Stigma Continues in Hollywood

Negative stereotypes of patients with mental illness have a long history in Hollywood. Inaccurate portrayals have an important and underestimated negative effect on the perception of people with mental disorders--by the public, legislators, families and patients themselves. In this update of a 1991 presentation given by Glenn Gabbard, M.D., Irving Schneider, M.D., and myself, I will review some of the common stereotypes seen in film and television and discuss several recent films that perpetuate such myths.

This stereotype dates back to early one-reel films. Several years before his famous Birth of a Nation (1915), D. W. Griffith gave the American public The Maniac Cook (1909). In this film, Griffith introduced the stereotype of the "deranged" mental patient who is dangerously violent and requires incarceration lest he or she wreak havoc upon society. Later versions of this stereotype can be found in the genre of horror films that first appeared in the 1960s, such as Psycho (1960), Halloween (1978) and the Friday the 13th series (1980 and later), and continue to the present. Recently, several popular films that reinforce this stereotype have appeared. Silence of the Lambs (1991) brought to the screen the character of Hannibal Lecter, the homicidal psychiatrist who killed his victims and, in one case, ate his liver "with some fava beans and a nice Chianti."

Other recent films of this genre include American Psycho (2000), adapted from the controversial book of the same name by Bret Easton Ellis. Christian Bale plays Patrick Bateman, the ultimate yuppie homicidal maniac. The film never resolves whether the character is actually committing the gruesome murders or whether they exist solely in his imagination. In any event, the title and the message are that psychosis is equivalent to homicidal mania. Summer of Sam (1999), directed by Spike Lee, tells the story of the summer of 1977, when all of New York City was paralyzed with fear by the Son of Sam, David Berkowitz. The murders are depicted in chilling detail, and there are vivid demonstrations of the protagonist in the throes of his psychosis, howling at the moon and wrecking his room. There were many other films of this genre, including The Bone Collector (1999) and Primal Fear (1996).

In actuality (with certain exceptions, e.g., substance-induced psychoses), individuals with mental disorders are not more likely to commit violent crimes than is the general population. Hollywood's equating mental illness with violence reinforces stereotypes that commonly appear as tabloid-press headlines that focus on the violent acts of the few individuals who have mental disorders. What is likely to be the cumulative effect on audiences who see the mental patient frequently depicted as a homicidal maniac? Are viewers likely to be sympathetic to people with mental illness or to welcome warmly (or even with a neutral reaction) psychiatric halfway houses or day-treatment centers in their community? What effect might the perception of mental illness as akin to demonic possession, as per The Exorcist (1973), have on legislators who vote whether to allocate limited funds for mental health research? If the equation is that Mad = Bad, is it any surprise that incarceration in correctional facilities in the United States is at the highest level in history, while the census in mental facilities is at an all-time low?

The stereotype of mental patients as self-centered attention-seekers involved in a narcissistic relationship with their therapists has been popularized in many Woody Allen films (e.g., Annie Hall [1977]), as well as in Lovesick (1983), Love at First Bite (1979) and Mel Brooks' High Anxiety (1978). In Down and Out in Beverly Hills (1986), there is even a psychoanalyst, Dr. Von Zimmer, who treats neurotic canines. Although not as overtly noxious as the homicidal maniac, this stereotype serves to stigmatize actual patients by ridiculing them and trivializing their problems. This stigma makes it unlikely that patients will reveal to others their positive experiences with psychiatric treatment.

A new stereotype that has appeared in the past few years is a hybrid of these two stereotypes. It combines features of both of them to coalesce into what I will name "Mob Boss with Anxiety Disorder." This is typified in Robert De Niro's portrayal of Paul Vitti, a patient being treated by Billy Crystal's Dr. Ben Sobel in the films Analyze This (1999) and Analyze That (2002). This character is so dependent on the utterances of Dr. Sobel that he parrots back to him all the psychobabble he is offered and demonstrates the veracity of the doctor's interpretations. The Tony Soprano character (played by James Gandolfini) in the critically acclaimed HBO television series The Sopranos is another example. Whether accidentally or deliberately, these shows both present highly neurotic organized crime overlords who suffer from panic attacks and who are in therapy (and on medication) for their symptoms. Why this characterization has been so wildly popular is difficult to determine. Perhaps the fish-out-of-water characterization of the macho mob boss suffering from the same neurotic symptoms as the rest of the population makes them warmer and cuddlier and less threatening and dangerous, alleviating our fears. While we may be entertained by these characterizations, it is important not to lose sight of their clinical implications. What effect might these stereotypes have on executives of a medical insurance company, health maintenance organization or managed care company who make decisions about coverage of psychiatric outpatient treatment and determine reimbursement rates for such treatments? Might not the trivialization of the difficulties faced by people with genuine mental disorders influence insurance executives to decide that company employees might be better served by offering dental coverage rather than outpatient mental health coverage?

The stereotype of the female patient as a seductress--a nymphomaniac of mythic proportions--appeared in the films Spellbound (1945), The Caretakers (1963), Lilith (1964) and Dressed to Kill (1980). A recent film character illustrating this stereotype is Lisa Rowe (played by Angelina Jolie) in Girl, Interrupted (1999). In one scene, Lisa casually mentions that she has had sex with several of her previous therapists. This certainly reinforces the stereotype of male therapists acting out their own countertransferential impulses by sleeping with their attractive female patients. Imagine the possible effect of the stereotype of the female mental patient as seductress on a woman with genuine emotional problems or a past history of abuse who is grappling with the issue of whether she should consult a psychiatrist. Might she postpone or decide against seeking help for a clinically significant depression, anxiety disorder or posttraumatic stress disorder?