Mental illness has been portrayed in cinema with varying degrees of accuracy since as early as the 1920s, when The Cabinet of Dr. Caligari (Robert Wiene, 1920) used the elaborately abstract mise-en-scène of German Expressionism as a visual extension of the protagonist’s ego and state of mind. Since then, mental disorder and psychiatric health has been depicted in cinema within a range of representations, including: retrograde amnesia in RoboCop (Paul Verhoeven, 1987); autistic disorder inRain Man (Barry Levinson, 1988); clinical depression in Melancholia (Lars Von Trier, 2011); dissociative disorders in Black Swan (Darren Aronofsky); personality disorder in the guise of the monstrous-feminine in Fatal Attraction (Adrian Lyne, 1987); schizophrenia in I’m a Cyborg, But That’s OK (Park Chan-wook, 2006); and dissociative identity disorder in Shutter Island (Martin Scorsese, 2010), among others. As argued by Graeme Harper and Andrew Moor,
Films about illness are not only drawn to bio-medical storylines, of course, but to psychological and psychiatric ones. Or, alternatively, to socio-medical perspectives – elements sidelined by the clinical gaze […] Clearly, cinema is fascinated with the mind as a subject, for which a host of explanations can be offered. The post-Romantic narratives which are a grist to popular cinema’s mill are driven by issues of character motivation and interior depth, and the mysteries of the malfunctioning mind are traditional melodramatic fare, especially when its strangeness can import metaphysical connotations (for example, of ‘genius’). Popular cinema (particularly Hollywood) has also tended towards personalised, libertarian or existential aesthetics, and individualism like this is thought to reside in the mind.
(Harper and Moor, 2005: pp.3-4)
Otto Wahl extends the argument by stating, “People who are perceived as “different” are often the target of disrespectful humour. So it should be no surprise that people with mental illnesses, who are frequently the subject of such humour, also tend to be viewed and portrayed as fundamentally different” (Wahl, 2003: 36). Subsequently, the patient is often elaborated into a comedic persona. Additional to the patient is the manifest presence of the nurse (and the doctor), the confines of the psychiatric institute, the patient, and, included within the narratology, the ‘treatment’ the patients are treated/subjected to. While the institute is generally more often displayed as a place of restriction and confinement – from the locked doors and barred windows of I’m A Cyborg, to the shackled patients ofShutter Island – the nurse and the patient are habitually presented to the spectator with fluctuating modes of representation. This essay will examine two films portraying mental health, the psychiatric institute, the nurse and the patient: Girl, Interrupted (James Mangold, 1999) and One Flew Over The Cuckoos Nest (Milos Forman, 1975), and will compare and contrast the representational elements of themise-en-scène that are present in both films.
Girl, Interrupted is based on the real-life accounts of writer Susanna Kaysen’s 18-month stay in a psychiatric institute, due to her being diagnosed with Borderline Personality Disorder following a suicide attempt. While inside, Susanna (Winona Ryder) befriends fellow patients Lisa (Angelina Jolie), Daisy (Brittany Murphy), Georgina (Clea DuVall) and Polly ‘Torch’ Clarke (Elisabeth Moss). The film’s opening shot focuses on a close-up of a window, its thick black bars establishing the main locale as a space of captivity, which in turn foreshadows the film’s recurrent themes of confinement and restriction. The film is non-linear (the opening scene is taken from one of the final moments of the film), and it is this style of editing that helps to depict Susanna’s mental state of mind. Susanna’s voice over, which asks, “Have you ever confused a dream with life?” (Girl, Interrupted), alludes further to her condition, which the following edit depicts. As the voice-over continues, a close-up of Susanna shows her turn to look directly into the camera (momentarily removing the fourth wall) as she utters the word “interrupted”, and this shot allows the spectator to witness a pair of hands quickly place themselves on her shoulders. This image rapidly cuts to a shot of Susanna being pushed onto a hospital bed, as the close-up of her face and the presence of hands almost seamlessly segues from the previous shot. However, what was once a mellow and somewhat tranquil scene of calm has now been replaced with a scene of chaos and confusion, and Susanna is shown sweating and distressed, with a thick tube having been inserted into her mouth in order to pump her stomach. The scene represents Susanna’s confused mind, in which a physical act or noise can inadvertently trigger a traumatic memory and present itself as a current event. However to the viewer, it becomes evident that this represents a flashback, which aids the narrative in giving a back story into Susanna’s past.
This form of editing is used intermittently throughout the film, including the following scene. While still on the hospital bed, Susanna is disorientated and drowsy, shown by placing the camera at an unnaturally canted angle. The skewed position shows Susanna telling the doctors that the bones in her hands are missing, while another close-up shows swelling and bruising around her wrists. Susanna states that it is “hard to stay in one place”, while off screen, a voice asks, “Susanna, if you had no bones in your hands, how did you pick up the aspirin?” (Girl, Interrupted). As Susanna lies on the bed, she responds by turning to the direction of the voice, and at this point the edit again jumps to another scene showing Dr. Crumble (Kurtwood Smith) sitting in his office, questioning Susanna. Followed by yet another flashback triggered by a dog barking, these first minutes confirm Susanna to be a confused person, not having the ability to establish what is real and what is memory.
Theorist Michel Foucault argues,
No doubt there are sick persons who have no family, and others who are so poor that they live ‘cooped up in attics’. For these, ‘communal houses for the sick’ must be set up that would function as family substitutes and spread, in the form of reciprocity, the gaze of compassion; in this way, the poor would find ‘in companions of their own kind naturally sympathetic creatures who are at least not entirely strangers to them’.
(Foucault, 1991: 40)
Dr. Crumble, who informs Susanna that she is to be admitted to a psychiatric institute, in this case is he who casts the “gaze of compassion”, and subsequently, the manifestation of Claymoore Psychiatric Hospital is the physical representation of the “communal houses for the sick”, and her “own kind” are the patients she befriends. As Susanna approaches the institute in the back of a cab, the mise-en-scènesuggests the institute itself is a picturesque space of openness and peace. Unlike the institute on Shutter Island, there is an absence of armed security, no depiction of handcuffed patients, and no apparent gates to keep the patients detained. Instead, a subjective shot taken over the shoulder of the taxi driver displays the surroundings as welcoming, with overt connotations of freedom in the surrounding woodland area. The windows show no bars, and the smiling face of Valerie Owens (Whoopi Goldberg) emphasises a welcoming environment.
The interior of Claymoore, however, displays a conflicting view of the institute. As Valerie shows Susanna around, a high angle shot shows the two walking up stairs, with gates briefly obstructing the view from the foreground. It is this close-up of the gates which soon becomes a familiar sight within the aesthetics of the films, emphasising the characters’ internment and the elements of constraint and imprisonment. Patients are often shown in close-up looking through windows at the freedom of the outside, bars or gates often partially obstructing their view. In the scene in which Valerie shows Susanna the art room, musical instruments are shown locked away, however still visible and almost within reach. Toward the end of the room, windows are visible, the bars partially covered by curtains which merely mask the implication of imprisonment.
The bars and gates of the institute formulate a reoccurring feature of Girl, Interrupted, that being the concept of control. Control is shown in the film in a routinely repetitive way: patients are shown being handed pills by Mrs. McWilley (Josie Gammell) at the nurse’s station, a long line of individuals who are seemingly willing to have their personalities (and even bowel movements in the shape of laxatives) suppressed and controlled. The administration of the drugs from the nurse’s station, which functions as a scopophilic haven and safe space for the nurses to monitor the patients, is a daily act of repetition. In his analysis of the prison, Foucault comments on the ideology of routine:
The time-table is an old inheritance. The strict model was no doubt suggested by the monastic communities. It soon spread. Its great three methods – establish rhythms, impose particular occupations, regulate cycles of repetition – we soon to be found in schools, workshops and hospitals […] An attempt is also made to assure the quality of the time used: constant supervision, the pressure of supervisors, the elimination of anything that might disturb or distract.
(Foucault, 1977: 150)
Mrs. McWilley hands the drugs to Susanna, who apprehensively swallows them and steps back, furthering herself from the rest of the patients. As McWilley’s voice fades into the background, Susanna is shown in mid shot walking down the corridor and separating herself from the situation, the stark lighting providing a contrast to the natural sunlight shown previously in the film, providing the spectator with the notion of Susanna’s detachment from the outside world. The shot is significant for several purposes: Firstly it emphasises the elements of control and manipulation that are practised at the institute. Secondly, the shot underlines Susanna’s solitude and isolation from the rest of the patients, and thirdly it depicts the repetitive daily scenario of the patients’ daily routine. Behind Susanna, M.G. (Drucie McDaniel) is shown sitting on a bench, who stands, walks behind Susanna and manoeuvres around Polly. The stiff movement of the characters combined with the fluidity of the interaction suggests the action is a rehearsed, repetitive movement that the couple potentially engage in on a day-by-day basis.
The final few moments of the scene adds another dimension of control to the narrative. As Susanna approaches the end of the corridor, she stops in her tracks and the camera provides a subjective shot of Lisa sitting on the floor of the isolation cell, who appears to be under the influence of a repressive treatment. In an article analysing Shutter Island, film theorist Frances Pheasant-Kelly comments of the narrative element of both detention and control:
The use of solitary confinement is readily discernible across a range of institution films, commonly the prison genre but also apparent in the asylum film (for example, in Girl, Interrupted, the characters of ‘Torch’ [Elisabeth Moss] and Lisa are both confined to isolation cells). These aspects are important in providing narrative interest to what would otherwise be mundane and highly repetitive scenarios, although at times, they may reflect the practices of real institutions (Shah 2010, 883).
(Pheasant-Kelly, 2012: 215)
The shot of Lisa on the floor suggests her to be recovering from a form of treatment known as electro-convulsive therapy (ECT), which the institute uses as a means to repress a patient’s identity, and a form of ‘treatment’ that is potentially repeated on her towards the film’s final scene, where Lisa is returned to Claymoore. Pheasant-Kelly continues by stating that the “narrative aim is usually to subdue the patient, resulting in a personality change or in extreme cases, brain damage, and is clearly an excessive form of regulation rather than therapeutic measure” (2012, 214). When Lisa returns, a long shot shows her having handcuffs taken off by a police officer, followed by her being escorted into the isolation cell by a male nurse and Valerie. A close-up shows Lisa looking confused, unaware of her surroundings, her personality seemingly diminished as she appears to not recognise Susanna, whom she simply glances at when walking past. The therapy has apparently rendered her psychologically unrecognisable from her former self, as these evident side effects correlate with the side effects following ECT treatment:
Pioneered in the late 1930s, electroshock therapy, as it was more commonly known, was a scientifically crude practice that often left patients dazed and disoriented, sometimes with broken bones. For many it became a symbol of the callousness that often characterized the treatment of the mentally ill.
Although by the late 1960s the therapy was beginning to be used less frequently, Girl Interrupted portrays the treatment as still crudely and freely in use, somewhat abused by the hospital staff in order to suppress and control patients. William C. Cockerham comments on the medical model of mental health, and the ‘cures’ that are associated with it:
The medical model views mental disorder as a disease or a diseaselike entity that can be treated through medical means. That is, the medical model attributes mental abnormalities to psychological, biochemical, or genetic causes and attempts to treat these abnormalities by way of medically grounded procedures such as psychopharmacology (drug therapy), electroshock therapy (EST), or psychosurgery (brain surgery).
(Cockerham, 1996: 57)
A further example of the representation of the psychiatric institute features in the film One Flew Over The Cuckoo’s Nest. Jack Nicholson plays R.P. McMurphy, who upon arrival at a mental institution, almost immediately gains status as alpha male among the patients on the ward, and forms a significant relationship with Nurse Ratched (Louise Fletcher). Despite being diagnosed with a mental order and being admitted to the institute, it is questionable as to whether McMurphy is actually insane, or whether it is a façade created by him to avoid going to prison for his crimes. McMurphy’s arrival (and sociopathic character) mirrors that of Lisa’s in Girl, Interrupted, and, as with Lisa, the spectator sees him arrive to the institute in a car, with the camera placed at a high angle, placing the spectator as a patient looking through a window. When McMurphy emerges from the car, he is shown in handcuffs. Brian Glasser argues,
It has recently been suggested that people may seek a safe haven from life’s difficulties by retreating into the sick role (Malleson, 2002). However, in the cinema there are a few examples where physical sickness is seen as being worth prolonging, despite the benefits it has bought in its wake; whereas mental ill-health is often depicted as being in many ways a superior state to normality (for example, One Flew Over The Cuckoos Nest (Milos Forman, 1975) and Morgan: A Suitable Case For Treatment (Karel Reisz, 1965), with Nicholas Ray’s Bigger Than Life (1956) straddling the fence), in an artistic tradition that can be traced back through the idiot savant to the Shakespearean fool, if not further.
(Glasser, 2005: 16)
McMurphy’s arrival at the institute shows him being lead into the building handcuffed and somewhat maniacally dancing and fooling around. His ‘insanity’ appears more mocking than bonafide, and upon having the handcuffs taken off, he has an outburst of laughter and kisses an officer, reiterating Glasser’s argument of the “idiot savant”. A low angle subjective shot shows patients looking over the staircase cautiously at McMurphy, who appears to enjoy the attention. Slightly ironically, the scene also foreshadows Nicholson’s later role in Batman (Tim Burton, 1989) as the maniacal Joker. Mike W. Martin argues, “Sick people (as well as healthy ones) are completely determined by biological and environmental forces in ways that remove moral responsibility” (Martin, 2006: 51). However, McMurphy serves as a contradiction to this, as the narrative of the film alludes to the questionability of his mental state of health, and whether his act is a smokescreen allowing him to shun his responsibilities outside the institute.
The institute featured in One Flew Over The Cuckoo’s Nest is similar to that featured in Girl, Interrupted in the sense that the underlying elements of control are emphasised within the mise-en-scène. The exterior of the institute is similarly shown as a space of freedom – the film’s opening shot displays a wide mountain range and a lake, emphasising openness. However the interior of the institute contrasts this freedom by overtly and repeatedly showing bars on the windows. While Girl, Interrupted’s main location is a female ward, the patients of One Flew Over The Cuckoo’s Nest are all male. This, however, does not mean that the illnesses displayed are necessarily distinguishable from one another: Several of the patients in both Girl, Interrupted and One Flew Over The Cuckoo’s Nestdisplay characteristics that are easily identified as infantilised. The character of Martini (Danny DeVito) serves as a male counterpart to M.G., as both display physical attributes likened to the soft body, have a small stature, and similarly display child-like qualities of infantile mannerisms and facial expressions. Several female characters in Girl, Interrupted are shown holding dolls, while in One Flew Over The Cuckoo’s Nest, male characters are displayed in their underwear, underscoring a child-like impression. In one such scene displaying this, McMurphy shows Martini a set of adult playing cards, and as the camera is placed in front of Martini’s face, McMurphy’s hand waves the cards around before his eyes. This shot mimics a baby who is learning to focus on a parent’s finger, as it is glides before its eyes. As McMurphy and Martini walk off to look at the cards, Cheswick (Sydney Lassick) appears distressed, and repeatedly asks “Don’t you wanna play?” (One Flew Over The Cuckoo’s Nest) which underscores elements of infantalisation. An extension of this infantile state is in the patients’ tantrums, which lead to them being taken away by orderlies and confined. Further still, both films depict the patients as being unable to articulate their own illnesses. Upon arrival at the institute, Susanna appears to deny her suicide attempt, and likewise McMurphy is shown with a mocking facial expression while the doctor asks why people suspect that his illness is being simulated.
A form of control exercised in the institute is the administration of drugs, and later, shock therapy. The nurse’s station acts as the main locale of control in the film, and when first introduced to the spectator, a nurse is seen dispensing the drugs. This image is followed by a shot of an orderly opening a cell, which reveals a patient on a bed, waking up, with his feet and hands bound with restraints. This serves as a reminder of the control elements of the institution, the authoritative figure of the institute being Nurse Ratched, who acts as a somewhat oppositional character to that of Valerie Owens. While both are clearly the authoritative presence on the ward, and while both enforce methods of control and routine upon the patients, the characters are opposites in terms of character. As Julia Hallam argues,
The binary stereotypes of femininity, the virgin and the whore, take on a set of particular characteristics in nursing images that have their origins in early nineteenth-century ideas about the ‘essential’ nature of the feminine. The ‘good’ nurse is invariably seen as a form of self-sacrificing angel who gives up everything to dedicate her life to caring the sick; the ‘bad’ nurse is her exact opposite, misusing her position of power and authority to satisfy her own needs and desires, whether these are material, sexual or simply sadistic.
(Hallam, 2000: 20)
While Nurse Ratched does not necessarily display sexual desire, she is presented as manipulative and sadistic. Hallam argues, “Women and caring have strong cultural associations in Western culture, which can lead to assumptions that caring is a natural or essential attribute of those born female, a genetic inheritance rather than a socially learnt pattern of behaviour” (2000: 14), which is more overtly evident in the character of Valarie – Nurse Ratched is presented as a near binary opposite in terms of her caring nature. While she is portrayed as being polite, she is, however, shown as merciless and cold at times, particularly when the patients disrupt regulation or the day-to-day repetitiveness of routine. From the opening scene in which she arrives at work in the morning, Nurse Ratched is presented in themise-en-scène as having a degree of demonic presence. A long shot in the film’s opening few moments shows her arriving on the ward in the morning, a red light above the door alluding to an element of demonic implication, which, as she walks toward the camera, positions itself above her head. Further still, she is dressed all in black (providing an opposite representation of the general impression of the nurse, who is usually depicted wearing white), and her hair is pulled up from her face, forming a hairstyle that subtly resembles two large horns. Also significant is her unblinking eyes, which, unlike the welcoming and often sympathetic look as seen in Valerie, hold a stony, crude stare throughout the film. This gives her character an unnerving poise, as seen in the scene in which she is conducting a group meeting. Positioned directly opposite McMurphy, the two cross-cut shots of each other frame the pair at the same height in the middle of the screen. While McMurphy is shown as loud and disruptive within the group, the shots of Nurse Ratched present her as unmoving, unblinking and threatening, which extends the notion of the institute being a threatening space to the patients.
Not unlike the theatrical mise-en-scène of The Cabinet of Dr. Caligari, the institutes in Girl, Interruptedand One Flew Over The Cuckoo’s Nest serve as an extension of the patients’ egos and states of mind. Additionally to the institutes representing a maternal authority over the patients, the network of tunnels that form part of the structure of the institutes, located underground, represent the mental and physical body:
Apart from commonalities of theme, costume, figure behaviour and narrative pattern, the fictional institution also tends to possess distinctive spatial qualities. In addition to a system of highly regulated spaces that are subject to various means of control, a network of tunnels often shadows the formal, visible architecture, these sometimes resembling the interior convoluted nature of the physical body (see Nellis and Hale 1982). In other cases, the labyrinthine workings of the institution may reflect the pathologically or criminally disturbed mind. Descent into these underground passages, secret tunnels and sewers often provides a temporary reprieve from the intense surveillance that dominates the upper levels, as well as offering a means of escape.
Towards the climax of Girl, Interrupted, Susanna goes down to the tunnels to look for her cat, and subsequently confronts Lisa. The chaotic camera movement and blurred lighting denote her confused state of mind, and thus the film comes full circle, the following scene leading to that which the spectator was first made witness to in the opening few shots, further emphasising the non-linear narrative. Both films portray institutes as an enclosed space, an enclosure not too different from a prison, where patients’ moods, personalities and even sexual energy is suppressed by the drug administering, controlling medical authority that is the nurse.
© Paul Anthony Jonze, 2012.
Cockerham, W. C. (1996) Sociology of Mental Disorder (fourth edition). New Jersey: Prentice-Hall, Inc.
Foucault, M. (1977) Discipline and Punish: The Birth of the Prison (second edition). London: Penguin
Foucault, M. (1991) The Birth of The Clinic (fifth edition), Bristol: Routledge.
Glasser, B. (2005) Magic Bullets, Dark Victories and Cold Comforts: Some Preliminary Observations About Stories of Sickness in the Cinema in Harper, G., Moor, A. (eds) Signs of Life: Medicine and Cinema.London: Wallflower Press, pp.7-18.
Hallam, J. (2000) Nursing The Image: Media, Culture and Professional Identity. London: Routledge
Harper. G., Moor, A. (2005) Introduction in Harper G., Moor, A (eds) Signs of Life: Medicine and Cinema. London: Wallflower Press, pp.1-6.
Pheasant-Kelly, F. E. (2012) Institutions, Identity and Insanity: Abject Spaces in Shutter Island, New Review of Film and Television Studies, 10:2, pp.212-229
Martin, M. W. (2006) From Morality to Mental Health. New York: Oxford University Press.
Wahl, O. F. (2003) Media Madness: Public Image of Mental Illness. New Jersey: Rutgers University Press.
Zajac, A. (2011) FDA Revisits Risk of Electric Shock Treatment, Los Angeles Times [online] March 19 2011 [Accessed 14 May 2012]. Available at: <http://articles.latimes.com/2011/mar/19/nation/la-na-electric-shock-20110320>
Batman (1989) Directed by Tim Burton. USA: Warner Bros.
Black Swan (2010) Directed by Darren Aronofsky. USA: Fox Searchlight Pictures.
Fatal Attraction (1987) Directed by Adrian Lyne. USA: Paramount Pictures.
Girl, Interrupted (1999) Directed by James Mangold. USA: Columbia Pictures.
I’m a Cyborg, But That’s OK (2006) Directed by Park Chan-wook. Korea: CJ Entertainment.
Melancholia (2011) Directed by Lars Von Trier. Denmark/Sweden/France: Nordisk Film.
The Cabinet of Dr. Caligari (1920) Directed by Robert Wiene. Germany: Decla-Bioscop.
One Flew Over The Cuckoo’s Nest (1975) Directed by Milos Forman. USA: United Artists.
Rain Man (1988) Directed by Barry Levinson. USA: United Artists.
RoboCop (1987) Directed by Paul Verhoeven. USA: Orion Pictures.
Shutter Island (2010) Directed by Martin Scorsese. USA: Paramount Pictures.