Visual Media: An Aperture Into the Past and Future of Psychiatry

Since the first movie in 1895, cinema has significantly influenced psychiatry, and vice versa, in a way that other visual media forms, such as photography or painting, could not. The mutual interest in the mind, behavior, and society made it inevitable for the two fields to study each other. It is important to familiarize ourselves with the history and current portrayals of psychiatry in popular media to understand preconceived perceptions that patients may bring into a therapeutic session. Here, we briefly summarize the relationship between psychiatry and forms of visual media (films, television, and social media) that have become increasingly influential in the 21st century. In addition, we discuss our practical experiences in our training program, through “Psych Movie Nights” and “The Gathering,” and potential future directions.

Starting in the early 20th century with the silent movie Dr. Dippy’s Sanitarium (1906), psychiatry and psychiatrists became major subjects in cinema. Filmmakers have rarely portrayed psychopathologies, treatments, and psychiatrists realistically or positively (2). Negative, stereotypical portrayals of mental illness, psychiatrists, and psychiatric treatment not only contribute to society’s false beliefs about psychiatry but also serve as an outlet for public discussion of the impact of some psychiatric practices (e.g., commitment, forced treatment, and conversion therapy) (3). Many movies demonize or caricaturize people with psychiatric disorders as violent criminals or a danger to society, although evidence demonstrates that these individuals are more likely to be the victims of violent crimes rather than the perpetrators (4). Overidealization of psychiatrists and their psychotherapeutic approaches in some movies, such as Ordinary People (1980), led to unrealistic expectations of the treatment process and further confused the public on the role of psychiatrists. When portraying other evidence-based treatment modalities, such as medication treatment or electroconvulsive therapy, there often is a negative or punitive theme, such as in A Women Under Influence (1974) and One Flew Over the Cuckoo’s Nest (1975) (1). Many movies unrealistically portray “love” (sometimes controversially between the patient and psychiatrist), talk therapy, or hypnosis as a cathartic cure for psychiatric disorders. Some of the most popular stereotypical portrayals of mental illness and psychiatry are listed in Table 1.

With advancements in media and Internet technology in recent decades, accessibility to television and film has risen dramatically. In the case of psychiatry, its sensitive and historically stigmatized topics draw a strong public curiosity and remain fodder for entertainment. Around the turn of the millennium, one-fifth of prime-time television programs depicted some aspect of mental illness (5). Around the same time, mass media was reported as the most common source of knowledge in the United States (6). But when we are engrossed in the world on the screen and caught up in the lives of relatable characters, we easily forget the effects these portrayals have on unconscious biases and perceptions.

A 2000 study found that among a group of young adults who indicated television as their primary source of information on mental health, increased exposure was associated with intolerance and authoritarian views toward people with mental illness (7). A 2006 review on the extent, nature, and impact of portrayals of psychiatric disorders found that “on-screen portrayals are frequently, generally negative, and have a cumulative effect on the public’s perception and on the likelihood of patients seeking appropriate help” (8). These representations are overwhelmingly dramatic and distorted, often emphasizing dangerousness, criminality, and unpredictability. Moreover, entertainment media frequently depict mental health providers as dubious or exploitative (which persists in modern media, such as a therapist making and consuming an alcoholic beverage while conducting sessions in the 2011–2021 series Shameless, or a therapist asking his client out in the 2005–2014 series How I Met Your Mother), which promotes distrust of providers and avoidance of psychiatric care (9).

Some recent portrayals have been linked to more direct harm. In 2019, the National Institute of Mental Health (NIMH) issued a press release reminding the public of the dangers of portrayals of suicide. NIMH cited a study that showed increased suicide rates among youths in the United States in the month following the release of the Netflix show 13 Reasons Why, which chronicles the story of a victim of bullying who kills herself and leaves behind tapes detailing the reasons why she chose to end her life. In the study, researchers compared expected historical trends and found a nearly 30% increase in suicide rates among youths ages 10–17 in the month following the show’s release and an additional 195 deaths by suicide in the following 7 months, compared with predictions (10).

There is a movement for portrayals of mental illness to serve a more positive or productive purpose. In addition to accounting for sensitivities and excluding exaggerations or stereotypes (such as the inaccurate overemphasis of violent tendencies among patients with dissociative disorders depicted in the 2016 movie Split), “good” representations in media display help-seeking behavior, such as reaching out to a trusted adult or professional, and include a message of treatment and recovery (11). The 2012 film The Perks of Being a Wallflower attempted to show this through its protagonist Charlie, who has depression and had been hospitalized for suicidal ideation, when he, in a pivotal scene, opens up to his psychiatrist and begins engaging in his treatment. However, the desire to depict hope and helpful providers can also lead to misrepresentations; for example, in the contemporary sitcom Crazy Ex-Girlfriend, the therapist violates professional boundaries, becomes attached to her patient, and conducts a session while stuck on a plane (a kind of “overidealized” but professionally questionable depiction also present in work such as Ordinary People). Some argue that this decreases the stigma of reaching out to mental health professionals. However, these depictions can also promote unrealistic expectations of the treatment process and perpetuate misinformation about the mental health field. The utilization of mental illness as a theme in mass media will continue to grow, and regardless of whether the overall effect is positive or harmful, these portrayals undeniably had and will continue to have far-reaching effects on the practice of psychiatry.

The rapid rise in social media over the past decade renders it powerful and unpredictable. While often discredited as frivolous entertainment, social media is in fact one of the predominant forms of information consumption across almost all age groups (12). Attempting to define this potentially new category of media has been difficult. The word “social” emphasizes facets of shareability, interaction, and thematic community creation (for example, digital interest groups, such as subreddits, Doximity, and Facebook groups); the word “personalized” is also fitting. Once a lip-syncing app, the now giant TikTok has championed the often-copied idea of the seemingly endless and individualized feed of videos, aptly named the “for you page.” On the basis of interaction with content (through likes and dislikes, posts, and comments), it is now possible—from anywhere there is a cellular signal or WiFi connection—to watch algorithmically curated videos from children to celebrities, politicians, classmates, neighbors, brands, and more. Never has there been this amount of “information” available to people at one time. A person can watch a video of political unrest, then scroll to the next clip of a cat dancing or the new viral pasta recipe, and then to a person detailing his or her inpatient psychiatric stay. Although there is certainly an emotional and cognitive impact of access to this type of content, our interest is in the way in which psychiatry and mental illness have become popular features of this medium.

As social media gained traction in the 2010s and deepened its breadth, both in form and function, the discussion about mental illness was also gaining momentum. Whether interest in mental illness became acceptable at the same time as social media is an important question. Social media facilitated numerous societal changes, including increased awareness of mental health, the option to be anonymous, and its power to bring people together, but it is unclear whether the relationship between the visibility of mental health and use of social media is correlative or causative. Nevertheless, the vast conversation that social media has allowed is staggering: the videos on TikTok with the hashtag #MentalHealth have a cumulative 98,200,000,000 views as of August 8, 2023, and there are more than 49,000,000 similarly tagged individual posts on Instagram as of August 8, 2023.

Social media has the power to bring together experts in an approachable format, as seen on DocTok (doctor TikTok); to consolidate information and crowd-source questions both for doctors and patients, as seen in Reddit threads for psychopharmacology; to normalize and raise awareness of specific conditions and medications; and to detail personal experiences and resources. At the same time, it creates further biases on the basis of interactions, giving rise to echo chambers for the antipsychiatry movement, as well as self-diagnosis and overpathologizing. Even more concerning is the social contagion concept, as recently addressed by the Tourette Association of America, regarding the unprecedented increase in the diagnosis of “functional tic-like behaviors” (13). We are in a critical time both in psychiatry and digital content, and although some psychiatrists may not be interested in personally or professionally participating in social media, fluency is now a necessity.

For more than a century, visual media has been influencing the public view of psychiatry. We strongly believe that every psychiatrist should be familiar with the popular portrayals of psychiatry to understand the perspective of patients and society. Movies, television, and social media can serve as unique tools for this goal. Visual media can offer memorable depictions of psychopathologies and diverse sociocultural contexts of mental health to trainees and medical students (14, 15). Screening of visual media also can be used as educational material and a platform for group discussion and exchange of information and experience (16). Although there are examples of movie or media interest groups in many psychiatry departments, visual media has been underutilized in psychiatry training (17).

At Washington University in St. Louis, our Psych Movie Interest Group organizes two alternating bimonthly events. At our departmental movie night, we watch a voted-upon film related to psychiatry with faculty, residents, and fellows, followed by an open discussion. At our bimonthly collaborative event series with colleagues from the St. Louis University Psychiatry Department and the St. Louis Psychoanalytic Institute (called “The Gathering”), we watch visual media related to psychotherapy, such as the HBO television series In Treatment (2008–2021), that was chosen by expert psychanalysts. At both events, we view the characters and their behaviors through psychiatric and therapeutic perspectives, exchange experiences, and get to know our colleagues. We are currently working to expand our scope to include new forms of visual media given the rising importance of social media. Overall, these event series have been educational and fun for all levels of trainees in our department, and we are working to include medical students.

Visual media is historically important and has serious implications for real-world clinical practice. As such, incorporating visual media education into the psychiatric curriculum is essential. This may require collaborative effort among residents, faculty, program directors, and organizations, such as the American Psychiatric Association. Initial efforts can include launching an online platform for trainees and faculty to exchange ideas on and experiences with visual media education; hosting online discussion events; and creating a collective reference list of movies, television series, and social media trends related to psychiatry. We are apprehensive yet excited about the expanding influence of visual media on psychiatry and need to work together to leverage our expertise in this changing world.