Mental Health & Our Relationship With Film
As the television and film industry has expanded over the past century, filmmakers have increasingly turned to crafting the most sensational stories to bring in money at the box office.[1] Because television portrayals of atypical or dangerous characters have proven especially lucrative, American films often portray mental illness in ways that emphasize or exaggerate the otherness of characters.[2] Thus, severe mental illness has become overrepresented in film: filmmakers prefer the utility of mental illnesses such as antisocial personality disorder, dissociative identity disorder (DID), and schizophrenia in developing mass appeal narratives with "sensational" stories, effectively erasing more invisible mental illnesses such as social phobias and anxiety.[3,4] In fact, in a study of 60 top-grossing films, schizophrenia and DID were found to be distortedly overrepresented in comparison to their relative rarity in the real world.[5] In exaggerating the prevalence of severe mental illness, films can influence viewers to begin seeing such sensational stories as the reality of mental illness around them.
Our experience with film is not confined to the theater. Whether a passenger on the metro brings to mind a character from Netflix, or an office we visit is reminiscent of a movie scene, the media we consume is incorporated into our daily realities. "Film dominates the environment of the viewer, who interacts with the film psychophysically," writes film researcher O'Hara (2019).[6] Our immediate experience with a film is physical and visceral, experiencing emotions as sensations.[7] Subsequently, this hyperrealism within film can blur the lines between fiction and reality, a "mystification" causing us to incorporate flawed and even harmful representations into our understanding of certain groups and conditions.[8]
Riles et al. (2021) find that routine exposure to popular messages, themes, and associations in film can influence viewers' judgment to make less systematic processing of content.[9] Riles (2020) explains this phenomenon: according to media priming theory, when a disparaging message is presented frequently, that message becomes more accessible in the mind of the viewer when encountering an individual meeting the criteria of that message via the availability heuristic.[10] Quintero Johnson & Riles (2018) add that mass media depictions can shape viewers' mental schema and enhance the accessibility of those schema, influencing their subsequent evaluations and behaviors.[11] With American films grossing more than 10 billion dollars USD at the box office annually, and with streaming services bringing film into our homes, media consumption has become one of the main pathways to expose Americans to these potentially harmful mass messages.[12]
As many Americans use media as their primary source of information about mental illness, the exaggerated exposure perpetuates stigma towards disorders that are already misunderstood: recall of disparaging messages about mental illness when encountering individuals with mental illness is strongest when this message is "vividly" and "exaggeratedly" portrayed.[13] According to exemplification theory, representations of mental illness that are most extreme are also the most cognitively accessible.[14] In fact, vivid exposure to negative portrayals of mental illness is associated with stereotypical and stigmatizing perceptions of mental illness, less positive attitudes, and heightened social distance preferences towards people with mental illness.[15-17] These effects are widespread; a study by Quintero Johnson & Riles (2018) found that weekly television use predicted disproportionately higher estimates of the prevalence of both general and severe mental illness.[18] While the National Institute for Mental Health (NIMH) reports an 18.6% incidence of mental illness at any given time, participants estimated an incidence of 31%—close to twice as high.[19] Even worse were participants' estimates for severe mental illness. While the NIMH reports 4.1% of the population having serious mental illness, participants estimated that 14.7% of the population has severe illness—well over three times as high—and that 46% of those with mental illness are dangerous.[20] With television broadcasting highly dramatized caricatures of people with mental illness, viewers are incorporating those stereotypes into their conceptions of the population around them and perpetuating stigma towards mental illness.
Prevalence of Othering Stereotypes
In addition to exaggeration, media representations can serve to alienate people with mental illness by using negatively charged, imprecise language and representations, such as using the word "crazy" to conflate different mental illnesses with one another.[21] In fact, in Quintero Johnson & Riles' (2018) study, a significant number of participants wrote "he acted like a crazy person" when asked to describe the characteristics and conditions of mentally ill media characters, noting abnormal speech patterns and unkempt or dirty appearances.[22] Such stigmatizing conceptions are othering towards people with mental illness and perpetuate their marginalization within society. As discussed by O'Hara (2019), films such as The Fisher King (1991) banish the mentally ill to the basement and other fringes of society, a depiction of behavioral and psychological disturbance as "craziness" and "monstrosity" that ostracizes this group.[23] Notions of mental illness as "craziness" can even cast doubt on the efficacy of therapy: Byrne (1997) discusses how stereotypes of psychiatrists, themselves, as "crazy" and ineffectual can parallel references to patients as "simple idiots" and "loonies."[24] In fact, Quintero Johnson & Riles (2018) found a negative association between television viewing and perceived benefits of talking to a mental health therapist.[25]
Stereotypes of mental illness as incurable and all-consuming can also serve to alienate therapists and patients. Byrne (1997) discusses a second film stereotype of psychiatrists as "pitiable good fellows" trying to "cure the incurable," paralleling patient stereotypes as "poor wretches who cannot cope with life's adversities."[26] By casting a lens of pity and futility onto the realm of mental illness, films distance viewers from patients. Representations of mental illness disproportionately depict patients excessively struggling and participating in risky behaviors to cope, with muted success with dealing with their pressures in life.[27] In a study by Riles et al. (2021), 48% of mentally ill characters were depicted crying, 10% had their struggles diminished by others, and 5% attempted suicide, while 33% drank alcohol and 24% smoked cigarettes.[28] Such depictions perpetuate stereotypes of those with mental illness as weak and lacking willpower, or even as a lost cause. This can alienate viewers with mental illness and lead them to see these unhealthy coping representations as the only possible solutions or end results.[29]
Overrepresentation of Violence and Danger
Another side to the misrepresentation of people with mental illness as less able to engage in healthy living and adversity management is the overrepresentation of characters as erratic, violent, and dangerous.[30] Doing so similarly discredits people with mental illness from social acceptance: in a survey of families of people with mental illness and their perceptions of what causes stigma, 86.6% blamed "popular movies about mentally ill killers."[31] This blame is not unfounded: a study by Quintero Johnson & Riles (2018) found that 72% of mentally ill television characters hurt or killed other characters and were ten times more likely to commit violent crime than other characters, despite the relatively low actual risk of violence among this population.[32-34] Riles et al. (2021) similarly found that 70% of characters with mental illness were associated with physical aggression, 55% with verbal aggression, and 12% with sexual aggression.[35]
According to stigma theory, the "association of a particular social identity with physical or social threats and abnormalities is a potent means through which that identity can be disqualified from social acceptance."[36] With the media showcasing mental illness as synonymous with increased violence and danger, viewers begin to associate mental illness with fear and criminality. Especially with news reports tending to focus on the most sensational stories, reporting individuals with schizophrenia involved with major violent crimes, public attitudes towards people with mental illness are shifted towards greater preference for social distance.[37] Quintero Johnson & Riles (2018) corroborate this finding, discussing how when behaviors of a target character are labeled as mental illness, college students' perceptions about the dangerousness of and their desire for social distance from that person increase.[38] The lack of differentiation between psychotic (losing touch with reality) and psychopathic (exhibiting abnormal or violent social behavior) mental illness in popular media contributes to this desire for social distance, as people with mental illness are grouped into a single stereotype of violence.[39,40]
Horror films are particularly notorious for crude and sensationalized depictions of mental illness as monstrous. Films as early as The Maniac Cook in 1909 and The Cabinet of Dr. Caligari in 1920 have held inaccurate and stigmatizing representations of psychosis, depicting mental health environments as cruel, prison-like Victorian institutions and their inhabitants as grotesque creatures and villains.[41] A study of 55 horror feature films made between 2000 and 2012 by Goodwin (2013) finds that similar stereotypes persist in films featuring psychosis today.[42] A troubling 78.78% of the films studied included the stereotype of a "homicidal maniac," while 72.73% featured "pathetic and sad characters" and 12.12% treated patients as "zoo specimens."[43] An additional 66.67% of films studied commonly used glass imagery to showcase fragility or a split personality, an othering depiction of a "whole self" that the patients have "lost."[44] Other stereotypes can be dismissive of the gravity of mental illness. These include horror films where harmless eccentricity is labeled as mental illness and inappropriately treated, in addition to 18.18% of films studied where supposedly delusional people were in fact telling the truth.[45] Such characterizations of mental illness can be misleading, dismissing the legitimacy of psychosis and its capacity to make its patients lose touch with reality.
In addition to othering patients with mental illness, horror films can be highly stigmatizing towards mental health care professionals and institutions, further dissuading people from seeking treatment. In Goodwin's (2013) study, 51.11% of films featured dangerous hospital staff tackling clients with batons and tasers, along with 64.44% using some kind of restraint such as a straitjacket or chaining clients to a wall.[46] 37.77% of films included a stereotype of an evil doctor or nurse, and 35.55% involved boundary violations by the therapist in treating their patient. Within the mental health setting itself, 57.77% of films also included dirty and unhygienic environments, while 53.33% included haunted or supernatural hospitals patients needed to escape from. Harmful stereotypes also abound toward neurosurgery and biological psychiatric treatments in horror films, casting them as primitive tools that block creativity and intelligence; 28.89% of films studied included negative depictions of electroconvulsive therapy and lobotomies.[47] Such representations can be extremely harmful given the success rate of these psychiatric treatments for treatment-resistant mental health conditions. By contributing to misinformation about these treatments' stereotyped "barbarism," horror films stigmatize seeking life-saving help.
Romanticization of Mental Health Conditions
Another form of misrepresentation and sensationalization of mental health in film includes romanticization. In the effort to craft a compelling tale, film makers will often embellish, simplify, or decontextualize complex mental health conditions, resorting to unrealistic tropes where "willpower" or "love" can "conquer" mental illness.[48,49] O'Hara (2019) examines this sensationalization in studying A Beautiful Mind, a 2001 film telling the story of John Nash, a successful mathematician who won the Nobel Prize with paranoid schizophrenia.[50] From his study, O'Hara argues that the movie exhibits "schizophilia," a modernist tradition of "overvaluing madness" through prioritizing and sensationalizing Nash's psychiatric disorder over other aspects of his life. For example, the film places a large focus on vivid visual hallucinations, when in actuality Nash had auditory hallucinations as is most common in patients with schizophrenia. Through emphasizing twists, suspicions, and intrigues, the film becomes "a blindly dumb attempt to turn schizophrenia into an adventure for the audience … schizophrenia becomes an occasion for a cinematic magic trick that leaves the viewer with no concept of the difficulty in getting well."[51]
Perhaps the most harmful example of this romanticization comes with the film's choice of ending: in it, Nash stops taking his medication and decides to reject his hallucinations by simply refusing to interact with them. By doing so, his life becomes seemingly normal and controllable, and he wins the Nobel Prize.[52] This ending is highly misleading and serves more the purposes of a dramatic narrative than realistically portraying schizophrenia; by promoting the idea that schizophrenia can be cured with self-discipline, the film heavily simplifies mental illness and implies that patients with schizophrenia may just lack willpower. Like in the horror movies discussed earlier, this film similarly stigmatizes medication by making halting medication by personal choice appear to be the "brave" action, when in reality stopping medication usage can cause rapid relapse or withdrawal effects and should not be done without consulting a medical professional.
Although not a mental illness, autism spectrum disorder (ASD) is a neurodevelopmental disorder with mental effects that are often depicted and misrepresented on screen. Because many people do not have substantial or direct contact with those on the spectrum, they often look to other sources, like film, to draw understanding.[53] This can have benefits and drawbacks: while some film representations of ASD are highly matched to diagnostic characteristics, fictional autistic characters showcase an overrepresentation of savant-like skills. In a study of 26 films and TV series featuring ASD across four continents, savant-like skills were reported in 46% of characters, when in fact savantism is estimated to exist in 10-30% of populations with ASD.[54] Although the inclusion of these skills can develop a character's value and capability within a dramatic narrative, the exaggerated representation can serve to romanticize the condition and propagate the message that these skills constitute a person with ASD's worth, when in fact only a minority of the population exhibit them. Another misrepresentation was noted in the 1999 film Molly, which depicts experimental brain surgery "curing" autism.[55] Though such a depiction again facilitates the resolution of a dramatic narrative, it contributes to attitudes towards autism as a disease and can be very stigmatizing towards people who identify as neurodivergent.
Additional concerns can actually arise when ASD is represented correctly on screen. The majority of characters with ASD on screen typically show the maximum possible score on the DSM-5 symptom scale for ASD, acting as "archetypes" for the diagnostic criteria.[56] Although this shows diagnostic accuracy, it actually increases the likelihood of stereotyping by lacking nuance and does not fully represent the broad spectrum of experiences with ASD. Nordahl-Hansen et al. (2018) argue that films should not only show diagnostic accuracy, but also accurately portray the real-life obstacles faced by people on the spectrum in addition to what they can accomplish in a supportive environment, a fully fleshed out representation of their autonomy and personhood.[57]
Other Inaccuracies in Representation
Films on mental health exhibit additional overarching misrepresentations. One of the largest concerns is that mental illness is predominantly portrayed in privileged majority populations: a study by Riles et al. (2021) found that 97% of characters with mental illness were white, 79% were male, 88% were adult-aged, 94% were heterosexual, and 72% were non-religious.[58] When the media fails to portray marginalized populations experiencing mental illness, it casts mental health as a "Caucasian phenomenon" and reinforces ideas in many minority populations that mental healthcare and therapy are also only for the majority populations.[59] Doing so also ignores the compounded effects of mental illness and marginalized identity, particularly with the higher likelihood for certain ethnic groups and LGBTQ+ youth to experience mental health conditions.[60] Increasing portrayal of minority groups with mental illness would also help to address an overall lack of representation: although 25% of adults experience mental illness, only 5% of film characters have a mental illness.[61] Increasing representation of mental health in film, in a thoughtful and accurate way, is crucial to help mediate this inaccuracy.
Moving Forward in Film
Moving forward, Goodwin (2013) recommends that the mental health sector work more closely with the film and television industry to reduce stigmatizing content and voice their opinions in advocacy groups.[62] Byrne (1997) concurs, suggesting setting up a mental health information service where complaints from interest groups and inquiries from the media could both be addressed.[63] During production, O'Hara (2019) suggests film makers consider a series of ethical questions: What effect will this portrayal have on the audience? Is this portrayal exploiting the lived experiences of persons with psychological disabilities? How does this portrayal engage with the agency, voice, and access of people with mental illness? If symptoms manifest differently in different patients, how can we depict the condition without reinforcing stereotypes and stigmatizing attitudes?[64] By making these considerations, films can reduce harm and exploitation of people with mental illness.
Another important way to combat misrepresentation begins with public education, especially in K-12 schools when children are forming their first conceptions of mental illness.[65] Byrne (1997) suggests disseminating mental health information through audiovisual packages for schools that have been regulated for accuracy.[66] O'Hara (2019) leans more towards developing critical thinking skills in children so that whether or not they end up consuming misrepresentative media, they can be more wary of its stereotypes and flaws.[67] O'Hara suggests incorporating discussions around deconstructing stereotypes and critical questioning skills in classrooms, and reminds us that "students viewing movies create meaning through their past experiences in relation to images on the screen."[68] In this way, mental health film can be used to instruct about equity if done well, including perhaps increased exposure to nonfiction films and documentaries on mental illness.[69] By starting education about mental illness and critical thinking early, teachers can help to dismantle stereotypes and lessen the stigmatizing effects of the media around us.
Contributed by: Anna Kiesewetter
Editors: Jennifer (Ghahari) Smith, Ph.D. & Brittany Canfield, Psy.D.
References
1 O'Hara, M. (2019), Cinema of the Monstrous: Disability and “Eye-Feel”. Journal of Curriculum Theorizing, 34 (5): 44-57. https://journal.jctonline.org/index.php/jct/article/view/869.
2 Ibid.
3 Riles, J.M., Miller, B., Funk, M., Morrow, E. (2021), The Modern Character of Mental Health Stigma: A 30-Year Examination of Popular Film. Communication Studies, 72 (4): 668-683. https://doi.org/10.1016/j.psychres.2017.08.050.
4 Riles, J.M. (2020), The social effect of exposure to mental illness media portrayals: Influencing interpersonal interaction intentions. Psychology of Popular Media Culture, 9 (2): 145-154. https://psycnet.apa.org/buy/2018-58786-001.
5 Riles et al. (2021)
6 O'Hara (2019)
7 Ibid.
8 Nordahl-Hansen, A., Tondevold, M., Fletcher-Watson, S. (2018), Mental health on screen: A DSM-5 dissection of portrayals of autism spectrum disorders in film and on TV. Psychiatry Research, 262: 351-353. https://doi.org/10.1016/j.psychres.2017.08.050.
9 Riles et al. (2021)
10 Riles (2020)
11 Quintero Johnson, J.M., Riles, J.M. (2018), "He acted like a crazy person”: Exploring the influence of college students’ recall of stereotypic media representations of mental illness. Psychology of Popular Media Culture, 7 (2): 146-163. https://psycnet.apa.org/buy/2016-19244-001.
12 Riles et al. (2021)
13 Riles (2020)
14 Quintero Johnson & Riles (2018)
15 Ibid.
16 Riles (2020)
17 Riles et al. (2021)
18 Quintero Johnson & Riles (2018)
19 Ibid.
20 Ibid.
21 Riles (2020)
22 Quintero Johnson & Riles (2018)
23 O'Hara (2019)
24 Byrne, P. (1997), Psychiatric stigma: past, passing and to come. Journal of the Royal Society of Medicine, 90: 618-621. https://journals.sagepub.com/doi/pdf/10.1177/014107689709001107.
25 Quintero Johnson & Riles (2018)
26 Byrne (1997)
27 Riles et al. (2021)
28 Ibid.
29 Ibid.
30 Ibid.
31 Byrne (1997)
32 Quintero Johnson & Riles (2018)
33 Riles et al. (2021)
34 Riles (2020)
35 Riles et al. (2021)
36 Ibid.
37 Riles (2020)
38 Quintero Johnson & Riles (2018)
39 Byrne (1997)
40 Goodwin, J. (2014), The Horror of Stigma: Psychosis and Mental Health Care Environments in Twenty-First-Century Horror Film (Part II). Perspect Psychiatr Care, 50: 224-234. https://doi.org/10.1111/ppc.12044
41 Ibid.
42 Ibid.
43 Ibid.
44 Ibid.
45 Ibid.
46 Ibid.
47 Ibid.
48 Ibid.
49 O'Hara (2019)
50 Ibid.
51 Rockwell, C. (2002). A Beautiful Mind [Review of the motion picture]. Cineaste, 27(3). 36-37.
52 O'Hara (2019)
53 Nordahl-Hansen et al. (2018)
54 Ibid.
55 Ibid.
56 Ibid.
57 Ibid.
58 Riles et al. (2021)
59 Ibid.
60 Mental Health America. (2022) https://www.mhanational.org/issues/lgbtq-communities-and-mental-health.
61 Riles et al. (2021)
62 Goodwin (2013)
63 Byrne (1997)
64 O'Hara (2019)
65 Ibid.
66 Byrne (1997)
67 O'Hara (2019)
68 Ibid.
69 Ibid.