Theory & Science (2001)

ISSN: 1527-5558

Representations Of Psychiatric Disability In Fifty Years Of Hollywood Film:
An Ethnographic Content Analysis

Lisa Lopez Levers
Counseling, Psychology, & Spec Ed Dept.
School of Education
Duquesne University


This is a synopsis, partial revision, and update of a more detailed qualitative study of the treatment of �mental illness� in 21 selected Hollywood films involving scenes of psychiatric hospitalization and spanning the half century from the 1940�s through the 1980�s. Taking off from Gilman�s 1982 expose of the portrayal of �madness� in the pictorial arts through the Nineteenth Century, this ethnographic content analysis resulted in an annotated filmography providing a thick description of relevant aspects of each film and a multiple case study of how psychiatric disability has been depicted--by way of an iconography of �madness� and stereotypes of �mental illness�--in mainstream, mass-market movies, with their often-remarked effects on �the public eye.� This updated synopsis, aside from a brief description of some of the more interesting results of the longer study, offers a discussion of theoretical problems of approach, practical problems of research, of some implications for practice, as well as some implicated but not here explorable questions of visual literacy.

Lisa Lopez Levers is an assistant professor in the Department of Counseling, Psychology, and Special Education; School of Education; Duquesne University. She would like to thank Professors Emeriti Martha L. Walker, Normand R. Bernier, Richard L. Myer, and the late Fred H. Wallbrown for their support in making this research possible. Correspondence concerning this article should be addressed to the author at Duquesne University, School of Education, Canevin Hall, 600 Forbes Avenue, Pittsburgh, PA 15282. Electronic mail may be sent via Internet to [].

Stereotypes of “madness” are powerful and deeply rooted within Western culture (Gilman 1985). Visual media, especially film (Hollander 1991), are powerful purveyors of social attitudes and stereotypes (Hyler et al. 1991). Yet until quite recently, little research has been conducted on the symbolic representation of psychiatric disability, that is, “mental illness,” in film (Fleming & Manvell 1985; Winick 1978).

Stereotypes of psychiatric disability are often conveyed to mass audiences by popular movies, their reach vastly extended by constant TV replay. These stereotypes have deep roots in older pictorial media, and their structures possess great power to reflect and shape perceptions with a directness not easily accessible to conscious understanding (Gilman 1982). Film theorists (e.g., Freedberg 1989; Hollander 1991; Metz 1982) have concerned themselves with just such deep-rooted structures, structures regarded as “at work in the movies” by Gabbard and Gabbard (1987), who also hold that, “Numerous, often overlapping forces–ideological, sociological, financial, historical, technological, political–have governed what Americans see at the movies” (1987:177). Following Derrida (1978), Hodder posits that, “meaning does not reside in a film but in the making and the viewing of it” (1994:394).

Gilman’s (1982) cultural history of “madness” in art offers an analysis of “how the portrayal of stereotypes has both reflected and shaped the perception and treatment of the mentally disturbed” (title page) from the Middle Ages to the end of the 19th Century. There have been calls for an extension of this work into the 20th Century and its most popular pictorial form, film (Gilman 1982; Schoeneman 1987). The present study answers that call by examining the stereotypic portrayal of psychiatric disability in selected Hollywood films, representing the first 50 years of films with sound tracks.

An Ethnographic Content Analysis

In the study summarized here (Levers 1988), stereotypes of psychiatric disability and associated, largely negative, images or “icons of madness” (Gilman 1982) were identified in an ethnographic content analysis, one treating “document field work” (Altheide 1987:65). The analysis examined representations of persons with a psychiatric disability in popular films, considering these within their larger historical as well as immediate filmic contexts. The result was an annotated filmography, comprised of multiple case studies and thick in descriptive detail, which may be useful to educators and mental health professionals in understanding the social stigma associated with psychiatric disability.

Psychotherapists, like other health care providers and the general public, are consumers of prejudicial portrayals that are transmitted by the media. In the words of Hollander:

The visual elements in films are similar to music, in the way they transmit emotive material without calling attention to it....In this way a lot of visual movie material has been swallowed whole, seen without being remarked, responded to without consciousness. Many visual movie myths have seeped unnoticed into the culture....[These] back-ground-musical [elements] are the ancient legacy of the cinematic painters. Such painterly effects had made their mark on the public eye long before...[and had] prepared the modern eye for film language. (1991:449-450)

Greater cultural understanding of such film language, that is, how persons with psychiatric disabilities are stereotyped by the media, is needed. The importance of this type of examination is twofold. First, it helps us to become more canny deconstructors of culturally pervasive stereotypes. Second, it provides an example of one qualitative research strategy, and how it can be structured to examine culturally pervasive stereotypes and their relevance.

Deconstructing Images of “Madness”

Popular films can be viewed as texts for the study of stereotypes (Foucault 1973b; Gilman 1985). Smith (1990: 83) contributes to this discourse by offering the following: “Textual realities are the ground of our contemporary consciousness of the world beyond the immediately known....and are not fictions or falsehoods; they are normal, integral, and indeed essential features of the relations and apparatuses of ruling...” Images in media, such as advertising and film, often have been deconstructed to investigate stereotypical representations of groups based on race and gender (e.g., Bogle 1989; Killborne 1979, 1987; Jhally 1990; Lester 1996). Freedberg points to the intrinsic power of such images:

People are sexually aroused by pictures and sculptures; they break pictures and sculptures; they mutilate them, kiss them, cry before them, and go on journeys to them; they are calmed by them, stirred by them, and incited to revolt. They give thanks by means of them, expect to be elevated by them, and are moved to the highest levels of empathy and fear. They have always responded in these ways; they still do. They do so in societies we call primitive and in modern societies; in East and West, in Africa, America, Asia, and Europe. (1989:1)

Fleming and Manvell cite the historical recurrences of certain visual depictions of the “mad” and note that it is the very nature of the visual representation which makes it especially powerful since “it allows for a more immediate and concrete identification” (1985:18).

Gilman refers to “madness” as a concept which has never been clearly defined and points out that, “the icons [by which he means images that are highly symbolic and representative of a theme] for treatment and representation tend to evolve and interrelate, reappearing more and more as the image of an undifferentiated sense of deviancy” (1982:42). Such perceptions of psychiatric deviancy, as distinguished from the psychiatric disability itself, nevertheless have had very real consequences, as shown not only in fictional portrayal in film, but by social-scientific analyses and the history of psychiatric institutionalization (e.g., Foucault 1973a, 1981; Gilman 1982; Goffman 1961; Smith, 1990; Szasz 1970b, 1974); the dynamics of these consequences are characterized by Smith (1990:107) as implicit “...institutional relations of power.”

Attitudes Toward Disability

Stigmatization of persons with physical disabilities has been well researched (Altman 1981; Finkelstein 1980; Goffman 1963; Roth 1983; Siller 1976), and the extent to which negative attitudes have been conveyed by the media has been well documented (Biklen & Bogdan 1977; Bogdan et al. 1982; Byrd 1989; Byrd & Elliott 1985; Byrd & Pipes 1981; Elliott & Byrd 1982; Gartner 1982; Institute for Information Studies 1979; Kriegel 1982; Quart & Auster 1982). Research has shown that stigmatizing portrayals in the media have a direct effect on the viewer’s attitudes toward persons with disabilities (Bywater & Sobchack 1989; Domino 1983; Elliott & Byrd 1982; Wahl & Lefkowits 1989). Individuals with psychiatric disabilities also are stereotyped by the media; however, less has been written describing this phenomenon. In her anthropological analyses of the symbolic representations of medicine and healing in various cultures, Comaroff (1978, 1980, 1982) has pointed to the relative lack of such analysis regarding the symbolic representation of most aspects of modern biomedicine, including psychiatry.

Stigma. There is still a great deal of stigma attached to psychiatric disability, despite recent increases in social acceptance of seeking help from mental health professionals (Gilman 1985). In a syndicated newspaper editorial, for example, Cokie and Steven Roberts (1995) lamented the lack of public understanding of mental illness, even in the face of an event involving an esteemed public figure, Colin Powell, and his disclosure of his wife’s clinical depression. Another syndicated column reprinted from the Seattle Times reported on the work of the National Stigma Clearinghouse, a nationwide network that originated from a project begun in 1989 by the New York State chapter of the National Alliance for the Mentally Ill (Colon 1995). Volunteers of the Clearinghouse have monitored television, advertising, and other media for the “flood of mental-illness stereotypes that [has been] overwhelmingly negative” (Colon 1995:A-10). They have generated public response to and protest against the use of negative media stereotypes, but they have not always been successful in persuading advertisers to alter offensive media campaigns. A small body of research suggests that negative media reports can contribute to deleterious attitudes toward mental illness (e.g., Thornton & Wahl 1996). It is important, especially for practitioners working with individuals with severe mental disorders, to recognize the depth of the stigma (Goffman 1963) and the powerful stereotypes which affect their lives.

Language and Communication. Any discussion of stigma calls for some discussion of language usage. For present purposes, “psychiatric institutionalization” refers to confinement in an asylum or hospital. “Psychiatric disability” is a term adopted from the rehabilitation literature (e.g., Anthony et al. 1990; Katz, 1992); its theoretical grounding traces back to a developmental-based rehabilitation model rather than a more pathology-based medical model. Decisions about language choice are based partly on the cultural meanings ascribed to deviancy terms. My preferences are influenced by the discussion about “mental illness” revolving around the views of Thomas Szasz. As he has pointed out, “the term ‘mental illness’ is also widely used to describe something quite different from a disease of the brain” (Szasz 1970a:14). The rationale for the doubts he raises can be found in the social, cultural, political, and philosophical underpinnings of the history of psychiatric institutionalization in our culture (see Foucault 1973a, 1981; Goffman 1961; Smith, 1990; Szasz 1970a, 1970b, 1974; White 1983). Clearly, I do not mean to call into question the medical reality of a “disease of the brain,” but rather, only to examine the powerful cultural metaphors used by the proverbial person-on-the-street and the popular media to discuss psychiatric deviancy. It is the very power of these deviancy-based metaphors, often of mythic proportions, that leads to the stigmatization which often prevents persons having psychiatric disorders from seeking and sustaining needed treatment.

Deviancy. Historically, deviancy has been ascribed to individuals with severe mental disorders (Foucault 1973a, 1981; Goffman 1963; Smith, 1990; Szasz 1970a, 1970b, 1974; Wolfensberger 1972). They frequently have been stereotyped in Hollywood films by using icons associated with deviancy. This has served to reinforce societal stereotypes of “madness,” “insanity,” and “mental illness.” Szasz (1970a) explains how, within the history of psychiatry, a social perception of deviancy has come to be labeled “mental illness.” The deviant are also the “mad” (Szasz 1970a). When a disability is perceived as deviant, the negative value attributed to the individual with a disability increases (Wolfensberger 1972).

Gilman’s (1982) survey of the iconography of “madness” in the older visual arts reveals a set of deviancy icons of “insanity” which has had common currency at least since the Middle Ages. Major thematic stereotypes of disability present in printed and visual media have been identified (Biklen & Bogdan 1977; Institute for Information Studies 1979), and some have been theorized to encompass psychiatric disability as well (Hyler et al. 1991; Wall 1978). However, little has been written about how stereotypes of psychiatric disability are communicated in film. This is a significant lacuna since film is one of the more important media (Hollander 1991; Sless 1981); since it quite often deals with psychiatric disabilities, sometimes even before they are officially recognized by the professions--Post-traumatic Stress Disorder, for instance, appeared in Hollywood film noir in the 1940s, more than thirty years before inclusion in the DSM III (Miller 1987); and since, finally, filmic communication has significant social and political import that can support misleading metaphors and stereotypes (Andrew 1984; Nichols 1981; Thomas 1982).

Metaphor and Myth. It has been proposed by some that “mental illness” is a metaphor for an undifferentiated construct, perhaps more related to a sense of social deviancy and cultural myth than to biochemical etiology (e.g., Gilman 1982; Kriegel 1982; Schneider 1977; Szasz 1974). Lakoff and Johnson (1980:3) have described metaphor as “pervasive in everyday life, not just in language but in thought and action. Our ordinary conceptual system, in terms of which we both think and act, is fundamentally metaphorical in nature.” Wright (1975: 124) has argued that “...myth provides a conceptual model of social action and that, therefore, the narrative action of the myth relates to the everyday social actions of individuals.”

Sontag (1979) has examined the ways in which our culture construes illness as metaphor. When individuals are threatened by the difference of “the Other,” negative characteristics are projected onto those who are “different.” The use of deviant images of “madness” in film is one way that the ‘myth of mental illness’ (Szasz, 1974) has been extended to the contemporary everyday social actions surrounding “Othering.” In his analysis of another filmic genre, Wright (1975: 2) has offered this explanation for the popularity of the genre, based on its mythic structure:

...the [genre], like any myth, stands between individual human consciousness and society. If a myth is popular, it must somehow appeal to or reinforce the individuals who view it by communicating a symbolic meaning to them. This meaning must, in turn, reflect the particular social institutions and attitudes that have created and continue to nourish the myth. Thus a myth must tell its viewers about themselves and their society.”

Gilman (1985) has described the strong social need to create stereotypes as a way of ordering and fixing reality, suggesting that anxiety and ensuing stereotypes arise from a fear of losing control. From a social constructionist perspective (Berger & Luckman 1967), psychiatric institutions have evolved, at least on some level, in response to this anxiety, and the socially constructed reality has become the “experience” upon which stereotypes of “the mad” have been based. The structure of the stereotype of “madness” is so deep and pervasive, according to Gilman (1985)–and of such mythic proportions, according to Szasz (1974)–that we may regard it as having common currency.

The Inquiry

The research questions addressed in this study primarily emerged from a long-term general concern about how some segments of our culture are ostracized, and a particular concern about the way in which “mental patients” are stigmatized. Formulation progressed in stages from a tacit concern to a more formal theory that finally framed the qualitative research question (for a cogent discussion of the model for this research cycle, see Marshall & Rossman 1989). The literature regarding media stereotypes of disability (Biklen & Bogdan 1977; Institute for Information Studies 1979), the iconography of psychiatric disability (Gilman 1982), the history of psychiatric institutionalization and its ensuing stigma (Foucault 1973a, 1981; Gilman 1985; Goffman 1961; Smith, 1990; Szasz 1970a, 1970b, 1974), and social and cultural constructionism (Berger & Luckman 1967; Geertz 1973) informed the research questions.

The Research Questions

The main research question that served to guide the overall inquiry was: How are individuals with a psychiatric disability depicted in Hollywood films? Four subsidiary questions also were posed: 1) What major thematic stereotypes of psychiatric disability in Hollywood films can be identified and analyzed? 2) What icons of “madness” identified in the historical perspective of the traditional visual arts also are used in the representation of psychiatric disability in Hollywood films? 3) Do icons of “madness” reflect the stereotypes of psychiatric deviancy in Hollywood films? and 4) Have any changes occurred in the depictions of psychiatric disability in Hollywood films in the fifty years between 1940 and 1990? Answering the four subsidiary questions served to provide a context for informing the guiding question. The nature of the guiding question required a descriptive research methodology. The research design which evolved lent itself well to qualitative findings about stereotypes of psychiatric disability as depicted in film (Berger 1982).

Research Design

This study is grounded in the assumptions of naturalistic inquiry, which, as Tesch has pointed out, “is actually not a type of research, but the label for an entire knowledge producing paradigm” (1990:67). This is a naturalistic inquiry into the nature and contextual meaning of how the media portray persons with “mental illness.” Not atypical of qualitative research, this study is multimodal (Goetz & LeCompte 1984; Tesch 1990; Wilson 1977), using a number of research strategies to collect data and investigate the research questions. A multimodal approach such as this constitutes methodological triangulation. Triangulation is “the act of bringing more than one source of data to bear on a single point” (Marshall & Rossman 1989:146); it represents a combination of procedures, “using multiple perceptions to clarify meaning” (Stake 1994:241). Triangulation is considered “one important way to strengthen a study design” (Patton 1990:187).

Methodological Approaches

In order to address a rather complex set of research questions aimed at understanding a rather complicated dimension of a particular type of communication and its context and meaning, a blend of qualitative methods was necessary. While the main research approach was ethnography, case study and ethnographic content analysis comprised the major methodologies used. Other theoretical orientations also were incorporated, all sharing similar or compatible philosophical assumptions. This blend of methods resulted in a research modality designed for “dialoging with data” (Tesch 1990:93), that is, for “interpretation” (Tesch 1990:94) of the texts of the films.

The primary research task was to provide a greater understanding of how persons with psychiatric disabilities are depicted in the media by identifying stereotypes and associated icons used to portray psychiatric disability and by examining any changes in that portrayal over the course of a five decade span of time. The study combined a multiple case study of 21 films with an ethnographic content analysis of each of the films. A purposeful sampling (Patton 1990) required that films be chosen that were most likely to reveal how attitudes about “mental illness” are transmitted to and reinforced within the culture. Data collection consisted of an interrogation of each film comprised of the following components: 1) identification of stereotypes of “mental illness” that exist, 2) identification of icons of “madness” that exist, and 3) assessment and interpretation of information that emerged as a result of the protocol. A structured viewing of each film allowed for the generation of a detailed and rich knowledge base about how psychiatric disability is portrayed in film and for tracking changes in depiction over a significant time span (one-half of a century, or the first 50 years of films with sound tracks).

Ethnography.Ethnography means “literally, a picture of the way of life of some identifiable group of people” (Wolcott 1988:188). The films investigated in this study represent, literally, the way in which persons with a psychiatric disability were “pictured” or portrayed. The purpose was to “learn about, record, and ultimately portray the [film] culture” (Wolcott 1988:188) of the time in question. “Ethnography offers a perspective for analysis of human action in the field and in documents; the key is to reconceptualize the latter as the former and vice versa” (Altheide 1987:76).

Case Study.A qualitative case study is an in-depth examination of a phenomenon, rich in detail, description, and interpretation (Merriam 1988; Stake 1994; Yin 1989). There are several advantages to case study method (Donmoyer 1990): it has accessibility, as it enables the researcher to cover ground that would be impossible in other types of research; it allows the reader a view through the eyes of the researcher, perhaps seeing the subject in a way not otherwise possible; and it can add nuance and subtlety to knowledge about the phenomenon. “In short, case studies can help those who are uninitiated into a particular theoretical viewpoint come to understand that viewpoint” (Donmoyer 1990:125).

The qualitative case study “is particularly suitable methodology for...extending the knowledge base” (Merriam 1988:xiii) of a problem such as the one under investigation here. Pescosolido has identified Frances–one of the films examined in this inquiry–as a “movie [that] best represents a ‘case’ to which sociological ideas can be applied” (1990:340). Other case studies have appeared in the literature, providing analyses of One Flew Over the Cuckoo’s Nest, (Pescosolido 1990; Sodowsky & Sodowsky 1991), Nuts (Pescosolido 1990), Lilith (Leibman 1987), and Splendor in the Grass (Leibman 1987). The investigation reported here offers analyses of 21 case studies. Merriam (1988) points to increased levels of reliability and validity with multiple case studies.

Ethnographic Content Analysis.While sometimes associated with quantitative research, the method of content analysis can be qualitative in nature, depending upon the overall research design (Altheide 1987; Berger 1982; Guba & Lincoln 1981; Merriam 1988; Tesch 1990). In fact, Altheide has suggested that “several aspects of an ethnographic research approach can be applied to content analysis to produce ethnographic content analysis... [which he defined as] ...the reflexive analysis of documents” (1987:65). This type of reflexive analysis (Altheide & Johnson, 1994) of text--or film--has a rich tradition in semiotics, the study of “how meaning is generated in any [sign] systems, including human gestures, road signs, literature, painting, and music as well as film” (Gabbard & Gabbard 1987:177).

The purpose for using ethnographic content analysis is to “document and understand the communication of meaning, as well as to verify theoretical relationships” (Altheide 1987:68). Ethnographic content analysis, then, would seem to be an appropriate methodology to describe film-mediated stereotypes of “mental illness.”

Purposive Sample

In qualitative research, sample size is generally small, and sampling is purposeful, therefore requiring careful selection that is informed by the research design (Patton 1990; Marshall & Rossman 1989). The aim in this study was to select content-relevant mainstream Hollywood films, given their audience share and thus social impact.

Initial Data Collection

Identification of these films proved to be an arduous task at the time of the original study (Levers 1988). Library computer searches were conducted, and reference librarians familiar with the relevant literatures were consulted at several large university libraries. While newly published subject indexes are now available–both current and retrospective–nothing in the literature at that time categorically indexed films containing scenes of psychiatric hospitalization. My sources of discovery included a filmmaker with an interest in the topic, a knowledgeable theater owner, and several individuals with reputations as “film buffs.” I also scanned the film titles in popular film anthologies (e.g., Maltin 1988, 1993) and filmographies, using descriptors such as asylum, crazed, mental, psyche/i/o-, and so forth, which was not nearly as fruitful as the interviews with the film aficionados.

Dozens of films were previewed for this study so that the sample could be carefully selected. The main criteria for selection were that the films depicted persons confined in psychiatric institutions (or psychiatric wards of general, private, or VA hospitals); and that they were Hollywood-made, and classifiable as mainstream (having a sound track, being feature-length, having a large, not a-typical viewing audience, etc.).

I spent almost three years researching and locating the films for this inquiry. [Gabbard and Gabbard (1987) have provided a useful filmography in their text on psychiatry in the cinema; however, I completed the study by the time their book became available. Nonetheless, their text served to triangulate my research; I had identified nearly every representative film.]

Of the 28 films selected, I was able to procure 21 for research. After much effort, the other seven simply could not be bought or rented at the time. The seven films that were described in the literature as containing psychiatric hospitalization scenes, but unavailable for my use, were: Private Worlds (1935), Harvey (1950), The Cobweb (1955), The Nun’s Story (1959), Caretakers (1963), Captain Newman, M.D. (1963), and Shock Corridor (1963). A sample size of 21 is considered large for this type of qualitative study, and the films obtained, based on the process of delimitation, were highly representative of the phenomenon under examination in this study. Since the completion of this investigation, I have been able to procure copies of Harvey, The Cobweb, The Nun’s Story, Caretakers, and Captain Newman, M.D., along with four later films from the same fifty-year span of time: Dream Team (1989), Crazy People (1990), Awakenings (1990), and Chattahoochee (1990). While the protocol for this study was not formally applied to these nine films, each was viewed, and each fit the stereotype and iconography patterns represented by the sample used in this inquiry. Chattahoochee, of the same genre as One Flew Over the Cuckoo’s Nest, . Never Promised You a Rose Garden, and Frances, was of particular interest, providing a filmic rendering of the actual case of an institutionalized veteran of the Korean conflict whose late 1950s litigation against the State of Florida set the stage for President John F. Kennedy to sign the original mental health law in the early 1960s, establishing catchment areas for community mental health centers throughout the country and ultimately inaugurating the deinstitutionalization movement in the U.S. Harvey was of the same genre as They Might Be Giants, that is, a metaphoric fantasy treatment of mental illness. The films appear in Table 1 in chronological order.

Table 1: Films Identified for Scenes of Psychiatric Hospitalization

The rationale for limiting sample selection to include only American feature-length theatrical films with sound is based on theoretical as well as practical considerations. Three points highlight the logic of the decision. First, considering the difficulty in identifying English-title films, a choice to search for foreign-language titles, especially languages with which I am unfamiliar, would have been an insurmountable barrier to conducting this research. Second, Hollywood can be viewed “ a meaning-making institution” (Denzin, 1995: 3); mainstream Hollywood films have viewing audiences around the world, and feature-length theatrical Hollywood films are representative of films viewed by populations outside of as well as inside the United States. Third, a treatment of American films is of particular utility to American educators and mental health practitioners, and may be of use as well to professionals outside the U.S.

In order to narrow the scope of this study to a performable task, several genres of film–including made-for-TV movies (available only late in the fifty-year period); silent films; experimental/art films; horror, monster, and slash-and-splash films–were excluded from consideration, primarily because they were not as representative as mainstream films but also because of difficulty in tracking and procurement and their relatively smaller and less mainstream viewing audiences. Any one of these genres could be treated independently in separate or comparative studies.

Data Collection and Analysis

In qualitative studies, the investigator is central to the research (Altheide 1987). In terms of data collection, the investigator is the instrument (Altheide 1987; Marshall & Rossman 1989; Merriam 1988; Patton 1990; Tesch 1990); all data collection, analysis, and interpretation flow through the investigator. I viewed video tapes of the films in chronological order (Yin 1989) at my home, where I had maximum control of my environment. Every effort was made to view each film as consistently as possible and to eliminate any potential for interruption once the viewing had begun. In addition, it was necessary to maintain a posture of being both an “insider” and an “outsider” (Guba & Lincoln 1981; Marshall & Rossman 1989; Spradley 1980; Tesch 1990), that is, to assume a dialectical perspective that was both emic and etic (Fetterman 1989; Levers 1997; Patton 1990). I experienced the film culture of psychiatric disability portrayals as a subjective viewer of the films as I researched this culture, while at the same time, I was as objective-as-possible a viewer as I investigated constructs of iconography and stereotype identified prior to beginning the structured data collection process.

“Structured data collection based on a protocol combined with ethnographic field notes supports a theoretically informed account” of film content (Altheide 1987:74). The data collection for this study was structured in several ways. Each film was interrogated separately for its contents. Three structured elements of interrogation were used consistently with each film and formed the protocol for inquiry. The protocol included a stereotypes tool, an icons tool, and a structured narrative, described below; ethnographic field notes allowed me to capture additional previously unidentified categories of data as they emerged during the interrogation. During this stage of data analysis, I held frequent consultations with a psychiatric rehabilitation professional, a sociologist, a psychologist, and a filmmaker to check my perceptions and the reliability of the findings.

Stereotypes. The literature regarding media portrayal of disability (Biklen & Bogdan 1977; Institute for Information Studies 1979), identified the following ten thematic stereotypes of persons with physical disabilities as they appear in the media:

The Institute for Information Studies (1979) also suggested that the following positive depictions of people with disabilities would be desirable for portrayals in the media:

I created a checklist that served as a tool for identifying the stereotypes and their frequencies of appearance in the films. The tool also allowed for the possibility of positive portrayals. The checklist was adapted from a “Values Checklist” used by the Council on Interracial Books for Children (1976:25). The checklist was modified for the purpose of this study and included cells for notation as to whether the stereotype was demonstrated by image or in speech; “like all ethnographic research, the meaning of a message is assumed to be reflected in various modes of information exchange...and style, e.g., aural and visual style, as well as in the context of the report itself and other nuances” (Altheide 1987:68). Blank paper was also available for the notation of any additional stereotypic or positive portrayals.

Iconography. An iconography of “madness” in traditional visual art was identified and examined by Gilman (1982), who points out that the Renaissance concept of the unique appearance of the “madman” was based upon older traditions of perceiving and portraying the “otherness” of “the insane”:

The madman was already visible in the Middle Ages, through a vocabulary of images which blended schematic representations of various symptoms and symbolic references to madness into an integrated portrait of the insane. This iconography was extended to all the figures associated with any divergence from the society’s accepted norms for sanity, whether the maniac, the idiot, the melancholic, the wild man, or the possessed. As the images of the madman evolved, aspects of the imagery of each group permeated the others, generating an interchangeable set of icons by which the insane were either observed or identified. (Gilman 1982:2)

Drawing on Gilman’s work, I created a list of icons, associated with the historic portrayal of “madness” in traditional art, to discover whether the same representations could be found in films. The icons examined in this study include such images as objects near to or held by the “insane” subject, clothing worn, facial expressions, physical characteristics, physical posturing and gesturing, and environments, or characteristics of the same, in which subjects portrayed as “mentally ill” are placed. I created a tool that listed the icons and provided cells for counting their frequencies of appearance in the films. The list of icons drawn from Gilman’s work and used in this study is presented in Table 2.

Table 2: Rank Ordering of Iconography of Psychiatric Disability by Total Frequencies. Table 2 also indicates number of films in which each icon appears

Structured Narrative. The structured narrative was comprised of basic information that emerged during data collection and as a part of the interrogation of each film. This part of the protocol included examination for the following elements: the usual credit and descriptive information about the film; a brief description of the main theme, the setting, and any form of foreshadowing–that is, the pre-credit or during-credit presentation of any motiff, music, quotation, or symbol, such as a foreboding entrance to an asylum, that sets a tone or mood for the film; and a detailed narrative of the plot. Integrated into the plot narrative were a description of the instances of icons and a list identifying the icons and the frequency of their appearance; a description of the instances of stereotypical portrayals and a list identifying the stereotypes and the frequency of their appearance, based on both sound and image; and a description of the hospital settings and/or ward environments. Analysis and interpretation of depictions were interwoven throughout the plot narrative. Additional questions that arose during early data collection and that were incorporated as part of the protocol were: Does musical score or other sound effects, such as screams or sirens, contribute to communication of stereotypes? Are there additional icons present that were not identified previously? Are there additional stereotypes present that were not identified previously?

The Filmography

The protocol was used with each film. The ensuing narratives comprise the annotated filmography, one major result of the study. The filmography provides thick descriptions of how individuals with a psychiatric disability are portrayed in each of the 21 films. The interested reader can find the full descriptive text of the filmography in the original version of this study (Levers 1988).


An examination of 21 films brought numerous methods and sources of data to bear on the single point of determining how persons with a psychiatric disability are depicted in film. A cross-case analysis of the 21 cases and their cultural context was consistent with the assumptions and theories outlined above (Lincoln & Guba 1985; Marshall & Rossman 1989; Merriam 1988; Patton 1990). This study also involved a constant search for negative instances of the phenomena (stereotypes and icons) under consideration, that is, positive portrayals, and those findings were analyzed and interpreted as well as the stereotypes and icons being sought (Marshall & Rossman 1989; Patton 1990). Throughout, I was concerned with data quality control (Marshall & Rossman 1989; Patton 1990) and frequently consulted with psychiatric rehabilitation, sociology, psychology, and filmmaking professionals during data collection, analysis, and interpretation phases of the study.

The reporting here is limited to information related to the presence of stereotypes, “icons” in the meaning already indicated, and positive portrayals associated with the filmic depiction of persons with psychiatric disabilities. All of the stereotypes identified prior to the research were found in the 21 films that were analyzed. Two additional stereotypes emerged during data collection: the stereotype of psychiatric disability as “artistic/creative genius” and the stereotype of psychiatric disability as “pathological” or “medicalized.” A number of associations were made in the films between “madness” and artistic or creative genius. Individuals were shown engaged in activities involving art, music, dance, and so forth, and icons associated with this stereotype were observed. Likewise, persons depicted as having a psychiatric disability were portrayed with strong linkages to illness or medical pathology. This stereotype was triangulated by Gilman’s (1985) description of “mental illness” as a stereotype of pathology, and Pescosolido’s reference to the “medicalization of deviance” (1990:341). The iconography associated with this stereotype was largely medical in nature. People were shown in medicalized environments, their representations relying heavily on the use of hospital technology and other hospital accoutrements, for example, wheel chairs, bandages, and professionals dressed in white. They were discussed using language which either overtly referred to or inferred sickness, illness, and poor or failing health.

All of the icons identified prior to the research were found in the 21 films except the rat icon (see Table 2). Additional icons emerged during data collection and are presented in Table 3.

Table 3: Rank Ordering of Additional Iconography of Psychiatric Disability, Not Previously Identified in Still Art, by Total Frequencies. Table 3 also indicates number of films in which each icon appears.

The iconography of “madness” reflects the stereotypes of psychiatric disability that have been identified in the films analyzed. The icons can be collapsed into related groupings, and these groupings can be categorized by the stereotypes. Table 4 is a classification of icons of “madness,” listed categorically by stereotypes. Many of the icons relate to more than one stereotype.

Table 4: Classification of Icon by Stereotype

Instances of all positive portrayals suggested prior to the research were identified. However, they were present in only three films: . Never Promised You a Rose Garden (1977), Coming Home (1978), and Nuts (1987).


Persons with a psychiatric disability are largely depicted as dangerous on the one hand or as passive objects of violence on the other, as medically pathological, and as pathetic or comical figures, whose stereotypical representations in most films seem crucial to establishing a pathological or deviant atmosphere. The iconography present in the films supports this pattern of stereotyping. Most of the frequently appearing icons illustrate either the dangerous stereotype (staff/club, restrained, held/guided by warders, body invasive technique, and cage), or the object of violence/passive stereotype (eyes cast down, hiding hands, seated, restrained, scampering fools, held/guided by warders, body invasive technique, and cage). These portrayals of “madness” are not necessarily or even usually reflective of the reality of a psychiatric impairment; however, they are significant in considering the powerful impact which such stereotypical filmic images may have upon the viewer. I am, of course, not attempting to deny the real dangerousness that may be associated with the symptomatology of some forensic psychiatric patients, but I argue that such truly dangerous patients are in the minority.

A full discussion of the results is not possible here. However, one important element of this study is how depictions have changed over time. From this emerges the question of any time-bound accuracy of the portrayals. It is this dimension that is perhaps most relevant to those interested in the cultural aspects of modern psychiatry.

Change Spanning Five Decades

The frequencies of appearances of icons, stereotypes, and positive portrayals in each film are shown in Table 5, and their averages are listed by decade. Fluctuations in frequencies from decade to decade do not yield much meaningful data. However, when the data are analyzed relative to the Hollywood Production Code–the rules by which films could be produced–the frequencies take on significance. Beginning in 1934, the Production Code virtually prohibited the use of “insanity” as a major theme in films (Roffman & Purdy 1981). It was only after 1968, after the 1934 Production Code had been discarded, that “mental illness” was finally permitted as thematic subject matter for commercial films (Winick 1978).

Table 5: Depictions of Psychiatric Disability by Year

In Table 6 the films are grouped as pre- or post-1968, and the frequencies of the icons and stereotypic and positive portrayals are listed according to their appearances during or after the Code. Corresponding averages appear after each grouping.

Table 6: Pre- and Post-Code Portrayals of Psychiatric Disability

The data from Tables 5 and 6 indicate an increase in the instances of icon occurrence, stereotypic portrayals, and positive portrayals. While the frequency in the appearance of icons more than doubled, the incidence of stereotypic portrayals rose slightly after 1968, and at the same time, the appearance of positive portrayals emerged. This is a paradox which needs further explication.

Prior to 1968, the theme of “mental illness” really could not be treated in any naturalistic way in the films. Hence, the presentations–especially of protagonists–were highly stylized renditions of how a director, filmmaker, or actor construed the subject. After 1968, once the ban was lifted, it seems that an attempt was made to delve into the issues surrounding “mental illness” in a more socially conscious, or at least relatively more accurate, manner (Roffman & Purdy 1981). In so doing, films were produced that deal more accurately with the environment of “mental hospitals.” Ironically, it is within the group of films (post-1968) which depict the hospitals with greater accuracy that an increase is seen in the appearance of iconography associated with “madness” and also in stereotypical portrayals. Since it is the institutionalization of persons with a psychiatric disability that has separated them from the mainstream of society, thus establishing them as “mentally ill” (i.e., “deviant” enough to warrant separation from “normal” others), it is plausible, then, to view the hospitals at least as participants–at least historically–in generating stereotypes of “madness.” From a social constructionist perspective, the hospital/institution has constructed or manufactured a stigmatizing environment, the filmmaker has portrayed this environment, and all the stereotypes continue to be reinforced in the eyes/brains (Sless 1981) of the viewers. This notion triangulates with Goffman’s (1961) discussion of learned “crazy” behaviors in asylums.

On the other hand, the appearance of positive portrayals is not a contradiction. It is predictable that any social cause, including the cause of those who are psychiatrically disabled, would be treated more openly and realistically after 1968, given societal changes occurring in the 1960s and 1970s. It is also predictable that at least some positive portrayals would emerge as a by-product of the trend to depict “mental hospitals” and “mental illness” with greater accuracy. However, in spite of their appearance after 1968, these positive portrayals are found in only three films.

From this historical perspective, a question emerges about a possible relationship between the manner in which society stereotypes “mental illness” and the way in which “mental illness” is interpreted to the society by psychiatric professionals. Society construes “mental illness” in a particular way and thus has manufactured an environment in which to frame it, that is, the hospitals. “Mental illness” is a social construct which at the same time arises from and re-creates a stereotype of “madness.” It becomes a reification which takes its final embodiment in horror chambers: the prototypes for the first Nazi gas chambers were built in German mental hospitals in 1939, and “the gassing of mental patients (and some other chronically ill patients)...[began] death rooms disguised exactly as they later were in Auschwitz, as shower rooms and bathrooms” (Szasz 1970b:314); patients were “warehoused” in U.S. asylums, under deplorable conditions, from the 19th Century until well past the middle of the 20th Century, and “remedies” included lobotomy, removal of the clitoris, and other body-invasive “treatments.” Although significant reform has taken place, the history of cruel treatment has left a legacy of stigma and deviancy-related stereotypes. When an individual was placed into the deviant environment of a “mental hospital,” a strong expectation was placed upon the individual to act deviantly, that is, “mentally ill.” Thus the paradox is explained, and it is plausible to consider that the filmmaker both has translated an actuality to the cinema screen and also has reactivated the transmision of age-old stereotypes. As put by Denzin (1995:2), “...society capitalized on the camera’s gaze as a method of creating and documenting reality.”

Metz (1983) has illustrated how media can provide a means for examining institutions. Pescosolido (1990) has explained that films can be examined as case studies of institutions. As the data emerged in this study, it became clear that the case studies reflected the portrayal of psychiatric institutional environments as much as the portrayal of psychiatric disability or the portrayal of individuals with a psychiatric disability. In the pre-1968 films, highly stylized protagonists were shown in juxtaposition to their dreadful environments. However, in the post-1968 films, the protagonists were shown more as part of their deviant environments. To a large extent, the depictions of protagonists changed over the five-decade period, but the portrayals of the hospital environments remained fairly constant.

Observations made in this study of the mostly highly stylized pre-1968 film protagonist (e.g., Elizabeth Taylor, who more-or-less remains beautiful, usually without a hair out of place, in Suddenly Last Summer, in stark contrast to the horror and prurience of the mental asylum), versus the more blended post-1968 protagonist (e.g., Jessica Lange, also beautiful, but blending into or taking on the horror and persecution of the environment into which she is placed in Frances), support the premise that post-Code filmmakers seem to have attempted a more serious, more realistic view of “mental illness” in contemporary society, that is, a more accurate portrayal of the “mental institution.” It suggests at least the possibility, or generates the hypothesis, that perhaps the hospitals themselves have been a strong stigmatizing force in this society.

One change observed relative to the filmic hospital environs was a move from darkness and shadows in the earlier films to bright/white/light in the later films. It seemed almost like a reflection of social policy, moving from the darkness and shadows of uninformed and reactive treatment to the sterility of “modern” Mental Hygiene Reforms. Foucault (1981) explains this phenomenon in terms of what he calls the “medical gaze” and the need for architectural shifts that can properly maintain the balance of power between those who gaze and the objects of the gaze.

Cultural Implications

It is important to understand the manner in which a culture can stereotype a group of people, then base and justify social treatment upon that stereotype. We need not necessarily look to such distant historical incidents as the Inquisition (Szasz 1970b) or the witch-craze cycles (e.g., Ehrenreich & English 1973) in order to establish that this occurs. We only need look at the Twentieth Century, and its move into the Twenty-First, for sufficient examples of the tragic effects of systematic bigotry, from Nazi Germany to Rwanda to Bosnia, and all the other well-known examples.

These sociocultural problems, arising from stereotyping, are contemporary. In one newspaper article, for example, it was reported that a German cemetery for victims of the Dachau concentration camp “was damaged and smeared with swastikas...and foreigners in a half-dozen cities were attacked” (Beelman 1992: A3); another article in the same section of the newspaper reported that when a woman in Los Angeles wrecked and overturned her car, a naked man boarded to sexually assault her, attempting to rape her while she was still strapped in her seat belt in the wrecked car (“Man Attacks” 1992).

Perhaps of special significance through the 1990s, and at the turn of the century, is the re-emergence of the perceived “necessity” for hospitalizing identified groups of people. The issue of homelessness, for example, has been construed more and more frequently as a psychiatric problem related to the need for hospitalization, rather than as a social problem related to poverty and the need for alternative economic assistance; critics of deinstitutionalization have promoted this view of homelessness (e.g., Torrey 1997). Other threats to deinstitutionalization have surfaced in recent years and include the immediate economic success of private psychiatric wards that specialize in treating substance abuse, dissociative identity disorders (with more and more civil and now even criminal trials in this area, this one already an un-success?), and variations on child and adolescent conduct disorders. The medicalization of existential constructs that results in forced psychiatric hospitalization demands to be viewed cautiously, if not skeptically. The danger therein rests with a society that has not yet examined its stereotypical, that is, socially constructed, views of “mental illness”; the harm that has resulted historically as a consequence of these views has gone mostly unchallenged. It is hoped that this examination will inspire other studies of stereotypes and deconstructions of stereotypical media portrayals, and that continued research will analyze the effects of such symbolic representation upon the viewer.


This cross-case analysis of 21 films confirms that Hollywood’s portrayal of psychiatric disability replicates Gilman’s (1982) iconography of “madness” and resonates with stereotypes historically associated with disabilities. Visual representation is a powerful means of communication; visual stereotypes reflect the attitudes of the culture and also shape and reshape the perceptions of the viewer.

Can one hope that investigations of this type can facilitate a better understanding of the deep structure of the stereotype of “madness,” a structure rooted in centuries of mistreatment? Throughout history, artists have depicted this “culture of insanity” in stereotypical imagery, but today’s media of mass communication–film and video–are so pervasive that the negative effects of stigma propagation through them becomes especially dangerous. On the other hand, they could, by the same token, also be powerful agents of enlightenment. There is useful work to be done here by people in all the various professions touching on this problem. In any event, it is important that we understand and continue to question the manner in which persons with a psychiatric disability are socially stigmatized.


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