Association of Viewing the Films Joker or Terminator: Dark Fate With Prejudice Toward Individuals With Mental Illness | Media and Youth | JAMA Network Open | JAMA Network
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Table 1.  Sample Characteristics
Sample Characteristics
Table 2.  Results of Lagged Bayesian Regression Analysis on Change in Prejudice After Watching Joker
Results of Lagged Bayesian Regression Analysis on Change in Prejudice After Watching Joker
1.
Owen  PR.  Portrayals of schizophrenia by entertainment media: a content analysis of contemporary movies.   Psychiatr Serv. 2012;63(7):655-659. doi:10.1176/appi.ps.201100371PubMedGoogle ScholarCrossref
2.
Domino  G.  Impact of the film, “One Flew Over the Cuckoo’s Nest,” on attitudes towards mental illness.   Psychol Rep. 1983;53(1):179-182. doi:10.2466/pr0.1983.53.1.179PubMedGoogle ScholarCrossref
3.
Driscoll  A, Husain  M. Why Joker's depiction of mental illness is dangerously misinformed. The Guardian. Published October 21, 2019. Accessed March 25, 2020. https://www.theguardian.com/film/2019/oct/21/joker-mental-illness-joaquin-phoenix-dangerous-misinformed
4.
Kenny  A, Bizumic  B, Griffiths  KM.  The Prejudice towards People with Mental Illness (PPMI) scale: structure and validity.   BMC Psychiatry. 2018;18(1):293. doi:10.1186/s12888-018-1871-zPubMedGoogle ScholarCrossref
5.
Rosseel  Y.  Lavaan: an R package for structural equation modeling and more.   J Stat Softw. 2012;48(2):1-36. doi:10.18637/jss.v048.i02Google ScholarCrossref
6.
Clement  S, Schauman  O, Graham  T,  et al.  What is the impact of mental health-related stigma on help-seeking? a systematic review of quantitative and qualitative studies.   Psychol Med. 2015;45(1):11-27. doi:10.1017/S0033291714000129PubMedGoogle ScholarCrossref
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    1 Comment for this article
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    Comment on "Association of Viewing the Films Joker or Terminator: Dark Fate With Prejudice Toward Individuals With Mental Illness" article
    Alexis Demas, MD | Hospital Jacques Monod, Le Havre, France, Department of Neurology
    I read with interest the article by Scarf and colleagues (2020) on the association of viewing the Films Joker or Terminator: Dark Fate with prejudice towards individuals with mental illness. 1

    In their article, Scarf et al showed that watching the movie Joker was associated with higher level of prejudice toward people with mental illness.

    Several aspects of this article should be highlighted. The first one, and most striking, is that the authors make the viewer watch a film in which the main character has a neuro-psychiatric disorder, but do not describe the symptoms he suffers from.
    In this psychological thriller film, another possible origin story for this iconic character is reported. Contrary to other interpretations, we discover a lonely, timid and uncharismatic man (Arthur Fleck). He seems to be suffering from psychobehavioral disorders and seems depressed. There is a strangeness in his behavior along with social withdrawal. He suffers from fits of laughter that occur at socially inappropriate times. He also suffers from psychotic symptoms with visual delusions. Crucially, we learn through the film that he was a beaten child, psychologically and physically abused with severe traumatic brain injury (TBI). The uncontrollable outbursts of laughter, behavioral and psychotic disorders followed these elements. As a neurologist, I was intrigued by these symptoms and according to the literature we can assume that the Joker is suffering from neuropsychiatric sequelae related to childhood TBI involving the frontotemporal regions and, in particular, the lateral aspect of the left frontal lobe. This seems essential.

    Furthermore, the score used does not specify the psychiatric pathologies explored. Can we compare a patient suffering from an anxiety disorder and a patient suffering from schizophrenia? Nevertheless this scale remains interesting especially in the current context of COVID-19 pandemic and containment with the risks of exacerbation of psychological disorders.

    The management of patients with neuropsychiatric illness is difficult and it is a public health problem. There is a cultural dimension to these difficulties, the boundaries between neurology and psychiatry are thin and must become porous. Above all, this article stresses the importance of the stigma associated with mental illness, the necessity to consider psychotic disorder due to TBI, and more broadly neuropsychiatric symptoms, as neurobiological syndromes.

    In Joker, the main character said at the end of the movie: “You wouldn’t get it.” It’s time for medicine to get it, to develop a neurobiological consideration of neuropsychiatric symptoms.

    Damian Scarf 1, Hannah Zimmerman 1, Taylor Winter 2, Hannah Boden 1, Sarah Graham 1, Benjamin C Riordan 3, John A Hunter 1. Association of Viewing the Films Joker or Terminator: Dark Fate With Prejudice Toward Individuals With Mental Illness. JAMA Netw Open. 2020 Apr 1;3(4):e203423.
    Alexis Demas, David Tillot. Pathological laughing and psychotic disorder: the medical evaluation of the Joker. Acta Neurologica Belgica (2020).
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    Psychiatry
    April 24, 2020

    Association of Viewing the Films Joker or Terminator: Dark Fate With Prejudice Toward Individuals With Mental Illness

    Author Affiliations
    • 1Department of Psychology, University of Otago, Dunedin, New Zealand
    • 2Department of Psychology, Victoria University of Wellington, Wellington, New Zealand
    • 3Discipline of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
    JAMA Netw Open. 2020;3(4):e203423. doi:10.1001/jamanetworkopen.2020.3423
    Introduction

    The movie Joker provides an origin story for its namesake character, played by award-winning actor Joaquin Phoenix. Phoenix’s character Arthur is depicted as having a mental illness; he visits Arkham State Hospital to receive medication and frequently displays symptoms that suggest some form of serious mental illness. Because of budget cuts, Arthur stops receiving his medication and consequently carries out a campaign of violence.

    Joker is the first R-rated film to earn more than $1 billion at the box office, with more than 100 million people viewing it worldwide. Because Joker continues the tradition of movies depicting individuals with mental illness as violent,1,2 it has reignited discussion about the role of media in perpetuating prejudice toward those with a mental illness.3 To investigate the associations of the Joker with prejudice toward those with mental illness, we had a community sample attend a screening of Joker or Terminator: Dark Fate (as the control condition) and complete a measure of mental illness prejudice before and after watching their assigned movie. We hypothesized that, compared with viewing Terminator: Dark Fate, viewing Joker would be associated with higher levels of prejudice toward individuals with mental illness.

    Methods

    In this survey study, participants enrolled from November 22, 2019, to December 4, 2019. On December 5, 2019, participants attended a movie theater in Dunedin, New Zealand, and were randomly assigned to watch either Joker or Terminator: Dark Fate. The only inclusion criterion was that participants be aged 18 years or older. Participants completed an online consent form before being presented with the premovie survey. Participants completed the 28-item Prejudice Toward People With Mental Illness (PPMI) scale4 before and after watching their assigned movie. An overall association of viewing either movie with prejudice was estimated using confirmatory factor analysis in R version 3.6.1 (R Project for Statistical Computing), with the lavaan command.5 Change in prejudice was assessed using a lagged Bayesian regression, using a weakly informative normal prior with a mean of 0 and an SD of 1. Age, sex, history of mental illness, and movie were included as covariates. Association was determined based on a posterior probability greater than 95%. Posterior probability is the percentage of posterior samples above or below 0, depending on which direction has the highest probability (akin to a 1-tailed test). The study was reviewed and approved by the University of Otago Human Ethics Committee.

    Results

    Overall, 164 individuals participated in the study, approximately evenly split between viewing Joker (84 [51.2%]) and Terminator: Dark Fate (80 [48.8%]). Samples were similar in terms of age, sex, and race/ethnicity (Table 1). Participants viewing Joker had a mean (SD) PPMI of 2.99 (0.66) before the movie and 3.20 (0.78) after the movie. Participants viewing Terminator: Dark Fate had a mean (SD) PPMI score of 2.91 (0.61) before the movie and 2.88 (0.70) after the movie (Table 1). The lagged Bayesian regression revealed neither age nor sex was associated with PPMI scores. Whether participants have had or currently have a mental illness was associated with lower PPMI scores (estimate, −0.21 SD; 95% CI, −0.4 to 0 SD; posterior probability, 100.0%). Consistent with our hypothesis, viewing Joker was associated with a 0.37 (95% CI, 0.19 to 0.55) SD increase in PPMI score (posterior probability, 100.0%) (Table 2).

    Discussion

    Joker was associated with higher levels of prejudice toward those with mental illness. Beyond prejudice, associating mental illness with violence may erode support for policies that we know to be beneficial for those with mental illness (eg, integration into communities). Additionally, Joker may exacerbate self-stigma for those with a mental illness, leading to delays in help seeking.6 A limitation of the current study is that we did not assess whether viewing Joker was associated with actual behavior.

    In The Dark Knight, Joker asks, “Why so serious?” One might level that question at us, arguing that Joker is nothing to be concerned with. However, what this view ignores is the profound consequences prejudice has on those with a mental illness.

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    Article Information

    Accepted for Publication: February 25, 2020.

    Published: April 24, 2020. doi:10.1001/jamanetworkopen.2020.3423

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Scarf D et al. JAMA Network Open.

    Corresponding Author: Damian Scarf, PhD, Department of Psychology, University of Otago, 95A Union Pl E, Goddard Laboratory Bldg, Dunedin, New Zealand 9054 (damian@psy.otago.ac.nz).

    Author Contributions: Dr Scarf and Mr Winter had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Scarf, Winter, Graham, Riordan.

    Acquisition, analysis, or interpretation of data: Zimmerman, Winter, Boden, Graham, Riordan, Hunter.

    Drafting of the manuscript: Scarf, Winter, Graham.

    Critical revision of the manuscript for important intellectual content: Zimmerman, Winter, Boden, Riordan, Hunter.

    Statistical analysis: Winter.

    Administrative, technical, or material support: Zimmerman, Winter, Boden, Graham, Hunter.

    Supervision: Scarf.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Owen  PR.  Portrayals of schizophrenia by entertainment media: a content analysis of contemporary movies.   Psychiatr Serv. 2012;63(7):655-659. doi:10.1176/appi.ps.201100371PubMedGoogle ScholarCrossref
    2.
    Domino  G.  Impact of the film, “One Flew Over the Cuckoo’s Nest,” on attitudes towards mental illness.   Psychol Rep. 1983;53(1):179-182. doi:10.2466/pr0.1983.53.1.179PubMedGoogle ScholarCrossref
    3.
    Driscoll  A, Husain  M. Why Joker's depiction of mental illness is dangerously misinformed. The Guardian. Published October 21, 2019. Accessed March 25, 2020. https://www.theguardian.com/film/2019/oct/21/joker-mental-illness-joaquin-phoenix-dangerous-misinformed
    4.
    Kenny  A, Bizumic  B, Griffiths  KM.  The Prejudice towards People with Mental Illness (PPMI) scale: structure and validity.   BMC Psychiatry. 2018;18(1):293. doi:10.1186/s12888-018-1871-zPubMedGoogle ScholarCrossref
    5.
    Rosseel  Y.  Lavaan: an R package for structural equation modeling and more.   J Stat Softw. 2012;48(2):1-36. doi:10.18637/jss.v048.i02Google ScholarCrossref
    6.
    Clement  S, Schauman  O, Graham  T,  et al.  What is the impact of mental health-related stigma on help-seeking? a systematic review of quantitative and qualitative studies.   Psychol Med. 2015;45(1):11-27. doi:10.1017/S0033291714000129PubMedGoogle ScholarCrossref
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