October 24, 2001
Analyze This: What's Behind These Psychodramas?
By RICHARD NATALE, SPECIAL TO THE TIMES
Three new movies, "K-PAX," "Donnie Darko" and "Don't Say a Word," each with a psychiatrist as a central character, face the same dilemma: how to realistically depict the medical profession and still serve the needs of the drama. Movies almost always sacrifice the former for the latter, according to Dr. Glen Gabbard, professor of psychiatry at Baylor University School of Medicine and author of "Psychiatry and the Cinema," in which he looked at more than 400 movies dealing with the profession and found most of them wanting.
"Among all those films, fewer than five had some semblance of real psychotherapy," says Gabbard. "The practice of movie psychiatry bears almost no resemblance to real-world psychiatry. In movies, psychotherapy is generally used only as a plot device."
That assessment could apply to the three current films. In the thriller "Don't Say a Word," which opened Sept. 28, a psychiatrist played by Michael Douglas has less than a day to coax crucial information out of an almost catatonic woman, who has kept her secret for 10 years.
The central character in the sci-fi drama "Donnie Darko," which opens Friday, has a condition diagnosed as paranoid schizophrenia by a psychiatrist who prescribes medication to deal with his destructive tendencies.
In "K-PAX," also opening Friday, Jeff Bridges has the daunting task of dealing with a man who claims, not altogether unconvincingly, to be an extraterrestrial (Kevin Spacey), another melding of mental illness and science fiction.
Which is not to say that these movies don't attempt to get it right. Both "Word" and "K-PAX" enlisted the advice of psychiatric consultants.
Dr. Robert Berger, director of forensic psychiatry at Bellevue Hospital in New York, has been involved with "Word" since the early 1990s, as the project moved through different directors and writers.
His main contribution to the film, he says, "was helping to make the [psychiatric] sessions more real," though other of his suggestions were sacrificed to the film's ticking clock structure. "I tried to make the interactions [between Douglas and actress Brittany Murphy] more direct and simplistic," he says, "I wanted it not to be incredulous, though I understood that some of it was exaggerated so that the audience could fully understand the emotions and the stress Douglas was under."
To a limited extent, he says, he succeeded. However, there could have been further clarification as to how Douglas "flips" a patient (gets her to open up and trust him) in a single day after she had been emotionally shut down for a decade. Some of those suggestions, he says, fell prey to dramatic expediency, the culprit in other movies for which he has served as consultant, such as "Final Analysis," starring Richard Gere.
A significant contribution to the more recent film, however, was Berger's mention that the patient may be faking her illness to remain in the safety of a medical hospital. Gary Fleder, the director of "Word," "dug that concept," says Berger, because it gave more credence to the doctor's ability to quickly break through to the patient. It also made sense from the audience's perspective, because the woman's many diagnoses could all be attributed to a significant trauma in her past that can manifest itself in many ways, he adds. "Think now of the people who have been close to this terrorist attack. Would anyone question the most bizarre reactions from them?"
The psychiatric consultant on "K-PAX," Dr. Alessia Gottlieb of UCLA, whose specialty is child and adolescent psychiatry, worked closely with the filmmakers as well as actors Bridges and Spacey to present the patterns of mental illness portrayed in the film and the environment in which the patients are confined.
Considering the limitations of a movie's two-hour time frame and the needs of the plot, she says, many of her suggestions were integrated into the script. Gottlieb enlisted two specialists, one in associative disorders and one in hypnosis, to map out the regression therapy scenes in which Spacey's character is hypnotized by Bridges'. "The hypnosis scenes are authentic," she says, even if she admits that the doctor's ability to speedily plumb his patient's subconscious for trauma may lean more toward science fiction than psychiatry.
Gottlieb also sought to bring a spine of realism to the presentation of the other patients at the Manhattan psychiatric facility in "K-PAX." In this film, as in movies like "One Flew Over the Cuckoo's Nest," the portrayal of the subsidiary characters as eccentric and sometimes downright endearing can make the audience wonder what danger they present to themselves or society, especially when major city streets are populated by men and women who seem to be in dire need of psychiatric intervention.
The book on which "K-PAX" is based, she explains, was written when hospitalization was more common for less severe problems. "Today involuntary hospitalization is for more acute patients," she says. She endeavored to inject touches into the script that lent credence to the characters' hospitalization: burn marks and slashes on one woman, mention of another man's violent outbursts in his workplace.
"Donnie Darko" writer and director Richard Kelly did not have a consultant on his independent film, culling most of his information about his central character's paranoid schizophrenia diagnosis from the Internet.
"I knew he wasn't crazy at all and that the experiences he was having were more due to supernatural circumstances," says Kelly. "In my research I learned that paranoid schizophrenia is a broad disorder that's difficult to define and that it manifests itself in different ways. It was a great way to ground a supernatural story in some semblance of science and medicine."
The psychiatrist in the film, played by Katharine Ross, mainly functions as a sympathetic ear, one who doesn't believe her patient is psychotic. Kelly chose a psychiatrist for this character rather than a psychologist because a medically certified doctor can prescribe medication. A scene that was cut out of the film reveals that the medication is actually a placebo, Kelly's jab at "the overprescription of medication" to children and young adults.
"Not that I'm against medication or think it unnecessary," he says. "But a lot of psychological problems can be cured without medication. I was commenting on how Ritalin and other 'gatekeeper' drugs can do more harm than good and how overmedicating children has gotten out of control since the '80s. A lot of my friends when I was growing up were not getting good grades and were diagnosed with ADD [attention deficit disorder], which is a bunch of [baloney] in many cases. They weren't getting good grades because they were lazy, and kids have been lazy since the beginning of time."
The ability to write prescriptions seems to be the main distinguishing characteristic between psychology and psychiatry in movies, and characters in mental facilities are often presented as heavily--and consistently--medicated.
Berger says such presentations are "inaccurate. It doesn't all start out with prescriptions." Advances in new types of medications with fewer side effects notwithstanding, he says, "It's no substitute for therapy." Adds Gabbard, the process of psychiatric therapy can be long and boring, which is why filmmakers look for shortcuts. An analogy would be the courtroom drama, which usually presents only the highlights of the legal process.
The "quick-fix" of medications is one of the fallacies about psychiatry that movies perpetuate, according to Gottlieb. Others include "the perception that psychiatrists are unfeeling about their patients or simply burnt out. It's much more complex than that," she says.
"There are disorders, especially psychotic disorders, in which drugs are necessary, or else the therapy feeds into the person's delusions." Especially because she works with children and adolescents, Gottlieb said she takes "every opportunity not to prescribe medication."
Berger breaks down the depiction of his profession in movies even further: "There's the evil psychiatrist, the over-involved psychiatrist, the bumbling psychiatrist and the one who's got a lightbulb going off every three seconds."
Because of time constraints, says Gabbard, movie shorthand about psychiatry procedure is perhaps unavoidable. On a TV series like "The Sopranos" (Berger also cites the short-lived "Wonderland," which he helped develop), the process is allowed time to develop, allowing for a more balanced presentation. Gabbard lauds the work of character Dr. Melfi (played by Lorraine Bracco) with Tony Soprano (James Gandolfini) and is writing a book about it.
"'The Sopranos' is by far the most accurate portrayal of psychiatry ever to appear in any electronic media," he says. "To be fair, in 39 one-hour episodes over three seasons, it's possible to achieve some reflection on the complexity of therapy that isn't possible in a two-hour feature."
The series is also unique in how it depicts the dynamic between a female therapist and a male patient, as opposed to films like "Spellbound" and "The Prince of Tides," to mention just two, in which, he says, "you always see the beautiful female therapist succumbing to the charms of the male patient and dropping her professional boundaries to engage in a sexual affair."
Still, there are some films that have remained true at least to the letter of the psychiatric process. Berger mentions "Ordinary People," which takes its time building the relationship between the psychiatrist (Judd Hirsch) and his patient (Timothy Hutton), establishing the evolutionary process of uncovering the character's trauma through the creation of a relationship of trust between them. Another movie to which he gives a thumbs up is, oddly, Brian De Palma's "Dressed to Kill," an "evil psychiatrist" movie, although he says the early sessions between the therapist (Michael Caine) and the patient (Angie Dickinson) were "very accurate in the way he handled her thoughts and dreams."
Gabbard says the "one example in movies of psychotropic medication being effectively prescribed is 'As Good as It Gets,' in which [Jack Nicholson] improves his obsessive-compulsive disorder by taking his medication. Even then, the film suggests that it was his love for Helen Hunt that did the trick, rather than his medication."
Gabbard concedes that psychiatrists are not alone in griping about how they're treated in movies and that Hollywood is not likely to reverse that any time soon. At periodic panel discussions sponsored by the American Psychiatric Assn., filmmakers were resistant to such complaints, insisting "they have no obligation to do anything but entertain people," he says.
"But I also know," he adds, "that at scientific conferences, there were complaints about how someone like Michael Crichton portrays scientists. Nobody likes how they're portrayed on film, except maybe for prostitutes, who usually come off looking pretty good."