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Friday, 8 March 2013

Silver Linings: Is Sickness a Shield Against Stigma?

John McGowan

Silver lining or more rain?
Photo: By Im Unicke
I’d been avoiding Silver Linings Playbook. Nothing against it particularly, it’s just that Very Serious films about mental health always feel like a busman’s holiday. I got corralled into seeing it by the missus though, more observant than me, who had clocked that a) it was warmly sentimental, and b) it featured a dance contest. These days plucky young hoofers channelling Patrick Swayze are all I ask of a film. And if someone is also (spoiler alert) saved by the love of a good woman, then my cup runneth over.

As well as Jennifer Lawrence’s Oscar, the talk on the internet has been about how realistic SLP is (or isn’t), and what it tells us about social attitudes to mental illness. Opinions are split between those who see it as a ground-breaking and nuanced portrait of people having emotional difficulties, and those who view its happy ending as idealised and simplistic. Lawrence has been lauded for her portrayal of Tiffany, the aforesaid good woman, who is frequently a bad girl as she seeks to drown the pain of widowhood. This makes her, according to your point of view, either an ideal candidate or the worst possible bet to get things together by dancing/falling in love with fellow recoverer Pat (Bradley Cooper).

We open with Pat checking out of a psychiatric hospital: a stay prompted by finding his wife in flagrante with another fella. The GBH he performed on his rival earned him a diagnosis of bipolar disorder. Pat clearly doesn’t take his illness seriously though. As well shirking his medication, he is using hospital, and his friendship with Tiffany, simply to fulfill the implausible fantasy of getting back together with his estranged spouse. Pat and Tiffany practice their dance moves in her garage, and shout painful truths at one another, but in a way that brings them closer. I’ll leave you to guess the ending. There are some interesting wrinkles along the way, such as Pat’s dad (Robert de Niro) who has obsessive rituals, and a psychiatrist (Anupam Kher) who pipes distressing music into his waiting room and bonds with Pat during a fight at a football game. He probably qualifies as one of the less plausible therapists in the pantheon of TV and movie shrinks.

So is the film simplistic or nuanced? Well, a bit of both really. Clearly a ‘love conquers all’ storyline is going to disappoint if you’re in the market for no-holds-barred realism. But telling Hollywood to eschew happy endings is like telling the wind not to blow. What's more there are those of us, myself among them, who go to the cinema for just such neat resolutions. And there is some complexity in SLP too. Lawrence gives Tiffany emotional heft, balancing sadness, promiscuity, and self-loathing with dignity. Cooper isn’t bad either. He manages to make a socially inept, sometimes unpleasant guy, into someone we can root for. Finding out he has bipolar disorder helps keep our sympathy. However, it’s here that SLP lost me.

While the character of Tiffany has some experience with mental health services (at one point she talks about medication), her arc is primarily about sadness and loss. By contrast Pat is more explicitly offered to us as someone who is mentally ill. Rather than angry, or cuckolded, or bereft, or any one of a host of other adjectives appropriate for a guy who has found his wife cheating on him, he is ultimately bipolar. His illness is invoked every time a minor character tries to diss him. Sickness is his shield against stigma, a point also made by the director. Much of the comment around the film stresses this. It’s praised for its openness about mental illness and how this may break down prejudice.

Most of the stuff I’ve read about stigma lately seems to concentrate on how mental illness is portrayed in the media. By this yardstick SLP is way ahead of something like the Kathy Bates character in Misery (also bipolar). That was over 20 years ago and maybe we’ve moved on.  In our current cultural moment people can be mad-sad, as opposed to just mad-bad. However, we are now stuck in a place where the way to respond to behaviour emerging from emotional problems is with a label of illness. And it’s not just film and TV. The people at Time to Change, the campaign against mental health stigma, are absolutely explicit about it: we should not stigmatise  people with mental illness because these are real health problems, just like physical ones. “As real as a broken arm” says their website. There seems no alternative to seeing emotional struggles through the lens of illness and health.

Nailing one’s colours to the mast in such a concrete way is obviously well-intentioned but, as I’ve argued before,* there are many downsides to diagnosis. These apply to both the reality of the categories and their usefulness. Perhaps the most profound problem is a narrowing of how we understand a person and their struggles. Silver Linings Playbook is a product of a climate dominated by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Pat’s experience and feelings are complicated but we are asked to sympathise with and like him because he’s sick. Look, it’s in the book! And it can happen to anyone. Surely though this isn’t the only way to think about emotional pain and still be compassionate? Instead could we understand Pat as someone with a weird and dominating dad and who has a tricky relationship with his brother? Or perhaps as someone existing in a tough and macho working-class culture (something beautifully realised in the film incidentally), who may struggle to express the humiliation of being so directly faced with his wife’s infidelity? Where would such a wider understanding leave us? Certainly with a more rounded picture of how Pat got to his particular position. And maybe with some more psychological routes forward, rather than the proffered solution being medication compliance.

On the flipside SLP, as Richard Brody in the New Yorker has pointed out, shows Pat straightening out his life via love rather than medicine, and via relationships rather than psychiatric orthodoxy. Though perhaps his dodgy therapist helps that decision. Some of the medical critics who seem most worried about the depiction of mental health problems cured by love, are also fretting about showing recovery without drugs. It’s clearly viewed as the wrong message. While I don’t want to deny that diagnosis and medication are helpful  for some people, I found it sort of a relief that his redemption doesn’t come out of a bottle. The film is more subversive perhaps than it initially seems. Though I’m a sucker for a romantic ending I also think that, in the real world, most of us can buy that not everyone gets a silver lining. It does seem though, that in the face of emotional distress, we can all get a psychiatric diagnosis.

* And so have many, many others. For further reading see: Mad in America, Demedicalising Misery, the Critical Psychiatry Network and the following chapter by my colleague Anne Cooke.


  1. I fall on the side of the film being good and realistic. As a carer it seems to me that people are sometimes "sick". They need medicine and sometimes hospital. I know it's not the whole story but we shouldn't throw it out. R

  2. My view is certainly that people experiencing severe emotional distress, with uncotrollable moods, very frightening or distressing thoughts, voices etc need compassion, support and help from a mental health system that is really geared to understanding what is going on for them. But I also feel that the tendency to label people as bipolar, schizophrenic or whatever, which often comes with insistence on taking certain kinds of pharmaceutical product, is far too often the first and main response of the mental health system.
    The negative effects of psychiatric drugs are often played down greatly, and there is little attention to the social and psychological causes and potential solutions to people's distress. These can seem a lot more difficult to implement than prescribing a pill, and they are not backed by big companies with massive marketing budgets.
    Although I don't view mental distress (and I have experience of severe depression) as 'an illness like any other', I do feel that I have been harmed by some of my experiences in life. I don't shirk my responsibilities to look after myself as best I can, but bad things happen to people, and I think psychiatry too often ignores this. Injury is, I feel, a better analogy than illness, and much more accurate than 'disease'. Some injuries can heal completely with the right support, and some don't. A lot of mental injuries, I think, still get the equivalent of medieval 'bleeding' as treatments.
    There is an interesting review of research on whether biological explanations of human behaviour reduce or increase prejudice and stigma, written by Dar-Nimrod and Heine (2011), called “Genetic essentialism: On the deceptive determination of DNA”, published in Psychological Bulletin, Vol. 137, pp. 800-818. Some studies seem to show that stigma and prejudice is actually made worse by belief in biological explanations.
    Angermeyer and colleagues (2011) have also reviewed research on whether biological explanations for mental health conditions reduce stigma and mostly it appears that they not only fail to reduce stigma but they can make it worse.
    I summarised both articles in the journal 'Mental Health and Social Inclusion' (2012, vol. 16, pp. 116-120).

    Sue Holttum

  3. Thanks you for the comments. I think I'm with both of you in the sense that I'm not completely against an illness/medical model. It's about what an overwhelming focus on that leaves out. Since writing this I've had a couple of interesting exchanges. One on Twitter was especially striking. It was with with a strong advocate of an very orthodox medical/psychiatric position who took offense at one of the phrases in the article. To quote, 'mental illness is not "emotional struggles" and that characterization is insulting.' While I don't really agree with such a position for all sorts of reasons (scientific as well as practical) it's good to be reminded of of how important a diagnosis can be to some people in some circumstances.

    I'm really interested in the Angermeyer paper you mention Sue. In writing this and in looking at things like Time to Change, and websites like that of the person I was chatting with on Twitter, I've been really struck by the extent to which a label of illness seems itself to wheeled out as a direct response to stigma. I'm not saying that there are not negative connotations but I'm wondering a bit if things are changing slightly, or getting more complicated in this regard.

    1. Sorry. Should have said that that comment was by John McGowan the author).

    2. Funnily enough, as we speak (or post perhaps?), Dave Harper and I are working on piece on this very issue to be published here. As they say, watch this space!

  4. Hi,

    I haven't seen the movie and don't plan to, so this comment isn't about that.

    This comment is about the notion that mental illness is an "emotional problem" - it isn't. And to characterize it as such invalidates the experience of thousands of people. Mental illness is as much characterized by _physical_ symptoms as it is psychological ones.

    It's only once you have experience the _physical_ pain of a so-called "mental" illness that you truly understand this or possible once you watch a loved one go through the physical agony.

    - Natasha Tracy

  5. I have had a diagnosis of bipolar disorder and lengthy periods of hospitalisation. As much as I've resented being labelled and what that has done to my life, as well as my self-image, I do think that diagnosis is a double-edged sword. It can help make sense of the suffering involved in mental illness, in some ways. There's also something about this article that makes me slightly uncomfortable - it implies that there are easy answers. The love of others might be important, but it doesn't necessarily do away with the beast of bipolar.

    1. Thanks for the comment. Much appreciated. I very much agreed that diagnosis can be a double-edged sword. A few weeks back I posted a different article on this site acknowledging (and trying to explore) this more fully. It should be in the side bar (It's titled 'Gazza, Lance and the difficulties of psychiatric diagnosis'). One commenter on that referred to diagnosis as 'Janus-faced' which I though was quite a good way of putting it. I think my concern is not that the concept of mental illness has absolutely no validity (though I do know people who will argue for such a position) but rather that an over emphasis on the illness label leads us to a position where the problem is one about individual pathology and, ultimately, biology. Other factors like circumstances, life events, social inequalities etc can be squeezed out.

      I didn't mean to give the impression incidentally that there were easy answers to these kinds of problems. The film is very Hollywood in that the character is basically saved by love. I was slightly parodying my own attachment to that sort of story at the beginning of the piece. However, it seemed to me that this was one way in which the film was a bit subversive with psychiatric orthodoxy. He doesn't take his meds and finds a way through by a different route.

  6. I think the idea of a biomedical notion of mental illness exacerbating stigma is an interesting one. To my mind, this makes sense - if someone is biologically and therefore inherently 'broken', they can be managed but not 'fixed'. I wonder if stigma can be understood in relation to this sense that people who suffer mental distress are viewed as different and deficient in some essential, categorical way. Viewing indiviudals determinstically and reductively does not account for a sense of time, context, history and humanness, or indeed that we all overlap in our experiences of normality.


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