Mental Illness on the Screen: No More Snake Pit

Just 2 minutes before an episode of the television show Boston Legal aired, Roger Pitman, MD, professor of psychiatry at Harvard Medical School, received a telephone call from his sister-in-law informing him that the show would include a segment on propranolol, a drug he was researching for the prevention and treatment of posttraumatic stress disorder (PTSD).

After watching the "Selling Sickness" episode,¹ Pitman was amazed at how quickly his research, albeit substantially embellished, had made it to a popular television show viewed by more than 10 million people.

The episode included a fictional story about a 16-year-old girl, Michelle, who had recently been molested by a rabbi, and about the ensuing conflict between her divorced parents over whether Michelle should take the "forgetting pill." Michelle's psychiatrist father sought a court order to permit her to take the pill, while her mother opposed it. The pill was propranolol (Inderal), a ß-blocker, which is FDA-approved for the treatment of hypertension and angina pectoris, among other disorders.

In the courtroom drama, the father's attorney described the drug as essentially blocking "adrenaline from entering the nerve cell, and adrenaline attaches emotion to memories. If you take the drug quickly enough, it can prevent you from remembering and being scarred by the trauma." He then added that it had been used "with soldiers suffering from PTSD with good results."

Opposing the drug's use, Michelle's mother argued: "You just can't erase the bad parts of life," and "our best artists are informed by their pain. . . . Certainly, if the trauma affects your life, treat it, either behaviorally or with medication. But some miracle amnesia pill, so you have no memory of bad things-what kind of brave new world are we entering into?"

The episode segment ends with the judge ruling against Michelle being given the drug.

Boston Legal's writers "used artistic license to make more out of this than there currently is," Pitman said. "I thought the [drug's] effects that were portrayed in the show were beyond what we know the effects to be, but . . . the discussion of the ethical issues was fairly good."

Pitman believes the Boston Legal script was based on a CBS 60 Minutes segment aired November 26, 2006, in which correspondent Lesley Stahl interviewed him, other researchers, and study participants with PTSD who had received propranolol.²

"The 60 Minutes show indicated that this research was experimental and that there were not any firm results yet," Pitman said. "Now, in . . . Boston Legal, the plaintiffs were portraying it like it was this miracle drug. On the other hand, the defendant's lawyer did say that it hadn't even been shown to be effective yet."

Summarizing his reaction to the episode, Pitman said, "It was an interesting show, but what we need is more data rather than more interest. . . . At this point, the most important thing for us to do is to continue our research and see what there really is to this drug."

Writers draw on life experience As with the Boston Legal episode, many story lines of television series and films are increasingly imitating life. But is the information accurate? The importance of this question is highlighted by a 2001 Healthstyles Survey that found more than half (57%) of regular viewers reported learning something about a disease or how to prevent it from a daytime/ prime time drama.³

Certainly, when mobster Tony Soprano sought treatment for panic attacks in The Sopranos, the process and purpose of psychotherapy received wide exposure. The television series provided one of the best depictions of psychotherapy "to ever appear on film or television," according to Glenn Gabbard, MD, Brown Foundation Professor of Psychoanalysis at Baylor College of Medicine and author of a book about The Sopranos.⁴

Increasingly, writers, directors, and producers of prime time shows or feature- length films, along with actors, are shifting away from mental illness stereotypes and seeking the input of psychiatrists, psychologists, other mental health experts, family members of the mentally ill, and those suffering from the disorders.

In a commentary on a recent Grey's Anatomy episode called "Wishin' and Hopin'," Joan Rater, one of the episode's writers, explained that the episode was "really about Alzheimer disease. How devastating it is to families, how it turns spouses and children into caretakers, how it robs people of their memory, their identity."⁵ In the episode, Ellis, mother of one of the main characters, Meredith Grey, suffers from middlestage Alzheimer disease. But on this one day, she has a lucid moment, recognizes her daughter, and remembers everything up until the last 5 years, when she has been in a supervised living facility.

"The concept of someone with this disease having a lucid day is real," Rater said. "The disease varies for everyone, but experts we talked to said that patients have bad days and good days, and then sometimes they have great days where it seems like they are their old selves."

In the FX television series Dirt, a drama about the ruthless editor of a celebrity tabloid, actor Ian Hart portrays Don Konkey, a paparazzo who suffers from schizophrenia and who is often reluctant to take his medication. To research his part, Hart said he relied on his memories of distant relatives who have schizophrenia, some reading materials about the disorder, and BBC radio documentaries that featured conversations with individuals who have schizophrenia.⁶

One of the most thorough investigations of schizophrenia is in a new independent film, CANVAS, starring Academy Award-winner Marcia Gay Harden as Mary, a woman suffering from schizophrenia who paints her dreams on canvas; Sopranos' Joe Pantoliano as her husband, John, a construction foreman; and newcomer Devon Gearhart as Chris, their 10-year-old son.⁷

In the story, Chris attempts to conceal his mother's illness, but her bizarre public behavior alienates him from his schoolmates and widens the rift between him and his father. When Mary's illness leads her to violence, endangering her family and herself, John hospitalizes the woman he adores and tries to cope by building a large sailboat in his driveway. When Chris is suspended from school for fighting with bullies, John punishes him. A pivotal confrontation follows between father and son, ending in a reconciliation during which they come to terms with Mary's illness.

The film, an award winner at several film festivals even before going into general release, is a fictional narrative. Yet, its story is inspired by real childhood experiences of writer/director Joseph Greco, whose mother has schizophrenia.

"She was actually hospitalized for several months when I was a child. That's where the idea for the story came from," he told Psychiatric Times. Greco's father taught him how to sail.

"That is how we were able to cope as a family, by him taking me sailing," he said. "I'm lucky, because I had a really great father. In some instances, he was both the father and the mother, while she was away in treatment. We leaned on each other and that is really what the movie is about-how a family ultimately can overcome problems if given the right opportunity."

"My goal first and foremost was to tell a good story and make a good movie to entertain people, but I would also like people to learn about mental illness and if we can combat stigma in the process, then all the better," he added.

Obtaining professional input
Beyond relying on his own experiences for the plot, Greco told Psychiatric Times that he did some research about schizophrenia.

"I wanted to be sure that I portrayed mental illness accurately and sensitively, so I enlisted the support of the mental health community. In particular, there is a script consultant that I worked with, Susan Dempsay, who founded a rehabilitation center [for individuals suffering from severe and persistent mental illness] called Step Up on Second. Her son, unfortunately, has schizophrenia, so she has a personal connection to mental illness and first-hand experience. More than that, she has consulted on other movies."

Before the film was finished, Greco invited Stella March, national coordinator of StigmaBusters for the National Alliance on Mental Illness (NAMI), to attend a rough-cut screening in Beverly Hills. She urged Greco to send the movie to NAMI's headquarters in Arlington, Va. Last July, it was shown at NAMI's national convention, received 2 standing ovations, and was praised by NAMI's executive director Michael Fitzpatrick, MSW, as "one of the few dramatic films that can be considered authentic in its portrayal of schizophrenia- presenting both heart-breaking and heart-warming dimensions and even touches of humor." The film has since received enthusiastic reviews from entertainment industry critics, including John Anderson writing for Variety.

Not only Greco, but also Harden and Pantoliano researched schizophrenia. At Greco's request, they spent a day visiting Fountain House in New York City, a self-help program operated by individuals recovering from mental illness, in collaboration with a professional staff.

Before the film goes into general release, Greco said, "We are doing our best to give people in the mental health community a first look at the film."Greco and Pantoliano recently screened the film at a gathering of psychiatrists and other mental health professionals at Tufts University.

Drama for therapy, education
When viewed as a whole, mental health issues are being portrayed more accurately in recent movies than in the past, said psychotherapist Birgit Wolz, PhD, MFT, author of E-Motion Picture Magic: A Movie Lover's Guide to Healing and Transformation. The improvement in accurate portrayals parallels an improvement in psychiatric diagnoses, she told Psychiatric Times.

In her own work,Wolz uses movies as a catalyst for the psychotherapeutic process and for educating mental health professionals. Currently, she is developing an online continuing education program for psychologists and others that will utilize specific movies to illustrate diagnoses cited in DSM-IV-TR.

It is a way to learn about fairly dry material in an entertaining format, she explained. For example, the movie As Good As It Gets can be helpful in diagnosing obsessive-compulsive disorder, while Mr Jones presents a useful picture of bipolar disorder.

With Ofer Zur, PhD,Wolz has written an online CE course, "Therapeutic Ethics and the Movies-What Films Can Teach Psychotherapists About Ethics and Boundaries in Therapy."⁸ The course uses movie vignettes to discuss such ethical dilemmas as confidentiality, self-disclosure, touch, and out-of-office experiences.

"We looked at several movies where therapists are portrayed and in just about every one there is a boundary violation, so it is easy to portray ethical issues," Wolz said, adding that she and Zur are collaborating on a second course on ethics and the movies. Examples Wolz provided include Basic Instinct and Mr Jones, in which sexual relationships occur between therapist and client; Antwone Fisher, in which a client is invited to a family dinner with his therapist; and What About Bob? in which a client follows his analyst on his vacation.

Wolz also has developed an online course on cinema therapy. In the course description, she explains the power of films: "Movies affect us powerfully because the synergistic impact of music, dialogue, lighting, camera angles, and sound effects enables a film to bypass our ordinary defensive censors. They draw us into the viewing experience and at the same time-often more easily than in real life-afford a unique opportunity to retain a perspective outside the experience, the observer's view."⁹