Psychiatry in Kerala
| ABSTRACT
This article reviews and analyses the depictions of suicide, grief, stigma, mentally ill persons, and psychiatric treatments in Malayalam movies. While the portrayals of suicide, grief and stigma have been sensitively handled, some depictions of mentally ill and the methods used to treat them have been stereotypic, negative, prejudiced and inaccurate. Accurate portrayals can help patients and caregivers in understanding the processes involved in psychiatric treatment, and thus help reduce stigma and resistance to treatment. Malayalam cinema can serve as a rich resource to teach undergraduate and postgraduate medical students and paramedical professionals of the state about mental illness and related issues, and needs to be harnessed adequately for this purpose. Keywords: cinemeducation, Malayalam cinema, mental illness, stereotypical portrayal, treatment |
This review looks into the depictions of various topics related to mental health, including suicide, grief, the mentally ill, stigma, psychiatrists and psychiatric treatments in Malayalam cinema. Movies were selected for inclusion in this review if they met any of the following criteria:
Depicted suicide or grief in detail
Depicted assessment and treatment of psychiatric patients in detail
Discussed etiologies of mental illnesses
Another of our articles in this issue of Kerala Journal of Psychiatry describe many truthful and erroneous depictions of specific mental illnesses in Malayalam movies.1 In continuation of that, in this review we also included:
Movies which erroneously portray a kind of generic “mental illness”
Here we cover nearly 70 films, released between 1968 and 2015, which met the above criteria. The details of how we found the specific movies etc. are mentioned in the other article.1
Oru May Masa Pulariyil (1987), Utharam (1989) and Kadhavasheshan (2004) had stories that traced the reasons for the central characters’ suicide, akin to a psychological autopsy. Causes of the suicides have been rejection by lover in Oru May Masa Pulariyil, confrontation of the female protagonist with her illegitimate son who has become a vagabond in Utharam, and the inability to cope with evils of the society in Kadhavasheshan.
There have also been films which end with the protagonist committing suicide. Reasons for the act have ranged from grief of the patriarch on losing all his family members in Moonnaampakam (1988) and inability of a man to cope with the abandonment by his wife in Mattoral (1988) to an altruistic act by the protagonist to allow his wife to be with her lover in Ulsavapittennu (1988). The stigma of being labeled as mentally ill is seen as a cause of suicide in Thaniyavarthanam (1987), where the mother poisons herself and her son after he becomes isolated and ostracized by the society and his family after being suspected of mental illness. The protagonist of Sukrutham (1994), a cancer survivor, takes his own life after realizing that his family and friends were more accepting of his possible death than his recovery. The protagonist in Nakhakhshathangal (1986) commits suicide after being torn between his love and his commitment to his employer who attempts to coerce him into marrying his daughter.
These films portrayed strong-willed characters choosing suicide to escape stressors of life. Shame, grief, loss of hope and despair can be summarized as the mediators for these suicides, and these very factors work in real suicides in real lives too. movies like these can send a wrong message that suicide is the only means of escape from stressors. Such depictions can also lead to copycat suicides (Werther effect).2 However, studies on influence of media on suicide have been lacking in India.
The suicide attempts in Ulsavapittenu, Aham, and Moonampakkam can also described as altruistic, egoistic and anomic type of suicide respectively as described by Durkheim.3
In Aham (1992), the mentally ill protagonist, who had been deprived of love and affection in childhood, is seen in an institution for the mentally ill. He has had a tumultuous marriage due to his delusions of infidelity because of which his wife ends in a coma following an accident during an argument and also murders his girlfriend following command hallucinations of his wife’s voices. He is seen leading a spiritual life in the institution whereupon he develops affection to one of the guests of the institution. In due course, he understands his feelings are not being reciprocated; he commits suicide realizing he will be deprived of a meaningful and loving relationship in his life.
Attempts at deliberate self-harm have been displayed by the lead characters in an effort to seek attention in Ente Suryaputhriku (1991) and Sradha (2000), in attempts at projective identification in Thinkal Muthal Velli Vare (2015), Kakkakkum Poochakum Kalyanam (1995) etc., or following financial stressors in Made In U.S.A. (2006) and the story segment Aviramam in Kerala Café (2009).
Grief is the main theme of Varsham (2014), which depicted the story of a couple coping with the loss of their only son. Kubler Ross’s stages of grief have been portrayed in the film, with the lead character, a father, expressing numbness and shock upon learning of his son’s sudden death; anger and bargaining prior to the funeral; depressed mood, decreased self-care and decreased interest in household activities and work in the days following the funeral; and finally acceptance of the death.4 The film also depicted altruism as means by which the family coped with the grief. Other films dealing with themes related to grief include Piravi (1988), Pappayude Swantham Appoos (1992), Maya Mayuram (1993), etc.
Stressors have been portrayed to cause mental illness in various movies: death of the lover in Ulladakom, Thalavattom, etc., childhood neglect in Anantaram (1987) and Aham , and curse of goddess and other cultural beliefs/superstitions in Thaniyavarthanam and Patham Nilayile Theevandi (2009). In Swayamvarapanthal (2009), the psychiatrist describes that mental illnesses are actually coping mechanism the patients use to escape from their stressors. No films have discussed a biological explanation of mental illness.
Thaniyavarthanam and Patthaam Nilayile Theevandi had themes of mental illness affecting subsequent generations. However, rather than citing genetic reasons, superstitions like the curse of the Goddess on the family are depicted as the cause of the illness. And the movies depicted an exaggerated sense of doom prevailing in the unaffected family members of whether one will be the next in line to get the illness.
Negative comments on mental illness have been depicted in numerous films, apart from the use of colloquial derogatory terms for mentally ill like “Bhraanthan”, “Vattan”, etc. The hero in Silence (2013) describes the mentally ill villain as “He is mad! A madness that does not get cured no matter how much you treat!”
Positive descriptions exist too. In Vadakumnathan (2006), the protagonist with bipolar disorder is shown to have heightened creativity coinciding with his periods of decreased sleep. In Swapanam (2014), the protagonist, a percussionist, who suffers from mania, is described by his colleague that it was his manic symptoms that helped him in getting the pace and drive needed to excel in his work. Such descriptions have the capability of sending a message to the audience that mental illness can also be a boon to its sufferers.
Physical appearance of the psychiatrist has had a stereotypical portrayal of wearing spectacles and sporting a French beard, as in Ice Cream (1986), Kaliveedu (1996), Annum Innum Ennum (2013), etc. Psychiatrists are portrayed to have their own eccentricities in Manichitrathazhu (1993), Sadgamaya (2010), Nee-Na (2015) etc., where they behave as oddly as their patients. In Shesham (2002), the psychiatrist accepts that the public perceives him to be as mad as his patients even though he is not.
In Thalavattom, Sundarapurushan, etc., the psychiatrist is portrayed as a saviour/ good Samaritan, willing to go to any extent for his patients. In Thalavattom, a psychiatrist, who is indebted to the family of the protagonist for his current professional status, kills the protagonist to save him from the miseries of a post-psychosurgery life. On the other hand, Thalavattom, First Bell (1992) and Pathaam Nilayile Theevandi depicted cruel psychiatrists who resort to physical abuse, electroconvulsive therapy and psychosurgery to punish uncooperative and unruly patients. In Thalavattom and First Bell psychiatrists were villains who misused their position to enforce their hidden agendas. When the psychiatrist-heroine of Thalavattom displays love and affection towards the hero (a patient admitted in their hospital), her father, the chief psychiatrist, opposes the relationship and resorts to electroconvulsive therapy and later psychosurgery on the hero. In First Bell, the villain unlawfully incarcerates the heroine to coerce her into marrying him, with the main motivation of snatching her inheritance.
Schneider classified the films’ stereotypical portrayal of the psychiatrist into three: Dr. Dippy - the comical psychiatrist with his own eccentricities, Dr. Evil - the psychiatrist with sinister motives, and Dr. Wonderful - the selfless and dedicated psychiatrist.5 Psychiatrists in Ice Cream and Nee-Na may belong to the Dr. Dippy category, and those in Ulladakkom and Sundarapurushan to Dr. Wonderful category. The antagonists in Thalavattom and First Bell fit the Dr. Evil category.
Transference has been described in Ulladakom, when the mentally ill heroine begins to display affection towards her therapist who later describes the concept of transference to his fiancé. Countertransference has been shown when the nurse and psychiatrist fall in love with their mentally ill patients in Shangupushpam (1977) and Thalavattom respectively.
Breaching of confidentiality by the therapist is portrayed in Aham, where the protagonist is shown to become upset when the therapist shares his details to a third person. Similarly, the therapists in Sanmanassullavarkku Samadhanam (1986) and Ee Adutha Kalathu (2012) share details of the mentally ill protagonists to third parties without consent.
Ulladakkom had a comical portrayal of the common myth of the layman that a psychiatrist can read minds. The psychiatrist becomes an unknowing accomplice in the schemes of the antagonist in Mannar Mathai Speaking (1995).
Mental hospitals are commonly depicted as located in beautiful locales like hill stations, as in Thalavattom, Sundarapurushan, Ulladakkam and Nee-Na (2015), or similar to lake resorts as in Ithiri Neram Othiri Karyam (1982) and Swayamvarapanthal (2009). Patthaam Nilayile Theevandi was filmed in a real mental hospital, Government Mental Health Centre, Thiruvanathapuram, Kerala. All these movies depicted mental hospitals as pleasant, well-kept and clean places, where patients are free to roam in the surroundings, and activities like exercise and games like chess and caroms are provided. However, Swapaanam (2014) depicted a treatment center where patients are chained to poles in dilapidated conditions, and depicted the patients, including the protagonist, getting caught in an accidental fire, echoing the harrowing Erwadi tragedy of 2001.
Patthaam Nilayile Theevandi depicted a Medical Board taking place to discuss about the discharge of the patients.
Shesham (2002) handled issues of deinstitutionalization and rehabilitation. The young protagonist, Lonappan, who is depicted to have difficulties in socialization, has been institutionalized for a long time for reasons unknown. The heroine, a journalist, takes him up with hopes of integrating him with the society, but he is shy and naïve to the world beyond the walls of the institution. The film conveys the need to understand stigma and the particular patient’s strengths and weaknesses, and underlines that the rehabilitation of chronic psychiatric patients need a lot of dedication and patience. The film also portrays why some patients who have been incarcerated in institutions for long prefer the status quo — in the outside world they will have to face stigma, whereas in the confines of the institution they can feel safe and accepted for who they are.
In Thalavattom, the protagonist is evaluated by a group of doctors, and is asked to interpret three cards that contain pictures. The first card has an abstract painting; the second, though not a proper Rorschach card, has an inkblot; and the third featured a rider on a horse. Though the exercise was based on important psychological tests of projection, the way it was conducted and the materials used were unscientific.
In Ulladakkom, the protagonist is evaluated with the Rorschach test. The first two cards displayed were valid Rorschach cards. However, the third card was not, and rather featured a water body — a scene related to her traumatic past.
A block test is used for patient evaluation in Swapnadanam (1976).
Depiction of psychological testing is helpful in sensitizing the society about the processes involved in psychiatric evaluation. However, depictions of these tests, especially truthful depictions, cannot be done on screen due to copyright issues and the possibility that such depictions can influence test results in real life settings.
Earlier films like Yakshi (1968) and Punarjanmam (1972) portrayed psychoanalytic and psychodynamic treatments, and even depicted the Freudian couch. This was in tune with the understanding and practices of psychiatry during that period. However, though these methods have waned into oblivion with the advent of new treatment methods, many filmmakers of the state are still not updated about recent developments in psychiatric treatments. Many recent films, including Ayal Kadha Ezhuthukayanu (1998), Sadgamaya (2010), Swaymvarapanthal (2001), Njangalude Veetile Athithikal (2014), etc. portrayed psychoanalytic/psychodynamic treatments; and focused on uncovering the traumatic events that might have caused the symptoms, and dramatic cures on unraveling and resolving traumatic issues from the past.
The term “psychotherapist” finds mention Nombarathipoovu (1987) and Nee-Na (2015). In the former, the psychotherapist is seen in an institution for the mentally retarded, imparting occupational skills. In the latter, the psychotherapist is seen in a deaddiction center, involved in group therapy and psychoeducation. The systematic method of psychotherapy has not been adequately portrayed in these films — but such portrayals in future films can orient the audience about the role of and indications for psychotherapy in management of the mentally ill.
Psychodrama has been used in Manichithrathazhu (1993) and Ayal Kadha Ezhuthukayanu (1998), where scenarios related to the patient’s condition are elaborately recreated for treatment purposes. Hypnosis is used in Kaliveedu (1996), Manichithrathazhu and Sadgamaya. In Kaliveedu, it was incorrectly depicted as a method that can extract the truth from anyone within seconds.
Narcoanalysis is depicted in Swapnadanam and Black Dahlia (2009), and administration of the narcoleptic medication and interviewing is shown in both the films. While in Swapanadanam the procedure is conducted at the bedside, in Black Dahlia there is a more dramatic portrayal —the administration of the hypnotic is described as very dangerous, and the interviewer and the patient are in separate rooms.
A fictitious therapy, christened “Love therapy”, has been described in Aham, where patients in an institution run by nuns are treated with care, affection and acceptance of who they are — and it is the only treatment those inmates get.
Though such unscientific portrayals of treatment methods may lend to the drama, they can mislead the audience as to what are the major treatment options available for the mentally ill in this era, and on how various psychotherapeutic interventions are really carried out.
We did not find any films which mention the importance of pharmacotherapy. Pirkis et al., in their review of mental illness in cinema, did also observe the paucity of the depiction of pharmacotherapy in films, and hypothesized that a possible reason could be that the film makers may not find pharmacotherapy to add to or extend the narrative of the film.6In other words, pharmacotherapy might not lend to the drama of the films or capture the viewer’s attention like electroconvulsive therapy (ECT) or the therapies mentioned above.
Patham Nilayile Theevandi depicted a scene where a senior psychiatrist debates with his junior who wants to try a new psychotropic agent. The senior psychiatrist rebukes his junior’s efforts, saying that his years of experience has taught him that no new drugs can cure mental illness, and that institutionalization and punishment are the only effective treatments. Medications have been described to be sedating in Nombarathipoovu, and, after treatment, the protagonist is shown in a zombie-like state in Thaniyavarthanam. A psychologist has been shown to prescribe medications in Seconds (2014), adding to the misconceptions about pharmacotherapy.
Ayurvedic treatments have been shown in Junior Mandrake (1997), Naranathu Thamburan (2001), Thilakkam (2003) and Sahodaran Sahadevan (2003).
ECT has had a controversial depiction in Malayalam cinema. The commonest portrayal has been that of the unmodified ECT, as in Thalavattom, Ulladakom, First Bell, Pathamnilayile Theevandi and Thaniyavathanam. These films convey a sense of doom on the mention of “shock therapy”, and depict whole body seizures which can instill a sense of fear in the audience.
Nidra depicted general anesthesia being administered prior to the ECT, but what we get to see is whole body convulsions. The 2012 remake of the movie too portrayed modified ECT, with the settings of cardiac monitoring and general anesthesia, along with a less frightening depiction of seizure occurring only in one limb. In Thalavattom, Thaniyavathanam, and both versions of Nidra, after administration of the ECT the characters are erratically and misleadingly depicted to enter a zombie-like state.
A common on-screen indication for ECT has been aggression, as in Ulladakom and Pathamnilayile Theevandi, whereas it is portrayed as a form of punishment in Thalavattom and First Bell. The primary indication for ECT as a life-saving procedure for depressed patients with suicidal tendency has not been mentioned in any film. McDonald et al. and Andrade et al., in their reviews of portrayal of ECT in Hollywood and Bollywood films respectively, have also observed depictions of wrong indications for use of ECT like its use as punishment, patients entering a zombie like state after its administration, and excessive dramatization of the procedure.7, 8
Malayalam cinema has many stereotypical portrayals of mentally ill. A popular portrayal of mental illness, real or malingered, has been that of regression to a childlike behavior, as in Daivathinde Makan (2000), Swayamvarapanthal (2001), Thilakkom (2003), etc. Characters trying to feign mental illness are depicted to throw tantrums to meet their demands, be destructive in their behavior, and be considered a nuisance to the society in Kilukkam (1991), Pidakozhi Koovuna Noottandu (1994), First Bell (1992), etc.
Another portrayal has been that, even after admission to a mental hospital, a patient continues to perform the steps related to his job. Such portrayals have been there in minor characters of Ulladakom (1991), Thalavattom (1986), Sundara Purushan (2001), etc. Mookilla Rajyathu (1991), Ulladakom, Thalavattom, etc. depicted inmates of institutions for the mentally ill to exhibit odd behaviors and eccentric pranks. Though such scenes succeed in eliciting a few laughs, presentations of mental illness as depicted in these movies are rarely seen in real life. One of the characters in Mookilla Rajyathu is shown to have his mental illness appear and disappear with a blow to the head.
There are films where the central characters are diagnosed to be having “mental illness”, but all the symptoms they exhibit are bouts of irritability, a pervasive irritable mood along with periods of being calm, or symptoms of hyperthymic personality. Such movies include Yakshi (1968), Nidra (1981, 2012), Padamudra (1988), Ayal Kadha Ezhuthukayanu (1998) and Swapanam (2014).
Hyler et al. classified negative portrayals of the mentally ill in films to the homicidal maniac, rebellious free spirit, enlightened member of the society, the female patient as the seductress, the narcissistic parasite and the zoo specimen.9 The antagonists in Memories (2013) and Oruvan (2007) can be considered as the homicidal maniac, the protagonist in Thalavattom as the rebellious free spirit, the characters portrayed as mentally ill in Mookkillarajyathu as the enlightened member of the society, the female characters in Ice Cream as the seductress, and the institutionalized patients in Thalavattom, Ulladakkom, and Sundarapurushan as zoo specimens as per the classification.
Norman Sartorius, in his essay for the Lancet, stated that to fight stigma, psychiatrists should be active and vocal advocates for the mentally ill.10 There are various measures psychiatrists of the state can take to reduce such negative portrayals and to promote accurate portrayals. Workshops and seminars can be conducted for fraternity of the media, including cinema, to sensitize them on various issues, including the importance of accurate portrayal of psychiatric disorders and the harms that can be caused by negative and inaccurate depictions. Films like Thanmatra (2005) and the Bollywood film Taare Zameen Par (2007) can be cited as examples of accurate portrayals, respectively of dementia and specific learning disorders, that have been widely appreciated, helped to spread awareness of the respective conditions, and were also commercially successful. For this, a structured curriculum and modules will have to be created. Such a process can enhance the dialogue between media and mental health professionals, and by this we can also gain insights on the perspectives of the filmmakers too.
Psychiatrists can also do their part by publishing reviews of films based on mental illness, and professional organizations can appreciate and honor films with sensitive and accurate portrayal of mental illness. Dr. CJ John, former President of the Indian Psychiatric Society-Kerala State Branch (IPS-KSB), has been doing movie reviews for the Malayalam magazine “Manashastram”. The Kerala Journal of Psychiatry too has started publishing movie reviews. 11,12 In 2014, IPS-KSB organized an exhibition on psychiatry and cinema, titled “Minds Maladies in Movies”, at the 19th International Film Festival of Kerala.
Pandve et al. suggested seeking help of the censor board to check wrongful portrayals of mental illness in films.13 Byrne, in his review of negative portrayals of mental illness in films, does not advocate censorship or restriction on filmmakers, but proposes to them to drop stereotypes and clichés about the mentally ill and to be careful about stigmatizing dialogues and terms in films, and encourages them to talk to people with mental health problems and to understand them, rather than making their impression of the mentally ill from cinematic stereotypes.14
Cinema has been used to teach about stigma faced by mental health professionals and to gain cultural competency.15,16 Cinema as a part of therapy has been described, where films are viewed with patients and discussions are conducted with them about what they viewed, along with their real life experiences.17,18 Also, metaphors from the movies can be used to facilitate the treatment process. With the rich content that Malayalam cinema can provide, an attempt can be made to use it for aforementioned purposes.
We would like to conclude our review with the comments made by Hyler, that psychiatrists should be aware of the way their profession is depicted in films, as such depictions might reflect the image the society has formed about them, and as the influence the movies have on the public can contribute to various challenges faced during treatment of a patient.19
Acknowledgements: We would like to acknowledge Dr. CJ John, Past President, Indian Psychiatric Society Kerala State Branch; Dr. Jayaprakashan KP, Secretary, Indian Psychiatric Society Kerala State Branch; Dr. Shahul Ameen, Editor, Kerala Journal of Psychiatry; Dr. Jomon Joy, Assistant Professor, Travancore Medical College, Kollam; Dr. Lallchand Anilal, Assistant Professor, Government Medical College, Thiruvananthapuram; Dr. Harish Prabhakaran, Consultant Psychiatrist, Sri Ramakrishna Mission Hospital, Thiruvananthapuram; and members of the Facebook group “Psychiatry and Cinema” for their valuable contributions to our article.
1. Ratnakaran B, Anil SS, Thomas S, Ampanattu SD. Psychiatric disorders in Malayalam cinema. Kerala Journal of Psychiatry 2015; 28(2):195-203.
2. Phillips DP. The influence of suggestion on suicide: substantive and theoretical implications of the Werther effect. Am Sociol Rev. 1974; 39:340–354.
3. Durkheim E. Le suicide: étude de sociologie. F. Alcan; 1897.
4. Kubler-Ross E. On Death and Dying. New York: MacMillan; 1969.
5. Schneider I. The theory and practice of movie psychiatry. Am J Psychiatry. 1987; 144:996–1002.
6. Pirkis J, Blood RW, Francis C, McCallum K. On-Screen Portrayals of Mental Illness: Extent, Nature, and Impacts. J Health Commun. 2006; 11:523–41.8.
7. McDonald A, Walter G. The portrayal of ECT in American movies. J ECT. 2001; 17:264–74.
8. Andrade C, Shah N, Venkatesh BK. The depiction of electroconvulsive therapy in Hindi cinema. J ECT. 2010; 26:16–22.
9. Hyler SE, Gabbard GO, Schneider I. Homicidal maniacs and narcissistic parasites: stigmatization of mentally ill persons in the movies. Hosp Community Psychiatry. 1991; 42:1044–8.
10. Sartorius N. Stigma: what can psychiatrists do about it? The Lancet. 1998; 352:1058–9.
11. Balasubrahmanya KR. Njangalude Veettile Athidhikal (2014). Kerala J Psychiatry. 2015; 28:115–7.
12. Balasubrahmanya KR. Nee-Na. Kerala Journal of Psychiatry 2015; 28(2):216-8.
13. Pandve H, Banerjee A. Do popular media such as movies aggravate the stigma of mental disorders? Indian J Psychiatry. 2007; 49:144.
14. Byrne P. Screening madness. [cited2015 Nov 13]. Available from: https://www.time-to-change.org.uk/sites/default/files/film-report-screening-madness-time-to-change.pdf
15. Kalra G. Talking about stigma towards mental health professionals with psychiatry trainees: a movie club approach. Asian J Psychiatry. 2012; 5:266–8.
16. Lim RF, Diamond RJ, Chang JB, Primm AB, Lu FG. Using non-feature films to teach diversity, cultural competence, and the DSM-IV-TR outline for cultural formulation. Acad Psychiatry. 2008; 32:291–8.
17. Yazici E, Ulus F, Selvitop R, Yazici AB, Aydin N. Use of Movies for Group Therapy of Psychiatric Inpatients: Theory and Practice. Int J Group Psychother. 2014; 64:254–70.
18. Sharp C, Smith JV, Cole A. Cinematherapy: Metaphorically promoting therapeutic change. Couns Psychol Q. 2002; 15:269–76.
19. Hyler SE. DSM-III at the cinema: madness in the movies. Compr Psychiatry. 1988; 29:195–206.