Cinema both reflects and influences public attitudes and beliefs. It is, therefore, a particularly useful medium in which to assess how we view certain institutions and professions in society. Psychiatry is one of those institutions and professions that people can have very strong opinions about, and which is regarded by many as a force in society to be mistrusted. While there are, indubitably, valid criticisms of psychiatry coming from the critical psychiatry and anti-psychiatry movements, I argue that a great deal of public perception of psychiatry is influenced by cinema (and mass media more generally).
Most people do not have first-hand experience with psychiatry and people who do have first-hand experience often say little to nothing about their experience to most people they know, due to stigma and fear of judgement. However, portrayals of psychiatrists and psychiatric care are commonplace in Hollywood films, and for many people, this may be the only – or the main – exposure they have to the institution of psychiatry. Again, there are valid criticisms of psychiatry, which I have raised in the past, but when people have a negative, black-and-white opinion on psychiatry, viewing psychiatric medication and psychiatrists as ‘evil’, one has to wonder what is contributing to such an attitude.
Personal negative experiences with medication and psychiatrists can, of course, be a factor, as can a strong attachment to an anti-psychiatry worldview. But in this piece, I’d like to argue that seeing psychiatry as a completely corrupt, malignant, controlling, and inhumane force in society seems to fit in with the stereotypes of the institution portrayed in cinema.
Psychiatrists on Screen
In an essay titled The horror, the horror: stigma on screen (2014), published in The Lancet Psychiatry, the psychiatrists John Shand, Susan Friedman, and Fernando Forcen offer examples in which psychiatry has been misrepresented, which they believe “can lead to lasting negative impressions”.
In films, psychiatrists are often portrayed in films as nefarious, untrustworthy characters, intent on manipulating or harming patients for their own twisted ends. We see this in The Cabinet of Dr Caligari (1920), in which Caligari, who later turns out to be the director of an asylum, induces a trance state in Cesare, by way of hypnosis, in order to commit murder by proxy. According to Irving Schneider (1987) and Susan Friedman (2011), psychiatrists on screen often fit into the mold of “Dr Evils”. Dr Hannibal Lecter and Dr Mabuse are also prime examples of this.
There are also often differences in how female psychiatrists are portrayed compared to their male counterparts, with female psychiatrists often portrayed as acting unprofessionally and transgressing the boundaries of the client-clinician relationship. Adam R. Fisher, a family psychologist, states:
Regarding psychiatrists, women in film often establish sexual relationships with patients (Byrne, 2009), despite the fact that in reality, a male psychiatrist is much more likely to cross boundaries and engage in a sexual relationship with a female patient than the other way around (Gabbard, 2001; Gabbard & Gabbard, 1989).
We can see this, for example, in The Departed (2006), where Dr Madolyn Madden ends up sleeping with – and falling for – her patient Billy Costigan.
Psychiatric Patients on Screen
The portrayals of psychiatric patients in cinema can sometimes be realistic, humanising, and favourable, but all too often they fit into negative stereotypes. Shand, Friedman, and Forcen point out:
Caligari was not the first film to portray mental illness and violence as being intertwined—that distinction probably goes to The Maniac Cook (1909)—and it certainly wasn’t the last. Some mental health patients are shown as being weak-willed and easily manipulated, such as Caligari‘s Cesare and Dracula‘s Renfield (1931). In recent years, the portrayal has become more negative still, and equally inaccurate; psychosis is misrepresented as being synonymous with homicidality, with or without an accompanying dissociative identity disorder.
Indeed, Hollywood films – and mass media, in general – often make a clear link between psychiatric illnesses and violence. These inaccurate portrayals of psychiatric conditions are not just inconsequential artistic decisions. As Shand, Friedman, and Forcen argue:
One common response to these points is to say that horror films are fantasies, and have no bearing on real-world attitudes. But this attitude is, we would argue, complacent. Fictional constructs bleed into real-life perceptions. In the days when Dracula and Caligari first played in movie theatres, asylums literally walled off those with mental illness from the rest of society. Since deinstitutionalisation, it is stigma that keeps mental illness hidden, despite efforts to fight the disparate treatment of people with mental health problems. Stereotypes continue to inundate society, where casual uses of derogatory terms such as “maniac”, “lunatic”, “madman”, “crazy”, and “psycho” abound. These same representations appear in horror films, and mental health patients are insulted by their representations in the media. Whether or not these stereotypes are the root of mental health stigma, they certainly provide an egregious example.
The Image of Psychiatric Hospitals
Many films depict psychiatric hospitals and facilities as cruel, imprisoning, and scary places to be. In One Flew Over the Cuckoo’s Nest (1975), the audience is led to believe that mental hospitals are like prisons, where patients are deprived of their human rights. And while many people do definitely have unpleasant and unhelpful experiences with psychiatric hospitalisation, patients’ experiences are also mixed – psychiatric wards can be both curative and unsettling places. Problems with wards can often be attributed to issues like underfunding, poor training, and management issues, rather than inherent issues with psychiatric institutionalisation as a whole.
For instance, in the 1950s, the French psychotherapist Felix Guattari worked at La Borde, an experimental psychiatric clinic in the Loire Valley – and this hospital was run in accordance with a communist ethos, with doctors, staff, and patients all working together to run the facility. Guattari believed that what made patients with psychosis ill was social alienation, and by turning the hospital itself into a method of treatment, with patients becoming part of a group working together, he thought this would be a more humanising approach than what the psychiatric system traditionally offered at the time.
But many popular films portraying psychiatric facilities show them as places to fear. Indeed, the creepy psychiatric hospital has become a staple of horror films. Shand, Friedman, and Forcen state:
Frequently cinematic psychiatric facilities have overlooked any screening or supervision for their employees, and as in The Ward (2010), hire baleful and aggressive employees. The facility itself is dirty, dark, and even haunted.
Films, however, have evolved in the ways they depict psychiatric facilities and the people who work in them. Girl, Interrupted (1999), for instance, is an accurate representation of long-term hospitalisation in the 1960s. In a masters dissertation titled Stigma on the Screen: A Textual Analysis of Mental Illness in Film (2015), Alexis Ian Rainey compares One Flew Over the Cuckoo’s Nest with Girl, Interrupted:
In Girl, Interrupted, the head nurse, Valerie, is extremely maternal and undoubtedly wants each of the patients to recover. The doctors are present and shown throughout the film treating the patients and working toward reviving their mental health. The audience even gets glimpses of the notes doctors have made about Susanna’s diagnosis and recovery. On the other hand, in One Flew Over the Cuckoo’s Nest, the nurses and doctors are seemingly apathetic to the patients’ wellbeing. The antagonist, Nurse Ratched is in clear and conscious opposition to Mack’s recovery, and her ostensible indifference to the patients’ wellbeing ultimately leads to the death of two of the men.
The Portrayal of Psychiatric Treatment
Psychiatric treatment often doesn’t receive a favourable depiction in cinema, either. Psychiatrists and nurses in psychiatric facilities in films often try to force medication onto patients. For instance, Mack, in One Flew Over the Cuckoo’s Nest, only agrees to take the medication because Nurse Ratched’s assistant threatens to inject it into him intravenously if he doesn’t comply. This runs contrary to the fact that in most cases, force is never employed – patients have a right to refuse medication.
As is common in horror films, treatments for psychiatric illnesses often include “inaccurately dramatised depictions of chemical sedation, straitjackets, locked rooms, electroconvulsive therapy, and frontal lobotomies” (Shand, Friedman, Forcen, 2014). There’s nothing intrinsically wrong with inaccurate dramatisations or exaggerations since they’re often crucial to creative freedom and viewer entertainment but one does have to wonder what persistent impressions the general public will have of psychiatric treatment as a result of such depictions. A possible effect of these impressions is that they would make you avoid psychiatric treatment or dissuade others from seeking it. Often we don’t think to question whether what our opinion of psychiatric treatment is based on, but the influence of cinema and mass media are stronger forces than we may appreciate. Even if they don’t create impressions themselves, they can at least serve to strengthen them.
Psychiatric treatments are sometimes shown on screen as tools of manipulation, as in the case of hypnosis in The Cabinet of Dr Caligari (hypnosis was a common psychiatric treatment utilised at the time). In their essay in The Lancet Psychiatry, the authors underscore:
Therapies, in horror movies, are used as a punishment and patients are treated in an inhumane way. Electroconvulsive therapy features in Child’s Play (1988) and House on Haunted Hill (1999). In film, electroconvulsive therapy can be given without anaesthesia or a muscle relaxant: thus it is accompanied by jaw clenching and uncontrolled seizures, often with flickering lights to exaggerate the immense amount of power being used during the procedure.
People will also be familiar with the disturbing electroconvulsive therapy (ECT) scene in One Flew Over the Cuckoo’s Nest, yet ECT does not result in the effects shown in the scene, which includes violent bodily seizures when the treatment is administered. Instead, during actual ECT, the body tenses for a bit and then relaxes. In spite of its negative portrayal in cinema, ECT can be extremely beneficial for patients, and is highly effective in the treatment of severe and treatment-resistant depression (not to say the treatment doesn’t have its downsides and side effects, of course).
Films that negatively portray ECT can make people irrationally fearful of the treatment, viewing it as a cruel practice of a bygone era. And this means people can avoid treatment that could be ameliorative (and potentially life-saving, in cases of suicidality). Due to its portrayal of ECT, One Flew Over the Cuckoo’s Nest caused a public backlash against the treatment, with it falling out of favour in the 1980s and 1990s.
Based on all of these considerations together, we can see how psychiatry has become overly stigmatised and feared through its presentation in film. Cinema reflects back to us – and feeds – our fears surrounding psychiatrists, mental hospitals, patients, and psychiatric treatments. Much of the general public, then, may have a somewhat warped perception of what psychiatry involves. Many approaches in psychiatry – such as the biopsychosocial model – probably don’t fit in with the common perception that psychiatry is all about treating patients as chemically imbalanced brains that need to be medicated.
This isn’t to say that we need to ban or boycott films that inaccurately portray psychiatry, or that we should become outraged at filmmakers who perpetuate stereotypes. I don’t see raising concerns about stereotyping in film as censorial; I see it as a form of critical analysis that should get both filmmakers and viewers thinking about the effects of artistic expression. Trying to aim for both creative expression and destigmatisation is not a zero-sum game, as is illustrated by the fact that many high-grossing and well-reviewed films do portray psychiatry and mental illness in a realistic way. For example, in It’s Kind of a Funny Story (2010), Craig (a 16-year-old played by Keir Gilchrist) checks himself into a psychiatric ward because of his depression and suicidal ideation. But the hospital he stays at is not a scary place and the patients there are not presented as generically ‘mad’ or ‘insane’. We also see a positive representation of a psychiatrist and psychiatric hospitalisation in The Perks of Being a Wallflower (2012): Dr Burton comes across as caring and trustworthy when speaking with Charlie, who was hospitalised due to post-traumatic stress disorder (PTSD) symptoms, and the facility he stays at is safe and conducive to his recovery.
Freedom of expression will always include the freedom to critique, and if the trend of cinema changes based on the normative values underlying a critique, this does not necessarily mean cinema is becoming restricted and choked by over-sensitive and censorial thinking. If we look at how much cinema has changed over the decades, we can see how certain negative stereotypes have disappeared or declined, and we can collectively agree why this has been beneficial.
Psychiatry is an imperfect institution in need of change, but we may come to realise that cinematic portrayals of this institution are making us overly critical and suspicious of it. Perhaps it is time for new films to explore psychiatry in a nuanced way, showing its flaws, but also being honest about the positive impact it can have on people’s lives.
