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The Royal College of Psychiatrists Improving the lives of people with mental illness

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02/07/2014 10:45:00

The Savages

 

This is the third blog in my short series about elderly residential care.


Introduction

The SavagesThe Savages, written and directed by Tamara Jenkins, and described as a tragicomedy, was released in 2007. It tells the story of two middle aged siblings, Wendy and John, estranged from their father Lenny for many years, who are suddenly faced with his physical and cognitive decline in older age, which demands their involvement. The film explores the different responses of the two siblings to this enforced caring relationship in light of the revelations about their father’s abusive relationship to them both as children.  Of interest to Old Age Psychiatrists is the suggestion that Lenny is suffering from a dementia associated with Parkinson’s Disease, allowing for a discussion about the possible differential diagnosis.

The filmThe Savages opens in a retirement village in Sun City, Arizona, where Lenny Savage, played by Philip Bosco, is living with his long time girlfriend Doris, who has a home healthcare professional, Eduardo, to assist her with her daily living. When Lenny fails to flush the toilet after Eduardo asks him to do so, and Lenny writes an insult on the bathroom wall with his faeces, alarm bells start ringing. Shortly after this Doris dies and her family call Wendy, played by Laura Linney, to inform her of the crisis. Both siblings John, played by Philip Seymour Hoffman, and Wendy are deeply engrossed in their own lives on the east coast of the USA where John is a professor of drama and Wendy a playwright yet to find financial backing. Neither have settled relationships and both seem to struggle with a life outside of their work. As they meet in Arizona to visit their father, they learn that he has no legal right to live in his girlfriend’s home and that he has been admitted to hospital for tests after suffering from episodes of faintness and the faecal smearing incident. On their first visit to see Lenny in hospital, John and Wendy find him restrained in bed because he was attempting to pull out his intravenous line and to get up from bed despite being unsteady and having falls. The doctor informs them that their father does not have vascular dementia but most likely a dementia associated with Parkinson’s disease, which accounts for his masked face and blank stare, his disinhibition, aggression and fluctuating disorientation.

 

John decides to find a nursing home for Lenny near to where he lives and although Wendy considers that they should try to look after their father or find him a supported living placement, she is reluctantly persuaded that residential care is the only realistic option. Once a residential placement has been sorted out by John, Wendy is tasked with bringing her father to Buffalo, New York state, by plane from Arizona. This is a painful scene that brings home the reality and potential difficulties of traveling any distance with someone who suffers from a significantly disabling dementia, as Lenny becomes perplexed and agitated when in the unfamiliar surroundings of the aircraft cabin and cannot move about freely. Once admitted to the Valley View home in Buffalo, Lenny shows his complete lack of understanding about his circumstances, believing it to be a hotel. Wendy’s guilt cannot be assuaged and she attempts to get her father admitted to ‘a much nicer’ residential home. However, this requires Lenny to ‘pass an interview’ that proves he is not cognitively impaired. Of course he fails this test but remains unaware and unaffected by the heated emotional discussion that follows between Wendy and John as the latter tries to get his sister to accept their father’s disability and his consequent care needs. The film follows the siblings as they deal with Lenny’s death and the period that follows it as they move forward positively in their individual lives, able to mourn for their father, whilst being released from their traumatic childhood experiences.

 

Relevance to the field of Mental Health

The Savages offers an excellent opportunity to consider the issue of care for an elderly person who may not have any close biological family ties. In contrast to the first film in this movie series, A Simple Life, that portrayed the bond of employer and employee proving strong enough to support an ageing housekeeper after her move into a care home, The Savages deals with estranged adult children forced into the caring role by duty. As more people in our society live longer and suffer from dementia in greater numbers, these issues are likely to become increasingly important for professionals to consider and understand, as not everyone has family members prepared to take on the unpaid role of personal carer. The need for greater support of people suffering with dementia in the community is acknowledged in the UK and a recent initiative by Public Health England and the Alzheimer’s Society is encouraging people to learn more about dementia in order that they might befriend someone with the illness. This initiative is called Dementia Friends and more information can be found on the Alzheimer’s Society website.

 

The other topic of psychiatric interest in this film is Lenny’s tentative diagnosis of dementia related to Parkinson’s disease. This provides the opportunity for learning about dementia in Parkinson’s disease and Lewy-body dementia. As Lenny has a masked face with a blank stare, disinhibition, aggression, apathy, faintness, unsteadiness with falls and fluctuating disorientation it might be argued that he most likely has dementia with Lewy bodies as the cognitive change precedes the development of the classic Parkinsonian movement disorder. In contrast, dementia in Parkinson’s disease usually presents first with the classic movement disorder and later with the cognitive impairment. However, both conditions are caused by the presence of Lewy bodies in various areas of the brain and their location determines the symptoms that are seen. The Alzheimer’s society has a good information page about dementia with Lewy bodies (DLB )and the Alzheimer’s Association in the USA has a good page outlining the difference between both DLB and dementia in Parkinson’s disease. In addition, for mental health professionals, a detailed article on Dementia with Lewy bodies by I G McKeith, published in BJPsych in 2002 (The British Journal of Psychiatry (2002)180: 144-147) might be useful to read.

 

The Savages is a sad and painful film to watch as it deals with a difficult subject that many people wish to avoid until it visits their own circle of family or friends. However, by the end of the film there is a positive sense that the adult siblings have found a stronger and more meaningful relationship with each other as a result of being forced to confront the care of their father before his death and that this may also have helped them to find better fulfillment in their lives generally. As a depiction of the guilt suffered by adult children often associated with placing a parent with dementia into residential care The Savages is essential viewing.

 

• More information about The Savages can be found at IMDB as can a short trailer.

The Savages can be purchased from amazon.co.uk.

• Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida

 

02/06/2014 09:23:42

Wrinkles or Arrugas

This is the second blog in my short series about elderly residential care. 

Introduction Wrinkles

Wrinkles is a feature length animated film directed by Ignacio Ferreras and first released in Spanish in 2011. An English language version has been released in April 2014, with a soundtrack dubbed into English as well as with English subtitles. The screenplay is based on the award winning graphic novel of the same name by Paco Roca. The film won 3 awards in 2012. I would highly recommend first watching the film in the original Spanish with English subtitles as the tone is significantly different in the dubbed version voiced by Martin Sheen and Matthew Modine. 

Ending with the dedication ‘To all the old people of today and of tomorrow’ this is a film intended to place the viewer in an environment that all of us may one day encounter. It explores the very real vulnerabilities brought about by memory impairment in dementia but also the value of later life friendships that may develop in a residential setting. In particular, Wrinkles focuses on the bond that is formed between Miguel and Emilio, two elderly gentlemen in a residential care home, one of who has Alzheimer’s type dementia. 

The Film 

Wrinkles begins cleverly by introducing us to Emilio, a bank manager, turning down a mortgage application for a young couple. This is revealed as a misperception as, in reality, he is refusing to cooperate with his son and daughter-in-law who are trying to persuade him to eat his supper and take his medication so that they can leave for a concert. This incident appears to be the trigger for Emilio’s admission to a residential care home, arranged by his son, where he is immediately confronted by an elderly man who repeats everything that is said to him. Perplexed and lost, Emilio says good-bye to his family and is shown to the room he will share with another man called Miguel, who has no apparent cognitive impairment. Miguel immediately undertakes to show Emilio around the home and becomes his support in the new and unfamiliar environment. However, as he does so it becomes apparent that Miguel makes money from a number of other residents by charging them for favours that they do not actually get from him. Emilio learns from Miguel that the upstairs in the home is for the more severely ill residents who can no longer care for themselves and that he must avoid going there at all costs. To this end, Miguel tries to cover up Emilio’s failing memory and abilities by diverting attention during the doctor’s mental state test of him. Emilio’s family only visit him at Christmas when he fails to recognise his young grandson who asks him why he is wearing his jumper over his suit jacket and startles him by taking flash photographs. The lost family connection is palpable. 

With the exception of some slightly improbable incidents involving the care home swimming pool and a car ride near the end of the film that causes a final deterioration in Emilio’s mental state, the day to day routine is captured very well. The group of friendships formed at the dining table serve as a focus for certain conversations that trigger poignant flashbacks from childhood for several of the residents, including Emilio, and the nature and strength of earlier bonds of love become apparent. It is only when Emilio has deteriorated sufficiently to need care upstairs that Miguel becomes sad at the loss of his friendship, but this in turn prompts a change in his behaviour toward other residents, perhaps proving the old adage that ‘it’s never too late....’. 

Relevance to the Field of Mental Health 

Wrinkles provides the viewer with a vicarious experience of life in a care home environment with numerous examples of residents vulnerable to emotional and financial abuse as a result of their dementia, who are being exploited by Miguel without the knowledge of staff. The film highlights an important problem for dementia sufferers who have significant memory impairment, in that they are often unable to clearly recall wrong doing of any kind and therefore cannot report it to others. This aspect of the film would make a very good focus for teaching about such abuse. A viewing of Wrinkles alongside a reading of the Safeguarding Policy from the Office of Public Guardian in the UK would offer an excellent platform for discussing the important topic of safeguarding adults at risk (previously called vulnerable adults). The film also illustrates the problem of paranoia that can arise as a result of impaired memory when Miguel eventually finds Emilio’s watch and wallet hidden carefully for safekeeping in their shared room, after Emilio has repeatedly accused Miguel of taking both things. 

With the care home sector under particular scrutiny at present and with the prospect of many more elderly people needing care in such settings, these are important topics to discuss openly within our society. A very interesting account of her own move into a residential home, by the 96 year old author Diana Athill, in The Guardian in 2010, would make additional complementary reading to the film. In contrast to Athill’s personal decision to move in to residential care, Emilio, who is suffering from dementia, is not happy to leave his home and the move is arranged by his son. This issue presents an opportunity for teaching about the deprivation of liberty safeguards (DOLS), a part of the Mental Capacity Act, and whether such a move is in Emilio’s best interests. One could debate whether, if the care home was in the UK, Emilio should have his deprivation of liberty authorised by the procedure known as DOLS, especially in light of the recent supreme court judgment in March 2014 stating that anyone under continuous control and supervision of staff and who is not effectively free to leave whenever they choose, should be protected by the independent scrutiny that DOLS provides. For a good summary on the supreme court judgement, see the RCPsych web page. 

Wrinkles is a warmly moving and at times humorous animation that deals with a difficult subject extremely well. It is essential viewing for all care home staff and might encourage greater empathy and understanding about the plight of residents, and assist in the training of staff dealing with some of the most vulnerable individuals in our society. 

  •  More information about Wrinkles can be found at IMDB as can a short trailer. 

  •  Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida 

30/04/2014 15:04:06

A Simple Life

 

... or 桃姐 (Tao jie)

 
This is the first blog in a short series focusing on films about moving into a residential care home for the elderly.

Introduction

A Simple Life or 桃姐 (Tao jie)
A Simple Life is directed and co-produced by Ann Hui and was released in the UK in 2012. Set in Hong Kong, it is in Cantonese with English subtitles and stars some very well known Hong Kong actors and actresses, namely Andy Lau and Deanie Ip, who won the best actress award at the Venice Film Festival 2011, and at eight other festivals, for her role as Ah Tao. Inspired by the true life experiences of one of the film’s producers and co-writer, Roger Lee, the film focuses on the changing relationship between Ah Tao, a maid to the Leung family for 60 years, who looks after Roger an unmarried film producer and the only one of the family remaining in Hong Kong after they relocated to America. Ah Tao’s life is the simple life of the title and the film follows the reversal of their caring role after Ah Tao suffers a stroke and Roger becomes involved in providing support for her. The director, herself now 66 years old, has described the film as a documentary style drama in which she sought to portray the featured Hong Kong residential care home in a realistic way, making it of particular interest to Old Age Psychiatrists.



The Film

A Simple Life opens with Ah Tao buying food in the local market where she seems well known and warmly regarded as a quirky character. She then cooks a luxurious, healthy meal of fish for Roger which she delivers with minimal fuss or conversation but maximum care and attention. Her loyalty is very apparent. Their relationship, although one of employer and employee, is seemingly symbiotic and words are almost unnecessary as they have such mutual understanding that has developed since Roger was young. Ah Tao raised Roger as a baby and child and he is now a successful film producer who travels a lot but does not have a wife or partner. On returning from a trip to mainland China, Ah Tao does not answer the door to the flat. Roger eventually finds that she has collapsed inside having suffered a stroke and she is admitted to hospital. As she begins to recover a little, Ah Tao states that she must now retire and wishes to live in a care home. Roger helps to find a suitable place and then finds that he is drawn to regular contact with Ah Tao as he becomes her provider. She requests that Roger inform his mother about Ah Tao’s situation, as the majority of the Leung family now live in America. A visit follows which delights Ah Tao but highlights the more distant bond that Roger has with his mother in contrast to that which he has with Ah Tao. Her gradual recovery from the stroke allows greater freedom to leave the care home on outings with Roger, which she never takes for granted, and they begin to develop a friendship quite distinct from their previous relationship. Roger takes Ah Tao to a film premiere where he introduces her as his godmother, which touches her enormously. Their bond is finally sealed as they leave the screening arm in arm talking about the film. Interspersed with the portrayal of their developing relationship are scenes involving other residents at the care home. After suffering another stroke, Ah Tao is confined to a wheelchair and deteriorates steadily with dignified acceptance and serenity. Roger is at her bedside in hospital as her death approaches, with the full awareness of how important Ah Tao was to him.

 

Relevance to the field of Mental Health

A Simple Life tackles the very topical subject of how best we can provide care for older people no longer able to live independently. The film shows the effect on Ah Tao, a previously productive, capable individual, who enjoyed being a carer, when she chooses to move into institutional care after suffering a stroke. The film sensitively examines the nature of the bonds that sustain people in residential care providing a commentary on the importance of non-familial as well as familial bonds. The opportunity to compare these issues as seen in another culture with our own experiences here in the UK, and elsewhere, is a useful and important exercise that broadens and deepens our understanding of elderly care.

A Simple Life highlights certain positive interventions that enhance the lives of those in residential care, such as meaningful engagement in groups, access to the community, the importance of visitors, the joy of pet therapy sessions and above all the delivery of compassionate care. It also hints at the cynicism of some who interact with the residents during the visit of a professional singer and her entourage for the Autumn Festival as they snatch the gifts away from the residents after photographs are taken so that they can use them at the next care home. The film also reminds the viewer of the commonly felt loss of privacy experienced by individuals relinquishing their own home for a life lived in a communal space which is often the most troubling prospect for those elders facing a move into residential care.

With its slow and gentle pace, and its deeply humane perspective, this film is a gem and a real joy to watch. I would highly recommend it to anyone working with older people.

 

• More information about A Simple Life can be found at IMDB as can a short trailer.

 

A Simple Life can be purchased from amazon.co.uk.

 

• Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida

 

01/04/2014 12:33:54

Les Invisibles

IntroductionLes Invisibles

Les Invisibles is a documentary film about the experiences of being lesbian, gay or bisexual in  Southern France. In French with English subtitles Les Invisibles was directed by Sébastien Lifshitz and released in 2012. It features a number of men and women aged 60, 70 and 80 recounting their memories of ‘coming out’ and living with their sexual orientation at a time when this was not easy. The film includes some accounts of the emerging gay rights movement in France, accompanied by archive film footage, and also reminds us that when many of the interviewees were discovering their homosexuality or bisexuality, it was still classed as a mental illness. As same sex marriages are now legal and available in England and Wales from March 29th 2014, but certain other countries are making it harder to be openly LGBT, Les Invisibles is an important film to highlight at this particular moment.

 

The Film

Les Invisibles is composed around a series of monologues delivered to camera by various men and women either alone or in couples and in their home environments. Each person starts by explaining how they first became aware of their sexual orientation and what implications this had on their immediate relationships with family, friends or work colleagues. They then proceed to discuss the experience of being lesbian, gay or bisexual through adulthood up until the present time, in which the effects of ageing now play a part. At all times respectful, the integrity and dignity of all participants are portrayed beautifully as they describe the struggles that many endured by being open about their sexual orientation at a time when this was widely disapproved of.

 

Relevance to the Field of Mental Health

Les Invisibles provides the viewer with an important reminder about the continued existence of sexual behaviour in older age, whether heterosexual, bisexual or homosexual in orientation. It is also the case that, as it has become easier in our society to be openly gay, there is an increasingly visible elderly population who need acknowledging within that community and that this may not be quite so easy for them. As an article in The Guardian newspaper in September 2013 describes, the sheltered housing and care home sector can present significant difficulties for older LGBT people. The Alzheimer’s Society has a useful webpage providing advice on the topic, entitled: Moving into a care home - advice for lesbian, gay and bisexual people.

 

This is a very warmly moving documentary that handles its subject matter sensitively whilst providing valuable insights for all who may encounter elder LGBT people as they work within the caring professions.

 

• More information about Les Invisibles can be found at IMDB as can a short trailer.

• The Les Invisibles can be purchased from amazon.co.uk.

• Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida

 

02/03/2014 12:50:04

The Impossible

Introduction The Impossible

The Impossible is a film about a British family caught up in the Indian Ocean Tsunami of 2004, directed by Spanish film director J.A. Bayona and released in 2012. It is based on the true story of a Spanish family, the Alvarez Belóns, whose detailed account provided by María Belón Alvarez informed the making of the film at all stages. Bayona has described the process he chose to create the Tsunami scenes using digital effects and a huge water tank to replicate the moments of chaos after the wave hits the beach resort in order to make them as realistic as possible. He worked with real water surges to destroy miniatures of the resort, while Naomi Watts and Tom Holland, who play mother Maria and her son Lucas, filmed for five weeks in the tank for the turbulent underwater scenes. The film received much critical acclaim and prompted Simon Jenkins, a British survivor of the Tsunami from the same beach resort, to comment on its authenticity in a film blog entitled The Impossible is ‘beautifully accurate’  written for The Guardian in January 2013, in response to some criticism that the film didn’t focus on the majority of local victims.


The Film

The Impossible opens with the Bennett family on the plane to Thailand for Christmas.

When they arrive at the resort of Khao Lak they are mildly disappointed to discover that they have not been given the rooms that they had booked but then find that the replacement beachside suite is much to their satisfaction. After celebrating Christmas day with an exchange of presents there is no awareness of how significant one of those gifts, a red ball, will become in the events that follow. On Boxing Day, as the family are relaxing and playing by the poolside there is a sudden change of atmosphere and with almost no warning the scene is swamped by a ferocious wave. The devastation that follows is powerfully experienced by the viewer as mother Maria and her eldest son, Lucas are tossed around beneath the water like rag dolls. Maria is seriously wounded, but they manage to stay together and survive being swept inland. Lucas finds himself having to find the strength required to become his mother’s main support and with the help of some locals she is taken to a hospital nearby. As this story is told there is no indication of how the other family members have fared and the pain of not knowing is brilliantly recreated in the midst of the most extreme chaos that has been inflicted on the area. Then we see father Henry (played by Ewan McGregor) searching the wreckage of the beachside, calling for Maria and Lucas, until returning to the rubble of the hotel where his two young sons are waiting. The emotional pain of separation is palpable in all of the characters and at this stage neither family group knows whether the other is alive or dead. Henry then makes an agonisingly difficult decision to put his two youngest sons in the care of the authorities for evacuation to safety while he continues to search for Maria and Lucas in all of the surrounding hospitals.

The remaining suspenseful scenes show how the family are finally reunited at the hospital where Maria receives life saving treatment. The film ends as they are evacuated by plane to Singapore only then beginning to process the fact that they have survived where so many others did not.


Relevance to the Field of Mental Health

The Impossible provides the viewer with the vicarious experience of a sudden and serious life changing event that is an immediate threat to life, placing us, cinematically, under the Tsunami wave with Maria and Lucas. It also presents a powerful portrait of the emotional consequences of separation in the immediate aftermath of the disaster and provokes the viewer to question what they would do in such a situation. The harrowing portrait of survival against the odds offers an excellent opportunity to explore the psychological consequences that such traumas might cause in both the short and the long term. A good article to read alongside a viewing of the film is called Early mental health intervention after disasters by David A. Alexander, published in Advances in Psychiatric Treatment (2005) 11:12-18. In it the author examines the factors that may play a part in determining the ability of survivors to cope with the impact of such events and notes that very few people display overt psychopathology in the immediate period after a disaster.

The Impossible is not a comfortable film to watch, although with the knowledge that it is based on true events, it is hugely compelling and involves a significant emotional commitment by the viewer. This is an important film for anyone working in mental health to see, especially for anyone who may work with people affected by sudden trauma or who have been caught up in a disaster.

• More information about The Impossible can be found at IMDB as can a short trailer.

The Impossible can be purchased from amazon.co.uk.

 

• Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida

 

03/02/2014 09:39:14

The Crash Reel

Introduction The Crash Reel

The Crash Reel is a documentary directed by UK film director Lucy Walker which premiered at  the Sundance Film Festival in January 2013. It tells the story of champion snowboarder, Kevin Pearce, who suffered a serious head injury in 2009, in his early twenties, whilst training for the 2010 Winter Olympics. It follows him and his family through the difficult stages in the immediate aftermath of his injury, when he spent six days in a coma, through the stages of his physical recovery to the following years in which they are all confronted by the cognitive changes caused by his traumatic brain injury (TBI).

As well as considering the very personal circumstances of Kevin Pearce and his family, this documentary explores the world of extreme sports from the perspective of both the athletes and the spectators. Athletes are driven to perform ever more spectacular stunts, perhaps motivated in part by greater sponsorship deals, and spectators seek the thrill of watching them take these extreme risks. The documentary’s title refers to the portfolio of filmed crashes that snowboarders collect over time and which audiences enjoy watching. By juxtaposing many of these filmed falls with the reality of Kevin Pearce’s accident, and some other snowboarding tragedies, the film challenges the viewer to feel differently about those Crash Reels in the future. The director discusses some of these issues in an interesting interview given at the Sheffield documentary festival in 2013.

The Film

The Crash Reel opens with footage from the successful years of Kevin Pearce’s rise to fame as a champion snowboarder, competing for the top spot with his life long rival Shaun White, and hoping to take a gold medal at the 2010 Vancouver Winter Olympics. Kevin is seen to be a fearless, talented young man, from a hugely supportive, loving family, at the height of his athletic ability when he suffers a terrible accident, during a training session, that results in his traumatic brain injury. The film follows Kevin and his family as he progresses steadily through each stage of his rehabilitation.

Of particular interest, are the scenes with Kevin’s parents and his brothers, one of whom, David, has Downs syndrome. David is given the opportunity to talk about his own struggle with his disability in a very open and honest way that gives further insight into how this family functions. The positive effect that his family undoubtedly has on Kevin’s recovery is recorded in an unsentimental way. The film also provides the viewer with empathic understanding of how challenging it could be to interact with someone you love who has lost their judgement and insight about their mental and physical abilities. The interactions between David and Kevin are particularly significant in helping the family try to persuade Kevin to reconsider his desire to return to snowboarding again, and are fascinating to watch.

However, despite his family’s misgivings, Kevin is determined to make a return to snowboarding, only to find that he cannot function at anywhere near his previous level of ability, causing him much frustration but forcing him to realise that he must accept the different person that he has become.

Several other stories are told alongside Kevin’s and they do not have such a positive outcome. One of these is the tragic death of freestyle skier, Sarah Burke, on exactly the same half-pipe where Kevin had his accident. Another story focuses on the snowboarder, Trevor Rhuda, who has been left with severe cognitive and physical disabilities resulting from three successive TBIs caused by a return to snowboarding against medical advice. Kevin meets with him and his mother and is visibly moved by hearing his mother describe Trevor’s aggressive challenging behaviour and inappropriate affect. This seems to shift something for Kevin in his understanding of his own limitations and for the first time brings some insight that he should accept his ‘new brain’ and his ‘new life’. With this improvement comes a sense of progress again, more than two years after his accident. Finally Kevin begins to find a role as a sports commentator and as an advocate for others with TBI which brings him a renewed purpose and enjoyment, albeit of a very different kind.

 

Relevance to the Field of Mental Health

The Crash Reel offers the viewer a perfect opportunity to learn about traumatic brain injury  and its long term sequelae. Through the portrait of Kevin both before and after his accident and during his lengthy recovery phase one gets a good sense of the protracted time it may take for recovery to occur. In conjunction with the recently released and updated guidance by NICE on the management of Head Injury (CG176), the film might be especially useful for those teaching students from a variety of healthcare disciplines. From a mental health perspective, the film is particularly good at presenting the effect that Kevin’s TBI has had on his insight, judgement, memory, mood and ability to regulate his impulses. Further learning is provided in a scene where Kevin’s brain scans are shown to him by a specialist who points out the area of damage that explain some of his ongoing difficulties.

The Crash Reel also offers the opportunity to teach about the assessment of mental capacity by considering the changes that the viewer is shown in Kevin’s ability to understand, weigh up and make fully formed judgements about whether to snowboard again. The contrast between Kevin and Trevor Rhuda on this issue is brilliantly illustrated in the scene where Trevor seems unable to weigh up the important information presented to him by Kevin. Most significant, however, is the demonstration of an alteration in Kevin’s mental capacity over time as he recovers greater insight and executive function, which is a really important aspect to consider when teaching about this topic. In essence, it demonstrates that mental capacity assessments must always be decision and time specific.

In the USA The Crash Reel  has given rise to a campaign called LOVEYOURBRAIN led by Kevin Pearce  which aims to inform people, especially snowboarders and skiers, about TBI. The Kevin Pearce Fund has also been established to help fund organisations that support families facing challenges as a result of TBI. In the UK, the charity Headway offers advice and information about brain injury and has some excellent resources available on its website about the condition. This film offers an important learning opportunity for anyone wanting to know more about living life with a brain injury and I would highly recommend it.

 

• More information about The Crash Reel can be found at IMDB as can a short trailer.

• The Crash Reel can be purchased from amazon.co.uk.

• Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida

 

 

 

02/01/2014 11:31:14

Trapped in a Purple Haze

Trapped in a Purple Haze
Introduction

For the third blog in my series about drug addiction, I would like to recommend Trapped in a Purple Haze, an American film made for TV, directed by Eric Laneuville, which was first shown in 2000. It was subsequently released on DVD in the UK in 2004.  This film provides a good portrait of the process in which a middle class teenager becomes addicted to heroin. There are excellent performances by Jonathan Jackson as teenager Max Hanson and Carly Pope as his girlfriend Molly White.


The Film

Trapped in a Purple Haze begins at a high school ice hockey match where we first meet Max Hanson, the star player on the team, and see him scoring a goal that wins the match. Evidently happy with his success as a sportsman, Max enjoys the acclaim he receives from his peers but it soon becomes apparent that his mother’s hopes for him are very different. She wants him to develop his talent as an artist, something she had wanted to do but had abandoned when she had a family. Max tries to tell his mother that he is not so sure about pursuing a career in art but she is reluctant to listen. Max finds himself attracted to a girl at school called Molly who seems impressed with his sporting prowess and invites him to a party. The relationship with Molly develops quickly into a powerful and intoxicating means of escaping from the intrusive scrutiny of his mother. It is Molly who introduces Max to drugs and a whole new world associated with them. The film follows Max on a painful downward spiral as his successful school career slips away from him and he loses his place on the hockey team. He becomes estranged from his close friends as he is drawn ever deeper into the world of drug addiction and associated criminal activity. Max begins to suffer from some physical health problems as a result of using heroin, which others start to notice. However, with his family’s concerns dismissed and their influence diminished, Max disregards their concerns and leaves home for a precarious existence on the edges of society. It takes the persistence of his father, who searches for Max after a serious incident occurs involving the police, to find him just in time although he is by then suffering from extremely serious health problems. It is only then, and after discovering the tragic death of Molly from a heroin overdose, that Max agrees to seek help with the support of his family.


Relevance to the field of Mental Health

Trapped in a Purple Haze explores some of the underlying reasons that young people may come to find themselves addicted to illegal drugs, in particular the peer pressure from other teenagers, especially when this involves a romantic attachment. The film provides a context for Max’s initial rebellious behaviour by sensitively portraying the difficult relationship that he struggles to manage with his mother, whose high expectations of him feel intolerable. At the same time his mother’s failings in her relationship with Max are portrayed with depth and understanding, showing the complexity that always exists when a parent ‘tries to do the best for their child’. As a viewer, one can gain empathic experience of Max’s need to escape from a suffocating home environment in which his hopes and wishes cannot be heard. This might help someone to understand why a young person, such as Max, could seek relief through substance abuse from such pressures when the drugs are provided by a very desirable other who appears to offer appreciation and understanding. Trapped in a Purple Haze goes on to portray the physical addiction that develops with the use of heroin and how the supply of that substance becomes the main focus of desire and daily necessity for Max.

 

As an educational resource, the film offers the opportunity to consider and discuss the variety of underlying causes that may result in a previously well functioning, successful young person developing an addiction with all of the serious associated health and social consequences that Max suffers. It openly invites commentary on the way in which Max is parented by his mother and father and allows the viewer to gain understanding of why treatment must often involve some form of psychotherapeutic intervention with the whole family.

An openly available article published in Advances in Psychiatric Treatment, in 2000, entitled Substance misuse in adolescents by Harith Swadi (Advances in Psychiatric Treatment (2000) 6: 201-210) offers a good introduction to this subject area and would be useful to read alongside a viewing of the film for teaching purposes. A more recent article in the same journal called Adolescent substance misuse: an update on behaviours and treatments by Paul McArdle and Bisharda Angom (APT July 2012 18:299-307 abstract) brings the discussion up to date.

* More information about Trapped in a Purple Haze can be found at IMDB. 

* Trapped in a Purple Haze can be purchased from amazon.co.uk.

* Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida

 

 

28/11/2013 10:32:38

Oslo, August 31st

A short series of blogs focusing on various aspects of drug addiction as portrayed in films.


Oslo poster

Introduction

For my second blog about drug addiction as portrayed in films, I would highly recommend Oslo, August 31st, a Norwegian film subtitled in English, directed by Joachim Trier and released in 2011. The film focuses on the process of recovery from drug addiction and touches on the difficulties of reintegration back into a community after time spent in an inpatient treatment unit. Widely acclaimed, and with a fantastic central performance by Anders Danielson Lie who plays Anders, the film follows him for 24 hours of authorised leave as he travels to Oslo for a job interview where he also meets up with some old friends and family. It is a subtle portrait of his internal thought processes as he appraises his place in the world without drugs and reflects on why he has ended up facing the very real challenges of finding intimacy and employment at the age of 34 after squandering his potential for success as a young intellectual middle class adult.

 


The Film

The film opens with a collage of personal home-movie memories narrated by people who grew up in Oslo. Then we see Anders draw the curtains in a room overlooking a city before watching him walk through woodland to a lake where he unsuccessfully attempts to drown himself. He returns, soaking wet, to the drug rehabilitation centre situated in the countryside on the outskirts of Oslo. After making good progress in conquering his heroin addiction, Anders is granted leave to visit Oslo for a job interview at a magazine publisher. Before his appointment, he phones his ex girlfriend and leaves a message on her phone asking to have contact with her again. He visits a previously close friend and peer, Thomas, who is now married with children and is a successful academic. The encounter seems to highlight just how much Anders has lost in terms of his purpose in life when compared to the achievements of his old friend. However, Thomas confesses that his existence isn’t quite as wonderful as it first appears which raises the issue of what actually constitutes happiness in life for these old friends now that they must accept greater responsibility as they age. Thomas invites him to an old friend’s birthday party that evening but Anders declines. Having had no reply from his ex girlfriend, he tries phoning her again and leaves another message.

The job interview acts as a pivotal point in the film, as it reveals Anders’ poor self-esteem and lack of confidence in his journalistic abilities. Forced to reveal his drug addiction as a cause for the gap in his CV, Anders doesn’t wait to hear the response from his interviewer and storms out, as if uncovered as a fraud, using the experience as supporting evidence for the hopelessness of his life now. He arranges to meet his sister in a cafe but finds her female partner there in her place. He demands a key to their parents’ home, which she reluctantly provides him, but he is hurt that his sister did not come to see him and he leaves the café angrily. He later decides to go to the birthday party after all only to find that Thomas and his wife haven’t turned up. At the party he encounters an ex-lover and much temptation in the form of freely available alcohol, which he starts to drink. He meets a young woman and follows her and two others to a club in the city, followed by a night spent ‘on the town’, although his mind seems resolutely fixed on his ex girlfriend and his feelings of alienation. He then acquires some illegal drugs. In the final scene, Anders visits his parent’s home where he makes a crucial decision.

 

Relevance to the field of Mental Health

Oslo, August 31st examines the very important issue of how a recovering drug addict reintegrates into society after the initial stages of treatment and the maintenance of abstinence for a short period of time. By focusing on 24 hours in Anders’ life as he attempts to reconnect with his friends and community and to find meaningful employment, it offers a closer examination of his inner thought processes that highlights the various areas of difficulty a recovering addict may encounter. The emptiness, hopelessness and suicidal intent in Anders is well portrayed and would make an excellent case study to teach about the diagnosis of depression and suicidal risk in those recovering from drug addiction. But the film also offers a view on the changed relationships that may result when an individual has betrayed the trust of those close to them as a result of their addictive patterns of behaviour. It shows the ease with which Anders can form a new superficial relationship but actually craves forgiveness, understanding and acceptance from those who he perhaps hurt the most. It is the portrayal of just this reality that emerges slowly through the film and makes viewing it such a powerful experience. 

A useful publication that might enhance an educational viewing of Oslo, August 31st is freely available at the American National Institute on Drug Abuse (NIDA) website and is called Principles of Drug Addiction Treatment: A Research-Based Guide (3rd Edition revised in Dec 2012).

* More information about Oslo, August 31st can be found at IMDB as can a short trailer.

* Oslo, August 31st can be purchased from amazon.co.uk.

* Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida


You can now follow Minds on Film on Twitter @psychfilm

 

01/11/2013 15:14:59

Down to the Bone

This is the first in a short series of blogs focusing on various aspects of drug addiction as portrayed in films

down to the bone
Introduction

Down to the Bone was co-written and directed by Debra Granik and released in 2004. As a film about drug addiction in small town America, the director chose to create a naturalistic portrayal by using real locations and some nonprofessionals in certain supporting roles. In an incredibly powerful central performance, professional actress Vera Farmiga plays Irene, a working class mother of two young sons, living in a stale marriage, who has a cocaine habit. The film won eight awards including two at the Sundance Film Festival in 2004 for the director and for Farmiga’s performance. The story is based closely on the experiences of a real family whom the director met over several years, first producing a short film about them called Snake Feed, which was released in 1997, and later her first full time feature Down to the Bone. In the director’s own comments (available on the Film’s Official website), Granik states her motivation for making the film:

I was drawn to this story because of the questions that it raises. Why do some people keep going and others give up? Why do some people change and how do they do it? Why do some of us run with people who are not good for us? When does a person become dangerous to another? When is it safe to trust? Why are so many people prone to addictive patterns? Why do people relapse?”

 


The Film

The film opens with Irene returning from work at the supermarket to prepare for a Halloween night of Trick or Treating, in which she tries to encourage her reluctant young sons into dressing up and walking around the neighbourhood. She seems to be a busy caring mother until we watch her dash into the bathroom before they leave home to snort some cocaine while her son knocks on the door asking her a question. Her job at the checkout doesn’t pay enough to feed her drug habit and so she begins to owe increasing amounts to the man who supplies her. He eventually calls a halt to this and refuses to give her any more cocaine without payment. Desperate, Irene tries to offer him her son’s birthday cheque in part payment but the dealer will not accept it. As her physical state of craving becomes more intense, Irene realises that she must get help and so takes a ‘holiday’ to book into a residential drug rehabilitation unit. Unfortunately, despite making good progress, Irene feels she must discharge herself sooner than planned, against the advice of those at the clinic, as she must get back home and to work. Initially, she remains abstinent and starts attending Narcotics Anonymous meetings, where she meets Bob, played by Hugh Dillon, a nurse who Irene saw at the residential clinic, who is an ex-addict and they form a strong attraction for each other.

Unfortunately, without the influence of cocaine, Irene’s performance is slower at the supermarket checkout and she is soon dismissed from her job after revealing the reason for the change in her efficiency. Struggling to survive economically, she begins to do cleaning work with a female friend she met in the rehabilitation clinic and this is initially successful until she starts to have a secret affair with Bob. As he relapses and starts using heroin, Irene is drawn back into her old habits but this time tries heroin with Bob. They are soon caught by police while driving her car, which brings their affair to the attention of Irene’s husband, Steve, and he asks her to leave the family home. She finds a place of her own to live, where her sons can visit and stay, and Bob soon joins her there. But Irene begins to realise that she will be hampered in her attempts to recover from her addiction with Bob in close proximity to her, and so she asks him to leave. The film ends there, without resolution, perhaps reflecting the uncertainty that so many addicts face every day that they strive to stay free of their addiction.

 

Relevance to the field of Mental Health

Down to the Bone presents a naturalistic portrait of drug addiction that doesn’t shy away from the human effects that it may have on an individual as well as on partners, children and friends. It also gives the example of treatment in a residential drug rehabilitation clinic as well as support in the community through attendance at Narcotics Anonymous. But Down to the Bone is particularly good at demonstrating the vulnerability of someone seeking to recover, taking each day at a time as they strive to stay clean and showing how easy it can be to lapse without a supportive structured environment. In particular this is highlighted by Irene’s ill advised relationship with Bob, himself an ex-addict, which occurs in the context of her unsatisfactory marriage to Steve who also uses drugs. Neither can give her what she truly needs to manage her addiction and we are not given any certainty about her future as the film ends.  Because it was closely based on the experiences of a real person there is an authenticity in the film that provides an excellent opportunity for learning about this complex issue.

Viewing this film accompanied by an exploration of some of the following resources would offer a very good basis for a discussion about the management of drug addictions and the role of various treatment options. An article published in Advances in Psychiatric Treatment in 2003 would make a good starting point. It is titled What works in drug addiction?by Jason Luty (Advances in Psychiatric Treatment (2003) 9: 280-288).

A major addiction charity in the UK, called Action on Addiction, has lots of information about prevention, treatment, research and family support for people with addictions as well as providing lots of useful links to further resources. One of these resources that mental health professionals may find helpful and interesting is the archive of podcasts on addiction posted at the King’s College website of the Institute of Psychiatry, Addictions Department

 

• More information about Down to the Bone can be found at IMDB and a trailer can be viewed at the Film’s Official website.

Down to the Bone can be purchased from amazon.co.uk

• Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida

02/10/2013 10:13:33

Take Shelter

Introduction

Take Shelter was written and directed by Jeff Nichols, and released in 2011. It won 33 awards, including several at the Cannes Film Festival. It tells the story of a family man in his thirties, called Curtis LaForche, who starts to believe that he is in the early stages of developing paranoid schizophrenia. His mother was diagnosed with the illness when she was a similar age and he is fearful of suffering the same fate.

Set in Ohio, USA, a state used to storms and tornadoes, the film brilliantly explores Curtis’ increasing fixation on the need to prepare for an apocalyptic storm that he believes is coming.

With superb acting by Michael Shannon, who plays Curtis and Jessica Chastain, who plays his wife Samantha, the film also offers an opportunity to consider the challenges of parenting their deaf child, Hannah, played by Tova Stewart who is hearing impaired in real life.

Take Shelter

The Film

The film opens with a dream sequence in which Curtis experiences the arrival of a terrifying storm. Brown oily rain falls from the sky as a tornado gathers itself on the horizon. Several more similar nightmares ensue and in one of them the family dog bites his arm. After waking he continues to feel the pain of that dog bite throughout the rest of the day causing him to house the dog outside for the first time ever and alarming his wife.

He does not share any of these bad dreams with her at this stage although the nightmares cause Curtis to question his psychological health and he takes a trip to the library to borrow books on mental illness. At the same time he begins to review the adequacy of the family’s storm shelter in their garden, as a part of him also believes that the dreams are premonitions of a catastrophic storm to come. Meanwhile, Hannah, their young daughter who is profoundly deaf, finally gets the go ahead from Curtis’ health insurance policy to have cochlear implant surgery after many months of waiting. Samantha is both relieved and excited as she prepares her daughter for the operation.

It is only after one very frightening dream in which he wakes to find that he has wet the bed that Curtis visits his family doctor to ask for sleeping tablets. The doctor is reluctant but agrees to a short course whilst suggesting that Curtis see a psychiatrist.

He does not do this but instead visits the free state counseling service where he starts by giving a comprehensive self diagnosis on the basis of his ‘delusions and hallucinations’, suggesting that he has schizophrenia. By this time, his abnormal beliefs and extreme anxiety have been noticed by his close friend and work colleague who reluctantly agrees to help him borrow a work place digger to extend the storm shelter in Curtis’ garden.

When Samantha discovers Curtis’ project she is horrified by the costs involved and concerned about his health. Curtis reveals to her that he has borrowed money for the storm shelter construction project thereby increasing their financial pressures. It is only when his boss finds out about the borrowed digger that Curtis loses his job and his health insurance with it. This in turn means that Hannah cannot have her cochlear surgery.

After the loss of his job he has an angry outburst at a community dinner in which he warns everyone about the pending storm danger. This is followed by the arrival of a real storm which allows the family to test out Curtis’ new shelter, but after the storm clears he is unable to leave the shelter, despite his wife’s reassurance that all is clear, convinced that he can still ‘hear it and feel it’.

He finally agrees to visit a psychiatrist who suggests that medication will help but that a vacation away from the storm shelter at home is also advisable. With the loving support of his wife, who tells him firmly that she will not leave him, they go on their planned beach holiday.

In an ambiguous ending all of the family witness a storm at the beach in which oily brown rain falls from the sky and a large tornado is seen on the horizon. Perhaps this ending leaves the viewer questioning their own understanding of the film in the same way that Curtis has been struggling to understand his perceptions.

 

Relevance to the field of Mental Health

Take Shelter is a film about mental illness and the diagnostic difficulties that mental health professionals may encounter when assessing patients who present with delusions. In particular it offers viewers an opportunity to think about and detail the possible causes for Curtis’ presenting symptoms in the context of his anxiety about the family history of paranoid schizophrenia in his mother.

The film also demonstrates the importance of exploring the context of someone’s delusional beliefs. It is because Curtis lives in a geographically storm prone area that the mental health professional must be sure that his beliefs are inappropriately extreme and abnormal when compared to others around him.

For those teaching students of mental health, this film invites a discussion of the presenting symptoms that are necessary to definitively diagnose paranoid schizophrenia and offers a wider consideration of delusional disorders as a part of schizophrenia spectrum disorders. An article in Advances in Psychiatric Treatment earlier this year called Recent developments in the management of delusional disorders by Christopher Fear (Advances in Psychiatric Treatment (2013)19: 212-220, abstract), brings the topic up to date and would be very helpful reading material alongside a viewing of Take Shelter.

 

  • More information about Take Shelter can be found at IMDB, as can a short trailer.
  • Take Shelter can be purchased from amazon.co.uk.
  • Minds on Film is written by Consultant Psychiatrist, Dr Joyce Almeida.

 

 

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About this blog

 

Minds on Film is a monthly blog that explores psychiatric conditions and mental health issues as portrayed in a selection of readily available films.

Please note that this blog may contain plot spoilers. Any views expressed are purely my own.

Dr Joyce Almeida

Dr Almeida is a consultant
psychiatrist working in the private sector in the UK.

 


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