Accessibility Page Navigation
Style sheets must be enabled to view this page as it was intended.
The Royal College of Psychiatrists Improving the lives of people with mental illness

MINDS ON FILM

RSS Logo RSS 2.0
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.
03/09/2013 10:05:35

An Index to Minds on Film

Here is an index of links to the relevant blog posts discussing specific psychiatric conditions and mental health issues covered by Minds on Film over the past three years.

 

An Index to Minds on Film

Alcohol dependence 

Alzheimer’s disease

Anterograde amnesia

Anxiety

Assisted suicide

Bipolar disorder/Schizoaffective disorder

Bulimia nervosa

Carer stress

Cerebrovascular accident

Challenging the stigma of mental illness

Childhood autism

Dementia

Depression

Developmental delay in childhood

Divorce - the effects on teenage children

Domestic violence

Dyslexia

Epilepsy and psychiatric illness

Grief for the loss of a child

Growing up in Care

HIV related dementia

Homelessness and psychiatric morbidity

Insomnia

Locked in syndrome

Mindfulness

Morbid jealousy

Obsessive compulsive disorder

Personality disorder

Problem gambling

PTSD

Schizophrenia

Sexuality - changing in later life

Stalking

Suicide/Attempted suicide

Tourette’s syndrome

Transgender issues

Uncomplicated Grief

Unemployment and psychiatric morbidity

Vascular Dementia

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

01/08/2013 10:11:46

A New State of Mind: Ending the Stigma of Mental Illness

introduction

“A New State of Mind”  is an hour long documentary that was produced in the state of California by the public television station KVIE-TV for a mental health awareness month in May 2013. Its aim is to reduce the stigma and discrimination associated with mental illness and to encourage sufferers to seek help earlier rather than later in their illness. The film is freely available to watch online at Vimeo.com and the makers are keen for it to be viewed as widely as possible. Further information about California’s Mental Health Movement can be accessed at their website called Each Mind Matters, where there are also some other interesting videos available to watch.

“A New State of Mind”  features some famous people from the political and sporting worlds as well as ordinary people who come from a variety of cultural and ethnic backgrounds. The film is filled with hope and a positive attitude and is narrated by the well-known actress Glenn Close, co-founder of the national anti-stigma campaign in America called Bring Change 2 Mind, which aims to remove misconceptions about mental illness through public education. Glenn Close has become a mental health advocate as a result of having her sister diagnosed with bipolar disorder and her nephew diagnosed with schizoaffective disorder. 

Relevance to the field of Mental Health

Educating everyone in our society about mental illness is crucial if we are to counter the stigma that continues to exist about it. “A New State of Mind”  is part of an initiative that aims to achieve real change in attitudes to mental illness within a geographical area that is home to a culturally diverse population. Although it was principally made for Californians, “A New State of Mind”  has much to offer a wider audience by presenting many individual stories of those suffering from depression, suicidal intent, bipolar disorder, schizoaffective disorder, substance abuse and post traumatic stress disorder. The film also explores various initiatives in California that help with treatment and rehabilitation, which may interest those professionals working in the field of mental health wherever they are based.

In England, Time to Change is the biggest campaign trying to challenge mental health stigma and discrimination and is run by mental health charities Mind and Rethink Mental Illness. They have worked with the Bring Change 2 Mind campaign in America to share certain initiatives.

A New State of Mind”  is a useful educational resource for anyone interested in understanding more about mental illness and the challenges it presents to societies.

* Minds on Film is written by consultant psychiatrist, Dr Joyce Almeida.

01/07/2013 10:07:47

Helen

introductionHelen

Helen is a film about depression. It was written and directed by Sandra Nettelbeck and released  at the Sundance Film Festival in 2009. Inspired by the death of a depressed childhood friend through suicide, Nettelbeck researched the topic over many years before producing the screenplay. With excellent performances by all of the main actors this is an important film that contributes to a much needed wider understanding of depressive illness.

Helen offers a deeply realistic portrait of the symptoms that sufferers of depression may experience and the efforts that are often made to manage the illness, which may involve a variety of treatment options, including electroconvulsive therapy. The film brilliantly highlights the sense of isolation that people with depression may have. It also depicts well the impotence and frustration that partners can feel as they witness their loved one becoming more distant and disconnected within their relationship, affording a valuable empathic experience of life with a partner or parent suffering from depression.

 

The Film

The film opens with silent footage from an early home movie featuring David, Helen and her young daughter Julie playing on a beach. This is followed by a quote by Andrew Solomon, himself a sufferer of depression and author of a book called The Noonday Demon: An Atlas of Depression published in 2001 (New York Times review). It states:  “Two and a half years ago, Hell came to pay me a surprise visit.”. This sets the scene for the story that follows.

We first meet Helen, played by Ashley Judd, as she comes home to a surprise birthday party with friends and family to find a giant bow on a new piano. Even in this opening scene there are hints of Helen’s unhappiness that prepare us for what follows as she is seen in a room away from the guests, head bowed. She works as a professor of music at university and lives seemingly happily with her second husband of ten years, David, played by Goran Visnjic, and her teenage daughter Julie, played by Alexia Fast. In another early scene, one of her students at the university called Mathilda, played by Lauren Lee Smith, is seen struggling to compose cello music to some video footage when Helen encounters her late at night on campus. This meeting reveals that Mathilda has issues of  frustration and low self esteem. But Helen’s illness first becomes obvious when she leaves a dinner party in a restaurant with friends to go home, telling no one. When David gets back later she tells him that she doesn’t feel well and from that point on her descent into illness proceeds steadily. A visit to the doctor results in some medication being prescribed and a warning to ‘keep an eye on her’. But without a positive response to the antidepressants, and a disturbed sleep pattern, Helen is found holding a knife to her chest by her husband in the middle of the night. After taking her to the hospital for an informal admission to the psychiatric ward, David expresses his inability to understand why his wife could be unhappy. The doctor replies “Your wife is not unhappy. She is ill.” David also learns that Helen suffered from an episode of depression several years before they met. A compulsory admission follows later and a recommendation for electroconvulsive therapy.

In hospital, Helen meets her former student Mathilda, who is also an inpatient in the same ward, suffering from acts of self-harm, anger and depression. They forge a bond of mutual understanding which develops beyond discharge and results in Helen leaving her home and husband to lodge with the much improved Mathilda while Helen continues to struggle with her chronic depressive symptoms. Mathilda takes her on a trip to stay in a house by the sea that was left to her at the age of eight after Mathilda’s mother committed suicide. This brings greater awareness of the childhood traumas that may have shaped Mathilda’s disturbed behaviour and depression. During this visit, Helen tries to drown herself and is rescued by Mathilda. A confused kiss takes place between the pair which feels laden with transferential overtones for both the mother and daughter figure that they represent for each other.

On returning to Mathilda’s city apartment, Helen is visited by her daughter Julie and this seems to jolt her into seeking help once again. This time she returns to the hospital for electroconvulsive therapy that had been recommended by doctors earlier. After a course of treatments, realistically portrayed, Helen begins to recover. It is then that she makes contact with her husband and the family is finally reunited. However, when Helen revisits Mathilda in her apartment, she finds a worrying situation but is powerless to prevent the tragic consequences that follow.


Relevance to the field of Mental Health

Helen provides a very good foundation for a discussion about depression, deals with the issue of suicide, and also considers various treatment options. With two of the main characters presenting a portrait of depression, Helen offers an opportunity for learning about recurrent depressive disorder and depression associated with Borderline Personality Disorder. Readers may find it helpful to access the NICE guidance on depression in adults (CG90) for more information about the treatment of the illness alongside a viewing of the film.

The treatment options shown include medication, voluntary and compulsory inpatient admission and the administration of electroconvulsive therapy (ECT), which is the treatment intervention that is ultimately responsible for Helen’s recovery. This provides an excellent basis for learning about the role of ECT in the management of depression and there is a good factsheet at The Royal College of Psychiatrists website that could be used to enhance this.

The film uses many scenes in darkened rooms, where the viewer struggles to see what is happening. This effectively reflects the hopeless isolation that many with severe depressive disorder describe, when they talk about not being able to see a way out of their situation and which may lead to a contemplation of suicide. The viewer experiences both Helen and Mathilda attempt suicide, making this an excellent film for teaching about this difficult topic.  An article, freely available online, that may be helpful to those working in mental health settings called Suicide following discharge from inpatient psychiatric care by Mike J. Crawford was published in Advances in Psychiatric Treatment (2004) 10: 434-438 provides very relevant background reading.

In contrast to Helen, Mathilda is seen seeking out destructive violent sexual encounters that cause her pain and self-loathing as well as acts of deliberate self harm in a repeated attempt to feel something and fill her emptiness. Understanding about this portrait of depression associated with borderline personality disorder might be enhanced by a reading of the article entitled Recent developments in borderline personality disorder by Anthony P. Winston published in Advances in Psychiatric Treatment (2000) 6: 211-217, available in full online.

Helen is a compelling film that engages the viewer wholeheartedly in two fictional case histories of depression. As there are so few films focusing in this way on the detailed portrayal of this illness and its treatment, Helen is essential viewing for anyone interested in working in the field of mental health.

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

  • Helen can be purchased at amazon.co.uk, but is only available as a region 1 import from the USA. It is also available on Lovefilm instant.

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

03/06/2013 09:13:47

The Apple

introduction

The Apple is an Iranian film directed by Samirah Makhmalbaf when she was just sevThe Appleenteen years old. It was scripted by her and her father, the well known Iranian director Mohsen Makhmalbaf and filmed in Tehran. Released in 1998, it won five awards including one from the London Film Festival. Classed as a docudrama, it tells the true story of eleven year-old twin girls Zahra and Massoumeh Naderi who were kept locked in their home by their parents from the age of two without any contact with the outside world. Their mother is blind and their father an older man who begs for money in return for saying prayers.  Samirah Makhmalbaf became fascinated by the story and arranged an interview with the father, Ghorban Ali Naderi. When he started talking to her, she almost immediately gained his consent to film the family and this started soon after. Makhmalbaf was sure that the girls would begin to change very quickly once they started to meet other children and adults, which is indeed what the viewer sees as the film unfolds. It is unclear quite why the father agreed to the filming but he seems to relish the opportunity to explain the motives for confining his daughters to their home and is clearly very upset by the publicity that the case received.

What is unusual about The Apple is that the family members appear as themselves and tell their story to the camera as the girls are encouraged out into their community by the social worker. The Apple was filmed over an eleven day period beginning almost immediately after the girls returned home from state care. Some scenes show the family members responding to scripted interactions with children outside the home, some of which could be viewed as inappropriate teasing. This could raise ethical questions around the whole family’s ability to consent to such a project and would certainly offer a useful platform for a discussion about the filming of a family actively struggling with issues of psychological health that affect their ability to give informed consent.

It is perhaps interesting to note that, since this film was made, the girls were fostered and have gone on to do well in mainstream education.



The Film

The film opens with evidence that concerned neighbours have signed a petition to the welfare service about the confinement of two girls in their home over many years. Once the situation has been discovered, the eleven year-old twins are taken into state care, where they are found to be developmentally arrested in their use of spoken language and in their interactions with others. They were only allowed back home on the condition that their parents allowed them to socialise normally outside of the home.The film follows the Naderi family closely as they re-enact the immediate days after Zahra and Massoumeh are allowed home whilst they are being monitored in the community by a social worker.

On the social worker’s first visit she finds that the girls are still locked in, behind the bars of their home, contrary to the agreement that was made. She forces their father to let them out on to the streets to play with other children and uses an unorthodox intervention (I understand that this was scripted) to make him empathise with how his daughters may have felt during their imprisonment. Out in the community the girls encounter things that other children take for granted, like a young boy selling ice creams and another young boy who dangles an apple on a string as he lures them to the local fruit shop (this was another of the scripted interventions) in a scene reminiscent of the tale of the Pied Piper of Hamlyn. Keeping the viewer on edge about the outcome of this interaction, this is a particular example of the powerful storytelling represented by the film.The apple of the title perhaps represents the life which the girls finally get to taste as they explore and experience a wealth of new situations. One of the more interesting encounters occurs between the twins and two other young girls who are playing hopscotch in a park, as it demonstrates the twins’ lack of ability to play appropriately for their age. However, with the kind and tolerant responses of their new found playmates, they appear to learn certain ‘rules of engagement’ quite quickly.

But what is especially interesting are the scenes at home between the two girls when they are alone together, using their unique form of communication, which show them seemingly quite happy and playful in their close sisterly relationship. One suspects that this aspect of their emotional development has been positive enough to allow them to engage effectively with the world and with mainstream education when they are finally given the chance.

 

 

Relevance to the field of Mental Health

The Apple provides an excellent opportunity for discussing the ways in which health professionals can assess children and families from a different culture who speak another language. It also encourages the viewer to reflect on the underlying motivations of each parent in this case and to try and understand why they took the extreme action of locking their daughters up in the home for so long. It is because the film tells its story in such a non-judgmental manner that this process is fostered and it reminds us that we should always strive to understand the underlying context for any presenting problem when carrying out a full psychiatric assessment.

But it is because the film uses the girls themselves to enact the early days after they are released out into their local community that makes it such interesting and relevant viewing for mental health professionals. The viewer is quite literally watching changes occur in the twins’ ability to communicate and negotiate as they meet with other children and adults outside their home, whether in spontaneous or in scripted interactions.

The Apple could be viewed alongside a reading of an article called Developmental assessment by Patrick Bolton, published in Advances in Psychiatric Treatment in 2001, and available in full online (Advances in Psychiatric Treatment (2001)

7: 32-40), as a valuable teaching package. The fact that the film is not in English, makes the assessment all the more challenging but equally relevant in our diverse and multi-cultural society.

With the focus, in this film, on the role of the social worker in the community as the health professional that we see, there is also scope for comparison across cultures and to consider how such a case might be dealt with in the UK by health and social services. At times painful and poignant, The Apple will almost certainly stay with the viewer for some time after watching it.

• More information about The Apple can be found at IMDB, and a short trailer is available on youtube.

The Apple can be purchased at amazon.co.uk.

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

30/04/2013 16:59:04

Canvas

IntroductionCanvas - Minds on Film blog

Canvas was written and directed by Joseph Greco and released in 2006. It is Greco’s first feature length film and is based on his own childhood experiences. In the director’s statement about Canvas, Greco wrote “I grew up watching my mother battle schizophrenia and those harrowing memories had a profound impact on me.”. Generally viewed as giving an accurate portrayal of a mental illness, the film has been well received by both critics and mental health professionals. It deals compassionately with the wider effects that a psychotic illness can have on a partner and child living in a small community. Greco chose to shoot the film in Hollywood, Florida where he grew up. There are superb performances by Marcia Gay Harden as Mary, Joe Pantoliano as her husband John, and Devon Gearhart as their 10 year old son Chris, who is extraordinarily convincing in his central role. The film explores the strain that a psychotic mental illness can put on a family and shows how each individual finds their own particular coping strategies to survive the more difficult times.

The Film

The film opens with Mary and her son Chris being reunited after he returns from a stay with relatives in Alaska. It soon becomes clear that the reason for his trip away was that Mary has been mentally unwell. The awkwardness of the bond between mother and son is obvious as she urges him to put on a floral dress and pose for a portrait that she is painting. Shortly after his return home, Chris is woken at night by the flashing blue lights of a police car that is returning Mary to their house in a state of distress. As the scenes unfold we learn that Mary has a diagnosis of paranoid schizophrenia and became unwell about eighteen months earlier. She has been prescribed various medications, none of which seem to have brought stability to her mental state as yet. On another night, when experiencing paranoid delusions, Mary becomes so disturbed in her behaviour that she threatens her husband John and accidentally hurts Chris. On this occasion the police handcuff her and take her to hospital where she is compulsorily admitted.

Chris attends school, clinging to this normality in his life as he tries to make sense of the frightening experiences he has witnessed as a result of his mother’s illness. Unfortunately, he encounters the ignorance and cruelty of certain schoolmates who bully him by making fun of his ‘crazy Mum’. As he struggles to maintain a regular routine at school, his father copes with the stress of his wife’s illness in a very different way, by deciding to build a sailboat. He tells his son that he and his mother first met whilst sailing and that he intends to make her a boat that will help her to recover her former self. However, John becomes increasingly absorbed in his project to the detriment of parenting his son and soon the school bullies are taunting Chris about his ‘weird father’ too. Chris, upset and angry with his father, seeks his own connection with his absent mother, by discovering he has a talent for sewing using Mary’s sewing machine. Just before being hospitalised, Mary had made Chris a patchwork t-shirt to cover up a tear in the fabric of his top and Chris copies this technique to make another shirt for a school friend who admires it. With her support, he soon finds that other school friends are asking for patchwork shirts too and he begins to make and sell them on a wider scale. This activity absorbs him, boosts his self-esteem but also keeps him connected to his mother.

Throughout this time, Mary is seen in the psychiatric hospital, at first medicated and struggling to comply with treatment before gradually beginning to make a recovery aided in part by her love of painting. However, the challenges to this recovery are well portrayed during some home leave for Chris’ birthday, when Mary insists on giving him a homemade cake in front of his friends, causing him huge embarrassment. But for Mary the feeling of rejection at this moment is palpable and one knows that her sensitivity to the knocks of everyday parenting will be an ongoing test. Chris seems to mature before the viewer’s eyes by this point in the film as he realises that he and his father must unite in the face of their stresses in order to survive and to support each other. By this time, John has decided to give up his boat project and focus on parenting his son, but Chris suggests that he helps his Dad to finish constructing the sailboat hoping that this will actually bring them closer together. It does just that and in the process Chris hears more about his mother before her illness developed. John and Chris plan a sailing trip together again as a family, when Mary is well enough to leave hospital. This is not achieved in an orthodox manner, as the viewer sees at the very end of the film, but this shows that sometimes achievements must be measured in very personal ways.

Relevance to the field of Mental Health

Canvas provides an opportunity for the viewer to gain an empathic understanding of what it might be like to live with a loved one who has paranoid schizophrenia. The suspicion and fear of persecution that Mary suffers is sensitively portrayed both at home and in hospital, highlighting how difficult it can be to persuade someone to accept medication in this state of mind. This could be used as a good example for teaching about compliance and the assessment of an individual’s mental capacity to consent to treatment.

Canvas would also provide a good platform to discuss the recovery model, which now has a greater focus throughout mental health services in the UK. Mary’s family do not give up hope and continue to support her in her role as wife and mother to the best of her ability, however difficult this may be when she is ill. The film emphasises the role that positive loving bonds can play in providing a stable framework in which recovery can take place alongside the psychiatric treatments being prescribed in hospital or in the community. There is an excellent article entitled Recovery and the medical model by Deborah Mountain and Premal J. Shah in Advances in Psychiatric Treatment (2008) 14:241-244 that could be used to enhance learning on this topic.

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

Canvas can be purchased at amazon.co.uk, although it is only available as a Region 1 DVD.

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

 

 

27/03/2013 10:47:27

Amour

IntroductionAmour - Minds on Film

Amour was directed by Michael Haneke and released in 2012. In French with English subtitles, it tells the story of Georges and Anne, a retired middle class couple in their eighties, living contentedly in their Paris apartment. With brilliant performances by the two main actors, Jean-Louis Trintignant as Georges and Emmanuelle Riva, herself aged 85, as Anne, Amour won the Palme d’Or at Cannes in 2012 and an Oscar in 2013 for Best Foreign Language Film. This is a chamber drama, filmed almost entirely in the couple’s apartment. It shows how suddenly their lives are changed when Anne has a stroke and it follows the couple and their daughter, played by Isabelle Huppert, as they all deal with the resultant deterioration in Anne’s physical and mental health. Amour is an incredibly important film for all health care professionals who will increasingly encounter a swelling elderly population presenting with the consequences of cerebrovascular pathology. But at its core, this film offers the viewer a stark reminder of the realities faced by informal carers day in and day out as they struggle to provide personal care for their loved ones suffering from dementia regardless of the underlying cause.This is a film about ageing in the context of a close, loving relationship that is tested by the suffering of one partner declining inexorably toward death.

The Film

Amour begins dramatically at the end of the story with scenes of police and a fire crew battering their way into a Paris apartment to find an elderly lady laid out dead on her bed which is strewn with flowers. The film then proceeds to fill in the events that led to this scene. At the start of the flashback we meet the main protagonists, Georges and Anne, attending a piano recital, played by one of Anne’s former pupils. The couple are clearly enjoying their retirement bound together by a shared love of classical music after a lifetime working as music teachers. This is the only time in the film that we see them outside the confines of their home. On returning to their apartment they find that they are victims of an attempted break in. This highlights their vulnerability, especially to Anne, but also demonstrates the mutually supportive relationship that exists between them.  The following morning at breakfast, Anne suffers a transient loss of awareness and responsiveness, a probable transient ischaemic attack or TIA. Frightened and perplexed by this event, Anne is encouraged to visit her doctor by Georges. This results in her having an operation on her carotid artery, which we learn fails to have a positive outcome. Whilst Anne is still in hospital, Georges is visited by their daughter Eva. In conversation with him, Eva reveals that her husband Geoff has had another extramarital affair, contrasting the nature of her marriage with her parents’ marriage. Eva asks her father if she can help in any way, but Georges tells her, “We’ve always coped, your mother and I”.

Before Anne returns from hospital, a hospital bed is installed in their bedroom and when we see her next, she is confined to a wheelchair, paralysed down her right side. The scenes that follow show how rapidly Georges must learn to be a carer, despite his own frailty and unsteadiness, and fulfill the many new tasks necessary to allow Anne to stay with him at home. Delighted to be back together, Anne asks Georges to promise that he will never allow her to be admitted to hospital again. The film brilliantly portrays the negotiation that then begins between the couple about the need for support versus Anne’s desire for independence in personal care tasks as the balance in their relationship changes. This is exquisitely demonstrated when Anne needs to call for help when on the toilet, shifting their intimate relationship into a new realm.

After Georges returns from attending a funeral of an old friend, he finds Anne on the floor in the hallway. She is low in mood and tells Georges that she does not want to go on living like this as she knows that she will only get worse. Georges clutches at her potential for improvement and will not believe her. A visit from her former pupil, now a successful pianist proves awkward as the musician finds it hard to adjust to Anne’s disability and she refuses to talk about it. Her depression is apparent. Some humour is introduced in the form of an electric wheelchair which provides Anne with some more independence around the apartment but this is short lived. Then a further stroke leaves her with trouble speaking (an expressive dysphasia) and the onset of dementia. During a visit from her daughter and son-in-law, Georges informs them that he is planning to pay for a carer to come in three times a week. This presents a huge challenge for Georges as he is forced to relinquish some control over Anne’s care but cannot bear to see one of the carers fail to deal with Anne in a sufficiently dignified and respectful manner, forcing him to dismiss her.

I will not describe in detail the final part of the film which follows Anne’s deterioration into the final stages of her dementia, when she requires full assistance in all areas of personal care. It is then that Georges takes a very particular decision to end their mutual suffering.

 

Relevance to the field of Mental Health

Amour offers a number of learning opportunities for those interested in or involved in caring for the elderly population. It provides a valuable lesson on the effect of sudden physical disability caused by stroke in an individual, which radically alters the balance within the longstanding relationship with their partner; it portrays an episode of post-stroke depression and then, after another stroke, it follows the onset of dementia with the subsequent deterioration demanding ever increasing levels of assistance with personal care. 

With its focus on the very private and intimate caring relationship between Georges and Anne after she has developed dementia, Amour offers an incredibly powerful portrait of the real stress that carers may experience, if they continue to want to provide the majority of the personal care required. It conveys the loneliness that informal carers often experience when looking after their loved one who can no longer converse meaningfully with them. Highlighting the emotional vulnerability that such a caring role can cause, this film must surely encourage health professionals to be attuned to the needs of the unpaid carers who support dementia sufferers in the community. Further information about the stresses that carers face can be found at the Alzheimer’s Society website.

The film also raises the complex issues around the final stages of life when an individual has expressed their own preference to stay at home until the end of their life. The issues of wider family are brought in very effectively in the person of Eva, their daughter, who is herself a busy musician living abroad and somewhat distant from her parents. Her right to express a view on her mother’s caring arrangements is sensitively explored as the tensions between the generations emerge, raising the very important question “who gets to choose what is best for an individual when mental capacity to make a particular decision about care is lost?”. This would be a perfect foundation for a discussion on The Mental Capacity Act in the UK and the process by which a Best Interests Decision is reached on behalf of a person lacking mental capacity for that particular decision. It also offers an opportunity to consider the use of Advanced Decisions to refuse treatment. These topics are explained clearly in a Factsheet published by the Alzheimer’s Society. The film’s ending will surely also generate much discussion.

As a portrait of vascular dementia, Amour provides a perfect case study. A very good article published recently in Advances in Psychiatric Treatment (2012), vol. 18, 372-380 entitled Vascular  dementia: a pragmatic review by Hugh Series & Margaret Esiri (abstract) would provide an excellent learning opportunity set alongside a viewing of the film. Additionally the full text of an article published in the British Journal of Psychiatry (2002),

180: 152-156 entitled Vascular dementia: a diagnosis running out of time by Robert Stewart may provide further useful background information.

I would highly recommend this film to all health professionals interested in working in Older Age Medicine or Psychiatry. But perhaps most important of all, Amour challenges the individual viewer to reflect upon their own attitudes to ageing and disability questioning how they would cope with the suffering of a loved one in a similar situation.

* More information about Amour can be found at IMDB, as can a short trailer.

* Amour can be purchased at amazon.co.uk

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

 

01/03/2013 09:27:53

Owning Mahowny

IntroductionOwning Mahowny

Directed by Richard Kwietniowski and released in 2003, Owning Mahowny is a film about one man, called Dan Mahowny, played by Philip Seymour Hoffman, in a position of financial power in a bank, who has a serious gambling problem. It is based on a book, by Gary Ross called Stung, about the true story of a Canadian banker, Brian Molony, who committed the largest single-handed bank fraud in the country’s history, embezzling approximately $10 million from his workplace. Molony served six years in prison and is now working as a financial consultant having stopped gambling completely. Hoffman met with him to discuss his role in preparation for the film. The film accurately portrays the signs and symptoms of pathological gambling and the serious consequences such a disorder can have on all aspects of a person’s life. It is particularly relevant at the current time with the proposed reclassification of problem gambling as an addiction called ‘gambling disorder’ alongside substance use disorders in the DSM-V classification, due to be published in 2013. The impact of this planned change in classification is discussed in the editorial of the February 2013 issue (Vol 37: 41-43) of The Psychiatrist, called Proposed changes for substance use and gambling disorders in DSM-5: impact on assessment and treatment in the UK (abstract).

 

The Film

The film opens with Mahowny in conversation with a psychiatrist in prison, stating that his ‘secret life’ is a lot less secret than anyone else’s at the moment. This sets the scene for the back story to be told and begins from the point that Mahowny, a successful banker, has just been promoted in the Canadian bank where he works. His girlfriend, played by Minnie Driver, also works as a clerk at the same bank and soon shows that she is frustrated by her shy, workaholic boyfriend, who never seems to have enough time for their relationship. The viewer’s opinion of Mahowny is immediately changed when two ‘bookies’ turn up at Mahowny’s office asking him to pay the money that he owes them or violence will ensue. As he doesn’t have the money himself, he realises that he can use some funds from a client account to pay these debts, initially planning to repay the unofficial loan. However, once he has successfully defrauded the bank and realises that he can get away with it easily, he becomes locked into a cycle of taking greater sums of money from the bank to place ever larger bets with his ‘bookies’. He also begins to travel regularly to a casino in Atlantic City to play the tables, lying to his long-suffering girlfriend in the process. She slowly comes to understand the nature of his problem. The unscrupulous casino boss in Atlantic City, played by John Hurt, becomes fascinated by the unglamorous Mahowny and soon realises that he can make a lot of money from him as Mahowny’s gambling problem becomes evident. It is in the scenes at the casino that the viewer shares Mahowny’s compulsion to place bets without regard to the consequences of losing huge sums of money. Any attempt by his girlfriend to make Mahowny acknowledge his problem is met with complete denial by him. Although she has no idea of the extent of his financial difficulties, she alone understands the gravity of his situation but decides to stick by him regardless of this. The final unravelling occurs as the police investigate the ‘bookies’, who have continued to place bets for Mahowny, finally leading them to Mahowny himself.

The viewer is finally returned to the conversation between Mahowny and the psychiatrist in prison. Mahowny is asked to rate the thrill he got from gambling on a scale of one to a hundred. He answers with ‘a hundred’ and then says that the biggest thrill he has had outside of gambling would score twenty on that same scale. Mahowny goes on to acknowledge that he must now accept a maximum of twenty out of a hundred for excitement in his future life and ends by saying “twenty’s OK”.

 

Relevance to the field of Mental Health

As gambling is a common and accepted leisure activity in many societies, and with an increasing number of avenues now open to gambling on the Internet, it is likely that this problem will increase. It is timely to suggest that doctors, and in particular psychiatrists, may need to be more aware of this important public health issue. As it is also associated with significant psychiatric comorbidity and often has a negative impact on family and society it is important that health professionals are confident about the detection, diagnosis and management of pathological gambling. Owning Mahowny provides a very good portrait of how problem gambling may present in an individual who appears to be trustworthy and balanced in his social and working life, making detection of the problem more difficult. The film demonstrates very well the addictive nature of Mahowny’s gambling at the expense of everything else in his life, resulting in a downward spiral of self-destruction. Owning Mahowny also demonstrates how vulnerable an individual can become whilst in the grip of this addiction as it shows the casino owner ‘taking Mahowny for all he has got’. In the real life case, the casino was ordered to close for a day by the New Jersey Casino Control Commission (something previously unheard of) for giving Molony preferential treatment and encouraging him to gamble with very large sums of money without seeking to find out their source.

For a good introduction to the topic of pathological gambling, there is an excellent article by S. George and V. Murali, published in Advances in Psychiatric Treatment (2005) 11: 450-456, called Pathological gambling: an overview of assessment and treatment, which is freely available. A reading of this article alongside a viewing of the film would provide a very good understanding of this disorder. In an editorial in The Psychiatrist (2013), 37, 1-3, entitled Problem gambling: what can psychiatrists do?, S George, H Bowden-Jones, J Orford and N Petry discuss how psychiatrists can screen for the disorder and what interventions psychiatrists can offer once they have made a diagnosis (abstract). An even more recent article in Advances in Psychiatric Treatment (2013) 19: 23-29, by S. George, O Ijeoma and H. Bowden-Jones (abstract) entitled Gamblers Anonymous: overlooked and underused?, offers some detail about Gamblers Anonymous as a treatment option, using the twelve steps approach common to Alcoholics Anonymous. The authors note that this treatment can work very well for some individuals and is also compatible with the use of CBT for gambling addiction.

 

I would highly recommend this film to all of those working in the field of mental health wanting to gain a greater understanding of problem gambling.

• More information about Owning Mahowny can be found at IMDB, as can a short trailer.

Owning Mahowny can be purchased at amazon.co.uk

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

 

04/02/2013 09:29:50

The Unloved

IntroductionThe Unloved

The Unloved, was directed by actress Samantha Morton and released in    2009. It was produced for Channel 4 television in the UK, where it was first screened as part of the Britain’s Forgotten Children series. The film is loosely based on the experiences that Morton herself had growing up in various children’s homes. She collaborated with writer Tony Grisoni to produce a screenplay that conveys a deep understanding of the real issues encountered by young people dependent on the state for their care needs. Her original motivation to tell her story came from a Television Workshop, which she attended at the age of sixteen when still in residential care. Within that setting she devised a play with the workshop group that would eventually form the basis for the film. The film provides a child centered view of the main protagonist, eleven year-old Lucy’s experiences in care when her estranged parents are unable to care for her adequately.

The Unloved was filmed in Morton’s hometown of Nottingham and the two principle young actresses were cast from auditions held in local schools in that area. Molly Windsor, who plays Lucy, and Lauren Socha, who plays Lauren, both deliver hugely accomplished and moving performances. In an interview, Morton acknowledged how lucky she felt in completing the project “because I have been able to make the film I desperately wanted to make”. She has also stated that she hoped to give audiences a greater understanding of the vulnerability and lack of control that children in care can suffer. The film certainly pulls no punches in its dark and harrowing portrait of Lucy’s experiences.  Morton decided to set it in the present day rather than in 1989, when she was in care, to avoid it being cast as an historical piece. It won a BAFTA TV award in 2010.

The Film

The first shot of the film shows Lucy, dressed in her primary school uniform, lying at the bottom of the stairs in her home and it is followed by scenes that explain how she got there. This involves a conversation with her father, played by Robert Carlyle, who becomes increasingly angry and frustrated before giving Lucy a painful beating with his belt. The violent action remains effectively hidden from view as we only hear the sounds of the cruelty.

Lucy is next seen at school where she appears withdrawn and isolated in the classroom. However, she is able to tell her teachers that she needs to speak with her social worker. After taking her to hospital for a physical examination, Lucy’s social worker tells her that she cannot return home to her father and takes her straight to a children’s home where she must live until a foster family can be found. On arrival at the residential home, Lucy is introduced to her roommate, Lauren, who is 16 and very reluctant to have Lucy share with her. However, she soon suggests that Lucy join her on a trip into town, where Lauren proceeds to shoplift some cosmetics. They are caught by security staff, who interview the pair before calling the police. The girls then briefly spend time in a holding cell. It becomes clear that Lauren is a regular offender well known to the police and the girls are soon taken back to the children’s home.

Ever observant of her surroundings in a quiet, self-contained manner, Lucy begins to realise that there is a special connection between Lauren and one of the older male care workers, called Ben. This becomes clearer to Lucy when Ben visits Lauren in bed one night. Upset by this, Lucy runs away and spends a night out in the city, moving through various locations. She returns to the home the next morning and finds the caring concern of female care worker Vicky a rare comfort. Vicky takes Lucy out to buy some casual clothes and shoes. Lucy says more to Vicky during this outing than to anyone else at any other time in the film, suggesting that this relationship is perhaps her most trusted. In contrast, a visit by Lucy’s social worker soon after seems so alienating for Lucy as the conversation revolves around paperwork that must be filled out. The visit doesn’t appear to allow any form of fruitful communication about Lucy’s feelings or experiences.

Some time later, after a night out at the fair, where she witnesses Lauren engaged in prostitution, Lucy makes her way alone to the pub where she knows her father will be drinking. In a painful scene they greet each other and both say that they have missed the other. Spending the night back at home with her unshaven father, Lucy sees photos of herself as a baby and hears from him about how much he loved her. He also explains that her mother was just not able to cope with the job of parenting. Lucy returns to the children’s home and to a Christmas party, where she sees some angry scenes between several of the male care workers who finally confront their colleague Ben about his inappropriate sexual behaviour with Lauren. This seems to provoke Lucy into leaving again, this time to visit her mother’s home where she manages to gain entry through the back door. Lucy surprises her Mum and gives her a Christmas present, whilst asking if she can stay and live with her. In the poignantly painful scene that follows, Lucy is once again disappointed. 

Relevance to the field of Mental Health


The Unloved is a film that gives its viewer a child’s eye view of life in a children’s home.  Because it is informed by the director’s personal experience it has some authority on this matter. For this reason the film offers an invaluable insight for anyone who might deal with children who are in, or have recently been in, residential care but also for those professionals dealing with adults who were in care when growing up. For those interested in a gaining greater understanding about residential homes for children, there is a recent research publication, commissioned by the last Labour government, entitled Living in Children’s residential homes which may be a useful resource to read alongside a viewing of the film. This short study examines the characteristics and circumstances of the young people who live in residential homes and looks at the short-term outcomes for them. It is freely available to download from the Department of Education website

The Unloved captures very well the sense of isolation and loneliness that its main protagonist Lucy suffers in the care system, without being able to connect with or express the emotions that she is struggling to process. This film might be a useful starting point for a more general discussion on the psychological development of children and the key elements that constitute ‘good enough’ parenting.

Although this film is not always easy to watch, I would strongly recommend it to all health professionals but especially those working with children and adolescents.

* There is further information about The Unloved at IMDB and a short trailer at Channel 4. * The DVD can be purchased at amazon.co.uk.

* Minds on Film is written by consultant psychiatrist Dr Joyce Almeida.

 

04/01/2013 13:59:43

My son, my son, what have ye done

My Son, My Son, what have ye done
Introduction

My son, my son, what have ye done was directed by Werner Herzog and released in 2010. Conceived and written by Herzog and Herbert Golder in 1995, it was not made until the project found favour with executive producer David Lynch. Herzog’s fascination with unusual mental states was discussed in one of my previous blogs on his Grizzly Man film. My son, my son, what have ye done was inspired by the true story of a talented Californian drama student, Mark Yavorsky, who murdered his mother with an antique sword whilst involved in a production of the Greek matricidal tragedy The Oresteia. Yavorsky was suffering from a psychotic illness at the time of the murder. In the film, Michael Shannon plays the part of the main protagonist Brad in a brilliantly intense performance that expertly captures a descent into psychosis.

The Film

The film opens in San Diego with two detectives, played by William Defoe and Michael Peña, driving to the scene of a murder. As they attend the suburban crime scene and walk through a crowd gathered in the street, they brush past a man holding a coffee mug with ‘Razzle Dazzle’ printed on it. He says “Razzle them, dazzle them” to one of the detectives as he passes by. This man is Brad, the murder victim’s son, who then walks slowly across the street to his own home, stopping to feed his flamingos, whom he calls his ‘eagles in drag’, before barricading himself inside with a shotgun. The siege at Brad’s house forms the main storyline of the film. The homicide detectives piece together Brad’s back-story, which the film tells partly through flashbacks, as they interview the various people close to him, who have witnessed his gradual mental deterioration.

The first to be interviewed is Brad’s fiancée, played by Chloe Sevigny, who recounts how Brad told her “I’ve seen God, right here in the house” before he showed her an oatmeal packet with a picture of a 17th century Quaker on it, who he believed was God. She also describes an over-involved and unhealthily close relationship between Brad and his mother. The next friend to appear at the crime scene is Lee Meyers, theatre director and drama teacher, played by Udo Kier. He had been rehearsing Brad in the part of Orestes in a production of The Oresteia. Meyers is able to tell the detectives how the antique sword, used as the murder weapon, had been acquired from one of Brad’s relatives and how Brad’s preoccupation with it had been unnerving to the point that he had asked him to leave the theatre group. Finally, the neighbours, in whose house the murder took place, feel able to talk and inform the detectives that Brad had been acting strangely ever since he returned from a trip to Peru, where, we learn, he heard voices telling him not to go white water rafting in the river. The neighbours tell that Brad actually asked them to kill him before he did something terrible. The film ends as a SWAT team is called in to end the siege and Brad emerges from the house to be taken away.

 

Relevance to the field of Mental Health

My son, my son, what have ye done offers the viewer an experience very like that of being in the presence of someone suffering from a schizophrenic illness, with its disjointed atmosphere of strangeness and unreality. The bizarre and often intensely stated delusions held by Brad with absolute conviction are well presented in ways that allow the viewer to experience his disturbed mental state at close hand. His conviction that the picture of a Quaker on the Oatmeal packet IS God is a fine example of this. Brad’s aggressive assertion that his view of the world is the only possible view demonstrates how hard it can be to persuade someone with delusions, who lacks insight, to seek help. The fact that My son, my son, what have ye done is loosely based on a true story in which Mark Yavorsky quite literally acted out the crime that he was rehearsing in a theatre production, provides the foundation for a deeper understanding of the difficulty individuals with psychosis may have in separating truth from delusion.

As the film progresses and the flashbacks tell the story of Brad’s developing illness, the viewer shares in the anxieties and helplessness of those close to him. They struggle to reason with him and support him in his distress, whilst trying to rationalise his abnormal beliefs. The film can be used to demonstrate how difficult it may be to encourage someone to seek psychiatric help when they lack insight into their mental state.

My son, my son, what have ye done specifically offers an opportunity for learning about the subject of violence in schizophrenia and could be viewed in conjunction with a reading of several suitable articles. This might begin with a freely available article entitled Schizophrenia and violence: from correlations to preventive strategies by Paul E. Mullen, published in Advances in Psychiatric Treatment (2006) 12: 239-248. In another open access review article called Schizophrenia and Violence: Systematic Review and Meta-Analysis by S Fazel, G Gulati, L Linsell, J Geddes and M Grann, published in the August 2009 issue of PLOS Medicine, the authors undertook a systematic review of studies that reported on associations between violence and schizophrenia and other psychoses. They also systematically reviewed investigations that reported on the risk of homicide in individuals with schizophrenia and other psychoses.

The link between homicide and the length of untreated first episode of psychosis is discussed in another open access article entitled Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment by Dr. Matthew Large BSc (Med), MBBS, FRANZCP & Dr. Olav Nielssen MBBS, MCrim, FRANZCP, published in Social Psychiatry and Psychiatric Epidemiology (January 2008, Volume 43, Issue 1, pp 37-44.)

I would highly recommend this film to anyone interested in forensic psychiatry and for those training as psychiatrists, there is an short podcast at The Royal College of Psychiatry website, which can be downloaded, providing some information about working in this field within the UK.

• Minds on Film is written by consultant psychiatrist Dr Joyce Almeida

• Further information about My son, my son, what have ye done can be found at IMDB, as can a short trailer

• The film can be purchased at amazon.co.uk

03/12/2012 10:11:04

Tulisa - My Mum and me

Introduction

Tulisa - My Mum and me is an hour long documentary film directed by Rowan Deacon featuring the singer songwriter Tulisa Contostavlos, formerly a member of the group N-Dubz but now a solo artist and judge on the ITV entertainment programme X-Factor. The film, which was made for the BBC in 2010, is an account of Tulisa’s life as a young child and teenager growing up with her mother who has schizoaffective disorder.  Presented and narrated by Tulisa, she meets and interviews several other young people who are involved in caring for their mentally ill mothers. She encourages them to explore options for support in the community that might alleviate the strain that all of them are suffering in various ways. Unusually for Minds on Film, interested readers will not have to purchase Tulisa - My Mum and me to see it, as it is freely and legitimately available to view on-line, at Vimeo, where the director has posted it.

 

Tulisa: My Mum and Me from Rowan Deacon on Vimeo.

The Film

The film opens with Tulisa visiting the hospital in North London where her mother was detained under the Mental Health Act when Tulisa was just five years old. She remembers how distressing it was to see the police forcibly restrain her Mum and remove her from their home. Her father left the family when Tulisa was nine, and she has been the main carer for her mother since that time. Tulisa recalls the effect that her home situation had on her and how it resulted in her dropping out of secondary school by the age of 15, abusing alcohol and cannabis, joining a gang and attempting to harm herself. Tulisa recounts that she was depressed in mood from the age of 13 until she discovered her musical ability, which quite literally ‘saved her’. Tulisa realises that music has given her a road out of the life that she grew up with, in contrast to the other younger people that Tulisa interviews for the film, who are all still struggling to manage the difficulties of their caring role.

First, she visits Mia, aged 16, who lives with her younger brother and her mother who suffers from bipolar disorder. Mia describes the very frightening experiences of supporting her mother when depressed and suicidal as well as how precarious life became when her mother was elated. Mia also needed to take care of her little brother when her mother was unwell. For Mia, it was a love of reading that rescued her and offered her a means of escaping from her reality. Things have been better for Mia since her mother has been stable on regular medication. Next Tulisa meets with Hannah, aged 15, who lives with her Mum who suffers from depression. She has been forced to leave mainstream education after a fight with a teacher and is struggling to manage her anger and low mood. Hannah’s life appears to be quite desperate and isolated and she is asking for help urgently. Tulisa persuades Hannah to attend a Young Carers group some distance from her home, which proves to be a positive experience for her. Lastly, she visits Andy, aged 17, who lives with his younger brother and his Mum, who suffers from depression and cannot survive without knowing that Andy is physically close to her. He describes their relationship as “connected at the hip....She [his Mum] is just like my best friend”. He hopes to leave home and join the Navy in two years, if his Mum can let him go.

In a particularly sensitive interview that Tulisa has with one of her aunts, she hears how her mother also had musical talent and was part of a successful singing group, with her own sisters, when she first became mentally unwell at the age of 22. Worries about the stresses of touring and performing in her pop star lifestyle, prompt Tulisa to ask questions about her own risks of developing an illness like her mother’s. Tulisa meets with Professor Nick Craddock to seek advice from him about the genetics of schizoaffective disorder and  the individual risk factors that she herself may have for developing an illness similar to her mother’s. Some footage of N-Dubz on tour help to give a flavour of Tulisa’s lifestyle with its necessary highs and lows. Finally, she revisits the three other young people for a follow up on their progress before we see her moving in to her own home in which she has prepared a special room for her Mum to come and stay. As we see her showing her Mum the room and wondering about their future, Tulisa says “You never stop being a young carer”.

 

Relevance to the field of Mental Health

This film explores a very important topic, that of young people who find themselves as carers for a mentally ill parent. The film estimates that there are around 80,000 young people caring for a parent with mental health problems in the UK. Through the very personal form of narration, the viewer is witness to an intimate experience of the stresses young carers must deal with and how their lives can be adversely affected. In particular it highlights the sense of isolation that is commonly experienced by a young person in this situation and offers some suggestions about how they might get support. This film would be a perfect foundation for a discussion of the wider effects that mental illness can have on a family, especially when there are young people in the home.

A detailed discussion of this subject is available in an article published in Advances in Psychiatric Treatment in 2010, called ‘Living upside down': being a young carer of a parent with mental illness' by Dr Alan Cooklin (16: 141-146; abstract). This topic was also discussed in an earlier Minds on Film blog about the film Tarnation, which readers might find interesting to watch alongside Tulisa My Mum and me. Further advice is available for young people who find themselves in the role of carer at the NHS choices website and also at the Carers Trust YCNet.

As a freely available short documentary, I would recommend Tulisa My Mum and me to anyone working in the field of mental health.

•  Minds on Film is written by consultant psychiatrist Dr Joyce Almeida

 

 
31/10/2012 14:55:55

The Soloist

Introduction

The Soloist is a film based upon the true story of Nathaniel Ayers, a musician who suffers from schizophrenia, and Steve Lopez a journalist for the Los Angeles Times, who befriended the then homeless Ayers when he was living on the streets of LA. Lopez was a journalist in need of a story, but soon became drawn in to a closer involvement with Ayers, fascinated by how mental illness had affected the life of such a talented musician. In the process Lopez wrote a regular column in the newspaper about his encounters with Ayers and subsequently published a book called The Soloist: A Lost Dream, An Unlikely Friendship, and the Redemptive Power of Music. These form the basis of the film. The background to their meeting and friendship is told in a short documentary made for CBS in America in 2009.

The Soloist was directed by British filmmaker Joe Wright (who had previously made the very different Pride and Prejudice and Atonement) and was released in 2009. Robert Downey Jr. and Jamie Foxx play the parts of Lopez and Ayers respectively and their real life counterparts have publically appreciated their performances.  The film presents a realistic portrait of schizophrenia and the associated problems of homelessness. Using a significant number of the mentally ill homeless population of Los Angeles as extras gives the film an authenticity that is unusual for a Hollywood production.

The Soloist

The Film

The film opens with journalist Steve Lopez falling off his bicycle and sustaining nasty grazes to his face. Wounded and in need of a story for his newspaper column he encounters Nathaniel Ayers in a Los Angeles park, beside a statue of Beethoven, playing a violin with only two strings on it. As they start to talk it becomes clear to Lopez that all is not well in the mind of Ayers but he also hears from him that he was once a student at Juilliard, the highly prestigious New York music school. After some research and further meetings with Ayers on the streets of LA, Lopez begins to write a regular newspaper column detailing their encounters and their growing friendship. This attracts much interest from the public who send in musical instruments for Ayers to play. Lopez uses the lure of a cello, given by a member of the public, to persuade a reluctant Ayers to abandon his homeless location in the road tunnels of LA for a room in the sheltered LAMP community. Lopez begins to make an effort to connect Ayers with the classical music community based at the Disney Concert Hall in LA and they go together to see a rehearsal. During this visit, when listening to the orchestra, Ayers experiences a marked increase in the voices that he hears, affecting his ability to concentrate on the music. The film uses flashbacks to tell us more about Ayers’ childhood and his huge potential as a musician, leading up to the point at which he develops schizophrenia at Juilliard and drops out.

Lopez also tracks down Ayer’s sister, long time estranged from him, and eventually succeeds in getting her to visit her brother in LA. As the ties of friendship and family increase, Ayers seems to respond positively, although his lack of insight about his illness remains. This provokes an incident of aggression toward Lopez when he brings some legal documents for Ayers to sign, which state that he has a diagnosis of schizophrenia. It is then that Lopez truly realises that schizophrenia cannot be cured by friendship alone; although he sees that stable human connections can provide the opportunity for some progress toward social recovery.

 

Relevance to the field of Mental Health

The Soloist, with its basis in a real life story, offers a tremendous opportunity to examine a number of very important issues in the long-term management of schizophrenia. The film gives us a good example of the effect the illness can have on the words, thoughts, perceptions and behaviour of sufferers and highlights the fluctuations that occur naturally in the disorder. It also raises the topic of treatment and the individual’s right to choose whether or not to take medication. As a teaching tool, this film could provide a wonderful starting point for a discussion about when the use of the Mental Health Act (in the UK) becomes appropriate and when we must respect a person’s right to choose their treatment options.

At its core this film also explores the role of kindness and compassion in the treatment of those suffering from chronic psychotic illnesses and the power of the social environment to aid recovery in such disorders. The Soloist examines the effect of a stable, consistent friendship in supporting and promoting recovery in an individual with schizophrenia. It shows that a trusting relationship must be developed before any attempts can be made to engage Ayers in any treatment services (in this case the acceptance of shelter rather than living on the streets). The film highlights Ayers’ loss of contact with his family when he became unwell, his relocation far away from the family home, and the subsequent alienation he experienced. But more than anything this film focuses our attention on the reality that it is individuals within societies who suffer from schizophrenia and that each of them has a personal story. If we can see someone who has schizophrenia as a person not a disease, society might begin to lessen some of the stigma of mental illness that is so often present.

It is interesting to note that Ayers and Lopez are still friends several years after their first meeting and now campaign for better housing for the mentally ill in America (as seen in this short video made in 2011). As mentioned in that short video, Ayers was invited to play for President Obama in 2010 to commemorate the 20th anniversary of the Americans with Disabilities Act at the White House.

In broader terms The Soloist challenges the viewer to consider mental health as an important public health issue, consistently associated with low income, unemployment, and poor physical health. I have previously discussed the topic of homelessness and mental illness in an earlier Minds on Film blog about the film The Christmas Choir. But for a greater understanding of the more general topic of public mental health there is the recent editorial in Advances in Psychiatric Treatment by Professor Sir Michael Marmot, entitled Health inequalities and mental life (APT (2012)18: 320-322). In addition, a detailed   position statement by The Royal College of Psychiatrists, published in October 2010, is available to read on the website by following the link to No health without public mental health.

 

•  More information about The Soloist is available at IMDB as well as a short trailer.

•  The film can be purchased at amazon.co.uk

•  Minds on Film is written by consultant psychiatrist Dr Joyce Almeida.

 

01/10/2012 13:09:55

A Separation

Introduction

A Separation is an Iranian film, with English subtitles, written and directed by Asghar Farhadi. It was released in March 2011. It won several international awards including a British Independent Film Award for Best Foreign Independent Film in 2011 and several at the 2011 Berlin International Film Festival. In 2012 it won an Oscar and a Golden Globe for the Best Foreign Language Film of the Year. A Separation has gathered much critical acclaim and is the first Iranian film to win an Oscar. The film deals with marital breakup in a middle class Iranian family made up of husband Nader, his wife Simin, their daughter Termeh and Nader’s aging father, who lives with them and is suffering from Alzheimer’s Disease. The director’s real life daughter plays the eleven year-old Termeh.

A Separation

The Film

The film begins with a long single camera shot in which Nader and Simin are at the divorce court putting their respective cases to an unseen judge. Simin is petitioning for divorce on the grounds that her husband will not agree to leave Iran with her and their daughter to begin a new life in another country, where she and her daughter would have better opportunities to work and study as women. Nader explains that he cannot leave Iran as he is duty bound to care for his elderly father who is suffering from Alzheimer’s Disease and who needs twenty four hour care and supervision. Simin does not find satisfaction in the court and so moves out of the family home leaving Nader to care for their daughter and his father. As Nader must work, he is suddenly plunged into a dilemma about how to care for his father, daughter and the home without his wife to help. Reluctantly, he employs a devout working class woman, Razieh, from a distant part of town who needs to bring her own young daughter with her as she takes on the role of housekeeper and carer for Nader’s father. Razieh is desperate for money as her husband has lost his job and she finds herself haggling to negotiate her wages as Nader tries to pay her as little as he can. Both finally reach an agreement and Razieh gets the job, however she is not wholly prepared for what the job actually involves. A Separation presents an interesting dilemma for Razieh as she suddenly encounters the need to give intimate personal care to Nader’s father after an episode of incontinence whilst still obeying her religious guidelines. Razieh, unsure of how to proceed, decides to phone her Imam to consult on whether she can go ahead and change the elderly man in her role as his carer.

 

At this point the scene is set for the main theme of the film to be developed when a clash occurs between the increasingly stressed Nader and his struggling employee Razieh, in an angry spur of the moment incident, which results in both families ending up in court. As viewers we are invited to be observers of the evidence and to form our own judgement as we join the studiously watchful daughter Termeh as she tries to work out whether her father is telling the truth or not. Termeh is forced to learn a lot more about the complexities of the adult world than she would wish at her age. I do not want to reveal any more details about the plot because this is a film to watch without preformed ideas. As it unfolds, it invites viewers to reach their own conclusions about all of the major characters within the drama.

 

Relevance to the field of Mental Health

This film cleverly involves the viewer from its outset as an observer and a judge of what is right or wrong in a variety of different situations. It poses more questions than it gives us answers and invites us to decide where we stand on a range of familiar and unfamiliar issues, given that the film is set in Iran, which is a theocracy. From the opening scene in the Iranian courtroom when both Nader and Simin put their case to camera, in lieu of the judge, we are intimately involved in the dilemmas of all of the main characters. Attempting to understand the struggles that other people are having in their lives, separating truth from untruth in people’s accounts, and identifying which events have acted as triggers for an episode of mental ill health, are often at the core of our work in psychiatry and psychotherapy assessments and can be especially challenging in our increasingly multicultural society. A Separation offers an incredibly rich experience that shows us the universality of suffering and mental turmoil in a culture that may be unfamiliar to many non-Iranian viewers. The effect of parental separation on an eleven year-old girl, brilliantly portrayed here, and the strain within a family of caring for an elderly relative suffering from dementia, are shown to be no different in this Muslim middle class family than in one beyond Iran.

 

As a platform for discussion about the effects of stressful life events on mental health and well being, A Separation is compelling from beginning to end and the presence of subtitles is soon forgotten as the viewer is drawn in to its excellent psychological drama. I would highly recommend this film for anyone involved in working in mental health, especially those working with ethnically diverse communities.

 

•  More information about A Separation is available at IMDB and a short trailer is available here.

•  The film can be purchased at amazon.co.uk

•  Minds on Film is written by consultant psychiatrist Dr Joyce Almeida.

 
03/09/2012 12:19:00

After Thomas

Introduction

After Thomas was a film made for TV in the UK, directed by Simon Shore, and released in 2006. It stars Keeley Hawes, Ben Miles, Sheila Hancock and Duncan Preston, with a first performance by the young actor Andrew Byrne, as the young boy Kyle. It is based on a true story, also written in a book called A Friend Like Henry by Nuala Gardner, about her autistic son Dale who gained a therapeutic benefit from the presence of a Golden Retriever dog called Henry in the family. After winning a small dog competition, the family and Henry were invited to appear on Pet Power (a TV show that focused on stories about extraordinary pets) and this moved one viewer, Lindsey Hill, so much that she contacted the family asking to write a screenplay about their experiences. The family agreed in the hope that their story might help other families, and invited Hill to stay with them on two occasions to enable her to produce this, her first ever screenplay. Hill, worked closely with the family over nine years and involved them in developing the screenplay, which included some actual experiences that help to make the portrayal especially realistic.

After Thomas

In producing the film, there was a determination to make the film as authentic as possible, undertaking much research and preparation to gain sufficient insight in to children with autism. The cast and crew visited two schools for autistic children over several weeks before filming in order to prepare the children in both of those settings prior to shooting the scenes. In the scenes set in the schools, all of the children have autism, apart from the young actor Andrew Byrne playing Kyle. There is more information about After Thomas at the Hartswood Films website, including a link to the press pack, which contains an interesting interview with the Gardner family. When Dale, aged18, was interviewed about how it felt to watch himself being played by an actor, he said ‘It was very strange, though at times I pretended it wasn’t me so it made it easier to watch....It helped me remember how bad I was - I saw how severe my autism was’. 

The Film

The film opens with six-year-old Kyle and his mother Nicola out shopping for shoes. Kyle dislikes any change and cannot bear this process. A massive tantrum ensues in the shoe shop, including some physically challenging aggressive behaviour directed at the sale’s assistant. We are immediately absorbed in to the exhausting world of mother and a son who has autism. After leaving the shop a further serious and potentially dangerous tantrum follows as they are crossing a road. Members of the public are seen looking on aghast, but not offering any help, prompting a desperate outburst from Nicola as she manages to manhandle Kyle home. Once home, Kyle is calmed by a Thomas the Tank Engine video because trains are his main interest and the focus of his attention.

When Kyle’s dad, Rob, returns home the strains in his marriage with Nicola are all too clear and despite his huge love for Kyle and his respect for Nicola’s attempts at connecting with Kyle, he suggests that they consider sending Kyle to a residential school with a good reputation. After Nicola’s initial reluctance, she agrees to a visit. During this visit, Rob and Nicola are reassured by the charismatic headmaster, that Kyle’s current day school has a very good reputation. This supports Nicola in her attempt to remain the main influence in Kyle’s life and to continue trying to breakthrough the barriers to communication brought about by his autism. In this she is solidly supported by her own mother, Pat, and father, Jim, played brilliantly by Sheila Hancock and Duncan Preston, who offer her some brief respite from her role as a carer. In her extensive research of interventions that might help a child with autism, Nicola comes across a book about a dog that made a difference to one family. She suggests to Rob that they get a golden retriever dog, but he is initially against the idea. However, he agrees to visit some puppies with Kyle and the first positive signs of a connection between boy and puppy are seen. The puppy is bought and named Thomas, after Kyle’s favourite train, and then slowly Kyle begins to show affection for his pet building to an apparent understanding of Thomas’ feelings. Cleverly Rob finds that he can stop a tantrum that Kyle is having by speaking in the ‘voice’ of Thomas and soon both parents are able to use this technique to communicate with Kyle. As further progress is made, the family is shaken by the sudden death of Grandma Pat, and then by the illness of Thomas, who eventually recovers, but by then too much progress has been made by Kyle to shatter the intimate bonds he is starting to develop with both his parents.

Relevance to the field of Mental Health

After Thomas offers an excellent platform for anyone wanting to learn about the subject of autism and the spectrum of disorders associated with it. As a teaching tool it would make a great starting point for a discussion about diagnosis as well as treatment, in conjunction with the reading of an article, assessing the evidence base for certain psychological treatments used for children with autism-spectrum disorders. It was published in Advances in Psychiatric Treatment in 2010 (16: 133-140), entitled Evaluating psychological treatments for children with autism-spectrum disorders by Professor Patricia Howlin (abstract).

Many personal reviews written about After Thomas, by parents of children diagnosed with autism, support the accuracy of the portrayal of the condition and of the effect it can have on parents and wider family. Many of those reviewers have stated that this film provides an excellent window on their difficult world as they struggle to raise a child with autism.

There is plenty of excellent information about autism at The National Autistic Society, the leading UK charity for people with autism and their families. There is also a helpful fact-sheet at the Royal College of Psychiatrists. I would recommend this film to anyone wanting to work in the field of child and adolescent mental health.

•  More information about After Thomas is available at IMDB as is a short trailer.

•  The DVD is available to purchase at amazon.co.uk

•  Minds on Film is written by consultant psychiatrist Dr Joyce Almeida

31/07/2012 12:16:57

El or This Strange Passion

Introduction

Directed by Luis Buñuel and released in 1953, this black and white film, in Spanish with English subtitles, tells the story of the jealous relationship between Francisco and his wife Gloria. Filmed in only three weeks, during Buñuel’s years in Mexico, it is based on the memoir of an abused wife. Buñuel is quoted as saying “It may be the film I put the most of myself into”, identifying himself with the protagonist Francisco, something that is confirmed by his wife Jeanne, who in her own memoirs wrote about her husband’s jealousy. Later in his life, Buñuel was friends with the psychoanalyst Jacques Lacan, who is said to have shown El to his training analysts in order to teach them about paranoia (This and further information can be found in the book Luis Buñuel The Complete Films by Bill Krohn/Paul Duncan Ed. Published by Taschen).

El or This Strange Passion

 

The Film

The film opens in church where Francisco, a rich bachelor, is the water bearer for a priest who is washing the feet of a line of boys. During a moment of distraction, Francisco finds himself focusing on the feet of a woman, who we find out is Gloria as the camera pans up to her face slowly. Francisco becomes instantly attracted to her, chasing her out of the church in an attempt at conversation but failing to meet her until another visit to church brings the opportunity to talk. Gloria’s lack of interest in Francisco is clear and she tells him that they cannot speak again. However, he follows her to a restaurant, where he sees her meet with a friend of his called Raúl. When Francisco subsequently meets with Raúl, he learns that Raúl and Gloria are engaged to be married. This appears to increase Francisco’s determination to woo Gloria and so he arranges a party to which the couple are both invited. Although Gloria is initially wary, she finally falls for his charm and we next find out that Francisco and she are married at some time in the future. We then observe Raúl driving through the city streets where he meets a distraught Gloria, who gets in to his car in panic and recounts the story of her unhappy marriage. It is this ‘flashback’ that forms the next part of the film.

During their honeymoon Francisco takes Gloria to see some property, once owned by his family, that he believes should still rightfully belong to him. We learn that Francisco is fighting a lawsuit to regain the property, but is struggling to find a lawyer willing to take on his case and defend his view that he is being wronged. This is the first sight that we are given of his paranoia. At this early stage in their marriage, Gloria remains calm and non-judgmental, even when she begins to experience Francisco's jealousy on the honeymoon when she meets an old male friend. From this point on, Francisco’s suspicions that Gloria is behaving in an over familiar manner with other men grow and he begins to accuse her in a critical and unreasonable way. She feels misunderstood by others, who continue to view Francisco as an upstanding member of the community and becomes increasingly isolated. After he finds out that she has spoken with the priest about the matter, Francisco is angry and decides to frighten her in to submission by firing a gun with blank bullets at her.

`After further escalating threats and then actual aggression, Gloria finally runs away. It is at this point that she encounters Raúl driving through the city. He suggests that she must leave Francisco, but she returns once again to her marital home, not realising that Francisco has seen Raúl bring her home. That night, Francisco enters her room as she sleeps, carrying rope and sewing implements, possibly to bind her and stitch her up so that no one can enter her, or perhaps to murder her. Whatever his intention, she wakes in time to scream and escape from the house. Francisco sets off in pursuit with a gun, mistaking other people for Raúl and Gloria, but is unable to find her. When he reaches the church where his friend the priest is delivering a service, he experiences some frightening paranoid visual hallucinations that suggest the whole congregation is laughing at him. Suffering from an acute paranoid psychotic episode, he tries to attack the priest and is restrained by the crowd. Some period of time later, we see Gloria, Raúl and their young son visiting a monastery, where Francisco now lives in the care of monks.

Relevance to the field of Mental Health

This film provides a brilliant opportunity to consider the topic of morbid jealousy, a symptom rather than a diagnosis, related to a number of underlying mental disorders and often co-existing with substance abuse. Morbid jealousy refers to the abnormal preoccupation that a partner is being sexually unfaithful. The strength of this belief may take the form of an obsessional rumination, an overvalued idea or a delusion. This may arise de novo as a delusional disorder or it may be associated with an underlying mental disorder such as schizophrenia, depression, and substance misuse or arise in the context of a personality disorder. The temporal relationship between the symptoms of morbid jealousy and any other illness are crucial in determining the cause and thereby informing the treatment.

As in the case of Francisco and Gloria, the symptom of morbid jealousy usually carries significant risk of violence to the partner suspected of infidelity or to the third person accused of involvement with them, but there is also a risk of suicide. It is for this reason that forensic psychiatrists are often involved in the management of such patients.

An excellent review article entitled Aspects of morbid jealousy, by forensic psychiatrists Michael Kingham and Harvey Gordon, is available in full in the journal Advances in Psychiatric Treatments (Advances in Psychiatric Treatment (2004)10: 207-215). A reading of this alongside a viewing of El would provide a very good foundation for learning about this very important symptom.

Of additional value to students learning about mental health is the scene near the end of the film when Francisco experiences terrifying paranoid visual hallucinations in the church. Buñuel manages to recreate the experience for viewers of the fear and confusion that those suffering from such paranoid psychotic symptoms might feel, by using point of view camera shots.

Although this film is more difficult to obtain than my usual recommendations, I highly recommend a viewing for anyone interested in working in the field of forensic psychiatry.

•  More information about El can be found at IMDB.

•  Unfortunately, the DVD is more expensive to buy. Several copies are currently available on amazon.co.uk marketplace.

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

02/07/2012 09:02:20

Tyrannosaur

Introduction

Tyrannosaur was written and directed by the actor Paddy Considine. It is his first full-length film as a director and was released in 2011. It stars Peter Mullen (who plays Joseph), Olivia Colman (Hannah) and Eddie Marsan (James) whose excellent performances make this powerful drama so unforgettable. Tyrannosaur has been very well reviewed, and won several awards, including three British Independent Film Awards in 2011 (Best Actress, Best British Independent Film and Best Debut Director) and a BAFTA in 2012 for Outstanding Debut for a British Writer, Director or Producer. It is set in an unnamed town in Northern England and was actually filmed on location in Leeds and Wakefield, using local residents as extras.

 

Tyrannosaur

The Film

The film opens with a most distressing scene of unbridled rage as widowed ex-prisoner Joseph destroys the only thing he really loves. This deeply unpleasant vision sets the tempo for what follows as we are drawn in to his world of anger, aggression and conflict, only occasionally relieved by some lighter, humorous moments. It demonstrates the well-recognised close association between love and hatred, so often present when things go wrong within relationships, that frequently becomes a focus of psychoanalytic psychotherapy sessions. Why do we hurt the ones we love? That is the fundamental question that this film poses.

After a pub brawl, Joseph takes refuge in a charity shop where he encounters a volunteer sales assistant, Hannah, who tries to reach out to him in his obvious distress, buoyed up and driven by her Christian beliefs. Joseph initially responds in his characteristic way, by being hurtful and abusive to Hannah and humiliating her for attempting to be kind. However, it soon becomes clear that all is not what it seems in her suburban middle class marriage to James and this draws Joseph closer to her, perhaps united by their shared unhappiness and despair. The viewer soon learnss that she is struggling to survive emotional and physical abuse perpetrated by her husband James, which is portrayed in harrowing scenes that pull no punches. As Joseph and Hannah’s friendship forms and then deepens, the cracks in Hannah’s marriage develop and spread, with ultimately disastrous consequences. 

Relevance to the field of Mental Health

Tyrannosaur is a film about anger and violence that is portrayed in a painfully realistic way. This anger is embodied both by an individual, Joseph, who is consumed by rage, and by a couple, Hannah and James, whose middle class marriage is destroyed catastrophically by domestic violence. The film eloquently makes the point that physical and emotional abuse can be found in all areas of society. Anger is something that will certainly be encountered by those working in the field of mental health at some time in their career, if not throughout it, but anger also affects those working in many other areas of healthcare, including in general practice. Tyrannosaur gives the viewer the opportunity to experience, at close hand, anger that is out of control and in particular gives insight in to the important issue of intimate partner violence, often hidden from view in apparently satisfactory relationships.

Those employed in the health and social care professions are often the first port of call for victims of domestic violence and it is crucial that professionals are vigilant about the possibility, and ask the right questions of an individual who may be subject to partner abuse. A recent editorial in the British Medical Journal in March 2012, called Responding to domestic violence in primary care (BMJ 2012;344:e757), highlighted the need for clinicians in primary care to routinely enquire about intimate partner violence in order to increase its detection. Further consideration was given to the topic in an earlier article in the BMJ entitled Violence between intimate partners: working with the whole family (BMJ 2008; 337 doi: 10.1136/bmj.a839). The Department of Health published a document, in 2005, containing guidance on managing domestic violence (Responding to domestic abuse: a handbook for healthcare professionals) that can be accessed and downloaded from the following link.

A viewing of Tyrannosaur alongside a reading of these articles and guidance would provide a very good platform for discussion and learning about the very important issue of domestic violence. But perhaps the film can also give an understanding to viewers who have grown up in circumstances largely free of anger and violence, what it might be like to live in such an environment. For medical students, lacking a first hand experience of violence, who may find themselves treating people from a wide variety of unfamiliar backgrounds, this film may offer invaluable insights in to some of those foreign territories.

Be warned, this is not an easy film to watch, but it is well worth the challenge.

•  More information about Tyrannosaur is available at IMDB as is a short trailer.

•  The DVD can be purchased at amazon.co.uk.

•  Minds on Film is written by consultant psychiatrist Dr Joyce Almeida.

 

 
06/06/2012 09:30:20

Grizzly Man

Introduction

Released in 2005, Grizzly Man is a documentary film directed by German film maker Werner Herzog, which examines the life and death of a man named Timothy Treadwell. He lived among the grizzly bears of Alaska for 13 summers before being killed, along with his girlfriend Amie Huguenard, by one of the animals. Herzog, who is renowned for his interest in unusual individuals who suffer some degree of inner turmoil, was able to use more than one hundred hours of video filmed by Treadwell over several of the years that he lived among the grizzly bears. Treadwell used the camera to record his often intimate thoughts and feelings as well as his encounters with the bears in the beautiful wilds of Alaska.

Interspersed with interviews that Herzog had with friends, family and various professionals, Grizzly Man provides a personal case history of Treadwell, without any judgement, which allows viewers to reach their own conclusions about his life and, in particular, his mental health. The original soundtrack was created by a group of musicians, including British songwriter and guitarist Richard Thompson, who improvised the musical accompaniment while watching the film.

Grizzly Man

The Film

The film opens with Treadwell talking to camera as two large grizzly bears roam in the background. He repeatedly states how he loves the bears, that he is a peaceful warrior whose role is to protect the bears, and how it is really only his special skills that keeps him from being decapitated and eaten by these wild animals. A spine tingling premonition as Herzog uses footage of the encounters between Treadwell and the bears to show an alternative view that the grizzlies are just being tolerant of a human who insists on getting close to them. It becomes apparent that Treadwell treats them almost like human characters in bear skin costumes, giving each names and representing them as his family in the wilderness. By way of background, the film informs us that when Treadwell left home to study in California, he changed his name and told people that he was an orphan from Australia. After dropping out of his studies, he wanted to become an actor, but his failure to do so led him to drink and drugs. Treadwell speaks of his early struggle with alcohol and drugs and how he nearly died after an overdose. He describes how he credits a friend, who suggested he might find purpose in studying the grizzly bears, for rescuing him from his self-destructive behaviour. In fact, it seems that he swapped his earlier addictions for another all consuming one. When he was not in Alaska, his aim was to educate people, especially children, about the bears and he did this by touring schools and giving presentations. He appeared on TV and became a celebrity of sorts, as he campaigned to protect the bears that he believed were being threatened by humans.

On one occasion, Treadwell discusses his failure in having any lasting relationships with women, genuinely struggling to understand why. Many clips show Treadwell with boyish exuberance playing in the wilderness with the bears he has grown to love. At one point in the film Herzog interviews Treadwell’s parents, who state that he had been ‘a normal young boy growing up’ as his mother is shown clutching Treadwell’s large childhood teddy bear, a toy he had apparently taken with him on every trip to Alaska. In fact the teddy bear appears in several sequences to camera filmed in his tent in the wilderness. However, a darker side of Treadwell is revealed later in the film, when he rages to camera about the US park rangers, whose rules he is constantly breaking, and whom he blames in a paranoid manner for failing to care for the bears. Another example of his paranoia is seen when he misinterprets a smiley face carved on a stone as a sinister threat towards him.

Throughout the film, Herzog explores the circumstances leading up to and including Treadwell’s final minutes. Herzog is seen listening to the audio recording which captured the moments of Treadwell and Amie’s deaths that now belongs to Treadwell’s ex girlfriend, Jewel. The film concludes with Treadwell’s three closest friends scattering his ashes in the Alaskan wilderness near to the site of one of his previous camps.

Relevance to the field of Mental Health

Presenting us with the candid records of Treadwell’s thought processes, emotions and his behaviour with wild animals, Grizzly Man offers the viewer an opportunity to consider the nature of his undoubted psychological dysfunction. As such, the film provides a very good platform for a discussion about the differential diagnoses that might be relevant in Treadwell’s case. With his obvious grandiosity, exaggerated sense of self-importance and ‘specialness’ to the fore, there is a strong argument for a personality disorder with narcissistic features (of the two diagnostic systems of classification [ICD and DSM], it is DSM-IV that identifies narcissism as a specific personality disorder). His energy and exuberance might also suggest adult ADHD and would be in keeping with the report of Treadwell having suffered from substance misuse and depression in the past. There is a history of him being prescribed a mood stabiliser drug, which Treadwell stopped taking because it ‘dampened him down’. It therefore seems reasonable to consider the diagnosis of a Bipolar spectrum disorder with or without a concomitant narcissistic personality disorder. A contribution from other personality disorders, such as borderline and histrionic types would need to be considered too.  

The topic of personality disorder has recently been considered in an excellent article in Advances in Psychiatric Treatment (2012) 18: 162-172, entitled The nature of personality disorder by G Adshead and J Sarkar, where the authors argue that personality disorders are like other mental disorders, the social manifestations of a pathological process. An editorial in the The British Journal of Psychiatry (2007)190: 189-191 by J Angst MD entitled The bipolar spectrum considers the dimensional and categorical principles for classifying mood disorders and is now freely available to read in full. The topic of diagnosing bipolar disorders using categorical or dimensional approaches is discussed in another article in The British Journal of Psychiatry (2011)199: 3-4 called Detection of bipolar disorder by A Young and H MacPherson. For further reading on the long-term manifestation of bipolar disorders, the article published in Advances in Psychiatric Treatment (2010) 16: 318-328 by K Saunders and G Goodwin called The course of bipolar disorder might be of interest. These articles, read alongside a viewing of Grizzly Man, could provide a very good introduction to the subject of personality disorders and their precise relationship to the bipolar disease spectrum. Grizzly Man is a film that I would highly recommended for anyone interested in debating these issues further or in teaching them to students of mental health. 

* More information about Grizzly Man is available at IMDB as is a short trailer.

* The film can be purchased at amazon.co.uk

* Minds on Film is written by consultant psychiatrist Dr Joyce Almeida.

 

02/05/2012 09:23:24

Beginners

Introduction

Released in 2010, Beginners was written and directed by Mike Mills. The film is a largely autobiographical exploration of the issues he found himself needing to process after the death of his own father, Paul Mills. Paul had revealed that he was gay after being widowed at the age of 75 and forged a closer relationship with Mike Mills in the five years before he died from cancer. The numerous parallels between Mike and Paul Mills and the characters of Oliver, played by Ewan McGregor, and Hal, played by Christopher Plummer, are outlined clearly in an article published in May 2011 in the New York Times. In February, 82 year old Plummer became the oldest actor to win an Oscar, for his supporting role as Hal. He also won a BAFTA and a Golden Globe for his performance. To date, Beginners has won a total of 25 awards.

Beginners

The story is told through the eyes of Oliver, a 38 year-old graphic designer who is single. The film does not follow a chronological timeline, but rather cuts between three distinct narrative lines, which correspond in a natural way to the memories that are triggered for Oliver as he deals with Hal’s passing. The film also uses a mixture of documentary forms within the drama; real film clips and still photos set the historical context of being homosexual in postwar America in contrast with the experiences of gay men in 2003.

The Film

The film opens in 2003 when we see Oliver clearing out his father’s belongings after his death and taking responsibility for his dog, a very cute Jack Russell called Arthur, who is comically given a voice through subtitles. In this timeframe, Oliver falls in love with Anna, a French actress, whom he meets at a fancy dress party a few months after being bereaved and when he is still suffering significant grief. A clue as to the psychological credentials of the film is given in this comical scene when Oliver chooses to dress up as Freud and finds himself analysing other partygoers, one of whom is Anna. It is slowly revealed that both have struggled to commit to intimate relationships in their past, and that their shared sadness seems to be the spark that fuels their attraction. From this beginning, the film tells two different back stories. The first involves the young Oliver observing the somewhat distant, cold relationship between his parents as he repeatedly seeks answers to his question “ Is everything alright”. The only early parental relationship that we see is with his mother as he reflects on her unfulfilled life and her embittered sadness, in the light of what he now knows about his father’s sexuality.

The second flashback scenes tell the story of Oliver and his father after Hal has ‘come out’ as gay and begun a relationship with a much younger man, Andy. Hal begins this four year period with renewed vigour and a sense that it is never too late to get it right, before the discovery is made that he has lung cancer. This forces an even greater closeness to develop between father and son as Oliver becomes increasingly involved in caring for Hal. Hal insists on hiding his diagnosis from his lover, Andy, and his new gay friends, against the advice of Oliver who is continually seeking honesty and truthfulness. In essence this is a major theme of the film, as every character searches for their true self. The question that is repeatedly raised is what is real, especially where love is concerned. Oliver’s experience of seeing his father happy and in love with Andy suggests to him that success in an intimate relationship is possible and this knowledge begins to inform his exploration of love in the scenes with Anna.

Relevance to the field of Mental Health

This film presents several issues of great importance that are relevant to doctors in general, and to mental health practitioners in particular. It highlights at its centre the important topic of sexual activity in older adults, often neglected by younger professionals in particular, and adds to that the additional issue of repressed sexual identity that emerges later in life. A viewing of Beginners would offer a good platform to discuss these topics alongside a reading of some suitable articles or books. One of the few studies of older lesbian and gay men undertaken in the UK, was published in the journal Diversity in Health and Care in October 2011(Volume 8, Number 3) and is called Hidden lives: the importance of recognising the needs and experiences of older lesbians and gay men within healthcare practice, byFenge & Hicks (abstract), in which one of the key themes is a focus on the issue of ‘coming out’. An interesting study published in the BMJ in 2010 entitled Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageingby Lindau and Gavrilova at University of Chicago examines the relation between health and several dimensions of sexuality in middle and older age adults. For more extensive coverage of the topic, including a chapter about the older LGBT population in America, I would suggest a recently published book, entitled Sexuality and Aging: Clinical Perspectives by psychologist Jennifer Hillman, which was recently published in 2012. A section of the book is available to read at Google books.

Beginners also explores sadness in a number of the characters and gives an exquisite portrait of grief, as Oliver looses Hal without really having had a long enough time to get to know him after he has come out. The frustration for Oliver at having insufficient time to process the whole meaning of his parent’s marriage, before Hal’s death, is brilliantly captured. In interviews with the director Mike Mills, he makes clear that his reasons for making Beginners were grounded in his need to continue processing his own personal experience of his father in the last years of his life through the characters of Hal and Oliver.

I would highly recommend this film for its authenticity in presenting such sensitive issues of older age and sexuality in a truthful and unsentimental manner. All of the acting is superb and is certainly the reason that the film, and Christopher Plummer in particular, received so many awards. Oh yes, and Arthur the dog is unforgettable!

•  More information about Beginners can be found at IMDB, along with a short trailer.

•  Beginners is available to buy at amazon.co.uk.

•  Minds on Film is written by consultant psychiatrist, Dr Joyce Almeida

 

03/04/2012 09:43:04

Control

Introduction

Control is a biographical film, directed by Anton Corbijn, about Ian Curtis, the lead singer of the post-punk band called Joy Division, whose life ended in suicide at the age of 23. The screenplay by Matt Greenhalgh was based on the book Touching from a Distance, written by Curtis’ widow Deborah. Control was shot in black and white and released in 2007. Corbijn is a Dutch photographer, known for his work in black and white, who had met and photographed Joy Division before Curtis’ death in 1980. The film won several awards at Cannes Film Festival, five British Independent Film Awards and a British Academy Film Award, as well as being named Best Film at the 2007 Evening Standard British Film Awards.

 

Control

It tells the story of Ian Curtis throughout the formative years of Joy Division, but also focuses on the difficulties in his marriage, his affair with another woman and his struggle to cope with recurrent seizures and later depression, which results in his tragic death. As a very human portrait of epilepsy in a young adult, Control offers much to students of psychiatry as it presents so many important issues concerning medication (both compliance and side effects), the influence of stressors, the role that substance abuse may play in altering the seizure threshold and the psychological effect of fear and of stigma. I am sure I will not be alone, as a spectator who is a mental health professional, in wanting to ‘intervene’ at many stages of this film and change the course of events. 


The Film

We first meet Ian Curtis (Sam Riley) at school, as a day dreamer interested in poetry. He falls for his close friend’s girlfriend, Debbie (Samantha Morton), and they soon become engaged. In 1975, they marry when Ian is just 19 and Debbie is 18. However, Ian struggles to share in domestic life and prefers to write poetry alone in a room of the house. At this time, he is working as an employment agent at the local job centre, where he deals with a young woman, called Corrine, who suffers from epilepsy. She attends the appointment wearing a protective helmet and Ian witnesses her having a seizure at his desk. By 1977, Ian and fellow band members Peter Hook, Bernard Sumner and Stephen Morris formally debut as Joy Division and Ian & Debbie provide the finance for the band’s first record.

As the band’s success grows, their manager gets them their first gig in London in 1978, and it is after this event, on the way back home that Ian experiences his first grand mal seizure. The diagnosis of epilepsy is followed by a recommendation to take several antiepileptic drugs, which cause significant drowsiness and soon threaten his ability to work at the employment agency. It is at this time that he hears of the sudden death from epilepsy of Corinne. Giving up his job just after the birth of their daughter Natalie in 1979, Ian chooses to focus on his career in Joy Division, leaving Debbie to look after their daughter and earn some money whilst he goes on tour. In a gloomy mood, feeling that his marriage was a mistake, he starts an affair with a Belgian journalist, called Annik, who is reporting on Joy Division’s 1980 European tour. On his return home, Ian tells Debbie that he probably doesn’t love her anymore and not long after this she finds evidence of his affair and confronts him. Telling Debbie that the affair is finished, he continues to see Annik, who is present at a concert when he has a seizure on stage, and so is able to comfort him as he regains consciousness, whilst telling him she loves him.

Once he gets back home, Ian makes a suicide attempt by taking an overdose of his medication, leaving a note for Debbie, but also telling her before collapsing. A brief scene in hospital, just before his discharge, shows no psychiatric assessment or intervention despite it being very clear that his mood is significantly depressed. As the band prepare for their first tour in the USA, they perform at a small local venue, where Ian finds himself unable to perform onstage, walking off after only one verse of a song. Racked with guilt, he expresses the view that he has lost control of his life. As the affair with Annik continues, Debbie asks him for a divorce, and asks him to leave. He first moves in with band member Bernard, who offers him help using hypnotherapy tapes, and then with his parents. He writes to Annik of his fear that epilepsy will kill him and that he loves her. But nothing relieves his distress and he returns home to Debbie, pleading for her not to divorce him. When she refuses, he becomes angry, asking her to leave and he sits alone drinking until he has a seizure. On waking from the floor the next morning he hangs himself in the kitchen.

Relevance to the field of Mental Health

Control offers the opportunity to consider an important mental health issue, namely the relationship between depression, suicidal behaviour and epilepsy.

An article published in 2011, in Advances in Psychiatric Treatment entitled Epilepsy and neuropsychiatric comorbidities by Niruj Agrawal & Suren Govender (2011, vol 17, 44-53), provides an excellent introduction to epilepsy in its various forms and discusses its association with depression, anxiety and psychosis. The abstract makes clear that the wide range of neuropsychiatric comorbidities has only recently been truly appreciated and the full article provides a thorough consideration of the relationship between epilepsy and depression. The article states that there is also a strong association between the risk of suicide and the onset of epilepsy at an early age, especially during adolescence.

A population based case-control study by Christensen et al in 2007 (Lancet Neurology 6:693-8) suggested that the risk of suicide is 32 times higher in those with epilepsy and depression than in the general population, as opposed to 2.4 times higher in those with epilepsy alone (link to the abstract). Antiepileptic medications can also have depressive effects as well as having a possible influence on suicidal behaviour. In the recently revised book entitled The Neuropsychiatry of Epilepsy, edited by Michael R. Trimble and Bettina Schmitz, published by Cambridge University Press 2011, there is a chapter on Antiepileptic drugs and suicide by Trimble, which is accessible online at Google Books, in which the author discusses the neurochemistry of affective disorders, suicidal behaviour and antiepileptic medications.

A viewing of Control, alongside a reading of these articles and the chapter, would form the basis of an excellent introduction to the psychiatric aspects of epilepsy for mental health professionals. But this film can also give all viewers some understanding of the personal and social implications of suffering from recurrent seizures.

To quote from a review of this film on the Disability Now website:

Control is of huge benefit to people with epilepsy. As a hidden disability, it has little profile. People who have seizures on the street continue to terrify the population. Control gets the issue out there.

Written by Clair Chapwell, who has had epilepsy since she was 14.

This film would be especially beneficial to medical students and psychiatric trainees and I strongly recommend it.

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

•  The DVD can be purchased at amazon.co.uk

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

 

 
28/02/2012 09:06:23

Archipelago

Introduction

Archipelago is the second feature film by the British writer-director Joanna Hogg. Released in the UK in March 2011, it tells the story of an upper middle class family who are gathered together for a farewell family reunion in a rented house on Tresco, one of the Scilly Isles off the coast of Cornwall. In a style of cinema known as neorealism, the film is composed of still shots, eschews close ups until the later stages, and creates its intimate atmosphere through the use of natural light in both indoor and outdoor scenes. The audio track is composed solely of sounds from the environment it depicts. 

 

Archipelago

Additionally, and in keeping with neorealism, two of the characters are played by non-professional actors, the artist and the cook, and the scenes were filmed on location, in chronological order with a significant amount of improvisation in the dialogue. This creates a very realistic feel to the film and increases our voyeuristic involvement in its characters interactions, which are sometimes painfully difficult to watch. Infused with quiet desperation, lightly veiled unhappiness and unexpressed emotions, Archipelago tackles the uncomfortable truth that ‘all is not well’ beneath the surface of the apparently prosperous upper middle classes. In particular, the film examines the subject of absent fathers, in two different contexts, and the effect that this has on their young adult children. 


The Film

The film opens with the arrival of Edward (Tom Hiddleston), by helicopter, on Tresco, where he is met by his mother Patricia (Kate Fahy) and sister Cynthia (Lydia Leonard). The back story slowly unfolds as we learn that Edward, who is in his late twenties, has left his well paid city job and is soon to travel to Africa where he will work as a volunteer for eleven months, helping to teach sexual health within communities afflicted by AIDs. He outlines his need for a purpose in life but gradually reveals his uncertainty about whether he has actually made the right decision. Cynthia, his older sister, is critical of his choice and shows her resentment of his freedom to travel abroad in this way. Patricia, their mother, has arranged this farewell get together in a rented holiday home that they visited many times when Edward and Cynthia were young and where they all seem to recall fond memories. However, the full family reunion fails to take place as time passes and Patricia’s husband doesn’t arrive. We feel his distant presence only through phone calls that he makes to Patricia and Cynthia, in which Patricia becomes increasingly frustrated and let down by his absence at her longed for gathering. As his father’s failure to show up becomes more certain, Edward voices several critical and disrespectful comments about him, revealing their lack of closeness.

The two other significant characters in this drama are the cook, Rose, who has been hired to look after the culinary needs of the family during the holiday and Christopher an artist and friend who is engaged in teaching Patricia and Cynthia painting. The real life artist, Christopher Baker, describes his painting process as a need to find the chaos in representation while he resists exercising too much control, something Patricia openly acknowledges is hard for her to do. In contrast to the extremely controlling attitudes of both Patricia, her absent husband, and Cynthia, Christopher becomes a proxy father figure to the ‘hen pecked’, over compliant Edward as he tries to reflect on the meaning and purpose of his own life.

Rose, the paid cook, attracts the attention of Edward, who tries to treat her as an equal, in a way that brings criticism from both Patricia and Cynthia, as he befriends her and wants her to join the family at mealtimes, blurring the boundary of employer and employee. The ensuing debate gives rise to one especially embarrassing scene, in which we feel Rose’s discomfort acutely. However, we also learn that Rose’s father died suddenly in an accident a few years earlier and she, her mother and her sisters, have only just ‘emerged from the coma’ of grief that they were in. In an attempt to include Rose, the family invite her and Christopher to lunch at a hotel, empty at this time of year, where Cynthia creates a scene by complaining about her food, whilst the rest of the group remain mostly silent. Her growing anger and frustration is later released in a row at the house, but the real feeling of equilibrium only returns to the group when Patricia loses her temper with her husband on the phone just before the end of the holiday.

Relevance to the field of Mental Health

Archipelago is not a film that portrays overt mental illness, rather it seeks to give us an insight in to the complex origins of the problems that may drive someone to seek psychotherapy of some form. Cynthia’s unhappiness, irritability and seeming dissatisfaction with her self and the world, suggests that she might benefit from a psychological treatment. The film is so skillful at involving the viewer in the family’s interactions that it would definitely offer a great platform to discuss the role of unconscious motivations, inner conflicts and defence mechanisms that form the basis of psychoanalysis and the approach taken by psychoanalytic psychotherapy, described on the information pages of the British Association of Psychotherapists.

For a broader consideration of psychological therapies, a reading of the Royal College of Psychiatry factsheet on Psychotherapies could form the basis of a discussion on the whole variety of treatments that might be of use to the various characters in Archipelago were they to seek help. I would strongly recommend this film to anyone interested in, or actually working as a psychotherapist with individuals or families.

For anyone interested in a further psychoanalytic exploration of films, The Institute of Psychoanalysis is currently showing a series of films and discussions called Screening Conditions, which takes place on Sunday mornings, at The Institute of Contemporary Arts, London. Here is further information about all of the Institute’s events examining the relationship between psychoanalysis and the arts.

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

•  The DVD can be purchased at amazon.co.uk

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

 

 
01/02/2012 09:36:35

In Our Name

Introduction

In Our Name is a low budget feature film, written and directed by Brian Welsh, which was launched at the London Film Festival in October 2010 and dedicated to all military service personnel who end up in prison after trying to return to civilian life. It was well researched through Welsh’s discussions with returning soldiers as well as his contact with the charity Combat Stress. It tells the story of Suzy, brilliantly played by Joanne Froggatt, a soldier just returning to her home in a run down area of the North East of England after a tour of duty in Iraq.

In Our Name

The film follows her struggle to cope with civilian life again and in particular with the difficulties she has in reconnecting with her young daughter. It is interesting to note that the parents of the young girl who acts Suzy’s daughter, are actually both soldiers in the army. It offers an excellent portrait of post-traumatic stress disorder (PTSD), but also focuses on the topical issue of guns and mental illness. Unusually, the protagonist is a female soldier, and In Our Name highlights the effect that Susie’s PTSD has on both her husband and her daughter. 


The Film

The film begins with private Suzy and the fellow soldiers from her unit returning home by train, where she is welcomed by family and friends at the house she shares with husband, Mark, who is also a soldier who has previously served in Iraq, and their daughter, Cass. At first Cass is unwilling to interact with her mother and Suzy seems able to cope with this behaviour, until it becomes clear that all is not well in Suzy’s perception of the world. In the context of some hooliganism in their impoverished residential area, Suzy starts to develop paranoia that eventually becomes extreme. Her hypervigilance for potential dangers is brilliantly portrayed, and permeates throughout the majority of the film, as she becomes especially fixated on protecting her daughter. Unable to get close to her husband and unable to sleep properly, Suzy starts to drink alcohol in greater amounts.

When her sister invites Suzy and her soldier colleague, Paul, to attend the primary school where she teaches, in order to talk to the children about their experiences of war, Suzy recounts the memory that is haunting her. This revelation explains the origins of the guilt that Suzy is feeling and the flashbacks she is suffering as well as providing an understanding of the importance, for her, of protecting her daughter. As Suzy’s symptoms of paranoia, flashbacks, hypervigilance, loss of libido and depression increase, her relationship with husband Mark becomes ever more strained. Her absence of libido is the trigger for Mark’s increasing frustration that results in him suspecting that Suzy has been unfaithful to him. His mental health begins to suffer and his underlying angry personality traits are revealed, with serious consequences.

In the final scenes, when Suzy flees with her daughter and a gun that she has taken from the barracks for protection, the serious nature of her condition becomes even more apparent. I do not wish to describe the ending here, but suspect that it will raise your heart rate.

Relevance to the field of Mental Health

As a contemporary portrait of post-traumatic stress disorder, In Our Name offers a perfect platform to discuss the diagnosis and management of the condition, with reference to Suzy’s symptoms and behaviour, and the effect that her condition has on her close family. The film also depicts the difficulties that some servicemen may have in seeking help, because they feel doing so may jeopardise their chances of promotion. For a general introduction to PTSD, the Royal College of Psychiatrists has a good factsheet, but for more information about PTSD related to military combat, the charity Combat Stress also has lots of information, including some case studies.

The other topical issue that is raised by In Our Name is that of gun possession and mental illness. There are two aspects of this issue that could be further explored alongside a viewing of the film. The first is the topic of mentally ill soldiers carrying guns and the second concerns the process of licensing guns to the general public who may have had or may develop a mental disorder. For the first topic, I would recommend a reading of the recent article published in Advances in Psychiatric Treatment, in September 2011, by Peter McAllister, Neil Greenberg & Max Henderson entitled: Occupational psychiatry in the armed forces: should depressed soldiers carry guns? (vol17, 350-356). The abstract of this article is freely available. This article describes the work of the UK Defence Mental Health Services in detail. With regard to the second issue, most people in the UK will be aware of the recent tragic events on New Years Day 2012, in which a middle aged man, legitimately licensed to hold 6 firearms, with previous mental health problems, shot dead his partner, her sister and her niece. This incident has highlighted the growing debate about how gun licences should be issued and then monitored. The medical profession currently have no statutory role in the process, but the BMA is involved in discussions with the Association of Chief Police Officers about this matter. A statement of the current interim guidance for doctors on this matter is available at the BMA website. The film could provide a good starting point for a debate on this very important issue.

Perhaps the fact that the film’s ending does not resolve the outcomes for all of the main characters offers an even better opportunity to discuss their possible futures. What is left in no doubt, however, is the detrimental effects that serving in a war can have on an individual’s mental health and on their close family relationships and it highlights the importance of having appropriate care available whenever it is needed.

•  More information about In Our Name is available at IMDB and here is the link to the official trailer.

•  The DVD can be purchased at amazon.co.uk.

•  Minds on Film is written by consultant psychiatrist Dr Joyce Almeida.

 

 
04/01/2012 10:39:17

Spring, Summer, Autumn, Winter....Spring


Introduction

Spring, Summer, Autumn, Winter



Spring, Summer, Autumn, Winter....Spring is a South Korean fiction film, directed by Kim Ki-duk,  and released in 2003. Subtitled in English but with sparse dialogue, it is 102 minutes in length. It is set almost entirely in a tiny Buddhist monastery that is located in the middle of a lake, within the remote forests of Korea, and follows a Buddhist monk through the cycle of his life. The exquisite cinematography envelopes the viewer in the beautiful natural scenery of the lake as the five seasons in the title transform the landscape over the five sections of the film that cover the different stages of the monk’s life.

In its portrayal of the Buddhist practice of mindfulness, this film offers the viewer an insight into the techniques of focusing on the moment and accepting thoughts and feelings without judgement, both of which are now being used in Mindfulness-Based Cognitive Therapy (a therapy that was developed from the Mindfulness Based Stress Reduction programme of Jon Kabat-Zinn) as well as in Dialectical Behaviour Therapy. I would argue that the process of watching this film actually offers the viewer some experience of mindfulness practice. Whilst the intricate details of many actions are played out in real time, the viewer is forced to follow the story at a much slower pace than we are often accustomed to doing. 


The Film

Spring, Summer, Autumn, Winter....Spring begins with the opening of a wooden gate which stands by the landing stage on the edge of the lake. The crossing of this threshold is repeated at the start of each season or segment of the film. A young boy is living with a Buddhist monk on a small monastery in the middle of the lake, where everything that they need for daily life must be brought to the island by rowboat. The seasons in the title represent the ages of this young boy as he develops from childhood, through his teenage years, to a 30 year old man fleeing from a crime, then a middle aged monk and finally as an older monk who repeats the cycle when he takes care of a baby boy abandoned by its mother.

In the first section of the film there are some wonderful examples of how the young apprentice is taught empathy and compassion. On one occasion, after the master finds him tormenting a fish, a frog and a snake by tying stones to them, the master ties a small rock to the apprentice’s back at night and tells him that he must carry this burden until he can free the creatures that he tormented. The lesson that the apprentice learns from this teaching stays with him for the rest of his life, represented visually as a repeating motif throughout the film. As a teenage apprentice, he encounters a young woman brought to the monastery by her mother, who is seeking help from the older monk for symptoms suggestive of depression in her daughter. As the young woman begins to improve, romance develops between the two teenagers and the apprentice is consumed with lust. When the young woman departs the monastery, the apprentice cannot bear the separation and leaves the monastery too, stealing a statue of the Buddha from his master.

In the following chapter, the master catches sight of a newspaper report telling that the apprentice has fled after killing his wife. Soon, the apprentice arrives back at the monastery seeking asylum. What follows is an interesting scene in which the older monk tries to manage the young man’s anger and help him to process the unbearable feelings that he is experiencing. As this is in process, the police arrive at the monastery to arrest the young man. After a period in which we imagine he has served his sentence, and the older monk has ended his life in a ritual manner, the middle-aged apprentice returns to inhabit the monastery alone and to devote himself to his practice. In this section of winter, he seems to use physical exertion as a means of processing the things that he has done wrong in his past. It is in this cold winter landscape, in which the lake is literally frozen over, that a mother, who conceals her identity, delivers her baby boy to the monastery for the cycle of master and apprentice to begin again.

Relevance to the field of Mental Health

Mindfulness-Based Cognitive Therapy (MBCT) is increasingly used in therapeutic practice and for anyone interested in learning about mindfulness, Spring, Summer, Autumn, Winter....Spring offers the viewer a useful resource. The film gives some very good examples of the therapeutic benefit that can come from complete absorption in a task and how this may reduce anger and arousal. It demonstrates the struggles that people may face during their lives in dealing with the obstacles that they encounter and shows the positive effect that acceptance of a situation may have on an individual. But the stunning setting of this film also gives us the ability to understand the role of stillness and focus in meditative practice by offering the viewer a chance to become totally absorbed in the breathtaking natural beauty of the lake and its surrounding hills as the scenery changes through the seasons.

To learn more about Mindfulness Based Stress Reduction (MBSR), there is an excellent lecture recorded at Google, in 2007, in which Jon Kabat-Zinn outlines some of the science surrounding his MBSR programme. In a shorter interview filmed in 2010, Kabat-Zinn outlines his more recent and general reflections on mindfulness. For further information on the application of mindfulness in current psychiatric and psychological practice, there is much information available at the website of the Oxford Mindfulness Centre, a UK based charity working with the therapeutic use of mindfulness to prevent depression and enhance the emotional quality of our lives. Founded in 2008, within Oxford University’s Department of Psychiatry, the centre is involved in training, education, clinical and neuroscience research in the field of mindfulness. Two members of the centre, Mark Williams and Danny Penman, have recently published a book entitled Mindfulness: A Practical Guide to Finding Peace in a Frantic World (Includes Free CD with Guided Meditations). There is also a good introductory article called Mindfulness in psychotherapy: an introduction by Chris Mace, Consultant Psychotherapist, in Advances in Psychiatric Treatment (Advances in Psychiatric Treatment (2007)13: 147-154).

It is also significant to note that The UK’s National Institute for Health and Clinical Excellence has recommended MBCT as a cost-effective treatment for preventing relapse in depression. The book called Mindfulness-Based Cognitive Therapy for Depression (Segal, Williams, Teasdale), published in 2002, has contributed significantly to advancing the evidence-based therapy for recurrent depression.

I would recommend this film to anyone interested in understanding the role of mindfulness based therapy in mental health.

•  More information is available about this film at IMDB, as is a short trailer.

•  Spring, Summer, Autumn, Winter....Spring is available to buy, although it has recently become unusually expensive, at amazon.co.uk or it can be rented.

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

 

01/12/2011 10:15:47

Longtime companion

Introduction

To mark World Aids day on 1st December 2011, and the thirty-year anniversary of the first identified cases, I wish to recommend Longtime Companion, directed by Norman René, and released in 1989. The title is taken from the words used by the New York Times obituary section, then unable to acknowledge a homosexual relationship, to describe a same sex partner of someone who had died. The film is set during the 1980s, in America, when the world witnessed the emergence of a new disease that we have come to know as Acquired Immune Deficiency Syndrome or AIDS, caused by a then unknown agent, now well known as Human Immunodeficiency Virus 1 or HIV-1.

Longtime companion
The film follows several New York gay men from 1981 until 1989 during which time the disease emerged and caused death and panic to spread rapidly through the group. As well as the historical account of a disease that has emerged in our time, this film is of particular interest to psychiatrists because it gives us a portrait of AIDS related dementia in one of the characters. As a final year medical student, in 1982, I worked on the medical firm at St Thomas’ Hospital when Terrence Higgins was admitted (the Terrence Higgins Trust was subsequently founded in his name), and witnessed my baffled seniors struggle to save him as he declined rapidly to death from untreatable opportunistic infections. He was one of the first people to die from AIDS in the UK. I have never forgotten him.

The Film

Through the interconnected lives of several gay men, Longtime Companion tells the chronological story of the beginning of the AIDS epidemic. Within the group, there are two well established partnerships: that between David and Sean, who writes a daytime soap opera and that between Howard, who stars in the soap written by Sean, and his partner Paul. The other single friends in the circle are Willy, who is a personal trainer, a young man called John and a lawyer called Fuzzy, on account of his facial hair. Howard and Paul live next door to Lisa, who is a friend of Fuzzy and part of the group. Willy and Fuzzy meet early in the film and begin a relationship. The affluent couple, David and Sean, have a beach house on Fire Island where they frequently invite their friends to stay. In 1981 the New York Times publishes news of a new ‘gay cancer’ called Kaposi’s sarcoma and all of the friends react in different ways to the report. In 1982, John develops pneumonia, deteriorates rapidly and dies soon after he is admitted to hospital. By 1983, the attitude to the illness among the group is very different and fear has taken hold. David and Sean are seen arguing over Sean’s fears that he might have the illness. In 1984, Paul becomes unwell and investigations in hospital reveal that he has toxoplasmosis. In the same year, Sean is hospitalised and during a visit to him from Willy, the film demonstrates brilliantly the fear that Willy has of contracting the disease from a kiss Sean gives him on the neck. By 1985, Sean is being nursed at home, by his partner David, and is now suffering from AIDS related dementia. David is trying to support Sean with his screenwriting in order to keep the extent of his illness hidden from the studio. At the same time Fuzzy tries to secure Howard a movie role when the producer has refused to cast him after hearing an untrue rumor that he has AIDS. By 1986, Sean has severe dementia and is bed bound, incoherent and incontinent. He dies soon after and Fuzzy offers support to David by phoning to find a ‘gay friendly’ funeral home that will deal with the body. The next scene, at a memorial service, takes place in 1987 when we discover the deceased is David. By 1988, Howard has been diagnosed as HIV positive and is fundraising for AIDS causes. The film ends in 1989 with Willy, Fuzzy and Lisa walking along the seashore contemplating how much their lives have changed, in the few years since AIDS has emerged. There is a final brief fantasy scene in which all of their lost friends return to the beach to be fleetingly reunited before disappearing once again and leaving the three friends alone on the empty shoreline.

Relevance to the field of Mental Health

Longtime Companion presents a number of relevant mental health issues that are related to infection with the Human Immunodeficiency Virus. These include the effect of repeated bereavements on those who lose close friends and or a partner from the disease; anxiety and panic about developing the illness in healthy, but at risk, individuals and finally it offers a portrait of HIV related dementia in one of the characters. As the film is set at the time when AIDS first manifest, when the mortality rate was 100%, there is an inevitable historical context to be taken into account in relation to the medical content.

Thankfully the intervening years have brought huge success in managing those who suffer from HIV infection, using highly active antiretroviral therapy (HAART). As a recent study in the UK has shown (BMJ 2011; 343:d6016), there is now a significantly improved life expectancy for those with HIV when antiretroviral therapy is started soon after diagnosis, transforming it into a chronic disease rather than what was usually a fatal illness.  However there is still no vaccine or cure and in current times the disease presents huge problems worldwide, especially in sub-Saharan Africa, where it is estimated that one in three people are living with the virus in the worst affected countries. In the UK the estimates suggest that between 80,000 - 90,000 people are living with HIV and that the two groups most affected are men who have sex with men and people who have moved to the UK from areas of the world with a high incidence of HIV. In this second group, heterosexual sex is the commonest cause for the spread of infection among men and women.

Since the mid 1990s, with the use of HAART in the treatment of those infected with HIV, the incidence of HIV associated dementia has declined and has been replaced by less severe HIV associated neurocognitive disorders (HAND). The impairments commonly seen include reduced attention and slower information processing and subtle changes are estimated to be present in up to 35% of people with HIV infection who are under the age of 40. When AIDS dementia does occur, it presents as a subcortical dementia associated with basal ganglia pathology whose severity appears to correlate with the levels of virus in the brain and cerebrospinal fluid. As increasing numbers of HIV positive people are now living longer, it is important to remember that HIV is a potential cause of anyone presenting with mild cognitive impairment or early-onset dementia. For some basic information about HIV related cognitive impairment, The Alzheimer’s Society has a good factsheet on the topic.

Any psychiatrists wanting to consider the subject area in greater detail might find interest in a book entitled Handbook of AIDS Psychiatry by M.A. Cohen, H.Goforth, J. Lux, S. Batista, S. Khalife, K. Cozza, J. Soffer. Oxford University Press USA. 2010, which was reviewed recently in the British Journal of Psychiatry by Derek Summerfield, Consultant Psychiatrist (BJP September 2011 199:259-260). There is also the earlier Comprehensive Textbook of AIDS Psychiatry Edited by Mary Ann Cohen & Jack M. Gorman. Oxford University Press. 2007, which was reviewed in 2009 in the British Journal of Psychiatry by Jose Catalan, Consultant Psychiatrist (BJP 2009 195: 277).

Longtime Companion is a film that puts a very personal face on the experiences of a close group of gay men as they struggled to face the frightening consequences of a new disease, one which proved a challenge to professionals from all branches of medicine then and, in different ways, is still doing so today.

  • Further information is available at IMDB, and the official trailer is available on You Tube.
  • Longtime Companion can be purchased at amazon.co.uk.

 

03/11/2011 10:19:45

Matchstick Men

Introduction

Matchstick Men, directed by Ridley Scott, was released in 2003 and is based on the book by Eric Garcia called Matchstick Men: A novel about Grifters with Issues. It is a film about confidence tricksters in which the main protagonist, a con artist called Roy, is convincingly played by Nicolas Cage as a man who suffers from Tourette’s syndrome and obsessive-compulsive disorder. There are two themes in this film that run alongside each other: a clever story of conmen, filled with the expected twists and an impressive final ‘sting’, and a deeply personal tale of a man struggling to cope with serious mental illness who is challenged by the appearance of a teenage daughter he didn’t know existed.

 

Matchstick Men

Matchstick Men also presents us with an interesting portrait of a psychiatrist, Dr Klein, whom Roy visits for help with his condition. This is a film about deception and disclosure in various settings and relationships and offers much for the viewer interested in how we assess the truth about what we are told. 


The Film

For anyone who hasn’t yet seen the film and doesn’t want the plot revealed, please do not read on until viewing it.

Matchstick Men opens with Roy, at home, suffering with his numerous obsessive compulsive symptoms, which take the form of a need for order and cleanliness and a compulsion to open and close doors three times, whilst counting aloud, before he can walk through them. His Tourette’s syndrome consists of a facial tic involving mostly his left eye and audible grunting. In the following scenes, we watch Roy and his partner in crime, Frank, play out a ‘short con’ on an unsuspecting housewife. Roy is exposed to bright sunlight, when a door is opened to her garden, which triggers an increase in his facial tics, grunts and then the onset of a panic attack.

Roy takes regular medication for his symptoms, but despite this treatment he lives a lonely life and seems unable to act on a clear attraction, apparently reciprocated, toward a cashier at his local supermarket. Although Frank is seen to be generally supportive and tolerant of Roy’s symptoms, he occasionally finds pleasure in upsetting him by deliberately defying his need for cleanliness. Matchstick Men creates a tremendous tone of anxiety for the viewer in the scenes in which Roy struggles to control his world. His smoking, an attempt to self medicate, increases as he becomes more stressed and anxious and is at times almost unbearable to watch, especially in the confined space of his car.

When Roy accidentally loses the remaining supply of his psychiatric medication down the waste disposal unit of his sink, a comic element is briefly added to the film, soon followed by Roy’s horror and despair when he finds that the doctor, who was supplying them illegally, has moved away. Without medication, his symptoms worsen, such that Frank arranges for him to see a psychiatrist he knows called Dr Klein. In the first meeting with Dr Klein, Roy begs for just a few tablets. Dr Klein refuses and insists on a proper assessment, during which Roy reveals that he has been without an intimate partner since leaving his wife almost 15 years before and that his wife had been pregnant when they parted. Roy, uncertain as to whether he had been the father of the baby, becomes curious to know whether he now has a 14 year-old child. Dr Klein supplies Roy with some different pills, that he believes will help him to feel much better, and says he will contact his ex-wife on his behalf. The new pills appear to help improve all of Roy’s symptoms. After learning that has a daughter, called Angela, who would really like to meet him, Roy is challenged by his newfound role as her father and his obsessive-compulsive disorder is tested to its limits by her visits to his house. As he struggles to cope with a messy teenager in his life he also becomes aware of the positive emotional effect that she is having in his sterile life. Faced with the dilemma of whether he should tell her the reality about his work, she makes some discoveries in his home, which force him into telling her the truth.

As Angela learns about her father’s real profession and the amount of money that he has made from it, she asks to learn the trade from him. Wanting to keep her presence in his life, he reluctantly agrees. Caught up in the wish to please Angela, he reluctantly teaches her how to carry out a simple ‘con’, but forces her to return the money to the victim after it has been successfully completed.  Frank, by this stage, has persuaded Roy to carry out a ‘long con’ with him, that promises to extort a much larger sum of money from a businessman that Frank has met. Contrary to Roy’s wishes, Angela becomes involved in the final part of the operation, which goes very wrong. On returning home, Roy and Angela find the business man holding Frank hostage and he requests all of the money that Roy has in the house. When Angela goes to get the money, she returns with a gun and shoots the businessman. Frank and Angela drive away at Roy’s request before he receives an unexpected blow to the head from the businessman. As Roy wakes up in a hospital bed, he is questioned by police officers, but refuses to answer anything until he can see his psychiatrist. When Dr Klein arrives at his bedside he whispers the pass code for his bank vault box and asks that it be given to his daughter. It is only when Dr Klein has left and no one else returns that Roy gets up and opens his hospital room to reveal that he is on the roof top of a tall building and is himself the victim of an audacious sting carried out by Frank, with the help of a fake daughter, psychiatrist and businessman. However, one year later, after having lost all of his money, Roy has found love and marriage with the cashier, who is now pregnant with their first child. He is also honestly employed as a carpet salesman and suffers far fewer symptoms. 

Relevance to the field of Mental Health

The subject of OCD has been covered in my previous Minds on Film blog about The Aviator and I would refer readers, wanting more information about OCD, to that post. In the character of Roy, there is ample opportunity to examine the day-to-day effect that obsessive-compulsive disorder might have on an individual and their relationships. However, Matchstick Men also introduces viewers to one of the conditions commonly associated with OCD, Tourette’s syndrome. This is a neurological condition characterised by involuntary, random sounds and movements, known as tics, which usually begins in childhood. It is thought that up to 60% of children with Tourette’s syndrome develop OCD. The tics are often used to relieve uncomfortable feelings or sensations and many people are unaware of their tics. In Roy’s case his tics and grunts are seen to be closely linked to his level of anxiety, something that is well recognised in sufferers generally. His vulnerability at the hands of others reminds us of the predicament that many people with mental illness live with. It is only when Roy has abandoned his stressful life of crime and finds a meaningful loving relationship, that he is able to overcome the most distressing symptoms of both of his disorders.

There is excellent information about all aspects of Tourette’s syndrome at the NHS Choices website, including a discussion about the co-morbidity with OCD and ADHD, and further advice is available at the website of the charity Tourettes Action. Medication does have a role in treating some of the symptoms of Tourette’s syndrome and there are three types of drugs that may be used: alpha2-adrenergic agonists; muscle relaxants and neuroleptics. Behaviour therapy is the widely used non-pharmacological treatment of choice, which can be used alone or with drugs depending on the severity of the symptoms. Through using relaxation and a technique called habit reversal many people with Tourette’s syndrome are enabled to manage their symptoms better.

I would highly recommend Matchstick Men to anyone interested in working in Adult Mental Health, whether in psychiatry, psychiatric nursing, psychology or in any of the branches of psychotherapy.

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

•  More information about Matchstick Men is available at IMDB, as well as a short trailer.

•  The film can be purchased at amazon.co.uk.

 
03/10/2011 15:40:22

Like Stars on Earth

Introduction

Like Stars on Earth (Taare Zameen Par in Hindi), is a Bollywood movie - the popular name for Hindi-language films that are made in Mumbai - which was released in the UK in 2007. Characteristic of most Bollywood films, it is long at 156 minutes and uses songs and dance, which are relevant to the storyline by offering the opportunity to explore what may be going on in the mind of a character or to anticipate an event that has or is about to occur. The songs may usefully be seen as ‘dream sequences’, which allow things to happen that are not founded in reality.

The soundtrack is a significant part of the final product and is often released separately to the film, as it is in this case, where the CD is enclosed within the DVD box. For a good introduction to Hindi-language cinema, the British Film Institute website has an excellent article by Shyam Benegal.

Like Stars oon Earth

Like Stars on Earth was produced and directed by Aamir Khan, who also stars in the film, in a collaboration with Disney Studios. It tells the story of undiagnosed dyslexia in a young boy with aspirational middle class parents. This film was made to educate families in India about dyslexia and other related conditions such as attention deficit disorder, as outlined in the panel discussion included in the DVD extras. Khan, who is a very popular and well-regarded Bollywood actor, made his directorial debut with Like Stars on Earth, receiving much critical acclaim. 


The Film

The film opens with Ishaan, an eight-year-old boy, trying to net some small fish in the water by the side of a street, oblivious to the waiting school bus nearby. He is delighting in the task of fishing and completely absorbed in the task. In the next scene at school, Ishaan gazes out of the window of his classroom, distracted from the lesson he is in, which gets him into trouble and it becomes clear that he is repeatedly failing to attend to and complete his school work. At home, his older brother is a high achiever, to the clear approval of his aspirational parents. In contrast, Ishaan is drawn to the world of creativity, with a love of painting, puzzles and model building, which his brother is alone in praising. The first song sequence perfectly portrays the difference between Ishaan’s inner world and that of his striving goal directed family.

It is only after a series of failures in his class tests that Ishaan truants from school and gets his brother to fake the absence note. The head teacher finally makes his parents aware of the extent of his problems and suggests that he cannot proceed to the next year. His mother, who has tried to coach him in reading and writing at home, is frustrated by Ishaan’s apparent lack of concentration and ability in his studies whilst trying to counter her husband’s exasperation that Ishaan is being deliberately stubborn and lazy. As a result, Ishaan is sent away to a strict boarding school to be ‘sorted out’. Here he continues to fail academically and Ishaan soon becomes increasingly low in mood and more withdrawn socially, interacting only with another physically disabled pupil, who becomes his friend. During this period, he also loses enthusiasm for his creative activities, which have always brought him so much pleasure, as he struggles to cope with the loss of his family and his home environment.

It is only with the arrival of a temporary Art Teacher at the boarding school, called Ram Shankar Nikumbh, that there is hope for Ishaan. This teacher uses different methods to engage the pupils, as illustrated by his introductory song, in which he introduces himself to the class dressed as a colourful clown. Nikumbh soon becomes aware that Ishaan is not a happy child and begins to suspect the true nature of his difficulty. Nikumbh’s alternative attitudes to learning and his emphasis on creative freedom eventually engage Ishaan, as he realizes that they share a similar way of viewing the world that is acceptable. It is through this bond that Nikumbh eventually reveals he too suffered similar difficulties as a child, giving Ishaan a positive role model and a way out of his depression. Gradually, Ishaan’s self-esteem recovers with the sensitive encouragement of Nikumbh, who highlights Ishaan’s artistic talents to his parents and headmaster, who are finally able to be proud of him for his unique achievements.

Relevance to the field of Mental Health

As an introduction to the topic of dyslexia, Like Stars on Earth provides a wonderful case history that highlights not only the first hand experience of dyslexia in a young child but also the consequences of a missed diagnosis. Although viewers might find it hard to believe that Ishaan’s experiences at school could actually happen in the UK, it is important to recognise how easy it is for children to be labeled naughty or stupid when, in fact, they are struggling with dyslexia. As the actress Greta Scacchi writes, in her recent article for the Evening Standard newspaper, her son suffered from significant problems as a result of his dyslexia in the earlier years of his schooling in the UK, in both the state and the private sector. 

The clever use of animation, in the song bheja kum, provides the viewer with an opportunity to experience what a dyslexia sufferer may see when they look at a page of print or numbers and the symbols dance around. As such, it would be a perfect springboard for a discussion about the symptoms of dyslexia. But this song sequence, with its fantastical exaggerations, also offers the viewer an important insight into the effect on a child of repeatedly failing in their academic studies and being made to feel stupid and lazy at such a young age. In turn, it becomes very easy to understand why there is a close association between dyslexia and both conduct and mood disorders.

Dyslexia or specific reading disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as ‘reading achievement (that is, reading accuracy, speed or comprehension as measured by individually administered standardised tests) that falls substantially below that expected given the individual's chronological age, measured intelligence and age-appropriate education. The disturbance in reading significantly interferes with academic achievement … If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it.’

According to the Dyslexia Research Trust, a UK charity, ‘1 in 10 children suffer from dyslexia. Dyslexia is the most common cause of childhood loss of self-esteem, leading to profound misery and even suicide, or vandalism, violence and criminality. 50% of convicted criminals are thought to be dyslexic’. There is a genetic basis to the condition, as confirmed by twin studies, which causes differences in the development of the brain, including microscopic differences in the arrangement and connection of neurons. These tend particularly to involve visual and auditory 'magnocellular' systems which are specialised for rapid information processing. Dyslexia is more common in males than females and there is often an overlap with attention deficit hyperactivity disorder, conduct disorders and with dyspraxia. The film offers an excellent opportunity to consider the issue of co-morbidity when considering Ishaan’s behaviour at various stages of the story.

The NHS choices website has some very informative pages on dyslexia, with a good discussion of the symptoms, causes and treatment options. It is interesting to note that brain imaging studies have shown that people with dyslexia use different parts of their brain, and that they make more use of the right hemisphere, which is involved in the more creative aspects of thought. Ishaan’s story helps to reinforce this different way of engaging with the world that people with dyslexia often have and that this can be used to their advantage once the condition has been recognised and the educational supports are in place. People with dyslexia are often very good at thinking ‘outside the box’ in an innovative and creative way. There is further information available about all aspects of the condition at the British Dyslexia Association website.

For psychiatrists, there were two excellent review articles, published in 2010 in Advances in Psychiatric Treatment, written by child and adolescent psychiatrist Dr M.S. Thambirajah, entitled Developmental dyslexia: An overview (Advances in Psychiatric Treatment 2010 v. 16, p. 299-307 abstract) & Developmental dyslexia: clinical aspects (Advances in Psychiatric Treatment 2010 v. 16, p. 380-387 abstract). These articles could be read alongside a viewing of Like Stars on Earth to provide comprehensive learning about dyslexia for anyone interested in working in Child and Adolescent Psychiatry.

This post is dedicated to C.P.

Thanks to my colleague Dr S.S. for the film recommendation

•  Further information about Like Stars on Earth is available at IMDB, as is a short trailer.

•  The film can be purchased at amazon.co.uk.

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

 

 
01/09/2011 10:37:27

Birdy

Introduction

Birdy was released in 1984 and directed by Alan Parker. It won the Jury’s Special Grand Prix in 1985 at the Cannes Film Festival and is based on the novel of the same name by William Wharton. It tells the story of two friends, Birdy and Al, played by Matthew Modine and Nicolas Cage respectively, who are conscripted to fight in Vietnam, where they both suffer different degrees of mental and physical trauma.  The film alternates between scenes after their return from the war, which take place in the military psychiatric hospital where Birdy is a patient, and the back-story of the friends’ early life together, told chronologically in flashbacks.

Birdy

These flashbacks reveal the gradual development of Birdy’s extremely bizarre behaviour, involving his preoccupation with birds and flying, which is firmly in place before he goes to Vietnam. In contrast, the scenes in the psychiatric hospital reveal how both Birdy and Al have been affected by their experiences in the war. The film offers a perfect opportunity to consider the issues of Post Traumatic Stress Disorder in both characters, and the development of catatonia in Birdy. 

The Film

The film begins after the friends have returned from the war and are both in separate military hospitals. Birdy is seen squatting on the floor of a bare cell looking up at the high window, in a position suggestive of a bird. Al is returning from surgery to a ward with his face in bandages, the result of severe burns requiring skin grafts. Al is soon sent to visit Birdy, at the request of Birdy’s mother, in the hope that their friendship will help to entice Birdy out of his bizarre unresponsive, mute state. Al learns that Birdy was missing in action for a month in Vietnam before being found and that he has not talked since then. Al starts trying to communicate with his old friend using their shared memories. At this point we see the first flashback from their youth, in which Al catches sight of Birdy squatting high in the branches of a tree, and learn that the neighbourhood children have given him the nickname ‘Bird Boy’ or ‘the weird kid’. As the back-story progresses, Al and Birdy’s unlikely friendship unfolds as Birdy’s singular passion for birds and flight draws Al in to many daring and sometimes dangerous ventures.

In the scenes at the psychiatric hospital, Al becomes more and more frustrated by Birdy’s lack of response, and his own need to reconnect with his friend becomes increasingly apparent. Al chooses to withhold the important information about Birdy’s background from Dr Weiss, the psychiatrist, wanting to keep the things that they did together private. The flashbacks begin to reveal the development of Birdy’s increasingly strange and abnormal behaviour as he is seen trying to live in the pigeon coop like his birds, and later when he strips naked to sleep in the large birdcage with his female canary, whilst he experiences some erotic fantasies centered on his pet. As well as this, Birdy’s social isolation and lack of interest in any intimate human sexual relationship is brilliantly portrayed when Birdy’s parents force him to go to the school prom with a date. It later becomes clear that Birdy believes that he will fly one day, using his own muscle power, and that he can learn to talk to his pet birds. In fact in one conversation with Al, Birdy states that he saw himself fly one night and believed that he was a bird.

As Al becomes more angry and agitated by his inability to connect with Birdy, we learn that he suffers from flashbacks of the events that injured him, which occur during his sleep and that wake him, drenched in sweat. He doesn’t want anyone to know that he is suffering in this way, but it becomes clear that Al is struggling to maintain his own mental health. After having no success in helping Birdy to speak again, Dr Weiss threatens to send Al away, but Al makes one final request of the psychiatrist, that he hopes might trigger Birdy’s memory of their past friendship. By this time, Al is desperate for Birdy’s friendship and conversation and the breakthrough comes as Al tells him, in tears, how awful he is feeling. As Al sits holding Birdy close to him on the floor of his cell, he is astonished when Birdy says “Al sometimes you’re so full of s**t”. When Al asks him why he decided to talk, he replied “I didn’t, it just happened”. The ending of the film must be left for the viewer to experience.

Relevance to the field of Mental Health

This film provides an excellent opportunity to discuss the development of a catatonic schizophrenic illness in a young man, from his pre-morbid schizoid personality to his episode of mute posturing in the pose of a bird, triggered by his experiences of war. It also offers a platform to consider the effects of traumatic war experiences on both young men.

As catatonic schizophrenia has become less common in our society, perhaps because there is earlier intervention and effective drug treatment for schizophrenia now available, Birdy provides a very important opportunity for students of all mental health professions to gain an understanding of the condition. Catatonia is defined as a disturbance of motor behaviour that may have a psychological or neurological cause. In its most well known form, the individual may remain fixed and immobile in a bizarre and uncomfortable position for a lengthy period of time lasting days or even longer. It can also present with agitated hyperkinetic behaviour. Catatonia, as a symptom, is associated with a variety of mental disorders, only one of which is schizophrenia. Other conditions associated with the symptom are brain disease, mood disorders, drugs, alcohol and metabolic disturbances.

As outlined in the ICD-10 classification of mental disorders, the diagnosis of catatonic schizophrenia is indicated if there is pronounced psychomotor disturbance present, with a marked decrease in reactivity to the environment. Bizarre postures may be held for lengthy periods of time and mutism may be a feature. The other features of schizophrenia, such as delusions and hallucinations may also be present, but if a person is mute, this will not always be possible to assess at the time of presentation. The film provides a superb understanding of the importance that past history plays in unraveling the possible causes of mutism. Because Al withholds this important information from the psychiatrist, there is no possibility of Dr Weiss understanding the context in which Birdy has become unwell.

For further information about schizophrenia, the Royal College of Psychiatrists website has some useful pages.

Of particular interest in this film is the fact that the story is not just about Birdy’s mental illness, but also about the effects on Al of his traumatic experiences in Vietnam. He is seen to develop some of the symptoms of post-traumatic stress disorder. This provides an additional platform for considering the topic of PTSD, perhaps alongside a reading of the information at the Royal College of Psychiatrists website on the condition. The NHS choices website also has an informative video featuring the personal account of a victim of the 7th July London bomb blast.

I would recommend this film for anyone interested in general adult mental health and in particular for learning about the development of a schizophrenic illness.

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

•  Further information about Birdy is available at IMDB, as is a short trailer.

 
01/08/2011 10:05:15

Private Property


Introduction

Private Property, or Nue Propriété, is a film in French with English subtitles, co-written and directed by Belgian director Joachim Lafosse and released in the UK in 2008. It stars Isabelle Huppert, as Pascale, who gives an excellent portrayal of a single mother struggling to parent her adult twin sons, played by brothers Jérémie and Yannick Renier. The film is an intimate family portrait of the aftermath of divorce ten years previously, showing how each family member has been affected. Private Property explores the vulnerable position of children caught up in the post divorce hurt and anger that can continue indefinitely if both parents remain confrontational in their quest to win the allegiance of their children.

Private Property

But the film also considers the issue of personal boundaries between siblings, parents and their young adult children, giving it a particular interest to psychotherapists working with families or individuals who have experienced divorce, in an age when an increasing number of children remain in the family home well into their twenties. 

The Film

The film opens with Pascale trying on a negligee in front of her bedroom mirror and calling for one of her twenty year-old sons, François, who appears wearing only his underpants and a t-shirt, to give her his opinion about how she looks. They are soon joined by his twin, Thierry, similarly dressed, who makes some jokingly crude and hurtful comments about his mother. From this first scene we understand immediately the difficult and disrespectful relationship that exists between Pascale and her sons. As we watch her prepare meals for them, which her sons always eat ravenously whilst criticising everything she says, it becomes apparent that Pascale has no parental control over them, but especially over Thierry’s angry bullying behaviour. When she returns home from work one day to find her ex husband in the house with their sons, she becomes enraged and asks him to see them elsewhere, frustrated by the intrusion into her personal space which so undermines her authority. Filmed with slow static takes that perfectly capture the claustrophobic atmosphere within the rooms of the home, Private Property painfully portrays the intense emotional interactions between the twin brothers and their mother.

Private Property shows the difficult job of a single mother, dependent on the financial support of her ex husband, struggling to make things good for her sons without the balance and support of another adult partner in the home. Her devotion to her sons has been her major focus for the ten years since the divorce until she begins to recognise the need to focus on her own life again. We learn that she is having a secret relationship with her neighbour, Jan, a cook who wants her to sell up the family home and move away with him to open up a B & B. She gradually builds the courage to tell her sons this plan, but they are so shocked at the prospect of a change to their lives that they completely forbid a sale of the house, which they remind her was bought by their father for them. Thierry meets with his father, Luc, to inform him of Pascale’s plan and is reassured by him that she will not be allowed to sell the house. However, François reflects on the possibility of actually helping his mother and Jan in the B & B, revealing a difference between the brothers in their relationships with Pascale. Throughout the film we are shown scenes of the brothers playing table tennis and computer games or lounging in front of the TV whilst waiting for Pascale to feed them.

Desperate for some adult support in regaining parental authority in the discussion about her future, Pascale invites her lover Jan to supper. He cooks the family a special meal and is rewarded by rudeness from Thierry and disinterest in eating his food. Soon after, Jan tells Pascale that she must sort out her relationship with her sons before he can see her again and she becomes more isolated than ever. The brothers start to argue more frequently between themselves, and with their mother, causing the family to finally disintegrate when Pascale leaves home in search of some space for herself, unable to cope with Thierry’s behaviour.

I will not describe the end scenes in any detail, except to say that they reveal the ultimate emotional vulnerability and immaturity of Thierry, whose anger finally causes great damage to the family. We come to understand that there has been a catastrophic failure in helping him to process the deep hurt and loss that he experienced as a result of his parents divorce and that he has continued to suffer as a result of their ongoing poor relationship. Perhaps appropriately for the subject matter, the film concludes without resolution.

Relevance to the field of Mental Health

Private Property provides us with a window on the world of the post divorce family ten years from their break up and gives us an opportunity to reflect on the harm of continuing conflict between divorced parents over many years. The film is especially good at illustrating the damaging effects that an acrimonious divorce can have on older children, particularly when their divorced parents continue to undermine each other as they fight for the allegiance of their children. Because Luc has bought the farmhouse for his sons and ex wife, he remains essentially in control of the family, depriving Pascale of any freedom to move on. Her dilemma is very well performed by Huppert as the downtrodden, impoverished, exhausted single mother who is trying too hard to put her sons needs first, trapped by the role that she has played in creating their inconsiderate selfishness, whilst unable to realise her own desired future.

Private Property might also be of particular interest to psychotherapists, working with families or individuals, as a focus for discussion about the role of inter-personal boundaries within relationships. Indeed the film opens with a dedication “To our boundaries”, setting the psychological agenda that will be explored. The close bond that is presented between the twin brothers, as we watch them shampooing each other’s hair in a shared bath, gives rise to uncomfortable feelings of an inappropriate inter-personal boundary between the siblings, characterised by inadequate emotional separation from each other and from their mother. Later on in the film we witness the dangerous consequences of that inadequate separation. In the opening scene in which Pascale asks François for his opinion of her newly purchased undergarment, we are in equally uncomfortable territory, as we witness a sexualised conversation between a mother and her adult sons. As a training exercise for those wanting to work with families in distress as a result of divorce, this film offers a wealth of opportunities for observing both verbal and non-verbal interactions that point to the difficulties each family member is experiencing.

For further reading, The Royal College of Psychiatry website has a good factsheet on the effect that separation and divorce of parents may have on children and young people, in their Mental Health and Growing Up series. The website Divorce Aid also has a number of relevant pages for teenagers. As such, this film could be used as a springboard for discussions about the effects of divorce on the mental health of children for medical students and psychiatric trainees.

•   Further information about Private Property can be found at IMDB.

•   The DVD can be purchased at amazon.co.uk, but only from third party sellers. However it is available to rent from various sources.

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

 

 

04/07/2011 14:49:21

Sharing the Secret

Introduction

Sharing the Secret was made as a television drama in the United States in 2000 and first released in the UK on DVD in 2003. It received a Peabody award in 2001 for the accuracy of its portrait of a teenager in crisis. Directed by Katt Shea, with perceptive performances from its cast, it explores the subject of bulimia nervosa in a high achieving teenage girl, Beth, whose parents divorced a few years earlier. Offering a wonderful platform for a discussion about eating disorders in general, it could also be used to explore the differential diagnoses that may be associated with the symptom of binge eating. Of additional interest is the fact that Beth’s mother, Dr Nina Moss, is a child psychologist who treats children suffering from emotional difficulties as a result of divorce but who is unable to detect the early signs of emotional difficulty in her own daughter.

Sharing the Secret

The Film

The film opens with teenager Beth having breakfast in a restaurant with her father John, who is remarried and has a young son.  Beth excuses herself to go to the toilet, looking tense and upset. We next see her in the flat, where she lives with her mother Nina, as Beth is doing homework w ith a friend. Her mother comes home hungry that evening and is unable to find a portion of Chinese food that she had stored in the fridge. Beth tells her that she had thrown it out because the smell made her feel sick. Nina comments to Beth that she has grown ‘tall and skinny’ and Beth replies that she likes looking that way. These first few minutes set the scene for the story that unfolds, introducing the suspicion of something secretive about Beth’s behaviour concerning food and that she has a particularly acute focus on her own body image.

Beth is a bright and able student who has a passion for ballet. She is struggling to fit in with her peers, who are all preoccupied to some extent with their body appearance and the world of dating. At a friend’s party, Beth actively sabotages the approaches of a boy and in the following scenes she is seen to avoid eating, always giving a seemingly plausible reason for her abstinence, until we are eventually shown her binging secretly on a large amount of food before making herself vomit.

Her father wants to integrate Beth more fully into his new family and invites her to stay over at his house for a weekend, something that she has not done since his remarriage. In a particularly poignant scene, during the first sleepover, her father tells Beth that she is gorgeous and then says “I wish I’d frozen you at 10, you’re growing up so fast”. Beth, clearly upset by this, denies that she is growing up. In contrast, Beth’s mother does not have a new partner but works long hours as a child psychologist. She and Beth appear to have an overly close, loving relationship in which Nina even shares certain details about her patients. Indeed, Nina’s therapy sessions with one young girl, Rachel, are shown in some detail. The film portrays Nina’s attempts to ‘give Rachel a voice’, to express the difficult feelings she has in her father’s newly blended family. This storyline contrasts brilliantly with Beth’s reality in which her parents seem to have worked hard to avoid any openly expressed negative emotions about their separation, although animosity simmers just below the surface. This, in turn, has left Beth trying hard to please them both with her compliant behaviour and high academic achievements.

Beth’s secretive bulimic behaviour finally comes to light as her physical health deteriorates and she collapses at school. Forced into therapy by her mother, Beth initially rebels but then begins to engage with the therapist, allowing her to acknowledge her illness. It is only then that she asks for some inpatient help, as she recognises the need to get some distance from both her mother and her father. In a brilliant scene between Beth and Nina, in which Nina describes the shame and guilt that she is having to bear, Beth shouts out angrily “ It’s not about you....it’s about me”. The film ends with Beth beginning to make progress in the inpatient unit but with more still to achieve, viewers must decide how they feel about her future.

Relevance to the field of Mental Health

As a clinical case study, Sharing the Secret presents a very good portrait of bulimia nervosa and provides an excellent presentation of some of the underlying psychological issues that may play a part in the genesis of an eating disorder in the teenage years. The film also offers an opportunity for discussing the difficulties that may be encountered in trying to engage sufferers in any form of psychological therapy.  Sharing the Secret could also be used for teaching students about the wider effects that an eating disorder, in one family member, can have on others in the family. In particular, it explores the painful struggle of a mother who is forced to cope with the guilt she feels about failing to recognise her own daughter’s eating disorder.

There is a useful, detailed discussion on the topic of bulimia and binge eating in an article by Zaffra Cooper and Christopher G. Fairburn, in Advances in Psychiatric Treatment (2009) 15: 129-136 entitled Management of bulimia nervosa and other binge eating problems (abstract). This article was a revision of a paper by Christopher G. Fairburn with the same title, published in Advances in Psychiatric Treatment (1997), vol. 3, pp. 2-8, now freely available in its entirety. Beth clearly presents the three cardinal features required for the diagnosis of bulimia nervosa; frequent binges of large amounts of food; the use of vomiting, fasting and or exercise to control shape and weight, and, lastly, an extreme focus and concern about weight and body shape, indeed a fear of being fat, bound up closely with a low self-worth. All of this occurs without excessive weight loss.

Further information can be found on eating disorders at the Royal College of Psychiatrists website as well as a leaflet on anorexia and bulimia. The  NHS choices website has a good short video featuring consultant psychiatrist Professor Janet Treasure, from the eating disorder unit at South London and Maudsley NHS Trust, discussing bulimia.

CBT for the treatment of bulimia nervosa has a good evidence base and there is an interesting article discussing the use of CBT for a variety of conditions when working with young people and their families, entitled Cognitive-behavioural therapy with children, young people and families: from individual to systemic therapy in Advances in Psychiatric Treatment (2010) 16: 23-36 (abstract) written by consultant psychiatrist Nicky Dummett.

With its excellent portrait of an eating disorder in a teenager, I would definitely recommend Sharing the Secret to anyone interested in working in the field of child and adolescent psychiatry regardless of their discipline. This film may also be of interest to sufferers and their families.

•   More information about Sharing the Secret can be found at IMDB.

•   The DVD can be purchased at amazon.co.uk.

•   Minds on Film is written by consultant psychiatrist Dr Joyce Almeida

 

 
01/06/2011 08:21:50

The Machinist

Introduction

Released in the UK in 2005, The Machinist was directed by Brad Anderson and stars Christian Bale in one of the most committed performances to be seen in cinema. Bale loses so much weight for the part of Trevor Reznik, more than 4 stones in a matter of months, that his skeletal form is almost too difficult to watch at times. The film opens with the main protagonist, Reznik, in an extremely disturbed state of mind, seemingly disposing of a body rolled in carpet. What follows is the back-story to this scene, as we learn that Reznik has suffered from a year of crushing insomnia and dramatic weight loss. The film ends with us understanding the cause of his initial insomnia and the subsequent development of his paranoid psychosis.

The Machinist

With a tagline to the film that states ‘A little guilt goes a long way...’ we find ourselves firmly in the realm of psychiatric illness for the whole of the 98 minutes and it gives the viewer an opportunity to experience the confusing and frightening world of paranoia at close quarters. The screenplay was written by Scott Kosar, who states that he was influenced by Dostoyevsky’s The Double: A Petersburg Poem, a short novel that describes the inner struggle of its protagonist, who starts seeing his double everywhere, as his mental state deteriorates. It is worth mentioning that some scenes in The Machinist are disturbing, despite it being rating as a 15. 

The Film

I do not intend to reveal the entire plot of The Machinist, but wish to consider the way in which the film provides us with suggestions about Reznik’s mental state. This begins with the choice made by the director, throughout most of the film, to use a cinematic atmosphere of low light and grimy surroundings, which contribute to an overall tone of hopelessness and despair. The musical score also reinforces what we see of Reznik’s fearful, persecutory state of mind for much of the film. But it is the gaunt, haunted skeletal appearance of Bale himself who manages to convey the complexity of his character, racked with guilt, denial and increasing persecutory anxieties, that makes this an extraordinary visual account of a mental illness unfolding before our very eyes.

After the initial opening scene described above, we learn that Trevor Reznik is single and works as a machine operator at the local factory. We discover that he visits a prostitute, called Stevie, regularly and that he is a friend to her as much as a client. Early in the film, she is clearly concerned about both his weight loss and his distracted mental state and suggests that he see a doctor. However, he refuses to seek help of any kind. The management at his workplace also express concern about his weight loss and mental state, asking him if he is ‘doing drugs’. To them he states that he has got a lot on his mind, but he’s dealing with it.

 

His distracted mental state then leads to an awful accident at his work in which a colleague loses a limb, resulting in the other workers turning against Reznik for his ‘weird’ state of mind. His paranoia in this context appears real and justified. In the investigation of the incident, Reznik confesses to having been distracted by another worker, called Ivan, leading him to discover that there is no such person employed by the factory. However, Ivan continues to pursue Reznik, who begins to feel increasingly persecuted. He begins to neglect his day-to-day responsibilities and personal care and in a downward spiral of despair also loses his job. But he continues to turn to Stevie as someone he can trust until, finally, she too becomes a part of his persecutory world and she throws him out of her flat. A parallel storyline, with particular significance to the film, concerns Reznik’s late night trips to the airport coffee bar where he has become well known to the waitress there who works the night shift. Interestingly, these scenes are bathed in light and seem to offer some temporary way out of the darkness for Reznik.

 

As the film progresses the boundary between truth and delusion becomes completely blurred for Reznik and the viewer. Certain everyday objects, like the cigarette lighter in his truck, appear to take on a special significance only understandable after the final scenes of the film. We are not sure what to believe until we are given several clues that Ivan is in fact a part of Reznik himself, hounding him until he finally makes the right choice about something he has done. Only when he takes full responsibility for his earlier action does he get any resolution of his guilt and can at last fall into a deep sleep.  The film provides us with the final piece of the psychological puzzle at its very end but some viewers may have managed to collect enough clues before then to reach the correct conclusion for themselves.

 

Relevance to the field of Mental Health

For any professional engaged in carrying out mental state assessments, this film offers the opportunity to enter the persecutory world of an individual and to experience the blurring of boundaries between truth and delusion that so disturbs people suffering from a paranoid psychosis. An excellent article on paranoia, entitled Helping patients with paranoid and suspicious thoughts: a cognitive–behavioural approach by Daniel Freeman and Philippa Garety (Advances in Psychiatric Treatment (2006) 12: 404-415) could be read alongside a viewing of this film for enriched learning.

 

The Machinist offers not only a brilliant springboard to teach about the experience of paranoia but also presents the opportunity to consider the differential diagnosis in someone who presents with such symptoms and to examine the predisposing, precipitating and perpetuating factors that might be used in constructing a psychodynamic formulation. Further discussion about psychodynamic formulations is available in a two-part article published in Advances in Psychiatric Treatment entitled Teaching of psychodynamic formulation to psychiatric trainees (2005) 11: 416-423 and (2006) 12: 92-99 both by Chris Mace and Sharon Binyon.

 

With regards to Reznik, one could suggest that his premorbid personality, shaped perhaps by the absence of his father from a young age, coupled with his single status and lack of intimacy, has predisposed him to develop a depressive episode, in which he suffers from extreme anorexia and chronically impaired sleep, which in turn further impair his cognitive functions. We come to understand that the trigger for his illness was his spur of the moment decision to flee from a traumatic event generating huge guilt. His depression steadily worsened over a year without any professional help, until he develops a severe psychotic depressive episode with mood congruent paranoid delusions, visual hallucinations and second person auditory hallucinations. I suggest that Ivan represents a projection; the mental mechanism described by psychoanalysts whereby a person attempts to get rid of unacceptable impulses or parts of the self by externalising them.

 

The Machinist could also offer a platform for discussion about the topic of insomnia and chronic sleep deprivation. A very good and broad introduction to the topic of insomnia and its causes can be found on the NHS choices website. It is important to note that although Reznik states that he hasn’t slept for a year, we actually watch him having a brief lapse into sleep that lasts a few seconds one night. In reality, the sleep deprivation record is thought to stand at 266 hours (a little over 11 days) achieved on live webcam in 2007 by a 43 year old Cornishman called Tony Wright, as this BBC report describes. The Guinness Book of Records stopped acknowledging attempts at sleep deprivation prior to his achievement because of the negative consequences for health.

The Machinist could definitely be used to teach students from various backgrounds about persecutory delusions and abnormal perceptions and it illustrates the importance of obtaining an independent history from an informant, whenever possible, when interviewing someone suffering from paranoid symptoms. I would recommend this film for anyone seeking to work in adult mental health.

 

Finally, after mentioning the first national medical film festival, Medfest 2011, in my last post, I was fortunate to attend the St George’s event as a panellist. The three contrasting films shown made for a very interesting evening of viewing and discussion, one of which, called Shadow Scan, tells the harrowing story of an over stressed, drug addicted and depressed, self-harming junior doctor. Written and directed by doctor turned filmmaker, Tinge Krishnan, Shadow Scan won a BAFTA in 2001. Lasting ten minutes, it is available to watch on YouTube and could definitely be considered alongside The Machinist in a discussion about the filmic techniques used to create an atmosphere of despair and depression in a character. Shadow Scan can be viewed in its entirety here and for anyone interested in hearing more about the festival, there is an excellent review at the Lancet online, May 18, 2011.

 

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

•   The DVD can be purchased at amazon.co.uk

•   Minds on Film is written by Dr Joyce Almeida

 
04/05/2011 09:18:43

The Diving Bell and the Butterfly

Introduction

The Diving Bell and the Butterfly, released in 2007, was directed by Julian Schnabel and is based on the book of the same name. The film won a Bafta for best screenplay, a Golden Globe and an award for best director at Cannes Film Festival.

In French with English subtitles, it tells the true story of Elle magazine editor-in-chief, Jean-Dominique Bauby, who suffered a brain stem cerebrovascular accident at the age of forty-three. He consequently developed locked-in syndrome, a rare neurological condition characterised by quadriplegia and an absence of verbal communication but with preservation of eye movements and intellect.

The Diving Bell and the Butterfly


Bauby’s book was dictated by the blinking of his left eye in response to a translator who would recite the letters of the alphabet, a task requiring an extraordinary amount of patience, and it tells the story of his experiences from the moment he regained consciousness in hospital. The book was published in France in March 1997, ten days before Bauby died of pneumonia. Unusually for a film, we spend a great deal of time seeing things solely from Bauby’s direct perspective. This makes The Diving Bell and the Butterfly a particularly instructive experience for any mental healthcare professional seeking to better their empathic skills. 

The Film

The film opens with the blurry opening of Bauby’s eyes as he regains consciousness in a hospital room. We find ourselves sharing his view of the world as he wakes up to his new surroundings. We hear his internal voice attempt to answer the first questions from staff before realising that they cannot hear him because he cannot speak aloud. Very rapidly, his struggle to be understood becomes the viewer’s struggle as we are quite literally trapped inside his head. From his personal viewpoint, we experience the various professionals who come to help him, some better than others at empathizing with him. In this context, we can feel the relief when a speech and language therapist brings him a method that she believes will help him to communicate. Initially negative, Bauby soon finds a positive outlook on his situation and states that; “apart from my eyes, two things aren’t paralysed…my imagination and my memory”. In his mind, these are the two things symbolically represented by the Butterfly, which remain free to roam, whereas his body he represents as a Diving bell, in which his mind is trapped.

All of the devices used in filming succeed in putting us firmly in the protagonist’s place and this is the only viewpoint we are given for the first 15 minutes of the film before we begin to see Bauby from the outside, as a separate person. This technique has the effect of trapping us inside his body too, until we are released and able to view the world from our usual (in film, multiple) perspectives. This moment occurs for him and us at the point at which he is taken from his room for the first time and wheeled down a corridor, seeing his image reflected in a pane of glass as he is taken to a balcony and the fresh air. From this point on, we move between his perspective of the world and our own.

The fact that Bauby must rely solely on his left eye to communicate, and that he manages to express so much with it, reminds us of just how much can be transmitted by non-verbal cues in people with poor or non existent verbal speech. But most impressive of all is the real time experience we are given of the blinking alphabet dictation method that allows his thoughts to be heard and his book to be written. We are left in no doubt as to the enormous effort, determination and perseverance that was required to bring this story to its audience.

As well as his progress in the hospital, the film pieces together some of Bauby’s life before his cerebrovascular accident, with the help of intermittent flashbacks. One such flashback allows us to see the tender and close relationship he has had with his ageing father, which sets the scene for a particularly moving moment later on when his father phones him in hospital and tries to talk through his translator about his deepest feelings. Throughout the film he receives a series of visits from friends and family, each revealing a different reaction to his appearance and to the communication difficulty. One friend, who had been held hostage in Beirut for four years, sees a similarity between his own experience of confinement and Bauby’s entrapment in his body advising him to “hold fast to the human inside of you and you’ll survive”. His mistress is unable to visit him in contrast to the mother of his children, from whom he is separated, so that the film is also about the different reactions that his loved ones have to his condition.

Relevance to the field of Mental Health

The Diving Bell and the Butterfly offers the viewer a clinical case study of a rare neurological condition called locked-in syndrome. It presents us with a patient centered view of the extraordinary experience involved in living with such a disability whilst highlighting his experience of the professionals he encounters. The Diving Bell and the Butterfly is already recommended viewing for speech and language therapy students, but I believe it should be seen as widely as possible by anyone who cares for patients with any degree of impaired speech and movement, some of who find themselves within the mental health care services.

In particular, the film reminds healthcare professionals of our responsibility to treat every individual in our care with respect and dignity, using our empathic skills to put ourselves in others shoes, whether or not they can speak to us or communicate their thoughts effectively. The film is very good at demonstrating how small actions by a care assistant can have a huge effect on Bauby, when one turns on the TV, which is showing children’s cartoons, as she leaves his room, and another turns off the TV when it is showing a football game that Bauby is actually enjoying enormously. In both cases, he is powerless to get his needs met. These scenes might offer a perfect starting point for teaching students from a variety of backgrounds about how to develop empathy in a therapeutic setting.

For anyone wanting more detailed clinical information about this condition, it is discussed in a review article published in the BMJ in 2005 (Smith E, Delargy M. Locked-in syndrome. BMJ 2005; 330: 406-09). For another excellent patient centered account of locked-in syndrome and the distinction between it and persistent vegetative state, the BMJ published a very good clinical review, in 2005, written by a young man called Nick Chisholm, who suffered a series of brain stem cerebrovascular accidents after suffering concussion during a rugby match. As both the articles explain, locked in syndrome is caused by a lesion in the brain stem, commonly caused by a vascular incident, trauma or by extensive demyelination which affects the brain’s peripheral connections. As such, I would highly recommend this film for anyone interested in neuropsychology or neuropsychiatry.

At a time when the topic of teaching medical students empathic skills is being increasingly discussed, this film offers one of the best opportunities yet for stepping in to a patient’s shoes and experiencing life from the other side of the bed.

Any medical students interested in exploring the relationship between medicine and film further, may want to visit one of the many free events taking place, during May, at locations around the UK as part of Medfest 2011, the first national medical film festival, whose theme is ‘the Image of Doctors’.

* More information about The Diving Bell and the Butterfly can be found at IMDB as can a short trailer .

* The DVD is available on amazon.co.uk.

 

07/04/2011 09:19:24

Brassed Off

Introduction

Brassed Off, directed by Mark Herman and released in 1996, stars Pete Postlethwaite, Tara Fitzgerald, Stephen Tompkinson and Ewan McGregor. Strangely marketed as a comedy, this film tells the very moving story of impending mass redundancies in Grimley, a Yorkshire mining town, when its profitable colliery is threatened with closure.

It is set in 1992, at a time of great change in the coal industry, and chooses to focus on the lives of the miners who play in the Grimley Colliery Brass Band. The band is led by their passionate conductor Danny, who is determined to take the group to the finals of the National Championships at the Albert Hall. The late Pete Postlethwaite plays Danny, in one of his most acclaimed performances. This film was said to have played a part in the inspiration for The Coalfield Regeneration programme set up in the late 1990s to improve the quality of life in Britain’s coalfield communities.

Brassed off

The Film

The opening scene shows us some miners finishing a shift at the coalface before transforming into cleanly scrubbed workers clocking off. We first meet the all male group of musicians soon after that at their rehearsal where they are joined by a young woman called Gloria, who is visiting Grimley, and turns out to be the grand daughter of a former member of the band. An exception is made to the all male constitution of the band by allowing her to join them, after an audition in which she proves that she will be an asset to them in their quest to win the National Championships.

 

A love interest develops between Gloria and a young man in the band called Andy, which provides one of several storylines, as it becomes clear that Gloria’s presence in the town has something to do with the potential closure of Grimley’s coalmine. Through the following scenes, the film introduces us to the respective families and partners of each of the main members of the band and we come to understand the precarious financial predicament that some of them are in as they contemplate redundancy.

 

As Brassed Off progresses, the miners are offered a very favourable redundancy package by management, which many can’t resist and when a majority vote to accept the deal, pit closure becomes inevitable. One of those accepting the offer is Danny’s son, Phil, who is the trombonist in the band. He is already struggling to survive as a result of debts he accrued from the lengthy strike action he took ten years earlier. We watch him develop depression as he struggles to provide for his wife and four children. Unable to share his problems with anyone, he struggles to earn money as a children’s entertainer called Mr Chuckles. His serious financial predicament only comes to light with the arrival of two moneylenders at his front door, who demand the immediate payment of his debts before taking all of the possessions from his home. As a result, his wife leaves, taking the children with her, because she can no longer cope with such an impoverished life. At this point, Phil finds himself completely alone, having lost his job, his wife, his children and the contents of his house. When his father collapses in the street and is admitted to hospital with coal related lung disease, Phil attempts suicide.

The miner’s band seems likely to collapse after these events but doesn’t and they manage to keep the hope of National Championships alive as they struggle to hold on to their self esteem and community identity through their music, at the same time as contemplating a period of great personal uncertainty.

 

Relevance to the field of Mental Health

Brassed Off provides an ideal platform to discuss the effects that job insecurity and involuntary redundancy can have on the mental health of individuals and their families. Using the example of Phil and his family, the film provides us with an unfolding case history in which to consider the precipitating triggers for his depression and attempted suicide. It also provides an opportunity to reflect on the role of purposeful goal directed activity, both paid and unpaid, in maintaining an individual’s self esteem and self worth.

In the current economic climate in which there are, once again, threats of large-scale job losses, Brassed Off’s themes may be as pertinent to our society now as it was in the 1990s. With the recent announcement that the pharmaceutical company, Pfizer, is to close its R&D establishment in Sandwich, Kent, where 2,400 jobs will be lost (Guardian newspaper; 1st February 2011), there is concern about the effect that this will have on the town and its surrounding area. A whole infrastructure has grown up to cater for the staff and their families at the Pfizer plant and local groups talk of devastation to the surrounding environs when the facility closes. In a very direct way the issues portrayed in the film are relevant to the community in Sandwich.

 

An editorial in the March 2011 edition of the British Journal of Psychiatry by Dunlop and Mletzko entitled Will current socioeconomic trends produce a depressing future for men? ( BJPsych 2011 198, 167-168) discusses the topic some have called ‘Mancession’, reminding readers that approximately 75% of jobs lost since the beginning of the recession in 2007 were held by men. This is because the construction and manufacturing industries have been disproportionately affected by redundancies in the past few years.

 

An article entitled Job insecurity, socio-economic circumstances and depression by Meltzer H, Bebbington P, Brugha T; Psychol Med 2010 Aug (40(8): 1401-7) considers the topic of job insecurity in the context of the current economic difficulties in the UK and concludes that job insecurity has a strong association with feelings of depression in the people that they studied.

 

An interesting editorial in the BMJ from 2009, reviews the topic of Unemployment and Health (BMJ 2009; 338:b829). Written by Danny Dorling, professor of human geography, the article discusses the effects of mass unemployment on physical and mental health by reflecting on past epidemics and highlights how young adults, in particular, are affected. These topics are all brought to life by a viewing of Brassed Off and the film is surely relevant to all mental health professionals, as well as those working in primary care, as the UK faces a period of time characterised by spending cuts and rising unemployment.

 

For more specific advice on how to approach the consequences of losing ones job, the NHS choices website has an excellent short video called ‘coping with redundancy’, as well as plenty of other information on managing the health consequences of threatened or actual job loss.

 

  • More information about Brassed Off is available at IMDB.
  • The DVD can be purchased at amazon.co.uk.

Minds on Film is written by Dr Joyce Almeida.

21/03/2011 10:52:13

When a Man loves a Woman

Introduction

Directed by Luis Mandoki in 1994, When a Man loves a Woman stars Andy Garcia and Meg Ryan. It tells the story of an airline pilot, Michael Green, and his wife, Alice, a school counsellor, who seemingly have a wonderful life living with their daughters in San Fransisco, until the truth about her alcohol dependence reveals itself and threatens to destroy everything.

What is especially interesting about the film is that it is based on the actual experiences of one of the two writers, Al Franken, who is now a United States Senator from Minnesota. His wife struggled with alcohol dependency whilst their two children were young and he supported her through some very difficult times.  This was publically revealed in a campaign Ad made by Franken in 2008, which featured his wife talking about her addiction.

When a Man Loves a Woman

The Film

The film opens with a playful scene between Alice and her husband in a bar, clearly fuelled by the effects of alcohol on Alice. Soon afterwards, an anniversary dinner leads to some late night, disinhibited, public disorder as Alice eggs a car whose alarm keeps going off outside their home. In these various introductory sequences, we also see the role that Michael has within their relationship as the strong, capable partner, who often steps in and takes over, even in Alice’s role as mother to daughters Jess and Casey.

 

The problems first surface when Alice goes out for a drink after work with a friend who needs to talk, completely forgetting that Michael has a flight and must leave that evening. When confronted about this by him, her irritability soon dissolves into despair about the loneliness of her situation when Michael is away flying. Her secret drinking is soon uncovered and she confesses to having vodka bottles hidden in various places around the home. As Alice’s behaviour becomes more painfully disturbed and openly drunken, the effect on the children takes centre stage. This situation is brought to a dramatic head after she hits her eldest daughter shortly before falling through the plate glass shower cubicle in her bathroom, where she then lays unconscious on the floor. Her daughter Jess frantically calls her Dad, who is away at the time, to tell him that she thinks that Mummy is dead.  He finds himself organising emergency help from a distance in an extremely poignant scene. This episode leads directly to Alice being admitted, for ‘detox’, into an inpatient unit, where we follow her progress and that of the family.

The second part of the film focuses on Alice and the family after she has stopped drinking and is in recovery back home, attending regular Alcoholics Anonymous meetings. We watch the change in the balance of the marital relationship brought about by Alice’s new found ‘true self’ which threatens to tear them apart. The film illustrates the increasing emotional strain placed on Michael as he struggles to make sense of those changes and to understand his own part in their failing marriage whilst, at the same time, seeking some stability in his life again. The scenes between Michael and his daughters when he tells them that he is finally relocating to Detroit are a painful reminder of the effect that parental separation can have on children, and how the age of the child commonly determines their response.

The ending is not completely negative, but leaves open the possibility of something good ultimately developing between two individuals who have learned a lot about themselves and their relationship through an incredibly challenging experience. Although there is a more positive tone to the ending, When a Man loves a Woman succeeds in communicating the vulnerable situation experienced by every recovering alcoholic as they set out to live one day of their life at a time.

 

Relevance to the field of Mental Health

When a Man loves a Woman provides us with a platform to explore not only the general topic of alcohol addiction, but in particular the specific issues relating to women and alcohol. It reminds us that it is impossible to tell who may be drinking excessive amounts of alcohol in our communities and that we must always ask about alcohol consumption when taking a medical or psychiatric history. The BMJ has recently reviewed the NICE guidelines on Diagnosis, assessment and management of harmful drinking and alcohol dependence; Stephen Pilling et al (BMJ 2011; 342:d700) and alongside this, in the same issue of the journal, there is an account by a 78 year old man of his experience with alcoholism, written with his GP, Dr Adrian Raby, entitled  A Patient’s Journey: Alcoholism (BMJ 2011; 342:d956) that highlights, in particular, the effect that his excessive drinking had on his wife.

 

For similar reasons, I believe that this film is especially valuable in its portrayal of the effect that Alice’s alcohol addiction has on her marriage and on her children. The anguish, confusion and hurt that we observe in her older daughter, as she becomes aware of her mother’s problem, are at times almost too painful to watch. These scenes place us directly into the battleground so often described by families struggling to cope with a relative’s alcohol dependence. The effects on Alice’s marriage to Michael are also fully explored and a glimpse of their marital therapy help to remind us of the complex work that usually needs to be done by a couple struggling to make sense of the causes and to repair the damage that so often accompanies alcohol addiction. When a Man loves a Woman follows all members of Alice’s nuclear family closely, giving us a powerful reminder of the consequences that one person’s mental ill health can have on their loved ones, especially any dependent children.

 

As the film focuses on Alice’s journey through detoxification and on to Alcoholics Anonymous meetings, it highlights the important role of advice and support that individuals need to deal with their addiction. This might help to illuminate and support the argument being made in a recent report by Alcohol Concern that more alcohol health workers in hospitals and GP surgeries, offering counselling and advice, would ultimately save the NHS money. As alcohol misuse has created a steady rise in costs for the NHS through an increase in alcohol related illnesses, there is an urgent need to recognise it as a major health priority.

 

Recent media attention has highlighted the particular risks facing middle class, professional woman who seem to be consuming more alcohol on a regular basis than other females (The Telegraph, March 2011). The Institute of Alcohol Studies has produced a number of very informative factsheets about alcohol consumption in the UK and in particular one on women and alcohol, which may be interesting to read in conjunction with a viewing of this film. The NHS web pages on Alcohol and Drinking have a number of useful links (including to a downloadable Alcohol tracking app for iPhone or desktop) and a Carer’s story, written by a husband about his alcoholic wife, which provides an account which describes some similar issues to those portrayed in When a Man loves a Woman.

 

I would highly recommend this film for anyone seeking to work in the field of alcohol or addictions as well as for those involved in family therapy. But for a wider mental health audience, When a Man loves a Woman reminds us that alcohol dependency is no longer the preserve of any one particular group in our society alone.

 

Minds on Film is written by Dr Joyce Almeida.

 

23/02/2011 08:15:30

Memento

Introduction

Memento, directed by Christopher Nolan, is based on a short story by his brother, Jonathan Nolan, called “Memento Mori”. The film was released in 2000 and is described by Nolan as “a psychological thriller about a guy who can’t make new memories and who is looking for revenge”. It belongs to the neo-noir film genre, with some of the characteristic features of bleakness, alienation, paranoia, the presence of a femme fatale and the lack of a happy ending.

In an interview about the film, Nolan explained that he was very interested in the process of memory and in the way it can be distorted. He also stated that, in making Memento a film about an unreliable amnesic narrator, he had “attempted to put the audience into the head of the protagonist and make them experience some of his confusion, uncertainty and paranoia”. It is precisely for this reason that I believe Memento has much to offer the mental health practitioner, especially anyone working with individuals suffering from memory impairment.

 

Memento

Because memory is so deeply entwined with our sense of identity and is one of the means by which we understand our world, this film explores how it might feel to be unable to trust what we know about ourselves, and others that we meet. Because it uses a complex and unorthodox form of story telling, Memento challenges us, requiring a greater than usual degree of concentration and use of our own memory, in pursuit of the truth. Indeed, the film invites multiple viewings as we strive for greater understanding, again giving us the experience of a person trying to work out the world they are perceiving, when handicapped by an impairment of memory.

The Film

On this occasion, I do not intend to give a detailed description of the plot but rather to outline the complex structure of the storytelling as a guide to orientate viewers to the complex way the film plays with memory and time. Anyone wanting an “unspoiled” viewing of the film should stop reading now and return to the blog after watching it.

 

Memento is essentially a film of two parts, one filmed in colour and the other in black and white, intertwined together in alternating sequences that set out to explain the events leading up to the opening scene. The film’s opening sequence, in colour, takes place quite literally in reverse and is the only scene to do this. In it, we witness the revenge killing of Teddy, a policeman, by Leonard, the protagonist who suffers from anterograde amnesia. The sequences filmed in colour, tell the story backwards in short segments that play forwards, whereas the black and white sequences tell a storyline that unfolds in the conventional (that is moving forward in time) way. We discover that the black and white scenes preceded the colour sequences in chronological time. Often in the colour scenes we are thrust into the action with Leonard, sharing his lack of understanding about what he is doing in any particular place. We very soon learn that the strategy he uses to keep track of events, people and objects, and to attempt to make sense of his world, is to take polaroid photos which he then annotates. For the really important things that he wants to remember, he has them tattooed on various parts of his body. The final black and white scene seamlessly merges with the last colour sequence, bringing the whole film to an end as a complete piece of storytelling, but perhaps failing to provide all of the answers that the viewer may be seeking after the first viewing.

 

Ultimately, Memento is like a puzzle whose pieces can only be reassembled with the help of an intact memory. In contrast to Leonard, we can use our memory of previous scenes to inform our understanding of the consequences of his actions in the scene that we are currently watching.

 

Relevance to the field of Mental Health

Memento specifically explores the condition of anterograde amnesia and reflects the difficulty that sufferers have in appreciating the passage of time as they struggle to exist with very limited recent memory. For anyone wanting to gain a better understanding of what it might feel like to suffer from such a disability, this film captures some of the aspects of confusion and perplexity very well. By making the viewer unsure of what to trust in what they see through Leonard’s eyes, Memento can help the viewer to appreciate why such an individual may experience paranoia.

 

The film can also offer a starting point for a discussion about the different strategies that may be employed to prompt the sufferer into recalling recent experiences (autobiographical memories). There are many different rehabilitation techniques used to help individuals with anterograde amnesia. Some involve the use of compensatory techniques like mobile phone alerts or written notes and diaries, others consist of intensive training programmes involving the active participation of the person with their family members. Work by clinical neuroscientists in Cambridge, UK, comparing written versus visual aids for memory retrieval in memory impaired individuals, has begun to suggest that the recording of a pictorial, person-centred view of events, using a wearable camera, whose images are re-viewed later on a computer screen, may be an effective way to improve autobiographical recollection and one that is superior to a written diary (Berry E, Kapur N, Williams L et al; Neuropsychological Rehabilitation. 2007; 17(4-5):582-601; The use of a wearable camera, SenseCam, as a pictorial diary to improve autobiographical memory in a patient with limbic encephalitis: a preliminary report).

 

For anyone wanting to compare the fictional character of Leonard with a real person suffering from the same condition, the well-known case of the English musicologist, Clive Wearing, who has a severe form of anterograde amnesia, offers further insights into the disability. He is unable to remember more than 10-30 seconds at a time and has no detailed memories of his life before herpes simplex encephalitis damaged the hippocampi in his brain (one of the areas of the brain involved in laying down memories) more than 20 years ago. He is only able to recognise his wife, who he married the year before his illness. What is especially interesting is that he retains his previous ability to play the piano, because this involves procedural memory (involving other brain areas such as the basal ganglia and cerebellum). He featured in a BBC documentary about how humans experience time, which can be viewed via the Wellcome Collection website.

 

Another famous amnesic patient, an American man named Henry Molaison, died in 2008 at the age of 82. An excellent account of his life with anterograde amnesia, caused as a result of neurosurgery for epilepsy, is available in The Telegraph obituary published in February 2011. He was studied extensively for many years, and was particularly interesting because he retained his intellectual abilities and personality but was unable to live independently or to hold down a job. Leonard, in the film, illustrates just how vulnerable and open to exploitation someone is without a functioning short-term memory, which can help us to understand why someone with this condition might require supervised care, of some sort, throughout his or her lifetime.

 

Memento is a film that requires us to use our memory to the full, at the same time as giving us the experience of being in the world without it. I would definitely recommend this film to anyone interested in memory and its disorders.

 

 

01/02/2011 11:45:18

A Song for Martin



Introduction

Based on a book by Ulla Isaksson about her own relationship with her husband, this film, in Swedish with English subtitles, was scripted and directed by Billie August. It is interesting to note that the two actors in the main roles, Viveka Seldahl (Barbara) and Sven Wollter (Martin) were married in real life, giving some added poignancy to the film. Sadly, Viveka Seldahl died from cancer shortly after the film was released in 2001. Both actors won the equivalent of a Swedish Academy Award for their performance in A Song for Martin.

A Song for Martin

 

Unusually for ‘Minds on Film’, which normally focuses on readily available films, this DVD is only available as a Region 1 disc and as such can only be played on a multi-region DVD player. However, I have chosen to discuss it because it presents a very good portrait of Alzheimer’s Disease and the challenges that face any caregiver.
 
A Song for Martin is also a film of mid-life romance and second marriage, which is blighted a few years later by the onset of Alzheimer’s Disease. It portrays the reality of living with, and caring for, a loved one over several years, who is suffering from a neurodegenerative disorder. 

The Film

The film opens with the rehearsal of an orchestral work composed by Martin, who is conducting the orchestra in which Barbara plays first violin. They are obviously attracted to each other, despite both of them being married, and we watch in the following scenes as they fall madly in love, separate from their respective spouses and embark on a loving, intellectually stimulating and truly satisfactory second marriage. We see them on honeymoon, rejoicing in this late found romantic happiness despite this being tinged with guilt for Barbara. In a significant scene, the viewer witnesses them promise to be open and honest with each other whatever the future brings.

 

A few years later, settled in their new home, we watch Barbara and Martin at work together, with her contributing to his composing, and we are shown the complex skills that are required for his work. The first hint of problematic change occurs when Martin struggles to remember the name of his manager and later calls Barbara ‘Alice’, which was the name of his ex-wife. They think nothing of these slips until Martin experiences a frightening lapse of memory whilst shaving one morning and is unable to recognize the bedroom. He fears that he has suffered a cerebral haemorrhage, but a visit to his doctor fails to detect a problem and the episode is attributed to overwork. A family gathering a little later shows him playing the piano and interacting with his grandchildren very capably.

 

The real problems begin as Martin is conducting the first public performance of his new concerto, live on television, when he freezes in the opening bars, confused and unable to focus on the task. This leads to a CT brain scan and assessment by a specialist who delivers the diagnosis of early Alzheimer’s Disease. He is encouraged to carry on as normally as possible with his work and family life. As a result, Barbara attempts to support him in completing his next major project, which is to compose an opera.

 

From this point on, A Song for Martin follows the relationship between Barbara and Martin closely over a number of years as his disease gradually progresses. We witness Barbara struggling to ‘do the right thing’ but being unable to contain her own needs and frustrations at times. Martin’s perplexity is brilliantly portrayed when he is trying to grasp a situation that should be familiar, but isn’t any longer recognizable to him. It is painful to watch when Barbara’s decision to revisit their honeymoon destination for a much-needed holiday almost ends in tragedy and clearly indicates the next stage of his illness.

 

With his increasing dependence on Barbara for his personal care, Martin develops some difficult behavioral symptoms, which end up leading to him being assessed in hospital, confirming significant deterioration and resulting in the recommendation for long term institutional care. My only gripe with the film comes at this point when the specialist suggests that Barbara should “forget he is your husband…he is not the man you married”, advice Barbara certainly doesn’t follow. That apart, the film poignantly explores Barbara’s guilt at ‘giving up as a caregiver’ and brilliantly illustrates her loneliness when she returns to an empty home from hospital, exhausted after years of caring. The film ends with us seeing Barbara make a gradual return to a more normal life and managing a lovely good bye to the husband she adored, despite the fact that he remains in full time care, no longer able to recognise her.

 

Relevance to the field of Mental Health

A Song for Martin tracks the development of Martin’s Alzheimer’s Disease from its earliest signs to his final move into care, providing us with a potted clinical history. It also convincingly represents the emotional strain that his wife Barbara suffers throughout the various stages of his illness. There are situations that Barbara chooses to manage in a certain way that may make some viewers want to shout out ”don’t say that” or “don’t do that”. But for anyone who is involved in Old Age Psychiatry, there will surely be numerous points in the film that bring back memories of a real clinical situation, in which real people in difficulty don’t always do or say the right thing.

There is excellent information for dementia sufferers and caregivers about the disease at the Alzheimer’s Society website and I can highly recommend the Alzheimer’s Association’s ’10 signs of Alzheimer’s’ detection checklist, that could be read in conjunction with a viewing of the film, to aid learning about the diagnosis of Alzheimer’s Disease. The film does not shy away from portraying several difficult to manage behavioral problems, in the later stages of Martin’s dementia, and could definitely serve as an excellent starting point for a discussion about the stresses of care giving. This can be further explored using the excellent page on the Alzheimer’s Society website called Carers: looking after yourself.

 

The film illustrates the positive encouragement given to Martin, at the time of diagnosis, to maintain as normal a life as possible, for as long as possible, although it also manages to highlight just how much this depends on the stamina and capability of his wife. Martin is encouraged to continue composing, giving him a sense of purpose and worth, long after he has lost his previous level of ability.

 

There is an increasing awareness of the need to maintain a positive approach to dementia care wherever possible, encouraging the individual personality of the dementia sufferer to be recognized throughout their illness. The book entitled “I’m still here”, by American sociologist John Zeisal, Ph.D (2009; Published by Avery, a member of the Penguin Group (USA) Inc.), explores the non-pharmacological treatment of Alzheimer’s and takes a decidedly ‘glass half full ‘ look at the disease. Zeisal is a founder of the Artists for Alzheimer’s™ programme in the USA, which has enabled thousands of people living 
with Alzheimer’s disease to have cultural opportunities and artistic experiences.

 

Recognition of the need to reduce anti-psychotic medication use for the behavioral and psychiatric symptoms in dementia, outlined in the independently commissioned report produced by Professor Sube Banerjee for the Department of Health, in 2009, has led to an exploration of various different non-pharmacological strategies, such as the use of sensory rooms and aromatherapy massage. A few other initiatives, which have been reported in the UK media in recent months include a reminiscence room set up at a care home in Wiltshire, UK, or the recent project developed by Middlesex lecturer, Trish Hafford-Letchfield, who made a short ‘mockumentary’ film of a royal visit to a day centre for dementia sufferers in north London (with the aim of involving people with dementia in the education of social workers and nurses).

 

A Song for Martin gives the viewer an opportunity to experience, close up, a life and an intimate relationship affected by Alzheimer’s Disease. The film offers a good starting point for anyone wishing to teach students, from a variety of professional backgrounds, about dementia, with a particular focus on the progression of the illness and its effect on the main caregiver. I would certainly recommend it to anyone wanting a career in Old Age Psychiatry.

 

  • More information about A Song for Martin can be found at IMDB.
  • The Region 1 DVD is available on amazon.co.uk.

 

06/01/2011 09:18:37

Enduring Love

Introduction

Based on the novel written by Ian McEwan, Enduring Love is an intense and powerful film telling the story of a shared traumatic event that leads to the stalking of one character by another with ultimately very serious consequences. It is rated as an 18 certificate.

Directed by Roger Michell in 2004 and starring Daniel Craig, Samantha Morton and Rhys Ifans as the main protagonists, Enduring Love presents an account of several lives affected by stalking, including that of the stalker. The director has stated that it is a film about the ability of love to endure the tests of life and the ups and downs of relationships. The author of the book, Ian McEwan, describes his novel as an exploration of obsession in various forms. Both of these threads come together in the film.

 

Enduring Love

The Film

Enduring Love begins with an idyllic countryside scene in which university lecturer, Joe, has planned a champagne picnic for his girlfriend, sculptor Claire, with the intention of proposing marriage. However, this perfect moment is interrupted by the appearance of a hot air balloon in trouble. Several other people in the vicinity, along with Joe, join in a rescue attempt, and all witness the dramatic events that follow. Of all of those present that day, it is Joe and another man named Jed, who find themselves alone together witnessing a horribly disfigured body.

In the days and weeks after the accident, we watch Joe’s struggle to process the horrific events of the balloon accident. The film demonstrates some of the post-traumatic experiences that an individual may have. In particular, we hear Joe struggle with survivor guilt and watch him experience numerous visual triggers that remind him of balloons as he tries to go about his everyday life. It is perhaps this mental state which renders him more vulnerable to the unwanted attention of Jed, whose initial contact after the accident seems so plausible. However, Jed’s repeated contact with Joe gradually builds in intensity until Claire suggests that Joe might need help to deal with Jed’s unwanted attentions.

 

Joe believes that he can manage the situation himself, but he and Claire start to suffer from the stress of being stalked and this threatens their relationship. The tone of the film darkens when Jed starts to involve Claire in his stalking, and we discover that he believes she is an obstacle him and Joe being together. Joe’s mental health deteriorates further as we see his, initially well meaning, attempts to reason with Jed fail and we witness his descent into irrational, angry behaviour and depression.

Towards the end of the film, both Joe and Jed are consumed by violent behaviour, reminding us of the significant danger that can befall any victim of stalking, in extreme cases.

 

Relevance to the field of Mental Health

Enduring Love offers the opportunity to understand empathically how it feels to suffer the protracted harassment experienced by a victim of stalking. It depicts the sense of intrusion, violation and isolation, experienced by the victim, which slowly escalates, producing intolerable stress that may cause them to become mentally ill. The film also demonstrates the fact that there is always a potential risk of violence to the victim and that this should be kept in mind when making an assessment.

As we watch Enduring Love, we see Joe break all of the fundamental rules recommended for dealing with stalkers. Perhaps it is because Joe has shared a traumatic event with Jed, and is struggling to process the experience, that initially he believes he is dealing with a reasonable person who was similarly affected by the accident. Indeed, Joe says that he feels sorry for Jed. The film brilliantly records Joe’s gradual realisation that Jed is not behaving reasonably at all. A victim of stalking is never advised to meet with, contact or attempt to reason with their stalker, as this usually just fuels the stalker’s abnormal behaviour. The film demonstrates this escalation brilliantly.

 

From a psychiatric viewpoint, a review article in March 2000 entitled Stalking – a contemporary challenge for forensic and clinical psychiatry; J.H.Kamphuis and P.M.G. Emmelkamp (British Journal of Psychiatry (2000), 176, 206-209) provides an excellent introduction to the topic, with particular focus on the underlying mental health problems found in those that stalk. In essence, stalkers fall into two distinct categories: those that have had some form of relationship with the victim and those that have had no real relationship at all and, the authors state, they usually suffer from either a psychotic disorder or a personality disorder. The article reminds us that stalking is an abnormal behaviour, not a diagnosis, and that it is important to determine the underlying pathology before any treatment can be recommended. In Enduring Love, Jed is seen to suffer from a delusional disorder, erotomania (also known as de Clerambault’s syndrome), believing that there is some special love relationship between himself and Joe. This is evidenced by various signs he has misinterpreted from Joe, such as the gentle touch that Joe makes on Jed’s shoulder when they both discover the body at the start of the film or Joe’s opening and closing of his curtains.

 

Those working in the health professions are at particular risk of being stalked (20% risk over the course of a career), with a higher risk in forensic and general adult psychiatry than in other subspecialties.

With an increasing number of cases reported in the UK media, there has been a move to improve the support given to victims of stalking and harassment, especially by the police. New guidelines published in August 2009 by the Association of Chief Police Officers have given advice on how such cases should be investigated. With this increasing general public awareness, the Home Office, supported by several charitable organizations, has financed a National Stalking Helpline (0300 636 0300) for victims needing confidential support and guidance.

 

The website Protection against Stalking has an excellent page of facts on the subject, including some Do’s and Don’ts for managing any unwanted attention from another person. This page also provides a link to the downloadable Stalking and Harassment Risk Identification Checklist (S-DASH 2009), which gives some indication of whether there may be an increased risk of violence in each individual case.

Enduring Love could act as an excellent springboard for education and discussion about the various types of psychopathology that are associated with stalking and the strategies for the treatment of both stalkers and their victims. As a portrayal of a delusional disorder, the film gives some incredibly accurate examples of the kind of things that someone with erotomania might say about, or to, their victim. I would highly recommend this film to anyone thinking of working in the forensic mental health field.

 

Minds on Film blog is written by Dr Joyce Almeida.

 

13/12/2010 09:55:28

The Christmas Choir

Introduction

As the festive season is upon us, it seems appropriate to consider a suitably seasonal film. The Christmas Choir offers an updated version of Dickens’ A Christmas Carol by telling the story of a workaholic, self-absorbed man who is jilted into realising that life is about so much more. It is essentially a tale of redemption, love and second chances that highlights the power of music to unite and to transform.

A Christmas Choir

 

What makes this film especially interesting is that it is based on a true story. A French dental technician named Pierre Anthian, who had a background in classical music, moved to Canada in 1995 and began volunteering at a shelter for the homeless in Montreal, because he had always devoted much of his time to helping disadvantaged people. He was motivated by a long held aim to create a choir of homeless men, which was partly inspired by the important role that music played in his life. Anthian is quoted as saying “Music is good for the soul. I hoped a choir might provide these men with a way to earn a little money and to gain self-confidence and dignity.” He put out a call amongst the street community in downtown Montreal, asking for choir members and stating that musical experience and talent were not necessary. Not long after rehearsals began he had collected 20 people, ranging in age from 19 to 67, some with drug and alcohol problems and a few with musical ability, which resulted in the birth of the Accueil Bonneau Choir. They made their debut in December 1996 in a subway station and went on to make six albums and to tour as far afield as Paris and New York. The choir disbanded in 2003, as many of its members had found jobs.

 

Written by Donald Martin and directed by Peter Svatek in 2008, The Christmas Choir was first shown on television in America and has only just been released on DVD, in the UK, in September 2010.

The Film

As the film opens, we are introduced to Peter Brockman, hard at work in his office, where his secretary asks him, apologetically, if she can have leave during the week after Christmas, to see her family. Absorbed in his accountancy work, he almost forgets that he is supposed to meet his fiancée for a meal that evening and consequently arrives late to hear her tell him she no longer wants to marry him because he is a workaholic. Confused and upset, Peter consoles himself in a bar where a man called Bob is playing the piano and singing. They start to talk and find that both had mothers who believed in the power of music to nourish the souls. Bob invites Peter back to meet ‘his family’, which turns out to be the residents of a homeless shelter. Here Peter meets sister Agatha, a formidable nun who runs the centre. She accepts a generous donation from him but also invites him to give his time to volunteering if he is able. He tells her that this is unlikely as he has very little time, but he finds himself drawn back to the shelter with the idea of starting a choir for the men there. He hopes to give them the chance to earn some money for Christmas. With some scepticism and reluctance, sister Agatha allows him to try. The rest of the film tells the story of his struggle to make the choir a success and to find out what really matters to him. As Peter finds purpose in his life through the choir, he also finds new love.

 

The Christmas Choir is also a film about estrangement between fathers and sons. We discover that Peter has had no contact with his father for sometime and that Fred, one of the homeless men, has been shunned by his son.  We find out, too, that Peter’s father has a problem with alcohol, which Peter finds very hard to deal with. This difficulty is echoed in the problem drinking of one of the choir members, which almost threatens to destroy the project at one point. The film reminds us that anyone, from any walk of life, can encounter difficulties with alcohol and money that may set them on the slippery slope to homelessness and that receiving help at just the right time can make the difference between success and failure for an individual.

 

Relevance to the field of Mental Health

The Christmas Choir presents us with two important topics that have a great relevance to those involved in mental health: the first is the field of Music Therapy and the second is the issue of psychiatric morbidity among the homeless.

To quote from Nordoff Robbins, the UK charity that specialises in using music to transform the lives of mentally or physically disabled adults and children: “Clap your hands. Tap your feet. Sing out loud. Dance or stomp. Shout or cry. We all react to music in different ways. But we all react. Because music has a universal power to reach us, touch us and make us feel different.”

 

There is a growing body of research in the Music Therapy field that seeks to examine its clinical effectiveness as an evidence-based practice in a wide range of client groups. The Nordoff Robbins research department presents some of this research in a publication, freely available online, called Presenting the Evidence. Of particular interest to psychiatrists is the work being done, by music therapists, with dementia sufferers, stroke victims, individuals with learning disability and those diagnosed with autistic spectrum disorders.

 

The Christmas Choir may touch many of us, at least in part, because the Carols in the film have probably been known to most viewers living in Christian societies since their childhood, whatever their religious beliefs. They often provoke memories of past Christmases, whether good or bad, just as they do for Peter in the film. This musical recognition can demonstrate to us how music might be used in a therapeutic setting. In a reminiscence session, for example, individuals suffering from dementia, who lived through the second World War, may be able to connect with their early life by singing along to wartime tunes when they are unable to express those memories in words.

 

Turning to the other topic of relevance to the mental health field, The Christmas Choir brilliantly highlights some of the psychosocial issues associated with being homeless. Much research has examined the psychiatric morbidity that is associated with homelessness. An original paper by Marianne Hayward entitled Psychiatric morbidity and health service use among attendees at a winter shelter, (Psychiatric Bulletin (2007), 31, 326-329), found 31.3% of 597 attendees, at a Christmas shelter in the UK, were recorded as having psychiatric morbidity. Many other studies have shown an increased rate of depression, anxiety, psychosis and substance misuse in the homeless population, making it hugely important to target this population and encourage better engagement with mental health services.

 

For homeless people, breaking away from their social exclusion and poverty is often very difficult as it can be almost impossible to get employment whilst they are homeless, but to find even temporary accommodation can be too great a financial challenge. Organisations like Off the Streets and into Work and Crisis (who merged together in April 2010) work hard to find employment solutions for homeless people. In the current economic climate this has become an even tougher task. Homeless Link is the national membership organisation for frontline homelessness agencies in England. Their mission is to be a catalyst that will attempt to bring an end to homelessness.  Their website provides the interested reader with a wealth of information on the issues and facts surrounding homeless living.

 

This year, the BBC Radio 4 Christmas Appeal also addresses the issue of homelessness by highlighting the work of The Connection, an organization providing specialist services for the homeless in central London.

 

The Christmas Choir, based upon the real life experiences of a small number of homeless men, provides a wonderful introduction to some of the complex issues surrounding homelessness, as well as to the power of music to transform lives.

 

Minds on Film blog is written by Dr J Almeida, Consultant Psychiatrist.

 

22/11/2010 10:34:28

Spider

 

Introduction

SpiderBased on a novel by Patrick McGrath, Spider was directed by David Cronenberg, in 2002, and stars Ralph Fiennes, Miranda Richardson, Gabriel Byrne and Lynn Redgrave. Set in the 1980s during the beginning of the movement from institutional to community care, the film tells the story of a mentally ill man suffering from paranoid schizophrenia, who is released from a psychiatric hospital after 20 years to live in a hostel for the mentally ill. Cronenberg says about the film, “Spider is an austere psychodrama with a profound human mystery at its heart. It has the feel of Samuel Beckett confronting Sigmund Freud."

David Cronenberg is a director well known for his highly original horror films and this film was regarded as a departure from his more usual style. It is interesting to note that Cronenberg deferred his own salary to make Spider. He is quoted as saying: “Everybody's a mad scientist, and life is their lab. We're all trying to experiment to find a way to live, to solve problems, to fend off madness and chaos.” Spider is definitely a film that explores one man’s struggle to fend off psychotic breakdown and chaos whilst trying to face the reality of his past.

The Film

From the opening credit sequence, showing a series of Rorschach inkblot images to the accompaniment of a beautifully haunting folk song, the scene is set for a film about the mind.

Spider begins with a train pulling into a London station and disgorging its commuters, all purposefully bound for their destinations. Only as the platform begins to empty are we shown the dishevelled figure of Mr Cleg (played by Ralph Fiennes), apprehensive and unsure of his surroundings, carrying a small suitcase. From this very first encounter, we experience Mr Cleg’s self-absorption and preoccupation with an internal dialogue. He walks the familiar streets of East London, in search of a half way hostel, where the authoritarian Mrs Wilkinson (Lynn Redgrave) is in charge. She shows Mr Cleg to his room, where we see him react anxiously to the sight of the gas heater, an ominously significant motif in the film.

 

The main body of the film focuses on Mr Cleg’s trips out into the local community, where he grew up, and examines the effect these visits have on him. The viewer shares several different views of his past experiences mixed up with each other. These comprise some apparently accurate flashbacks to his boyhood, showing the early signs of his schizophrenia developing, and several scenes from his time in the psychiatric hospital. The remaining recollections are made up of Mr Cleg’s distorted beliefs of the events leading up to the tragic death of his mother, in which he is also present in the frame, commenting on the characters. In these scenes, the film makes us party to the psychotic internal workings of his mind.

 

We learn how he acquired the nickname of Spider from his much loved mother (Miranda Richardson), and how he would weave string webs in his room as a child. We witness Spider’s emerging jealousy of his parents’ intimacy and his feeling of rejection by his mother, as he watches her attempts to reignite the sexual relationship with her husband (Gabriel Byrne) when their marriage is under strain. The story that unfolds in Mr Cleg’s mind reveals a very traumatic childhood involving the death of his beloved mother at the hands of his father and the arrival of his hated stepmother, a prostitute. However, the film gives us a clue that what we see may not be a wholly accurate account of what happened, by using the same actress, Miranda Richardson, to play the part of both his mother and his prostitute/stepmother.

 

In his hostel room, Mr Cleg scribbles ‘non words’ frantically in a special notebook that he must hide safely in his room. As his mental state deteriorates, we see him convinced that gas is leaking from his heater requiring him to strip off his clothes and tie himself in newspaper for protection. Challenged by ever more powerful, painful memories, his paranoia increases and he steals some tools from Mrs Wilkinson.

 

In a seemingly accurate boyhood memory, we see Spider plan to avenge what he believes was the murder of his beloved mother using string connected to the gas tap in the kitchen. In the hostel, he tears up his precious notebook, weaves a string web about his hostel room, echoing the same behaviour from his childhood, before threatening violence toward the hostel manageress. At this moment, Mrs Wilkinson is played by Miranda Richardson rather than Lynn Redgrave, to represent the confusion in his mind about her identity. Finally, overwhelmed by the accurate memory of his mother’s death, he suffers a relapse of his paranoid schizophrenic illness and is recalled back to the psychiatric hospital.

 

Relevance to the field of Mental Health

This is a film that focuses on the inner and outer worlds of its main character. It tells the story of Mr Cleg’s external reality as a man with incompletely remitted schizophrenia, as well as plunging us into his psychotic internal world where we are unsure of what is true and what is falsely constructed. As such, the shifting sands of reality in the film give the viewer a glimpse of what it might be like to suffer from schizophrenia.

 

On the one hand, the film presents an accurate portrait of someone suffering from paranoid schizophrenia, who has spent many years in an institution. The excellent performance by Ralph Fiennes is very believable and draws us in to caring about Mr Cleg and his predicament. He demonstrates some of the negative symptoms of schizophrenia very well, such as social withdrawal, blunted affect, poor concentration and paucity of speech. In addition to this, the personal details, such as his wearing of four shirts at once, having tobacco stained fingers and keeping his possessions in a sock, are all in keeping with the diagnosis and a long period of institutional care. He shows evidence of responding to the abnormal perceptions of auditory, olfactory and, possibly, visual hallucinations. By the end of the film we learn that many of his recollections were in fact delusional memories. For these reasons, Spider could serve as a very good starting point for a discussion about schizophrenia in its more severe and intractable form and the effects of long term institutional care, as well as examining the issue of risk assessment at the time of transfer from an inpatient setting to the community.

 

On the other hand, the film explores Mr Cleg’s internal world and in so doing, it offers an introduction to the Object Relations theory of the psychoanalyst Melanie Klein. Spider visually represents the defence mechanism called splitting, employed to manage the persecutory anxieties associated with what Klein called the paranoid-schizoid position. The delusional memory sequences give us access to Mr Cleg’s inner world of thought and feeling and suggest that when his ‘good mother’ seeks to reinvigorate the sexual aspect of her marriage, she is split off and experienced as a ‘wicked prostitute/stepmother’. The use of the same actress to play both his ‘good mother’ and his ‘bad stepmother’ supports this view. With Klein’s Object Relations theory in mind, one can suggest that this defensive splitting, which occurred in his childhood and is represented in his delusional memories, has served to protect his idealised ‘good’ mother from the persecuting ‘bad mother’ whom he ultimately attacks. It is only when his boyhood attack on the ‘bad’ mother results in her death, that the film shows us that he has also killed his ‘good’ mother, confirming that they are parts of the same person.

 

In schizophrenia, there is thought to be a pathological development in the paranoid-schizoid position in which the mechanisms of projection, introjection, splitting, idealization, denial and projective and introjective identification may fail to master anxiety, resulting in a defensive disintegration of the ego if anxiety is too great. It is only when Mr Cleg is placed back in the community where he grew up, and where he is unable to avoid being confronted by the anxiety associated with the truthful recollections about his childhood, that these defence mechanisms are overwhelmed and he suffers a complete psychotic relapse.

 

The phenomenon of transference is also visually represented in the film. By once more substituting the actress who plays his ‘wicked stepmother’ for the one playing Mrs Wilkinson, we are shown his unconscious redirection of angry feelings for his ‘bad’ mother on to the hostel manageress, perhaps triggered by her harsh, authoritarian manner. The transference in this case very nearly results in serious violence.

 

Spider therefore also offers the opportunity to discuss Klein’s Object Relations theory, and could lead to a further exploration of her work. For a good summary of these concepts, I would also recommend a book entitled “Introduction to the Work of Melanie Klein” by Hanna Segal, (New edition 1988, Karnac Books).

 

  • For more information about schizophrenia and its management today, there is a very good leaflet on the Royal College of Psychiatry website.
  • For psychiatrists, there is further reading about the assessment and management of risk in a Royal College Council report produced in 1996.
  • Further information about Spider can be found at IMDB where a short trailer can also be viewed.
  • The DVD is available at amazon.co.uk.
  • Minds on Film is written by Dr Joyce Almeida.
29/10/2010 11:09:10

The Sea Inside

Introduction

The Sea Inside (Mar adentro) is a Spanish film with English subtitles, directed in 2004 by Alejandro Amenábar, and starring Javier Bardem. It won the 2004 Oscar and the 2004 Golden Globe award for Best Foreign Language Film.

It is based on the true-life story of Ramón Sampedro, a Spanish ship mechanic who broke his neck at the age of 25 diving into shallow sea from rocks near his home in Galicia, a region in northern Spain. He spent 29 years as a quadriplegic confined to bed, cared for by his family with enormous love and commitment, aware that his mind was sharp and highly functional but that his body was capable of only occasional involuntary spasms.

The Sea Inside

 

With much time to consider his situation, Ramón became certain that life in this state was not dignified and not what he wanted. He fought for the right to end his life knowing that, due to his quadriplegia, he would need assistance to die. His was a 28-year battle for the right to assisted suicide, appointing a lawyer and petitioning the lower courts in Spain for permission, then its higher courts and finally the European Commission on Human Rights in Strasbourg, without ultimate satisfaction. His case attracted countrywide, and later worldwide, interest.

 

His determination to raise the profile of his struggle was demonstrated by the fact that he managed to write a book about it, using his teeth to hold the pen.

 

Of particular poignancy is the fact that Ramón’s family held religious pro-life beliefs and so, with that in mind, when left with no other option, he left the family farm to stay and be cared for by friends approximately two months before he was helped to die using a cyanide laced drink. He made a video of himself voluntarily drinking the poison through a straw whilst telling the camera “When I drink this, I will have renounced the most humiliating of slaveries: being a live head stuck to a dead body”. 

The Film

The film opens with Ramón Sampedro engaged in a relaxation exercise with guided imagery in which he is imagining himself walking along a picturesque beach, the waves lapping at his feet. We then see him lying in bed, only able to move his head and soon learn just how much he depends on the care that his family provide for all of his daily needs.

 

His sister-in-law, Manuela, who is his main carer, her husband who is Ramón’s older brother, their son Javier and Ramón’s elderly father all live together in the family farmhouse and support Ramón in a variety of different ways.

 

The Sea Inside recounts Ramón’s struggle to end his life and it tells the story through the relationships he forms with three women. First is Gené, who works for the Association for the Right to Die with Dignity. The second is Julia, a lawyer recommended by Gené, who takes on his case and has her own reasons for being interested in the topic of assisted suicide. Julia helps him to write the book about his life story and it is through their collaboration that a strong emotional bond develops. Last is Rosa, a local woman who is initially attracted to him because she is energized by the challenge of persuading him to choose life but who subsequently finds herself drawn to him for the strength she finds in his presence.

Through these relationships, his resilience and determination is revealed as well as the very powerful positive influence he has on others. The Sea Inside provides some interesting reflections on the nature of love and intimacy as, despite his quadriplegia, we watch the relationships with two of the women deepen and intensify.

 

The painfully complex emotions and views of each family member are also portrayed particularly well in several scenes, resulting in a balanced consideration of the film’s sensitive subject from all viewpoints.

Dream sequences are used to communicate Ramón’s psychological release from his immobility as he imagines himself flying across the countryside that he can now only glimpse from his window.

In the later stages of the film we are shown Ramón’s death through the home video scene. But this is not the end: The Sea Inside actually finishes by focusing on another character who has made a very different choice from Ramón.

 

Relevance to the field of Mental Health

This film brings to life the debate about assisted suicide and assisted dying and helps the viewer to consider the issues concerning the quality of life and the right to choose death for mentally competent people in certain circumstances. As such it offers a brilliant starting point for a discussion on the topic especially because it presents the various sides of the argument in this complex debate so vividly.

The particular relevance that The Sea Inside has for those interested in psychiatry concerns the topic of Mental Capacity. In countries where assisted suicide is legal, it is usual for medical practitioners to examine the person’s mental state and assess their Mental Capacity for making the decision to end their life. It is possible to argue that the film invites the viewer to act as a virtual psychiatrist in assessing whether Ramón has the Mental Capacity to make his decision. We are encouraged in this process by the large number of close up shots of Ramón as he speaks to friends and family, and especially when Julia is eliciting his history. In this way, we slowly build an understanding of his life story and form an opinion about his personality.

 

For a good introduction to the process of assessing Mental Capacity, I would recommend the article by M. Church & S. Watts in The Psychiatrist (2007) 31: 304-307.  More detailed guidance on the topic can be found in the Mental Capacity Act 2005 Code of Practice.

 

As relevant today as ever, this film brings to mind the recent case of 23 year-old Daniel James, a promising young England rugby player, paralysed in a training session, who travelled to a Swiss assisted suicide clinic, accompanied by his parents, in September 2008, where he died. After investigation by the police, his parents were not charged (for more information about this case, there is a good report in the Telegraph newspaper on 9 December 2008) but the case raised the profile of the issue for the general public.

 

The British Medical Association’s guidance is clear. It remains opposed to doctors taking a role in any form of assisted dying including giving advice on fatal doses of drugs or writing medical reports that would facilitate assisted suicide abroad. However, the need for further debate on the subject is demonstrated by the existence of a recently set up group called Dignity in Dying: Healthcare Professionals for Change (BMJ 2010;341:c5498) who aim to challenge the BMA and a number of royal colleges in their stance against assisted dying for the terminally ill.

 

The Sea Inside also offers valuable insights to anyone wanting to gain a greater empathic understanding of life confined to a bed, without the freedom to move, toilet or eat independently. The film additionally provides an excellent portrait of the strains imposed on a family willingly engaged in providing fulltime care for a relative.

 

Minds on Film blog is written by Dr J Almeida, Consultant Psychiatrist.

29/09/2010 10:05:41

Ordinary People

Introduction

This is a film about the sudden death of a teenager and the psychological effect that the loss has on each remaining family member.  It provides a portrait of depression, and possible post-traumatic stress disorder, in a teenager, in the context of a family that can’t communicate effectively.

 

Ordinary People also captures the essence of the relationship between patient and therapist as the process of psychotherapy is shown to unfold between the teenager and his psychiatrist. One interesting anachronism in the film is that the psychiatrist is seen smoking during almost every session, reminding us just how much has changed since 1980.

Ordinary People

 

Based on a book by Judith Guest and directed by Robert Redford in 1980, Ordinary People won four Oscars and attracted critical acclaim. After the film’s release, Redford also received many letters of praise from psychiatrists in America, who were pleased that their profession was shown in a better light than was usual in the movies.

 

This film was Robert Redford's directorial debut and he is quoted as saying about it: "Ordinary People has lots of colors. It is a picture of behavior, about something of depth. It has to do with the family unit, which interests me. And with people who keep their lives in perfect order — they interest me. It's about the effort to communicate by a young person through the fog of social structures he's raised in. I don't know what this picture will say to teenagers but I hope it has a message for their parents. I hope it tells them loud and clear to listen to what their children have to say."

The Film

Ordinary People is set in upper-middle class suburban America (Illinois), where the Jarrett family have lived a seemingly ‘perfect’ life until the sudden death of their eldest son,  Buck, in a boating accident which also involved their younger son Conrad, who survives.

 

The film begins with scenes that show the family trying to get on with their lives but revealing that just below the surface lies a profound lack of communication. Mother, Beth, is desperate to keep up appearances in public and show that all is now well. It becomes apparent, however, that Conrad is struggling with insomnia, flashbacks, isolation at college and an inability to ‘play happy families’. His father, Calvin, seems more attuned to his son’s difficulties and encourages him to seek help from a psychiatrist, Dr Berger. At this point it becomes clear that Conrad has been in hospital for four months following a suicide attempt.

 

The ‘back story’ is told through Conrad’s twice weekly therapy sessions with Dr Berger and reveals that Buck, a successful athlete, was always his mother’s favourite while Conrad struggled to feel love from her.  This feeling of rejection by his mother seems to have worsened since the death of Buck and the film shows us evidence to support this belief.

 

Conrad is gradually enabled to express many unspoken feelings about the relationship with his mother as well as his survivor guilt and rage about the boating accident and his brother’s death.  The complex transformation that begins to take hold in Conrad is well illustrated and leads to changes in his father Calvin too.

 

We see Conrad begin to recover optimism as he starts dating a sensitive, nonjudgmental girl from school but an unexpected event threatens his improving mental state.  He turns in crisis to Dr Berger at this point and is helped to recognise the damaging effect of his unspoken resentment and anger toward his mother. In the confrontation that follows between Conrad and Beth we find out that she never visited him in the psychiatric hospital.  This exchange is witnessed by Calvin, who begins to question his relationship with his wife as he observes her coldness toward Conrad.

 

The final scenes are not ‘Happy ever after’ but are grounded in Calvin and Conrad experiencing the beginnings of an honest and truthful relationship between parent and teenage child.

 

Relevance to the field of Mental Health

This film, in the broadest sense, explores the varied responses of different personality types struggling to work through their grief. It is also about a family trying to deal with the aftermath of their surviving son’s suicide attempt and ongoing depression.  It highlights the importance of good communication within families as the film gradually uncovers the significant difficulties that were present between the members of the Jarrett family before the accident. Under stress these difficulties become magnified.

Ordinary People provides a wonderful starting point for a discussion about the indications for individual psychotherapy and family therapy and accurately illustrates the psychological resistance of a family member to any form of outside intervention that can so seriously interfere with the healing of the whole family.

 

By using the scenes of the therapy to tell the ‘back story’, the film cleverly mirrors the way in which information is often revealed over a period of time during psychodynamic psychotherapy, with neither the therapist nor the patient knowing the complete story at the start.  It also demonstrates the importance, to the therapist, of observing when and how a patient chooses to disclose particular information and offers a very good understanding of the processes involved in discovering hidden emotions and allowing them to find expression.

 

Finally, Ordinary People highlights the stigma that still surrounds psychiatric treatment for many people and perhaps helps us to understand why there is an urgent need to encourage awareness amongst young people about depression, suicidal feelings and the help that is available.  For an excellent review of the topic of self-harm in adolescents, I can recommend the article by Alison Wood in Advances in Psychiatric Treatment last November.

 

There is plenty of information for young people about all aspects of mental health on the Royal College of Psychiatrists website and a booklet is available to download on Child and Adolescent Mental Health Services (CAMHS), specifically for young people in the UK.

 

Any member of the Royal College of Psychiatrists interested in recording their view about the portrayal of the psychiatrist in this film or any other film can cast a vote in the survey set up by psychiatrist, Dr Peter Byrne, at http://www.surveymonkey.com/s/50films, in preparation for a Top 50 Psychiatry Film series beginning in the BJPsych in 2011.

 

(Thanks to my colleague D.G. for suggesting this film to me).

 

  • Further information about Ordinary People can be found at IMDB, and a short trailer can be viewed here.
  • The DVD is available to purchase at amazon.co.uk.

Minds on Film blog is written by Dr Joyce Almeida.

 

02/09/2010 11:01:32

Transamerica

Introduction

Transamerica was released in 2006 and was written and directed by Duncan Tucker.  It is a road movie whose central character, Bree, played by Felicity Huffman, is a pre-operative male-to-female transsexual, awaiting final gender realignment surgery, who discovers that she has an unknown son called Toby.  His story forms an important part of the film too, portraying his search to find his father and his roots.

Felicity Huffman’s performance is outstanding and won her numerous awards, including the Golden Globe (2006) for Best Performance by an actress in a Motion Picture Drama, two International Gay and Lesbian Film Festival Awards for Best Feature Film (2005) as well as an Oscar nomination.

Transamerica

 

In an interview with Robert Newton in 2005, Duncan Tucker was asked what had prompted him to write the screenplay and he replied: “I was thinking about the themes of family and what it's like to feel like a misfit and not at home in your own skin. Anyone who has been to high school knows these themes. Everyone's journey in life is to grow up, and Bree thinks her journey will end when she becomes female, but realizes that hers is really a journey into womanhood, to a place where she can feel the pain and joy of life again.” He also explains that the portrayal of Bree’s mother was inspired by his experience of his own mother.

 

In the same interview, Tucker reveals that his story was inspired by a woman he knew in Los Angeles, who one day revealed her true identity to him as a male-to-female transsexual. This led him to research the topic extensively, meeting more than a dozen transsexual women, and reading everything he could on the subject. Tucker even considered using a male to female transgendered actress for the part of Bree, but as those known to him were living ‘stealth’ (passing as women without revealing their original biological sex) he felt it would be too difficult for them.

The Film

We meet Bree, formerly known as Stanley, at the start of the film practising the voice exercises that help her to sound more like a woman.  She then takes a phone call and states that “Stanley doesn’t live here anymore”, but learns from that call that Stanley has a son, called Toby, who is in trouble in New York.  Bree, unaware that she had ever fathered a child, mentions Toby to her therapist when she is about to hand over the paperwork allowing Bree to proceed with surgery.  Her therapist consequently suggests that she must find out more about her son before the surgery can proceed. Bree’s male biological identity, and her ability to have fathered a child, must be acknowledged and explored before it can be relinquished.

 

This sets the scene for the journey that follows as Bree, posing as a church worker, bails her son from jail and travels back across America to Los Angeles with him, only revealing various truths about herself to him at different stages along the way.  Toby’s search for a stable and positive relationship with his unknown father adds dramatic tension for viewers, who are in the privileged position of understanding just who Bree is to Toby before he discovers the truth. It is through Toby’s eyes that we are able to scrutinise Bree’s performance as a woman, such as when they befriend a man who gives them a ride part of the way, and who appears to fall for Bree, unaware of her history.  We watch as Toby struggles to see his father as a woman, to whom another man is attracted as a woman.

A reluctant visit to her family home provides some very painful scenes, as her mother states that she cannot respect Bree’s new identity and both parents express grief for the loss of their son Stanley.  However, even crueler is their delight in the discovery that they have a grandson, who somehow replaces their lost son. It is in this setting that Bree is forced into revealing her circumstances fully to Toby and to outline her plans for surgery.

 

Bree and Toby do finally end up in Los Angeles but the film resists a completely ‘Happy ever after’ ending. While Transamerica tells its story with humour, it does not trivialise any of the big issues at the core of the film.

 

Relevance to the field of Mental Health

The challenge for anyone working in the mental health field is always to elicit and understand what a person is thinking and feeling whilst recognising that this may be in contrast to their appearance and behaviour.  This is especially so in matters of gender identity (the gender that you feel you should be) and gender dysphoria (a condition that describes the feeling of being trapped in a body of the wrong sex). Transamerica offers the viewer the experience of just such an assessment, through the eyes of Toby, from his first encounter with Bree to the final scenes. The film raises an awareness of the psychological conflict an individual may experience if they decide to be open about their transsexuality and illustrates the courage that is required to make such a life choice. Bree, like many others had not chosen the path of openness, but is unexpectedly forced into revealing her history to Toby, giving us an empathic understanding of what it may be like to be ‘outed’ against one’s will.

 

Transamerica is a film about performance and the search for authenticity.  We watch, in some detail, the struggle of Bree as she tries to pass as a woman. At the same time, we are drawn to the work of the actress, Felicity Huffman, who must offer us a credible performance as a biological male before she can perform as a transitioning transsexual woman. The film encourages us to reflect upon the performance of gender stereotypical roles that we all learn at an early age and to consider how hard it might be to change those performances.

 

Transsexualism is an extreme and long-term type of gender dysphoria. It is defined in ICD-10 as a mental disorder of adult personality and behaviour (F64.0). For diagnosis, the individual must have a very strong desire to live as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, their anatomic sex and a wish to make his or her body as congruent as possible with the preferred sex (usually involving hormone treatment and surgery). It is also important that none of these feelings exist as a symptom of another mental disorder like schizophrenia or as a result of a genetic or chromosomal abnormality.

 

The NHS has good information available on its website on the subject of Gender Dysphoria, which has an estimated prevalence in the UK of 1 in 4,000 people who are receiving medical help, although there may be many more people with the condition who have yet to seek help. On average, men are diagnosed with gender dysphoria five times more often than women.

 

The subject of transsexualism is gaining wider general public awareness in the UK, through various openly transsexual individuals, such as supermodel Lea T who is the new face of Givenchy, and Juliet Jacques, who has been describing her personal transgender journey in a regular column in the Guardian newspaper as well as TV soap Hollyoaks, which is tackling the subject in a storyline about a teenager with gender dysphoria.

 

For anyone wanting to gain a greater empathic understanding of the enormously complex issues facing people who seek to realign their biological sex to match their gender identity, Transamerica is a perfect starting point.

 

Minds on Film blog is written by Dr J Almeida, Consultant Psychiatrist.                          

16/08/2010 12:02:13

The Aviator

Introduction

The Aviator is a biographical film about the American billionaire, Howard Hughes, that presents an extremely well researched and accurate portrait of the development of his obsessive compulsive disorder (OCD), from its first emerging symptoms, to his struggle with severe symptoms in middle age. It tells the story of his lifetime achievements as a filmmaker, an aviator, a record breaker, a playboy and a successful entrepreneur. These successes were probably aided by his extreme perfectionism and his determination to attend to every small detail in a project, something the film illustrates brilliantly.

 

The film, directed by Martin Scorsese in 2004, with Leonardo DiCaprio playing Hughes, won 5 Academy Awards.

 

The Aviator

Scorsese consulted with OCD specialist, Dr Jeffrey M. Schwartz MD, an Associate Research Professor of Psychiatry at the UCLA School of Medicine and a medical advisor to the UK’s national Obsessive Compulsive Disorder charity OCD-UK, on every aspect of DiCaprio’s portrayal throughout the filming.

On the DVD with bonus features, there is a 15-minute film about the condition presented by Dr Schwartz in which several patients recount their own experiences of the illness. Di Caprio reveals, in an interview on the bonus disk, that he spent a significant period of time with a sufferer, before filming, in an attempt to understand what lay beneath the compulsive behaviour of excessive hand washing. DiCaprio also admits that he rediscovered some obsessional behaviour from his own childhood, involving cracks in pavements, when preparing for the part. This resulted in him sometimes taking ten minutes to walk from the studio door to the set.

The Film

Lasting for 163 minutes, this is an epic film but one well worth the investment in viewing it.  It tells the story of the early life of Howard Hughes from the 1920s to the 1940s and records the history of his OCD from the first subtle signs to the full blown incapacitating episodes in which he was almost certainly suffering from depression as well.

 

The film opens with shots of his mother bathing his naked body as a boy and telling him that he is not safe from disease, giving the viewer clues about a strong family history of OCD (which was in fact also present in other relatives) as well as early parenting influences in the causation of his OCD.

The Aviator beautifully depicts the grand age of the Hollywood studios with all of their glamour and shows the many famous actresses of the day with whom Hughes had sexual relations. However his personal isolation and difficulty in finding intimacy is particularly well enacted, especially in his relationships with Katharine Hepburn and Ava Gardner.  Through their eyes we are given insight into how the early symptoms of his illness become apparent and how OCD can adversely affect the partner in a close relationship.

 

A significant focus of the film is on Hughes’ contribution to the aeronautical industry and his involvement in the birth of modern aviation as we now know it.  His meticulous attention to detail and extreme perfectionism, coupled with his technical vision, are shown transcending the real limitations imposed by his OCD. This is a film that demonstrates just what can be achieved despite such a serious mental illness.

 

In contrast, his excessively controlling behaviour, in all of his personal relationships is shown as causing him huge difficulties.  His ability to employ staff to carry out his compulsions, an extraordinary facet of his illness, is an unusual feature of his mental ill-health made possible only by his great wealth.

The most severe episode of his OCD is brilliantly illustrated near the end of the film in the scene showing him living as a naked recluse in his screening studio. His nakedness at this point in the film has powerful echoes of his nakedness as a boy at the beginning of the story, being washed clean of germs by his mother.

 

Relevance to the field of mental health

For anyone interested in learning more about OCD, this film provides tremendous insight into the thoughts and compulsions that can cause sufferers so much distress.  It also illustrates the fact that depression may arise in association with untreated OCD and can contribute to the burden of illness. The Aviator helps us to imagine how it might feel to be close to someone with OCD who has not yet sought help.

 

Our understanding of this illness has grown significantly since the decades represented in The Aviator, when frontal lobotomy was the treatment of last resort for the condition. Although the role of early influences is acknowledged, the majority of scientific research now supports the view that in a significant proportion of sufferers it is a brain disorder.  It is also well recognised that stressful events and major life changes can bring on or worsen the symptoms of OCD, something that is well illustrated in the film.

 

Fortunately cognitive behavioural treatments have been developed in the past two decades that are very effective in treating the symptoms, using either exposure and response prevention (3 out of 4 people are helped significantly) or cognitive therapy (very effective for mild OCD on its own).

Additionally, there are thought to be problems with a neurotransmitter, serotonin, which is deficient in certain brain areas of people with OCD. This explains the use of certain drugs in the SSRI group of antidepressants, which increase available levels of serotonin, in the treatment of moderate to severe OCD, even when depression is not present. People who find relief with medication alone (around 6 out of 10 people) tend to relapse when it is stopped, unless it is combined with cognitive behavioural therapy.


The film portrays clearly that Hughes’ obsessive compulsive symptoms fluctuated significantly in severity in response to the stresses and traumas in his life, especially his near fatal plane crash.  But even during the worst episodes of his earlier life, he was able to suppress the symptoms fairly effectively when totally absorbed in a task.  The complete focus and absorption required to fly a plane seemed to overcome his symptoms and gave Hughes some of the happiest experiences in his life.  This makes sense to us now because effective treatments involving mindfulness in the present moment and distraction into activity are known to help lessen some of the symptoms of OCD.

 

I believe that this film offers the viewer an opportunity to gain an empathic understanding of the suffering that individuals with severe OCD might experience.  Indeed, one wonders what further achievements Howard Hughes might have made in later years had he been able to access the treatments available today, when he had first developed symptoms.

 

These issues were examined in a recent prospective, long-term follow up study of children and adolescents, seen at the specialist OCD Clinic for Young People at the Maudsley Hospital, London.  Published in the August 2010 issue of The British Journal of Psychiatry, the authors concluded that “early recognition and treatment of OCD in childhood might prevent chronicity“ and urging “a need for increased recognition at the earliest stages of the disorder” (Long-term outcomes of obsessive-compulsive disorder: follow-up of 142 children and adolescents N. Micali, I. Heyman, M.Perez, K. Hilton et al; The British Journal of Psychiatry (2010) 197, 128-134.).

 

  • The Royal College has a good leaflet on obsessive compulsive disorder for anyone wanting further information on the symptoms and treatments available.
  • Further information about The Aviator can be found at IMDB, as can a short trailer.
  • The DVD is available to purchase at amazon.co.uk (either with 2 discs and bonus features or one disc without the extras).

Minds on Film blog is written by Dr J Almeida. 

                         

21/07/2010 16:28:35

Tarnation

Introduction

Tarnation is an autobiographical documentary film about the very personal experience of growing up with a mother who was suffering from a schizoaffective disorder, an episodic illness in which both affective and schizophrenic symptoms are prominent within the same episode (ICD-10 classification of mental disorders, code F25). It tells the story of three generations of a Texas family. The film was made in 2003 by Jonathan Caouette.

Tarnation DVD cover

He created a collage of still photos, Super-8 video tape, answering machine messages, video diaries and early short films, from the previous nineteen years of his life and put the film together on his Apple Mac home computer, using the free iMovie software. It cost just over $200 to make the initial film. Some well-known producers, including Gus Van Sant, spent more money enhancing its technical qualities to bring it to a wider audience. It was later shown at the Sundance and Cannes film festivals, where it received positive acclaim.

Caouette began shooting home movies at the age of eleven and in an interview with him, which accompanies the DVD, he said, "I've wanted to be a filmmaker since I can remember, and filmmaking definitely saved my life. It was always a defence mechanism and a way to have a sense of control over my life." It is interesting that he also recounted his mother's reaction to his film, saying, "Renee loves Tarnation. She loves that her story is getting out there." Summing up the whole project, Caouette stated, "It has been the most cathartic, therapeutic, frightening and bloodcurdling experience of my life. Putting yourself out there like this is scary and exciting, but it has definitely healed me and seems to heal others as well, so all the pain I went through to get there is worth it." His was not an easy story to tell. Anyone interested in learning more about the making of this film can read Jonathan Caouette's interview with the Guardian in April 2005 and with the BBC in 2005, in which he explained that he chose the title, Tarnation, from a Southern American word used to mean 'Hell' or 'Damn', but also because it was the name of one of his favourite bands.

 

The Film

The opening credit sequence introduces us to the members of Caouette’s family whilst the prose poem The Desiderata is recited, and then goes on to show Jonathan as an adult at home in his New York apartment in 2002. He is on the phone anxiously trying to get news of his mother Renee, who is in hospital after taking a Lithium overdose and he seems to suffer a panic attack associated with the stress of the situation.

 

Tarnation is essentially a film of two parts. The first recounts the author's childhood and teenage years as affected not only by his mother's psychosis but also by her lengthy absences from his life when she was sometimes hospitalised for several years at a time. It tells of his first teenage experience with marijuana, obtained from a drug dealing friend of his mother, which was actually spiked with PCP, resulting in his first admission to hospital and the diagnosis of depersonalization disorder (ICD-10 classification of mental disorders, code F48.1). A core symptom of this syndrome is a subjective experience of unreality, as if dreaming, in which the individual feels that his own feelings and/or experiences are detached, distant and not his own, a quality that the film definitely manages to convey at times.

 

This part of the film also tells the story of his mother Renee's life from her early days as a beautiful child model to a teenager who embarks on a lengthy course of twice weekly Electroconvulsive therapy (ECT). She recovers enough to marry a salesman, who leaves her before she realises that she is pregnant with Jonathan. In a psychotic state she takes herself and her baby to Chicago, where she is raped and, on the way home to Texas, is ejected from a bus because of her disturbed behaviour. She spends six weeks in jail and baby Jonathan is taken in to foster care, as Renee moves in to hospital for several years. Jonathan experiences physical and emotional abuse as a toddler in foster care, and is finally adopted by his grandparents who became significant parental figures from that time onward. From the age of eleven Jonathan began to film the important elements in his own life including his developing homosexuality. His mother's relapsing psychosis led to a total of one hundred psychiatric hospital admissions and many courses of ECT. The film uses intertitles to tell the facts of the story, speeded up sequences, slow motion frames, multiple images and other special effects to express his inner turmoil. At times, the filming can feel almost too intrusive, uncomfortable and intimate giving rise to feelings in the viewer that may be interesting to examine.

 

The second part of the film deals with the period after Jonathan has left the family home in Texas and moved to New York, where he meets his partner David and begins to work as an actor. His mother comes to visit him there a few years later and he begins to build an adult relationship with her more closely than ever before. He tracks down his father and arranges a meeting with him and his mother together in the same room for the first time in thirty years. His mother, who is now living with her own father, is shown becoming unwell again and more demanding of contact before taking the serious Lithium overdose that opens the film. After release from hospital, now with brain damage from the lithium overdose, her disturbed mental state is shown more candidly. Near the end of the film Jonathan describes to camera the blurred boundaries that he experiences with his mother and how he feels 'as if she is inside me'. He also states his fears about becoming more like her. The film ends, as it begins with a recitation of the Desiderata.

 

Relevance to the field of Mental Health

As well as giving us an experience of Renee's mental illness, Tarnation also vividly depicts Caouette's own mental health struggles from drug induced hallucinatory experiences, depersonalization disorder and deliberate self-harm to anxiety and panic. Tarnation is a documentary film about the whole experience of mental illness from a very personal point of view that gives the viewer a real sense, affectively, of being in close proximity to significant mental disturbance. It could certainly help anyone considering a career in psychiatry to decide if this is truly the world of work that they are seeking. Tarnation doesn't hold back on portraying the pain and chaos that can be part of life where psychosis is present.

 

Of particular interest, too, is the process of Caouette's filmmaking, both the actual filming and, later, the editing, which seems to serve as a means of making sense of and managing his disturbing life experiences for him. The act of making Tarnation could be described as 'creative play' involving the imaginative creation of the film as a transitional phenomenon that helps him to process the highly charged, difficult emotions that exist between him and his mother. The concept of transitional objects and phenomena, introduced by the psychoanalyst D.W.Winnicott, in his essay “Transitional objects and transitional phenomena”, (1953, Int. J. Psychoanal., 34:89-97), had a major impact on psychoanalysis and, in particular, object relations theory. According to Winnicott, transitional objects are the means that the infant has for negotiating separation from its mother, and with age they form the basis of our use of symbols. Winnicott regarded transitional phenomena as the foundation of culture, religion and science.

 

Being behind the lens of a camera distances the individual from the events that they are viewing or in which they are involved. This can help to create a fictional reality that protects the person from being overwhelmed by painful feelings or life experiences. It seems that the ability to control and manipulate the images from his life whilst at the same time 'telling his story' were essential factors in producing a positive outcome for Caouette. As quoted above, he describes being healed by this project. As we the viewers watch this film, painful or uncomfortable feelings may be generated within ourselves. But, as it is a piece of fictional reality for us too, we are distanced from the action in the film and protected from the extremes of the experience, enabling us to process those uncomfortable emotions as and when we choose. We often need to get help with doing that by seeking out an opportunity to 'compare notes' with friends or colleagues and in so doing discuss how the film has affected us.

 

I recommend this film for viewing because it gives such a good insight in to a world that we often only hear about second hand from relatives and carers. It can, I think, bring greater understanding to us all about the nature of the stresses felt by relatives caring for a loved one with a psychotic illness and also of the mental illness that can result in them from that stress. This is particularly important to understand when the relative is a child of the patient. Along with the recent article in the Royal College of Psychiatry journal, Advances in Psychiatric Treatment, entitled 'Living upside down': being a young carer of a parent with mental illness' by Alan Cooklin (Vol. 16, Issue 2, p141), which looked at the issue of children who have parents with a mental illness, this film can only reinforce the need for a wider awareness of this extremely important topic.

 

Jonathan Caouette continues to work as a film director and an actor and has been with his partner David, who features in Tarnation, for the past 11 years.

 

  • Film reviews are available at IMDB, as is a short trailer. Running time: 91 minutes. Rated 15 in the UK (contains strong language and nudity).
  • The DVD may be purchased at amazon.co.uk.

24 June 2010

                          

15/06/2010 21:23:52

Summer Hours

Introduction

Summer Hours is a film about death and uncomplicated grief. It is also about families and the relationship between adult siblings thrown together at a time of shared crisis as they sort out the possessions and property of their deceased parent. It touches on the issue of how we plan for our death. In French, with English subtitles, it was directed by Olivier Assayas, in 2008.

The project was originally commissioned as part of a series of short films intended to celebrate the 20th anniversary of the Musee d’Orsay in Paris (an art museum housing works from 1848 to 1914).

Summer Hours

However when the museum project collapsed, Assayas remained drawn to the subject and developed his ideas into a full-length film.

 

He chose the title Summer Hours (the original title in French, L'Heure d'été , actually translates as the summer hour) to reflect the notion of transience in both nature and life. The film examines the interface between art and life and focuses on the dual role of artistic objects as heirlooms and as historical artifacts. It explores how emotional memories become associated with objects in their journey through families and how important those objects may become during the grieving process. Beautifully filmed, and with a wonderful soundtrack, this is a vivid, yet gentle, family drama that portrays individuals from different generations dealing with death and its aftermath.

 

The Film

This is a film that I do not wish to describe in too much detail. Summer Hours must be experienced, regardless of the fact that it is spoken in another language. In fact, the universal emotions portrayed are the reason that I recommend it. I will set the scene by outlining the main players in the story. We are first introduced to three generations of a family at Helene’s idyllic country home, not far from Paris. The family has gathered to celebrate her 75th birthday. We soon learn that she has three children; her eldest son Frederic, an economist and university professor in Paris; her daughter Adrienne, a designer working in New York and her youngest son Jeremie, a successful businessman working in China. Both sons are married with children whose ages range from teenage to toddler. Helene’s uncle, Paul Berthier, now dead, was a famous artist who lived and worked at the family home and was responsible for acquiring some of the art collection that fills the rooms. Helene has been committed to preserving the memory of her uncle for many years.

 

Relevance to the field of Mental Health

Summer Hours sensitively depicts death in a family and examines minutely the period that follows the sudden loss. It shows us the painful process of dismantling a life suddenly suspended at the point of death, a task that is central to the process of grieving. Through the course of the film, it examines the varied responses of people from different generations as they deal with their grief. All of them, it appears, suffer from uncomplicated grief.   As well as losing a family member, there are objects and a place that must be given up, portraying the complexity of the processes involved in bereavement. Where a family home must be relinquished, the severing of an attachment to childhood may have to be negotiated, introducing another important hurdle that must be overcome.

 

I suspect that most viewers will identify with the emotions portrayed in this film because loss is a universal phenomenon. Anyone working with the bereaved will recognize how important it is for an individual to work at their own pace when sorting through the deceased’s belongings and affairs. For anyone seeking to gain a greater knowledge and understanding of uncomplicated bereavement and grief this film could provide an excellent starting point for further discussion. Summer Hours does all of this without being gloomy or overly sentimental.

 

For anyone seeking more information about the topic of grief and bereavement there is an excellent leaflet produced by the Royal College of Psychiatrists on the subject.

 

The psychiatrist Colin Murray Parkes has spent a lifetime working in the field of attachment and loss. His Bereavement: Studies of Grief in Adult Life (now in third new edition, published by Penguin in 1998), remains a classic work. More recently his interest has focused on the nature of early attachment bonds that may influence the patterns of grief expressed by an individual in adult life, especially when grief is pathological. This subject, the result of his lifetime’s work, is presented in the book Love and Loss (published by Routledge, 2006). His central tenet is that loving and grieving are like the flip sides of a coin and that we cannot have one without the other. The price we pay for loving is the inevitability of grieving. The risk of losing the loved person is one that we must take in order to obtain the riches of intimacy. The nature of the bond formed will determine how we deal with the breaking of that bond.

 

In Summer Hours it seems that all three of Helene’s children have positive but varied experiences of growing up, and have developed into successful independent adults, able to cope well with her passing.

For psychiatrists, it might also be interesting to follow the discussions currently taking place about the proposed changes in the new ICD-11 and DSM-V systems of classification of mental disorders, with regard to grief. In DSM-V there is a suggested revision that will remove the bereavement exclusion criteria for Major Depressive Disorder with, some say, the potential to give an unnecessary psychiatric diagnosis to certain bereaved individuals. In another proposal, a new category of prolonged grief disorder is suggested, in both ICD-11 and DSM-V, following a study published in the open access PLoS journal by Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM et al Prolonged grief disorder: Psychometric validation criteria proposed for DSM-5 and ICD-11, (2009). This new category would be distinct from other forms of pathological grief response and allow for the detection and treatment of a specific group of people at risk of persistent dysfunction and suffering six months after bereavement.

 

Perhaps the greatest challenge will always be to recognize the difference between uncomplicated ‘healthy’ grief (which is not a mental disorder), and pathological grief, so that those needing help are offered it.  Summer Hours offers viewers an exquisite portrait of certain aspects of healthy grief and the practical issues that the recently bereaved often face.

 

22 July 2010

                       

 

 

Login
Make a Donation

 

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.

 


*
  You can now follow Minds on Film on Twitter @psychfilm

 

 

Other College blogs you may wish to catch up on:


 

sdf