Stephen Potts, MA, BMBCh, FRCPsych
University of Edinburgh and Royal Infirmary of Edinburgh, United Kingdom
Good Will Hunting publicity poster
The subject matter of medicine is inherently dramatic. Decisions taken by professionals who are highly skilled, but still human and therefore flawed, are applied to suffering patients in situations of pressure and can have radically diverse outcomes: life or death; disability or cure: a healthy baby born to a healthy mother – or disaster for both.
Not surprisingly, therefore, portrayals of medical encounters have featured in film fiction for as long as the medium has been in existence. Doctors have appeared on the cinema screen before criminals, clergy, or cowboys.1
On television, some of the earliest, most popular, and longest running shows have been fictional portrayals of medicine, beginning with City Hospital in 1951 in the US and Emergency Ward 10 in the UK in 1957, and continuing in many other forms around the world.2 Such ubiquitous programs influence the public perception of real-world medicine and the expectations of patients and their families. I have encountered patients who hope – sometimes explicitly – for a hug from their psychiatrist, much as Judd Hirsch gave in Ordinary People or Robin Williams in Good Will Hunting. Today, an apprehensive 13-year-old about to visit for the first time her critically ill mother in intensive care, asked, “Is it like on the TV?” My answer, laced with the ambivalence allegedly typical of a psychiatrist, began “Yes and no…”
Of all medical specialties the one featuring most commonly in these portrayals is my own, psychiatry. The crises may be less acute than say in cardiac surgery, and the choices to be made less frequently stark dichotomies between life or death—but the questions raised takes us closer to what it means to be human.
Emotionally engaging and dramatically powerful depictions of patients, psychiatrists, and the practice of psychiatry can be used in various ways, grouped under three headings. Film clips can convey, more immediately than any textbook or lecture, the personal impact of illness and the perspective of the patients. This is recognized in their growing use in the training of medical students, doctors, and nurses. They can also serve in non-professional education, teaching relatives and the general public about particular conditions. Finally, they can be deployed therapeutically, usually in group settings. A burgeoning list of books, websites, and journal articles3,4 attest to the growing interest in and increasing academic respectability of this area, whether approached from the perspective of film studies, general interest, or from medicine and psychiatry.
Much less widely explored, however, is the parallel between the practice of psychiatry and the process of screenwriting, which is my theme. Screenwriters are encouraged to express their story in a “logline” for the TV guide, or a “strapline” for the movie poster. Here is mine: Screenwriting is psychiatry in reverse.
This thesis emerges naturally from my work in these two separate fields. I have practiced psychiatry since 1987, concentrating on liaison or general hospital psychiatry, seeing patients in the emergency department, medical wards, and particularly the transplant service. I have worked part-time in order to purse a parallel career as an author, initially in the field of children’s fiction, before stepping sideways into screenwriting, where I specialize in adaptation. I have had one feature film produced, several scripts optioned, and more currently in development.5
The medical and the psychiatric models
At the risk of getting into deep water, I will nail my colors to the mast and declare now that psychiatry is a medical specialty and therefore has the medical model is at its heart. That is not to say that the medical model is sufficient, that it explains everything, or that it is fault-free—all of which is patently untrue, but no more so for psychiatry than for cardiology or orthopedics.
In this model, a doctor assessing a new patient is expected to obtain a history, a clear description of the symptoms that have brought the patient to the encounter. This should be as comprehensive as urgency allows, and be supplemented by a survey of relevant background information. The doctor then proceeds to the physical examination, concentrating on areas suggested by the history but taking in a general survey appropriate to the nature and urgency of the presentation. After this information is analyzed, a provisional diagnosis is reached, confirmatory investigations are ordered, and treatment is begun.
A psychiatrist assessing a patient who complains, for instance, of depression will also inquire about presenting symptoms (mood, sleep, energy, appetite, libido, concentration, suicidal thoughts, guilt, hopelessness) and associated symptoms (such as anxiety, panic attacks), and relevant background (previous episodes, family history, current stressors, substance misuse, etc.). The examination will include making observations (about self-care, reactivity of mood, tearfulness, eye contact, apparent anxiety, etc.), specific inquiries covering possible psychotic symptoms (delusions, hallucinations), quantifying cognitive function, and exploring suicidal thoughts. Ancillary tests may be necessary and third party information about the patient may be required. The result of this assessment is a diagnosis, leading on to a choice of treatment modalities.
The ideal psychiatrist is an observer of everything the patient says in the consulting room and peerless investigator of everything done outside of it. After assembling all of the details, a generality in the form of a diagnosis is constructed. The direction of travel is, therefore, from specific to general.
Ordinary People publicity poster
The huge numbers of would-be screenwriters form a ready market for the growing band of “script gurus” who advise and instruct, via books, DVDs, courses, and websites.7,8 While there is natural variation in this advice, there is also consistency in the core features, namely, brevity, “here and now,” and structure.
Brevity. A standard feature film screenplay will be 90-100 pages long, and be written in a format whereby one page of screenplay translates roughly to one minute of screen time. My screenplay Compass Murphy runs to 150 scenes in 91 pages, with a word count of 23,000.4 The book on which it is based5 is three times the length, (meaning, since the book was my own, a lot of darlings were killed in the cutting required for adaptation).
“Here and now.” Any descriptions of settings or characters must be brief, vivid and entirely visual, utterly grounded in the “here and now.” The body of a screenplay is made up of the totality of what the characters say (dialogue) and the key elements of what they do (action). There is no room for the internal monologues or digressions open to novelists, however entertaining or illuminating. The authorial voices so resonant in the first lines of Anna Karenina or Pride and Prejudice must be silenced.
Structure. The screenwriter who begins a script by typing “Fade In” followed by the first scene will soon learn the error of his ways. All the script gurus advise – and commissioning producers usually require – the writer to begin instead with a series of shorter documents with odd names (logline, pitch, synopsis, treatment, step outline, and beat sheet) before attempting a single word of the final script.
These documents are expected to answer a range of questions. Who is the protagonist? What are his goals? What stops him from getting them? Who is the antagonist? What are his goals? How do these goals relate to each other and to the theme? What are the key structural “turning point” scenes? What choices are made in these scenes? Who makes them? What is the theme? The tone? The genre? How does this story meet an audience’s expectations of the genre(s) in question?
The early short documents will address these questions explicitly, but as the documents lengthen in development work, the answers become more implicit within them, until in the full screenplay they are evident but not spelled out at all.
Sleepless in Seattle offers a good example within the romantic comedy genre, where there are usually two co-protagonists of roughly equal stature, each acting in a sense as the other’s antagonist. The audience expectations are clear: show two appealing people; have them make contact in a way that shows they are made for each other; put increasing obstacles in the way of them getting together. Show them overcome those obstacles until, at the end, they come together at last and kiss over the credits and an uplifting song. The challenge for each new exemplar of the genre is to meet these universal expectations within a new and unique story. Sleepless in Seattle achieved this by making the leads ill-matched (he is a widower and single parent, she is about to marry) and crucially, putting the three thousand miles of the continental United States between them. The film then finds inventive ways to link them up and put them together at the end on the observation deck of the Empire State Building.
Screenwriters are therefore akin to creator gods, making and manipulating their characters to serve their story ends, and governing everything those characters say and do. But they have no idea until the film is made whether the story will work or not, whether it will resonate with audiences and critics, and whether the expense outlaid can be recouped. This process of creation could be called specification, whereby the airy generalities of theme, genre, structure, and tone are solidified by the writing process into tangible action and audible words.
Similarities and differences
There are thus obvious parallels between the elements outlined:
|What is said||symptoms and history||dialogue|
|What is done||third party information||action|
|Key generalization||diagnosis||theme, genre, structure|
The most significant difference in the two approaches lies in the directions of travel, which are directly opposed. Psychiatrists work from the specifics of speech and behavior to the generality of diagnosis, under an ideal whereby omniscience about the specifics leads (it is hoped) to the most accurate and most beneficial generalities. The arrows in their column point downwards. Screenwriters, on the other hand, work from the generalities of structure, theme, tone and genre to the specifics of dialogue and actions. They may see the generalities through a glass, darkly, but they are omnipotent over the specifics of what their creations do and say (limited only by the interference of the producer, director, and cast). Their arrows point upwards.
Interesting perhaps, but is it relevant? To psychiatrists, probably not. But to a screenwriter stuck between drafts and unsure how to vivify his characters or make his plot cohere, it suggests a possible route to clarity, by putting his characters on a metaphorical couch, and interviewing them as a psychiatrist might a patient. The writer might ask probing but empathic questions: “What’s troubling you? How long have you felt that way? How bad is it? What makes it better/worse? Have you felt that way before?” The answers should be as specific as the questions, and always expressed in the language the character would use, in an attempt to gain a better understanding of a character’s core, and an audience’s perspective on whether that core shows through in what the characters say and do.
- Glasser, B. Medicinema: Doctors in Films. London: Radcliffe, 2010
- Turow J. Playing Doctor. New York: Oxford University Press; 1989
- Wooder, B Movie Therapy: How it Changes Lives. Rideau Lake, 2008
- Rabkin, L. The Celluloid Couch: An Annotated International Filmography of the Mental Health Professional in the Movies and Television, from the Beginning to 1990. Scarecrow Press 1998
- Potts, S. Compass Murphy. London: Egmont, 2004
- McKee, R. Story: Substance, Structure, Style and the Principles of Screenwriting. London: Methuen, 1999
- Field, S. Screenplay: The Foundations of Screenwriting: A Step-by-Step Guide from Concept to finished Script. Delta, 2005
STEPHEN POTTS, MA, BMBCh, FRCPsych, trained in medicine at Oxford and Cambridge, and in psychiatry at London and Edinburgh. Since 1996, he has been a consultant in liaison psychiatry at the Royal Infirmary of Edinburgh, where he works closely alongside the kidney and liver transplant services. He co-founded and co-chairs the UK Transplant Psychiatry interest group. He is also an author and screenwriter, with seven works of children’s fiction published, one feature film produced (a Philip Pullman adaptation), and more scripts optioned and in development. This essay arises from his experience in attempting to straddle the divergent worlds of screenwriting and psychiatry.