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A psychiatrist’s defense of Tully, a controversial new movie about postpartum struggles

Tully starts an important conversation about motherhood and mental health.

Charlize Theron in Tully.
Focus Features

“I believe that screenwriter Diablo Cody, director Jason Reitman, and lead actress Charlize Theron owe an apology to every survivor of maternal mental illness,” writes blogger Graeme Seabrook in a post titled “Why I won’t see Tully and why you should think twice before you do,” on a motherhood-centric website called All the Moms.

This is just one of many heated reactions coming from the mommy blogosophere about the new film Tully, which depicts a mother struggling with the responsibilities of parenthood after the birth of her third child. Most of the controversy revolves around the fact that the film implies that the lead character, Marlo, beautifully portrayed by Charlize Theron, may have postpartum depression or postpartum psychosis — yet the film fails to acknowledge this explicitly or depict the character seeking treatment.

“I am not sure if this was intentional, or if the film-makers did not realize that the character they created had [postpartum psychosis],” wrote Diana Spalding on Motherly. “I am surprised that they seem not to have consulted with a therapist to ensure that the topic was handled appropriately, whatever their intention was.”

I’m a psychiatrist who focuses on pregnancy and mental health. As an expert on this subject, I was eager to watch the film — and having seen it, I have to ask: Is all this heat deserved? Should we refuse to see Tully because a struggling mother’s illness is not recognized or treated appropriately? Or should we celebrate it for generating this heated discussion and raising awareness about maternal mental illness? I’m inclined to think the latter.

At the core of the controversy around Tully is its twist. To participate fully in the discussion around the film’s depiction of postpartum depression, we’ll need to reveal that twist at the end, so be warned: spoilers follow.

The film opens with Marlo, the mother, at the end of her rope. She’s frazzled by her “quirky” kindergartner, a child with implied special needs who regularly throws tantrums, and the pressure intensifies with the birth of her third child. Her husband plays video games instead of helping with the baby.

There are hints even early on that Marlo is more than just “stressed out” — her brother mentions that her behavior in the past few years has been radically different, saying, “I just want my sister back” — but overall, the beginning of the movie seems to be depicting the universal stresses of motherhood. We see spilled breast milk, dirty diapers, frozen pizza for dinner, and rage, all things to which any tired mother can relate. Marlo’s brother suggests she hire a night nanny.

Things take a turn with the arrival of a young woman named Tully, who we assume is that night nanny. Tully is a charming, helpful, engaging young woman who appears to exist solely to help Marlo. She cleans the house, allows Marlo precious sleep between feedings, bakes cupcakes. But by the time Tully climbs into a waitress outfit and has sex with Marlo’s husband the first time he meets her — and the husband does not seem surprised by this — we realize there is something off with Tully.

One night, Tully encourages Marlo to drive them both while drunk, which ends with Marlo crashing her car. And then comes the twist: When the film shows Marlo alone at the hospital, we realize that Tully is not real. She is an extension of Marlo, meant to represent a younger, less cynical version of herself. It’s that plot turn that has people up in arms.

Does Tully’s plot twist suggest that Marlo has postpartum psychosis?

So what illness does Marlo likely have, and what’s wrong with the way it’s portrayed in the film? Postpartum depression, which affects up to one in five women and is severely underdiagnosed and undertreated, is a devastating illness with long-term consequences for mothers and children.

A depressive episode in the first weeks or months after giving birth is typically characterized by changes in sleep and appetite, low mood, loss of interest or pleasure, irritability, feelings of low self-worth, and sometimes suicide. Anxiety in the period right before or after birth is also extremely common and can be part of postpartum depression or exist without depressive symptoms.

Postpartum psychosis, which seems to fit Marlo’s symptoms better than postpartum depression does, is a much less common disorder, affecting 0.1 percent of the population. Women with postpartum psychosis are sometimes depressed but more often exhibit mania, characterized by decreased need for sleep, grandiosity, and risky behavior, along with psychotic symptoms such as disorganization, confusion, and sometimes hallucinations and delusions.

Postpartum psychosis is often a manifestation of bipolar disorder and is much more common in women with preexisting bipolar disorder than in the general population. It is considered one of the few true psychiatric emergencies, in large part because of the high rates of suicide (5 percent) and infanticide (4 percent), and it nearly always requires psychiatric hospitalization.

Both disorders, if recognized, respond well to treatment, but in many cases they are not recognized. This happens because we don’t talk enough about mental illness in this country. What’s more, the media and the public at large tends to describe and depict motherhood as a glowing and happy time. Women who become ill are often ashamed that they don’t fit this model — and family members often chalk up serious symptoms to “normal” new motherhood and sleep deprivation.

Once we know that Tully isn’t real, some of the movie’s earlier plot points take on a distinctly different tone. The clean house and exquisitely decorated cupcakes weren’t the product of work done by an employee while Marlo slept but were things Marlo did herself, staying awake all night and frantically cleaning and decorating. That, alongside the impulsive drunk driving incident, makes me think that Marlo is probably manic. The idea that Tully is a hallucination, which is likely given that Marlo discusses her as if she’s a real person, is consistent with a diagnosis of postpartum psychosis.

In starting a conversation about postpartum mental health, Tully is doing a service

So is the film using serious health issues as a cheap plot twist? I don’t think so. It depicts one woman’s experience — and those of us who treat maternal mental illness know that no two mothers are alike and no two illnesses are the same. Hallucinations of postpartum psychosis do not usually take the form of benign, lighthearted helpers, but that’s not to say that they couldn’t.

The bigger question seems to be if the movie has a responsibility to recognize and name what this illness is and, as some have suggested, to show Marlo getting treatment. “As a Certified Nurse Midwife, here’s what I wanted to see next,” wrote Ann Smith in a statement for Postpartum Support International, a wonderful organization that has done more than perhaps any other to improve postpartum mental health. “I wanted to see her be screened, to get the treatment and the support she needed so that she can get well.”

I couldn’t agree more when it comes to women in real life — but I am reluctant to hold a movie to the same standard.

I think the fact that Marlo does not seek treatment is precisely the intention of Diablo Cody, the film’s screenwriter. Most people have never heard of postpartum psychosis, and some estimates suggest that more than 70 percent of moms with any maternal mental illness do not get diagnosed or treated, so any depiction of maternal mental illness that stokes controversy could be good for treatment. By creating a provocative film, Cody is generating discussion and awareness around this issue.

But Tully could have gone even further in this direction if it showed the lasting results of our society’s determination to ignore such symptoms. Maternal mental illness is real and scary and isn’t solely caused by clueless husbands and too little sleep. (Though neither of those helps, with lack of sleep especially considered a major risk factor for both postpartum depression and postpartum psychosis.)

At the end of the movie, we see the husband assisting with baby care and sharing Marlo’s earbuds while helping her cook dinner. The final shot of the two of them, intimately touching shoulders, implies a closeness and peace that puts a balm on her illness and implies all is well. An ending more consistent with what I take to be Cody’s intentions would have showed the husband’s increased efforts and engagement but Marlo, undiagnosed and untreated, still ill. That would have been a truly brave, and accurate, film about society’s treatment of mentally ill mothers.

Yet given how few depictions of postpartum mental illness exist, the benefits of Tully outweigh the negatives. May 2 was World Maternal Mental Health Day. I don’t think it’s any accident that Tully opened this week. Let’s take this film as a way to raise awareness and to keep talking about the importance of recognizing and treating maternal mental illness, for all the suffering mothers and for their children.

Correction: Diablo Cody is the screenwriter, not the director, of Tully.

Dr. Lauren M. Osborne is an assistant professor of psychiatry and behavioral sciences and of gynecology and obstetrics at the Johns Hopkins University School of Medicine. She is an expert on the diagnosis and treatment of mood and anxiety disorders during pregnancy, the postpartum, the premenstrual period, and perimenopause. She conducts research on the biological mechanisms of perinatal mental illness, with a focus on the immune system, and her work is supported by the Brain and Behavior Foundation and the NIMH.

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