Cinematic Psychotherapy Stereotypes

In perhaps the earliest on-screen fictional portrayal of a mental health professional, a young woman was depicted as being controlled by a hypnotist in the 1896 silent film Trilby. Psychotherapists and other mental health professionals have been portrayed in well over 5,000 films (Flowers & Frizler, 2004), and across many genres including drama, horror, musical, western, and even hardcore pornography (Greenberg, 2000). Indeed, 17% of the most popular films of the 1990s portrayed at least one mental health professional (Young, Boester, Whitt, & Stevens, 2008).

Mental health professionals have long been concerned about the potential negative effects of these portrayals (Peterson, 2001; Schultz, 2004b), including concerns that viewers will be less likely to seek help after viewing them (Stuart, 2006), that consumers' perceptions of mental health care will be negatively impacted (Vogel, Gentile, & Kaplan, 2008), and that misperceptions about the therapy process will be promoted (Schultz, 2004a). This paper will explore common misconceptions about mental health treatment, examine stereotypes of mental health professionals, and describe research and scholarly debates about the impact of these portrayals on the profession and the public.

On-Screen Misconceptions of Mental Health Care

Portraying the process of therapy is challenging for filmmakers, who may resort to representing effective treatment as resulting from sudden and dramatic catharsis or uncovering deep secrets (Gabbard, 2001). Films also tend to promote common misconceptions about psychotherapy for dramatic effect (Lasky, 2006). For example, mental health treatment is commonly portrayed as ineffectual (Kemshal-Bell, 2010), and when it does work, it is shown to be effective through love (e.g., Mozart and the Whale), sexual boundary violations by the female professional (e.g., The Prince of Tides) or other unethical behaviors (Macfarlane, 2004; Otto & McGroarty, 2012; Wedding, Boyd, & Niemiec, 2010), or a "miraculous minute cure." The latter may foster unrealistic expectations for real-life patients, who tend to experience added distress when their concerns are not as easily resolved (Orchowski, Spickard, & McNamara, 2006).

Although some have argued that portrayals have become more balanced overall in the last decade in U.S. (Niemiec & Wedding, 2006) and international cinema (Niemiec, 2010), films from 1999 to 2010 portrayed mental health professionals acting unethically more often than not (Otto & McGroarty, 2012). Therapists have been depicted as incompetent (Gharaibeh, 2005), unlicensed or lacking in training (Cannon, 2008), untrustworthy and unethical (Gordon, 1994; Kemshal-Bell, 2010), violating boundaries (Niemiec & Wedding, 2006), and participating in illegal behavior and sexual relationships with clients (Otto & McGroarty, 2012).

Gender-Based Stereotypes of Mental Health Professionals

A number of stereotypes of mental health professionals in film have been examined, with over 70 identified since 1947 (see below). Although about eight of these 70 categories specifically refer to female mental health professionals, only one of them is positive ("sympathetic," de Carlo, 2007), and four are of women who engage in sexual relationships with male patients. Female therapists are portrayed as nurturing and maternal when working with female patients, but depictions of female professionals working with male clients are often sexualized (DiBenedetto, 2004), particularly portrayals of female mental health professionals in their 20s or 30s (Young et al., 2008). Those who are not sexualized are either explicitly portrayed as not heterosexual, or are punitive and controlling (e.g., de Carlo, 2007).

On-Screen Stereotypes of Mental Health Professionals

The following are cinematic stereotypes of mental health professionals that have been identified by various scholars:

• All-Wise Father, Insane, Criminal, Seductive Female, Philosophical-Whimsical (Franklin,1947)
• Good: Cures by Presence, Effective & Caring, Omniscient Detective, Reconciling, Human and Fallible, Compassionate, Healing Lover; Bad: Ineffectual, Manipulative-Criminal-Vindictive, Arrogant but Misguided, Repressive and Malevolent, Neurotic and Ridiculous, Psychotic, Exploitative Lecher, Libidinous Clown (Gabbard & Gabbard, 1987; 1999)
• Dr. Dippy, Dr. Wonderful, Dr. Evil (Schneider, 1987)
• Libidinous Lecher, Eccentric Buffoon, Unempathic Cold Fish, Rationalist Foil, Repressive Agent of Society, Unfulfilled Woman, Evil Mind Doctor, Vindictive Psychiatrist, Omniscient Detective, Dramatic Healer (Gabbard & Gabbard, 1992)
• Detached and Flawed Yet Transformed by Patients, Harmful Researcher, Professionals Who Give in to their "Shadow," The Unchanged and Minimally Visible (Coleman, 1995)
• The Alienist, The Quack, The Oracle (Gabbard & Gabbard, 1999)
• Dr. Unethical (Toman & Rak, 1997)
• The Vampire, The Fisher King, The Zaddik (Pies, 2001)
• Learned and Authoritative, Arrogant and Ineffectual, Seductive and Unethical, Cold-hearted and Authoritarian, Passive and Apathetic, Shrewd and Manipulative, Dangerous and Omniscient, Motivating and Well-Intentioned (Wedding & Niemiec, 2003)
• Dr. Line Crosser, Dr. Rigid (Schultz, 2005)
• Dr. Sexy (Pirkis, Blood, Francis, & McCallum, 2006)
• Oracle, Societal Agent, Eccentric, Wounded Healer, Romantic (Orchowski, Spickard, & McNamara, 2006)
• Hardened, Middle-Aged Man, Butch Woman, Young and Nubile Sex Kitten, Working Class Stoic, Gestapo Nurse, Male Attendant-Rapist, Sympathetic, Male Nurse Mincing Queen, Monster Bull-Dyke, Asylum Bouncer (De Carlo, 2007)

Female therapists are also commonly portrayed as sexist and unprofessional (Samuels, 1985), and more likely to cross boundaries and engage in dual relationships (Coleman, 1995). Regarding psychiatrists, women in film often establish sexual relationships with patients (Byrne, 2009), despite the fact that in reality, a male psychiatrist is much more likely to cross boundaries and engage in a sexual relationship with a female patient than the other way around (Gabbard, 2001; Gabbard & Gabbard, 1989).

Sexual relationships between female therapists and their male patients are often portrayed as healing for professionals (Gabbard, 2001) and their patients (TrottPaden, 2001), in contrast with professional ethics (e.g., American Psychological Association, 2010) and evidence that these relationships are very harmful to patients (e.g. Russell, 1993). Films also tend to show women healing their patients through love rather than professional expertise, and are rarely effective otherwise (Gabbard, 2001; Gabbard & Gabbard, 1989). In the absence of a sexual relationship, the female professional tends to be taken care of or psychiatrically investigated by her male patient (Walker, 1993).

The sexualization of female therapists conveys a myth that successful professional women cannot have happy personal lives, and that unhappy women just need sex with the right man (Gabbard, 2001). According to Hollywood's "patriarchal thrust," women giving in to romance with male patients are merely fulfilling their "wifely" roles (Greenberg, 2000). Although mental health professionals hold considerable power over their clients, female professionals are particularly threatening to heterosexual, masculine hegemony (Clara, 1995; Samuels, 1985), a threat that can be ameliorated by either giving these characters little screen time (Niemiec & Wedding, 2006), portraying them as sex objects (Bischoff & Reiter, 1999; Kalisch, Kalisch, & McHugh, 1982), or as failures in their personal or professional lives (Clara, 1995; Niemiec & Wedding, 2006; Samuels, 1985). Thus, male patients sexually conquering their female therapists allow filmmakers and viewers to cope with the anxiety of women being in positions of power (Schorow, 2000), avoids undermining masculinity (Walker, 1993), and keeps femininity in its typical position in society (Bischoff & Reiter, 1999).

Bischoff and Reiter (1999) identify three gender-based themes which tend to be prominent in films in order to make them believable to the viewing public: (1) men in positions of vulnerability in therapy require the therapeutic relationship to be sexualized to restore the balance of power; (2) a portrayal of emotional intimacy between a male client and female professional must eventually involve sex; and (3) male therapists are less competent because men are not able to handle emotional problems. Perhaps because of the dominance of these beliefs, filmmakers are compelled to sexualize female therapists (Young et al., 2008).

The Impact of On-Screen Psychotherapy

Should mental health professionals be concerned about the negative effects of the media's portrayal of psychotherapy? Some, such as Greenberg (2011), feel that most viewers will see these portrayals as entertainment and nothing else. Others suggest that negative media images of mental health care impair one's willingness to seek treatment (Stuart, 2006), and psychologists have been concerned about the public learning about therapy from the media (Peterson, 2001). Although they identify and discuss accurate portrayals, many mental health professionals remain concerned about problematic representations of psychotherapy in film (Gregerson, Heide, & Jessup, 2012; Lasky, 2006; McDonald & Walter, 2009; Young, 2012). Clara (1995) expressed worry that the field of mental health care may be negatively affected by portrayals in film.

Despite these concerns, Robinson (2009) noted that claims that the public is negatively influenced by portrayals of therapists in movies lack empirical support. For example, a study of people seeking counseling found little evidence for the idea that the media influences potential clients' expectations of mental health professionals (Keith, 2005). Some experimental research has been done on the negative effects of portrayals of mental health professionals in the media (e.g. García Silberman, 1993), albeit with mixed results. One study found that those who viewed the film One Flew Over the Cuckoo's Nest developed more negative views toward mental health professionals, mental hospitals, and people with mental illness, compared to those in a control group (Domino, 1983). In a study of the effects of viewing a popular film about a psychiatrist who falls in love with one of his patients, Schill, Harsch, and Ritter (1990) found that college students who viewed the film became somewhat more accepting of sexual contact between psychiatrists and their patients, and more cynical about mental health professions which prohibit such contact. In a more recent study, media portrayals were found to have a small negative influence on the expectations of potential consumers of psychotherapy (Robinson, 2009).

Notably, even portrayals of mental health professionals judged to be positive by experts in the field had a negative impact on the participants. Indeed, any portrayal at all — whether positive or negative — could have negative effects (Robinson, 2009). For example, Timpson (2010) reviewed responses from the public about depictions of psychotherapy in film and on television, and found that a typical reaction after viewing these portrayals is anxiety about the idea that psychologists could read their minds.

On the other hand, Smithson (2009) found that, compared to a control group, undergraduates who viewed a single episode of the television series In Treatment became more willing to seek mental health care, and viewed disclosure to a therapist as more beneficial. In a study of exposure to television and negative attitudes about seeking mental health treatment, Vogel et al. (2008) found that the relationship between television exposure and negative treatment-seeking attitudes was mediated by other variables such as the perceived stigma or anticipated benefits of seeking therapy.

New Directions in Cinematic Psychotherapy?

Byrne (2009) believes that in order to influence the film industry, mental health professionals must comment on these portrayals rather than simply consume them. Lloyd-Elliott (1995) also stated that if psychologists want the public to be better informed about mental health care, engaging with the media — from newspaper interviews to television appearances — is necessary. However, many graduate programs in the field do not include interacting with the media as part of their training requirements (Tanenbaum, 1997).

Much has been written regarding how mental health professionals can ethically and directly engage with television programming (e.g. Crew, 2007; DeNoon, 2001; Rubin, Brown, Robinson, Sikula, & Anderson, 2003), and some psychologists view therapy on television as a potentially positive and effective way to make it more mainstream (e.g., Stamoulis, 2012). Other media psychologists have proposed the creation of a resource — such as a psychological information clearinghouse — for Hollywood to utilize, for the purpose of reducing misconceptions, promoting ethical representations, and even enhancing entertainment value (Gregerson & Fisher, 2013). A similar resource, Hollywood Health & Society, has been in place for the medical profession. Regardless, many mental health professionals believe that their colleagues need to be better informed regarding how portrayals of therapists in the media might impact their clients, particularly by discussing stereotypic portrayals with them (Orchowski et al., 2006). Some experts are concerned that the general public has more contact with media representations of therapy than actual mental health professionals do (Butler & Hyler, 2005).

Conclusion

Although Freud reportedly refused an offer of $100,000 in 1925 to consult with filmmakers (Schneider, 1977), some mental health professionals today suggest that the field can benefit the public and the film industry by not only commenting on and discussing stereotypic portrayals, but also by working with the media to enhance the accuracy of their portrayals (Niemiec & Wedding, 2006). Increased engagement of psychologists with the media in this way could decrease a number of the concerns described above (Lasky, 2006).