"I need to believe that something extraordinary is possible," Alicia Nash declares to her husband, John, in the Hollywood production of A Beautiful Mind. John suffers from schizophrenia, and Alicia desperately tries to help him recover from this devastating illness. The film's depiction of schizophrenia has inspired countless patients and their families, and psychiatric educators have already begun using it as a tool for instructing a wide variety of trainees.
Despite the high quality of A Beautiful Mind, the film, like most movies, focuses on a limited number of themes and aims the story at the general public. Perhaps, audiences and teaching goals might be better reached in other ways. However, many commercial movies, each having their own strengths and weaknesses, could be considered as alternatives to traditional teaching methods for illustrating schizophrenia.
Clean, Shaven, for instance, deserves closer examination for its stunning and dramatic presentation of schizophrenia. Contrasts between Clean, Shaven and the more commercially successful A Beautiful Mind may help psychiatric educators choose which of the two films to use and in which situations to use them.
The use of film for teaching psychiatry has been the subject of several recent articles and reviews (1)—(5). Popular movies are accessible, memorable, well made, fun, influential, and thought provoking. Movies show vivid examples of psychopathology in life context, rather than the narrative descriptions given in clinical interviews. A variety of groups can learn from film presentations of psychiatric issues: residents and fellows, medical students, undergraduates, allied health professionals, patients, families, and the general public. However, each audience is distinct, and the setting for the teaching (e.g., lecture, seminar, informal group, public presentation) should influence which segments of a particular film are viewed.
Film can be especially helpful in teaching about schizophrenia because it exposes a variety of audience types and sizes to the relatively unfamiliar phenomenology of schizophrenia. Although many people have experienced affective symptoms such as depression or anxiety to some degree, thought and perception disturbances, such as schizophrenia, may be harder for the average person to understand. Moreover, compared to clinical interviews (live or videotaped), film portrayals of schizophrenia may be easier to obtain, more anonymous, and more illustrative of active symptoms. Finally, dramatically edited commercial films—often with enhanced audiovisual special effects—may provide a more complete, concise, and memorable "virtual" window into the world of psychosis, an often emotional experience that most people might otherwise never have.
Even for professional audiences, film presentations may have advantages over clinical interviews. In a live patient interaction, trainees do not have the ability to "pause" and discuss content or process, "rewind" an interview to review what happened, or "fast forward" to more relevant sections. Similarly, for the lay audience, commercially edited films may be superior to videotaped clinical interviews in their technical presentation, quality, and efficiency. The popularity of commercial films may be a wonderful "hook" to inspire the initial interest of trainees, especially medical students.
On the other hand, psychiatric educators must exercise caution when selecting films for teaching, as many suffer from inaccuracies or contribute to stigma (6). For example, Me, Myself and Irene features Jim Carrey as a man who becomes "schizo" after his wife leaves him, with schizophrenia depicted as "split personality." Released in 2000 and directed by the Farrelly brothers, this clownish comedy has been roundly panned and protested by the media, mental health professionals, and advocacy groups who see it as being "almost entirely devoid of accuracy, sensitivity and subtlety" (7).
A Beautiful Mind avoids the insensitivity of other films. Released in 2001 and directed by Ron Howard, the film, which stars Russell Crowe as John Nash, dramatically explores the development and effects of psychosis on the patient, the patient's family, and the wider community. Nash, a brilliant mathematician, begins to believe that he has been approached by a shadowy government agency to assist with code breaking. As his illness progresses, he becomes more guarded and afraid. He is unable to function well at work, and he frightens his wife. A college roommate turns out to be an elaborate hallucination, and other aspects of his life appear to be built on paranoia, grandiosity, and ideas of reference. Committed involuntarily for insulin coma therapy and other treatments, Nash improves somewhat. Although his later course is marked by nonadherence and disabling negative symptoms, he eventually succeeds in his struggle to reintegrate into the academic community. The film culminates triumphantly in Nash's acceptance of the Nobel Prize.
Much of the film's clinical presentation, especially the patient and family experience of living with psychosis, seems to ring true. Max Fink, a professor of psychiatry at SUNY-Stony Brook, served as a consultant (7). Despite being "Hollywood" (Dreamworks Pictures/Universal Pictures/Image Entertainment) in terms of production, financing, star power, and distribution (8), the movie avoids clichés and unrealistic endings that have often marred other films on schizophrenia. Advocacy groups like the National Alliance for the Mentally Ill (NAMI) have promoted A Beautiful Mind as both a powerful teaching tool for patients and families seeking to learn more about the illness and counter stigma among the general public (9).
On the other hand, A Beautiful Mind has some weaknesses that may limit its teaching applicability or at least raise some cautions among psychiatric educators. Many patients who have watched the movie have derisively commented that much of the story seems unrealistic, especially the high achievement despite illness, the unwavering family support, and the degree of community reintegration. Clinicians and trainees have wondered about the nature of some of John Nash's symptoms, since having fully formed, interactive, and associated visual and auditory hallucinations is relatively uncommon (10). Although the movie is based on a true story, the director has admitted taking liberties for dramatic effect, raising doubt as to how much should be believed. For example, historical inaccuracies plague the depiction of insulin coma therapy, and Nash's wife actually divorced him (11). Although the film seeks to inspire hope and reduce stigma, some people, especially patients, have worried that A Beautiful Mind may swing the pendulum too far in the other direction, yielding a "Christopher Reeve effect," whereby family members expect their disabled loved ones to go out and win Nobel Prizes.
Despite some weaknesses, A Beautiful Mind is a powerful and influential film that will and should be used in psychiatric education. The best audiences may be patients, families, and the general public, who will get an outstanding introduction to schizophrenia: its symptoms, course, treatments, and complications. The movie would be perfect to show at a NAMI meeting for patients and families to learn more about the illness and recovery, with discussion used to highlight salient themes and correct any misperceptions that the film may generate. The film may also be recommended for patients struggling with discouragement about recovery. This "videotherapy," as a self-help psychoeducational tool, can have substantial benefits (12). Moreover, A Beautiful Mind can show how delusions develop, how patients could believe such thoughts to be true, and how such symptoms can devastate their lives and the lives of their family and friends.
Although not as publicized or widely released as A Beautiful Mind, the movie Clean, Shaven (1995) is distinct in its portrayal of schizophrenia. The film raises important issues that may better challenge psychiatric trainees. Matters pertaining to phenomenology, expressed emotion, dependent children, custody, stigma, and violence are depicted.
Clean, Shaven was produced, directed, and written by Lodge H. Kerrigan. The movie details a chapter in the life of Peter Winter, an individual suffering from schizophrenia, who is on a quest to find his adopted-away daughter. Following either his release or escape from an institutional setting, Winter returns to his childhood home to find an unsympathetic mother, a frightened community, and a suspicious detective who believes that he is responsible for a local murder. The plot, however, remains almost a minimalist backdrop for the powerful use of audio and video effects to illustrate symptoms of schizophrenia. Audiences uneasily listen to continual sound distortion and radio "fuzz" that simulate auditory hallucinations, and they cringe as Winter attempts to remove what he believes to be implanted transmitters from his scalp and fingernail bed. The edginess continues until the final, tragic, and disturbing conclusion.
The role of Winter is masterfully played by Peter Greene, who illustrates the cognitive symptoms, the highs, and the lows of those suffering from schizophrenia. Poignantly, the sufferer's intense and unfulfilled longing for family and recovery is also depicted. Both the performance and the special effects allow viewers to "get inside the head" of people with schizophrenia, while the plot delineates the social consequences of the illness, particularly family disruption and stigma. Some psychiatrists have described Greene's performance as "the best portrayal of untreated schizophrenia ever presented on film" (quoted in 13).
Kerrigan spent more than 2 years developing the script and raising funds for Clean, Shaven, his first feature film. While Ron Howard had $60 million to make A Beautiful Mind, Kerrigan's production company—fittingly named DSM-III Films—was limited to a budget of $60,000 (8,14). Shot in little-used 16mm film, the movie has been described by critics as "rough around the edges" (15). Even after receiving critical acclaim at the Cannes and Sundance film festivals in 1994, national release of the movie remained in doubt for 18 months while a distribution company battled Kerrigan in an unsuccessful attempt to purge one of the most disturbing scenes (13). Film critic, Roger Ebert, praised Kerrigan's "uncompromising experiment" (16), and viewers who sat through its 79 minutes walked out of theaters pondering numerous challenging questions. For a group of residents rotating on a schizophrenia inpatient unit, watching the movie in its entirety might generate lively discussion.
For professional audiences, some of those questions might include:
Ensuring that residents, medical students, and other trainees receive an extremely realistic and moving representation of schizophrenia that may enhance empathy for patients and inspire interest in the illness is most important. This dichotomy of viewing needs between professional—especially trainee—and public—especially patients and their families—audiences may be helpful in selecting which films to use for psychiatric teaching. In addition, a film's ability to generate discussion, present selected themes, challenge the audience, fit into a limited time frame, and lend itself to excerpting clips may all influence the choice of film.
In addition to A Beautiful Mind and Clean, Shaven, many other commercial movies can be considered for instructing trainees about schizophrenia (see t1). For instance, excerpts from The Fisher King, which shows visual hallucinations and delusions, might be ideal for an audience of high school students who know little about the illness. The film has relevant scenes that could stand alone, and it is fairly accurate in terms of symptoms and effects. A group of undergraduate students taking a seminar on the history of psychiatry might benefit from viewing and discussing The Snake Pit. A scene from Birdy could be used to help medical students understand catatonia.
Whatever film is chosen, the psychiatric educator should be familiar with the content in order to select appropriate scenes and prepare discussion points. Some of the films listed contain either inaccurate information, such as dissociative identity disorder presented as schizophrenia, or were made to implement specific agendas, such as antipsychiatry programs, that may limit their use for some audiences. Finally, film should not be used as a substitute for more formal professional teaching or as a stand-alone presentation without follow-up discussion and commentary.
These films, however, can assist a psychiatric educator in successfully meeting a variety of learning objectives for teaching schizophrenia. And what better way than to stimulate, challenge, and excite audiences using a medium specifically designed for that purpose?