Acad Psychiatry 31:407-410, September-October 2007
doi: 10.1176/appi.ap.31.5.407
© 2007 Academic Psychiatry
Bowlby Goes to the Movies: Film as a Teaching Tool for Issues of Bereavement, Mourning, and Grief in Medical Education
Benjamin A. Furst, M.D.
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INTRODUCTION
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Bereavement is a common life event and an issue inseparable from practicing medicine. Despite heightened morbidity and mortality associated with bereavement, it receives insufficient coverage in medical training. Depictions of bereavement in film may offer clinicians and students a better understanding of grief and the psychological process of mourning. An overview of bereavement, mourning, and grief, emphasizing the work of John Bowlby, is followed by examples in film. The ready access of film in video and DVD formats may increase the emphasis of bereavement issues in medical education and heighten the sensitivity of clinicians to identifying bereavement in patient care, enhance the empathic response to bereaved patients, and lead to better care through early referral to resources and targeted interventions.
Medical training largely focuses on survival. Death occurs only when all reasonable efforts have been made to thwart its advance. Bereavement is associated empirically with significant morbidity and mortality (1–5). Medical education has traditionally lacked coverage of end-of-life issues. A recent survey of the literature acknowledges that more U.S. medical schools are covering end-of-life issues, but that students feel their training is inadequate and educators are seeking to refine current didactic methods (6).
The complex psychological processes of mourning and grief do not lend themselves to tidy summarization. A need exists for teaching methods that are efficient and experiential. Cinema is a reasonable medium to convey these complex processes. The use of video and standardized patients has already become a fixture in medical education for its economy of time and wealth of vicarious experiences (7). The verisimilitude striven for in film not only provides the best approximation of these psychological processes, but illustrates their effects on social systems as well. Moreover, the availability of films on video and DVD allows for easy access to these potential teaching materials.
Many films depict bereavement, grief, and the mourning process. An overview of normal and pathological mourning, emphasizing the work of John Bowlby, is followed by a discussion of films that illustrate these concepts. Strategies are provided to incorporate film in teaching this topic.
Bereavement, Mourning, and Grief: A Definition of Terms and Theoretical Overview
The terms "bereavement," "mourning," and "grief" are often used interchangeably. Our diagnostic classification system, DSM-IV-TR, does little to differentiate these terms and their pathological variants. Yet these terms are distinct: bereavement describes the factual state of being deprived of a loved one; mourning characterizes the psychological process in the state of bereavement; and grief is one aspect of the process of mourning, specifically the somatic and emotional sensations caused by loss (8).
The modern theoretical framework of mourning originated with Freud. He defined the work of mourning as an intrapsychic process through which a person withdraws their libidinal attachment to the lost love object (9). Grief is the initial step in the process of mourning. Early studies characterizing acute grief were performed by Erich Lindemann (10). He identified five symptoms as being pathognomonic for acute grief: 1) somatic distress in episodes lasting 20 minutes to an hour, including sensations of tightness in the throat, choking, shortness of breath, sighing, emptiness in the abdomen, lack of muscle strength, and intense emotional distress; 2) preoccupation with the image of the deceased; 3) guilt; 4) hostile reactions; and 5) loss of patterns of normal conduct with regard to daily activity (10). He also coined the term "grief work," which bears similarity to Freud’s definition of the work of mourning (10).
John Bowlby furthered our understanding of the phenomenology of mourning through attachment theory. He elaborated four phases of mourning: 1) numbing; 2) yearning and searching; 3) disorganization and despair; and 4) reorganization (11). In numbing, most experience a sense of shock and difficulty comprehending the loss. Tension and apprehensiveness prevail, with a tendency towards intense emotional outbursts, such as panic attacks, anger, or elation. The phase of yearning and searching is characterized by intense pining and duress, with concomitant restlessness, insomnia, and rumination. There is a propensity to sense the object’s actual presence; environmental stimuli trigger a feeling that the loved one has returned. Vivid dreams of the lost object and corresponding desolation on wakening occur. A phase of disorganized behavior and despair ensues, with the process culminating in the phase of reorganization, whereby the bereaved separates from the lost object (11).
Pathological departures from normal grief and mourning are rooted in the failure to perform the work of mourning. This results in a disordered method of coping based on proclivities toward certain psychological defenses. For Freud, pathological mourning was caused by ambivalence to the lost object and resembled melancholic depression (9). Lindemann characterized pathological grief reactions as delayed or distorted. Distorted reactions consist of overactivity without a sense of loss, the acquisition of symptoms belonging to the deceased, psychosomatic symptoms, alteration in relationships, hostility, and agitated depression (10). Bowlby’s description of pathological mourning enjoys the widest acceptance. His model includes three subtypes: 1) chronic mourning, a prolonged and unusually intense mourning period, viewed as an extension of the phase of numbing; 2) the "prolonged absence of conscious grieving," or pathological denial, that may be considered a prolongation of yearning and searching or disorganization and despair, similar to Lindemann’s delayed grief reaction; and 3) a euphoric response that shares similarities with a manic episode, characterized by a refusal to accept the death combined with a vivid sense of the deceased’s presence, or an unusually increased level of activity combined with latent tension and anxiety (11). Mourners may oscillate between subtypes. In instances when the defenses employed in these pathological variants break down, the result is often intense grieving or a state resembling depression.
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A Discussion of Films
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The absence of conscious grieving is represented in "Under the Sand." "Ordinary People" exemplifies chronic mourning, and "Love Liza" depicts the euphoric response to bereavement. "The Son’s Room" shows acute grief and a relatively normal mourning process (Appendix 1).
Francois Ozon’s "Under the Sand"
Francois Ozon’s film represents Bowlby’s concept of the absence of conscious grieving. It is the story of Marie, whose husband Jean drowns while they are vacationing. The film chronicles how her denial defends against the loss. She attempts to preserve her attachment to Jean by denying facts about his disappearance—even denying the loss itself—and keeping her husband alive through fantasy.
The movie depicts a short phase of numbing and protest, followed by prolonged yearning and searching for her spouse. Denial is evident immediately after Jean does not return from the sea and lifeguards are advised, when we see Marie return to the cottage and prepare tea for two. As the movie jumps ahead in time, Marie is approached by one of the lifeguards, now a student in her literature class. She denies having ever met him the previous summer when Jean disappeared. At a dinner party with friends, Marie discusses Jean as if he were alive despite months passing since his disappearance.
When Marie meets another man, Vincent, the fact that her husband’s body has never been recovered allows her to engage in a relationship with a new lover while maintaining the hope that Jean may return—as he often does by way of fantasy. The persistent hope that Jean will return prevents her from forming an attachment to Vincent. When Vincent confronts her about Jean’s presumed death, she rebukes him to preserve her attachment to Jean.
It is only when Marie is notified that a body was recovered by fisherman that her defensive structure is challenged. Despite genetic evidence and dental records implicating that the body is Jean’s, when Marie is presented with a wristwatch found on the body, she laughs and claims the watch was not his. The movie closes with Marie visiting the site where Jean disappeared. Her tears betray her knowledge that the body recovered was indeed his. However, just as we see a return to the work of mourning, she spots a male silhouette on the beach. As Marie runs toward the silhouette, we wonder how long the yearning and searching will continue before she accepts Jean’s death.
Robert Redford’s "Ordinary People"
Redford’s film focuses on a family’s reaction to the loss of a child. The mourning process of Conrad, the surviving child, illustrates chronic mourning. The viewer experiences Conrad’s protracted phase of numbing in his self-reproach and depressive isolation from others.
In the film, the family loses their eldest son in a boating accident. Conrad survives, but the psychological effects are apparent: he was hospitalized after a suicide attempt in reaction to his brother’s death; disconnected from peers, he finds little enjoyment in daily activities. Conrad’s fragile emotional state is worsened by his parents, who evidence an absence of grief by flying into social commitments to distract from their loss.
Conrad’s mourning progresses with psychotherapy. Therapy destabilizes the tenuously balanced family system of absent mourner-parents and the melancholic Conrad. Paternal overtures toward reconciliation with Conrad occur at the expense of his mother, whose highly defended style prevents her from dealing with her anger, which is directed unconsciously toward Conrad. As Conrad pursues new attachments, his overture toward rapprochement with mother is rebuffed; this fractures the family structure. Father and son show signs of mutual acceptance, while the mother’s brittle state of absent grief drives her away from the family.
Todd Luiso’s "Love Liza"
The euphoric response to bereavement is captured in the story of Wilson, who loses his wife to suicide. Wilson’s abandonment of work responsibilities, forced enthusiasm, heightened interest in radio-controlled model airplanes, and huffing model plane fuel are examples of a manic escape to defend against the pain of loss.
We initially encounter Wilson in a phase of numbing and watch as it reaches pathological proportions. Unable to sleep in the bed he shared with Liza, he sleeps in his car and on the floor. He becomes detached and isolated. His insecure defense against the loss is shattered when he discovers a sealed suicide letter left under a pillow on the bed.
As a result, Wilson’s defensive structure changes. Overzealous laughter in the break room at work hints at a shift from a depressive reaction to manic escape. This change is apparent to his boss, who suggests a vacation. Wilson frolics blissfully on the beach, but on his return there is the loss of euphoria and reemergence of depression.
When his well-meaning boss pairs Wilson up with Denny, a hobby enthusiast, Wilson begins to inhale model airplane fuel and fluctuate between euphoric enthusiasm, irritability, and lability. Impulsively, he flees his hometown and stumbles upon a radio-controlled boat regatta, where he swims into the lake while the competition is occurring, only to be shielded from the participants’ anger by the fortuitous appearance of Denny from the crowd. Wilson is shepherded home and his failed manic defense collapses into depression.
Out of anger at his inability to read Liza’s suicide note, Wilson’s mother-in-law removes his possessions from his home. Wilson breaks into her home to find his mother-in-law there with letter in hand. Taking the letter home, Wilson opens it to find few reasons behind her suicide. Wilson sets the letter, and inadvertently his home, on fire. The film closes with Wilson exiting his burning home and wandering down the median of the street. Despite his apparent decompensation, the burning letter, possessions, and home suggest a separation from his former life and potential to complete the mourning process.
Nanni Moretti’s "The Son’s Room"
This film portrays acute grief and a fairly normal response to loss. A depiction of acute grief and the phase of numbing is followed by illustrations of yearning and searching. Disorganization and despair follow with evidence of reorganization of the family system at the film’s end.
"The Son’s Room" is a story of an Italian psychoanalyst, his wife, and teenage son and daughter. Their son, Andrea, drowns while scuba diving when the father is called away to attend to a patient in crisis. Acute grief is depicted effectively in the scene of Andrea’s mother on the bed in the throes of acute somatic and emotional distress.
After the numbing and shock have passed, we witness yearning and searching, which is well illustrated by the father, who repeatedly plays a passage of music that reminds him of the day of Andrea’s death. He researches scuba equipment seeking to explain the loss for which he feels responsible. His guilt is displayed in his dreams, where he attempts to undo the loss. In one dream, he convinces his son not to go scuba diving; in the other, he does not call on his patient in crisis and stays with his family. Additionally, we see the father acting out a fantasy when he goes to a record store to purchase music for Andrea’s friend and later confesses to the salesman that his purchase was intended for his deceased son.
There is also a moving portrayal of disorganization and despair over Andrea’s loss. The parents become emotionally distant. The daughter breaks up with her boyfriend and gets suspended from school competition for inciting a fight during a basketball game. The father is unable to continue analytic therapy as he finds himself overwhelmed by negative countertransference.
One month after the tragedy, the family receives a letter from a girl who previously corresponded with Andrea. The mother, yearning for her lost son, reacts by contacting the girl. Initially reluctant to visit the family, she arrives unexpectedly. Her arrival introduces a way for the family to join together and progress in their work of mourning. The girl, who is hitchhiking to France with a new boyfriend, shows that life continues on despite their loss. The family’s confrontation with this reality becomes an anchor point for their emerging phase of reorganization. The father’s decision to drive the family, the girl, and her companion to the French border is a way for the family to realign in the absence of Andrea. The film ends with the girl and travel companion leaving on a bus and the family walking away, showing the three of them minus Andrea.
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Discussion
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The reaction to bereavement is complex. According to Bowlby, mourning occurs in phases of numbing, yearning, despair, and reorganization. Based on one’s psychological health, mourning may proceed normally or pathologically. The potential benefits of film as a teaching tool have previously been raised (13). Using film as a didactic tool might be employed in various ways. The author has used a seminar format where films are screened with trainees and faculty in attendance. A discussion follows to elucidate the psychological processes portrayed and link them to clinical case material. Additionally, the author has presented the topic of mourning in lecture format using film clips to accompany teaching points. This allows for a broader overview as a single film may only convey one aspect of mourning.
The importance of death and dying issues in health care cannot be overstated. The use of film has the potential to communicate the universality of this experience and the degree to which it affects people’s lives. It could potentially serve to increase emphasis of bereavement issues in medical education and increase the sensitivity of clinicians to identifying bereavement as an important clinical issue and potential risk factor for poorer outcomes. Heightened sensitivity to the psychological process of mourning may enhance the clinician’s empathic response to those bereaved and could improve the quality of care through early referral to resources for more comprehensive support or targeted interventions for this higher risk population. Additional study is needed to evaluate whether this teaching method improves rates of identification of bereavement, rates of referral to treatment resources, or improves the morbidity and mortality experienced by those bereaved.
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REFERENCES
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- Li J, Precht DH, Mortensen PB, et al: Mortality in parents after death of a child in Denmark: a nationwide follow-up study. Lancet 2003; 361:363–367[CrossRef][Medline]
- Li J, Laursen TM, Precht DH, et al: Hospitalization for mental illness among parents after the death of a child. N Engl J Med 2005; 352:1190–116[Abstract/Free Full Text]
- Martikainen P, Valkonen T: Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort. Am J Public Health 1996; 86:1087–1093[Abstract/Free Full Text]
- Van Eijk J, Smits A, Huygen F, et al: Effect of bereavement on the health of the remaining family members. Fam Pract 1988; 5:278–282[Abstract/Free Full Text]
- Charlton R, Sheahan K, Smith G, et al: Spousal bereavement: implications for health. Fam Pract 2001; 18:614–618[Abstract/Free Full Text]
- Dickinson GE: Teaching end-of-life issues in US Medical Schools: 1975 to 2005. Am J Palliat Care 2006; 23:197–204[CrossRef]
- Stillman PL, Swanson DB, Smee S, et al: Assessing clinical skills of residents with standardized patients. Ann Intern Med 1986; 105:762–771[Abstract/Free Full Text]
- Ruark JE, Gonda TA: Grief and mourning, in Depression and Mania. Edited by Georgotas A, Cancro R. New York, Elsevier, 1988
- Freud S: Mourning and melancholia, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 14. London, Hogarth Press, 1966
- Lindemann E: Symptomatology and management of acute grief. Am J Psychiatry 1944; 101:141–148[Free Full Text]
- Bowlby J: Loss: Sadness and Depression. New York, Basic Books, 1980
- Alexander M, Hall MN, Pettice YJ: Cinemeducation: an innovative approach to teaching psychosocial medical care. Fam Med 1994; 26:430–433[Medline]
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INTRODUCTION
A Discussion of Films
