‘Joker’ Filled With Mental Illness Misconceptions – Medscape

The Batman characters have been cultural icons for generations spanning more than three-quarters of a century. How many of us had Batman (or the Joker) on our school lunch box or watched reruns of Adam West's campy televised rendition of Batman? The October release of "Joker" has been breaking contemporary box office records.

Dr. Susan Hatters Friedman

(Spoiler alert!) The Todd Phillips film associates mental illness with violent acts, spurring a slew of articles explaining that this association is uncommon and may promote stigmatization and public fear of people with obvious symptoms of mental illness. The protagonist, Arthur Fleck (Joaquin Phoenix), suffers from a condition in which his affect and facial expressions are not appropriate to his emotions or to the situation. He laughs uncontrollably when a situation is sad or upsetting. Sometimes he laughs and cries at the same time. As a result, he often is misunderstood, ridiculed, and victimized like many people with obvious mental illness.

Arthur Fleck is a loner who has difficulty with relationships and self-esteem, and is beaten severely while at work as a clown. Shortly after the incident, he is given a gun by one of his coworkers. He keeps it with him even when working as a clown in a children's hospital where it is accidentally revealed, and he is subsequently fired. Still in his clown garb, he later uses the gun when he is mocked and assaulted on the subway by three Gotham City bankers.

In an unusual tone, his mental health worker reminds him early in the film that he is prescribed seven different psychotropic medications, helping to cement for the viewer that mental illness is the cause of Arthur's problems and the Joker's origin story. Then the funding for Arthur's mental health treatment (even if it was not good treatment) was cut a problem not just in Gotham.

While some of Arthur Fleck's symptoms are consistent with real mental illness, the combination of symptoms is unusual. Although he is being treated with a variety of medications, it is unclear whether any of them are helping him or what exactly they are helping him with. (Ironically, once he is off of his medications, he becomes a better dresser and a better dancer.) He writes in a disorganized way in his journal; the only intelligible sentence that is focused on is, "The worst part about having mental illness is people expect you to behave as if you DONT." A smiley face in the O' suggests that his affect is inappropriate even in his writing. Arthur's condition of uncontrollable laughing and/or crying, associated with head trauma, appears more consistent with the neurologic condition pseudobulbar affect rather than a mental illness. In addition to pseudobulbar affect, Arthur demonstrates a constellation of symptoms of different kinds of mental illness, including erotomanic delusions, ideas of reference, and disorganized thinking. He also does not appear to take social cues, such as knowing when he is being mocked. He appears to believe that his neighbor is his girlfriend (as the viewer was similarly led to believe), eventually breaking into her apartment where he thought he belonged, much to her horror when she finds him there. Some of his symptoms may run in his family (whether it be his biological or adoptive family).

Penny (Arthur's mother) strongly believes (perhaps a delusion, perhaps not) that her previous employer Thomas Wayne (the future Batman's father) is the father of her love-child, Arthur. When Arthur obtains Penny's mental health records (through his own violent devices), he finds that she had been diagnosed with narcissistic personality disorder and a psychotic disorder. She had been found guilty of endangering the welfare of her (perhaps adopted, perhaps not) child Arthur, who had been malnourished, with severe head trauma, and tied to a radiator.

Arthur's smothering of his mother with a pillow in her hospital bed, after he was devastated by both her stroke and this newfound data, occurred in a perfect storm. The killing is not portrayed as an act of euthanasia. We know that schizophrenia is overrepresented among matricide perpetrators and that long-term dysfunctional relationships between mother and (grown) child usually precede matricides. Mothers are often seen as controlling, fathers are often absent (as in Arthur's case), and the child is often overly dependent. The mother and child (as seen here) often have a relationship marked by love and hate mutual dependence and hostility. But Arthur is not the only character in the Batman universe to commit matricide. Recall that the Batman's psychiatrist Amadeus Arkham himself killed his own mentally ill mother during his young adulthood.

Pop culture can give the public negative impressions of mental illness. While filmmakers need not portray actual mental illnesses or their symptoms in moving their stories forward, their portrayals have an impact on what the public sees as mental illness. This is similar to the current American president and others in political power asserting that mental illness causes mass shootings, and those in the public taking their word for it rather than the word of psychiatry.

In actuality, what felt the most true to life in the film was the early scene in which Arthur was seriously assaulted while waving the going-out-of-business sign on the sidewalk, just trying to make a living. As psychiatrists know, people with mental illness are more likely to be victimized by others in society than to be perpetrators of violence. To be sure, some of Arthur's characteristics are dynamic risk factors, such as his unemployment and social isolation. However, society often conflates mental illness with dangerousness, but most people with mental illness are not violent.

Dr. Karen B. Rosenbaum

In the final scenes, Arthur Fleck (who is now the Joker) is apparently back in the white-walled Arkham State Hospital, with an implication that he has gotten away with the murders, either found incompetent or insane. This, too, has negative implications for the public viewing the film and further perpetuates the misunderstanding that people with mental illness "get away" with their crimes. In reality, depending on the study, approximately one-quarter of those who pleaded insanity were found insane, and those facing jury trials (and public perception) are less likely to be found insane than those with bench trials. Public misinterpretations and outrage over the idea that a mentally unwell person might be found insane rather than guilty have existed for centuries, perhaps most memorably when John Hinckley Jr. attempted to assassinate former President Ronald Reagan, after identifying with a character in the film "Taxi Driver." Let's presume that Gotham has an insanity defense similar to other places in America. Then, in order to be found insane, Arthur's pseudobulbar affect or his (unclear) mental illness would have either caused him not to know the nature and consequences of his acts, and/or to appreciate the wrongfulness of his acts (if we are fairly certain that Gotham is actually New York City). Neither of these appear to be true from the film. He knew that he was killing. No delusions or hallucinations made him think his acts were not wrong. Rather, he had an arguably rational motive certainly the multitudes wearing clown masks in the subsequent uprisings against the powerful also believed his motive to be rational. He deliberately killed the bankers who mocked and beat him. He was also able to defer his killings until what he calculated was the right time to have the most impact for example, on live television, or when he was alone with his mother in the hospital.

In closing, unrealistic portrayals of the link between mental illness, violence, and forensic hospitalization are seen on the silver screen in "Joker." We hope that others who feign mental illness symptoms to evade criminal responsibility will emulate Joaquin Phoenix's Joker as it will make it much easier for forensic psychiatrists to ferret out malingerers!

Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington, D.C.: American Psychiatric Association Publishing [2019]), which was written by the Group for the Advancement of Psychiatry's Committee on Psychiatry & Law. Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill-Cornell Medical Center.

This article originally appeared on MDedge.com.

Read the rest here:
'Joker' Filled With Mental Illness Misconceptions - Medscape