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‘The Undoing’: A dramatization of ‘You Should Have Known’
Jean Hanff Korelitz’s ironic psychological thriller, “You Should Have Known,” (New York: Grand Central Publishing, 2014) was transformed into an HBO miniseries called “The Undoing,” written and produced by David E. Kelley and directed by Susanne Bier, which premiered on Oct. 25, 2020.
The television drama differed from the novel in fundamental ways, but both have themes related to the therapeutic process. In the novel, a New York City–based couples therapist, Grace Reinhart Sachs, had recently written a book called “You Should Have Known,” about women who married their spouses disregarding their gut instinct that their partner was not fundamentally right for them, or might potentially cheat on them, or whose stories contained contradictions. In the miniseries, Grace (played by Nicole Kidman), is a therapist but there is no mention of her having written a book. Grace in both the novel and the miniseries is married to a pediatric oncologist, Jonathan (his ethnicity and surname were changed in the miniseries from a Jewish New Yorker in the novel to a British Dr. Jonathan Fraser in the series, played by Hugh Grant).
[Spoiler alert]: Prepandemic New York City’s Upper East Side is scandalized when a murdered mother is found by her young son the day after a lavish fund-raising auction party for a private school. Grace and Jonathan’s son, Henry, attends this school as well, and Grace had served on the auction committee with the murdered mother. When two detectives question Grace in the course of their investigation, she assumes that they are questioning her as they would any parent in the school. However, when she tries to reach her husband about the news and the investigation, she cannot. She thought he was at a medical conference in Cleveland, but she realizes that she does not know exactly what conference and exactly where. After many failed attempts at calling and texting, she hears a familiar alert sound coming from his nightstand drawer where she retrieves the cell phone that had been deliberately placed.
In the novel, Jonathan never reappears from “Cleveland,” and although it takes Grace a while to understand that her husband is not who she thought he was, she eventually does. In the miniseries, Jonathan appears in their lake house and a trial ensues with Jonathan adamantly proclaiming his innocence despite all evidence to the contrary.
The Oxford Reference defines undoing as “an emotional conflict associated with an action is dealt with by negating the action or attempting ‘magically’ to cause it not to have occurred by substituting an approximately opposite action.” It is not that the consequences of the action are attempted to be negated (as in making amends or showing remorse), but the action itself. In this way, the miniseries is aptly named since both main characters, Grace and Jonathan, use this defense mechanism. Grace has difficulty acknowledging that her husband could be capable of any wrongdoing, even as she is faced with fact after fact that contradicts this premise – and counsels others about their relationship choices. Similarly, Jonathan’s choice of profession is likely an attempt to undo his 4-year-old sister’s death that occurred on his watch when he was 14. However, even treating children’s cancer cannot undo the many indiscretions he has apparently committed in his adult life.
In the portrayal of a doctor with narcissistic, and possibly psychopathic, traits, “The Undoing” joins multiple recent podcasts that document real-life bad doctors, including Wondery’s “The Shrink Next Door,” “Dr. Death” (seasons 1 and 2), and “Do No Harm.” While most physicians go into medicine to heal and improve peoples’ lives, others, such as the character of Dr. Jonathan Fraser, appear to become physicians for ulterior and sinister motivations. Jonathan’s difficulty with empathy was present when he was a child as a character trait – rather than being attributable to any childhood traumatic event, as Grace had let herself believe.
In a Dec. 11, 2020, New York Times op-ed, Richard A. Friedman, MD, a psychiatrist affiliated with New York Presbyterian-Cornell University, discussed three “dangerous doctors” during the pandemic who are potentially harming the nation. Scott Atlas, MD, a radiologist on leave from Stanford (Calif.) University, advised President Trump on the coronavirus despite having no training in public health or infectious disease. Before resigning, he questioned the use of face masks, contradicting scientific proof of their prevention of disease. Another doctor, a cardiologist in Washington, also publicly disputed scientific evidence of the efficacy of face masks and social distancing, and a third physician promoted hydroxychloroquine as a treatment for coronavirus despite scientific evidence that it has been ineffective and possibly even harmful to patients with the virus.
Both the novel “You Should Have Known” and the series “The Undoing” will be of interest to psychiatrists, especially therapists and forensic psychiatrists, because of the themes portrayed, such as defense mechanisms, therapeutic process, and a homicide investigation – as well as the common human experience of being an expert in something in one’s professional life, yet occasionally falling short of recognizing the same phenomena in one’s personal life.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and is on the faculty at Weill-Cornell Medical Center. She has no conflicts of interest. Dr. Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and which was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association. She has no conflicts of interest.
Jean Hanff Korelitz’s ironic psychological thriller, “You Should Have Known,” (New York: Grand Central Publishing, 2014) was transformed into an HBO miniseries called “The Undoing,” written and produced by David E. Kelley and directed by Susanne Bier, which premiered on Oct. 25, 2020.
The television drama differed from the novel in fundamental ways, but both have themes related to the therapeutic process. In the novel, a New York City–based couples therapist, Grace Reinhart Sachs, had recently written a book called “You Should Have Known,” about women who married their spouses disregarding their gut instinct that their partner was not fundamentally right for them, or might potentially cheat on them, or whose stories contained contradictions. In the miniseries, Grace (played by Nicole Kidman), is a therapist but there is no mention of her having written a book. Grace in both the novel and the miniseries is married to a pediatric oncologist, Jonathan (his ethnicity and surname were changed in the miniseries from a Jewish New Yorker in the novel to a British Dr. Jonathan Fraser in the series, played by Hugh Grant).
[Spoiler alert]: Prepandemic New York City’s Upper East Side is scandalized when a murdered mother is found by her young son the day after a lavish fund-raising auction party for a private school. Grace and Jonathan’s son, Henry, attends this school as well, and Grace had served on the auction committee with the murdered mother. When two detectives question Grace in the course of their investigation, she assumes that they are questioning her as they would any parent in the school. However, when she tries to reach her husband about the news and the investigation, she cannot. She thought he was at a medical conference in Cleveland, but she realizes that she does not know exactly what conference and exactly where. After many failed attempts at calling and texting, she hears a familiar alert sound coming from his nightstand drawer where she retrieves the cell phone that had been deliberately placed.
In the novel, Jonathan never reappears from “Cleveland,” and although it takes Grace a while to understand that her husband is not who she thought he was, she eventually does. In the miniseries, Jonathan appears in their lake house and a trial ensues with Jonathan adamantly proclaiming his innocence despite all evidence to the contrary.
The Oxford Reference defines undoing as “an emotional conflict associated with an action is dealt with by negating the action or attempting ‘magically’ to cause it not to have occurred by substituting an approximately opposite action.” It is not that the consequences of the action are attempted to be negated (as in making amends or showing remorse), but the action itself. In this way, the miniseries is aptly named since both main characters, Grace and Jonathan, use this defense mechanism. Grace has difficulty acknowledging that her husband could be capable of any wrongdoing, even as she is faced with fact after fact that contradicts this premise – and counsels others about their relationship choices. Similarly, Jonathan’s choice of profession is likely an attempt to undo his 4-year-old sister’s death that occurred on his watch when he was 14. However, even treating children’s cancer cannot undo the many indiscretions he has apparently committed in his adult life.
In the portrayal of a doctor with narcissistic, and possibly psychopathic, traits, “The Undoing” joins multiple recent podcasts that document real-life bad doctors, including Wondery’s “The Shrink Next Door,” “Dr. Death” (seasons 1 and 2), and “Do No Harm.” While most physicians go into medicine to heal and improve peoples’ lives, others, such as the character of Dr. Jonathan Fraser, appear to become physicians for ulterior and sinister motivations. Jonathan’s difficulty with empathy was present when he was a child as a character trait – rather than being attributable to any childhood traumatic event, as Grace had let herself believe.
In a Dec. 11, 2020, New York Times op-ed, Richard A. Friedman, MD, a psychiatrist affiliated with New York Presbyterian-Cornell University, discussed three “dangerous doctors” during the pandemic who are potentially harming the nation. Scott Atlas, MD, a radiologist on leave from Stanford (Calif.) University, advised President Trump on the coronavirus despite having no training in public health or infectious disease. Before resigning, he questioned the use of face masks, contradicting scientific proof of their prevention of disease. Another doctor, a cardiologist in Washington, also publicly disputed scientific evidence of the efficacy of face masks and social distancing, and a third physician promoted hydroxychloroquine as a treatment for coronavirus despite scientific evidence that it has been ineffective and possibly even harmful to patients with the virus.
Both the novel “You Should Have Known” and the series “The Undoing” will be of interest to psychiatrists, especially therapists and forensic psychiatrists, because of the themes portrayed, such as defense mechanisms, therapeutic process, and a homicide investigation – as well as the common human experience of being an expert in something in one’s professional life, yet occasionally falling short of recognizing the same phenomena in one’s personal life.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and is on the faculty at Weill-Cornell Medical Center. She has no conflicts of interest. Dr. Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and which was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association. She has no conflicts of interest.
Jean Hanff Korelitz’s ironic psychological thriller, “You Should Have Known,” (New York: Grand Central Publishing, 2014) was transformed into an HBO miniseries called “The Undoing,” written and produced by David E. Kelley and directed by Susanne Bier, which premiered on Oct. 25, 2020.
The television drama differed from the novel in fundamental ways, but both have themes related to the therapeutic process. In the novel, a New York City–based couples therapist, Grace Reinhart Sachs, had recently written a book called “You Should Have Known,” about women who married their spouses disregarding their gut instinct that their partner was not fundamentally right for them, or might potentially cheat on them, or whose stories contained contradictions. In the miniseries, Grace (played by Nicole Kidman), is a therapist but there is no mention of her having written a book. Grace in both the novel and the miniseries is married to a pediatric oncologist, Jonathan (his ethnicity and surname were changed in the miniseries from a Jewish New Yorker in the novel to a British Dr. Jonathan Fraser in the series, played by Hugh Grant).
[Spoiler alert]: Prepandemic New York City’s Upper East Side is scandalized when a murdered mother is found by her young son the day after a lavish fund-raising auction party for a private school. Grace and Jonathan’s son, Henry, attends this school as well, and Grace had served on the auction committee with the murdered mother. When two detectives question Grace in the course of their investigation, she assumes that they are questioning her as they would any parent in the school. However, when she tries to reach her husband about the news and the investigation, she cannot. She thought he was at a medical conference in Cleveland, but she realizes that she does not know exactly what conference and exactly where. After many failed attempts at calling and texting, she hears a familiar alert sound coming from his nightstand drawer where she retrieves the cell phone that had been deliberately placed.
In the novel, Jonathan never reappears from “Cleveland,” and although it takes Grace a while to understand that her husband is not who she thought he was, she eventually does. In the miniseries, Jonathan appears in their lake house and a trial ensues with Jonathan adamantly proclaiming his innocence despite all evidence to the contrary.
The Oxford Reference defines undoing as “an emotional conflict associated with an action is dealt with by negating the action or attempting ‘magically’ to cause it not to have occurred by substituting an approximately opposite action.” It is not that the consequences of the action are attempted to be negated (as in making amends or showing remorse), but the action itself. In this way, the miniseries is aptly named since both main characters, Grace and Jonathan, use this defense mechanism. Grace has difficulty acknowledging that her husband could be capable of any wrongdoing, even as she is faced with fact after fact that contradicts this premise – and counsels others about their relationship choices. Similarly, Jonathan’s choice of profession is likely an attempt to undo his 4-year-old sister’s death that occurred on his watch when he was 14. However, even treating children’s cancer cannot undo the many indiscretions he has apparently committed in his adult life.
In the portrayal of a doctor with narcissistic, and possibly psychopathic, traits, “The Undoing” joins multiple recent podcasts that document real-life bad doctors, including Wondery’s “The Shrink Next Door,” “Dr. Death” (seasons 1 and 2), and “Do No Harm.” While most physicians go into medicine to heal and improve peoples’ lives, others, such as the character of Dr. Jonathan Fraser, appear to become physicians for ulterior and sinister motivations. Jonathan’s difficulty with empathy was present when he was a child as a character trait – rather than being attributable to any childhood traumatic event, as Grace had let herself believe.
In a Dec. 11, 2020, New York Times op-ed, Richard A. Friedman, MD, a psychiatrist affiliated with New York Presbyterian-Cornell University, discussed three “dangerous doctors” during the pandemic who are potentially harming the nation. Scott Atlas, MD, a radiologist on leave from Stanford (Calif.) University, advised President Trump on the coronavirus despite having no training in public health or infectious disease. Before resigning, he questioned the use of face masks, contradicting scientific proof of their prevention of disease. Another doctor, a cardiologist in Washington, also publicly disputed scientific evidence of the efficacy of face masks and social distancing, and a third physician promoted hydroxychloroquine as a treatment for coronavirus despite scientific evidence that it has been ineffective and possibly even harmful to patients with the virus.
Both the novel “You Should Have Known” and the series “The Undoing” will be of interest to psychiatrists, especially therapists and forensic psychiatrists, because of the themes portrayed, such as defense mechanisms, therapeutic process, and a homicide investigation – as well as the common human experience of being an expert in something in one’s professional life, yet occasionally falling short of recognizing the same phenomena in one’s personal life.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and is on the faculty at Weill-Cornell Medical Center. She has no conflicts of interest. Dr. Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and which was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association. She has no conflicts of interest.
‘Defending Jacob’ and defending psychiatry
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
‘After Life’ and before good treatment
Portrayal of psychiatry in Netflix series could deter people from getting help
While many across the world who have access to Netflix and other streaming services have been on lockdown, the second season of Ricky Gervais’s dark comedy series, “After Life,” was released. The show will also return for a third season.
The setup of the show is that Lisa, the wife of Gervais’s protagonist, Tony, has died of breast cancer. Knowing that he would need help after, she made him a video guide to life without her, ranging from the mundane of a garbage day or house alarm to feeding their dog Brandy, tidying the house, and constantly reminding him to take care of himself.
When we first see Tony, he is not doing great on self-care, and he has turned his grief into a “super power” allowing himself to do or say whatever he wants to – from pretending to reprimand his dog for calling a man (who had just told him his dog should be on a lead) a “fat hairy nosy !#$%&” to getting into a name-calling exchange with a primary school child. He later (jokingly) threatens this same child with a hammer, so that the child will stop bullying his nephew.
Tony works as the head of features for the Tambury Gazette, the free local paper. The comedy is full of the hometown charm with Tony and the photographer, Lenny, visiting the homes of the interesting personalities who have called into the paper with their small-town newsworthy stories.
Colorful characters abound in his town, including Postman Pat, who pops in and helps himself to a bath. Tony develops an unlikely friendship with a sex worker whom he hires to clean his house – since she said that she would do “anything for 50 quid.”
Tony, in the midst of an existential crisis, visits his wife’s grave frequently. While there, he meets an older widow, Anne, who befriends him and offers good advice. (Anne is played by Penelope Wilton of The Best Exotic Marigold Hotel and Downton Abbey.)
Tony also dutifully visits his father daily at the Autumnal Leaves Care Home. His father has dementia and keeps asking about Lisa, forgetting that she is dead. Tony comments that if his father were a dog, he would euthanize him. In actuality, Tony’s dog, Brandy, stops Tony’s potential suicide throughout the series.
Matt, who is Tony’s brother-in-law (and boss at the paper) describes Tony as “devastated, suicidal.” Tony explains that he can do and say what he wants, and “then when it all gets too much, I can always kill myself.” By season 2, Matt’s wife has left him, and he, too, needs to see the psychiatrist.
The problem is the Tambury psychiatrist (played by Paul Kaye). General psychiatrists in film have been described in various ways by the late Irving Schneider, MD, including Dr. Evil, Dr. Wonderful, and Dr. Dippy types. “Dr. Dippy’s Sanitarium” was a 1906 silent film in which Dr. Dippy is seen lacking in common sense but being harmless overall. Based on the behaviors displayed in and out of therapy, the Tambury psychiatrist could never be described as Dr. Wonderful, leading to the Dr. Evil or the Dr. Dippy options. He is certainly using patients for his own personal gratification (like a Dr. Evil might) and is certainly lacking in common sense and acting “crazier or more foolish than his patients”1 (like a Dr. Dippy). However, this psychiatrist may need a category all to himself.
Tony sought out the psychiatrist at a desperate time in his life. The dark but comical way he expresses himself: “A good day is one where I don’t go around wanting to shoot random strangers in the face and then turn the gun on myself” is not met with compassion, but unfortunately by inappropriate chuckles. Instead of offering solace, the psychiatrist revealed confidential doctor-patient information about other patients. When pressed, the psychiatrist insists, “I didn’t say his name.” The psychiatrist also explains he is telling Tony privileged information to “let you know you’re not … the only mental case out there.” The psychiatrist is also blatantly tweeting on his phone during the session. He tells his patient that it is ridiculous to want a soul mate and explains that other species might rape their sexual conquest. He yawns loudly in a session with Tony. These are just some of the many cringe-worthy behaviors displayed by this (unnamed) fictional embarrassment to our field.
By season 2, the psychiatrist begins seeing Tony’s brother-in-law, Matt, in treatment, the first of his boundary violations with Matt since Matt is Tony’s close friend and relative. The psychiatrist soon makes the crass self-disclosure to Matt that, “I was bleeding from the anus for a month last year, and I never went to the doctor,” implying Matt is a wimp for coming in. The psychiatrist invites him to go out with him and his friends, and gives him a beer in a session. The psychiatrist tells Matt stories of his sex life and complains about why people are bothered about toxic masculinity. When there is no way it can get worse, Tony and Matt run into the psychiatrist and his mates in a pub. The psychiatrist tells his comrades: “That’s the suicidal one with the dead wife I was telling you about.” When asked about confidentiality, he again protests: “I didn’t say your name mate,” Gestures are made, and the patients are mocked and laughed at. Unfathomably, Matt still returns for therapy, but is told by the psychiatrist to “lie, cheat, just be a man,” and about lesbians using dildos. The psychiatrist complains to Matt he is “sick of this @#!&, hearing people winge all day.”
Dr. Dippy or Dr. Evil – or somewhere in between – Tambury’s psychiatrist is not anyone who should be seeing humans, let alone a vulnerable population seeking help. These satirical behaviors and comments perhaps suggest worries of the general population about what happens behind the closed doors of psychotherapy and the concern that there may not be such a thing as a “safe space.” Even though this character is meant to be funny, there is a concern that, in this difficult time, this portrayal could deter even one person from getting the help that they need.
In spite of this unfortunate characterization of psychiatry, “After Life” is a brilliant, dark portrayal of grief after loss, the comfort of pets, grief while losing someone to dementia, and even growth after loss. The theme of grief is especially poignant during this time of collective grief.
The difficulty is the portrayal of psychiatry and therapy – released at a time when in the real world, we are coping with a pandemic and expecting massive mental health fallout. Negative portrayals of psychiatry and therapy in this and other shows could potentially deter people from taking care of their own mental health in this traumatic time in our collective history when we all need to be vigilant about mental health.
Reference
1. Schneider I. Am J Psychiatry. 1987 Aug;144(8):966-1002.
Portrayal of psychiatry in Netflix series could deter people from getting help
Portrayal of psychiatry in Netflix series could deter people from getting help
While many across the world who have access to Netflix and other streaming services have been on lockdown, the second season of Ricky Gervais’s dark comedy series, “After Life,” was released. The show will also return for a third season.
The setup of the show is that Lisa, the wife of Gervais’s protagonist, Tony, has died of breast cancer. Knowing that he would need help after, she made him a video guide to life without her, ranging from the mundane of a garbage day or house alarm to feeding their dog Brandy, tidying the house, and constantly reminding him to take care of himself.
When we first see Tony, he is not doing great on self-care, and he has turned his grief into a “super power” allowing himself to do or say whatever he wants to – from pretending to reprimand his dog for calling a man (who had just told him his dog should be on a lead) a “fat hairy nosy !#$%&” to getting into a name-calling exchange with a primary school child. He later (jokingly) threatens this same child with a hammer, so that the child will stop bullying his nephew.
Tony works as the head of features for the Tambury Gazette, the free local paper. The comedy is full of the hometown charm with Tony and the photographer, Lenny, visiting the homes of the interesting personalities who have called into the paper with their small-town newsworthy stories.
Colorful characters abound in his town, including Postman Pat, who pops in and helps himself to a bath. Tony develops an unlikely friendship with a sex worker whom he hires to clean his house – since she said that she would do “anything for 50 quid.”
Tony, in the midst of an existential crisis, visits his wife’s grave frequently. While there, he meets an older widow, Anne, who befriends him and offers good advice. (Anne is played by Penelope Wilton of The Best Exotic Marigold Hotel and Downton Abbey.)
Tony also dutifully visits his father daily at the Autumnal Leaves Care Home. His father has dementia and keeps asking about Lisa, forgetting that she is dead. Tony comments that if his father were a dog, he would euthanize him. In actuality, Tony’s dog, Brandy, stops Tony’s potential suicide throughout the series.
Matt, who is Tony’s brother-in-law (and boss at the paper) describes Tony as “devastated, suicidal.” Tony explains that he can do and say what he wants, and “then when it all gets too much, I can always kill myself.” By season 2, Matt’s wife has left him, and he, too, needs to see the psychiatrist.
The problem is the Tambury psychiatrist (played by Paul Kaye). General psychiatrists in film have been described in various ways by the late Irving Schneider, MD, including Dr. Evil, Dr. Wonderful, and Dr. Dippy types. “Dr. Dippy’s Sanitarium” was a 1906 silent film in which Dr. Dippy is seen lacking in common sense but being harmless overall. Based on the behaviors displayed in and out of therapy, the Tambury psychiatrist could never be described as Dr. Wonderful, leading to the Dr. Evil or the Dr. Dippy options. He is certainly using patients for his own personal gratification (like a Dr. Evil might) and is certainly lacking in common sense and acting “crazier or more foolish than his patients”1 (like a Dr. Dippy). However, this psychiatrist may need a category all to himself.
Tony sought out the psychiatrist at a desperate time in his life. The dark but comical way he expresses himself: “A good day is one where I don’t go around wanting to shoot random strangers in the face and then turn the gun on myself” is not met with compassion, but unfortunately by inappropriate chuckles. Instead of offering solace, the psychiatrist revealed confidential doctor-patient information about other patients. When pressed, the psychiatrist insists, “I didn’t say his name.” The psychiatrist also explains he is telling Tony privileged information to “let you know you’re not … the only mental case out there.” The psychiatrist is also blatantly tweeting on his phone during the session. He tells his patient that it is ridiculous to want a soul mate and explains that other species might rape their sexual conquest. He yawns loudly in a session with Tony. These are just some of the many cringe-worthy behaviors displayed by this (unnamed) fictional embarrassment to our field.
By season 2, the psychiatrist begins seeing Tony’s brother-in-law, Matt, in treatment, the first of his boundary violations with Matt since Matt is Tony’s close friend and relative. The psychiatrist soon makes the crass self-disclosure to Matt that, “I was bleeding from the anus for a month last year, and I never went to the doctor,” implying Matt is a wimp for coming in. The psychiatrist invites him to go out with him and his friends, and gives him a beer in a session. The psychiatrist tells Matt stories of his sex life and complains about why people are bothered about toxic masculinity. When there is no way it can get worse, Tony and Matt run into the psychiatrist and his mates in a pub. The psychiatrist tells his comrades: “That’s the suicidal one with the dead wife I was telling you about.” When asked about confidentiality, he again protests: “I didn’t say your name mate,” Gestures are made, and the patients are mocked and laughed at. Unfathomably, Matt still returns for therapy, but is told by the psychiatrist to “lie, cheat, just be a man,” and about lesbians using dildos. The psychiatrist complains to Matt he is “sick of this @#!&, hearing people winge all day.”
Dr. Dippy or Dr. Evil – or somewhere in between – Tambury’s psychiatrist is not anyone who should be seeing humans, let alone a vulnerable population seeking help. These satirical behaviors and comments perhaps suggest worries of the general population about what happens behind the closed doors of psychotherapy and the concern that there may not be such a thing as a “safe space.” Even though this character is meant to be funny, there is a concern that, in this difficult time, this portrayal could deter even one person from getting the help that they need.
In spite of this unfortunate characterization of psychiatry, “After Life” is a brilliant, dark portrayal of grief after loss, the comfort of pets, grief while losing someone to dementia, and even growth after loss. The theme of grief is especially poignant during this time of collective grief.
The difficulty is the portrayal of psychiatry and therapy – released at a time when in the real world, we are coping with a pandemic and expecting massive mental health fallout. Negative portrayals of psychiatry and therapy in this and other shows could potentially deter people from taking care of their own mental health in this traumatic time in our collective history when we all need to be vigilant about mental health.
Reference
1. Schneider I. Am J Psychiatry. 1987 Aug;144(8):966-1002.
While many across the world who have access to Netflix and other streaming services have been on lockdown, the second season of Ricky Gervais’s dark comedy series, “After Life,” was released. The show will also return for a third season.
The setup of the show is that Lisa, the wife of Gervais’s protagonist, Tony, has died of breast cancer. Knowing that he would need help after, she made him a video guide to life without her, ranging from the mundane of a garbage day or house alarm to feeding their dog Brandy, tidying the house, and constantly reminding him to take care of himself.
When we first see Tony, he is not doing great on self-care, and he has turned his grief into a “super power” allowing himself to do or say whatever he wants to – from pretending to reprimand his dog for calling a man (who had just told him his dog should be on a lead) a “fat hairy nosy !#$%&” to getting into a name-calling exchange with a primary school child. He later (jokingly) threatens this same child with a hammer, so that the child will stop bullying his nephew.
Tony works as the head of features for the Tambury Gazette, the free local paper. The comedy is full of the hometown charm with Tony and the photographer, Lenny, visiting the homes of the interesting personalities who have called into the paper with their small-town newsworthy stories.
Colorful characters abound in his town, including Postman Pat, who pops in and helps himself to a bath. Tony develops an unlikely friendship with a sex worker whom he hires to clean his house – since she said that she would do “anything for 50 quid.”
Tony, in the midst of an existential crisis, visits his wife’s grave frequently. While there, he meets an older widow, Anne, who befriends him and offers good advice. (Anne is played by Penelope Wilton of The Best Exotic Marigold Hotel and Downton Abbey.)
Tony also dutifully visits his father daily at the Autumnal Leaves Care Home. His father has dementia and keeps asking about Lisa, forgetting that she is dead. Tony comments that if his father were a dog, he would euthanize him. In actuality, Tony’s dog, Brandy, stops Tony’s potential suicide throughout the series.
Matt, who is Tony’s brother-in-law (and boss at the paper) describes Tony as “devastated, suicidal.” Tony explains that he can do and say what he wants, and “then when it all gets too much, I can always kill myself.” By season 2, Matt’s wife has left him, and he, too, needs to see the psychiatrist.
The problem is the Tambury psychiatrist (played by Paul Kaye). General psychiatrists in film have been described in various ways by the late Irving Schneider, MD, including Dr. Evil, Dr. Wonderful, and Dr. Dippy types. “Dr. Dippy’s Sanitarium” was a 1906 silent film in which Dr. Dippy is seen lacking in common sense but being harmless overall. Based on the behaviors displayed in and out of therapy, the Tambury psychiatrist could never be described as Dr. Wonderful, leading to the Dr. Evil or the Dr. Dippy options. He is certainly using patients for his own personal gratification (like a Dr. Evil might) and is certainly lacking in common sense and acting “crazier or more foolish than his patients”1 (like a Dr. Dippy). However, this psychiatrist may need a category all to himself.
Tony sought out the psychiatrist at a desperate time in his life. The dark but comical way he expresses himself: “A good day is one where I don’t go around wanting to shoot random strangers in the face and then turn the gun on myself” is not met with compassion, but unfortunately by inappropriate chuckles. Instead of offering solace, the psychiatrist revealed confidential doctor-patient information about other patients. When pressed, the psychiatrist insists, “I didn’t say his name.” The psychiatrist also explains he is telling Tony privileged information to “let you know you’re not … the only mental case out there.” The psychiatrist is also blatantly tweeting on his phone during the session. He tells his patient that it is ridiculous to want a soul mate and explains that other species might rape their sexual conquest. He yawns loudly in a session with Tony. These are just some of the many cringe-worthy behaviors displayed by this (unnamed) fictional embarrassment to our field.
By season 2, the psychiatrist begins seeing Tony’s brother-in-law, Matt, in treatment, the first of his boundary violations with Matt since Matt is Tony’s close friend and relative. The psychiatrist soon makes the crass self-disclosure to Matt that, “I was bleeding from the anus for a month last year, and I never went to the doctor,” implying Matt is a wimp for coming in. The psychiatrist invites him to go out with him and his friends, and gives him a beer in a session. The psychiatrist tells Matt stories of his sex life and complains about why people are bothered about toxic masculinity. When there is no way it can get worse, Tony and Matt run into the psychiatrist and his mates in a pub. The psychiatrist tells his comrades: “That’s the suicidal one with the dead wife I was telling you about.” When asked about confidentiality, he again protests: “I didn’t say your name mate,” Gestures are made, and the patients are mocked and laughed at. Unfathomably, Matt still returns for therapy, but is told by the psychiatrist to “lie, cheat, just be a man,” and about lesbians using dildos. The psychiatrist complains to Matt he is “sick of this @#!&, hearing people winge all day.”
Dr. Dippy or Dr. Evil – or somewhere in between – Tambury’s psychiatrist is not anyone who should be seeing humans, let alone a vulnerable population seeking help. These satirical behaviors and comments perhaps suggest worries of the general population about what happens behind the closed doors of psychotherapy and the concern that there may not be such a thing as a “safe space.” Even though this character is meant to be funny, there is a concern that, in this difficult time, this portrayal could deter even one person from getting the help that they need.
In spite of this unfortunate characterization of psychiatry, “After Life” is a brilliant, dark portrayal of grief after loss, the comfort of pets, grief while losing someone to dementia, and even growth after loss. The theme of grief is especially poignant during this time of collective grief.
The difficulty is the portrayal of psychiatry and therapy – released at a time when in the real world, we are coping with a pandemic and expecting massive mental health fallout. Negative portrayals of psychiatry and therapy in this and other shows could potentially deter people from taking care of their own mental health in this traumatic time in our collective history when we all need to be vigilant about mental health.
Reference
1. Schneider I. Am J Psychiatry. 1987 Aug;144(8):966-1002.
‘Joker’ filled with mental illness misconceptions
The Batman characters have been cultural icons for generations – spanning more than three-quarters of a century. How many of us had Batman (or the Joker) on our school lunch box or watched reruns of Adam West’s campy televised rendition of Batman? The October release of “Joker” has been breaking contemporary box office records.
(Spoiler alert!) The Todd Phillips film associates mental illness with violent acts, spurring a slew of articles explaining that this association is uncommon and may promote stigmatization and public fear of people with obvious symptoms of mental illness. The protagonist, Arthur Fleck (Joaquin Phoenix), suffers from a condition in which his affect and facial expressions are not appropriate to his emotions or to the situation. He laughs uncontrollably when a situation is sad or upsetting. Sometimes he laughs and cries at the same time. As a result, he often is misunderstood, ridiculed, and victimized – like many people with obvious mental illness.
Arthur Fleck is a loner who has difficulty with relationships and self-esteem, and is beaten severely while at work as a clown. Shortly after the incident, he is given a gun by one of his coworkers. He keeps it with him even when working as a clown in a children’s hospital – where it is accidentally revealed, and he is subsequently fired. Still in his clown garb, he later uses the gun when he is mocked and assaulted on the subway by three Gotham City bankers.
In an unusual tone, his mental health worker reminds him early in the film that he is prescribed seven different psychotropic medications, helping to cement for the viewer that mental illness is the cause of Arthur’s problems and the Joker’s origin story. Then the funding for Arthur’s mental health treatment (even if it was not good treatment) was cut – a problem not just in Gotham.
While some of Arthur Fleck’s symptoms are consistent with real mental illness, the combination of symptoms is unusual. Although he is being treated with a variety of medications, it is unclear whether any of them are helping him or what exactly they are helping him with. (Ironically, once he is off of his medications, he becomes a better dresser and a better dancer.) He writes in a disorganized way in his journal; the only intelligible sentence that is focused on is, “The worst part about having mental illness is people expect you to behave as if you DONT.” A smiley face in the ‘O’ suggests that his affect is inappropriate even in his writing. Arthur’s condition of uncontrollable laughing and/or crying, associated with head trauma, appears more consistent with the neurologic condition pseudobulbar affect rather than a mental illness. In addition to pseudobulbar affect, Arthur demonstrates a constellation of symptoms of different kinds of mental illness, including erotomanic delusions, ideas of reference, and disorganized thinking. He also does not appear to take social cues, such as knowing when he is being mocked. He appears to believe that his neighbor is his girlfriend (as the viewer was similarly led to believe), eventually breaking into her apartment where he thought he belonged, much to her horror when she finds him there. Some of his symptoms may run in his family (whether it be his biological or adoptive family).
Penny (Arthur’s mother) strongly believes (perhaps a delusion, perhaps not) that her previous employer Thomas Wayne (the future Batman’s father) is the father of her love-child, Arthur. When Arthur obtains Penny’s mental health records (through his own violent devices), he finds that she had been diagnosed with narcissistic personality disorder and a psychotic disorder. She had been found guilty of endangering the welfare of her (perhaps adopted, perhaps not) child Arthur, who had been malnourished, with severe head trauma, and tied to a radiator.
Arthur’s smothering of his mother with a pillow in her hospital bed, after he was devastated by both her stroke and this newfound data, occurred in a perfect storm. The killing is not portrayed as an act of euthanasia. We know that schizophrenia is overrepresented among matricide perpetrators and that long-term dysfunctional relationships between mother and (grown) child usually precede matricides. Mothers are often seen as controlling, fathers are often absent (as in Arthur’s case), and the child is often overly dependent. The mother and child (as seen here) often have a relationship marked by love and hate – mutual dependence and hostility. But Arthur is not the only character in the Batman universe to commit matricide. Recall that the Batman’s psychiatrist Amadeus Arkham himself killed his own mentally ill mother during his young adulthood.
Pop culture can give the public negative impressions of mental illness. While filmmakers need not portray actual mental illnesses or their symptoms in moving their stories forward, their portrayals have an impact on what the public sees as mental illness. This is similar to the current American president and others in political power asserting that mental illness causes mass shootings, and those in the public taking their word for it rather than the word of psychiatry.
In actuality, what felt the most true to life in the film was the early scene in which Arthur was seriously assaulted while waving the going-out-of-business sign on the sidewalk, just trying to make a living. As psychiatrists know, people with mental illness are more likely to be victimized by others in society than to be perpetrators of violence. To be sure, some of Arthur’s characteristics are dynamic risk factors, such as his unemployment and social isolation. However, society often conflates mental illness with dangerousness, but most people with mental illness are not violent.
In the final scenes, Arthur Fleck (who is now the Joker) is apparently back in the white-walled Arkham State Hospital, with an implication that he has gotten away with the murders, either found incompetent or insane. This, too, has negative implications for the public viewing the film – and further perpetuates the misunderstanding that people with mental illness “get away” with their crimes. In reality, depending on the study, approximately one-quarter of those who pleaded insanity were found insane, and those facing jury trials (and public perception) are less likely to be found insane than those with bench trials. Public misinterpretations and outrage over the idea that a mentally unwell person might be found insane rather than guilty have existed for centuries, perhaps most memorably when John Hinckley Jr. attempted to assassinate former President Ronald Reagan, after identifying with a character in the film “Taxi Driver.” Let’s presume that Gotham has an insanity defense similar to other places in America. Then, in order to be found insane, Arthur’s pseudobulbar affect or his (unclear) mental illness would have either caused him not to know the nature and consequences of his acts, and/or to appreciate the wrongfulness of his acts (if we are fairly certain that Gotham is actually New York City). Neither of these appear to be true from the film. He knew that he was killing. No delusions or hallucinations made him think his acts were not wrong. Rather, he had an arguably rational motive – certainly the multitudes wearing clown masks in the subsequent uprisings against the powerful also believed his motive to be rational. He deliberately killed the bankers who mocked and beat him. He was also able to defer his killings until what he calculated was the right time to have the most impact – for example, on live television, or when he was alone with his mother in the hospital.
In closing, unrealistic portrayals of the link between mental illness, violence, and forensic hospitalization are seen on the silver screen in “Joker.” We hope that others who feign mental illness symptoms to evade criminal responsibility will emulate Joaquin Phoenix’s Joker as it will make it much easier for forensic psychiatrists to ferret out malingerers!
Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington, D.C.: American Psychiatric Association Publishing [2019]), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill-Cornell Medical Center.
The Batman characters have been cultural icons for generations – spanning more than three-quarters of a century. How many of us had Batman (or the Joker) on our school lunch box or watched reruns of Adam West’s campy televised rendition of Batman? The October release of “Joker” has been breaking contemporary box office records.
(Spoiler alert!) The Todd Phillips film associates mental illness with violent acts, spurring a slew of articles explaining that this association is uncommon and may promote stigmatization and public fear of people with obvious symptoms of mental illness. The protagonist, Arthur Fleck (Joaquin Phoenix), suffers from a condition in which his affect and facial expressions are not appropriate to his emotions or to the situation. He laughs uncontrollably when a situation is sad or upsetting. Sometimes he laughs and cries at the same time. As a result, he often is misunderstood, ridiculed, and victimized – like many people with obvious mental illness.
Arthur Fleck is a loner who has difficulty with relationships and self-esteem, and is beaten severely while at work as a clown. Shortly after the incident, he is given a gun by one of his coworkers. He keeps it with him even when working as a clown in a children’s hospital – where it is accidentally revealed, and he is subsequently fired. Still in his clown garb, he later uses the gun when he is mocked and assaulted on the subway by three Gotham City bankers.
In an unusual tone, his mental health worker reminds him early in the film that he is prescribed seven different psychotropic medications, helping to cement for the viewer that mental illness is the cause of Arthur’s problems and the Joker’s origin story. Then the funding for Arthur’s mental health treatment (even if it was not good treatment) was cut – a problem not just in Gotham.
While some of Arthur Fleck’s symptoms are consistent with real mental illness, the combination of symptoms is unusual. Although he is being treated with a variety of medications, it is unclear whether any of them are helping him or what exactly they are helping him with. (Ironically, once he is off of his medications, he becomes a better dresser and a better dancer.) He writes in a disorganized way in his journal; the only intelligible sentence that is focused on is, “The worst part about having mental illness is people expect you to behave as if you DONT.” A smiley face in the ‘O’ suggests that his affect is inappropriate even in his writing. Arthur’s condition of uncontrollable laughing and/or crying, associated with head trauma, appears more consistent with the neurologic condition pseudobulbar affect rather than a mental illness. In addition to pseudobulbar affect, Arthur demonstrates a constellation of symptoms of different kinds of mental illness, including erotomanic delusions, ideas of reference, and disorganized thinking. He also does not appear to take social cues, such as knowing when he is being mocked. He appears to believe that his neighbor is his girlfriend (as the viewer was similarly led to believe), eventually breaking into her apartment where he thought he belonged, much to her horror when she finds him there. Some of his symptoms may run in his family (whether it be his biological or adoptive family).
Penny (Arthur’s mother) strongly believes (perhaps a delusion, perhaps not) that her previous employer Thomas Wayne (the future Batman’s father) is the father of her love-child, Arthur. When Arthur obtains Penny’s mental health records (through his own violent devices), he finds that she had been diagnosed with narcissistic personality disorder and a psychotic disorder. She had been found guilty of endangering the welfare of her (perhaps adopted, perhaps not) child Arthur, who had been malnourished, with severe head trauma, and tied to a radiator.
Arthur’s smothering of his mother with a pillow in her hospital bed, after he was devastated by both her stroke and this newfound data, occurred in a perfect storm. The killing is not portrayed as an act of euthanasia. We know that schizophrenia is overrepresented among matricide perpetrators and that long-term dysfunctional relationships between mother and (grown) child usually precede matricides. Mothers are often seen as controlling, fathers are often absent (as in Arthur’s case), and the child is often overly dependent. The mother and child (as seen here) often have a relationship marked by love and hate – mutual dependence and hostility. But Arthur is not the only character in the Batman universe to commit matricide. Recall that the Batman’s psychiatrist Amadeus Arkham himself killed his own mentally ill mother during his young adulthood.
Pop culture can give the public negative impressions of mental illness. While filmmakers need not portray actual mental illnesses or their symptoms in moving their stories forward, their portrayals have an impact on what the public sees as mental illness. This is similar to the current American president and others in political power asserting that mental illness causes mass shootings, and those in the public taking their word for it rather than the word of psychiatry.
In actuality, what felt the most true to life in the film was the early scene in which Arthur was seriously assaulted while waving the going-out-of-business sign on the sidewalk, just trying to make a living. As psychiatrists know, people with mental illness are more likely to be victimized by others in society than to be perpetrators of violence. To be sure, some of Arthur’s characteristics are dynamic risk factors, such as his unemployment and social isolation. However, society often conflates mental illness with dangerousness, but most people with mental illness are not violent.
In the final scenes, Arthur Fleck (who is now the Joker) is apparently back in the white-walled Arkham State Hospital, with an implication that he has gotten away with the murders, either found incompetent or insane. This, too, has negative implications for the public viewing the film – and further perpetuates the misunderstanding that people with mental illness “get away” with their crimes. In reality, depending on the study, approximately one-quarter of those who pleaded insanity were found insane, and those facing jury trials (and public perception) are less likely to be found insane than those with bench trials. Public misinterpretations and outrage over the idea that a mentally unwell person might be found insane rather than guilty have existed for centuries, perhaps most memorably when John Hinckley Jr. attempted to assassinate former President Ronald Reagan, after identifying with a character in the film “Taxi Driver.” Let’s presume that Gotham has an insanity defense similar to other places in America. Then, in order to be found insane, Arthur’s pseudobulbar affect or his (unclear) mental illness would have either caused him not to know the nature and consequences of his acts, and/or to appreciate the wrongfulness of his acts (if we are fairly certain that Gotham is actually New York City). Neither of these appear to be true from the film. He knew that he was killing. No delusions or hallucinations made him think his acts were not wrong. Rather, he had an arguably rational motive – certainly the multitudes wearing clown masks in the subsequent uprisings against the powerful also believed his motive to be rational. He deliberately killed the bankers who mocked and beat him. He was also able to defer his killings until what he calculated was the right time to have the most impact – for example, on live television, or when he was alone with his mother in the hospital.
In closing, unrealistic portrayals of the link between mental illness, violence, and forensic hospitalization are seen on the silver screen in “Joker.” We hope that others who feign mental illness symptoms to evade criminal responsibility will emulate Joaquin Phoenix’s Joker as it will make it much easier for forensic psychiatrists to ferret out malingerers!
Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington, D.C.: American Psychiatric Association Publishing [2019]), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill-Cornell Medical Center.
The Batman characters have been cultural icons for generations – spanning more than three-quarters of a century. How many of us had Batman (or the Joker) on our school lunch box or watched reruns of Adam West’s campy televised rendition of Batman? The October release of “Joker” has been breaking contemporary box office records.
(Spoiler alert!) The Todd Phillips film associates mental illness with violent acts, spurring a slew of articles explaining that this association is uncommon and may promote stigmatization and public fear of people with obvious symptoms of mental illness. The protagonist, Arthur Fleck (Joaquin Phoenix), suffers from a condition in which his affect and facial expressions are not appropriate to his emotions or to the situation. He laughs uncontrollably when a situation is sad or upsetting. Sometimes he laughs and cries at the same time. As a result, he often is misunderstood, ridiculed, and victimized – like many people with obvious mental illness.
Arthur Fleck is a loner who has difficulty with relationships and self-esteem, and is beaten severely while at work as a clown. Shortly after the incident, he is given a gun by one of his coworkers. He keeps it with him even when working as a clown in a children’s hospital – where it is accidentally revealed, and he is subsequently fired. Still in his clown garb, he later uses the gun when he is mocked and assaulted on the subway by three Gotham City bankers.
In an unusual tone, his mental health worker reminds him early in the film that he is prescribed seven different psychotropic medications, helping to cement for the viewer that mental illness is the cause of Arthur’s problems and the Joker’s origin story. Then the funding for Arthur’s mental health treatment (even if it was not good treatment) was cut – a problem not just in Gotham.
While some of Arthur Fleck’s symptoms are consistent with real mental illness, the combination of symptoms is unusual. Although he is being treated with a variety of medications, it is unclear whether any of them are helping him or what exactly they are helping him with. (Ironically, once he is off of his medications, he becomes a better dresser and a better dancer.) He writes in a disorganized way in his journal; the only intelligible sentence that is focused on is, “The worst part about having mental illness is people expect you to behave as if you DONT.” A smiley face in the ‘O’ suggests that his affect is inappropriate even in his writing. Arthur’s condition of uncontrollable laughing and/or crying, associated with head trauma, appears more consistent with the neurologic condition pseudobulbar affect rather than a mental illness. In addition to pseudobulbar affect, Arthur demonstrates a constellation of symptoms of different kinds of mental illness, including erotomanic delusions, ideas of reference, and disorganized thinking. He also does not appear to take social cues, such as knowing when he is being mocked. He appears to believe that his neighbor is his girlfriend (as the viewer was similarly led to believe), eventually breaking into her apartment where he thought he belonged, much to her horror when she finds him there. Some of his symptoms may run in his family (whether it be his biological or adoptive family).
Penny (Arthur’s mother) strongly believes (perhaps a delusion, perhaps not) that her previous employer Thomas Wayne (the future Batman’s father) is the father of her love-child, Arthur. When Arthur obtains Penny’s mental health records (through his own violent devices), he finds that she had been diagnosed with narcissistic personality disorder and a psychotic disorder. She had been found guilty of endangering the welfare of her (perhaps adopted, perhaps not) child Arthur, who had been malnourished, with severe head trauma, and tied to a radiator.
Arthur’s smothering of his mother with a pillow in her hospital bed, after he was devastated by both her stroke and this newfound data, occurred in a perfect storm. The killing is not portrayed as an act of euthanasia. We know that schizophrenia is overrepresented among matricide perpetrators and that long-term dysfunctional relationships between mother and (grown) child usually precede matricides. Mothers are often seen as controlling, fathers are often absent (as in Arthur’s case), and the child is often overly dependent. The mother and child (as seen here) often have a relationship marked by love and hate – mutual dependence and hostility. But Arthur is not the only character in the Batman universe to commit matricide. Recall that the Batman’s psychiatrist Amadeus Arkham himself killed his own mentally ill mother during his young adulthood.
Pop culture can give the public negative impressions of mental illness. While filmmakers need not portray actual mental illnesses or their symptoms in moving their stories forward, their portrayals have an impact on what the public sees as mental illness. This is similar to the current American president and others in political power asserting that mental illness causes mass shootings, and those in the public taking their word for it rather than the word of psychiatry.
In actuality, what felt the most true to life in the film was the early scene in which Arthur was seriously assaulted while waving the going-out-of-business sign on the sidewalk, just trying to make a living. As psychiatrists know, people with mental illness are more likely to be victimized by others in society than to be perpetrators of violence. To be sure, some of Arthur’s characteristics are dynamic risk factors, such as his unemployment and social isolation. However, society often conflates mental illness with dangerousness, but most people with mental illness are not violent.
In the final scenes, Arthur Fleck (who is now the Joker) is apparently back in the white-walled Arkham State Hospital, with an implication that he has gotten away with the murders, either found incompetent or insane. This, too, has negative implications for the public viewing the film – and further perpetuates the misunderstanding that people with mental illness “get away” with their crimes. In reality, depending on the study, approximately one-quarter of those who pleaded insanity were found insane, and those facing jury trials (and public perception) are less likely to be found insane than those with bench trials. Public misinterpretations and outrage over the idea that a mentally unwell person might be found insane rather than guilty have existed for centuries, perhaps most memorably when John Hinckley Jr. attempted to assassinate former President Ronald Reagan, after identifying with a character in the film “Taxi Driver.” Let’s presume that Gotham has an insanity defense similar to other places in America. Then, in order to be found insane, Arthur’s pseudobulbar affect or his (unclear) mental illness would have either caused him not to know the nature and consequences of his acts, and/or to appreciate the wrongfulness of his acts (if we are fairly certain that Gotham is actually New York City). Neither of these appear to be true from the film. He knew that he was killing. No delusions or hallucinations made him think his acts were not wrong. Rather, he had an arguably rational motive – certainly the multitudes wearing clown masks in the subsequent uprisings against the powerful also believed his motive to be rational. He deliberately killed the bankers who mocked and beat him. He was also able to defer his killings until what he calculated was the right time to have the most impact – for example, on live television, or when he was alone with his mother in the hospital.
In closing, unrealistic portrayals of the link between mental illness, violence, and forensic hospitalization are seen on the silver screen in “Joker.” We hope that others who feign mental illness symptoms to evade criminal responsibility will emulate Joaquin Phoenix’s Joker as it will make it much easier for forensic psychiatrists to ferret out malingerers!
Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington, D.C.: American Psychiatric Association Publishing [2019]), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill-Cornell Medical Center.
