Community Mental Health Journal Volume 2, Number 1, Spring, 196fi
FILM
REVIEWS
S a f e to be T o u c h e d ; H o w
S a f e to be E x p o s e d ?
EDWARDA. MASON, M. D.
Harvard Medical School to locate interest without undercutting the traditional independence of the Verroosters. In camera interviews, one farmer says "No." Another candidly admits that he was skeptical at first and that he joined the group because he "liked to argue" but found that he profited instead because he was made to think. A young wife was worried for a while about what the neighbors would think, but proclaims her satisfaction with the discussions. Further examples of the potential of group techniques in urban areas are shown from the South Shore Mental Health Center in Quincy, Mass. Glimpses into a group of parents of child patients, a meeting of police and mental health consultants and a meeting with local ministers about marital problems record a few of the ways this Clinic is moving into the community. Its staff has since reported having made many arrangements for the filming activities which were extensive: seven hours of the police seminar were filmed for the less than three minutes which were used. Other material was undoubtedly used in the same ratio, and some even omitted entirely. It is in the nature of this type of filling, where one can never predict what will happen in front of the lens or how the spontaneous material will fit together to make a completed f i l l , that the producer spends money to get more than enough footage. Unfortunately, however, one of the results here is a poverty of riches. Much of this material is too scanty to appreciate techniques or results. However brief, it has impact by virtue of its actuality. On the other hand, some spontaneous material is included which is unsuccessful. The evidence showing the advantages of drugs resembles testimonials in second-rate
9 America's Crises # 1 0 : Trouble in the Family (90 minutes, black and white, 16mm. Rental $12.90, sale price $275). 9 America's Crises @ 12: E m o t i o n a l Dilemma (60 minutes, black and white, 16mm. Rental $9.15, sale price $200). Both films were made in 1965 for National Education Television. Directed by Harold Mayer and Edmond Levy. Distributed by Audio-Visual Center, National Education Television Film Service, Indiana University, Bloomington, Indiana 47405.
Two programs recently released by National Educational Television have stirred audiences with an inside look at several out of the ordinary mental health activities. They are part of a series called America's Crises which has included several programs of interest to community mental health in its two seasons on the air. Both of these films have a documentary-type approach, but they differ markedly in that the first reaches deeper into a single approach and the second gives a smorgasbord sampling of many clinical efforts. The latter, Emotional Dilemma, tackles the broader issue of the availability of mental health services and starts with one mother's challenge, "Do we have to go off the deep end in order to get help?" It states that "20 million Americans are in deep emotional trouble" and the "real tragedy" is that in the face of all our advances so many persons are still not being helped. For the rest of the hour it reports how a few programs in northeastern United States are trying to meet these needs. In rural Vermont, psychologist Harold Borris is bringing group discussions to persons who would ordinarily be geographically and emotionally distant from such a service. We see his associate visiting homes 93
94
THE COMMUNITY MENTAL HEALTH JOURNAL
commercials. Dr. Nathan Kline is given credit for his drug studies but his questioning of a patient seen both before and after anti-depressant medication undermines the respect and validity which are due his work. Also in a glimpse of the Walk-In Clinic of the Massachusetts Mental Health Center we hear Dr. Jack Ewalt speak of its potential in averting crises, but the film material lends no support. Not so with the illustration of a family in therapy with Dr. Nathan Ackerman. Here enough is shown of a dramatic family interview to vividly illustrate the fact that a child's symptom can be the expression of a family disturbance. Ackerman shows us his techniques for exposing significant family patterns and for mobilizing constructive efforts within the family unit. The therapeutic optimism which Emotional Dilemma conveys and its emphasis on building up services may be good public relations, but there were some disturbing points which were never explored and which might have made a more provocative film. A mother tells us that her son has waited five years' for treatment, whereas another child on the waiting list for two years gets immediate treatment by truanting! The problems of manpower, training, waiting lists, and the distribution of services are all mentioned, but so briefly that the program's focus becomes a blur. Typical of the way television too often covers an issue, this program seems to skim surfaces as if frantically trying to hold interest or get a Nielsen rating. Some of its material is fascinating by virtue of its spontaneity, but is dropped too soon. This disappointing second program might better have been first so as to introduce the other unique specialized case document. Trouble in the Family breaks many precedents: it is longer than the standard program, and it is an intensive summary of one family's therapy. A middle-dass New England family agreed to be photographed during their 13 sessions with Dr. Norman Paul and agreed to allow a film to be shown on educational television "in the hope that others, by sharing their experience, would have an opportunity to decide
whether family therapy might be useful to them." They were referred because their second son, Bob, at fifteen was not doing well in school, although bright and capable. His diglculties are explored briefly, but by the end of the first session the focus shifts away from Bob and he is taken "off the hook." Henry, the father, an earnest and ambitious store manager, is readier to speak than his wife, Judy, who seems frightened and inaccessible. Jay, the 18 year old, speaks briefly and superficially about going away to college soon, but Cheryl, age 13, barely utters a word in the film. The camera seems to drift without purpose between shots of quiet, uncomfortable children and glimpses of adults trying hard to make this [amily therapy. Dr. Paul explicitly encourages the expression of emotion but his therapeutic direction and purpose are not always dear, so that often his pressure or interruptions appear arbitrary. The most dramatic development occurs during the 8th interview when Henry's parents are invited to join the family and inadequately handled old grief is brought into the open. Tears are shed and Dr. Paul proves his point that "it is safe to be touched deeply." In a prologue to Trouble in the Family Mayer interviews Ackerman who speaks of the need for honesty in families: "we must do away with empty mouthings." He notes that many families "cease to deal with real problems" and he encourages communication within families. His authoritative invitation combined with the witnessing of a fairly typical family's experience ought to motivate many families to be interested and to seek out this form of therapy. As would be expected, Paul had several self-referrals after the film's showing on WGBH, Boston's educational television station. Viewers of that channel are not the ordinary television audience, it is true, and the casual viewer had to choose this over Patty Duke and the Beverly Hillbillies. Quite apart from this, there are other reasons viewers might switch away. Not only long, this program is emotionally painful to watch. The viewer has to be fairly well motivated to continue watching in spite of the rare and fasci-
Fxr.M REVIEWS nating opportunity to see such material. The rough camera work throughout and the poor quality recording in the first session impose some of the strain the viewer experiences. The camera, being stationary and behind one-way glass, is limited in its opportunity to catch the significant happenings and simultaneously the reactions of others. The editing of the material shows skill and understanding of the meaning of the events, however, and the film has many good qualities. What makes it hard to watch all the way through is its very ability to draw the viewer into the experience. Compared to ordinary television fare, there is no spacing of the buildup and relief of tension; there is no simplification of the complex relationships and behavior patterns in the family. The viewer suffers as if he were a participant without the usual protections from interruptions for advertisements or the knowledge that the action on the screen is only make-believe. For therapeutic purposes, Paul selects a theme the unfinished grief work--and capitalizes on the emotions this stirs. The drama of this part of the film is likely to be remembered best, but a great deal goes on in therapy that is not so dramatic. The viewer has to endure an irritating inner restlessness that denotes his grappling with the problems at hand. Perhaps each member of the family and the therapist, too, goes through a similar experience which may be a necessary precursor to commitment which in turn is necessary for therapeutic success. The viewer, in his living room, has less at stake and more to divert his attention. Perhaps the same will not be true when the film is used, as it certainly should be, in professional education. Because it illustrates in a reasonably condensed package what may take place in one style of family therapy, it certainly should promote discussion of its potential for helping in community mental health tasks, and understanding of family dynamics and therapeutic techniques. Clearly, this film has a place in professional usage, but it was made for and is available to the general public and its value
95
there must be discussed. Most likely to reach a fairly sophisticated lay audience, it may arouse interest and motivation in this group toward family therapy. Less obvious, however, is what I believe to be its greatest benefit. It is a kind of vicarious emotional "vaccination" which should help mobilize the coping "antibodies" in the viewer's own family orbit. The film fosters the recognition of feelings in individuals. It renews faith in the strengths which allow families to be touched, or even rocked, and emerge with more strength. On the other hand, there may be some negative reactions. A viewer may imagine that all therapy is like this and decide against any form of help because of his personal response to this therapist. The idea of bringing all the relatives into what might seem like an orgy of exposure is not going to attract a family whose style of response is intrepid. There is also a discomfort' about what has been omitted from the film. Judy's and Henry's marital adjustment is reportedly improved, but all references to their sexual life are omitted in the film, leaving a lopsided account which may raise doubts of the film's authenticity. Moreover, professional as well as lay viewers may well ask about the ethics of showing actual therapy to the public. This question is not to be dismissed as typical of the conservative streak among some professionals, nor merely as the outward objection to the inner turmoil the viewer experiences. In our march to spread mental health efforts to the community, we must not forget the protection of the mental health of individuals. Henry and Judy signed permission to show the film, naturally, and our concern need not perhaps dwell on the wisdom and healthiness of their decision. But we can speculate on the long-term effect on their 3 children who are presumably less able to decide for themselves. Are the participants' exhibitionistic tendencies kept in balance with the film's educational ambitions? The children can be protected by their own natural restraint accompanying the knowledge that they are on camera and their peers will be looking. They can be
96
THE COMMUNITY MENTAL HEALTH JOURNAL
protected also by the therapist's avoidance of excessive or too revealing focus on them. Finally, the film editor and the directors can protect the children by the manner in which they cut and assemble the film. In Trouble in the Family there does not seem to be anything damaging to the children, perhaps because all of these protective efforts were in effect and because the National Educational Television gave special attention to this pioneering television film. The question can better be raised, perhaps, as to the broader ethical and legal issues that should govern future similar films. The primary legal issue has to do with the right of privacy, recognized by a majority of the states as an inherent, inalienable right, but only in some states laid out in legislative action. The right to be left alone in the conduct of one's private affairs can be stated as a prohibition of "unwarranted appropriation or exploitation of one's personality or the publicizing of one's private affairs with which the public has no legitimate concern, in such a manner as to outrage or cause mental suffering, shame, or humiliation to a person of ordinary sensibilities" (Freedman, 1965). It is of special interest to note that the basic article on this subject was published in the Harvard Law Review in December, 1890 by Louis Brandeis and Samuel Warren. The stimulus to their widely quoted article is said to have been the newly available flash powder, making indoor candid photographs possible. Their words have a peculiarly pertinent ring still: "The intensity and complexity of life, attendant upon advandng civilization, have rendered necessary some retreat from the world, and man, under the refining influence of culture, has become more sensitive to publicity, so that solitude and privacy have become more essential to the individual." There have always been limitations to this right of privacy, just as there have with matters of confidentiality and privileged communication. Brandeis and Warren said that "publication of matter which is of public general interest" should not be prohibited. Thus pictures considered
newsworthy are regularly published without obtaining releases. The courts have certainly established that unauthorized commercial use of a person's name or picture would constitute an invasion of privacy, but "recovery has been granted only in the most blatant cases" (Chayet, 1965). Legal advice to a maker of films for professional education has consistently included obtaining signed permission in advance, and if he proceeds in a prudent and ethical manner there should be no cause for legal action, especially in view of the well established need for communicating case material within the professions. Care is advised to avoid any presentation which might harm or ridicule the patient and to make the effort to restrict the audience to professionals. If the film is for a general audience, even more attention should be paid to the editing and to gaining written permission. At least one producer of such films makes a cash payment to patients, presumably to increase the cooperation and decrease the likelihood of legal entanglements. The expansion of electronic means of recording sound and picture at lower costs and in increasing numbers of clinical and educational settings should evoke a new effort to clarify the legal issues. Mental health professionals as well as lawyers must be alert to the optimal balance which exists between the rights of the public interest and those of the individual. Exposure so frequently accompanies advances that we must use caution in breaking down the barriers to knowledge of mental difficulties. Aware of the risks, we need to use these new National Educational Television films, and more, in whatever way they can constructively alter the present scene through direct education or indirect stirring of interest. REFERENCES CHAYg'r,N. L. Confidentialityand privileged communication in psychiatry. Paper read at Seminar on "Psychiatry and the Law," Los Angeles, 1965. FREEDMAN,W. Societal behavior: new and unique rights oJ the person. Springfield, Illinois: Charles C Thomas, 1965.
FILM
REVIEWS
S a f e to be T o u c h e d ; H o w
S a f e to be E x p o s e d ?
EDWARDA. MASON, M. D.
Harvard Medical School to locate interest without undercutting the traditional independence of the Verroosters. In camera interviews, one farmer says "No." Another candidly admits that he was skeptical at first and that he joined the group because he "liked to argue" but found that he profited instead because he was made to think. A young wife was worried for a while about what the neighbors would think, but proclaims her satisfaction with the discussions. Further examples of the potential of group techniques in urban areas are shown from the South Shore Mental Health Center in Quincy, Mass. Glimpses into a group of parents of child patients, a meeting of police and mental health consultants and a meeting with local ministers about marital problems record a few of the ways this Clinic is moving into the community. Its staff has since reported having made many arrangements for the filming activities which were extensive: seven hours of the police seminar were filmed for the less than three minutes which were used. Other material was undoubtedly used in the same ratio, and some even omitted entirely. It is in the nature of this type of filling, where one can never predict what will happen in front of the lens or how the spontaneous material will fit together to make a completed f i l l , that the producer spends money to get more than enough footage. Unfortunately, however, one of the results here is a poverty of riches. Much of this material is too scanty to appreciate techniques or results. However brief, it has impact by virtue of its actuality. On the other hand, some spontaneous material is included which is unsuccessful. The evidence showing the advantages of drugs resembles testimonials in second-rate
9 America's Crises # 1 0 : Trouble in the Family (90 minutes, black and white, 16mm. Rental $12.90, sale price $275). 9 America's Crises @ 12: E m o t i o n a l Dilemma (60 minutes, black and white, 16mm. Rental $9.15, sale price $200). Both films were made in 1965 for National Education Television. Directed by Harold Mayer and Edmond Levy. Distributed by Audio-Visual Center, National Education Television Film Service, Indiana University, Bloomington, Indiana 47405.
Two programs recently released by National Educational Television have stirred audiences with an inside look at several out of the ordinary mental health activities. They are part of a series called America's Crises which has included several programs of interest to community mental health in its two seasons on the air. Both of these films have a documentary-type approach, but they differ markedly in that the first reaches deeper into a single approach and the second gives a smorgasbord sampling of many clinical efforts. The latter, Emotional Dilemma, tackles the broader issue of the availability of mental health services and starts with one mother's challenge, "Do we have to go off the deep end in order to get help?" It states that "20 million Americans are in deep emotional trouble" and the "real tragedy" is that in the face of all our advances so many persons are still not being helped. For the rest of the hour it reports how a few programs in northeastern United States are trying to meet these needs. In rural Vermont, psychologist Harold Borris is bringing group discussions to persons who would ordinarily be geographically and emotionally distant from such a service. We see his associate visiting homes 93
94
THE COMMUNITY MENTAL HEALTH JOURNAL
commercials. Dr. Nathan Kline is given credit for his drug studies but his questioning of a patient seen both before and after anti-depressant medication undermines the respect and validity which are due his work. Also in a glimpse of the Walk-In Clinic of the Massachusetts Mental Health Center we hear Dr. Jack Ewalt speak of its potential in averting crises, but the film material lends no support. Not so with the illustration of a family in therapy with Dr. Nathan Ackerman. Here enough is shown of a dramatic family interview to vividly illustrate the fact that a child's symptom can be the expression of a family disturbance. Ackerman shows us his techniques for exposing significant family patterns and for mobilizing constructive efforts within the family unit. The therapeutic optimism which Emotional Dilemma conveys and its emphasis on building up services may be good public relations, but there were some disturbing points which were never explored and which might have made a more provocative film. A mother tells us that her son has waited five years' for treatment, whereas another child on the waiting list for two years gets immediate treatment by truanting! The problems of manpower, training, waiting lists, and the distribution of services are all mentioned, but so briefly that the program's focus becomes a blur. Typical of the way television too often covers an issue, this program seems to skim surfaces as if frantically trying to hold interest or get a Nielsen rating. Some of its material is fascinating by virtue of its spontaneity, but is dropped too soon. This disappointing second program might better have been first so as to introduce the other unique specialized case document. Trouble in the Family breaks many precedents: it is longer than the standard program, and it is an intensive summary of one family's therapy. A middle-dass New England family agreed to be photographed during their 13 sessions with Dr. Norman Paul and agreed to allow a film to be shown on educational television "in the hope that others, by sharing their experience, would have an opportunity to decide
whether family therapy might be useful to them." They were referred because their second son, Bob, at fifteen was not doing well in school, although bright and capable. His diglculties are explored briefly, but by the end of the first session the focus shifts away from Bob and he is taken "off the hook." Henry, the father, an earnest and ambitious store manager, is readier to speak than his wife, Judy, who seems frightened and inaccessible. Jay, the 18 year old, speaks briefly and superficially about going away to college soon, but Cheryl, age 13, barely utters a word in the film. The camera seems to drift without purpose between shots of quiet, uncomfortable children and glimpses of adults trying hard to make this [amily therapy. Dr. Paul explicitly encourages the expression of emotion but his therapeutic direction and purpose are not always dear, so that often his pressure or interruptions appear arbitrary. The most dramatic development occurs during the 8th interview when Henry's parents are invited to join the family and inadequately handled old grief is brought into the open. Tears are shed and Dr. Paul proves his point that "it is safe to be touched deeply." In a prologue to Trouble in the Family Mayer interviews Ackerman who speaks of the need for honesty in families: "we must do away with empty mouthings." He notes that many families "cease to deal with real problems" and he encourages communication within families. His authoritative invitation combined with the witnessing of a fairly typical family's experience ought to motivate many families to be interested and to seek out this form of therapy. As would be expected, Paul had several self-referrals after the film's showing on WGBH, Boston's educational television station. Viewers of that channel are not the ordinary television audience, it is true, and the casual viewer had to choose this over Patty Duke and the Beverly Hillbillies. Quite apart from this, there are other reasons viewers might switch away. Not only long, this program is emotionally painful to watch. The viewer has to be fairly well motivated to continue watching in spite of the rare and fasci-
Fxr.M REVIEWS nating opportunity to see such material. The rough camera work throughout and the poor quality recording in the first session impose some of the strain the viewer experiences. The camera, being stationary and behind one-way glass, is limited in its opportunity to catch the significant happenings and simultaneously the reactions of others. The editing of the material shows skill and understanding of the meaning of the events, however, and the film has many good qualities. What makes it hard to watch all the way through is its very ability to draw the viewer into the experience. Compared to ordinary television fare, there is no spacing of the buildup and relief of tension; there is no simplification of the complex relationships and behavior patterns in the family. The viewer suffers as if he were a participant without the usual protections from interruptions for advertisements or the knowledge that the action on the screen is only make-believe. For therapeutic purposes, Paul selects a theme the unfinished grief work--and capitalizes on the emotions this stirs. The drama of this part of the film is likely to be remembered best, but a great deal goes on in therapy that is not so dramatic. The viewer has to endure an irritating inner restlessness that denotes his grappling with the problems at hand. Perhaps each member of the family and the therapist, too, goes through a similar experience which may be a necessary precursor to commitment which in turn is necessary for therapeutic success. The viewer, in his living room, has less at stake and more to divert his attention. Perhaps the same will not be true when the film is used, as it certainly should be, in professional education. Because it illustrates in a reasonably condensed package what may take place in one style of family therapy, it certainly should promote discussion of its potential for helping in community mental health tasks, and understanding of family dynamics and therapeutic techniques. Clearly, this film has a place in professional usage, but it was made for and is available to the general public and its value
95
there must be discussed. Most likely to reach a fairly sophisticated lay audience, it may arouse interest and motivation in this group toward family therapy. Less obvious, however, is what I believe to be its greatest benefit. It is a kind of vicarious emotional "vaccination" which should help mobilize the coping "antibodies" in the viewer's own family orbit. The film fosters the recognition of feelings in individuals. It renews faith in the strengths which allow families to be touched, or even rocked, and emerge with more strength. On the other hand, there may be some negative reactions. A viewer may imagine that all therapy is like this and decide against any form of help because of his personal response to this therapist. The idea of bringing all the relatives into what might seem like an orgy of exposure is not going to attract a family whose style of response is intrepid. There is also a discomfort' about what has been omitted from the film. Judy's and Henry's marital adjustment is reportedly improved, but all references to their sexual life are omitted in the film, leaving a lopsided account which may raise doubts of the film's authenticity. Moreover, professional as well as lay viewers may well ask about the ethics of showing actual therapy to the public. This question is not to be dismissed as typical of the conservative streak among some professionals, nor merely as the outward objection to the inner turmoil the viewer experiences. In our march to spread mental health efforts to the community, we must not forget the protection of the mental health of individuals. Henry and Judy signed permission to show the film, naturally, and our concern need not perhaps dwell on the wisdom and healthiness of their decision. But we can speculate on the long-term effect on their 3 children who are presumably less able to decide for themselves. Are the participants' exhibitionistic tendencies kept in balance with the film's educational ambitions? The children can be protected by their own natural restraint accompanying the knowledge that they are on camera and their peers will be looking. They can be
96
THE COMMUNITY MENTAL HEALTH JOURNAL
protected also by the therapist's avoidance of excessive or too revealing focus on them. Finally, the film editor and the directors can protect the children by the manner in which they cut and assemble the film. In Trouble in the Family there does not seem to be anything damaging to the children, perhaps because all of these protective efforts were in effect and because the National Educational Television gave special attention to this pioneering television film. The question can better be raised, perhaps, as to the broader ethical and legal issues that should govern future similar films. The primary legal issue has to do with the right of privacy, recognized by a majority of the states as an inherent, inalienable right, but only in some states laid out in legislative action. The right to be left alone in the conduct of one's private affairs can be stated as a prohibition of "unwarranted appropriation or exploitation of one's personality or the publicizing of one's private affairs with which the public has no legitimate concern, in such a manner as to outrage or cause mental suffering, shame, or humiliation to a person of ordinary sensibilities" (Freedman, 1965). It is of special interest to note that the basic article on this subject was published in the Harvard Law Review in December, 1890 by Louis Brandeis and Samuel Warren. The stimulus to their widely quoted article is said to have been the newly available flash powder, making indoor candid photographs possible. Their words have a peculiarly pertinent ring still: "The intensity and complexity of life, attendant upon advandng civilization, have rendered necessary some retreat from the world, and man, under the refining influence of culture, has become more sensitive to publicity, so that solitude and privacy have become more essential to the individual." There have always been limitations to this right of privacy, just as there have with matters of confidentiality and privileged communication. Brandeis and Warren said that "publication of matter which is of public general interest" should not be prohibited. Thus pictures considered
newsworthy are regularly published without obtaining releases. The courts have certainly established that unauthorized commercial use of a person's name or picture would constitute an invasion of privacy, but "recovery has been granted only in the most blatant cases" (Chayet, 1965). Legal advice to a maker of films for professional education has consistently included obtaining signed permission in advance, and if he proceeds in a prudent and ethical manner there should be no cause for legal action, especially in view of the well established need for communicating case material within the professions. Care is advised to avoid any presentation which might harm or ridicule the patient and to make the effort to restrict the audience to professionals. If the film is for a general audience, even more attention should be paid to the editing and to gaining written permission. At least one producer of such films makes a cash payment to patients, presumably to increase the cooperation and decrease the likelihood of legal entanglements. The expansion of electronic means of recording sound and picture at lower costs and in increasing numbers of clinical and educational settings should evoke a new effort to clarify the legal issues. Mental health professionals as well as lawyers must be alert to the optimal balance which exists between the rights of the public interest and those of the individual. Exposure so frequently accompanies advances that we must use caution in breaking down the barriers to knowledge of mental difficulties. Aware of the risks, we need to use these new National Educational Television films, and more, in whatever way they can constructively alter the present scene through direct education or indirect stirring of interest. REFERENCES CHAYg'r,N. L. Confidentialityand privileged communication in psychiatry. Paper read at Seminar on "Psychiatry and the Law," Los Angeles, 1965. FREEDMAN,W. Societal behavior: new and unique rights oJ the person. Springfield, Illinois: Charles C Thomas, 1965.
