An Exploration of how Film Portrays Psychopathology the

An Exploration of how Film Portrays Psychopathology: the Depiction of PTSD in Waltz with Bashir. Health Humanities Seminar The University of Nottingham, England. 28 th June 2013 Dr. Ahmed Hankir Dr. Mark Agius

Aims: • Signpost my own personal trajectory and broach on what has piqued my interest in cultural psychiatry and the health humanities: my background, Clare College (Cambridge University) and the vibrant cosmopolitan city of Manchester. • To provide you with salient information on Lebanon and the impact that the Sabra and Shatila massacres had on the Lebanese, the Palestinians and the Israelis. • A brief overview of PTSD • Art Therapy (cinematherapy, and bibiliotherapy) Medfest and the portrayal of mental illness in film. • An analysis and discussion of Ari Folman’s Academy Award nominated animated documentary film Waltz with Bashir.

This presentation is punctuated with slides that contain scenes from popular mainstream motion pictures. I will test your knowledge in film so to galvanise you lest my talk is soporific and you all succomb to slumber!

SPIEL!

Life is indeed darkness, save when there is urge And all urge is blind, save when there is knowledge And all knowledge is empty, save when there is work And all work is in vein, save when there is love And when you work with love, you bind yourself to yourself and to other and to God… Khalil Gibran, The Prophet

AN EXPLORATION OF HOW FILM PORTRAYS PSYCHOPATHOLOGY: THE ANIMATED DOCUMENTARY FILM WALTZ WITH BASHIR, THE DEPICTION OF PTSD AND CULTURAL PERCEPTIONS. Ahmed Hankir(1) & Mark Agius(2, 3, 4) (1) The Royal Oldham Hospital, Oldham, England, UK (2) South Essex Partnership University Foundation NHS Trust, UK (3) Department of Psychiatry University of Cambridge, UK (4) Clare College Cambridge, UK Psychiatria Danubina, 2012; Vol. 24, Suppl. 1, pp 70 -76 Abstract With the inauguration of the UK’s first ever Medical Film festival Med. Fest in 2011 there has been resurgence in the interest of the association between psychiatry and film. The festival in 2012 was titled “Health. Screen”: Understanding Illness through Film and its aim, according to the founder Dr Kamran Ahmed, was, 'To stimulate debate of the social, political and ethical implications of portrayals of health and illness on our screens' (1). Waltz with Bashir is a 2008 Israeli animated documentary film written and directed by Ari Folman. It portrays the protagonist (Folman) in search of his lost memories of his experience as a soldier in the 1982 Lebanon War and his attempt to both decipher them and reconcile himself with them. 2012 marks the 30 th year commemoration of the Sabra and Shatilla tragedies. Waltz with Bashir vividly depicts the massacres of Palestinians in the Sabra and Shatilla refugee camps in Beirut through the lens of an ex-IDF serviceman and the harrowing effects that PTSD has on him. Waltz with Bashir was nominated for an Academy Award for Best Foreign Language Film however despite the popularity of the film and much critical acclaim it is officially banned in Lebanon. The authors are mindful of the devastating effects that the atrocities have had on the mental health of all those who were involved, the Lebanese, Palestinians and also the Israelis. The purpose of this presentation is to explore how the film Waltz with Bashir portrays PTSD and how it has influenced cultural perceptions.

Meeting of Psychiatry Research Groups. September 2012. Clare College, Cambridge University. Organisers Dr. Mark Agius and Dr. Rashid Zaman.

Dr. Rashid Zaman Consultant Psychiatrist and Hon. Fellow, University of Cambridge and Dr. Ahmed Hankir. Clare College, Cambridge University, September 2012.

The Double Helix Noble Prize Laureates in Physiology or Medicine (1962) Professor James Watson and Professor Francis Crick. Discoverers of the Structure of DNA. Clare College, Cambridge.

2013 Cambridge/Luton Biennial International Conference in Mental Health • • • 5 -7 th September 2013 Clare College, University of Cambridge, England, UK Talks from many eminent psychiatrists in the world and much, much more… Competitions for Ph. D students and medical students All inclusive cost £ 537 (dinner each night, Gala dinner, breakfast, lunch, refreshments throughout the conference and accommodation). http: //www. bcmhr-cu. org/ (conference details posted later) For further information contact: Dr. Mark Agius; ma 393@cam. ac. uk

‘Oh, so you think the darkness is your ally? You merely adopted the dark. I was born in it, moulded by it, I didn’t see the light until I was already a man. By then, it was nothing but blinding to me. Your shadows betray you because they belong to me. Bane, The Dark Knight Rises

UK Jewish Film Festival 1 st – 18 th November 2012 “UK Jewish Film Festival promotes awareness of international Jewish life and cultures for an inclusive audience. ”

The 16 th UK Jewish Film Festival went national for the first time and screened at five cities around the UK throughout November 2012. The festival’s wide-reaching programme in CORNERHOUSE in Manchester included documentary, quirky French comedy and awardwinning drama.

“The UK Jewish Film Festival remains one of the highlights of the screen calendar. ” Empire “There’s always a mix of the serious and the hilarious. ” The Guardian

CORNERHOUSE MANCHESTER CORNERHOUSE is Manchester’s international centre for contemporary visual arts and independent film. It was founded in 1985 and has been at the forefront of Manchester’s vibrant cultural scene ever since. CORNERHOUSE’s patrons are Oscar winning director Danny Boyle and Oscar winning actress Dame Helen Mirren.

An Ode to Manchester: Vibrant City of Culture. . .

“My father’s people say that at the birth of the sun and of his brother the moon, the mother died. So the sun gave to the earth her body from which was to spring all life and he drew forth from her the breast the stars and through them into the night sky to remind him of her soul…” The Last of the Mohicans

Operation Peace for Galilee: Introduction • 1982 Israel-Lebanon War dubbed Operation Peace for Galilee. • Bashir Gemayal leader of the Phalange party in Lebanon and president elect assassinated. • 2, 000 Palestinian souls perished in the Sabra and Shatila Palestinian refugee camps in West Beirut as a result of the atrocities perpetrated by members of the Phalange party. • 2012 marks the 30 th year commemoration of the Sabra and Shatila massacres in Lebanon.

Waltz with Bashir • Waltz with Bashir 2008 animated documentary film inspired by true events and written and directed by Ari Folman. • Nominated for an Academy Award for best foreign language film. • Despite positive reviews Waltz with Bashir is officially banned in the Lebanon. • Depicts the Sabra and Shatila massacres through an Israeli veteran’s lens. Ari Folman served a tour of duty in the Lebanon in 1982 and is the protagonist of the film. • Memories of those dark days have not faded and still influence attitudes and discourse today.

What people have said about Lebanon… “Everything seemed possible in Beirut then-- every kind of person, every idea and identity…” Professor Edward Said, Professor of Comparative Literature Columbia University, The ‘Voice of Palestine’.

Greatest novel in the Arabic language of the 20 th century. The book was banned in author Tayeb Saleh’s country of origin the Sudan for being too salacious and lascivious which was in violation of the sanctity of Islamic propriety. Book was first published in 1966 in Beirut, Lebanon.

Pity The Nation… Pity the nation that is full of beliefs and empty of religion. Pity the nation that wears a cloth it does not weave, eats a bread it does not harvest, and drinks a wine that flows not from its own wine-press. Pity the nation that acclaims the bully as hero, and that deems the glittering conqueror bountiful. Pity a nation that despises a passion in its dream, yet submits in its awakening. Pity the nation that raises not its voice save when it walks in a funeral, boasts not except among its ruins, and will rebel not save when its neck is laid between the sword and the block. Pity the nation whose statesman is a fox, whose philosopher is a juggler, and whose art is the art of patching and mimicking. Pity the nation that welcomes its new ruler with trumpeting, and farewells him with hooting, only to welcome another with trumpeting again. Pity the nation whose sages are dumb with years and whose strong men are yet in the cradle. Pity the nation divided into fragments, each fragment deeming itself a nation Lebanese poet/mystic Khalil Gibran

Pity the Nation: an Alternative Account of Sabra and Shatila Massacres Foreign Correspondent Robert Fisk

Dr. Swee Ang, ‘The Angel of Beirut’: her book From Beirut to Jerusalem. Another Alternative Account of the Sabra and Shatila Massacres…

From Left to Right: Mr Hazem Badih, Dr. Ahmed Hankir, Dr. Swee Ang, Dr. Asad Khan, Dr. Zakaria Hankir. Talk on the 30 th year commemoration of the Sabra and Shatila Massacres. Labib Medical Centre, Sidon, Lebanon, 15 th of September 2012.

Lebanon is now, once again, boasting a spectacular opulence courtesy, in no small measure, of the efforts of the assassinated billionaire tycoon and former Prime Minister of Lebanon Rafic Hariri (the International airport in Beirut bears his name).

Beirut: the ‘Paris’ of the Middle East In 2009, the New York Times ranked Beirut the No. 1 travel destination worldwide due to its unique nightlife and hospitality.

Lebanon The Spectacular Roman Ruins of Baalbeck… The interminable streets of Down town Beirut… The romance of the ancient Phoenician port of Byblos… The irresistible of the Beach The lusterallure of beaches… Resort in Tyre…

Crossing Boundaries: Elective Opportunities in the Lebanon, the Abouzahr Elective Scheme of Phoenicia (AESOP) Dr Labib Abouzahr, Mr Mouin Abouzahr, Dr Hazem Badih, Dr Ahmed Hankir Dr Labib Abouzahr Sr Founder of LMC Ancient Phoenician Port of Sidon, Lebanon Labib Medical Center, Sidon, Lebanon • Labib Medical center (LMC) is a hospital situated in the ancient Phoenician port of Sidon, Lebanon • Dr. Labib Kamel Abouzahr founder of LMC in 1973. Dr. Abouzahr Sr was Chief Surgeon and Chief Executive Officer (CEO) of LMC. • Dr Abouzahr Sr general surgeon and graduate of the American University of Beirut. Received specialty training at Fordham Hospital in New York. • Labib Abouzahr Jr FRCSC, CEO & Chief of Staff incumbent, Mr Mouin Abouzahr General Director, Mr Hazim Badih FRCSI Medical Director, • AESOP enables medics to compare and contrast the disparate healthcare systems in the Mediterranean and the UK. • AESOP provides medics with hospital accommodation, daily meals, sponsorship to attend international conferences in Beirut, the dazzling capital city of Lebanon and much, much more… • http: //www. labibmedicalcenter. com/ • Contact: ahmedzakaria@doctors. org. uk Dr Labib Abouzahr Jr Mr Mouin Abouzahr, General Director of LMC CEO of LMC: Dr Labib Abouzahr Jr, MD, FRCSC • MD degree American University of Beirut • Residency training in General Surgery and Cardio. Thoracic Surgery at the University of Toronto • Fellow of the Royal College of Physicians & Surgeons of Canada (FRCSC) with certification in General Surgery (1994) & Cardiothoracic Surgery (1997) • Attending surgeon at Sunnybrook Health Sciences Centre & Lecturer at the University of Toronto, 1998 -9 • Assistant Clinical Professor, Mc. Master University & Hamilton Health Sciences, 1999 -2005 • CEO & Chief-of-Staff at Labib Medical Center (2005 -) • Founder and Chief of Cardio-Thoracic Surgery unit at Clemenceau Medical Center (Affiliated with Johns Hopkins International) (2005 -) • Teaching awards (for teaching students & residents) from University of Toronto & the Canadian association of General Surgeons

Elective Opportunities in Lebanon World Journal of Medical Education and Research Issue 1 Hankir, A ; Albazi, M. p. 91 -93 Elective Opportunities in Lebanon: the Abouzahr Elective Scheme of Phoenicia (AESOP). World Journal of Medical Education and Research Issue 1 Hankir, A ; Yaacoub, G; Abouzahr, L. p. 94 -96

“I’ve seen things you people wouldn’t believe. Attack ships on fire off the shoulder of Orion. I watched Cbeams glitter in the dark near the Tannhauser Gate. All those moments will disappear like these tears in the rain. Time to die…” Blade Runner

Post Traumatic Stress Disorder (PTSD) Severe anxiety disorder which may develop as a consequence of exposure to any event which results in psychological trauma. Symptoms of this condition include re-experiencing the original trauma(s) through flashbacks or nightmares, anger, hypervigilance and difficulty falling or staying asleep. The DSM and ICD diagnostic criteria require that the symptoms last more than one month and cause impairment of social, occupational, and other important areas of functioning.

C. S Myers The Lancet 1915 Shell Shock . . . everyone had a ‘breaking point’: weak or strong, courageous or cowardly- war frightened everyone witless. . .

Reference to Film. . . “Insanity is much like gravity, all it takes is a little push. . . ” ‘The Joker’ Batman, The Dark Knight

PTSD: Treatment and Epidemiology PTSD can be treated using psychological methods such as CBT and Eye movement desensitization and reprocessing (EMDR), as well as medical treatment with combinations of antidepressants and antipsychotics. It is known that sophisticated armies, such as that of the USA, do suffer important rates of PTSD. Interestingly and controversially, the British Army does not appear at present to suffer severe rates of PTSD. Another sophisticated army is the Israeli Defense Forces, but unlike in British servicemen, Israeli veterans did experience PTSD in significant numbers.

“The path of the righteous man is beset on all sides…” Ezekiel 27: 17

Who is he?

Film and Psychiatry “If you really want to understand a man, you have to slip into his shoes and walk around in them…” Atticus Finch, To Kill a Mocking Bird Cinema offers an unrivalled medium for entertainment, but also a unique interface for education. Indeed public opinion is heavily influenced by vivid images in the form of adverts, documentaries, and feature films. Film, as alluded to in the epigraph of this slide, can provide viewers with a precious qualititative insight into the psyche of people with psychopathology so that we may “Slip into their shoes and walk around in them”. By virtue of cinema, we can learn more about what mental illness is like from the inside and this in turn can help us to better understand what it is like to have a psychiatric disorder.

Medfest Med. Fest was founded in 2011 as the UK's first ever Medical Film Festival. The purpose of Medfest is to explore the relationship between medicine and cinema. The aim of the 2012 festival was, 'To stimulate debate of the social, political and ethical implications of portrayals of health and illness on our screens‘

Royal College of Psychiatrists: Minds on Film The Royal College of Psychiatrists has a section on its website entitled Minds on Film. According to the website, ‘Minds on Film is a monthly blog that explores psychiatric conditions and mental health issues as portrayed in a selection of readily available films. ’

Cinematherapy (Niemiec & Wedding, 2008): Deterring Substance Abuse/Misuse “Every time he put the bottle to his mouth, he wouldn’t suck from out of it but it would suck from out of him until he was yellow and wrinkled and not even the dogs would recognise him. . . ”

Cinematherapy (Niemiec & Wedding, 2008) : Inculcating values “The whole world is in chess, any move can be the death of you, do anything except for remain where you started and you can’t be sure of your end. None of us are sure of our end really or what hand will guide us there, a king may move a man, a father may claim a son, that man can also move himself and only then does that man truly begin to play his own game. Remember, howsoever you are played or by whom, your soul is in your keeping alone even though those who presume to play you be kings or men of power. When you stand before God you cannot say, ‘But I was told by others to do thus, or, ‘that virtue was not convenient at the time. Remember that. . . ”

The Health Humanities. . . 'To restore the human subject at the centre -the suffering, afflicted, fighting, human subject we must deepen a case history to a narrative or tale. . . ' (1985)

Jung’s Archetype ‘the Wounded Healer’ and Autobiographical Narrative: 2012 RCPsych Morris Markowe Award Winning Article, ‘Doctors Go Mad Too’ by Dr. Claire Polkinghorn …As a psychiatrist, I had hoped that I was pretty good at empathising with my patients. However, the last nine months of my life has taught me more about mental illness than years of clinics, ward-rounds, home visits or reading psychiatric literature. I have been signed off sick with a depressive illness, was detained under the mental health act and spent six weeks in an NHS psychiatric hospital…

Poet David Holloway’s Moving Autobiographical Narrative, ‘The ‘Colours’ of Schizophrenia’. Cutting Edge Psychiatry in Practice Issue 1

‘The Verses of Madness’: Schizophrenia and Poetry. BMJ Case Reports. Hankir, A; Holloway, D; Agius, M; Zaman, R Abstract In the early 19 th century Lombroso introduced the concept of ‘hereditary taint’ to describe the co-existence of ‘madness’ and creativity. In a more recent investigation, Rust et al reported a study designed to test the traditionally assumed relationship between creativity and schizophrenia. They uncovered an association between creative originality and the positive cognitive aspects of schizotypal thinking. Poetry is not only the ‘product’ of psychopathology but it can also be utilised as a form of therapy: ‘My name is David Holloway, I am a 32 year old poet/blogger with paranoid schizophrenia. A poet called Charles Bukowski has described poetry as the 'ultimate psychiatrist', and I am a firm believer in this. The strongest part of my personality is my belief in the power of love. My recovery has relied heavily on medication, diet and exercise. However it is the power of poetry that has been my true inspiration. ’

Dr. Ahmed Hankir, Poet David Holloway 2012 International Symposium of Poetry and Medicine, London, England

‘The soldier must make the decision, the man must live with the consequences. . . ’

Waltz with Bashir Ari and Boaz are both Israeli veterans. Boaz is tormented by flashbacks from his tour of duty in Lebanon. He beseeches Ari to help him. Ari doesn’t understand why Boaz has approached him, a film-maker not a psychiatrist. Boaz’s [emphatic] riposte: “Can’t films be therapeutic? ”

This encounter with Boaz triggered in Ari the first flashbacks of what happened in Lebanon 20 years ago, of what took place in West Beirut, in the Palestinain refugee camps of Sabra and Shatilla. Ari embarks on his quest to decipher the phenomena that has seized him and the meaning of his flashback.

Dissociative Events and Coping Mechanisms In a separate scene, Ari consults Professor Zahava Solomon, expert on post traumatic stress disorder. ‘Is it possible that I didn’t remember such a dramatic event’ ‘We call them dissociative events’ answers Professor Solomon, ‘It is when a person is in an experience but feels outside it’ she continues. When Professor Solomon asked a photographer how he got through Beirut, he said, ‘It was easy he just saw everything through an imaginary camera… However one day he entered a stable in Beirut and he saw therein the carcasses of horses and their entrails scattered around them. The situation overwhelmed him; it broke his heart he said, to see those dead horses, ‘what had they done? ’ Consequently ‘the camera’ broke down and the outcome was catastrophic. He had used a mechanism to stay outside of the events, as if watching the war through film instead of participating. This protected him. Once he was pulled in the events he no longer could deny reality, horror surrounded him and panic engulfed him.

The Assassination of the Leader of the Phalange Party and President Elect Bashir Gemayal and the Perversion that Ensued. . . Carmi, a fellow Israeli veteran, relates that, “Bashir was to them what David Bowie was to me… a star, a prince, an idol; I think they even felt eroticism for him. Their idol was going to become king; we were the ones who were going to crown him. The next day he was murdered. It was obvious they would avenge his death in some perverse way. It was as if their wife had been murdered. This was about family honor which runs deep. ”

In the final scene we join the camera as it forays into the camps with wailing lugubrious woman flailing their arms into the air mourning the deaths of their loved ones, their screams penetrating your soul and Ari standing at the end of the road beholding the spectacle before him utterly stupefied. And his search for his lost memories comes to an end… The animation stops and we see real footage of the massacre that took place, corpses strewn on the streets piled on top of each other, dismembered, disemboweled, old men, women and children. There is a deafening silence that cannot be stifled with words…

Conclusion Fanatics on either side cannot help but vilify their adversaries. This vilification process dehumanises the Israelis and the Arabs. Waltz with Bashir makes apparent that the Israelis succumb to psychopathology in the same way that other people do. They, too, have suffered from the cruelties that conflict invariably brings. The Palestinians suffered what John Steinbeck has termed, “a sorrow that weeping cannot symbolise”. Our thoughts and prayers go out to all the victims of the Sabra and Shatila massacres on this 30 th year commemoration.

If policy makers were aware of just how devastating the consequences of conflict are on our physical and mental well beings, perhaps they would put more time and effort into exhausting diplomatic channels before resorting to a call to arms. However, ours is not the realm of a politician. Our message to those who render psychiatric services is that the portrayal of psychopathology in film can help us to better understand service users and the catastrophic effects that psychopathology can have on them. The animated documentary film Waltz with Bashir provides us with a unique insight into what it is like to suffer from PTSD and this may allow us to empathize more with British troops returning from tours of duty in Iraq and Afghanistan who may have developed this debilitating illness.

In 2006 war broke out in Lebanon whilst my family were there. As an independent student my chances of progressing through medical school were threatened. . . I would never have qualified as a doctor if it weren’t for the unconditional kindness, unrestrained generosity and unlimited philanthropy of the Salmon family. If the Salmon family, a Jewish family, can embrace me, a Lebanese Muslim man, and transform my life and allow me to realise my dream of qualifying as a doctor may be one day the Israelis and Arabs will stand side by side, shoulder to shoulder in peaceful co-existence. . .

The Salmon Family, My Guardian Angels (suitably dressed in white!) Vanessa, Tobino (habibi!) and the honorable Charles Salmon QC.

Herschel’s Great Insight on Preparing the Human Mind in Order for us to See… Babbage: I cannot see these lines you mention…” Herschel: “An object is frequently not seen from not knowing how to see it, rather than from any deficit in the organ of vision. I will instruct you how to see them…” … and so he did. Babbage was soon able to see the faint lines, the forerunners of the spectral lines which were to prove in 1861 that every known star is made of the elements we know on Earth. Herschel’s great insight is that the mind must be prepared for what we will see, otherwise it will remain obscure…

World Psychiatry Association-Transcultural Psychiatry Section (WPA-TPS) Tuesday 06 th of November 2012 0900 -1000: Keynote Lecture by Eli Witztum & Ahmed Hankir- Waltz with Bashir: two views: Lebanon and Israel

Professor David Greenberg (organiser of the WPA TPS event and my friend) and Dr. Ahmed Hankir, Sheraton Hotel, Tel Aviv, Israel, November 2012.

Purpose of my Trip to Israel • To present my research in a World Psychiatry Association event • To deliver the peaceful message of co-existence • To remind policy-makers of the far reaching consequences of confict and how this should strenghten our resolve to deter it from happening. • The people of Israel in the conference were vehemently opposed to Operation Peace for Galilee and condemned the massacres of Sabra and Shatila. • To see what Israel is like for myself. • The people of Israel showed me utmost hospitality from the moment I landed in Ben Gurion Airport till I departed from Israel.

The Journey of an Idea… Advertisement for Waltz with Bashir first noticed in an underground Subway station in Piccadilly Circus, London. Abstract submitted to Cambridge University and World Psychiatry Association. Oral presentation and publication Clare College, Cambridge University. Keynote Lecture, World Psychiatry Association, Tel Aviv. Talk in Nottingham University. Next stop and final destination?

Watch your thoughts for they become words, Choose your words for they become actions, Understand your actions for they become habits, Study your habits for they become your character, Develop your character, for it becomes your destiny…

Thank you all for your attention.

Any Questions? ahmedzakaria@doctors. org. uk