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.

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

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.

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

•  Further information is available at IMDB, and the official trailer is available on You Tube.

•  Longtime Companion can be purchased at amazon.co.uk.

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.

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.

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.