table 7) have profound insights into the process, whereas others (first and second columns) portray some aspects of pathological grief.

Traits of mind

Representations of people with personality disorders are too numerous to list here. Borderline and dissocial personality disorders are excellently portrayed by Evelyn and Joey in Play Misty for Me (1971) and Goodfellas (1990) respectively. Although people with personality disorders and personality difficulties make for challenging patients, their dilemmas and behaviours make for great cinema: rule 4 (illness over health) and rule 5 (if it bleeds it leads). The challenge might be to list powerful dramatic films in which characters do not have personality difficulties: without conflict and misunderstanding there would be no drama. Referring back to Table 1, the absence of personality difficulties from the mainstream movie psychiatry genre is striking. Only three films feature a central character with a personality disorder. McMurphy's psychopathy in One Flew Over the Cuckoo's Nest and Bob Wiley's dependent personality disorder in What About Bob? are each stand-out performances, and a cinematic gift to teachers. Of equal merit, Girl Interrupted showcases borderline and dissocial personality disorder in two highly regarded central performances: Winona Ryder and Angelina Jolie. This film is exceptional in that it breaks the rule that, as with psychosis (Table 6), most representations of these two common personality disorders are of violence: rule 5 (if it bleeds…)

How long might it take to agree the personality profile of the eponymous Citizen Kane (1940)? The film showcases childhood loss, grief, narcissism, selective recall, alcohol misuse, attempted suicide and probable alexithymia in Kane himself. As with psychosis, violence – especially in the context of the two personality disorders mentioned above – dominates these representations: rule 5 again.

The return of the repressed

The films in Table 1 expend relatively little effort on determining which mental illness the patient has, and less on understanding wider societal reactions to their illness. Patients are passive foils: even as investigators, they go along with stronger characters in the narrative. In The Flame Within (1936), the female psychiatrist is advised to choose marriage and family over her career, and in Lady in the Dark (1944) a male psychiatrist advises Liza (Ginger Rogers) that she needs a man who will dominate her. During psychiatry's ‘Golden Age’ (1930s to 1960s) of positive representation of professionals, female deviance became an object of psychiatric discourse, played out as a subgenre (Reference WalkerWalker 1993).

Worse than in documentaries, people with mental illness in fiction films are either victims in melodrama (Table 1) or objects of comedy. As a rule, their only empowerment is as violent agents but this stereotype contributes most to stigma.

Contemporary film theory has borrowed even more from psychiatry than have film-makers (a story for another day) but it provides the means of deconstructing films. It seems unlikely that movie psychiatry will deviate from its current path unless, as professionals, we move beyond consumption to commenting on film. In engaging with media commentators or film-makers, think of yourself not as a ‘Christian thrown to the lions’ but as a dissenting voice who can assimilate ideas into ancient Roman culture – a project ultimately achieved by Christianity. Another thing the Romans did for us.