Introduction

The movie Joker provides an origin story for its namesake character, played by award-winning actor Joaquin Phoenix. Phoenix’s character Arthur is depicted as having a mental illness; he visits Arkham State Hospital to receive medication and frequently displays symptoms that suggest some form of serious mental illness. Because of budget cuts, Arthur stops receiving his medication and consequently carries out a campaign of violence.

Joker is the first R-rated film to earn more than $1 billion at the box office, with more than 100 million people viewing it worldwide. Because Joker continues the tradition of movies depicting individuals with mental illness as violent,1,2 it has reignited discussion about the role of media in perpetuating prejudice toward those with a mental illness.3 To investigate the associations of the Joker with prejudice toward those with mental illness, we had a community sample attend a screening of Joker or Terminator: Dark Fate (as the control condition) and complete a measure of mental illness prejudice before and after watching their assigned movie. We hypothesized that, compared with viewing Terminator: Dark Fate, viewing Joker would be associated with higher levels of prejudice toward individuals with mental illness.

Methods

In this survey study, participants enrolled from November 22, 2019, to December 4, 2019. On December 5, 2019, participants attended a movie theater in Dunedin, New Zealand, and were randomly assigned to watch either Joker or Terminator: Dark Fate. The only inclusion criterion was that participants be aged 18 years or older. Participants completed an online consent form before being presented with the premovie survey. Participants completed the 28-item Prejudice Toward People With Mental Illness (PPMI) scale4 before and after watching their assigned movie. An overall association of viewing either movie with prejudice was estimated using confirmatory factor analysis in R version 3.6.1 (R Project for Statistical Computing), with the lavaan command.5 Change in prejudice was assessed using a lagged Bayesian regression, using a weakly informative normal prior with a mean of 0 and an SD of 1. Age, sex, history of mental illness, and movie were included as covariates. Association was determined based on a posterior probability greater than 95%. Posterior probability is the percentage of posterior samples above or below 0, depending on which direction has the highest probability (akin to a 1-tailed test). The study was reviewed and approved by the University of Otago Human Ethics Committee.

Results

Overall, 164 individuals participated in the study, approximately evenly split between viewing Joker (84 [51.2%]) and Terminator: Dark Fate (80 [48.8%]). Samples were similar in terms of age, sex, and race/ethnicity (Table 1). Participants viewing Joker had a mean (SD) PPMI of 2.99 (0.66) before the movie and 3.20 (0.78) after the movie. Participants viewing Terminator: Dark Fate had a mean (SD) PPMI score of 2.91 (0.61) before the movie and 2.88 (0.70) after the movie (Table 1). The lagged Bayesian regression revealed neither age nor sex was associated with PPMI scores. Whether participants have had or currently have a mental illness was associated with lower PPMI scores (estimate, −0.21 SD; 95% CI, −0.4 to 0 SD; posterior probability, 100.0%). Consistent with our hypothesis, viewing Joker was associated with a 0.37 (95% CI, 0.19 to 0.55) SD increase in PPMI score (posterior probability, 100.0%) (Table 2).

Discussion

Joker was associated with higher levels of prejudice toward those with mental illness. Beyond prejudice, associating mental illness with violence may erode support for policies that we know to be beneficial for those with mental illness (eg, integration into communities). Additionally, Joker may exacerbate self-stigma for those with a mental illness, leading to delays in help seeking.6 A limitation of the current study is that we did not assess whether viewing Joker was associated with actual behavior.

In The Dark Knight, Joker asks, “Why so serious?” One might level that question at us, arguing that Joker is nothing to be concerned with. However, what this view ignores is the profound consequences prejudice has on those with a mental illness.

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Accepted for Publication: February 25, 2020.

Published: April 24, 2020. doi:10.1001/jamanetworkopen.2020.3423

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Scarf D et al. JAMA Network Open.

Corresponding Author: Damian Scarf, PhD, Department of Psychology, University of Otago, 95A Union Pl E, Goddard Laboratory Bldg, Dunedin, New Zealand 9054 (damian@psy.otago.ac.nz).

Author Contributions: Dr Scarf and Mr Winter had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Scarf, Winter, Graham, Riordan.

Acquisition, analysis, or interpretation of data: Zimmerman, Winter, Boden, Graham, Riordan, Hunter.

Drafting of the manuscript: Scarf, Winter, Graham.

Critical revision of the manuscript for important intellectual content: Zimmerman, Winter, Boden, Riordan, Hunter.

Statistical analysis: Winter.

Administrative, technical, or material support: Zimmerman, Winter, Boden, Graham, Hunter.

Supervision: Scarf.

Conflict of Interest Disclosures: None reported.