Silver Lining Playbook - Propsychiatry?

I went to see this film today for a couple of reasons.  Several people recommended it to me as a “pro-psychiatry” movie.  And I saw Robert De Niro interviewed about this movie with some of the cast and he was overcome with emotion and attributed it to the main character of the story and what he apparently went through with bipolar disorder.  As a film the structure and pace of this are well done.  It is enjoyable to watch.  The ensemble cast of Bradley Cooper, Jennifer Lawrence, Robert DeNiro and Jackie Weaver are focused at times on how depression and bipolar disorder affect people and their families.  I think it is generally known that the film focuses on Cooper’s character Pat, at the outset.  We learn that he has been court ordered to a psychiatric hospital.  In one of the opening scenes his mother picks him up and drives him to home to Philadelphia where he is supposed to comply with court ordered therapy, medications, and the conditions of a restraining order that prohibits him from contacting his wife or coming within 500 feet of her.  A police officer shows up to encourage compliance with the restraining order.

The first question in evaluating the movie and my friends’ comments is whether this very entertaining and well acted film is psychiatrically plausible.  Could the Cooper character (Pat Solitano) assault someone with the vigor we see in the film and end up being diverted to what appears to be a low security state psychiatric facility.  My understanding is that the film is based on the novel The Silver Linings Playbook by Matthew Quick.   There seems to be a general consensus that the film version is a very loose adaptation so I suppose I would need to read the novel to see the way this part of the plot was framed.  In real life, assaultive behavior in most states is handled as a criminal matter rather than court ordered psychiatric treatment.  It is one of the reasons that county jails have become large psychiatric facilities.  In some cases there is psychiatric care provided in jail.  In more enlightened systems competency evaluations are provided in jail and that may result in diversion to mental health court rather than criminal court.  An insanity plea has a low likelihood of success and defense attorneys are reluctant to consider it because the length of stay in a psychiatric hospital may be longer than in jail.

In this case Pat has been in the hospital for about 8 months.  We are told his mother made some kind of a deal to get him out.  In the process, one of his fellow patients leaves in the same car illustrating that security is not a priority.  While he is in the hospital, Pat spits his medication out after a mouth check by a nurse and when he gets home he proclaims he is not taking the medication because it affects his mental clarity and gives him physical side effects.  He is intense, wakes his parents up in the middle of the night, and creates a high level of tension in their home.  His parents seem at a loss in terms of how they can help him and invariably end up reminding him about the conditions of his release.  His apparent mental illness peaks with a scene where the entire neighborhood is disrupted and he physically injures his parents.  He eventually begins taking the medication.

His relationship with Tiffany (Jennifer Lawrence) begins in parallel with his initial stability and proceeds as he is getting more stable.  She also discloses a significant depression associated with her husband’s death and some sexual promiscuity.  She is portrayed as a very intense and at times angry and agitated women who is aware of the controversial parts of her character and says she has accepted them.  She has several angry confrontations with Pat and a very animated confrontation with his family about whether or not she is good for their home team’s juju.  Her emotional relationship to Pat as he recovers is one of the most compelling parts of the film.

At various moments, Pat is seen with his psychiatrist Dr. Patel (Anupam Kher) who does a good job of engaging a hypomanic Pat in movie psychotherapy.  Dr. Patel did have qualities that most people would like to see in a physician.  He listened, he was engaged, and he was able to relate to Pat.  In the first clinic scene, we learn that Dr. Patel played some music (or said that he did) to see how Pat would react.  Pat trashed the magazine stand in the waiting area.  This is dramatic license rather than actual psychiatry.  I can’t imagine any reasonable psychiatrist who would be eager to provoke a reaction from a person with a history of aggression who has been conditionally released from a state psychiatric facility.  The reality of these appointments for people with severe mental illnesses is that most of the time is not focused on psychotherapy.  In most public or managed care clinics Dr. Patel would have about 20 minutes to see Pat, discuss his symptoms, discuss medication side effects, order and review labs, and do the necessary documentation.  A casual armchair conversation like the one portrayed in the movie can occur only in special circumstances.

After the initial sessions we next meet Dr. Patel tailgating in the parking lot outside of the Philadelphia Eagle’s game.  He embraces Pat and utters a word that I have never heard a psychiatrist say.  There is an ugly scene involving racism and Dr. Patel and his fellow Indians and some of the locals.  Pat is back in the middle of this fighting to protect his brother.  Although he is arrested they all (including Dr. Patel) end up back at Pat’s parents home – a significant boundary problem.

I think that it is pretty obvious that I don’t really see this as a “pro-psychiatry” movie.  Psychiatrists don’t really act like Dr. Patel and many of the scenes highlighting problems with mental illness are more probably affected by dramatic license.  Some of those scenes were well done in terms of the chaos, aggressive behavior, anger and stress associated with mental illness.  Critics have faulted the film for not going far enough diagnostically, being an antipsychiatry film in that it demonstrates the failures of medical psychiatry, and generally seeing it as a random display of neurosis without enough details.  I think the outlines are there, but let’s face it.  This is not a clinical exercise.  This is art.  When I go to the movies, I am looking for compelling characters and good acting.  It is even better if those characters are acting out a fantasy that I can identify with.  Cooper and Lawrence clearly have a level of intensity that you don’t see in many places these days.  So while this film was really not about psychiatry (certainly not “pro-psychiatry”) it was very entertaining and it captured a lot of the reasons why I go to the movies.

I would like to have read what Robert De Niro read that gave him insights into the pain of the main character.  From what I saw today, they only scratched the surface on that issue.

George Dawson, MD, DFAPA         

Being Flynn - Another Cinematic Portrayal of Alcoholism

My previous post looked at the accurate portrayal of alcoholism in the film Flight.  I recently saw Being Flynn starring Robert De Niro in the role of an alcoholic father and self proclaimed novelist.  This film is also a study of alcoholism.

Like Denzel Washington, De Niro accurately portrays the ways that alcoholism impacts the lives of some men.  In this case we meet De Niro's character Jonathan Flynn in a downward spiral.  We first meet his son Nick Flynn and learn through a series of flashbacks that the elder Flynn abandoned Nick and his mother for unclear reasons and he has not seen his father in about 18 years.   We first see Jonathan Flynn when he is driving a taxi.  He is drinking vodka on a regular basis.  We see him lose his job and then his housing and end up at a homeless shelter.  Nick is floundering as a poet and author.  He lacks direction and the flashbacks suggest that childhood adversity has played a big role.  He comes to be employed at a homeless shelter where his father eventually seeks shelter.

The trajectory of that story line is impacted by the fact that Jonathan is a very volatile and generally unlikable character.  Although it is certainly dangerous to live on the street, he has an aggressive attitude at times that is not warranted.  It is the reason he was evicted.  At other times he is able to keep quiet when he witnesses some street thugs beating one of his drinking buddies.  He uses a lot of expletives and at times seems incoherent.  In his interaction with Nick he is unapologetic and grandiose - describing himself as one of America's greatest authors.  When he allows Nick to read his manuscript, the first chapter shows some promise but the rest is incoherent.

Nick is on his own parallel journey.  He is lucky to get the job at the homeless shelter and initially blends in seamlessly with the staff.  The shelter staff and the environment at the shelter is expertly portrayed and very realistic.   The tension at the shelter between caring for desperate and sometimes disagreeable men and the required altruism is palpable.  Eventually Jonathan's disagreeable temperament creates a situation where Nick has to vote on whether to expel him.   He does despite a staff person trying to convince him not to send his father out on one of the coldest days of the year.  Jonathan predictably acts like he relishes the thought and that living on the street is nothing.  When we see what actually happens out there it is clear that his attitude is another manifestation of his pathology.  There is a time when we are not sure whether Jonathan will survive or not.

There are a number of fascinating articles available that look at the process of making this film.  The gold standard for any film is the book and many critics suggest reading that as a starting point.  The real Nick Flynn has some fascinating interviews talking about the evolution of homelessness in America.  When did it become acceptable?  The motion picture business is averse to producing any films that portray characters or themes that the general public would find to be distressing and the main reason is how that translates into box office numbers.

As I contemplated the Flynns' predicament I naturally thought about all of the homeless alcoholic men I have seen in the past 25 years.  At some point in time they all create the anger, frustration, and hopelessness portrayed in this film.  Many of them are not only grandiose and paranoid, but permanently delusional or amnestic.  The good news is that they are also a stimulus for the altruism apparent in the shelter staff in this film and eventually Nick Flynn himself.  This film is similar to Flight in that there are no proposed solutions.  The are no public policy statements.  It is an accurate depiction of real people dealing the the problem of addiction in their daily lives.  Despite those significant problems there are hopeful messages everywhere.  After reading an interview with the author, I am skeptical of the origins of those messages, but based on my experience they seem real.

I also had associations to what I consider to be some of the most important work in alcoholism.  The first was a study of inner city alcoholics by George Vaillant in the 1980s and several subsequent studies by the same author.  Most of the original articles online are available only with steep fees for a one time read.  It is probably easier to look at The Natural History of Alcoholism - Revisited in your local library.  It contains most of the important graphics from the research articles and Dr. Vaillant's views circa 1995.  The summary section looks at seven very important questions about the nature of alcoholism and the answers provided by prospective research on the problem.  In looking at this research, Jonathan Flynn probably most closely resembles the follow up study of 100 consecutive admissions to a detoxification unit in Boston.  At the end of 8 years of follow up, about 32% were abstinent, about 30 % were still drinking and 32% were dead or institutionalized.  One of Dr. Vaillant's characterizations of the recovery process in alcoholism:  "... alcoholics recover not because we treat them, but because they heal themselves.  Staying sober is not a process of simply becoming detoxified, but often becomes the work of several years or in a few cases even of a lifetime.  Our task is to provide emergency medical care, shelter, detoxification, and understanding until self healing takes place." (p384).  Self healing was evident in this film.

The other work that I routinely discuss with people I have seen for alcoholism and the associated comorbidity is the work of Markku Linnoila.  Dr. Linnoila was a prolific researcher in both basic and clinical alcoholism research.  He did some of the early studies looking at cerebrospinal fluid metabolites, especially serotonin metabolites and how they correlate with depression, aggression, and impulsivity over time when men consume alcohol.  These studies continue to provide a scientific basis for advising patients on basic dietary changes and in some cases pharmacological interventions that may assist in recovery.  An important aspect of the work of shelters like the one depicted in this movie is getting protein back into the diet of the homeless with alcoholism.

This film is harder to watch than Flight but it is no less accurate a depiction of how alcoholism can impact the person and their family.  It speaks to the spectrum of intervention necessary to provide safety and assist with recovery.

George Dawson, MD, DFAPA

Vaillant GE. Alcoholics Anonymous: cult or cure? Aust N Z J Psychiatry. 2005 Jun;39(6):431-6. PubMed PMID: 15943643.