Introduction

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

Introduction

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

Introduction

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

Introduction

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.

 

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

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

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 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.

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.

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.

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.

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

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).

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.