Steven H. Hyler, MD

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 

 (1915), D. W. Griffith gave the American public 

 (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 

 series (1980 and later), and continue to the present. Recently, several popular films that reinforce this stereotype have appeared. 

 (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 

(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. 

(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 

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 

 (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., 

 (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 

 (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 

 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 

 (1980). A recent film character illustrating this stereotype is Lisa Rowe (played by Angelina Jolie) in 

 (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?

Representations of this stereotype are found in film characters such as R.P. McMurphy in 

 (1975), as well as in many of the patients (peripheral characters) in films such as 

 (1988). One of the more memorable recent film characters is Melvin Udall (played by Jack Nicholson) in 

 (1997). He has the Hollywood variety of obsessive-compulsive disorder, or perhaps obsessive-compulsive personality disorder. In any event, he dispenses homilies to the other characters while receiving some from the nurturing Carol Connelly (played by Helen Hunt). I imagine that this portrayal of individuals with OCD did not endear the filmmakers to real people with OCD, who may resent the protagonist being portrayed as egocentric, rude, obnoxious and destructive. 

Another stereotype to appear in a number of recent films is that of "Specially Gifted Mental Patient." This a person with an identifiable mental illness who happens to possess special powers that are either related to the mental illness or serve to compensate for the disorder. The character of Raymond Babbitt (played by Dustin Hoffman) in 

 (1988) presents a Hollywood portrayal of some sort of pervasive developmental disorder or autistic disorder. His autistic persona is accompanied by his prodigious powers of memory and calculation of sufficient capacity to break the bank playing blackjack in Las Vegas. The character is a form of idiot savant who combines the disability with the compensating special powers.

 (2001), the character of Prot/Robert Porter (played by Kevin Spacey) appears from nowhere (perhaps from outer space) in Grand Central Station, where he is taken immediately into custody and transferred to Manhattan Psychiatric Institute. He claims that he is from the planet K-Pax and proceeds to impress an assembled group of physicists with his remarkable knowledge of physics and astronomy. Along the way he assists several of the other patients in the ward in overcoming their mental disorders more effectively than the well-meaning psychiatrist. In 

 (2001), Russell Crowe acts out the life of John Nash, the man who won a Nobel Prize, despite being afflicted by terrifying psychotic experiences. Similarly, the David Helfgott character (played by Geoffrey Rush) in 

 (1996) is a world-class pianist who is told that his mental problems are due to his submitting to the rigors of learning to play piano concerti by Rachmaninoff. 

The idea that individuals with mental disorders are actually gifted (or at least compensated for their disorders) with special powers suggests that they can fend for themselves provided that they have the appropriate handlers (think of Tom Cruise's character in 

) to steer them toward harnessing their powers. That their special gift is linked to their illness suggests that treatment of the disorder will destroy the gift (and power) that accompanies it. Many of our patients who might identify with such characters may be led to believe that they would be better off discontinuing their medication and forgoing treatment for their mental disorders, lest they, too, have to give up their "gift" as would happen if they take medication to control their symptoms. 

It might be tempting to write off these depictions of mentally ill people as merely harmless Hollywood distortions, but as advertising executives thoroughly understand, media images insidiously work their way into the collective unconscious of society and influence the way we all regard the world around us. Although none of the images described can be said to have arisen de novo, the question of whether society's perceptions of the stereotypical representations came first cannot be resolved without empirical research. Regardless of which came first, it is important to recognize the effect that cumulative viewing of such images may exert. 

There are several strategies that might be useful in combating the effects of the negative stereotypes presented by Hollywood that stigmatize our patients. A letter-writing campaign to producers of films or television shows that depict stereotypes and to editors of newspapers and periodicals that advertise offensive films may be effective. The campaign launched against the television show 

illustrates the effectiveness of this technique. This series appeared briefly on ABC in 2000 and attempted to depict life in a psychiatric emergency room, based on Bellevue Hospital in New York City. Whatever the merits of the plot, characters or production values, many viewers representing patients with mental illnesses and their advocacy groups voiced their offense. After only two episodes the show was taken off the air. 

Other remedies include: public information campaigns such as the Mental Health Awareness week that has been observed for the past several years; encouraging public testimonials by respected celebrities who have experienced mental illness such as Patty Duke, Mike Wallace and William Styron; encouraging recognition of accurate depictions of patients with mental disorders that portray the suffering of the patients and their families; and enhancing communication between mental health professionals and clinicians in other medical fields.

Since the publication of our original paper on stigma (

1991;42[10]:1044-1048), the Internet has come to play an increasing important role in communication and imparting information. A recent Internet search has revealed many Web sites dedicated to overcoming the stigma of mental illness (Table). 

In addition, more sympathetic portrayals of individuals with mental disorder have appeared. One example is the Maggie character (played by Sally Fields), who suffers from bipolar disorder, on the NBC TV show 

. The manner in which she is portrayed and the effect on her family testifies to the fact that a character can be made interesting and engaging without resorting to over-the-top negative stereotyping.

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Stereotypical portrayals of people with mental illness are as old as Hollywood itself. What are some of the clinical implications of the continued stigmatization of the mentally ill in television and film?

Steven H. Hyler, MD

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