Disinformation in Discourse: A Mental Note on the Role of the DSM in Movie Analysis
“Mental illness makes for good visual melodrama” (9) write Pirkis et al. in their review of empirical studies on the representations of mental illness in fictional films. Numerous scholars reveal that American popular culture, especially Hollywood films, partake in a disinformation culture concerning mental illness. Scholarship in cultural, media, television and film studies as well as related fields in the critical medical humanities, narrative medicine, and psychology have focused on the negative reciprocal reinforcement of negative portrayals in media and the upkeep of negative attitudes toward mental illness in public. However, restating that Hollywood overly relies on stereotypes merely reinforces the powerful narrative of mental illness as a biological condition, rather than calling attention to the origins of this discourse that perpetuates disinformation. The shaky foundation of these analyses is The Diagnostic and Statistical Manual of Mental Disorders [henceforth DSM], the reference work for classifying mental illness in psychiatry. The controversial conceptualization of the DSM begs the questions of its usefulness for the (academic) discourse on mental illness. In the following, I argue that scholars who use this uncritical framing spend more time criticizing negative stereotypes in popular culture than discovering alternatives that diversify narratives of mental illness and veer from the classificatory constrictions of the DSM.
Schizophrenia, dissociative identity disorder, or paranoia are staple tropes in fictional films that add a twist to the narrative, propel the plot forward, or provide obstacles that characters have to overcome. A common response to stereotypical representations in Hollywood films can be found in medical practitioner Erin Heath’s monograph Mental Disorders in Popular Film: How Hollywood Uses, Shames, and Obscures Mental Diversity (2019). She argues that “mental disorder does not generally appear in ways that demonstrate real people’s lived experiences. Films […] intentionally make psychological breakdowns immediate and narratively convenient to provide audiences with an entertaining emotional struggle” (3). While certainly warranted, such studies reproduce uncritical insights that are chiefly interested in identifying ‘good’ and ‘bad’ representations of mental illness. This vague dichotomy is most often conflated with medical factuality: the more medically accurate a pathology is portrayed, the ‘better’ the representation. It is unsurprising that most of American popular culture fails the test of medical accuracy and is thus deemed to perpetuate mental illness stigma.
To determine whether representations are medically accurate and thus ‘good,’ scholars rely on the DSM, which has been described as the ‘Bible’ for the field (Insel par. 2) as well as “an absolute scientific nightmare” (Hyman, qtd. in Belluck and Carey par. 10). Scholars calling out the handbook on its lack of validity and scientificity reference the influential yet controversial third installment of the DSM from 1974. This edition revolutionized diagnostic psychiatry, abandoning the former model of dynamic psychiatry, which was largely based on psychoanalysis, for a biomedical classification system. In order to maintain the discipline’s professional legitimacy, symptom-based diagnoses were introduced to integrate psychiatry in the scientific community, changing the way we understand and respond to mental illness until today. Despite the DSM’s premise to understand mental illness as a biological condition, only a handful of disorders have distinct biological markers, so-called ‘organic mental disorders’ (e.g. amnesia, dementia, and Chorea Huntington’s Disease). Other forms of mental illness are subsumed under ‘functional mental disorders,’ indicating that these conditions are a reaction to environmental or psychological stressors without proof of an organic etiological factor (cf. Goldstein).
This paradigm-shifting classificatory system was thus not based on medical insights, but was a response to the changing social and economic environment (cf. Horwitz 210). The introduction of symptoms did not primarily yield advantages for the ones receiving the diagnoses, but rather the instances involved in making them: Clinicians were more likely to be reimbursed for treating specific diseases by insurers (cf. Horwitz 211); the pharmaceutical industry was able to offer specialized medication for each condition, as only products for distinct diseases could be marketed (cf. Healy); and direct-to-consumer pharmaceutical advertisement tapped a market that aimed to convince viewers that they have a medical condition that needs treatment (cf. Packer vx). While the nosology of mental illness is not entirely arbitrary and may have far reaching advantages, raising awareness of conditions and offering support for the ones afflicted, it may also “create the disorders it claims to classify” (Hacking, qtd. in Horwitz 218, emphasis in the original) on the grounds of dominant ideological, economic, and medical discourses. Much like Hollywood, medicine is a business and the second largest industry in America at that (cf. Conrad and Schneider 15).
Acknowledging the controversial history of the foundation of numerous interdisciplinary movie analyses, it seems detrimental to cling to a classificatory system that is entrenched in ideology and cost-benefit analyses. Analyzing fictional films from a strictly medical perspective may also block the view of new ways of narrating and visualizing mental illness that go beyond a meticulous representation of symptoms or the reliance on established tropes and stereotypes. A number of contemporary films implement mental illness in an artistic, expressive, or phenomenological way, attempting to capture the experience of living with neurodiversity instead of ticking off a medical checklist. Movies like Alejandro González Iñárritu’s Birdman or (The Unexpected Virtue of Ignorance) (2014) and, recently, Charlie Kaufman’s Netflix production I’m Thinking of Ending Things (2020) topicalize mental illness, but not in a medical, symptomatic, biological, or pathological way. Rather, these films offer an alternative narrative that narrows in on the characters living and experiencing these conditions.
Movie analysis is stuck in an interpretative rut, criticizing popular culture’s over-reliance on stereotypes and demanding the close observation of medical symptoms. However, the fact that these medical symptoms are themselves not an objective truth, but created to fit the dominant narrative of mental illness put forth by the DSM, is ignored and uncritical insights are restated time and again. In contrast, popular culture’s disinformation culture should be understood as arising from the DSM’s misinformation culture that is guided by ideological and economic concerns, rather than illness experience. Relying on the DSM for understanding fictional representations of mental illness disregards more artistic ways of visualizing neurodiversity that shift the dominant narrative of mental illness away from understanding afflictions as incurable biological conditions toward acknowledging them as part of human experience.
Belluck, Pam, and Benedict Carey. “Psychiatry’s Guide Is Out of Touch With Science, Experts Say.” The New York Times, 6 May 2013, http://nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html.
Conrad, Peter, and Joseph W. Schneider. Deviance and Medicalization: From Badness to Sickness. Expanded ed., Temple UP, 1992.
Goldstein, Gerald. “Organic Mental Disorders.” Advanced Abnormal Psychology, edited by Michel Hersen and Vincent B. Van Hasselt, Springer Science+Business Media, 2001, pp. 443–59.
Healy, David. The Anti-Depressant Era. Harvard UP, 1997.
Heath, Erin. Mental Disorders in Popular Film: How Hollywood Uses, Shames, and Obscures Mental Diversity. Lexington Books, 2019.
Horwitz, Allan V. Creating Mental Illness. U of Chicago P, 2003.
Insel, Thomas. “Post by Former NIMH Director Thomas Insel: Transforming Diagnosis.” National Institute of Mental Health, U.S. Department of Health and Human Services, 29 Apr. 2013, https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml.
Packer, Sharon. “Introduction.” Mental Illness in Popular Culture, edited by Sharon Packer, Praeger, 2017, pp. ix–xxiv.
Pirkis, Jane, R. Warwick Blood, Catherine Francis, and Kerry McCallum. “A Review of the Literature Regarding Fictional Film and Television Portrayals of Mental Illness.” Program Evaluation Unit, The University of Melbourne, 2005, pp. 1–27.