How accurate is 'Joker's portrayal of mental illness? The answer is complicated

During a pivotal scene in "Joker," Joaquin Phoenix's Arthur Fleck meets with his social worker for the last time, even as the troubled loner's mental health is clearly deteriorating. The problem, she informs him, is that funding for her treatment program has been pulled.

"They don’t give a (expletive) about people like you, Arthur," she tells Fleck, explaining bureaucratic indifference to mental illness and to those who try to help. "And they really don’t give a (expletive) about people like me, either."

The moment demonstrates the unusual perspective allowed through director Todd Phillips' film, on track to be the most successful R-rated movie in box-office history, told through the eyes of a man grappling with mental illness. Fleck's ultimate descent into violence, the origin story for DC Comics' most infamous archvillain, has mental health experts debating the message the film sends.

Like everything else about the polarizing "Joker," feelings around the film's depiction of mental health struggles are complex.

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Experts say it incorrectly strengthens the link between mental illness and violence

Psychiatrists Vasilis K. Pozios and Praveen R. Kambam of Broadcast Thought, a group that provides mental health consulting to film and television projects, expressed concern that "Joker" relies too much on the character's mental illness.

Fleck is presented with a mental health backstory: He's seen meeting with his counselor and taking seven different drugs for his unspecified condition. But Kambam points out that "Joker" takes pains to show how traumatic aspects in Fleck's life lead him on the "pathway to violence," not just his mental illness. The loner is treated with contempt and, as an adult, suffers a violent mugging on a subway and a brutal attack by young kids; he also rediscovers that he had been subjected to appalling violence as a child.

But his mental health issues unfairly stand out.

"It becomes muddied. The audience walks away associating Fleck's violent behavior, particularly the gun violence, with his mental illness," says Pozios, who fears the film buttresses arguments made after violent acts such as mass shootings. "It's like (Fleck) went on his killing spree because he is 'crazy,' that's the conclusion audiences come to, which is unfortunate. It reinforces perceptions people might have which are way overblown."

According to the U.S. Department of Health and Human Services, the vast majority of people with mental health problems are no more likely to be violent than anyone else: Only 3% to 5% of violent acts can be attributed to individuals living with a serious mental illness. Meanwhile, as "Joker" illustrates, people with severe mental illnesses are 10 times more likely to be victims of violent crime than the general population.

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The film blurs the line between truth and reality, which confuses the message

Donald L. Diefenbach, professor of mass communications at the University of North Carolina-Asheville, who has written extensively about perceptions of mental illness in popular culture, says he was heartened to see a "deep and thoughtful" character study with Fleck as the initially sympathetic protagonist. But the message is complicated by a sense of unreality through "Joker."

Key points in the film are clearly part of Fleck's delusions, such as his first meeting with his hero, talk show host Murray Franklin (Robert De Niro), who praises Fleck for taking care of his mother. Likewise, whole scenes of violence against Fleck's perceived enemies might be part of his imagination. The ending even suggests that much of the movie could have been imagined by Fleck.

"I don’t even know what in this film actually happened. How much is it real, or in Arthur's thoughts having a fantasy?" Diefenbach asks. "A lot of this is messing with us. Arthur doesn’t know the difference between truth and reality, so you as the filmgoer don’t know either."

As a result, it's "hard to judge" how people are taking the overall message, Diefenbach says, "Because I don’t know if everyone is receiving this film the way I was."

Arthur's daily struggle is accurate and powerful, experts say

One strong positive cited by experts: "Joker" takes an honest look at the daily life of a person struggling with mental illness and the breakdown of social support for those who desperately need it – especially that pivotal scene with the social worker trying to help Arthur.

"It depicted how one day you have a program, and the next day you don’t. That’s accurate. And you see how that impacts the people you serve," says northern Virginia social worker Devra Gordon. "It’s enormously frustrating. We’re dealing with people’s lives."

Gordon was blown away by Phoenix's "phenomenal" performance, nuanced right down to his fingernails, which were anxiously chewed to the nub – a symptom she sees in those with mental illness. She was heartened to have a mass audience experience this world.

"People who have mental health issues are suffering, and we don’t do well as a society where people are suffering," Gordon says.

Psychologist Roblyn P. Lewter at Virginia's Stratford University says "Joker" provides a powerful view into the "daily struggle for so many people with mental illness (as they try) to conduct 'regular' lives, and how knowingly and unknowingly cruel and insensitive the general public can be. That tends to only exacerbate their mental health symptoms."

But ultimately, 'Joker' is a work of fiction

Joe Parks, a psychiatrist and Medical Director for the National Council for Behavioral Health, says he felt the mental health portrayal in "Joker" was "unnecessary" and "stigmatizing," though he praised the film for emphasizing the importance of "being kind to one another, and not bullying."

"But we need to remember this a fantasy movie about a comic book villain," Parks says. "'Joker' is not a documentary about mental illness."

This article originally appeared on USA TODAY: 'Joker': What it gets right, wrong about mental illness, violence