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

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30/10/2014 14:51:24

Flesh & Blood

This is the first of two blogs about the topic of adoption.

 

IntroductionFlesh and Blood

Flesh & Blood is a full-length TV film, written by Peter Bowker and directed by Julian Farino. It was broadcast on BBC2 in 2002 and released on DVD in 2007. It features Christopher Ecclestone as an adult man, Joe, adopted at birth, who seeks out his biological parents after his own daughter is born, only to find out that they both have a learning disability and are totally unaware of his existence. Joe’s parents are played by two actors, Peter Kirby and Dorothy Cockin, who have a learning disability, with no formal training as actors before the filming, and who worked with an improvised script. The director reported that both actors enjoyed the experience although he is quoted as saying “they didn’t understand the structure of the story, but they did understand that they were pretending”. He also stated that learning disability organisations were consulted before production and were very supportive of the project.

The writer, Peter Bowker, has twelve years of experience, earlier in his life, in teaching individuals with special needs in a variety of settings, including in hospitals. He won the Royal Television Society Award for Best Writer in 2003 for the screenplay. Christopher Ecclestone won Best Actor at the same RTS Awards and the film won the Prix Europa award for TV fiction in 2003.

 

The Film

Flesh & Blood begins with Joe knocking on doors in Morecambe, in the Northwest of England, in an attempt to find his birth mother. When he succeeds in matching the name on his birth certificate with a mental health nurse, Joe believes that he has found his roots and can share the joy of his own baby daughter with her. However, at their first proper meeting, Barbara reveals her name had been used on his birth certificate to cover up the truth that two learning disabled inpatients, who had had a sexual relationship within the unit where she had been working, were actually his biological parents and were completely unaware of his existence. Joe finds that he is challenged by this news as he struggles to tell his wife, family and closest friends about the truth of his discovery and he becomes quite angry and aggressive toward his wife as he confronts his own prejudice. There are a variety of feelings expressed about learning disability by the other people close to Joe. The film also shows those in society working tirelessly to counter any negative views, when Joe volunteers at the local social club where his biological father, Harry, enjoys playing pool every week and Joe begins to befriend him. Joe finds himself really surprised when he learns that Harry has a job but then realises that this is absolutely as it should be. His encounter with Janet, his biological mother, proves more difficult as she has less ability to engage in conversation. Joe decides to arrange a family gathering for all of his family and friends to meet Harry and Janet at his home and it is during this event that Janet gets to hold Joe’s baby daughter, without the knowledge that this is her own grand daughter, with Harry sitting by Janet’s side. As a photo is taken of this important moment for Joe, a sense of integration and assimilation is reached in Joe’s personal journey to find his biological roots and a fuller understanding of his role as a husband and father.

 

Relevance to the Field of Mental Health

Flesh & Blood offers a very good platform for discussion about learning disability as well as the issue of adoption from the point of view of the adult adopted child seeking information about their biological origins. The film provides the perfect opportunity to consider the topic of mental capacity and consent in the context of sexual relationships between people with a learning disability. What makes this a valuable film for mental health professionals is the authenticity of the performances. As both of Joe’s parents are played by actors with a learning disability and their scenes are unscripted, the other actors respond to them spontaneously throughout the course of the filming, making the interactions feel much more real. Some of the scenes were filmed at the social club, which the actor playing Harry actually attended every week, as well as at the factory where he had worked for more than twenty years. For further information that could complement a viewing of the film, there is a good fact sheet available at The Royal College of Psychiatrists website and an excellent review article published in the British Journal of Psychiatry in 2000 by Sheila Hollins titled Developmental psychiatry - insights from learning disability (The British Journal of Psychiatry (2000)177: 201-206) now freely available on-line. It is interesting to remember that this article was written before the Mental Capacity Act of 2005.

 

Flesh & Blood also provides a good platform for discussion about the psychological issues often raised by adoption for the individual placed away from their biological parent or parents in early life. For those providing counseling and psychotherapy this may be an issue that causes individuals to seek help in adult life. More useful information is available at the Fostering and Adoption learning resources from Research in Practice website funded by the Department of Education in the UK. Here there is an interesting page on Attachment theory and research.

Although the circumstance of Joe’s adoption may surprise some viewers of the film, it is interesting to note the statement on the webpage of The National Archives:

Formal adoption, as we now know it, did not exist in England and Wales until 1927. Before then, adoptions were usually informal. In a few cases there was some legal documentation, but no central register.

This is a very valuable film for anyone interested in working in mental health and in particular with individuals who have a learning disability. The DVD contains a fascinating commentary by the director and Christopher Ecclestone, which includes much discussion about their experiences of working with the two learning disabled actors.

• More information about Flesh & Blood can be found at IMDB

Flesh & Blood can be purchased from amazon.co.uk.

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

 

 

30/09/2014 15:48:11

2 films on Huntington’s disease

 

Introduction

In this blog I want to present two freely available short films about Huntington’s disease (HD), an inherited progressive neurodegenerative disorder which causes abnormalities in movement and thinking and which is commonly associated with certain psychiatric conditions. In the first film, called Huntington’s Disease through Film, we hear about a Scottish family in which four adult children are positive for HD but are presenting at different stages of the illness. Three of them feature in the film. The film offers a really special insight into the clinical presentation of the movement disorder and speech impairment that manifests in HD. It also gives an important opportunity to understand how the sibling’s unaffected mother copes with the experience of caring for and supporting her children through her direct addresses to camera. The film was made by Mike Rea for The Scottish Huntington’s Association (SHA). The SHA is a charity which was established in 1989 by families living with the condition and has the aim of significantly improving the quality of life of everyone touched by Huntington’s disease. The charity also strives to increase knowledge about HD through training and education and this film is one such resource offered at their website. The second short film has been produced for the NHS Choices web pages about HD and is also posted on the Huntington’s Disease Association website. It features a 39 year old man, Lee, who has HD talking about how it affects him, and how his mother, who also suffered from HD, struggled with certain difficult behaviours. In this film, a consultant clinical geneticist presents information about the genetics and discusses some of the symptomatic treatments used.


The films

Huntington's Disease through Film from Mike Rea on Vimeo.

 

 

Relevance to the field of Mental Health

These are powerful short films, offering valuable clinical portraits of HD for anyone who is working in mental health services. Viewing the films alongside a reading of many excellent online resources about HD could offer an effective platform for learning about the condition. The Huntington’s Disease Association of England and Wales is a charity supporting people with HD which has a huge range of educational resources for patients, carers and the professionals involved in looking after them. They also won an award in 2014 for science communication at their website HDBuzz, which offers the latest HD research news ‘in plain, understandable language’. The HD society of America also has a huge amount of useful information on their website.

A reading of the article entitled Psychiatric and behavioural manifestations of Huntington’s disease by S Jauhur and S Ritchie published in Advances in Psychiatric Treatment in 2010  (Advances in Psychiatric Treatment (2010)16: 168-175) would provide an excellent additional resource for students and trainee psychiatrists alongside a viewing of these two short films. Readers seeking more information about the latest state of research into therapies for HD might be interested in a recently published review paper in the journal called Movement Disorders entitled Targets for future clinical trials in Huntington's disease: What's in the pipeline? by Edward J. Wild MD, PhD and Sarah J. Tabrizi MD, PhD (Movement Disorders; Special Issue: Huntington's Disease; Volume 29, Issue 11, pages 1434–1445, 15 September 2014) which has been made open access and is available at http://onlinelibrary.wiley.com/doi/10.1002/mds.26007/full

 

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

 

20/08/2014 13:23:38

Passionflower

 

IntroductionPassionflower

Passionflower is the first full-length feature film written and directed by Canadian filmmaker Shelagh Carter. Released in 2011 and screened at a number of film festivals in Canada and the USA, where it won several awards, it has been made available for streaming on iTunes in August 2014. Passionflower tells the story of a young girl growing up with a mother who develops a mental illness and is closely based on Carter’s own childhood experiences. Her ability to use the creative processes of writing and directing in such an articulate way to describe her subjective childhood experiences offers a huge amount to the viewer. Superbly cast and set in Winnipeg in the 1960s, the film also offers an insightful commentary on the attitudes toward mental illness prevalent in that period.

I was fortunate to be able to meet with Shelagh Carter in March 2014 and to discuss the process of making such a personal film. I hope that our interview will make the viewing of the film all the more interesting and rewarding.

As Carter says in our interview:

The film is about forgiveness, it was a freeing act for me to do.”

Shelagh Carter


Press play to listen to the interview


The film

Passionflower begins with Sarah, aged about eleven, walking home from school clutching her report card. She seems pleased, in a self-contained way, but this all changes when she gets home and tells the good news to her mother, Beatrice, who fails to acknowledge the report at all but instead criticises Sarah’s appearance. Sarah, bruised but seemingly unsurprised by this response, picks up her cat, Rosie, whispering her grades quietly into her ear as she pours milk into the cat’s bowl. Later at dinner, when Sarah and her younger brother Thomas are forced to wait in silence, staring at the table filled with food until their father David returns home, a palpable sense of control and tension caused by Beatrice sets the scene for what follows. After eating, Beatrice plays some mellow music on the record player and invites David to dance with her in a sexually charged manner. Sarah is watching by the side of the room, the constant observer and narrator of the story. That night, at 4am, Sarah is woken by the sound of her mother’s distressed sobbing in another room. Again Sarah crouches out of sight to watch as her father tries to console Beatrice as he carries her back to bed. At a dinner party Beatrice behaves in an inappropriately flirtatious way toward the other men present whilst also being extremely rude to a female friend. Later that night, Sarah finds her mother lying curled up, naked and screaming with despair on the kitchen floor while Sarah crouches, crying and frightened close by until David arrives again to carry his wife back to bed. After these events, Beatrice takes to her bed, tired, irritable and depressed in mood and David asks a doctor to visit the home. Beatrice denies any significant problems and only admits to being “too emotional....I need to get some rest” and that she is not sleeping. A sedative is prescribed and a short break in hospital offered but Beatrice does not appear willing to consider this seriously. As the doctor leaves the house he asks Sarah if there is anything she wants to say, to which she replies, “I just want everything to be OK”.

Sarah makes a friend in Charlie, a boy in her school class who shares her love and talent for art and they each share a special place with the other, both locations have pictures of topless women displayed. Sarah uses the new images she sees to start drawing naked women and dressing them with her own fashion designs. Sarah tells Charlie that her mother was once a model and now makes her own clothes. Charlie replies that his mother is ‘just a Mom’. Sarah gets to observe Charlie’s loving relationship with his mother, which only serves to highlight the lack of affection she receives from her own mother.

Beatrice takes Sarah to visit her own mother who is resident in a long stay psychiatric institution and lacks coherent conversation but mentions passionflower in some poetry she recites. Beatrice becomes distressed after the visit and takes them for something to eat. Her mood changes dramatically when she makes eye contact with a man who comes into the diner causing her to announce, “we’re having an adventure”. On the way home, Sarah reminds Beatrice that Thomas must be collected from school, but after taking Sarah home, Beatrice drives off into the countryside oblivious of her responsibilities. Stopping on a deserted stretch of road, Beatrice takes her top off and rolls in the dirty road as the sound track goes silent. When she finally gets home late that night, David is distraught and angry and his mother, Constance, has arrived to support him. But still no action is taken to get help for Beatrice. Soon after, Beatrice seduces her friend’s husband in the house and Sarah comes home early from school to witness the adultery. Then Beatrice has the cat put down by the vet because its collar bell was annoying her but telling the children that Rosie was sick. Sarah is angry with disbelief that such a thing could happen and David’s mother finally suggests that a line has been crossed that requires immediate action.

At school, Sarah’s teacher discovers some of her naked drawings and recognises the artistic talent she has at the same time as acknowledging the inappropriateness of such material. David is summoned to the school despite Sarah initially blaming her friend Charlie for the drawings. David cannot reveal that there is anything ‘going on’ at home and just says “everything is fine”. By now, Sarah is sad and muddled and tells her father that she fears she will be “crazy like her Mum and Grandma”. He tries to reassure Sarah and finally acts to insist that Beatrice gets help in hospital, where she has a course of ECT to good effect but with consequent loss of memory for recent events. On returning home to a muted celebration, Beatrice immediately hugs Thomas but cannot offer any such affection to Sarah. In a painfully poignant moment Beatrice calmly tells Sarah “the storm is over dear”.
 

Relevance to the field of Mental Health

Passionflower is a film that examines the painful and challenging time in a family when the wife and mother of two young children starts to develop a mood disorder, leading eventually to her first psychiatric hospital admission at the end of the film. It captures the ‘moment of dawning’ as everyone begins to realise that Beatrice’s behaviour is seriously abnormal but also presents the huge difficulties faced by father and husband, David, whose lack of action, in an attempt to maintain ‘normality’, becomes increasingly problematic. The film shows so well the precarious position that children are in when being parented by an adult who is mentally unwell and not receiving treatment or support from outside the home. David’s struggle to acknowledge the strain the family is under as a result of his wife’s mental illness is subtly portrayed and his lonely position is acutely felt as

his loving and well meaning attempts to try and cover over the cracks for too long finally fail and the crisis of hospital admission becomes inevitable. It is the intimacy of this drama that is so valuable to the viewer.

By telling the story through the eyes of Sarah, who is on the verge of puberty, the topic of her developing sexuality is sensitively contrasted with her mother’s increasingly disinhibited attitude to her own body and sexual behaviour, characteristic of hypomania. The film also portrays certain painful moments of depressive despair and irritability in Beatrice, witnessed by her young daughter, which could be used for teaching about the way such experiences can affect family members, especially children, and how interventions may be structured to support each individual in those circumstances. 

This is a powerful and compelling film to watch. With the knowledge that Carter had to tell this story to complete her own process of recovery from her childhood experiences, the viewer becomes part of that process, in bearing witness to these events. In some ways the film places the viewer in lieu of a psychotherapist receiving a subjective account from midlife of troubling childhood memories. Perhaps the film could be used as a foundation for discussion on how one might work with such memories, using a variety of different approaches to individual therapy, in order to aid the process of healing and recovery. In this context a book that might be of interest is The Handbook of Individual Therapy, edited by Windy Dryden and Andrew Reeves; SAGE Publications Ltd; Sixth Edition edition (15 Nov 2013), which examines the theory and practice of a broad range of therapies available in the UK at present.

Passionflower offers the viewer an opportunity to enhance their understanding of what it might be like to live with someone who is mentally unwell and whose behaviour is unpredictable, when explanations and reassurances are not forthcoming. As such it is a most valuable learning tool for anyone interested in working in the mental health professions.

* More information about Passionflower can be found at the film’s website as can a short trailer.

* Passionflower is available for streaming on iTunes.

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

 

 

01/08/2014 10:04:48

Granny’s Got Game

Granny's Got Game

Introduction

Granny’s Got Game is a documentary film, directed by Angela Alford and released in 2013, featuring seven women in their seventies who are members of a North Carolina Senior basketball team called the Fabulous Seventies as they try to win a National Senior Games Championship. It follows them for the year leading up to this major championship and sees them through all of the ups and downs that they encounter as they seek to progress through the earlier stages of the competition. The film’s tagline, which is a quote from Benjamin Franklin, usefully sums up the philosophy of the film: “We don't stop playing because we grow old. We grow old because we stop playing”.

The film

Granny’s Got Game is constructed around monologues from all of the team members alternating with footage of them practicing or competing on court in various state and regional competitions on the way to the national championship in Texas. Initially this involves them giving some background about their sporting achievements as young women at high school and goes on to talk about their physical health issues, the role of the team in their lives and their friendships that have developed over time. Some have developed significant physical health problems or have suffered injuries on court, but even then they show a determination to remain connected to the team by sitting on the bench during team practice or playing with protective padding. They have been playing together for seventeen years and so the women are able to offer a significant historical perspective on the role of the team and basketball in their lives as they are negotiating growing older. They share many interesting insights about how they cope with the experience of ageing.


Relevance to the field of Mental Health

Granny’s Got Game provides the viewer with a wonderful example of the benefits that regular physical exercise in later life can bring, especially when it involves social contact with team mates that encourages the development of mutually supportive relationships. Indeed the film examines the nature of friendships formed in later life and presents a clear argument in support of the mental health benefits of maintaining or creating a social network as we age. The style of the documentary helps the viewer to connect with each of the women very quickly and to appreciate their different personalities in relation to the task of growing older.

There is an increasing public health need for individuals at all ages and stages of life to take a greater responsibility for their physical and mental well being. Regular exercise is recognised as being central to achieving and maintaining good health and preventing the development of many diseases. Within the World Health Organisation Global Strategy on Diet, Physical Activity and Health the recommendations for Physical Activity and Older Adults are worth quoting at length:

In order to improve cardiorespiratory and muscular fitness, bone and functional health, reduce the risk of NCDs (Non-communicable diseases, which include a range of chronic conditions, such as cancer, diabetes, cardiovascular disease and hypertension), depression and cognitive decline:

1         Older adults should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.

        Aerobic activity should be performed in bouts of at least 10 minutes duration.

3         For additional health benefits, older adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate-and vigorous-intensity activity.

4         Older adults, with poor mobility, should perform physical activity to enhance balance and prevent falls on 3 or more days per week.

5         Muscle-strengthening activities, involving major muscle groups, should be done on 2 or more days a week.

6         When older adults cannot do the recommended amounts of physical activity due to health conditions, they should be as physically active as their abilities and conditions allow.

There is further useful information on the benefits of physical activity for older adults on the NHS choices website with some detailed guidelines about the 150 minutes a week recommended for better physical health. The webpage also includes an excellent short video about a playground designed for the over-60s somewhere in the UK in which users also link the social benefits of exercising with others outside of the home.

This is a wonderfully uplifting, at times moving, and compelling documentary film and I think anyone interested in working with older people would benefit hugely from watching it.

 

• More information about Granny’s Got Game can be found at IMDB and an extended trailer is available to view at Vimeo.

Granny’s Got Game can be purchased from itunes.

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

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02/07/2014 10:45:00

The Savages

 

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


Introduction

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

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

 

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

 

Relevance to the field of Mental Health

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

 

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

 

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

 

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

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

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

 

02/06/2014 09:23:42

Wrinkles or Arrugas

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

Introduction Wrinkles

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

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

The Film 

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

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

Relevance to the Field of Mental Health 

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

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

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

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

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

30/04/2014 15:04:06

A Simple Life

 

... or 桃姐 (Tao jie)

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

Introduction

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



The Film

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

 

Relevance to the field of Mental Health

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

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

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

 

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

 

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

 

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

 

01/04/2014 12:33:54

Les Invisibles

IntroductionLes Invisibles

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

 

The Film

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

 

Relevance to the Field of Mental Health

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

 

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

 

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

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

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

 

02/03/2014 12:50:04

The Impossible

Introduction The Impossible

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


The Film

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

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

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


Relevance to the Field of Mental Health

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

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

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

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

 

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

 

03/02/2014 09:39:14

The Crash Reel

Introduction The Crash Reel

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

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

The Film

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

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

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

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

 

Relevance to the Field of Mental Health

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

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

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

 

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

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

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

 

 

 

 

 

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About this blog

 

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

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

Dr Joyce Almeida

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

 


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