An interview with Dr. Morrison Loh, the Clinical Director at Raffles Health Insurance.
Dr. Morrison Loh regularly champions Mental Wellness through public and corporate talks. He is also a practising physician under Raffles Medical Group, and has mentored conditional doctors in training as a Physician Leader.
A Doctor’s Take on Joker - The Medical Perspective
*Warning! Spoilers ahead!*
We take a peek into the minds of Arthur and Penny Fleck from Todd Phillips’ movie “Joker”.
An interview with Dr. Morrison Loh, the Clinical Director at Raffles Health Insurance.
“The worst part about having a mental illness is people expect you to behave as if you don’t.”
“You’re on seven different medications. Surely, they must be doing something.”
This establishes that Arthur is clearly not mentally well. However, the movie never pinpoints any diagnoses, which was probably intentional, to prevent the Joker himself from being diagnosable. For those of us still wondering about the possible conditions Arthur displays, Dr Loh weighs in with his thoughts:
Q: What mental condition(s) do you think Arthur suffers from?
Dr Loh: In my opinion, Arthur displayed a multitude of mental conditions such as Depression, Delusional Disorder and Anxiety Disorder.
Q: Could you elaborate about the Delusional Disorder you mentioned?
Dr Loh: Delusional disorder is considered a psychotic disorder, where a person has trouble recognizing reality. They have very strong false beliefs that are based on an incorrect interpretation of reality. For example, Arthur is convinced that he is a comedian, like when he says “I am an undiscovered comedic genius”. It’s clear to the audience, and even his mother, that he is actually socially awkward and not very funny. However, Arthur does not realize this. Something particular about Arthur’s case is that he also has hallucinations, which complicates his treatment and prognosis.
Q: What is the difference between delusions and hallucinations?
Dr Loh: Delusions, as mentioned are beliefs that the person holds and are unshakeable regardless of the facts and arguments presented to them. These beliefs arise without any preceding events or experiences. An example in the movie is where Arthur’s mother, Penny Fleck, has the firm belief that she was in a relationship with Thomas Wayne and that Arthur is his son. It is arguable that there was no preceding event shown in the movie to elicit this belief or influence, other than the photograph Arthur finds of a younger Penny after he has killed her.
Hallucinations, on the other hand, can take a few forms:
1. Auditory hallucinations include hearing people talking or music where there is none.
2. Visual hallucinations would be seeing things that are not actually there.
3. Gustatory hallucinations cause some people to have strange or unpleasant tastes in their mouths without having consumed anything.
4. Tactile hallucinations cause a physical sensation that occurs without any stimulus.
5. Olfactory hallucinations involve smelling things that are not present in the environment. Arthur’s hallucinations are a combination of these, as he hallucinates having entire dates with his neighbour, Sophie, for example during his stand-up comedy show.
The extent of Arthur’s hallucinations is only shown towards the end of the movie, when he enters Sophie’s house and she barely knows who he is. This makes Arthur’s situation all the more heartbreaking, as the one good thing in his life is revealed to be false as well. We almost hope for his delusions to be true, as they offer him a kinder reality and some respite from his emotional toils. Aside from Arthur’s mental health, another glaringly obvious condition he has is his uncontrollable laughter, which comes up at the most inappropriate times and is a catalyst to him committing his first murders in the subway.
Q: What condition causes Arthur’s laughing?
Dr Loh: Arthur has a neurological condition, which means he has damage to his nervous system, possibly Tourette Syndrome or Pseudobulbar Affect (PBA). PBA is a condition where there is sudden uncontrollable laughter or crying due to a trigger such as stress. The laughter or crying is exaggerated and there is no connection to the person’s emotional state, so Arthur laughs even though he feels nervous, afraid, embarrassed or stressed. Because of this, PBA is also sometimes also referred to as ‘emotional incontinence’. We learn in the movie that Arthur suffered trauma to the brain as a child when he was abused, and this could be the reason for his condition. Joaquin Phoenix’s portrayal of PBA was very accurate.
The stark difference in Arthur’s laughs throughout the movie serves to highlight that his PBA is in fact a medical disorder. When compared to his “natural laugh” (when he sees himself on TV in the Murray Franklin show and is truly happy for a moment), and his “performance laugh” (when he forces himself to laugh to appear socially acceptable as a member of the audience in the stand-up comedy), we can see that the laughter from PBA takes a physical toll on him as he claws at his throat and gasps for air. Laughter is usually a conduit for happiness, but in this movie it is used as a channel for Arthur’s pain, which makes it all the more unnerving as we watch him suffer through each attack.
Q: You mentioned that Arthur has damage to his nervous system. Could this be a result of the childhood abuse he experienced?
Dr Loh: Yes, it is highly likely that head trauma, which he is mentioned to have suffered while being beaten as a child, could have led to some form of brain injury and caused him to develop PBA as a result.
Q: Why does Arthur have no memory of the abusive childhood he had?
Dr Loh: There are many possibilities for this. He might have simply been too young to remember. The severe head trauma he sustained could also have led to memory loss and his accompanying physical symptoms. Another possibility includes treatment with medication when he was previously hospitalized. People who have experienced trauma might also repress these memories away from their conscious minds. This allows them to avoid confronting the painful memories and escape from facts and reality. Lastly, Arthur might have also wholeheartedly believed in what his mother told him as part of his delusions.
Q: Speaking of his traumatic childhood, his mother, Penny Fleck, is a big part of it. In the movie, she was diagnosed to have ‘severe narcissism’. What do people with this condition experience?
Dr Loh: Narcissism is coined from a Greek myth about Narcissus. He was the first celebrity to be famous just for his beauty, but he was callous to those that loved him. (More about that story here)
In clinical psychology, individuals with Narcissistic Personality Disorder are identified using the DSM-5 diagnostic criteria, and must fulfil at least 5 of the following 9 criteria.
- Grandiose sense of self-importance
- Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love (Penny believes Thomas Wayne loves her)
- A belief that he or she is special and unique and can only be understood by, or should associate with, other special or high status people or institutions (Penny argued with doctors despite the facts presented to her about Arthur’s adoption and abuse. This point is closely linked to Penny’s delusions)
- A need for excessive admiration
- A sense of entitlement
- Interpersonally exploitive behaviour (Penny expects Arthur to care for her through her life)
- Lack of empathy (She allows Arthur to be abused as a child)
- Envy of others or a belief that others are envious of her
- Demonstration of arrogant and haughty behaviors or attitude (She displayed this during her treatment in Arkham State Hospital)
From the examples mentioned, as well as how every conversation she has with Arthur is turned towards her in the movie, we can see how Penny Fleck does indeed display Narcissistic Personality Disorder.
Sympathy for Arthur is inevitable, as we are presented with a broken man, moulded by psychological and emotional trauma into an outcast of society. Just when we think that things can’t get worse, Arthur faces yet another setback, as Gotham itself turns its back on him. Mental health services are cut and Arthur is left with no way to get the medications or help he needs.
And so we arrive at the final act.
"What do you get when you cross a mentally ill loner with a society that abandons him and treats him like trash?
Arthur asks his idol, Murray Franklin, before shooting him point-blank in the face on live television. This quote has created much dissent within the healthcare industry and for good reason. It is problematic because it shifts the blame for the violence and crimes committed in the movie directly onto mental illness, forgoing the greater conversation at hand about socio-economic stratification and inequality. By directly correlating mental illness to violence, the stigma against those with mental health issues or psychotic disorders is perpetuated.
Q: Is psychosis really often associated with violence as portrayed in the movie?
Dr Loh: There are many types of psychosis with varying levels of severity. The movie portrayed an extreme form of violence which is a result of the combined lack of family support, inadequate medical treatment (both medication and therapy), association with someone with mental illness from a young age, unfortunate trauma, disparity and desperation. Patients with severe psychosis can be a threat to people around them but more importantly, they are a threat to themselves. Studies show that people with severe mental illness are more likely to be a victim of violence than to cause it.
Q: In this case, was it a coincidence that Arthur seemingly committed acts of violence with greater frequency after being denied access to medication and therapy?
Dr Loh: That would mostly be a plot device in the movie rather than an actual clinical reason. One possible medical explanation for Arthur’s increase in violence after his first encounter with murder in the subway could be that the fear and adrenaline rush from killing brought relief and reward to Arthur. This is compounded by the fact that there had been a lot of media publicity and support from the general public. This was something Arthur very dearly yearned for as an aspiring comedian and a lonely person.
Q: To summarize Joker’s take on mental illness, what would you say the movie got right, and what was not clinically accurate?
Dr Loh: I would say that the physical manifestation of Arthur’s mental conditions was extreme in the movie. Most mental disorders are struggles that are won or lost in the mind. Physical attributes and displays can often be misleading. One who is often smiling and accommodating at work may be suffering from severe depression. Mental illness is one of the most difficult medical conditions to diagnose and treat as it is insidious and too often, patients do not seek help. In fact, many patients with mental illness choose to hide their problems for fear of stigmatisation. A positive point in the movie would be that Arthur is not afraid to seek help, as he was seeing a counsellor, taking his medications and was responsible enough to worry about not being able to obtain his prescriptions, until the choice was taken from him.
Q: What is the main message about mental illness you hope for the public to take away from this movie?
Dr Loh: Do not judge those struggling with mental illness and be proactive in offering assistance. Up to 70% of individuals with mental illness are not receiving the adequate care they require. The stigma that society has against this group of patients deters them from disclosing their conditions and in turn, receiving necessary support. This could worsen their conditions and encourage further hiding of their problems.
If you think about it, a colleague who has recently suffered from a heart attack or been diagnosed with diabetes gets attention from many people around them. People take care to express their concerns, pick the right places to eat or even buy the right kind of food or gifts for these colleagues. However, if a colleague was found to have had a recent mental breakdown or even suicide attempt, the natural tendency for people is to avoid the topic and not bring up the problem. The worst advice one can give to someone who is suffering from depression goes along the lines of “Snap out of it”, “Get a grip on yourself”, “Why are you thinking this way?”, “Why can’t you be strong?”. People with mental illness do not choose to be ill or think negatively, they cannot help it. Neither are these individuals able to “think their way out” of their problems. They need help and support from the people around them and constant reminders to navigate them to the right thought processes. I believe the real reason behind this social issue is the lack of awareness and proper education about mental illness.
Although Joker misrepresents certain aspects of mental health, it does provide a prominent platform for discourse on mental health and awareness. There is so much more that we, as a society, can do. Looking back at the social reasons for Arthur’s downfall, such as the lack of support and limited access to medication and therapy, his story is all the more tragic because it was preventable. Had he received the help he so desperately needed, he would not have been a man abandoned by society, mocked and despised.
In the end, Gotham created its own villain.