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International Perspectives
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On-Screen Portrayals of Mental Illness:

Extent, Nature, and Impacts
a b a
Jane Pirkis , R. Warwick Blood , Catherine Francis & Kerry
b
McCallum
a
Program Evaluation Unit, School of Population Health, The
University of Melbourne , Victoria, Australia
b
School of Professional Communication, The University of
Canberra , Canberra, Australia
Published online: 15 Aug 2006.

To cite this article: Jane Pirkis , R. Warwick Blood , Catherine Francis & Kerry McCallum (2006) On-
Screen Portrayals of Mental Illness: Extent, Nature, and Impacts, Journal of Health Communication:
International Perspectives, 11:5, 523-541, DOI: 10.1080/10810730600755889

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 Journal of Health Communication, 11:523–541, 2006
Copyright # Taylor & Francis Group, LLC
ISSN: 1081-0730 print/1087-0415 online
DOI: 10.1080/10810730600755889

On-Screen Portrayals of Mental Illness: Extent,

Nature, and Impacts

JANE PIRKIS
Program Evaluation Unit, School of Population Health, The University
of Melbourne, Victoria, Australia

R. WARWICK BLOOD
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School of Professional Communication, The University of Canberra,

Canberra, Australia

CATHERINE FRANCIS
Program Evaluation Unit, School of Population Health, The University
of Melbourne, Victoria, Australia

KERRY MCCALLUM
School of Professional Communication, The University of Canberra,
Canberra, Australia

This article reviews the published literature on the extent, nature, and impacts of por-
trayal of mental illness in fictional films and television programs. The literature sug-
gests that on-screen portrayals are frequent and generally negative, and have a
cumulative effect on the public’s perception of people with mental illness and on the
likelihood of people with mental illness seeking appropriate help. The article concludes
that there is a need for the mental health sector and the film and television industries to
collaborate to counter negative portrayals of mental illness, and to explore the potential
for positive portrayals to educate and inform, as well as to entertain.

It has been demonstrated that community attitudes toward mental illness generally
are negative and based on erroneous beliefs (Jorm, 2000). Such attitudes stigmatise
those with mental illness and reduce their likelihood of seeking appropriate help
(U.S. Department of Health and Human Services, 1999). There is evidence that non-
fiction media may have a role in perpetuating these negative attitudes by ‘‘framing’’
people with mental illness as violent or dangerous (Edney, 2004; Francis, Pirkis,
Dunt, & Blood, 2001) but that such media also may be harnessed to increase the
public’s ‘‘mental health literacy’’ via targeted campaigns or documentaries (Clare,
1992; Fonnebo & Sogaard, 1995; Medvene & Bridge, 1990; Paykel, Hart, & Priest,
1998; Paykel et al., 1997; Sogaard & Fonnebo, 1995; Vaughan & Hansen, 2004;
Wober, 1989).

Address correspondence to Jane Pirkis, Program Evaluation Unit, School of Population

Health, The University of Melbourne, Victoria 3010, Australia. E-mail: j.pirkis@unimelb.
edu.au

523
 524 J. Pirkis et al.

Less is known about the role of fictional films and television programs in shap-
ing community attitudes about mental illness. It might be expected that they could
exert an even more powerful influence because of their broad reach and appeal
(Wahl, 2001). Some would argue that if this is so, the film and television industries
have a responsibility to minimise negative portrayals and maximise opportunities to
educate the public. Others would contend that this is not the concern of the enter-
tainment industry. There is a need to consolidate the evidence on the extent, nature,
and impacts of portrayal of mental illness in fictional films and television programs,
in order to inform this debate.
The current paper1 draws on the published literature to answer three research
questions:
1. What is the extent and nature of portrayal of mental illness in fictional films and
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television programs?
2. Is there evidence that portrayal of mental illness in fictional films and television
programs can have harmful effects?
3. Is there evidence that portrayal of mental illness in fictional films and television
programs can have positive effects?

Method
Searches were conducted of key reference databases2 (from the year of their incep-
tion to January 2005) and the Internet, using search terms relating to mental illness
and fictional media.3 Potentially relevant articles were retrieved, and their reference
lists were scanned for further salient texts. Later articles that cited the original arti-
cles4 also were retrieved.
Articles were classified according to the particular research question they poten-
tially informed, and the findings from the individual studies were then synthesised in
order to formulate conclusions about the overall body of the evidence relating to
each of the three research questions. Each article was considered in terms of study
design, in order that the methodological strengths and weaknesses of given designs
could be taken into account in the appraisal process. Table 1 shows that all three
research questions rely heavily on evidence from small-scale descriptive studies,
anecdotal reports, and commentaries, but a number of larger-scale descriptive and
experimental studies have been conducted that inform the questions regarding the
extent of portrayal and evidence for harmful effects. Far fewer studies of this kind
have been conducted in the area of potential positive effects.
1
The article is based on a more comprehensive report, which is available from the authors
on request (Pirkis, Blood, Francis, & McCallum, 2005).
2
Medline, Psychinfo, Australian Public Affairs, Cambridge Scientific Abstracts (Com-
munication Studies, SAGE, Sociological Abstracts), EBSCOhost (Communication and Mass
Media Complete, Academic Search Premier), Dissertation Abstracts, WARC (World Adver-
tising Research Center), and Emerald Full Text (Health, Sociology, Social Policy).
3
MENTAL HEALTH (MENTAL HEALTH PROMOTION, MENTAL HEALTH
EDUCATION, MENTAL HEALTH LITERACY) or MENTAL ILLNESS (MENTAL
DISORDER , PSYCHIATR , DEPRESSION, SCHIZOPHRENIA, ANXIETY, MOOD
DISORDER , OBSESSIVE-COMPULSIVE DISORDER , EATING DISORDER ,
ANOREXIA, BULIMIA); and MEDIA (MEDIA, TELEVIS , FILM , MOVIE , PLAY ).
4
Identified from the ISI Web of Science Citation Index.
 Downloaded by [Northeastern University] at 16:21 03 November 2014

Table 1. Articles retrieved in literature review, by research question and source=strength of evidence
WHAT IS THE EXTENT AND NATURE OF PORTRAYAL OF MENTAL ILLNESS IN FICTIONAL
FILMS AND TELEVISION PROGRAMS?

Source of evidence Strength of evidence Articles

Small-scale descriptive studies,
anecdotal reports, and commentaries
Limited to examinations of single films or small
numbers of films, or discussions of particular
themes that draw on examples of films chosen
by unsystematic means. Some are not much
more than opinion pieces, while others employ
formal content analytic techniques. Have the
advantage of depth, permitting detailed
consideration of film(s) in question, but suffer
Anderson, 2003; Byrne, 2000; Fearing, 1946,
1947; Flory & Darton, 2004; Gordon, 1994;
Greenberg, 1992, 2000, 2003a, 2003b; Grinfeld,
1998; Hyler, Gabbard, & Schneider, 1991;
Jakab, 2001; March, 1999; Pies, 2001; Quadrio,
1996; Rosen & Walter, 2000a, 2000b; Rosen,
Walter, Politis, & Shortland, 1997; Schneider,
1987; Sieff, 2003; Sleek, 1998; Tam, 2002;

525
from lack of breadth, since they focus on a
limited range of stimuli.
Larger-scale descriptive studies Systematic analyses of samples of films or
television programs, typically identified by time
period or by official listings. Tend to employ
explicit analytic frameworks, involving a
combination of qualitative and quantitative
methods and utilising multiple coders who have
systematically, repeatedly, and critically viewed
each film or television program to identify
themes and code content.
Wedding & Niemiec, 2003
Beveridge, 1996; Condren & Byrne, 2000a, 2000b;
Diefenbach, 1995, 1997; Diefenbach, Burns, &
Schwartz, 1998; Fleming & Manvell, 1985;
Gabbard, 2001; Gabbard & Gabbard, 1999;
Schneider, 1977; Signorielli, 1989; Trott-Paden,
2002; Wahl, Wood, Zaveri, Drapalski, &
Mann, 2003; Wahl, 1995; Wilson, Nairn,
Coverdale, & Panapa, 1999a, 1999b, 2000

(Continued)
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Table 1. Continued

IS THERE EVIDENCE THAT PORTRAYAL OF MENTAL ILLNESS IN FICTIONAL FILMS AND TELEVISION PROGRAMS
CAN HAVE HARMFUL EFFECTS?

Source of evidence Strength of evidence Articles

Small-scale descriptive studies,
anecdotal reports, and
commentaries
Typically involve analysis of the impact of a single
film or television program on an individual or
small group of individuals. Provide some
insight into potential harmful effects of
negative portrayals, but suffer from a reliance
on subjective interpretation and=or lack of
generalisability.
Anderson, 2003; Byrne, 2000; Gabbard, 2001;
Grinfeld, 1998; Hyler et al., 1991; March, 1999;
Pies, 2001; Rosen et al., 1997; Signorielli, 1989;
Wahl, 1992, 2001; Walker, 1993; Wedding &
Niemiec, 2003

526
Larger-scale descriptive studies
involving cross-sectional surveys
and focus groups
Involve cross-sectional surveys or focus groups, Clothier, Freeman, & Snow, 2001; Granello &
designed to elicit information from respondents Pauley, 2000; Granello, Pauley, & Carmichael,
about their knowledge of and attitudes toward 1999; Lauber, Nordt, Falcato, & Rossler, 2003;
mental illness and the sources of these attitudes Lopez, 1991; Nunnally, 1957; Philo, 1996a,
and knowledge. Provide valuable data on the 1996b
extent to which the media has an influence on
community attitudes toward mental illness,
but criticised for reliance on self-report,
inability to determine whether media exposure
preceded knowledge about, or attitudes
toward, mental illness, and failure to
distinguish between different types of media
and to consider influence of non-media sources
of information.
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Larger-scale experimental studies
Assess attitudes toward mental illness in a group Domino, 1983; Sancho-Aldridge & Gunter, 1994;
of participants after they have viewed a Schill, Harsch, & Ritter, 1990; Wahl & Lefko
particular film or television program. The wits, 1989; Walter, McDonald, Rey, & Rosen,
weakest have assessed attitudes of a single 2002
group post- (but not pre-) viewing, and have
not involved any sort of control group; the
strongest have used before-and-after designs
and have employed control conditions.
Collectively, these studies provide sound
insights into the impact of films and television
programs on beliefs and attitudes toward
mental illness, although some have been
criticised for relying on samples from which
generalisations cannot be made.

IS THERE EVIDENCE THAT PORTRAYAL OF MENTAL ILLNESS IN FICTIONAL FILMS AND TELEVISION PROGRAMS CAN HAVE
POSITIVE EFFECTS?

527
Source of evidence Strength of evidence Articles

Small-scale descriptive studies,
anecdotal reports, and commentaries
Larger-scale descriptive studies
involving cross-sectional surveys
Limited to descriptions and commentaries. None
provides systematic evaluative evidence for
effectiveness of given measures, but some offer
anecdotal support for their impacts.
Involve surveys investigating the sources of
mental health promotion information
(including help-seeking information) among
people with mental illness. Provide useful
insights, but do not always explicitly examine
the role of fictional media, and offer limited
generalisability.
Berg-Cross, Jennings, & Baruch, 1990; Bhugra,
2003; Byrne, 2003; Clare, 1992; Fitzgerald &
Ebert, 2004; Greenberg, 2003a, 2003b; Hesley &
Helsley, 1998; Hyler, 1999; Mark, 2003; Oye
bode, 2003; Quadrio, 2004; Robinson, 2003;
Rosen et al., 1997; Wedding & Boyd, 1999;
Wedding & Niemiec, 2003
Kato, Yamanaka, & Kaiya, 1999; MacHaffie,
2002
 528 J. Pirkis et al.

What Is the Extent and Nature of Portrayal of Mental Illness in Fictional Films
and Television Programs?
Portrayal of People With Mental Illness
Many studies have explored the on-screen portrayal of people with mental illness. In
the case of television, investigators in different countries have found portrayal to be
extensive. In the United Kingdom, Condren and Byrne (2000a, 2000b) found 28
characters with psychiatric problems in 22 episodes of Casualty; and Rose (1998)
reported that 4% of prime-time coverage involved material relevant to mental
health. In the United States, Deifenbach (1995, 1997) found that 2.2% of speaking
characters on prime-time programs exhibited some evidence of a mental illness;
Wahl and Roth (1982) and Signorielli (1989) observed that the proportion of all
prime-time shows that involved a passing or major mental illness theme was one
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third and one fifth, respectively; March (1998) found that during a 2-week period
there were more than 50 programs that featured mental health themes; and Cassata,
Skill, and Boadu (1979) found that mental illness was the health problem most likely
to affect characters in 13 daytime soap operas. In New Zealand, Wilson, Nairn,
Coverdale, and Panapa (2000) determined that half of all children’s programs (and
80% of cartoons) broadcast in a given week contained references to mental illness.
Fewer studies have quantified the numbers of films with mental illness content,
but there are some examples. For instance, Wahl (2003) found that of 49 children’s
films released in 2000–2001 and available for study, 12 (24%) contained a character
with a mental illness. Likewise, Lawson and Fouts (2004) found that of 34 films
produced by Disney between 1937 and 2001 and available on video, 85% contained
verbal references to mental illness and 21% of the main characters were referred to as
mentally ill.
Beyond quantity, much work has been done on the quality, or nature, of por-
trayal. Overwhelmingly, studies in this area have shown that such portrayal is nega-
tive, and perpetuates stereotypes about mental illness. Various ‘‘framing’’ techniques
are used to indicate that characters with a mental illness are different from other
characters. Filmic devices such as the individual point of view, close-up shots, discor-
dant music, atmospheric lighting, setting selection, and scene juxtapositions are
frequently employed (Hyler, Gabbard, & Schneider, 1991; McDonald & Walter,
2001; Rose, 1998; Sieff, 2003; Wilson, Nairn, Coverdale, & Panapa, 1999a). Pejorat-
ive language—e.g., terms like ‘‘crazy,’’ ‘‘psycho,’’ ‘‘deranged,’’ and ‘‘loony’’—is
often used by other characters in reference to the character in question (Goldstein,
1979; Wahl, Wood, Zaveri, Drapalski, & Mann, 2003; Wilson et al., 2000). The char-
acters themselves often are given distinctive and unattractive features, like rotting
teeth or unruly hair (Wilson et al., 2000).
The negative portrayals have been classified by Hyler and colleagues (1991) into
the following stereotypes:
. The homicidal maniac: The most commonly cited negative stereotype perpetuated
by films and television programs is that people with a mental illness are aggressive
and dangerous to others or themselves. Numerous studies have shown that violent
acts are far more likely to be committed by on-screen characters with mental ill-
ness than by others characters, and at a rate much higher than occurs in real life
(Condren & Byrne, 2000a, 2000b; Diefenbach, 1995, 1997; Fruth & Padderud,
1985; Goldstein, 1979; Philo, McLaughlin, & Henderson, 1996; Rose, 1998; Wahl,
2003; Wahl & Roth, 1982; Wilson et al., 1999a, 1999b). Hyler and colleagues
 On-screen Portrayals of Mental Illness 529

(1991) provide classic film examples of this stereotype in their descriptions of the
‘‘homicidal maniacs’’ in films like The Maniac Cook (1909), Psycho (1960), and
The Exorcist (1973). Philo and colleagues (1996) discuss similar examples from
television, including an estranged husband in the British soap opera Brookside,
who inveigles his way back into his wife’s life by charming her neighbours, then
threatens to kill her, her children, and himself.
. The rebellious free spirit: Some commentators have observed that in both adult
and children’s films, eccentric, different, or free-spirited characters often are
labelled as mentally ill, and inappropriately treated (often incarcerated). Early
examples occur in The Maniac Chase (1904) and The Escaped Lunatic (1904),
and later ones in One Flew Over the Cuckoo’s Nest (1975), Dumbo (1941), Beauty
and the Beast (1992), and Mary Poppins (1964). The outcome is typically one
where justice is served, and the character’s sanity is vindicated and he or she is wel-
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comed back into the community, sending a message that characters who are
‘‘nice’’ cannot be mentally ill, and vice versa (Beveridge, 1996; Hyler, 1988; Hyler
et al., 1991; Wedding & Niemiec, 2003).
. The enlightened member of society: This stereotype depicts people with mental ill-
ness as capable of creating a utopian society. This is evident in King of Hearts
(1968), which tells the story of a group of fun-loving, pacifist patients who are
released from an asylum by a soldier during World War II, only to witness the
futile mass loss of lives in a major battle and return to the asylum in preference
to remaining in society. Although this image is less negative than some others,
it fosters misconceptions about mental illness (Hyler et al., 1991).
. The female patient as seductress: Under this stereotype, females with mental illness
are depicted as nymphomaniacs with seductive powers that can destroy men. An
example of this stereotype occurs in Dressed to Kill (1980), in which the female
protagonist tries to seduce her psychiatrist, then has a liaison with another man
whom she later discovers has a sexually transmitted disease, and is ultimately mur-
dered. Such depictions stigmatise women with mental illness, suggesting that their
problems are of their own making, and that they deserve punishment, rather than
treatment (Hyler et al., 1991).
. The narcissistic parasite: This stereotype sees people with mental illness depicted
as overprivileged, self-obsessed, and overconcerned with their trivial problems,
and occurs in Lovesick (1983) (Hyler et al., 1991).
. The zoo specimen: This stereotype depicts people with mental illness as dehuma-
nised, without rights, and open to unqualified scientific observation. In Bedlam
(1946), for example, a woman enters an asylum so she can watch the ‘‘crazies,’’
and in The Snake Pit (1948) the lead female character, who is an inpatient in a
psychiatric facility, likens her fellow patients to animals in a zoo (Hyler et al.,
1991).

Two other negative stereotypes that emerge from empirical studies but do not fea-
ture in Hyler and colleagues taxonomy are the simpleton and the failure or victim. The
simpleton occurs frequently in children’s films and television programs, and lacks
comprehension, appears lost, and behaves in illogical, irrational, or comic ways (Hyler
et al., 1991; Wahl, 1995, 2003; Wilson et al., 1999b). The failure or victim often is unre-
sponsive to treatment and incapable of making a meaningful contribution to society.
Several studies have shown that people with mental illness are more likely than other
characters to be portrayed as victims (e.g., of crime or exploitation), as having few
 530 J. Pirkis et al.

skills, as being unemployed, or as having a poor quality of life (Diefenbach, 1995,

1997; Gerbner, 1995; Signorielli, 1989; Wahl et al., 2003; Wilson et al., 1999b).
On-screen portrayals of mental illness also often are presented in a manner that
fosters misconceptions about specific disorders. First, they create the impression that
some quite rare disorders are in fact common, because they make for good visual
melodrama. Key examples are dissociative identity disorder, gender identity
disorder, and anterograde amnesia, featured in films like The Three Faces of Eve
(1957), Psycho (1960), and Memento (2000), respectively (Diefenbach, 1995,
1997; Fearing, 1946; Greenberg, 2003b). Second, they present misleading infor-
mation about particular disorders, most notably schizophrenia. Audiences viewing
Me, Myself and Irene (2000), for example, could be forgiven for leaving the cinema
with the view that people with schizophrenia have split or multiple personalities
(some of which are violent) (Byrne, 2000).
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Although negative stereotypes dominate, some caution should be exercised in

assuming uniformity in portrayals over time. The relationships between televisual
and filmic images of mental illness and the contexts of mental health care policy
change over time (Cross, 2004), and there is evidence of some more sympathetic por-
trayals in recent times (Byrne, 2000; Greenberg, 2003b; Henderson, 1996; Rosen,
Walter, Politis, & Shortland, 1997; Sieff, 2003; Tam, 2002; Wahl, 1995). For
example, the films Cosi (1996) and An Angel at My Table (1990) have been
applauded for presenting people with mental illness as real characters, and even as
role models (Rosen et al., 1997) and the British television series Takin’ Over the
Asylum has been acclaimed for depicting people with mental illness as articulate
and witty (Henderson, 1996; Philo, 1996b). That said, commentators do not always
agree on what constitutes positive portrayal. For example, Sieff (2003), Tam (2002),
Byrne (2000), and Flory and Darton (2004) have argued that the portrayals of math-
ematical genius John Nash in A Beautiful Mind (2002) and piano virtuoso David
Helfgott in Shine (1998) were constructive, demonstrating that some people with
mental illness achieve great heights in their chosen professions. By contrast,
Greenberg (2003b), Anderson (2003), Wedding and Niemiec (2003), Hyler (1988),
and Rosen and Walter (2000a; 2000b) have criticised the same films for implying that
those with mental illness will only succeed if they are exceptionally talented.

Portrayal of Mental Health Professionals

Considerable interest has been shown in the portrayal of mental health profes-
sionals—primarily psychiatrists—on the big and small screen. Such portrayal is
extensive, as is evidenced Gabbard and Gabbard’s (Gabbard, 2001; Gabbard &
Gabbard, 1999) identification of more than 400 films that featured some kind of
psychotherapist at work, and Diefenbach’s observation that 10 (9%) of 107 U.S.
prime-time television programs in a one-week sample involved a mental health
professional. These and other authors have suggested a number of reasons for the
popularity of on-screen psychiatrists. They hold much fascination for the general
public, and consequently their inclusion in a plot line augurs well for box office or
ratings success. Additionally, they are useful as a narration device, allowing the
viewer to be privy to the internal thoughts of key characters (Gabbard, 2001;
Gabbard & Gabbard, 1999; Greenberg, 1992, 2003a).
The nature of on-screen portrayals of mental health professionals has been
extensively studied. Schneider (1977, 1987) developed a taxonomy that categorises
on-screen mental health professionals into three types:
 On-screen Portrayals of Mental Illness 531

. Dr. Dippy, who is a comic character—bumbling, idiotic, incompetent, often

Austrian-accented and sometimes sanctimonious. Schneider took the name of this
type from Dr. Dippy’s Sanitorium, which was released in 1906. Other examples of
Dr. Dippy occur in the films The Front Page (1931), Harold and Maude (1972),
and Deconstructing Harry (1997) and in television comedy series like I Dream of
Jeannie, The Bob Newhart Show, and Frasier and various cartoons (Clara, 1995;
Diefenbach, Burns, & Schwartz, 1998; Greenberg, 1992; Grinfeld, 1998; Jakab,
2001; Macfarlane, 2004; Pies, 2001; Schneider, 1977, 1987, 1990; Turkat, 1977;
Walter, 1992).
. Dr. Evil, who is a sinister scientist—often outwardly charming but inwardly mal-
evolent, manipulative, and trust breaching. One of the earliest film examples of
Dr. Evil can be found in The Cabinet of Dr. Caligari (1919), in which the charac-
ter after whom the film is named is a malevolent psychiatrist who appears to be
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confining patients against their will (in fact, in a final twist, the character turns
out to be an invention of the narrator, who is an involuntary inpatient). Later
examples include Dressed to Kill (1980) in which the protagonist is presented as
a deranged psychiatrist with gender identity issues who violently attacks women
(Diefenbach et al., 1998; Fleming & Manvell, 1985). Still other examples can be
found in Spellbound (1945), Nightmare Alley (1947), and One Flew Over the
Cuckoo’s Nest (1975) (Clara, 1995; Diefenbach et al., 1998; Greenberg, 1992;
Macfarlane, 2004; McDonald & Walter, 2001; Pies, 2001; Schneider, 1977, 1987).
. Dr. Wonderful, who is attractive, selfless, dedicated, always available (to the
extent that he=she may transgress boundaries), and extraordinarily skillful (e.g.,
often effecting dramatic cures by honing in on a single traumatic event occurring
in the patient’s past [Gordon, 1994]). He=She often appears not to have a life out-
side work. Antwone Fisher (2002) provides a Dr. Wonderful in the form of Dr.
Davenport, who is likeable and warm, agrees to see Antwone (a naval officer with
an anger management problem) on his own time to circumvent the Navy’s restric-
tion on the number of therapeutic sessions available, and provides a cathartic cure
by suggesting that Antwone make contact with his estranged mother (Macfarlane,
2004). Similarly, Dr. Melfi represents Dr. Wonderful in the television series The
Sopranos. Dr. Melfi is readily available to the lead character (Mafia boss Tony
Soprano), and continues to see him and work through his problems for more than
4 years, despite this sometimes compromising her professional ethics, threatening
her career, jeopardising her marriage, and even endangering her life (Greenberg,
2000, 2003b). The literature cites other examples of Dr. Wonderful in Captain
Newman MD (1963) and The Three Faces of Eve (1957) (Clara, 1995; Diefenbach
et al., 1998; Greenberg, 1992; Macfarlane, 2004; McDonald & Walter, 2001; Pies,
2001; Schneider, 1977, 1987).

Schneider’s (1977, 1987) taxonomy has been widely quoted and provides a
framework within which to consider film and television portrayals of mental health
professionals. Other authors have used alternative nomenclature or created different
categories that can largely be ‘‘rolled up’’ into Schneider’s (1997, 1987) classification
(Pies, 1991; Fearing, 1947; Wedding & Niemiec, 2003). Only two truly additional
subtypes have emerged. One is the seductive female therapist, dubbed Dr. Sexy.
Dr. Sexy is typically deprofessionalised and her sexuality is presented as integral
to the patient–therapist relationship, with the resultant message that any positive
outcomes occur more as a result of the relationship than as a result of her
 532 J. Pirkis et al.

competency as a mental health professional (Fearing, 1947; Gabbard, 2001;

Macfarlane, 2004; Quadrio, 1996; Sleek, 1998; Trott-Paden, 2002; Wedding &
Niemiec, 2003). The other is the mental health professional as ‘‘rationalist foil.’’ This
therapist typically comes up with scientific arguments and psychodynamic formula-
tions to explain supernatural phenomena, only to be proved wrong as the plot unfolds
(Gabbard, 2001; Gabbard & Gabbard, 1999).
To summarise, on-screen mental health professionals generally have been
depicted negatively. The Dr. Dippys, Dr. Evils, Dr. Sexys, and the mental health
professionals as ‘‘rationalist foils’’ have all been set up to be ridiculed, feared, or
otherwise treated with contempt. Even the Dr. Wonderfuls, who might be admired
for their professional skills and devotion, have fatal flaws like overinvolvement with
their patients and shambolic personal lives. Based on his previously mentioned
study of more than 400 films, Gabbard (cited in Grinfeld, 1998) claimed that in
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the past 30 years only three films have portrayed mental health professionals sym-
pathetically–I Never Promised You a Rose Garden (1977), Ordinary People (1980),
and Good Will Hunting (1997). Even the latter of these is open to debate, since
Gabbard himself and others (e.g., March, 1999) have observed that the therapist
uses unorthodox methods (e.g., ‘‘roughing up’’ his young patient) that would have
ethical and legal sequelae if they were used in real life. Diefenbach and colleagues
(1998) present a slightly more positive picture in the case of television, observing
that at least some television dramas offer accurate, sympathetic images of the
mental health professional. This may be consistent with the argument of Pies
(2001) that television series can present the complexities of mental health profes-
sionals more readily than films because of the greater on-screen time available
for character development.

Portrayal of Treatments for Mental Illness

The portrayal of treatments for mental illness in fictional films and television pro-
grams is interesting for both its exclusions and its inclusions. Typically, only those
treatments that serve a filmic purpose are depicted. So, for example, psychotherapy
is common, for the reason noted earlier—that is, it provides opportunities for the
audience to learn what is going on inside the head of the character undergoing treat-
ment. Likewise, electroconvulsive therapy (ECT) is common because of its melo-
dramatic potential. By contrast, drug therapies, which do not further the plot and
are not visually interesting, rarely feature. In fact, Gabbard and Gabbard (Gabbard,
2001; Gabbard & Gabbard, 1999) observed that in the sample of more than 400 films
that they studied, none depicted a psychiatrist prescribing medication.
No studies have systematically examined the portrayal of on-screen psycho-
therapy per se, although the authors of some of the above studies of the portrayal
of mental health professionals have made passing reference to the nature of the
psychotherapy being provided. Typically, these comments relate to the lack of
realism in the portrayal, noting either that the therapy involves a breach of ethics
or that it involves an unfeasibly speedy identification of a repressed traumatic event
that, once uncovered, results in a total reversal of symptoms.
By contrast, several studies have examined the way in which ECT is depicted on
the screen. The largest of these studies is that of McDonald and Walter (2001), who
observed a range of inaccurate, negative presentations of ECT in 20 films depicting
such treatment. Electroconvulsive therapy was most commonly prescribed as a treat-
ment for antisocial behaviour, and then as a treatment for various psychotic
 On-screen Portrayals of Mental Illness 533

illnesses; consent rarely was sought and often over-ridden; administration never
involved the use of a general anaesthetic (the recipient typically was shown as fully
conscious and terrified); treatment always was given bilaterally; the most common
side-effect was metamorphosis into a zombie; and few films showed any positive
outcome. In a similar vein, Greenberg (2003b) discusses the lack of verisimilitude
in the portrayal of ECT in A Beautiful Mind (2002), noting that it did not mirror
the real-life experiences of the main character (John Nash, a mathematical genius
with schizophrenia). In particular, Greenberg observes that in the film, Nash’s wife
was witness to his experiencing dramatic convulsions during the administration of
ECT, which, in actuality, did not occur.

Is There Evidence that Portrayal of Mental Illness in Fictional Films

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and Television Programs Can Have Harmful Effects?

Perpetuation of Stigma Associated With Mental Illness
Numerous commentators have observed that representations of mental illness in fic-
tional films and television programs can negatively influence public images of mental
illness, which in turn can perpetuate stigma (Anderson, 2003; Grinfeld, 1998; Hyler
et al., 1991; Rosen et al., 1997; Signorielli, 1989; Wahl, 1992, 2001).
These observations are supported by the findings of various studies that have
explored sources of community attitudes toward mental illness. Typically, these stu-
dies have found that the media in general are perceived as the root of such attitudes
(over and above real-world experiences); that entertainment media may exert a more
powerful influence than news media; and that those who cite electronic media as
their primary source of information have less tolerant attitudes toward those with
mental illness than those who cite other sources (Clothier, Freeman, & Snow,
2001; Granello & Pauley, 2000; Granello, Pauley, & Carmichael, 1999; Lauber,
Nordt, Falcato, & Rossler, 2003; Lopez, 1991; Philo, 1996a). Granello and collea-
gues (1999) found that those who cited the electronic media as their main source
of information were more likely than others to have authoritarian and socially
restrictive views about people with mental illness, and were less likely to view moves
toward community treatment in a positive light—findings echoed in the study by
Lopez (1991). Granello and colleagues (1999) demonstrated a dose-response effect,
whereby the strength of negative attitudes increased as a function of amount of
exposure to films or television programs, but this finding was not supported by
Lauber and colleagues (2003), who found that amount of exposure was less impor-
tant than perceived realism. Lauber and colleagues (2003) found that an interest in
the media was predictive of respondents being unable to correctly recognise a person
described in a vignette as having schizophrenia, and instead considering them to be
‘‘in crisis.’’ Participants in focus groups conducted by Philo (1996a) commonly held
negative beliefs and made frequent references to films like The Silence of the Lambs
(1991), Psycho (1960), and Fatal Attraction (1987) and television soap operas like
Coronation Street and Brookside as the source of these beliefs. Even medical stu-
dents, who presumably had access to more accurate information about mental illness
and its treatment, held erroneous beliefs about ECT on the basis of film portrayal
according to the findings of a study by Clothier and colleagues (2001).
Results from relevant studies that have examined the impact of specific films or
television programs on attitudes toward mental illness also point in the same direction.
Domino (1983) found that students who viewed One Flew Over the Cuckoo’s Nest
 534 J. Pirkis et al.

(1975) demonstrated less positive attitudes toward mental illness than those
who did not, and that these attitudes did not dissipate over time, even in the face
of more positive screen portrayals. Likewise, Wahl and Lefkowits (1989) found
that those who viewed Murder: By Reason of Insanity (1985) were more likely to
hold negative attitudes towards mental illness than their counterparts who saw
Murder on the Orient Express (1974), regardless of whether the former film
included a trailer containing educative information. Medical students’ attitudes
toward ECT were strongly influenced by viewing the film clips in a study by Walter,
McDonald, Rey, and Rosen (2002) to the extent that the proportion who indicated
they would try to dissuade a family member or friend from having ECT increased
by 150% from previewing to postviewing. The only study that is at odds with this
body of evidence is that of Sancho-Aldridge and Gunter (1994), which found no
evidence to support the hypothesis that watching Shrinks resulted in misconceptions
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or stereotypical views.

Impacts on Help-seeking Behaviour by People With Mental Illness

A number of authors have commented that one of the by-products of negative por-
trayals of mental health professionals and mental health treatments in fictional films
and television programs may be a reluctance on the part of viewers with mental
health problems to seek or continue treatment (Gabbard, 2001; Hyler et al., 1991;
March, 1999; Rosen et al., 1997; Signorielli, 1989; Wahl, 2001; Walker, 1993;
Wedding & Niemiec, 2003). Gabbard (2001) and Pies (2001), for example, quote
examples of patients of their own revoking their consent for ECT after seeing One
Flew Over the Cuckoo’s Nest (1975), despite reassurances that the method depicted
in the film is not consistent with current practice. Some commentators have
expressed concern that this may be a particular problem for certain groups. For
example, Byrne (2000) observes that Me, Myself and Irene (2000), with its impli-
cation that schizophrenia equates to a violent split personality, misinforms those it
specifically targets—15-24-year-olds with the highest incidence of schizophrenia.
There is less evidence from scientific studies regarding impacts on help-seeking
behaviour than there is on perpetuation of stigma, but one study provides some
insights. Schill, Harsch, and Ritter (1990) found that participants’ beliefs were affec-
ted by watching Lovesick (1983), which involves a male psychoanalyst unethically
acting upon his feelings for a female patient. Specifically, the participants were more
accepting of intimacy between mental health professionals and patients. Such beliefs
could conceivably lead to erroneous expectations about what might be likely to
occur in therapy, and might therefore influence treatment decisions of those with
mental illness.

Is There Evidence That Portrayal of Mental Illness in Fictional Films

and Television Programs Can Have Positive Effects?
Educating Trainee Mental Health Professionals
A number of authors have considered the potential of fictional films and television
programs as educational resources for trainee mental health professionals. These
authors are divided.
Some argue that films and television programs can be an entertaining way of
teaching, offering realistic depictions of people with mental illness, and their experi-
ences of symptoms, treatment, and stigmatisation (Bhugra, 2003; Byrne, 2003; Mark,
 On-screen Portrayals of Mental Illness 535

2003; McCullough & Osborn, 2004; Oyebode, 2003). The most extensive work in this
area is that of Robinson (2003), whose book, Reel Psychiatry: Movie Portrayals of
Psychiatric Conditions, illustrates DSM-IV-TR diagnoses with characters from films,
and explicitly discusses the degree of accuracy of the given portrayal. This has
received positive reviews (Fitzgerald & Ebert, 2004; Quadrio, 2004), but has not been
formally evaluated.
Others fear that the overwhelming array of negative portrayals of people
with mental illness, mental health professionals, and mental health treatments
may do more harm than good. Greenberg (2003a, 2003b), for example, warns
that such teaching tools should not be regarded as a substitute for real-world
experience.

Encouraging Help-seeking Behaviour in People With Mental Illness

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Two studies have explored the potential role of films and television in promoting
help-seeking behaviour among people with mental illness, and their findings
are equivocal. On the one hand, MacHaffie (2002) found that health promotion
information provided by health professionals far outweighed the impact of any
information provided by the media. On the other hand, Kato, Yamanaka, and
Kaiya (1999) reported that of the different forms of media that were likely to
motivate help-seeking behaviour, television programs were among the top two
(second only to books).

Providing an Adjunct to Conventional Therapy for People With Mental Illness

Several authors have noted the potential benefits of using fictional films (or tele-
vision programs) as an adjunct to conventional therapy, including introducing
patients (and family members) to specific disorders, creating a therapeutic alliance
between therapist and patient, and helping patients work through problems by
reframing issues, providing role models, offering hope and encouragement, trigger-
ing emotional responses, improving communications, and prioritising values
(Berg-Cross, Jennings, & Baruch, 1990; Hesley & Helsley, 1998; Wedding & Boyd,
1999; Wedding & Niemiec, 2003). Various resources have been made available,
including a book by Hesley and Hesley (1998) entitled Rent Two Films and Let’s Talk
in the Morning: Using Popular Movies in Psychotherapy, which presents an in-depth
listing of films that might be used in therapy, detailing each in terms of the way it
might be used and the type of patient who might benefit. The Association of Direc-
tors of Medical Student Education in Psychiatry has published a similar listing, orga-
nised by diagnosis (Wedding & Niemiec, 2003).
There is an acknowledgment that ‘‘cinematherapy’’ is unlikely to work for all
patients, since it requires a certain level of sophistication on the part of both the
mental health professional and the patient (Wedding & Niemiec, 2003). In addition,
it has been suggested that it will be more appropriate in cases where the patient is
dealing with a specific issue that the mental health professional wants to expand
upon, and the mental health professional can brief and debrief the patient about
the film in a timely fashion (Berg-Cross et al., 1990). It also has been noted that
the therapist must take care not to allow the therapy session to deteriorate into a dis-
cussion of the film (Hyler, 1999).
Proponents of ‘‘cinematherapy’’ have provided numerous case studies that indi-
cate that it shows promise (Hesley & Helsley, 1998; Wedding & Niemiec, 2003). How-
ever, no formal evaluation of its effectiveness has yet been undertaken (Hyler, 1999).
 536 J. Pirkis et al.

Future Directions
The knowledge base regarding portrayal of mental illness in fictional films and
television programs is considerable, and it is timely to start using this knowledge
to inform action. The mental health sector (policymakers, mental health profes-
sionals, and people with mental illness and their families) should collaborate with
the film and television industries (producers, directors, scriptwriters, and actors) to
minimise negative portrayal and maximise positive portrayal.
The mental health sector should not embark on this collaboration in a naı̈ve
fashion, and should recognise that the primary imperative of the film and television
industries is to entertain and achieve box office or ratings success, not to educate the
public (although the two are not mutually exclusive; Greenberg, 2003b; Grinfeld,
1998; Henderson, 1996). In addition, the mental health sector should recognise that
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the idea that people diagnosed with mental illness should look different (or ‘‘mad’’) in
television programs or film finds expression historically in the artistic imagination.
Cross (2004) notes that Gilman (1988), among others, has argued that the way in
which society conceptualises and deals with illness is indicated by the iconography
of that illness. Cross observes that, despite its inaccuracy, key icons of mental illness
are used to convey to the audience the notion that mental illness is being portrayed:
‘‘Wild, unkempt hair and tattered clothing have long provided influential visual
signs of madness’’ (p. 199).
Within this context, the mental health sector should seek to develop fruitful rela-
tionships with the film and television industries, to understand their processes, to
comment on inappropriate portrayals, and to provide advice on appropriate por-
trayals (Henderson, 1996, 1999; Hyler et al., 1991; Philo, 1997; Salter, 2003; Wahl,
2001). There are documented precedents for this approach. In the United States,
for example, the Mental Health Media Partnership and the Institute for Mental
Health Initiatives have both worked closely with writers, directors, and actors
involved in productions portraying people with mental illness (Institute for Mental
Health Initiatives, 2005; Lurie, 2003). In the United Kingdom and Australia, Reve-
ley (a British psychiatrist) and SANE (a mental health advocacy and education
organisation) collaborated with the teams producing the soap operas EastEnders
and Home and Away, respectively, to develop plotlines about characters with schizo-
phrenia (Hocking, personal communication, March 1, 2005; Reveley, 1997). There
are suggestions that these efforts have achieved positive results (e.g., testimonials
on the Institute for Mental Health Initiatives website indicate that their materials
have been well received by entertainment media professionals, and the relevant East-
Enders episodes exposed 10 million people to the idea that schizophrenia is a treat-
able illness that affects ordinary people), but systematic evaluation is needed.

Conclusions
Viewers of fictional films and television programs frequently are confronted with
negative images of mental illness, and these images have a cumulative effect on
the public’s perception of people with mental illness. In turn, this has consequences
for people with mental illness, who experience stigma and may be less likely to seek
help as a result of this collective impression of what mental illness means. There is a
need for the mental health sector and the film and television industries to collaborate
to counter negative portrayals of mental illness, and to explore the potential for
positive portrayals to educate and inform, as well as to entertain.
 On-screen Portrayals of Mental Illness 537

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