Reflections
On psychiatry in cinema

E. Dennis Curry MSc1
Published online: 05 August 2020
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1Dalhousie Medical School, Dalhousie University, Halifax, Nova Scotia, Canada

Corresponding Author: E. Dennis Curry, email dcurry@dal.ca

Synopsis

Hannibal Lecter, Malcolm Crowe, and Arthur Fleck are three cinematic characters that relentlessly captivate viewers for different but powerful reasons. A common thread between these characters is their explicit connection to psychiatric illness or its treatment. The author explains how these characters obtain the audience’s attention through the lens of mental illness and how the viewer’s reservoir for compassion stands to deepen during this process. The author concludes with a social commentary on Todd Phillips’ Joker (2019) and the controversy surrounding its depiction of mental illness on the silver screen. (1)

Tags: Psychiatry, cinema, society, responsibility, joker


We live in a primitive time—don’t we, Will? —neither savage nor wise. Half measures are the curse of it. Any rational society would either kill me or put me to some use.
- Hannibal Lecter, Red Dragon

When people ask me if I went to film school, I tell them, 'no, I went to films.'
- Quentin Tarantino

How about another joke, Murray? What do you get when you cross a mentally ill loner with a society that abandons him and treats him like trash? I'll tell you what you get!
- Arthur Fleck, Joker


Artistic expression at its very best, moves. In cinema, medical themes are often used to effectively paint characters, build atmospheres, and emotionally provoke audiences. The very nature of the human experience that these themes are derived from allows for a special and highly variable kind of creativity to find its way to the screen. Few areas in medicine provide as much depth to both on screen character and plot development as psychiatric illness. The struggles, successes, and setbacks inherent to mental illness urge the viewer to invest emotionally in the film, often via connecting empathetically to the involved characters. Given that it is quite likely virtually every viewer has had either exposure to or experience with mental illness, either directly or indirectly, this investment doubles as an inherent artistry-driven phenomenon and experience.

Both sides of the so-called “gurney”

Astute audiences of modern-day cinema are likely familiar with the powerful amalgam formed when medicine and theatre collide. The cannibalistic serial killer and psychiatrist, Dr. Hannibal Lecter* in The Silence of the Lambs (1991), serves as an intriguing example of this. (2) Prior to even appearing on screen, Lecter is introduced in a terrifying and quasi-mythical way by his physician handler, Dr. Frederick Chilton, in the basement-level depths of the Baltimore State Hospital for the Criminally Insane. While escorting FBI agent Clarice Starling to interview the menacing psychiatrist, Chilton enthusiastically describes in vivid detail how Lecter savagely and gruesomely attacked a nurse after faking chest pains and finding a gap in prison security: “the doctors managed to reset her jaw more or less. Saved one of her eyes. His pulse never got above 85, even when he ate her tongue”. The scene is juxtaposed immediately with the introduction of Lecter in the flesh. He poses as a thoughtful and extremely well-mannered inmate during his initial interactions with Starling. As has been pointed out elsewhere more generally, this timid and unassuming outward demeanor when combined with the character’s ruthless tendency to physically harm, torment, and eat others, proves extremely unsettling. However, this dynamic also serves as a major point of intrigue from the perspective of the audience. As viewers, we do not necessarily find ourselves rooting for Lecter at any one point in time, but we do find ourselves yearning to witness his hypnotic interactions and crisp intellect increasingly as the story unfolds. This encapsulates the power of great character development and, importantly, the utility of intrigue in cinema. This is especially true in portrayals of mental illness – at times, one can find themself at ease and unguarded when faced with a character or situation normally regarded as the personification of capricious evil. It is true that we often fear what we do not understand and the kind of cinema presented in The Silence of the Lambs offers us the ability to let that fear slowly slip away given the invitation to be empathetic towards Lecter. This is true despite its meaning we will become more comfortable in the presence of something that does tend to terrify us in real life.

There is some irony to be found in this fact, given the potential risks of such portrayals supporting the familiar stigmas associated with mental illness. Because the filmmakers and actors had the fortitude to tell the story in light of these risks, we are more likely to become intimately familiar with the person behind the pathology, their life-story, and all the ins and outs that led to them to where they stand today. In Lecter, we do not become familiar with his origin story per se in The Silence of the Lambs, but we are able to see things from his point of view in a way that shifts our perception of his capacity to in fact, be vulnerable. His mistreatment and abuse at the hands of the hospital administrator is likely the best example of this in the film. A line that perhaps summarizes the injustice and cruelty of solitary confinement best is delivered by Lecter, quoting from William Blake’s Auguries of Innocence (1863) in Red Dragon (2002): “A robin red breast in a cage puts all heaven in a rage”. (3, 4) Despite the robust depiction of his psycho- or socio-pathic tendencies throughout the film, we are given the opportunity to realize and understand a character as a patient and as a person first and foremost, and that is a meaningful thought experience audiences would do well to lean into more. That is to say that part of the value of the cinematic experience in these cases comes from viewing the character beyond the superficial impressions we are initially offered and returning to reflect on a more fundamental ethic. In the case of Lecter, this would mean viewing him as both a patient with a psychiatric illness as well as a jailed cannibalistic killer, while at the same time not forgetting that he is a human being who can and does suffer in ways we should care about.§

Suffering, as we have seen, can become a centerpiece in a character’s story. Suffering itself and the role of those tasked with mitigating it in psychiatric contexts provide much in the way for fascinating plot development on screen. Despite the popular appeal of the villainous in film, there are also several powerful examples of characters who treat the mentally ill, giving us the unique perspective of the healthcare professional. M. Night Shyamalan’s classic The Sixth Sense (1996) offers the viewer an interesting parallel to The Silence of the Lambs. (5) We become acquainted with the child psychologist, Malcolm Crowe, who, in contrast to Lecter, still has a medical license, patients under his care, and the will to help rather than to eat them. His character follows and treats a disturbed young boy who harbors the uncanny supernatural ability to see the dead in ghost form. Crowe appears as someone earnest in his work and commitment to the child’s well-being. It is entirely likely that child and adolescent mental health professionals stand to create the most change for patients in healthcare systems, given the nature and timing of their illness.** Many factors impact the plight of these patients, such as brain plasticity, stress response, time, and luck, as well as the impacts of successful and timely intervention on life trajectory. Moreover, considering trajectory here briefly, the polemicist Christopher Hitchens once used a visceral analogy for life as akin to being “expelled from your mother’s uterus as if shot from a cannon toward a barn door studded with old nail files and rusty hooks”. He went on to say that “it’s a matter of how you use up the intervening time in an intelligent and ironic way”. Bleak and cold as this analogy may seem††, there is an undeniable truth to the fact that life trajectories are consequential, and that we are all headed towards the same end at a rather startlingly steady pace. In this context, psychologists like Crowe work hard to pour a stable foundation to provide support for the rest of their young patients’ lives. Crowe’s commitment to his patient and the sheer complexity that the boy provides are immensely satisfying. This film is particularly unique as it offers a realistic perspective of the experience of caring for sick patients while suffering in one’s own personal life, a perspective that few lay viewers will have encountered.


Joker: the transformation and the setup

One criticism that The Sixth Sense endures is the blurring of the lines between reality and the supernatural in preparation for the breathtaking and truly unbelievable twist ending Shyamalan serves us. In contrast to this, a recent film that blows the doors to realistic depictions of mental illness wide open is Todd Phillip’s Joker (2019), starring Joaquin Phoenix as the makeup-laden villain. (1) What sets the film apart from previous incarnations of the character is the focus on a more realistic and lengthy transformation into depravity. We are first introduced to the timid and relatively unassuming Arthur Fleck, a mentally ill, impoverished, and unsuccessful stand-up comedian. During the film’s first act, we come to realize Fleck is a hard-working and committed caretaker and early on, his intentions provide little cause for concern. Comfort begins to set in, despite the viewer being somewhat aware of the twisting road they are travelling and an inkling of the final destination it portends. This comfort with the player, if not the stage, or this calm feeling before the storm, is a full credit not only to Phoenix and his command of the screen, but to the vision of writer director Todd Phillips.

Joker is set in a turbulent time for the city and society. An ominous garbage collector’s strike and the build-up of trash and debris symbolize the decay of normal interpersonal relations. Over the course of the film, the insults to Fleck, his dignity, and his health steadily accumulate. His story, over time, becomes one of suffering, and his prospects continue to steadily worsen. In all tragedies, we can identify a breaking point; in Joker, there are perhaps multiple. The loss of Fleck’s job, his social supports, and prescription medications in the face of mental illness prove to be devastating. Frustrations in both romantic, social, and familial life plague him almost continuously. Physical and emotional traumas are revealed to be driving forces behind the character’s development, both those in the past and in that unfolded on screen.

This storm of events culminates in two defining moments in the character’s transformation. The first, on the subway when three corporate employees intimidate and harass a lone female passenger. Fleck is perhaps as tortured by inaction as we are, and this moment unfortunately becomes overtaken by a symptom of one of his illnesses, emotional incontinence, otherwise known as pseudobulbar affect. His unrelenting laughter draws the attention of the men and a physical assault ensues, culminating in his ruthless execution of one of the attackers. In this scene, Fleck transitions from a clown down on his luck into a dark and unforgiving character. As the masterful Hildur Guðnadóttir’s Bathroom Dance plays ominously, Joker dances hypnotically, accepting the role of someone no longer shackled to the rules of a society that he has carefully obeyed for so long. We begin to appreciate the destruction and caprice he is suddenly capable of, and of which he develops an unquenchable thirst for. The dramatization of the transformation is impressive by any standard, but so too is the story-telling and screenwriting itself. It is perhaps the cumulative nature of the insults and the breaking points we anticipate that allows us to reflect on how easily such a person could be abandoned by society and how such evil may result.

The second seminal moment takes place near the end of the film, when Fleck appears on The Murray Franklin Show. The late-night host, with his clearly corrupt intentions, invites Fleck on presumably as a freak show attraction. Again, a calmer and seemingly benign Fleck presents himself initially. Had we watched this scene as a standalone without knowledge of his newfound homicidal tendencies and suicidal ideation, we may not make much of the initially bizarre interactions. Franklin, however, was unaware of just how sick his guest was, and after chastising him for misplaced jokes, the tempo of the scene shifts dramatically. Quickly, after admitting his misdeeds, Fleck questions the worth of the corporate rats in relation to his own and those in similar socio-economic positions. Almost childlike in the way he morally evaluates the society that he believes has in part created him, he admonishes its baseline etiquette and defends his killing spree. After forceful pushback from Murray, that which the viewer is tempted to see as irritating or at least ironic given the host’s transgressions, Fleck transforms into Joker amid the roar of the score. His eyes liquify, and he seems to tear up as his grin becomes more and more unstoppable; we are owned by Phoenix in this moment. Without any sense of concordance between emotion and expression, he revels in both the chaos he has created and the attention he is about to ensure. A yelling match and lecture on mental health and society occurs before Murray himself is executed on live television.


On violence, stigma, and medical advocacy in Joker

Much analysis of the themes and violence put forth by Joker has been completed by audiences and critics. Both Phoenix and Phillips have been criticized for attempting to normalize or glorify the actions of the homicidal character. Some have remarked that the movie makers and studio behind its release are acting immorally given the possibility of copycat attacks in an era of gun violence. In response, they have claimed that it is simply not up to artists, writers, or directors to decide levels of morality for the general population or viewers of their work. Of course, they are right. Movies are not real, in the same way that books and television shows are also fiction. Free expression, as with free speech, should be viewed as an absolute if it is going to be called free at all. It is no matter that the film is exceedingly dark, and a viewer may spend most of the two hours sitting somewhat uncomfortably. The arts are supposed to move us, and what a bore it would be if these moves were always in one concerted, predicable, comfortable, and uncontroversial direction.

Others have also taken issue with the film’s portrayal of mental illness and the unfounded link it makes to violence. Some have even commented on the elusiveness of an actual diagnosis in the case of Fleck. These criticisms land glancing blows at best. Those suffering from mental illness are no more likely to commit crime compared to members of the general public, but this does not make the population exempt from misbehaving. Implicit in such criticism is the idea that these stories should not be told, given the risks of glorification or stigmatization. There are several issues with this sort of criticism. First, outlawing stories of this kind would be a clear and present affront to the cherished sentiment of free expression in the arts, and for that reason, indefensible. Second, this line of thought willingly ignores the obvious benefits of adapting the story to serve purposes of self-reflection and societal reflection. The main point the film attempts to underscore is that the character is ill and has, over time, succumbed to several devastating insults. Joker, in essence, asks us to question whether the society Fleck lives in, or the reservoir holding these insults, shares any of the burden of his transformation. Indeed, some viewers may extrapolate certain stereotypes about mental illness and violence, but this is a very small price to pay for the larger seminar on compassion and introspection that the film provides to audiences intent on listening. Further, whether Fleck portrays an authentic medical presentation related to any of his illnesses seems beside the point if the filmmaker’s aim was to force viewers to ponder their own decency and compassion, and the impact of society on the vulnerable. A useful analogy here may be the case of films related to space or time travel. While not always based in the most accurate versions of our physical or scientific understanding of the world, these narratives are still valuable to viewers because they invite audiences to begin thinking about big scientific ideas, the future, or the point of life or existence itself. The science behind the depictions need not be wholly true for the film to meet these objectives.

Joker, at the end of the day, is a rollercoaster of experience. In terms of the violence or potential glorification of evil doers in cinema, the film is not unique; Hannibal Lecter also demonstrates these themes, as well as Michael Corleone in The Godfather Part I (1972) and Part II (1974) and Jack Torrance in The Shining‡‡ (1980). (6-8) Joker sets new heights in both the quality of presentation of the subject matter and the discomfort it creates, by forcing us to turn a critical eye on our own society and medical systems. The realistic and progressive nature of the transformation is surely unsettling, however this is a result of the potential for viewers to see it as a disturbing reality, not because it is immoral, per se. Similar to Lecter, we also find ourselves alternating between feeling sympathetic for, and then horrified by, Fleck; this is an artistic accomplishment on the part of the filmmakers. Additionally, the film has promoted discussion via controversy at times, around the topics of the disenfranchised in society, mental illness, and access to healthcare; this is perhaps ironic, but valuable and important. Moreover, this depiction is the role of the arts as perfectly intended, and a powerful example of effective medical advocacy in film.

Conclusions

In discussing the appeal of cinema as a medium in a 2009 broadcast interview for Inglourious Basterds, the writer-director Quentin Tarantino quipped that as an art form, movie making was singular in its ability to bring stories to life: “and music doesn't quite do that on its own. And novels don't quite do it and a painting doesn't quite do it. It does -- they do it their way, but in cinema, especially if you are in a theater and you are sharing the experience with a bunch of other people, so it's this mass thing going on, it is just -- it's just truly, truly thrilling§§”. (9) Tarantino here, was in effect articulating the idea that cinema has the unique ability to take the best parts of these mediums and package them in a way that defines storytelling in its purest and most reachable form. When faced with a hard-hitting screenplay, underlying message, and the right players on the stage, the thoughtful audience has no choice but to reflect deeply on the authenticity of the content.

In terms of its ability to convey medical themes and experiences in art, cinema is unmatched. An exhilarating and intense example of this lies in the onscreen adaptions of psychiatric illness and its treatment. Characters who deal with mental illness, whether they are viewed as good or bad, have something special to offer to us. They bequeath an emotional experience, a window into the very depths of a tortured mind, as well as the human experience that comes with that torture and its potential resolution. However sick or disturbing we may find it, perceiving these experiences can unlock doors to compassion, understanding, and self-reflection. Importantly, such experience may also allow us an appreciation for the great art, that maybe, just maybe, we did not know existed within us.




* Lecter is played by the renowned actor Anthony Hopkins in the film and despite being on screen for just over 16 minutes, captured the academy award for best actor.

Lecter pounced after healthcare workers removed his restraints to complete an electrocardiogram (ECG).

To the best of the author’s knowledge, this serves as the most prominent description of hemiglossectomy in the history of cinema.

§ Interesting, some may argue that Lecter in fact stands to suffer more in solitary confinement than most others given his wide-reaching and appreciable intelligence. We see this preyed upon in the film with punishment involving removal of his books or drawings from his jail cell.

** Such comparisons between medical specialties are fraught with complexity. It seems uncontroversial, however, to say that child and adolescent mental healthcare workers are providing interventions at a time and with an illness that will, for better or worse, dictate the terms of the next decades (at least in an appreciable number of cases).

†† Hitchens was celebrated for his ability to turn a clever phrase and did indeed end the point (during an impromptu street corner interview) by saying that one should also “try not to do anything ghastly to your fellow creatures

‡‡ While we may find ourselves rooting for these characters more or less at different times throughout the respective movies, they have all, to some extent, become adored and glorified by film audiences and pop culture. The point here is that this is despite the clear issues they provide from a moralistic standpoint whether derived from illness, the supernatural or their own worldly nature.

§§ Tarantino went on to say: “And if the movie is more than that, if there is a lot underneath, if there is more there, and you go out and you have a piece of pie and coffee and you talk about it and you find that there is more to talk about -- I mean, one of the things that is actually fun is if you go with somebody and they don't like a movie and you do and you start talking about it. And yet they start digging deeper and deeper in the movie, you are not really talking about a movie -- this is not like you don't like it -- you're realizing there is a lot there. I love -- that is one of the things I love about film criticism when it is really good, is just the digging deep.”


References

  1. Joker. 2019. [film] Directed by T. Phillips. Los Angeles: Warner Bros.
  2. The Silence of the Lambs. 1991. Directed by J. Demme. Los Angeles: Strong Heart/Demme Production.
  3. Blake, W. Auguries of Innocence. 1863.
  4. Red Dragon. 2002. Directed by B. Ratner. Los Angeles: Universal Pictures.
  5. The Sixth Sense. 1996. Directed by M. Night Shyamalan. Los Angeles: Hollywood Pictures.
  6. The Godfather Part I. 1972. Directed by F. F. Coppola. Los Angeles: Paramount Pictures.
  7. The Godfather Part II. 1974. Directed by F.F. Coppola. Los Angeles: Paramount Pictures.
  8. The Shining. 1980. Directed by S. Kubrick. Los Angeles: Warner Bros.
  9. Quentin Tarantino on Charlie Rose. 2009. Charlie Rose LLC. Transcript available: https://charlierose.com/videos/26959./li>

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