Students will submit 1 written critiques of a research article (chosen by the student) from a counseling journal. The article i would like analyze is attached to the question. The headers listed on th

Citation:

Poulgrain, J.W.; Bremner,

N.M.; Zimmerman, H.; Jao, C.-W.;

Winter, T.; Riordan, B.C.; Bizumic, B.; Hunter, J.; Scarf, D. Why So Serious?

An Attempt to Mitigate the

Short-Term Harmful Effects of the

Film Joker on Prejudice toward

People with Mental Illness. Behav. Sci.

2022 ,12 , 384.https://doi.org/

10.3390/bs12100384

Academic Editor: Lauren Dundes

Received: 22 August 2022

Accepted: 4 October 2022

Published: 7 October 2022

Publisher 's Note: MDPI stays neutral

with regard to jurisdictional claims in published maps and institutional af l-

iations. Copyright:

Licensee MDPI, Basel, Switzerland.

This article is an open access article distributed under the terms and

conditions of the Creative Commons

Attribution (CC BY) license (https:// creativecommons.org/licenses/by/

4.0/). Article

Why So Serious? An Attempt to Mitigate the Short-Term Harmful Effects of the Film Joker on Prejudice toward People

with Mental Illness

John William Poulgrain 1

, Niquaila May Bremner 1

, Hannah Zimmerman 1

, Chia-Wei Jao 1

, Taylor Winter 2 ,

Benjamin Charles Riordan 3

, Boris Bizumic 4

, John Hunter 1

and Damian Scarf 1 ,

* 1

Department of Psychology, University of Otago, Dunedin 9054, New Zealand

2 Department of Psychology, Victoria University of Wellington, Wellington 6140, New Zealand

3 Centre for Alcohol Policy Research, La Trobe University, Melbourne 3550, Australia

4 Research School of Psychology, Australian National University, Canberra 2601, Australia

* Correspondence: [email protected]

Abstract:The media perpetuates many harmful stereotypes about people with mental illness. In two

studies, we demonstrate the impact of negative media portrayals of mental illness on prejudice and

attempt to mitigate these negative effects. Speci cally, in Study 1, participants watched the movie

Joker , a recent lm which associates mental illness with violent behavior, or a control lm ( Terminator ).

Participants completed the Prejudice towards People with Mental Illness (PPMI) scale before and after

viewing their respective lms. The PPMI consists of four dimensions: fear/avoidance (i.e., wanting

to avoid people with mental illness), malevolence (i.e., viewing people with mental illness as inferior),

authoritarianism (i.e., preference for control over people with mental illness), and unpredictability

(i.e., the behavior of people with mental illness is unreliable). We hypothesized that participants

who watched the lm Joker would display an increase in their fear/avoidance of people with mental

illness and their support for authoritarian approaches to their treatment. Consistent with these

hypotheses, participants who viewed Joker displayed a signi cant increase in the fear/avoidance and

authoritarian subscales of the PPMI, relative to participants that watched Terminator . In Study 2, in an

attempt to mitigate the impact of Joker on prejudice towards people with mental illness, directly after

the lm we displayed educational and counter-stereotypical statements on-screen that challenged

the view that people with mental illness are violent. A control group viewed Joker without these

statements. Identical to Study 1, all participants completed the PPMI scale before and after viewing

the lm. We hypothesized that participants who viewed Joker with the statements would display

lower prejudice relative to the control condition. Unfortunately, participants in the experimental and

control conditions displayed a comparable increase in prejudice. Together, these studies con rm the

negative effect of media portrayals of mental illness (as depicted in Joker ) and demonstrate that these

effects are not easily mitigated.

Keywords: mental illness; stigma; prejudice 1. Introduction

Goffman [ 1] de ned stigma as a label attached to a stereotype, connecting the stigma-

tized person to an undesirable characteristic or trait. For people with mental illness, these

stereotypes can range from being intellectually brilliant to profoundly violent. Largely,

these stereotypes are derived from popular media (e.g., news, movies, music). Indeed, the

media is the primary avenue through which most people learn about mental illness [ 2,3].

As news media is purportedly non- ction, one would expect that it provides the public

with an accurate and objective representation of people with mental illness. Unfortunately,

this is rarely the case [ 2,4]. For example, Corrigan, Watson, Gracia, Slopen, Rasinski and

Hall [ 4] examined a large sample of newsprint stories that focused on mental illness or

Behav. Sci.

2022,12 , 384.https://doi.org/10.3390/bs12100384https://www.mdpi.com/journal/behavsci behavioral sciences Behav. Sci.

2022,12 , 384 2 of 12mental health and coded them into one of four categories: dangerousness, blame, treat-

ment/recovery, and advocacy. From a nal sample of 3553 news stories, the most common

themes were related to dangerousness. Assessing change over time, McGinty et al. [ 5]

analyzed news media coverage between 1995 and 2014 in the United States. Although there

was a decrease in the total number of stories over time, the stories that included mental

illness still predominantly focused on violence. Stereotypical news coverage of mental

illness is not restricted to the United States, with similar ndings reported in Japan [ 6],

Canada [7] and Aotearoa, New Zealand [2].

Beyond news media, stereotypical portrayals of mental illness have a long history in

film. For example, in the 1975 film One Flew Over the Cuckoo's Nest , Jack Nicholson plays Ran-

dle McMurphy, a character who feigns insanity to avoid prison. Unfortunately, the character

is placed in a psychiatric hospital, deemed dangerous and receives a frontal lobotomy due

to his rebellious behavior. More recent films have tended to depict characters experiencing,

rather than feigning, symptoms of severe mental illness. For example, Owen [ 8] analyzed

characters from 41 films that depicted or displayed symptoms of schizophrenia, reporting

that many of the characters were violent towards themselves and others.

Several studies have investigated how viewing lms depicting mental illness in u-

ences prejudice. For example, Domino [ 9] investigated the impact of watching One Flew

over the Cuckoo's Nest on attitudes towards mental health professionals, hospitals and facil-

ities and people with mental illness. Participants' attitudes towards all three areas were

more negative after watching the lm. More recently, Perciful and Meyer [ 10] examined

the impact of four lms that varied in their portrayal of mental illness and likability (i.e.,

emotional tone). Broadly speaking, the lms were rated as inaccurate but likable ( Me,

Myself and Irene ), inaccurate and fear-based ( Donnie Darko ), accurate and educational ( The

Brush, the Pen and Recovery ) and neutral (a control lm). Participants who viewed the

fear-based lm displayed a desire for greater social distance from people with mental

illness, compared to participants who watched the other three lms. Promisingly, social

distance scores for participants who viewed the accurate lm were signi cantly lower than

those who viewed the inaccurate lms, suggesting participants had fewer stigmatizing atti-

tudes when they had viewed an accurate portrayal of mental illness. As this latter nding

suggests, the in uence of lm media is not always negative. Indeed, Thonon, et al. [ 11]

examined whether a documentary lm ( Radio Schizo ) reduced negative attitudes towards

people with schizophrenia. The documentary followed ve young people diagnosed with

schizophrenia, with the young people at a range of stages regarding symptom severity and

living conditions. After viewing the lm, participants displayed a reduction in their view

that people with mental illness are dangerous.

Reducing Mental Illness Stigma

A large number of studies have investigated whether mental illness stigma can be

reduced via mass-media campaigns and more targeted interventions [ 12–16]. Approaches

to reducing mental illness stigma have tended to focus on contact and education. Contact-

based approaches draw on social psychology theory and research, suggesting that contact

with out-group members reduces the anxiety and fear associated with unknown groups [ 17].

Although the literature on contact has primarily focused on racial and ethnic groups, several

studies have investigated whether direct (i.e., interpersonal) or indirect contact (e.g., video-

based) can reduce mental illness stigma [ 15,18]. For example, Corrigan et al. [ 19] had

college students listen to a 10-minute presentation given by an individual with a history of

severe mental illness. As part of the presentation, the individual not only outlined their

history of mental illness (e.g., symptoms, experiences of hospitalization) but also noted

that, although they were not symptom-free, they were working and living independently.

Further, to enhance the effects of contact, the 10-minute presentation was followed by a

5-minute discussion, providing a context for the students to interact with the individual.

Results demonstrated that contact improved attributions about the controllability and

stability of people with mental illness [19]. Behav. Sci.

2022,12 , 384 3 of 12Similar to contact, education-based approaches challenge myths regarding people with

mental illness. Although contact does this through interpersonal interaction (e.g., meeting

an individual with mental illness who is stable and working), education takes a more direct

approach, specifying the myths associated with mental illness and countering them with

evidence. For example, Finkelstein, et al. [ 20] presented students with a computer-based

program that provided information on mental illness (e.g., incidence, causes, treatment)

and challenged several myths regarding mental illness (e.g., people with mental illness are

dangerous). The program not only signi cantly increased students' knowledge regarding

mental illness but also signi cantly reduced mental illness stigma.

2. Mitigating the Negative Effects of Film

Despite clear evidence that lms can increase mental illness stigma, there is little

evidence that the depiction of mental illness in lm has improved over time. Given this,

an important question is whether the negative effects of viewing a lm can be mitigated

or reduced. In one of the few studies to address this question, Wahl and Lefkowits [ 21]

had participants watch the 1986 lm Murder: By Reason of Insanity , which told the true

story of a man who murdered his wife while out on a day pass from a psychiatric hospital.

Before and after the lm, a narrator read an on-screen statement that noted the violent

behavior depicted in the lm was “not intended to be a general re ection of the mentally

ill” and that people with mental illness “are not more prone to violence than the non-

mentally disordered”. Unfortunately, the educational information did not mitigate the

adverse effects of viewing the lm, with participants in the education condition displaying

comparable increases in prejudice (e.g., people with a mental illness are dangerous) to those

who watched the lm without the educational statements.

More recently, Ritterfeld and Jin [ 22] investigated whether a trailer played before or

after the movie Angel Baby could mitigate the movie's negative effects. Angel Baby was

released in 1995 and tells the story of Harry and Kate, two people with schizophrenia

that meet each other during a group therapy session. They start a romantic relationship

and, upon nding Kate is pregnant, discontinue their medication. The lm follows the

negative impact of them discontinuing their medication. Ritterfeld and Jin [ 22] developed

six different types of trailers that varied in their focus on the movie (i.e., comments about

speci c characters vs. general information about schizophrenia) and whether the person

speaking was a patient with mental illness or a psychiatrist. Promisingly, although the

movie alone increased mental illness stigma, pairing the movie with one of the six trailers

signi cantly reduced mental illness stigma. Moreover, this reduction was more marked

when the trailer followed, rather than preceded, the lm. 3. Current Study

Building on the work of Wahl and Lefkowits [ 21] and Ritterfeld and Jin [ 22], the

current study attempts to mitigate the negative effect of the lm Joker .Joker was released in

2019 and became the rst R-rated lm to break 1 billion dollars at the box of ce. In addition

to its popularity, our interest in Joker is a result of the movie 1) portraying its namesake

character as having a mental illness and 2) following a narrative in which, following the

character stopping his medication, he carries out a campaign of violence (including murder).

Thus, the lm does what many lms before it have done: it associates mental illness with

acts of violence. Previously, we have reported that watching Joker increases prejudice

towards people with mental illness [ 23]. Here, in Study 1, we reanalyze these data and

investigate whether Joker impacts speci c dimensions of prejudice. Speci cally, while Scarf,

Zimmerman, Winter, Boden, Graham, Riordan and Hunter [ 23] assessed the impact of

Joker on the overall score on Kenny, Bizumic and Grif ths' [ 24] Prejudice towards People

with Mental Illness (PPMI) scale, we investigate the impact of Joker on the PPMI's four

dimensions: fear/avoidance (i.e., wanting to avoid people with mental illness), malevolence

(i.e., viewing people with mental illness as inferior), authoritarianism (i.e., preference for

control over people with mental illness) and unpredictability (i.e., the behavior of people Behav. Sci.

2022,12 , 384 4 of 12with mental illness is unreliable). Given the themes in Joker , we hypothesized that watching

the lm would lead to signi cant increases in participants' fear/avoidance of people with

mental illness and their support for authoritarian approaches to the treatment of people

with mental illness (e.g., enforced treatment).

Building on Study 1, in Study 2 we attempt to mitigate the negative impact of Joker

by presenting messages that challenge one of the main themes of the lm (i.e., that people

with mental illness are dangerous). Speci cally, two messages were presented on the screen

directly after the lm (i.e., “90–95% of people diagnosed with schizophrenia or bipolar

disorder do not commit any violent crimes” and “People with mental illness are over 10

times more likely to be the victim of violent crime than the general population”). Study 2

had two hypotheses. First, that participants in both the educational and control (i.e., no

educational messages) conditions would display an increase in prejudice. Second, that the

increase in prejudice would be less marked for participants in the educational condition,

relative to participants in the control condition.

4. Study 1

4.1. Method

4.1.1. Participants

As noted above, Study 1 used data from Scarf, Zimmerman, Winter, Boden, Graham,

Riordan and Hunter [ 23]. Demographic information is provided in Table1. Participants

were members of the general public, recruited through poster advertising and online

advertising on websites such as Facebook. The only inclusion criterion was that participants

were required to be aged 18 or above. Participants were compensated with $20 to cover

travel costs to and from the theatre. The current study was reviewed and approved by the

University of Otago Human Ethics Committee (19/108).

Table 1. Sample demographic information for Study 1 and Study 2. Variable Study 1 Study 2

Mean Age (SD) 30.1 (10.2) 20.0 (2.47)

Gender Male 37.3% ( n= 60) 17.5% ( n= 30)

Female 62.7% ( n= 101) 81.3% ( n= 139)

Other - 1.2% ( n= 2)

Ethnicity New Zealand European 50.3% ( n= 81) 65.5% ( n= 112)

Other European 5.0% ( n= 8) 2.3% ( n= 4)

M ¯

aori 5.0% ( n= 8) 7.0% ( n= 12)

Indian 3.1% ( n= 5) 4.1% ( n= 7)

Asian 28% ( n= 45) 9.4% ( n= 16)

Middle Eastern 2.5% ( n= 4) 1.2% ( n= 2)

Paci c Islander 1.9% ( n= 3) 2.9% ( n= 5)

Other 4.3% ( n= 7) 7.6% ( n= 13)

Education High School Level 1 (Year 11) 3.7% ( n= 6) -

High School Level 2 (Year 12) 6.2% ( n= 10) 3.5% ( n= 6)

High School Level 3 (Year 13) 24.8% ( n= 40) 88.9% ( n= 152)

Polytechnic Diploma/Quali cation 19.3% ( n= 31) 0.6% ( n= 1)

University Bachelor 's Degree 26.7% ( n= 43) 7.0% ( n= 12)

Honours Degree 7.5% ( n= 12) -

Postgraduate Degree 11.8% ( n= 19) - 4.1.2. Procedure

Participants were asked to complete survey 1 online. Survey 1 opened with an informa-

tion and consent form. Once participants consented to take part, they were presented with

demographic questions, followed by several questionnaires. Speci cally, participants com-

pleted the contact and prejudice measures outlined below, in addition to the social/stress

and heredity/biology subscales of the Mental Illness Attribution Questionnaire [ 25], the

Very Short Authoritarianism Scale [ 26], the Social Dominance Orientation scale [ 27], the Behav. Sci.

2022,12 , 384 5 of 12empathic concern subscale of the Interpersonal Reactivity Index [ 28] and the beliefs for

others subscale of the Justice Beliefs scale [29].

The movie screening occurred 2 to 3 weeks after participants completed survey 1,

with participants attending a lm screening at a local theatre in Dunedin, Aotearoa New

Zealand. On arrival at the theatre, participants were randomly allocated to one of two

large (>100 seats) theatres. In one theatre, participants viewed Joker , while in the other,

they simultaneously viewed Terminator: Dark Fate . After viewing the lm, participants

completed survey 2 in the theatre as a paper and pencil survey. Except for the demographic

information and contact scale, all scales from survey 1 were repeated in survey 2.

4.1.3. Films

Joker. Joker was released in 2019. The lm was rated R due to the language in the

lm, brief sexual images and violence. The protagonist in the lm, Arthur Fleck, takes

medication and displays symptoms typically associated with schizophrenia, including both

hallucinations and grandiose delusions. It is important to note that no speci c diagnosis of

schizophrenia is given in the lm. Over the course of the lm, Arthur loses his job and the

help of his psychologist and stops taking his medication due to a lack of funding. Following

this series of events, he becomes violent and increasingly unpredictable, brutally killing a

co-worker, three subway passengers and a talk show host. The lm ends with his implied

killing of a prison psychologist, the nal lm shot being his walking and dancing along a

corridor, leaving bloody footsteps in his wake.

Terminator .Terminator: Dark Fate was released in 2019. The lm was rated R due to

the language in the lm, brief nudity, and violence. It is the sixth lm in the Terminator

franchise and provides a sequel to The Terminator (1984) and Terminator 2 (1991). The plot is

similar to that of Terminator 2 , with a terminator sent back in time to rewrite history and

kill a character that challenges Skynet (an arti cial intelligence) at a future time point. The

reason for selecting Terminator 2 is that it was also currently showing and, importantly, also

contained violence.

4.1.4. Measures

Demographic . Participants completed a questionnaire on general demographic infor-

mation such as age, ethnicity and gender.

Contact . Contact with mental illness was assessed using six items. Speci cally, partic-

ipants were asked whether they currently or have ever: had a mental illness, lived with

someone with a mental illness, worked with someone with a mental illness, had a neighbor

with a mental illness, had a close friend with a mental illness, had a family member with a

mental illness. The contact measure was only included in survey 1.

Prejudice . Mental illness prejudice was assessed using the PPMI [ 24]. As noted

above the PPMI has four subscales measuring fear/avoidance (e.g., “I am not scared of

people with mental illness”), malevolence (e.g., “People who become mentally ill are not

failures in life”), authoritarianism (“People who are mentally ill should be forced to have

treatment”) and unpredictability (e.g., “People with mental illness often do unexpected

things”). Responses were scored on a 7-point Likert scale (1 = strongly disagree to 7 = strongly

agree ). The subscales display adequate reliability at both Time 1 (Fear/avoidance: = 0.832;

Malevolence: = 0.688; Authoritarianism: = 0.717; Unpredictability: = 0.765) and

Time 2 (Fear/avoidance: = 0.889; Malevolence: = 0.737; Authoritarianism: = 0.846;

Unpredictability: = 0.845). The PPMI was included in both survey 1 and survey 2.

4.1.5. Data Analysis

Each of the four subscales was submitted to a repeated measures Analysis of Variance

(ANOVA), with Time (2: Before, After) as a within-participant factor and Film (2: Joker ,

Terminator ) as a between-participant factor. Contact was added as a covariate. Behav. Sci.

2022,12 , 384 6 of 12

4.2. ResultsFor fear/avoidance and authoritarianism, and relevant to the hypothesis that prej-

udice would be higher for those who watched Joker , we identi ed a signi cant Time by

Film interaction (Fear/avoidance: F(1, 158) = 7.532, p= 0.007, partial eta 2= 0.046; Au-

thoritarianism: F(1, 158) = 24.851, p< 0.001, partial eta 2= 0.136; Figure1). To investigate

the interaction, we conducted post-hoc paired-sample t-tests. Participants who watched

Joker displayed an increase in fear/avoidance and authoritarianism from Time 1 to Time 2

(Fear/avoidance: t(79) = 5.20, p< 0.001, Cohen's d = 0.581; Authoritarianism: t(79) = 4.86,

< 0.001 ,Cohen's d = 0.543), while those who watched Terminator displayed no signi cant

change on neither fear/avoidance nor authoritarianism (Fear/avoidance: t(80) = 1.83,

p= 0.071, Cohen's d = 0.203; Authoritarianism: t(80) = 1.97, p= 0.052, Cohen's d = 0.219). Figure 1.

Mean scores for participant in the experimental ( Joker ) and control ( Terminator ) conditions

on the fear/avoidance ( A), malevolence ( B), authoritarianism ( C) and unpredictability ( D) subscales

of the PPMI. The subscales were completed before (Time 1) and after (Time 2) each film. A total

of 81 participants viewed Joker , and 80 viewed Terminator . Error bars represent standard error of

the mean.

In contrast to fear/avoidance and authoritarianism, for malevolence and unpredictabil-

ity there was no main effect of Film (Malevolence: Film, F(1, 158) = 2.56, p= 0.111, partial

eta 2= 0.016; Unpredictability: F(1, 158) = 1.90, p= 0.170, partial eta 2= 0.012) or Time by Film

interaction (Malevolence: F(1, 158) = 0.367, p= 0.545, partial eta 2= 0.002; Unpredictability:

F(1, 158) = 0.108, p= 0.742, partial eta 2= 0.001). There was also no main effect of Time for

either measure (Malevolence: F(1, 158) = 0.029, p= 0.865, partial eta 2= 0.000; Unpredictability:

(1, 158) = 0.944, p= 0.333, partial eta 2

= 0.006).

4.3. Discussion

Study 1 hypothesized that participants who watched the lm Joker would display

an increase in their fear/avoidance of people with mental illness and their support for

authoritarian approaches to their treatment. Consistent with these hypotheses, participants

who viewed Joker displayed a signi cant increase in the fear/avoidance and authoritarian

subscales of the PPMI [ 24]. In contrast, there was no evidence that viewing Joker increased

participants' views regarding malevolence or their belief that people with mental illness

behave in an unpredictable manner. These ndings are broadly consistent with the themesBehav. Sci. 2022, 12, 384 7 of 13 Figure 1. Mean scores for participant in the experimental (Joker) and control (Terminator) conditions on the fear/avoidance (A), malevolence (B), authoritarianism (C) and unpredictability (D) subscales of the PPMI. The subscales were completed before (Time 1) and after (Time 2) each film. A total of 81 participants viewed Joker, and 80 viewed Terminator. Error bars represent ± standard error of the mean. In contrast to fear/avoidance and authoritarianism, for malevolence and unpredicta-bility there was no main effect of Film (Malevolence: Film, F(1, 158) = 2.56, p = 0.111, partial eta2 = 0.016; Unpredictability: F(1, 158) = 1.90, p = 0.170, partial eta2 = 0.012) or Time by Film interaction (Malevolence: F(1, 158) = 0.367, p = 0.545, partial eta2 = 0.002; Unpredictability: F(1, 158) = 0.108, p = 0.742, partial eta2 = 0.001). There was also no main effect of Time for either measure (Malevolence: F(1, 158) = 0.029, p = 0.865, partial eta2 = 0.000; Unpredictabil-ity: F(1, 158) = 0.944, p = 0.333, partial eta2 = 0.006). 4.3. Discussion Study 1 hypothesized that participants who watched the film Joker would display an increase in their fear/avoidance of people with mental illness and their support for au-thoritarian approaches to their treatment. Consistent with these hypotheses, participants who viewed Joker displayed a significant increase in the fear/avoidance and authoritarian subscales of the PPMI [24]. In contrast, there was no evidence that viewing Joker increased participants’ views regarding malevolence or their belief that people with mental illness behave in an unpredictable manner. These findings are broadly consistent with the themes displayed in the movie. That is, following the discontinuation of his medication, Joaquin Phoenix’s character is depicted carrying out a range of serious and violent crimes. Given this, it is not surprising people become more fearful of people with mental illness and, as a result, were more supportive of policies such as enforced treatment. With respect to malevolence, the film’s sympathetic depiction of Arthur’s life is con-trasting to the view that he is avoiding the difficulties of everyday life. If anything, Arthur is depicted as experiencing difficulties over and above that which we could consider nor-mal, including an extremely difficult upbringing (e.g., a parent with severe mental illness) and being treated poorly as an adult. Thus, the film is more likely to generate sympathy towards people with mental illness, which may, in turn, diffuse any potential feelings and beliefs related to malevolence. The way Arthur is treated in the film also relates to the null finding regarding the unpredictability subscale, as any violent behavior displayed in the Behav. Sci.

2022,12 , 384 7 of 12displayed in the movie. That is, following the discontinuation of his medication, Joaquin

Phoenix's character is depicted carrying out a range of serious and violent crimes. Given

this, it is not surprising people become more fearful of people with mental illness and, as a

result, were more supportive of policies such as enforced treatment.

With respect to malevolence, the lm's sympathetic depiction of Arthur 's life is

contrasting to the view that he is avoiding the dif culties of everyday life. If anything,

Arthur is depicted as experiencing dif culties over and above that which we could consider

normal, including an extremely dif cult upbringing (e.g., a parent with severe mental

illness) and being treated poorly as an adult. Thus, the lm is more likely to generate

sympathy towards people with mental illness, which may, in turn, diffuse any potential

feelings and beliefs related to malevolence. The way Arthur is treated in the lm also

relates to the null nding regarding the unpredictability subscale, as any violent behavior

displayed in the lm is predictable, in the sense that it is (1) a direct response to either

being humiliated or physically assaulted and (2) is relatively consistent across the course of

the lm.

As Joker makes clear, modern-day lms still associate mental illness with violence. An

important question is whether the negative impact of lms can be mitigated. As noted

above, typically, as part of educational interventions, some studies have directly addressed

the stereotypes we hold about people with a mental illness (e.g., that they are violent). For

example, Corrigan et al. [ 30] contrasted the myth that “persons with serious mental illness

like schizophrenia are violent and should be avoided” with the fact that “most persons

with serious mental illness are no more violent than the average citizen”. Participants

presented with this information displayed improvement in their attitude towards people

with mental illness.

Therefore, in Study 2 we utilize this myth-challenging approach by displaying edu-

cational messages at the end of Joker . Speci cally, we focused on including messages to

counteract the increase in fear of those with a mental illness. That is, participants watched a

version of Joker in which, immediately after the movie but before the credits, the following

statements were displayed: “90–95% of people diagnosed with schizophrenia or bipolar

disorder do not commit any violent crimes” and “People with mental illness are over 10

times more likely to be the victim of violent crime than the general population”. Both state-

ments were displayed for 12 seconds. We also included a control condition that, identical

to Study 1, simply involved participants watching Joker without the educational statements.

Study 2 had two hypotheses. First, that participants in both the educational and control

conditions would display an increase in prejudice. Second, that when directly compared,

the increase in prejudice would be less marked for participants in the educational condition,

relative to participants in the control condition.

5. Study 2

5.1. Method

5.1.1. Participants

One-hundred-and-seventy-one people participated in Study 2. Demographic informa-

tion is provided in Table1. All participants were undergraduate students at the University

of Otago recruited through the University of Otago Psychology Research Participation

program and advertising in the Department of Psychology. The only inclusion criterion was

that participants were required to be aged 18 or above. Participants received either course

credit or $30 for participating. Due to the nature of the study, full completion of all scales

used was not mandatory, and therefore, participant numbers vary slightly depending on

the particular scale. Speci cally, a single participant did not complete the Authoritarianism

subscale of the PPMI. The current study was reviewed and approved by the University of

Otago Human Ethics Committee (19/108). Behav. Sci.

2022,12 , 384 8 of 12

5.1.2. ProcedureParticipants were asked to complete survey 1 online. Survey 1 opened with an informa-

tion and consent form. Once participants consented to take part, they were presented with

demographic questions, followed by several questionnaires. Speci cally, participants com-

pleted the contact and prejudice measures outlined below, in addition to the social/stress

and heredity/biology subscales of the Mental Illness Attribution Questionnaire [ 25], the

Very Short Authoritarianism Scale [ 26], the Social Dominance Orientation scale [ 27], the

empathic concern subscale of the Interpersonal Reactivity Index [ 28] and the beliefs for

others subscale of the Justice Beliefs scale [29].

The movie screening occurred at least a day after participants completed survey 1,

with participants attending a lm screening at a university lecture theatre. On arrival at the

theatre, participants were randomly allocated to one of two large (>100 seats) theatres. In

one theatre, participants viewed Joker without the educational messages, while in the other

participants simultaneously viewed Joker with the educational messages. After viewing

their respective lm, participants completed survey 2 in the theatre, in the form of a paper

and pencil survey. With the exception of the demographic information and contact scale,

all scales from survey 1 were repeated in survey 2.

5.1.3. Measures

Demographic . Participants completed a questionnaire on general demographic infor-

mation such as age, ethnicity and gender.

Previously seen Joker. Study 2 was conducted well after Joker had moved from screening

only at movie theatres to being available to buy/stream. Given this, participants were

asked whether or not they had previously seen Joker, prior to participating in Study 2.

Contact . Contact with mental illness was assessed using six items as in Study 1. The

contact measure was only included in survey 1.

Prejudice . Identical to Study 1, mental illness prejudice was assessed using the PPMI [ 24].

The subscales display adequate reliability at both Time 1 (Fear/avoidance: = 0.686;

Malevolence: = 0.697; Authoritarianism: = 0.654; Unpredictability: = 0.753) and

Time 2 (Fear/avoidance: = 0.884; Malevolence: = 0.762; Authoritarianism: = 0.782 ;

Unpredictability: = 0.828). The PPMI was included in both survey 1 and survey 2.

5.1.4. Data Analysis

The data were submitted to a repeated measures ANOVA, with Time (2: Before, After)

as a within-participant factor and Condition (2: Joker ,Joker edited) and whether participants

had previously seen Joker (2: Seen, not seen) as between-participant factors. Contact was

added as a covariate.

5.2. Results

A total of 78 participants (45.6%) had seen Joker previously. Replicating Study 1, there

was a main effect of time for fear/avoidance, F(1, 167) = 52.053, p< 0.001, partial eta 2= 0.238,

and authoritarianism, F(1, 166) = 67.288, p< 0.001, partial eta 2= 0.288, but no effect of time

for malevolence, F(1, 167) = 3.842, p= 0.052, partial eta 2= 0.022, or unpredictability, F(1, 167)

= 1.337, p= 0.249, partial eta 2= 0.008 (Figure2). This implies that for fear/avoidance and

authoritarianism, responses were higher post-movie, than pre-movie.

We found no support for our second hypothesis that the edited version of Joker

would mitigate increases in prejudice when compared to the unedited version of Joker .

The second hypothesis was tested via a condition by time interaction (Fear/avoidance,

F (1, 167) = 0.668 ,p= 0.415, partial eta 2= 0.004; authoritarianism, F(1, 166) = 0.018, p = 0.895 ,

partial eta 2

= 0.000 ; malevolence, F(1, 167) = 0.126, p= 0.723, partial eta 2

= 0.001 ; unpre-

dictability, F(1, 167) = 1.624, p= 0.204, partial eta 2

= 0.010).

All other main and interaction effects were not signi cant (all ps > 0.202), with

the exception of a signi cant Time by Seen interaction, F(1, 167) = 5.302, p= 0.023,

partial eta 2

= 0.031 , for the Fear/avoidance subscale. To investigate the Time by Seen in- Behav. Sci.

2022,12 , 384 9 of 12teraction further, we conducted t-tests comparing participants who had seen Joker , to

those who had not seen Joker , at Time 1 and Time 2. Participants that had previously

seen Joker displayed signi cantly higher levels of fear/avoidance at Time 1, t(169) = 2.158,

= 0.032 ,Cohen's d = 0.331 , but there was no signi cant difference between groups at Time

2, t(169) = 0.654 ,p= 0.948, Cohen's d = 0.001. These ndings suggest that participants that

had previously seen Joker started the experiment with a higher level of fear/avoidance of

people with a mental illness. Figure 2.

Mean scores for participants in the control (i.e., Joker without educational statements) and

education (i.e., Joker with educational statements) conditions on the fear/avoidance ( A), malevolence

(B), authoritarianism ( C) and unpredictability ( D) subscales of the PPMI. The subscales were com-

pleted before (Time 1) and after (Time 2) each lm. A total of 80 participants viewed the control

version of Joker , and 91 viewed Joker with the educational statements. `Seen' refers to participants that

had previously seen Joker , `Unseen' refers to participants that had not previously seen Joker . Error

bars represent

standard error of the mean.

5.3. Discussion

Study 2 had two hypotheses. First, that participants in both conditions would display

an increase in prejudice. Second, that when directly compared, the increase in prejudice

would be less marked for participants in the education condition, relative to participants in

the control condition. Our results were mixed. Although we replicated our ndings from

Study 1, demonstrating that watching Joker increased fear/avoidance and authoritarianism,

but not malevolence or unpredictability, we found no evidence that the brief educational

messages attenuated the negative effects of watching Joker.

Interestingly, participants that had previously seen Joker reported a higher level of

fear/avoidance than participants that had not previously watched the lm. There are

two potential explanations for this nding. One possibility is that the impact of Joker on

fear/avoidance of people with mental illness is maintained over time, with the current study

revealing the increased level of prejudice participants have held since rst watching Joker .

Alternatively, given participants were informed that they would be watching Joker before

completing the baseline survey, it is possible providing participants with this information

resulted in participants recalling scenes from Joker , leading to a transitory increase in mental

illness prejudice.Behav. Sci. 2022, 12, 384 10 of 13 Figure 2. Mean scores for participants in the control (i.e., Joker without educational statements) and education (i.e., Joker with educational statements) conditions on the fear/avoidance (A), malevolence (B), authoritarianism (C) and unpredictability (D) subscales of the PPMI. The subscales were com-pleted before (Time 1) and after (Time 2) each film. A total of 80 participants viewed the control version of Joker, and 91 viewed Joker with the educational statements. ‘Seen’ refers to participants that had previously seen Joker, ‘Unseen’ refers to participants that had not previously seen Joker. Error bars represent ± standard error of the mean. 5.3. Discussion Study 2 had two hypotheses. First, that participants in both conditions would display an increase in prejudice. Second, that when directly compared, the increase in prejudice would be less marked for participants in the education condition, relative to participants in the control condition. Our results were mixed. Although we replicated our findings from Study 1, demonstrating that watching Joker increased fear/avoidance and authoritar-ianism, but not malevolence or unpredictability, we found no evidence that the brief ed-ucational messages attenuated the negative effects of watching Joker. Interestingly, participants that had previously seen Joker reported a higher level of fear/avoidance than participants that had not previously watched the film. There are two potential explanations for this finding. One possibility is that the impact of Joker on fear/avoidance of people with mental illness is maintained over time, with the current study revealing the increased level of prejudice participants have held since first watching Joker. Alternatively, given participants were informed that they would be watching Joker before completing the baseline survey, it is possible providing participants with this in-formation resulted in participants recalling scenes from Joker, leading to a transitory in-crease in mental illness prejudice. Behav. Sci.

2022,12 , 384 10 of 12

6. General DiscussionIn Study 1, participants who watched Joker displayed a signi cant increase in their

reported fear/avoidance of people with a mental illness and support for an authoritarian

approach to their treatment, while participants who watched Terminator displayed no such

changes. In an attempt to attenuate the negative effect of watching Joker , in Study 2, we had

participants watch an edited version of Joker with two educational statements (e.g., “90–95%

of people diagnosed with schizophrenia or bipolar disorder do not commit any violent

crimes”) that were displayed immediately after the movie ended, but before the closing

credits. Unfortunately, the educational statements had no effect, with participants in both

the educational and control conditions displaying a comparable increase in fear/avoidance

and authoritarianism.

Our inability to mitigate the negative effect of Joker on mental illness prejudice is

consistent with Wahl and Lefkowits' [ 21] research using the lm Murder: By Reason of

Insanity , but not with Ritterfeld and Jin's [ 22] promising results with the lm Angel Baby . A

number of explanations could explain this pattern of ndings. For example, Murder: By

Reason of Insanity and Joker are much more explicit with regard to linking mental illness

and violence. In contrast, Angel Baby has a more complex narrative, with the love story

between the two main characters the primary focus of the lm. Thus, the signi cant

ndings reported by Ritterfeld and Jin [ 22] may re ect the easier task of mitigating the

effects of a lm that provides a somewhat balanced view of mental illness. A second

important difference is that Ritterfeld and Jin [ 22] had their trailer narrated by either a

person with a mental illness or a psychiatrist, both of which could be important for stigma

reduction. Indeed, having a person with mental illness as the narrator is a form of contact,

eliciting empathy and potentially providing a counter-stereotypical example of a person

with a mental illness. Similar to counter-stereotypical examples, having a psychiatrist as

the narrator likely leads people to put more weight on the information included in the

trailer, such as information around most people with a mental illness being functioning

members of society.

The current study is not without limitations. First, in the absence of a long-term follow-

up, it is not clear whether the increase in prejudice displayed by participants that watched

Joker is maintained over time. Second, we did not measure actual behavior towards people

with mental illness. While participants' responses to the PPMI provide an estimate of how

people may behave, they may be in uenced by social-desirability bias [ 31]. It is important

to note, however, that Kenny, Bizumic and Grif ths [ 24] did not observe any relationship

between the PPMI subscales and the short form of the Marlowe-Crowne social desirability

scale [ 32]. Third, in Study 2, we did not assess whether participants paid attention to the

educational messages. Finally, we focused on a single movie (i.e., Joker ). Future studies

should investigate how other movies, both old and new, in uence the PPMI subscales.

7. Conclusions

Viewing Joker increased both fear/avoidance of those with mental illness and support

for authoritarian approaches to their treatment. Unfortunately, we were unable to combat

these negative effects with brief educational messages. With respect to the title of the current

article, "Why so serious?" is a line spoken by the Joker in an earlier movie, The Dark Knight.

One might level that line at the authors of the current study, arguing that Joker is simply a

work of ction and nothing to be concerned about. What this view ignores, however, is

the profound impact that stigma, and the prejudice therein, has on those suffering from a

mental illness.

Author Contributions:

Conceptualization, J.W.P. and D.S.; Methodology, J.W.P., B.B., N.M.B., C.-W.J.,

H.Z. and J.H.; Formal Analysis, T.W. and B.C.R.; Resources, D.S.; Data Curation, T.W.; Writing—

Original Draft Preparation, D.S.; Writing—Review and Editing, B.B., N.M.B., T.W., B.C.R. and J.W.P.;

Supervision, D.S.; Project Administration, H.Z., J.W.P. and N.M.B.; Funding Acquisition, D.S. All

authors have read and agreed to the published version of the manuscript. Behav. Sci.

2022,12 , 384 11 of 12

Funding:

Royal Society Te Ap ¯

arangi Rutherford Discovery Fellowship (RDF-UOO1901).

Institutional Review Board Statement:The study was conducted according to the guidelines of

the Declaration of Helsinki and approved by the University of Otago Human Ethics Committee

(Reference Code: 19/108; Date of Approval: 16 August 2019). Informed Consent Statement:

Informed consent was obtained from all participants involved in the study.

Data Availability Statement: The data presented in this study are available on request from the

corresponding author.

Acknowledgments: The authors wish to thank the people that participated in the current studies.

Con icts of Interest: The authors declare no con ict of interest.

References

1.Goffman, E. Stigma: Notes on the Management of Spoiled Identity ; Prentice-Hall: Englewood Cliffs, NJ, USA, 1963.

Coverdale, J.; Nairn, R.; Claasen, D. Depictions of mental illness in print media: A prospective national sample. Aust. N. Z. J.

Psychiatry 2002,36 , 697–700. [CrossRef] [PubMed]

Reavley, N.J.; Cvetkovski, S.; Jorm, A.F. Sources of information about mental health and links to help seeking: Findings from the

2007 Australian National Survey of Mental Health and Wellbeing. Soc. Psychiatry2011,46 , 1267–1274. [CrossRef] [PubMed]

Corrigan, P.W.; Watson, A.C.; Gracia, G.; Slopen, N.; Rasinski, K.; Hall, L.L. Newspaper stories as measures of structural stigma.

Psychiatr. Serv. 2005,56 , 551–556. [CrossRef] [PubMed]

McGinty, E.E.; Kennedy-Hendricks, A.; Choksy, S.; Barry, C.L. Trends in news media coverage of mental illness in the United

States: 1995–2014. Health Aff.2016,35 , 1121–1129. [CrossRef]

Kunitoh, N.; Suzuki, W. Portrayal of mental illness in Japanese newspapers, 2001-2014. Act. Nerv. Super. Rediviva 2015 ,57, 77–82.

7. Whitley, R.; Berry, S. Trends in newspaper coverage of mental illness in Canada: 2005–2010. Can. J. Psychiatry 2013 ,58, 107–112.

[CrossRef]

Owen, P.R. Portrayals of schizophrenia by entertainment media: A content analysis of contemporary movies. Psychiatr. Serv.

2012 ,63 , 655–659. [CrossRef]

Domino, G. Impact of the lm,“One Flew Over the Cuckoo's Nest,” on attitudes towards mental illness. Psychol. Rep. 1983 ,53,

179–182. [CrossRef]

10.

Perciful, M.S.; Meyer, C. The impact of lms on viewer attitudes towards people with schizophrenia. Curr. Psychol. 2017 ,36,

483–493. [CrossRef]

11.

Thonon, B.; Pletinx, A.; Grandjean, A.; Billieux, J.; Larøi, F. The effects of a documentary lm about schizophrenia on cognitive,

affective and behavioural aspects of stigmatisation. J. Behav. Ther. Exp. Psy.2016,50 , 196–200. [CrossRef]

12.

Grif ths, K.M.; Carron-Arthur, B.; Parsons, A.; Reid, R. Effectiveness of programs for reducing the stigma associated with mental

disorders. A meta-analysis of randomized controlled trials. World Psychiatry2014,13 , 161–175. [CrossRef] [PubMed]

13.

Corrigan, P.W.; Morris, S.B.; Michaels, P.J.; Rafacz, J.D.; Rüsch, N. Challenging the public stigma of mental illness: A meta-analysis

of outcome studies. Psychiatr. Serv.2012,63 , 963–973. [CrossRef] [PubMed]

14.

Clement, S.; Lassman, F.; Barley, E.; Evans-Lacko, S.; Williams, P.; Yamaguchi, S.; Slade, M.; Rüsch, N.; Thornicroft, G. Mass media

interventions for reducing mental health-related stigma. Cochrane Db. Syst. Rev.2013,7, CD009453. [CrossRef] [PubMed]

15.

Couture, S.; Penn, D. Interpersonal contact and the stigma of mental illness: A review of the literature. J. Ment. Health 2003 ,12,

291–305. [CrossRef]

16.

Corrigan, P.W.; Penn, D.L. Lessons from social psychology on discrediting psychiatric stigma. Am. Psychol. 1999 ,54, 765–776.

[CrossRef]

17.Allport, G.W. The Nature of Prejudice ; Addison-Wesley: Boston, MA, USA, 1954.

18.

Corrigan, P.W.; Larson, J.; Sells, M.; Niessen, N.; Watson, A.C. Will Filmed Presentations of Education and Contact Diminish

Mental Illness Stigma? Community Ment. Health J. 2007,43 , 171–181. [CrossRef]

19.

Corrigan, P.W.; River, L.P.; Lundin, R.K.; Penn, D.L.; Uphoff-Wasowski, K.; Campion, J.; Mathisen, J.; Gagnon, C.; Bergman,

M.; Goldstein, H. Three strategies for changing attributions about severe mental illness. Schizophrenia Bull. 2001 ,27, 187–195.

[CrossRef]

20.

Finkelstein, J.; Lapshin, O.; Wasserman, E. Randomized study of different anti-stigma media. Patient Educ. Couns. 2008 ,71,

204–214. [CrossRef]

21.

Wahl, O.F.; Lefkowits, J.Y. Impact of a television lm on attitudes toward mental illness. Am. J. Community Psychol. 1989 ,17,

521–528. [CrossRef]

22.

Ritterfeld, U.; Jin, S.-A. Addressing media stigma for people experiencing mental illness using an entertainment-education

strategy. J. Health Psychol. 2006,11 , 247–267. [CrossRef]

23.

Scarf, D.; Zimmerman, H.; Winter, T.; Boden, H.; Graham, S.; Riordan, B.C.; Hunter, J.A. Association of viewing the lmes Joker

or Terminator: Dark Fate with prejudice toward individuals with mental illness. JAMA Netw. Open2020,3 , e203423. [CrossRef] Behav. Sci.

2022,12 , 384 12 of 12

24.Kenny, A.; Bizumic, B.; Grif ths, K.M. The Prejudice towards People with Mental Illness (PPMI) scale: Structure and validity.

BMC Psychiatry

2018,18 , 293. [CrossRef] [PubMed]

25.

Knettel, B.A. Attribution through the layperson's lens: Development and preliminary validation of an inclusive, international

measure of beliefs about the causes of mental illness. J. Person. Assess.2019,101 , 32–43. [CrossRef] [PubMed]

26.

Bizumic, B.; Duckitt, J. Investigating right wing authoritarianism with a very short authoritarianism scale. J. Soc. Political Psychol.

2018 ,6 , 129–150. [CrossRef]

27.

Ho, A.K.; Sidanius, J.; Kteily, N.; Sheehy-Skef ngton, J.; Pratto, F.; Henkel, K.E.; Foels, R.; Stewart, A.L. The nature of social

dominance orientation: Theorizing and measuring preferences for intergroup inequality using the new SDO 7scale. J. Pers. Soc.

Psychol. 2015,109 , 1003–1028. [CrossRef] [PubMed]

28.

Davis, M.H. A multidimensional approach to individual differences in empathy. JSAS Cat. Selected Docs. Psychol. 1980 ,10, 85–93.

29. Lucas, T.; Zhdanova, L.; Alexander, S. Procedural and distributive justice beliefs for self and others: Assessment of a four-factor

individual differences model. J. Individ. Dif.2011,32 , 14–25. [CrossRef]

30.

Corrigan, P.W.; Rowan, D.; Green, A.; Lundin, R.; River, P.; Uphoff-Wasowski, K.; White, K.; Kubiak, M.A. Challenging two

mental illness stigmas: Personal responsibility and dangerousness. Schizophrenia Bull.2002,28 , 293–309. [CrossRef]

31.

Corrigan, P.W.; Shapiro, J.R. Measuring the impact of programs that challenge the public stigma of mental illness. Clin. Psychol.

Rev. 2010,30 , 907–922. [CrossRef]

32.

Fischer, D.G.; Fick, C. Measuring social desirability: Short forms of the Marlowe-Crowne Social Desirability Scale. Educ. Psychol.

ofBehavioral Sciences(2076-328X) isthe property ofMDPI anditscontent may

not

becopied oremailed tomultiple sitesorposted toalistserv without thecopyright holder's

express

writtenpermission. However,usersmayprint, download, oremail articles for

individual

use.