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
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R. WARWICK BLOOD
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:
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1. What is the extent and nature of portrayal of mental illness in fictional films
and 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.
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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
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,
52 permitting detailed consideration of film(s)
5 in question, but suffer 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.
Articles
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;
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
52
6 Larger-scale descriptive studies
involving cross-sectional surveys
and focus groups
Typically involve analysis of the impact of a Anderson, 2003; Byrne, 2000; Gabbard, 2001;
single film or television program on an Grinfeld, 1998; Hyler et al., 1991; March,
individual or small group of individuals. 1999;
Provide some insight into potential harmful Pies, 2001; Rosen et al., 1997; Signorielli,
effects of negative portrayals, but suffer from 1989;
a reliance on subjective interpretation Wahl, 1992, 2001; Walker, 1993; Wedding
and=or lack of generalisability. &
Involve cross-sectional surveys or focus groups, Niemiec, 2003
designed to elicit information from
respondents about their knowledge of and
attitudes toward mental illness and the Clothier, Freeman, & Snow, 2001; Granello &
sources of these attitudes and knowledge. Pauley, 2000; Granello, Pauley, & Carmichael,
Provide valuable data on the extent to 1999; Lauber, Nordt, Falcato, & Rossler, 2003;
which the media has an influence on Lopez, 1991; Nunnally, 1957; Philo, 1996a,
community attitudes toward mental 1996b
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 Domino, 1983; Sancho-Aldridge & Gunter,
group 1994; Schill, Harsch, & Ritter, 1990; Wahl
of participants after they have viewed a & Lefko wits, 1989; Walter, McDonald,
particular film or television program. The Rey, & Rosen, 2002
weakest have assessed attitudes of a
single 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.
52
7 IS THERE EVIDENCE THAT PORTRAYAL OF MENTAL ILLNESS IN FICTIONAL FILMS AND TELEVISION PROGRAMS CAN HAVE
POSITIVE EFFECTS?

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
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proportion of all prime-time shows that involved a passing or major mental

illness theme was one 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),
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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- 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
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that people with schizophrenia have split or multiple personalities (some of

which are violent) (Byrne, 2000).
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
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which the charac- ter after whom the film is named is a malevolent
psychiatrist who appears to be 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
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Grinfeld, 1998) claimed that in 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

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Films 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
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no evidence to support the hypothesis that watching Shrinks resulted in

misconceptions 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
na¨ıve 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,
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2003b; Grinfeld, 1998; Henderson, 1996). In addition, the mental health sector
should recognise that 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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