A veteran mental health doctor shares the difference between psychopaths and sociopaths — and if that creepy laughing condition exists in real life.
Dr. Imani Walker doesn’t play. She is a tall, bold, clean-shaven, outspoken psychiatrist who serves as Medical Director of Gateways Hospital & Mental Health Center in L.A. You may have seen her on the Bravo series, “Married to Medicine Los Angeles.”
Unlike Dr. Drew, Dr. Phil, Dr. Oz, or other docs on television, Dr. Walker is a psychiatrist and has been for quite a while. She specializes in treating violent criminals with mental disorders, much like Joaquin Phoenix’s character in “Joker.”
Who better to talk with about the complex film, and its many themes revolving mental illness?
Below is an edited excerpt of our 90-minute conversation **that includes spoilers** as well as Dr. Walker’s sharp insight into how we treat mental illness in pop culture and as a society.
Why did you want to see “Joker”?
I used to religiously watch the Batman cartoon in college. I knew of the Joker as a clown. He was like a weirder Krusty the Clown, with homicidal tendencies.
But when I heard about this movie, I was instantly intrigued because, obviously, Joaquin Phoenix is one of the best actors we have today. Someone who’s really willing to do the full De Niro: the weight gain, make himself kind of batty, all just to fulfill a role. So I walked into this movie without having read much about it. I just knew it was an origin story.
The only thing I read was a magazine article where the director said he didn’t want people to be able to easily diagnose the Joker.
Well, what I do is I am a psychiatrist, I am a physician, but I did a fellowship in Forensic Psychiatry, which is where the law and psychology meet. It’s kind of like what Clarice Starling did in “The Silence of the Lambs,” minus the gun.
So patients, when they are in mental hospitals, as soon as they get out, I see them. Some are patients who committed really heinous acts, or any time you hear of someone who stalked a star and ended up in their house, those are my patients.
So I was like, O.K., I’m gonna try to figure this out.
Is the Joker’s laugh a sign of a real condition?
I was watching the movie, and I was caught up in it. But at one moment I said, “this dude has Pseudobulbar affect (PBA). “
Remember in the beginning of the film when he is on the bus and he hands the woman a card that says, “I have a condition.” When I lived in New York, on the subway, some people would hand people cards that say “I’m deaf,” so when his card said ‘a condition’ I thought they’re purposely leaving it vague.
But I knew that PBA happens sometimes when people have trauma to their head, which I didn’t know he had had until later on in the movie. Sometimes people with Parkinson’s can get it.
Recently there was a medication approved by the FDA called Nuedexta. So I was like, “if Joker had gotten Nuedexta, and other medication, he wouldn’t do these things.”
I thought it was so genius how the writer, director, and Joaquin Phoenix approached the role because it really felt… to me, that the movie was a portrait of a realistic patient.
When Joaquin was laughing and crying at the same time it was brilliant.
People in the audience were laughing but inside I was crying because the only other time I have seen that is with people who have what’s called Rapid Cycling Bipolar Disorder where they can literally be happy and sad at the same time.
And it’s wild.
Britney Spears seems to have that. She’s actually really, really ill. It’s so sad.
I’ve never seen anyone who is not really ill be able to replicate that on-demand.
What was your reaction when the Joker’s therapist said, “the government has stopped funding this program. People don’t care about you and me”?
I was shouting in the theater. Because it’s true. Mental health funding is always the first to be cut. But unfortunately when there’s a mass shooting people will say “this person has a mental illness.”
I have been very outspoken about this, but being a white supremacist is not a diagnosable condition.
Racism isn’t something you can fix?
It’s something you can fix… for example, there are people who have personality disorders.
Let’s take narcissism. That was one of the diagnoses that the Joker’s mom was given when he looked through her hospital charts. She was diagnosed with delusional disorder and narcissistic tendencies, or something like that.
Someone who is a narcissist believes that they are always right, there’s nothing wrong with them… if you bring up something that they have done incorrect, they will not only tell you that you’re wrong, but that you have some sort of vendetta against them.
When you say something like, “no, you really did knock over that water. It’s wet. I didn’t do it. You’re the only other person here,” they will go to great lengths to convince themselves and everyone else that they are correct.
That’s a personality disorder. Personality disorders are largely not treatable.
So like in “Taxi Driver” — when I was in residency, we were told that he had a Schizoid Personality Disorder, which is not something you can give medicine to and treat. It’s going to be there. It’s so embedded in their Super Ego. They are completely unable to see the world through a lens that the rest of us can see.
When it comes to racism or people who are white supremacists, we do know people who have denounced that. People who can say, “I was clearly trippin’. I don’t believe that anymore.” But there are some who actively choose to construct their life around that.
I had a case of someone in a hospital, like where the Joker went to. I had a patient who was placed on a 72-hour hold by the police because he wrote on Facebook that he was going to go to a university where Milo Yiannopoulos’s speech was canceled and “do things with my guns.”
His friend saw it, called the police and the police put him on a hold.
The funny part is not only am I the psychiatrist, but I’m the medical director of that hospital, so I oversee all of the doctors. So the social worker who was there with me in the initial interview is also black. He had to explain to us why he was upset that when he was downtown a Latino man knocked his MAGA hat off of him.
So here’s the thing: he is actively choosing to see the world through a lens. He is watching Fox News, and receiving half-truths from whatever news source he’s getting it from.
When people are truly psychotic it is an organic situation. They don’t choose to be that way. Genetically their DNA is causing them to have chemical changes in their brain that are causing hallucinations, paranoia, delusions.
To be a white supremist really does take a lot of work. But for psychotic people, there’s no work involved.
So what’s your take on Heather Patton, the Eagle Rock woman from last month who was captured on video yelling the N-word at people? It sounds like you’re saying that she isn’t subscribing to certain newsletters. Are you suggesting she just needs treatment?
When I saw the initial footage I thought, “this woman’s bipolar.” And that can be treated.
I have had many patients in the 15 years that I have been practicing. And when patients, especially those who are not black, get manic, and here I come, and they are in the throes of pure mania… they don’t want to be there, they don’t know who I am, they’re in handcuffs, they’re completely wildin’ out, they yell “nigger, bitch, monkey…” And that makes sense because they’re searching for what they think is the worst thing they could say to me so that I will — and this is not logical thinking — so that I will “let them go.”
When they get better and they’re saying “oh thank you so much, I feel so much better,” sometimes I will ask, “do you remember what you called me when you first got here?” And I tell them and they will say, “oh that’s terrible! I am so sorry. I don’t mean that. Not you!”
Now let’s take Kanye West for example. When Kanye gets manic, as he does the majority of the time we see him these days, he believes in his mania.
The best way to describe mania is like cocaine without the cocaine.
It’s like “I feel fantastic. I’m not ever sleeping again. I have all the ideas. Everything’s wonderful.”
It’s that euphoria mixed with “I’m irritable because my mind won’t stop racing. I’m super anxious. I just want to be left alone but please God don’t leave me because we’re going to have so much fun.”
A lot of people blame the emergence of Kanye’s mania on the fact that his mom died. But Kanye was also of the age where bipolar symptoms would have likely emerged anyway. He clearly doesn’t want to take medications because… he doesn’t want to ever come down. I’ve been saying privately that he’s been bipolar for years.
And then his last album had the words “I hate being Bi-Polar, its awesome” on the cover. And I’m like “but, no, it’s not. And also you’re out of your mind because this album is terrible.”
One reason he is resisting treatment, I’m sure, is because when you’re manic you’re so creative. Sometimes your ideas are fantastic. But as you get older and you lose grip with reality, your output is awful.
Is it rare that the Joker seemed to be aware of his mental issues, which is why he found value in therapy and meds?
I don’t think it’s rare. But he had enough insight to know that he wasn’t well.
So my heart went out to him when his therapist said “well, the program is going to be cut next week.” That wouldn’t happen in reality, by the way.
I’m not saying a program wouldn’t get cut. But there’s never a situation where a patient isn’t going to somehow have access to medication, especially in a city as large as New York.
When I heard that I was like, “well that’s not legal, but alright then.” I think it was used as a plot device.
What also broke my heart was when he was writing in his notebook and he wrote, “the worst part about having a mental illness is people expect you to behave as if you don’t.” I’ve actually heard people say that to me.
How did you like the portrayal of the therapist/social worker?
I think it’s important to be relatable to your patients. So I was so happy when she said, “listen, nobody gives a shit about us. They don’t care about you and they don’t care about me either.”
And the other thing that was awesome in that movie was both of the people who evaluated him were black women. And I was like, “thank you!” Because there’s no greater diagnostician than a black woman.
Why’s that?
Because we just cut through the shit. She was like, “here’s the real.”
That makes for a great scene in a movie. But is that technique acceptable in your field?
Is it something that we do all the time? No. But is it an approach that I’ve taken? Absolutely.
In a tense scene, Joker kills one of his cohorts but lets another escape. Is showing mercy typical in this sort of psychotic person?
It depends on if the person is a psychopath or a sociopath.
Joker’s morals are skewed because this is someone who was neglected and beaten all under the umbrage of his mentally-ill mother. So his morality… it’s in the execution.
He said, “this guy ratted me out. We can have an argument, we can fight it out… but instead I’m going to kill him.” For him that was his best option, but it was executed poorly. He actually had some sense of decency, but the execution was poor.
So is Joker a psychopath?
If I had to choose one I would say so. Because sociopaths are people who are actually very likable. It’s a condition that you can’t really cure. A good example is Ted Bundy.
People would say of Ted Bundy, “oh he’s so attractive, he could never do that. Oh, he’s so affable.” They’re actually nice people.
Ted Bundy would always get drunk when he would go on rampages. He wasn’t sober when he did that. He would drink and turn into Mr. Hyde.
Psychopaths want you to trust them quickly so they can go in and destroy your life. Sociopaths are creepy from the jump.
So Joker’s definitely a psychopath.
What might be scarier than Joker were the others who appropriated his look to raise hell. Is that what you were saying earlier about people who study hate and then act out?
The Joker is just one person. By himself he can only do so much. And yes, what is frightening is the groupthink, so to speak.
To them, they’re anarchists. The Joker isn’t an anarchist, he’s ill. He was happy because he finally had acceptance.
And that’s crushing for people who are mentally ill: they don’t have a tribe. And if they do have a tribe, it’s typically with other people who they shouldn’t be around.
Those people were just being anarchist and chic. It didn’t have to be about him or his cause, it could have been anybody.
But in a really strange way I was happy for him, because I was like, “look you’ve got new friends. Look at you! But now you have to go to the state hospital.”
Can people like Joker, and other violent criminals with mental disorders, get cured in a place like Arkham Asylum, a state hospital? Or should they just go to prison with other killers?
It depends on the person. If they have a history of mental issues and that illness caused this person’s behavior — and therefore crime — then, yes, I believe they should go to state mental hospital.
Here in L.A. there’s Twin Towers which is the largest mental health facility in the country. It’s not supposed to be, but there’s so many mentally ill inmates that when I did my forensic fellowship I did it through there, through the jail.
They have a whole team of psychiatrists. They have different floors, different levels, depending on how sick you are.
I do believe in a state mental hospital you can get better. Those are the patients that I see. They absolutely can get better.
You have seen people, in Twin Towers Correctional Facility, very bad people, who did very bad things, get rehabilitated to the point where you would feel safe if you saw them walking down the street?
I’ll tell you right now, there are people at your local grocery store, bagging your groceries… and we tell them that being in society is a privilege because your ass could be in the state mental facility for-ev-er. So they take it really seriously.
And these are people, I swear on everything, you would never know. But they have to want to get better.
Which is what is so fascinating about Joker. He tried to get better.
Remember he had the insight enough to ask, “I need my medication to be increased.” And she said, “well you’re on seven medications, I don’t know what you want me to do.” And I was sitting there like “excuse me. Can I step in here? Because this is someone who wants the help. ”
It was so sad to me to see someone who had the wherewithal to be consistent and go to his appointments and wanted help. But because this was someone who society didn’t care about… we are to blame.
We do not care about the woman at the bus stop who might be mentally ill. We as a society don’t even pretend that they’re real people. And that’s what this movie is about. He never had a chance.
What is at the root of most of the mental illness that you have seen and studied? Is it something genetic? Is it something to do with trauma? Or is it mom-dad stuff? Obviously it’s a mix, but what do you think is at the core?
Most mental illness is genetic.
There have been studies with mono-zygotic twins. Their DNA is completely the same. It’s like they have a clone. When I was in school we used the Wistar rats, their DNA has been, sort of manufactured so they are all identical to each other. So you have a control.
The studies have shown that it’s mostly genetic. It’s not from stepping on a rusty nail.
Now you may have the code for bipolar disorder, it doesn’t necessarily mean that it’s going to be expressed in your behavior. What can happen, what is being hypothesized, based on certain stressors that the person goes through, that can make the DNA create protein that will then cause the expression of chemical changes in your brain.
In 2015 there was a study done in Mt. Sinai Hospital in New York. A researcher named Rachel Yehuda took DNA swabs of Holocaust survivors and their offspring. And she examined specific DNA changes. What she found was there was sequence damage in the survivors that was passed down to their children.
Now the Holocaust was four years and black people have been in this country for 400 years, mostly as slaves. Sure there’s systemic racism, but we are really going on, en mass, as a mentally ill people, but we’re not acknowledging it. And we’re not talking about it. And we’re not getting any help for it. But it’s not our fault.
So that is an example of trauma causing mental illness. But it’s not a chicken versus the egg thing. It’s mostly genetic, but environmental factors can definitely influence someone’s development of an illness.
O.K. you’re at Arkham Asylum. He gets you as his psychiatrist, another black woman. What do you do for the Joker?
He has bipolar disorder type 1, most recent episode manic, severe, with psychotic features, and he also has Pseudobulbar affect.
That can be treated by medication. He would need to take a mood stabilizer that will help with the mania. He would also need to take antipsychotic medication for the delusions. And then he would need to take a medication like Nuedexta. Therapy is very important because he is a trauma survivor.
So he needs to talk about his mom for a while?
Ohhhhh yes. There was a co-dependent relationship there. In addition to having the delusional disorder.
I mean Arthur was a grown-ass man. And when he was giving her a bath I was like, “chill.” If my mom was handicapped and couldn’t walk, OK, fine. But you’re telling me you can walk, dance and you could be gainfully employed, but you’re not because it’s more fun to be taken care of by your son, whose mental illness you caused for the most part?
Yikes.