Movies and television frequently depict psychological themes that provide excellent material for psychiatric pedagogy [1]. In this paper, we explore how depictions of post-traumatic stress disorder (PTSD) in The Missing, Encanto, The Sopranos, Good Will Hunting, and Ordinary People can be used to help trainees recognize cognitive distortions in PTSD. We discuss how these screen depictions support teaching the psychological model of PTSD employed by cognitive processing therapy (CPT), an evidence-based cognitive behavioral treatment of the disorder.

Background

PTSD is highly prevalent and associated with increased risk of cardiovascular mortality, depressive disorders, substance use disorder, and suicide [2, 3]. Clinical practice guidelines support trauma-focused psychotherapy as the most effective treatment for PTSD compared to medications alone or to other forms of psychotherapy [4]. In recent decades, there has been a decline in psychotherapy as a primary treatment modality; thus, for the well-being of patients and our field, it is imperative that educators find effective ways to teach this important skill [5]. Teaching psychiatry through film is an accepted method that invites engaged and focused discussion [6]. We review examples of PTSD in media to facilitate teaching a psychological model of PTSD derived from cognitive processing therapy (CPT).

CPT is a form of cognitive behavioral therapy (CBT) anchored in the principle that unhelpful thoughts, termed cognitive distortions, negatively influence emotions and behaviors. Cognitive restructuring is a technique used in CBT wherein patients are supported with identifying, challenging, and then replacing cognitive distortions with more realistic, balanced thoughts. For example, a patient involved in a motor vehicle collision may think, “I’m going to crash,” each time they get in their car. This thought may induce anxiety and result in avoidance of travel with a car. Through cognitive restructuring, the patient may recognize this thought as a form of “jumping to conclusions” and then self-correct, shifting to a more manageable thought: “While I might crash, this is unlikely. I can take actions to reduce my chances of an accident.”

Cognitive restructuring can also be applied to “core beliefs,” those deeply ingrained and foundational cognitions which can sometimes themselves be deeply irrational and jarring to one’s mental health. Through CPT, people can discover that distorted thoughts stemming from trauma have become core “stuck points” that do not allow flexible and accurate appraisal of themselves, others, or the world at large. Such cognitive distortions impede recovery.

CPT guides patients in examining how cognitive distortions play a role in intimacy, assessing safety, building trust, self-esteem, holding others in esteem, and exerting power or control. Patients frequently have distorted thoughts that touch on these themes, even when the events that led to their trauma greatly differ. Through CPT, patients’ beliefs are explored to assess how they have been informed or misinformed by the trauma, both in relation to views of themself and others. For example, a patient with PTSD may feel that being in-touch (termed “intimate” in CPT terminology) with their own emotions and thoughts is intolerable. This can reinforce avoidance. Similar distortions can prevent such patients from being in-touch or intimate with others. Patients may overestimate danger to themselves and those around them, be hypervigilant about safety when there are no imminent threats. They may erroneously mistrust themselves, doubt their own decisions, and develop an unwarranted distrust of others. Distorted and self-deprecating beliefs impair one’s self-esteem and prevent a fair appraisal of how one is viewed and regarded by others. Finally, an unpreventable and unexpected trauma may lead to overgeneralization that one lacks power and control over themselves and the world.

Didactic Format

The television show The Sopranos and the movies The Missing, Good Will Hunting, Ordinary People, and Encanto have characters who suffer trauma and exhibit cognitive distortions consistent with the domains that are the focus of CPT. The movies Iron Man 3, The Deer Hunter, and Manchester by the Sea and the series Euphoria provide additional examples. In our residency training program, this model was introduced to psychotherapy supervisees in individual supervision sessions. Trainees then independently read relevant portions of the CPT manual (summarized in Table 1) and watched their choice of a selection of suggested TV shows or movies [7]. Trainees were assigned the task of identifying relevant scenes in media that exemplified the five domains of CPT. Five 40-min sessions were then held to discuss the findings. A prescribed order (intimacy, safety, trust, esteem, power) presented in the article “I STEP: Recognizing cognitive distortions in post-traumatic stress disorder” was followed [8]. This summary is much-abbreviated relative to the CPT manual and best suited for integration of CBT-oriented approaches into supportive psychotherapy. Alternatively, the treatment manual follows a prescribed order (safety, trust, power/control, esteem, intimacy) to educate the trainees most effectively in a manualized format. If the I STEP method is used, the divergence from the manualized order should be made clear. Educators can reference Table 2, which indicates specific scenes for each theme to better individualize teaching. Trainees reported that seeing tangible examples reinforced the concepts, brought them to life, and made them more salient and relatable, albeit their fictionalized depiction.

Table 1 Recommended readings for trainees from Resick et al. (2017) [7]
Full size table
Table 2 Examples of cognitive distortions by media timestamps
Full size table

Examples in Film and Television

The Missing is a 2020 Philippine horror film. The protagonist, Iris, witnesses her sister’s kidnapping prior to the events of the film. She is portrayed to suffer from PTSD with flashbacks and anxiety. Examples of impaired intimacy stemming from Iris’ PTSD are seen throughout the film. After Iris receives a call from investigators confirming her sister’s death, she shows impaired intimacy when she declines to go home to comfort her mother, explaining that this will not help, a statement that also demonstrates both feelings of powerlessness and of worthlessness consistent with impaired self-esteem (1:14:58–1:15:44). In The Sopranos, Tony Soprano suffers trauma when his mother threatens to stab his eye with a fork as a child (S1 E7: 31:24–32:37). He experiences additional violence in childhood and adult life. Throughout the show, Tony has difficulty connecting with the women in his life. He suffers memory loss when he survives a failed carjacking, demonstrating difficulty with connecting to his own thoughts. He tells his therapist, Dr. Melfi, that he believes his mother was behind the attack. Dr. Melfi inferences that Tony’s troubles with intimacy cloud his understanding, and his mind convinces him that the carjacking was ordered by his mother in retaliation for putting her in a nursing home (S1 E13: 7:00–10:05, 25:15–27:00). Difficulty with intimacy is similarly displayed in Good Will Hunting. The character Will Hunting suffered childhood abuse. Throughout the film, he cannot decide if he wants to continue to date his girlfriend, worrying that he would taint her when she was already “perfect.” His therapist, Sean, reminds Will that imperfections are natural in human existence, and that this was more a reflection of how he sees himself, touching on the domain of self-esteem (54:55–58:11). In Encanto, after her husband’s death years ago, Abuela’s family was saved by a magical candle. That tragedy led Abuela to run her family with such lofty expectations, so much so that the family is crushed under the weight of her scrutiny. Abuela’s impaired intimacy is obvious in the scene where she walks through a hallway in her house with a detached expression, evoking a fearful response from each family member she passes (1:18:50–1:21:30).

In another domain of cognitive distortion, safety, people may perceive nonthreatening stimuli as dangerous following a trauma. Tony Soprano is a mob boss who often fears for his and his family’s lives. While his life is certainly at risk at times, he also has unrealistic fears that represent cognitive distortions. Despite familial challenges, his wife and children appear devoted to him. Yet feelings of irrational insecurity manifest and he experiences a panic attack after seeing a family of ducks, who were previously living in his pool, fly off. In sessions with his therapist, Tony reveals that this departure foreshadows his fear that everyone he loves will eventually leave him (S1E1: 18:30–20:00, 26:30–28:10, 50:00–53:30).

Traumatic events can lead to unmerited mistrust of others. In The Missing, after Iris becomes aware of a curse placed on the house they are restoring, she unfairly accuses her colleague Job of a cover up. She believes he is recruiting her to work on the restoration as a sacrificial offering for the evil Sir Riku (1:11:21–1:13:19). In Good Will Hunting, Will is unable to trust the long string of therapists that he sees. He repeatedly and purposely acts up, antagonizing them without giving them a chance to help. He goes as far as antagonizing one therapist by talking negatively about their deceased wife, nearly destroying his opportunity of receiving help by the therapist that can ultimately be entrusted with his care (28:49–33:05). Similarly, in Encanto, the family matriarch Abuela knows the magical candle that bestowed her family with miraculous powers is flickering, but she does not know how to fix it. In a panic, she accuses Mirabel of sabotaging the family and Bruno of not caring for them (1:11:40–1:13:35).

Impaired self-esteem may develop when patients inaccurately blame themselves for a trauma. When Tony Soprano’s friend goes missing, Tony demonstrates impaired self-esteem. He tells Dr. Melfi, “Everything I touch turns to shit. I’m not a husband to my wife, not a father to my kids, not a friend to my friends. I’m nothing” (S1 E12: 16:13–18:18). Similarly, Conrad feels bad about himself throughout Ordinary People. He feels guilty for surviving the boating accident that killed his brother and for attempting suicide, which put an added strain on his family. His mother, who was also affected by the trauma, demonstrates impaired esteem for Conrad, whom she cannot forgive for seemingly trivial mistakes (1:39:10–1:44:49). In Encanto, Abuela’s apology to Mirabel for her suffocating scrutiny is fueled by the memory of her husband’s death and her drive to maintain a tight order within her family. Abuela especially demonstrates impaired self-esteem when she says “You never hurt our family, Mirabel. We are broken… because of me” (1:18:00–1:21:30). In the climax of The Missing, the villainous Sir Riku has tied up Iris with the intent of convincing her to sacrifice herself. He yells that she is worthless, that it is her fault that her sister died, and that she will find redemption by dying to save Sir Riku’s son from the ghosts. Although she is gagged, the actress calms and appears resigned. Recognizing the change, Sir Riku thanks her, implying that she has agreed with his assessment of her worthlessness. In a continuation of the same scene, once she is released, she apologizes to her friend Job, even though she has done nothing wrong (1:31:12–1:36:00). This aligns with her impaired self-esteem with acceptance of undeserved guilt.

Following a trauma, individuals might feel they no longer have power to control their lives. Tony Soprano feels that he lost the power to choose his destiny, that his fate was set in stone, and that he had no other choice than to join the mafia (S1 E7: 39:00–41:30). Traumatized individuals may approach feelings of powerlessness by ineffectively attempting to control uncontrollable aspects of life. For example, Will Hunting initiates an altercation that is broken up by police. Will makes the poor decision to fight the police who were trying to restrain him, a fight he cannot win, which lands him in legal trouble (09:44–12:26). In Encanto’s climax, Abuela confesses that her husband’s death hardened her view of the world. She finally offers an apology to the family, singing “And I’m sorry I held on too tight/Just so afraid I’d lose you too.” These lines describe the feeling of powerlessness that fueled her problematic efforts to exert control (1:25:37–1:26:00). These are just a few examples among many that show how cognitive distortions in stereotyped domains can affect post-trauma patients’ sense of intimacy, safety, trust, esteem, and power/control.

Learning Through Media

The shows and films above provide an array of examples useful in teaching the model of PTSD employed by CPT. Understanding the context and story of what brings someone into treatment is not simply a prelude to symptoms or disorders (often erroneously considered the “thing we really treat or care about in psychiatry”) but is absolutely essential to our work. The media we explore in this paper and any well-done work of fiction elucidate the etiology, pathogenesis, and clinical manifestations of a character’s mental conditions in powerful, memorable ways [9]. Watching media can be enjoyable and thought-provoking for trainees, where even seemingly light-hearted films, cartoons, or comedies explore deeply profound themes [10]. In Glen and Krin Gabbard’s Psychiatry and the Cinema (1987), the authors argue that “if psychiatry had not existed, the movies would have had to invent it… Both movies and psychiatry have had as their prime focus human thought, emotions, behavior, and, above all, human motivation. In pursuit of common subject, movies and psychiatry have frequently intersected” [11]. Movies often succeed in depicting this because showing is inherently more powerful than telling. Watching a movie better recapitulates the experiential aspect of the human condition than purely verbal accounts. Movies do so in a manner that can evoke intellectual, emotional, and visceral responses, often eliciting empathy [10]. While trainees gain experience working with real patients in healthcare environments, media depictions help deepen understanding of patient experiences by providing vivid imagery of common themes, taking one back in time, to observe initial hurts that are playing out in the present.

There is inherent risk of inaccuracies in films because they often sensationalize phenomena for dramatic effect or can ignore particularly painful aspects of psychiatric illness [12]. They can gloss over some things and show flights to health, whereas victories in PTSD recovery can be slow and incremental. When considering movies for didactic potential, educators must review films and highlight clinical inaccuracies. When we use movies as depictions of specific diagnoses, we need to guard against biasing our view of how characters behave as always and necessarily the product of an assumed diagnosis, given that confirmation bias can adversely affect diagnosis and treatment [13]. For example, it is a reasonable assumption that Will’s challenges with intimacy may be explained by PTSD, but it could also be the result of other factors, and this possibility should be considered.

Trainees may be well-versed in DSM-based diagnostic criteria, but less familiar with psychological models that encourage full psychological formulation. This educational method through media allows trainees to understand patients’ experiences and incorporate this understanding into effective interventions. Our experience is also that it inspires trainees to value human experience, to deepen formulation, and to provide effective psychotherapy. So, in an era where fewer psychiatrists are practicing psychotherapy, we think the movies might just save our field. We offer a few suggestions that have helped us teach and preserve an important set of skills for our trainees so that their patients may live more freely in the present and less constrained by cognitive distortions born of the painful past.