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Ask a Psychiatrist: How Does Silver Linings Playbook Handle Mental Illness?

It's to be expected that one (or both) of a romantic comedy's protagonists will go a little crazy in some way. Silver Linings Playbook takes things a step further: Bradley Cooper's character, Pat, is newly released from a mental hospital, and his romantic foil Tiffany (played by Jennifer Lawrence) is battling her own demons. Neither, however, has the typical Hollywood version of mental illness, i.e. "My second personality is a prostitute with a Cockney accent!"

Pat's bipolar disorder and Tiffany's unnamed condition manifest themselves in ways that are realistically, even heartbreakingly mundane; Tiffany texts relative strangers for booty calls when she gets depressed, and Pat channels his mania into long jogs and rants about Hemingway. Yet the film has generated controversy among some reviewers about its portrayal of mental illness. Do the characters get off too easily, their symptoms falling by the wayside as soon as they find one another? Does the film imply that Pat's medication was doing him more harm than good? Seeking a professional opinion, Vulture consulted with Harvard Medical School psychiatrist Dr. Steven Schlozman. He loved the film.

Silver Linings Playbook has been accused of having an anti-psychiatry bias, but you seem to feel the opposite.
It's Hollywood, so there are still going to be things that are there more for the story than for accuracy. But they did a very nice job of depicting manic depressive illness or bipolar disorder in somebody who's quite bright, and who has limited but present insight on it. Only about 40 percent of people with bipolar disorder will look back on a manic episode and realize that they were manic. They'll often say something like, "Yeah, I was going a million miles a minute, but I was also onto something really good, really important, and if you guys hadn't interrupted me I probably could have pulled it off."

Pat is able to say, "That was a delusion, this isn't right." Yet he still seems to have very little insight into the situation with [his wife] Nikki: thinking he's going to get her back, without having a real understanding of the repercussions of what he did. We’re the viewers and we feel sympathetic towards him, so in some ways we understand his response. Maybe that's where some of the controversy's coming from.

Because beating up the guy who's having an affair with your wife seems like a fairly sane reaction?
There's plenty of people who don't have bipolar disorder who do that. If we had just seen that scene, and if psychiatric illness wasn't any part of the subtext of the movie, we wouldn't have any reason to believe that that was a manic episode. We would have every reason to believe that that was a crime of passion, and we've seen that a million times in movies. But it's the aftermath, the inability to recognize that what he did was over the top. We see his inability to understand why his ex-wife would have a restraining order against him, his inability to understand that getting her back wouldn't be as simple as just reading everything on her syllabus. Those are reactions you wouldn't expect from the average guy who beat the crap out of the person who was having an affair with his wife.

And then you have an added thing here, which is important: Contrary to what people think, it's really, really hard to be institutionalized for a violent crime unless the mental illness is pretty obvious. So the fact that he was institutionalized for so long in a psychiatric facility, is supposed to give us at least a hint that this was a slam dunk for the courts.

When he's in the institution, Pat is given a pill, puts it under his tongue to make it look like he took it, then spits it out. I feel like I've seen this in hundreds of movies.
Yeah, that's because it happens a lot. [Laughs] Yes, we have seen that in hundreds of movies. But that happens all the time on inpatient units. We do our best to get the folks to take their medicine. We can check to see whether they're taking them in other ways, through blood levels and stuff like that. But you always assume a certain level of lack of adherence to the regime, for a while, as people are getting better. And you can understand it; I mean, if you lack insight into the fact that there's something not right, it's hard to come up with a good reason to take the medicine. And even if you know you're better off on your medicines, a lot of them have really not-nice side effects. So there's a lot of reasons that you might decide not to take them.

But isn't there an implication that you're supposed to root for those characters in some way? Somehow, Pat not taking his meds — which he absolutely needs — is supposed to endear him to the audience.
We do read into that a kind of defiance that we find admirable. And who knows what that's related to; is it related to the stigma that is associated with psychiatric illness, the idea that a medicine can fix these very complex issues? Thinking back on my time on an inpatient unit, I actually feel some admiration for somebody who pushes back a little bit, too. It's an action that's meant to be conveyed as a message. Is he doing it because he doesn't think he's sick, is it because he's mad at his doctors, is it because he's determined to beat this thing on his own? All those things add to someone's character.

A lot of the criticisms of how the film treats mental illness come down to the fact that Pat is initially resistant to taking his meds, and it's not clear whether he was taking them again by the end.
This might very much have to do with what I do for a living, but I just assumed he went back on them. Towards the end, he says, in what feels like a very sincere way — remember, he's not been big on lying in the movie — and he says, "I'm taking my meds, I'm doing good." It never occurred to me that he might have stopped.

What did you make of the scene where Pat and Tiffany are swapping stories about their psychiatric medications?
To me, that felt de-stigmatizing, not stigmatizing. They got the pronunciations right, they got the side effects right. I mean, I've heard those discussions a thousand times. And actually, on an inpatient unit, those are the discussions you want. And that fact that this scene could so blithely make its way into a mainstream film without a lot of explanation around it — I thought that was important.

We see Pat him have several manic episodes, some of which are violent. He's basically entirely manic in the film; we don't really see a depressive episode, do we?
No, you're right. Which makes for a better storyline but it's not actually the most common case. Even though we picture bipolar disorder as this kind of sine wave thing where you go up-down up-down, most people have mixed states when they're decompensating. So they'll have be highly irritable, going a million miles a minute, but not euphoric. Pat is not sleeping, he's grandiose, he has pressured speech — he actually meets the criteria for mania. And you don't ever really see a purely depressive state. You see these times where he feels sort of defeated, like that hilarious scene where he finishes the Hemingway book and he goes "WHAT THE FUCK!" and throws it through a window.

The Hemingway scene felt like a very realistic portrayal of someone with mental illness, in that he was feeling this trivial thing so intensely.
I say to patients all the time, "Look, you've got a really big radar, so you're going to pick up on a lot of things and feel them real powerfully. And that's a gift and also a kind of curse." I've seen patients really get worked up over something like that. It's appropriate to get worked up over Hemingway; that's fine. It's not appropriate to throw the book through a window, wake up your parents, and pace and scream about it.

We know that Jennifer Lawrence's character, Tiffany, has been on meds, but we don't actually get a diagnosis. What was your take on her from a psychiatric perspective?
It's hard not to see that character and wonder a little about borderline personality disorder for her. I think we're probably supposed to think that, and then we're supposed to feel bad about thinking that after we hear her history — which is silly, because people are allowed to have horrible histories and people are allowed to have borderline personality disorder, and there's nothing wrong with either of those things.

So she's had a significant response to a pretty awful trauma, the death of her husband. But she wasn't doing well even before then, because we know she said, "Look, I can barely take care of myself." And we don't know whether those medications she talked about being on actually predated or came after that trauma. We can make the assumption that there's depression, because someone put her on Effexor, which is an antidepressant. But you can have both: You can have depression and borderline personality disorder. I guess I'd be most comfortable just saying: She's not doing well.

So her symptoms seem plausible: the promiscuity, the mood swings, the lying.
Oh yeah. What was frustrating to me as a watcher of the movie is, since she's basically a foil for Pat's character development, you don't see her develop a whole lot. I think her life's more complicated than she's leading on. So she's not out of the woods yet. I'd actually worry a little bit more about her than about him.

The Hollywood convention is that two crazy people find each other and somehow love cancels out all the crazy. Does this film fall into that trap?
I did leave the movie with the lingering concern that that could potentially be read into it. I mean, falling in love is an absolutely awesome wonderful thing, but it's not going to cure bipolar disorder any more than it's going to cure diabetes. It just doesn't work that way. The flipside of that is, we know from all sorts of really good studies, that people with psychiatric illnesses — horrible depression, bipolar disorder, even schizophrenia — they do better when they're in love. That's one of the things that confers resilience. So it's not an unheard-of story; the part that's unheard of is that you suddenly don't need your medicines and life goes on fine forever.

Photo: The Weinstein Company