Psychotherapy in Hollywood Cinema

Adiscussion of the way that the Hollywood cinema has portrayed psychotherapy must begin with the acknowledgement that movie psychotherapy has a set of principles unto itself that bears little resemblance to psychotherapy in real life. 1 , 2 The study of cinematic depictions of psychotherapy is of interest primarily from the standpoint of what it says about cultural myths and collective fantasies about the nature of psychotherapeutic work and the people who practice it. There may also be value for the clinician to know how these images on the great silver screen may affect the expectations of patients who come for help.

In Psychiatry and the Cinema, which was published in 1999, 1 my coauthor and I studied over 400 theatrically released American films that featured some form of psychotherapists or psychotherapist-like individual at work. From this study, we reached a number of conclusions:

Hollywood is fascinated with psychotherapy. The fact that over 400 theatrically released films feature some kind of psychiatrist or psychotherapist in and of itself suggests considerable interest in what we do. The cinematic psychotherapist performs a unique function in film that is indispensable. In a novel, the author can use an omniscient narrator or a first-person voice that allows the reader to know the innermost thoughts of the protagonist. In a film, that device does not work. Voice-overs are generally regarded as ridiculous. Hence the presence of a psychotherapist allows the protagonist to share an inner world on the screen that would otherwise not be available to the audience.

This usefulness of the role of psychotherapy in the narrative of the film may partially explain why the psychopharmacologic revolution in psychiatry never materialised on the movie screen. Psychiatrists are almost always portrayed as psychotherapists. In fact, after looking at over 400 films, I have yet to see one that depicts the effective prescribing of psychotropic medication. The only exception is the 1997 James Brooks movie, As Good As It Gets, where Jack Nicholson's obsessive-compulsive disorder appears to improve with medication. Yet, even in this film, it is not entirely clear whether medication or a woman's love is responsible for the clinical improvement.

Hollywood is thoroughly confused about the difference between psychiatrists, psychoanalysts, psychologists, social workers, and other assorted counsellors and therapists. In a 1946 film called Dark Mirror, the audience sees the office door of Dr. Scott Elliot, which says, ‘Scott Elliot, M.D., Ph.D., M.S., Psychologist’.

The way that psychotherapists have been portrayed in the cinema is a direct reflection of how society regards psychotherapy. In our study, we noted a historical rise and fall of the psychiatrists in Hollywood films. In the 1930s and 1940s, for example, psychiatrists were commonly depicted as Viennese-accented, jargon-spouting, pince-nez wearing buffoons. At the height of the popularity of psychoanalysis in the late 50s and early 60s, there was a brief Golden Age of the psychotherapist in the movies. In fact, between the years of 1957 and 1963, we counted 22 Hollywood movies that depicted highly idealised psychotherapists. This idealised image rapidly deteriorated, beginning in 1964, about the same time that the Berkeley free-speech movement and the anti-Vietnam-war movement were launched. Psychiatry was then seen as part of the military industrial complex, an establishment force that served as the repressive agent of society. This motif continued throughout the 70s in such films as One Flew Over the Cuckoo's Nest and Harold and Maude.

The needs of the cinematic genre far outweigh any concern about accuracy of portrayals. If Phil Joanou is making a Hitchcock thriller like Final Analysis, Richard Gere must act like a detective and solve a murder even though he is a psychoanalyst. If Marshall Brickman is making a romantic comedy like Lovesick, Dudley Moore must fall in love with his patient Elizabeth McGovern, and they must stroll off together in the moonlight at the end of the movie, even though sex between therapist and patient is highly unethical.

Many of us have had dialogues with Hollywood producers, screenwriters, directors, and actors over the years, and their consistent message is, ‘Moviemaking is a business. We're trying to entertain people and make money. That's all!’

If the self-appointed task of directors and screenwriters is to entertain their audiences, then they have always faced a formidable challenge when it comes to depicting psychotherapy. Movies are a medium of action. Talking heads on the screen, with some notable exceptions such as the 1981 Louis Malle film, My Dinner With André, are usually disasters at the box office. We can all imagine how dull it would be if any of us placed a video camera in our office and taped a typical session of psychotherapy and then tried to pass it off as a movie. The audience would demand their money back and walk out in droves.

To deal with this dilemma, filmmakers have seized the notion of what we 1 have called the ‘cathartic cure’ and used it repeatedly throughout the history of American film. Over and over again, audiences have been exposed to patients' being cured after they have de-repressed a traumatic memory and gone through a highly emotional abreaction with the aid of a sympathetic therapist.

The cathartic cure is highly dramatic, moving, and keeps the audience on the edge of their seats. Hollywood does not seem to understand that this approach to psychotherapy was abandoned 100 years ago when Freud realised that recovering the memory did not cure the patient. Nevertheless, filmgoers everywhere are repeatedly exposed to psychoanalytic technique as it was practiced in Studies in Hysteria in 1895, forever frozen in time, preserved on celluloid. What is particularly disconcerting about these depictions is that they may contribute to a wide-spread fantasy, even among educated people, that this technique is still the cornerstone of psychoanalytic therapy. Adolf Grünbaum, for example, based his 1984 critique of psychoanalysis on the assumption that the kind of psychoanalytic technique depicted in Studies in Hysteria is an accurate model of how modern psychoanalysts practice. Similarly, Frederick Crews 3 made a frontal assault on so-called recovered memory therapists, in which he discredited all psychoanalytically oriented psychotherapists because their treatment has been based on a theory that repressed traumatic memories needed to emerge in the course of psychotherapy for a cure.

Some cinematic depictions, which are reportedly based on fact, have been highly misleading in this regard because they presented a grossly oversimplified picture of pathogenesis and treatment. The climax of the 1957 movie The Three Faces of Eve, made during the Golden Age, depicts a cure by a heroic psychotherapist, played by Lee J. Cobb, of Joanne Woodward's character simply by helping her de-repress a traumatic memory of having to kiss her dead grandmother.

This depiction of psychiatric cure is pure myth. In her 1978 4 autobiography, I'm Eve, the real-life Eve, Chris Costner Sizemore, revealed that in fact the recovery of the repressed traumatic memory did not lead to a lasting resolution of her multiple personality. Following the treatment represented in the film, more personalities appeared, a total of 22 in all. She finally attained what she considered to be a lasting recovery in 1974 following a suicide attempt and more intensive therapy.

The cathartic cure may be psychiatric myth, but it is good drama. Obviously, the ‘showbiz’ value of any treatment is of much more importance to filmmakers than its clinical accuracy. Variations of this trend continue throughout more recent film history as well. Even the positive depiction of psychotherapy in the 1980 Academy Award-winning film Ordinary People directed by Robert Redford uses a variation of the cathartic cure.

Once again we see a heroic psychotherapist courageously struggling with his patient and encouraging him to remember something he does not want to remember. In this case he remembers that he held on to the boat while his brother did not. Movies do not lend themselves to complexity. Reductionistic formulas of psychopathology are much more satisfying to audiences and produce a catharsis for them as well as for the patient.

Another implication of Ordinary People is that the ultimate healer is love. Judd Hirsch hugs Timothy Hutton and tells him that he's his friend. This theme is much more fully developed anytime a female psychotherapist treats a male patient. From Ingrid Bergman in Alfred Hitchcock's 1945 film Spellbound through Barbra Streisand in Prince of Tides in 1991 and Lena Olin in Mr Jones in 1993, the scenario has become so clichéd as to be entirely predictable: An attractive female psychotherapist who lacks any type of romantic involvement in her private life is swept off her feet by a handsome male patient. In the course of the psychotherapy, the female therapist is shown to be more disturbed than the male patient, and ultimately the love of the male patient heals the female therapists and helps her blossom into a ‘real woman.’ In Prince of Tides (1991), after beginning the psychotherapy process as a reasonably competent professional, Dr Loewenstein (Barbra Streisand) becomes sexually involved with a handsome football coach (Nick Nolte) that she has assisted in the recovery of a traumatic memory and is ultimately transformed by him.

Dr Loewenstein is unhappily married to a European violinist. What does she need to make her happy? A ‘real man’ to transform her into a ‘real woman.’ She clearly has been profoundly changed by her love affair with the Nick Nolte character, despite its unethical nature. It is noteworthy that he also is cured by the relationship and goes back to his wife and family. The movie suggests that it is not the therapist's technique or training that matters - it is her love.

This theme of the love cure is consistent throughout film history when a female therapist falls in love and becomes sexually involved with a male patient. Indeed, twice as many boundary violations are depicted in this gender constellation than in the reverse, in which a male therapist falls in love and becomes sexually involved with a female patient. 1 In actual psychiatric practice, of course, male psychiatrists are far more likely to transgress boundaries than their female colleagues. 5 An even more revealing bit of data emerges from a comparison of the number of films in which a female therapist successfully treats a male patient (without falling in love with him) to the number of films in which a male therapist successfully treats a female patient. While many male psychiatrists cure their women patients, we could find only two (Private Worlds [¹⁹³⁵] and Last Embrace [¹⁹⁷⁹]) in which a female therapist clearly helps a male patient. 1

Here again we see how certain cultural stereotypes about sex roles creep into film narratives. A successful professional woman and a happy professional life almost never exist together in a film. Female therapists are repeatedly de-professionalised and reduced to sex objects. In fact, another pervasive cultural myth found in these films is that what an unhappy woman needs to make her happy is sex with the right man. The spectre of a female therapist may strike terror at the core of the male psyche. Remember that most of the Hollywood film industry is dominated by male screenwriters and directors, who may deal with this fear defensively by depicting all female professionals as basically ‘just a woman.’ Audiences, too, like to leave the theater with sex-role stereotypes restored, as in Prince of Tides.

Another theme that has occurred in these movies is that psychotherapists are basically ineffectual. Again and again we see films in which common sense, true love, or true grit is what's really needed to deal with problems. Woody Allen's ambivalence about his own analysis has come through in a host of movies featuring analysts and therapists that always seem to suggest that treatment doesn't really help much. In one scene from Stardust Memories, a 1980 Woody Allen film, the filmmaker protagonist, who appears to be remarkably similar to Woody Allen, creates a dream sequence in one of his films in which his own rage and destructiveness is depicted as a murderous beast.

This ineffectual analyst theme is repeated again and again in Allen films, although there appears to be some indication that his view changed a bit over the course of time. By 1985, in Hannah and Her Sisters, we see Michael Caine meeting with a silent therapist on two occasions, and the narrative of the film would suggest that he benefited from this process and eventually gave up a secret affair with his sister-in-law.

This fleeting view of psychotherapy as helpful disappeared in Husbands and Wives 6 years later, when a male therapist is sleeping with a young female patient. Then in Manhattan Murder Mystery (1993), he advises his wife not to go back to her therapist, telling her, ‘You don't have anything that can't be cured by a little Prozac and a polo mallet.’

In the 1993 hit Groundhog Day, Bill Murray finds himself stranded in time so that he must live the same day over and over again without any hope that tomorrow will ever come. Reaching the point of despair, he consults a psychiatrist. The ineffectual therapist clearly is unable to help the Bill Murray character, and the character eventually commits suicide repeatedly day after day, always waking up alive the next morning. This particular depiction is a common one in films that involve science fiction or the supernatural. We have referred to this stereotype as the rationalist foil, a therapist who comes up with brilliant psychodynamic formulations to explain the supernatural, only to be shown as a naïve blunderer. The scrupulously earthbound work of the psychiatrist is the perfect foil for the generic conceit of the unknown, the unseen, and the unseemly.

A corollary of the notion that the psychotherapist is essentially ineffectual is the idea that patients who seek a psychotherapist don't really have significant problems. In the opening scene of Lovesick (1983), Dudley Moore plays an analyst who sees one patient after another whose problems are all basically ridiculed as trivial or absurd.

This trivialisation of the psychotherapy patient has contributed to a substantial public policy problem in the U.S., where getting insurance coverage for psychotherapy is extremely difficult. Patients in psychotherapy are regarded as ‘the worried well’ who don't really need treatment. When I lobbied Congress in the 1990s for more equitable insurance coverage of psychotherapy, politicians repeatedly made comparisons to Woody Allen films.

DISCUSSION

What is the actual impact of these stereotypes on patients or potential patients? Some psychiatrists are highly skeptical that cinematic images seriously influence a person's attitude toward his current or future therapist. Any intelligent patient, the argument goes, can discriminate between the celluloid portrayal and the ‘real thing’. This argument paints the moviegoer as a purely rational thinker beyond the influence of unconscious forces. Media images work on us unconsciously throughout our lives, even if we consciously reject the film stereotypes that we see. We all harbour a mental warehouse full of internal stereotypes coded in our memory banks. The crooked politician, the heroic warrior, the whore with a heart of gold, and the socially inept intellectual are all examples of such internal stereotypes. Madison Avenue has mined these subliminally perceived and stored images to sell everything from toothpaste to political candidates. A purported compliment that many psychiatrists hear from time to time is: ‘You don't act like a psychiatrist’. This comment is usually meant to imply that one behaves in a more or less normal, rational manner. Clearly, the underlying message is that the psychiatrist under consideration does not fit the cinematic stereotype of a neurotic, pompous, jargon-spouting buffoon.

If, as I am suggesting, the average person may not be adept at distinguishing the true nature of a particular occupation from its distorted image in the media, emotionally disturbed individuals will certainly have even greater difficulty. I have seen numerous clinical examples of this phenomenon. After viewing One Flew Over the Cuckoo's Nest, a patient in a psychiatric hospital revoked his previously given consent for electroconvulsive treatments. His psychiatrist explained, in vain, that the barbaric depiction in the movie was in no way similar to the modern version.

A male patient seeing a female therapist might well assume that most female therapists are unfulfilled women more interested in finding a lover than a patient. Indeed, such was the case with a young professional man seeing a female resident for therapy. He said to her in one session, ‘I saw a movie where a woman doctor kissed her therapy patient to make him feel loved. I think it might help me if you would do that to me.”

Just as negatively tinged stereotypes may lead patients to expect that their therapists will somehow violate them, more positive portrayals may similarly result in a patient's developing unrealistic expectations of an idealised sort. A young female college student who had seen Ordinary People, for example, came to therapy for a variety of problems in her relationships. After several weeks of therapy, she was growing increasingly irritated with me. She insisted that I should behave more like Judd Hirsch in Ordinary People. Specifically, she wanted me to be less formal and hug her, as Judd Hirsch had embraced Timothy Hutton in the movie. I explained my reasons for thinking that hugging her would not be in her best interest. She found my explanation unsatisfying and demanded, ‘If Judd Hirsch can do it, why can't you?’ I maintained my position, and a split transference developed early in the psychotherapy, with the movie psychiatrist representing the idealised, ‘all good’ therapist, while I was devalued as ‘all bad.’

In conclusion, we must recognise that the public at large has always maintained an ambivalent view of psychiatrists. On the one hand, there is awe at their understanding of the mysterious workings of the unconscious mind. Alongside this idealisation and reverence, however, are contempt for our limitations, disappointment related to our inability to solve all the social ills of the world, and anger associated with our occasional failure even to solve the personal ills of the individual. Our perceived omniscience is envied and feared, so psychiatrists must be continually ridiculed and put down to neutralise these negative feelings. Movies reflect this process by seeking to demonstrate that psychiatrists are vulnerable to the same human frailties as everyone else. Psychiatrists may simply respond with, ‘So what? We already knew that.’ However, the fantasy that physicians specialising in psychiatry are somehow perfect or superior to everyone else dies hard. One is reminded of the humorous definition: ‘A psychoanalyst is someone who pretends he doesn't know everything’ (p. 185). 1

The choice of a career in psychiatry entails the acceptance that one must serve as a target for a variety of primitive feelings in one's patients. If therapists can accept that their roles as transference objects transcend the confines of the consulting room and spread onto the great silver screen, they can view the distortions with detached curiosity, with empathy, and with understanding, just as they approach transference attitudes in patients. In the meantime, psychiatrists can content themselves with the fact that the rash of films made about them reflects that what we do is of intense interest to filmmakers and film audiences. To paraphrase Oscar Wilde, ‘The only thing worse than being portrayed in the movies negatively is not being portrayed in movies at all’ (p. 173). 1