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Mental Health Issues Portrayed in 'Joker' are No Laughing Matter

October 28, 2019

By H. Steven Moffic, MD
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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

While on a recent father/son trip, my son wanted to see the film “Joker.” Though I had not seen any of the prior Joker movies, and am not a fan of most movies, this one also seemed more intriguing to me because I had heard that it incorporated mental health factors. Besides, as my son emphasized, the Joker was played by the renowned actor Joaquin Phoenix. So, even with the concern that has been circulated that this movie could provide another movie theater massacre opportunity, we went.

I did find it very absorbing, and it was safe. Why, though, does it turn out that the film is important to process and discuss, both among ourselves and the public? It is because it is a rare opportunity to explain why horrific violence perpetrated and received by individuals with mental illness, such as that of Joker and other clowns in the film, could be prevented with better societal leadership and competent mental healthcare. Indeed, if persons with mental illness do obtain such care and concern, they are both not at more risk to be violent and at less risk to be the object of increased violence.

For those who have not seen “Joker,” here is a brief selective summary: At the beginning of the film, this Joker is working as a clown. However, right from the get-go, he is beaten up by a random group of teenagers. Clearly, he is depicted as physically and mentally traumatized. We also soon learn in the backstory that he was subject to more trauma growing up and then that happens again and again, perhaps adding some traumatic brain injury. Another clown he works with apparently gives him a gun for protection, but he loses his beloved job on a hospital children’s ward when he inadvertently drops the gun on the floor.

He lives with his mother, who also seems to have some sort of mental illness. Meanwhile, in the fictional city of Gotham where he lives, the poor are feeling neglected and a group of other clowns begin to publicly protest. The new mayor speaks of “clowns” derogatorily. 

One challenge in viewing the plot is whether it is depicting reality, or is Joker imagining or hallucinating some, or all, of it? Of course, we can have that crucial challenge of making such a distinction in clinical practice, too. Regardless, many of the mental health aspects resonate with our times, perhaps accounting for some of its immense popularity. Many viewers seem to even come out of the film with some empathy and sympathy for Joker, despite his violent revenge murders.

Early on, Joker meets with his mental healthcare clinician, who he claims is not listening to him and just seems to be conveying clichés. He is also on seven medications and seems to feel that they help him somewhat. Then, funding is cut, Joker losses his therapist and medication, and soon deteriorates psychologically. How can that, as well as the plight of his fellow clowns, not connect to what we have recently termed “disorders of despair,” if not remind us of the “deplorables” mentioned in the last presidential race? Clearly, we have inadequate public mental health services too. The movie ends on a chaotic scene of street violence.

All the mental health components of “Joker” may be conducive to discussion and education among mental healthcare constituents:

  • How do we keep overworked and burned out public mental healthcare staff from losing empathy and compassion?
  • How do we reduce the real violence involving persons with mental illness that is more prone to occur when those who are paranoid and/or psychotic are without treatment?
  • What should mental healthcare leadership do to fulfill our ethical priority to address problems that worsen the public’s mental health?
  • What public relations statements might help to counter this portrayal of violent clowns, especially since clowning has been used as an inspiring therapeutic tool by such healers as the psychiatrist Carl Hammerschlag, M.D. and the physician “Patch” Adams?
  • The film offers an ideal opportunity for public education, especially since the ethical prohibition of the "Goldwater Rule” against the public analysis of public figures is not relevant in this account of the mayor of Gotham city and Joker because it is fictional.

The popular song “Send in the Clowns” is sung as background music both at the beginning and end of the movie. Perhaps that song title should be reframed to “Send in the Help.”

That help is us.

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