Joaquin Phoenix’s ‘Joker’-what can the clown prince of crime teach us about the world of psychiatry

*SENSITIVE CONTENT: abuse, violence, injury*

*FILM SPOILERS*

The most recent adaptation of ‘The Joker’, unlike its comic-based and often action-packed predecessors, adopted a more psychological drama approach that explored to an extent society’s interaction and perceptions of mental health problems.

The Joker, also known as city man ‘Arthur Fleck’, would fall under the category of a forensic patient given his extensive violent and murderous actions towards the end of the film. For this specific group of patients, risk is often directly linked to their mental illnesses. For example, paranoid schizophrenia is a very common diagnosis in these units. This typically involves symptoms such as persecutory delusions which commonly comprise the fixed, unshakeable beliefs that others are watching, following, laughing at, or even wishing to harm or kill the sufferer. This may invoke violence that is often committed in direct response to these beliefs. Auditory hallucinations (i.e. hearing voices) are also common in this group. A specific type of auditory hallucinations, aptly named ‘command hallucinations’, order the sufferer to commit certain acts, which might include attacking others.

The protagonist’s eventual criminality and violence, however, may have little to do with mental illness (although there may be indirect and subtle links).

It does not appear that Arthur becomes more paranoid due to mental illness, as the film progresses. If anything, he becomes increasingly grandiose and finds his social voice and platform in the power and sense of control he feels by violence and by inciting others. This is not a typical presentation of a mental illness and may be more in keeping with narcissistic and sociopathic personality disorder that becomes more recognisable by the end of the film. This is backed by Valentin Skryabin1 who, using the DSM-5 to determine if Arthur shows signs of a ‘real’ mental disorder, determines that the psychopathology Arthur exhibits is unclear, preventing diagnosis of psychotic disorder or schizophrenia. Skryabin concludes that the unusual combination of symptoms suggests a complex mix of features of certain personality traits, namely psychopathy and narcissism (he meets DSM-5 criteria for narcissistic personality disorder).

However, we are none the wiser by the end of the film whether certain elements of the film are real or imagined, including his relationship with neighbour Sophie and his altercation with his potential father Thomas Wayne, or even the final scenes where he is being worshipfully cheered whilst standing on the car in the context of his violent incitement of the crowds. While these experiences may suggest a break from reality literally meeting the definition for ‘psychosis’, lack of certainty in the genuineness of some of Arthur’s experiences makes this difficult to determine and backs Skryabin’s impression that there is no discernible diagnosable mental disorder.

This is not to say that Arthur is an emotionally healthy adult and does not preclude a mental disorder as we don’t have the full psychiatric history. Indeed there are a number of risk factors that predispose him to both offending and, on a separate note, developing a mental illness.

During sessions with his psychiatrist/therapist, Arthur describes his complaints as loneliness, isolation and ‘constant negative thoughts’. Multiple factors may have led him to this point, starting with his childhood and upbringing:

Unfortunately, we have very little information on his family history since he was abandoned as a child but this in itself may represent a traumatic experience in his childhood. Indeed childhood appears to have been a chaotic time for Arthur as he was brought up by a foster mother and did not have a father figure in his life. This was further compounded by his foster mother who has possible delusional disorder and possibly a personality disorder and underwent therapy during time spent as an inpatient at a psychiatric hospital. Arthur

also had a head injury which was apparently inflicted by his mother’s partner. He was found tied to a radiator, indicating that he was significantly physically and emotionally abused.

Head injuries in some cases, though not all, can lead to impulsivity and aggression (though again, this is technically a neurological, not a psychiatric condition). Arthur suffers from pseudo bulbar affect, resulting from this head injury. This is a condition that’s characterised by episodes of sudden uncontrollable, inappropriate laughing or crying. It may be the shame that Arthur feels due to his symptoms; he’s stigmatised, judged, mocked and even attacked because of his uncontrollable, inappropriate laughter. Although this apparent co-occurrence of both mental disorder and a neurological condition may be confusing for audiences trying to understand mental illness, his experiences lead Arthur to further isolation, which is typical for a whole host of mental illnesses as is addressed very credibly in the film.

Thus, Arthur is lonely, socially isolated, marginalised, bullied and mocked by both strangers (kids on the street, passengers on the train) and people who knew him (such as his peers and work colleagues), aptly highlighting the pervasive bio-psycho-social predisposing factors of mental illness.

On top of these background predisposing factors, there are a series of events during the film which precipitate his rage and lead to eventual violence. Arthur is fired from his job, he is pushed and bullied, and his healthcare professionals don’t support him or listen to him. This all occurs in the context of a brewing social divide between the rich and the disenfranchised and impoverished in Gotham, which Arthur absorbs. Then, being rejected by his potential billionaire father ignites something in him. Another huge factor, which is easy to understate is Arthur’s access to a gun. This is particularly relevant in the States and might tip somebody over the edge from thinking about killing, to actually doing it.

It may be all of these factors in combination that appear to catalyse Arthur Fleck’s transformation into the Joker, much more than any potential mental illness. Although the nebulous mixing of mental illness, neurological disorder, and permeating risk factors for biological, psychological and social adversities, the film does help to highlight that an individual, in the right context, can be pushed to their limit in committing extreme acts.