Introduction
In 2018, a film written and directed by Peter Hedges called Ben Is Back was released (Hedges, Jacobson, Simpson, & Schwarzman, 2018). This film has presented the audience with a thrilling while also warm-hearted family drama which takes place in a household with an opioid-addicted son who unexpectedly comes back from rehab to celebrate Christmas Eve with his family. This movie was intentionally created to focus on the effects and consequences of opioid use disorder (or substance use disorder in general) on adolescents and their families, as there was an epidemic of opioid abuse in the US in the past few years. Although the film industry has long been accused of misrepresenting and further stigmatizing mental illnesses in the popular culture, this movie is more or less an accurate and realistic depiction of opioid use disorder, probably due to the fact that both the producer and the director of this movie have had direct personal connections with similar mental illnesses in their lives (Lewis, 2018). As we can see, through these realistic depictions, the director and producers of this film are actually trying to do something exactly the opposite, which is to encourage and help with these people and their families to overcome the difficulties and challenges that come with these disorders. At the same time, they are also trying to present these disorders to a wider range of audience as both a warning for their negative consequences and a potential clarificationfor these people’s realistic experiences. As the producer Nina Jacobson once said in an interview, she hopes this film can eventually “[lead] to a dialogue and increased awareness of the scope of the opioid crisis” (Lewis, 2018). Therefore, I think it is important for us to reconsider the relationship between the film industry and mental illness in this new era. It is crucial to recognize that, as films are so influential in forming those stigmas about mental illnesses in the popular culture, they must be equally powerful in correcting these misconceptions and promoting the social awareness towards them, just as Peter Hedges and his team has accomplished through their multiple movies similar to Ben Is Back.
In this paper, I would like to first briefly introduce the opioid use disorder, its current and historical changes in diagnostic criteria, risk factors, possible etiologies, and also treatments. Then, by focusing on the analysis of the movie Ben Is Back, I would like to bring up the discussion on the role of film in promoting mental health awareness, and conclude with some suggestions on potential future approaches in better improving the social cognition towards mental illnesses.
Symptoms and Diagnostic Criteria
Current Diagnostic Criteria
According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), Opioid Use Disorder (OUD), categorized under Substance Use Disorder (SUD), is defined as a “problematic pattern of opioid use leading to clinically significant impairment or distress.” Patients with OUD often take in large amounts of opioids over a long period of time with no legitimate medical purposes, have cravings for opioids, tend to develop regular patterns of compulsive drug use, spend a lot of time in activities involving obtaining and using opioid in their daily lives, have persistent social and interpersonal problems, develop symptoms like tolerance and withdrawal, and may also develop conditioned responses to drug-related stimuli (APA, 2013). The symptoms may vary across individuals, and some of them are specifically and accurately presented in the movie Ben Is Back, which can potentially leave a deep impression on the audience and help them to understand these related symptoms better (Hedges, Jacobson, Simpson, & Schwarzman, 2018).
Historical Changes in Diagnostic Criteria
The categorization and diagnostic criteria of OUD have experienced significant changes throughout history. When DSM-I was first published in the 1950s, disorders similar to OUD belonged to the category of “Drug Addiction,” which was separated from “Alcoholism” (APA, 1952). “Opium,” instead of opioid, was listed under the former category, and this disorder was considered to be symptomatic of certain kinds of personality disorders or some organic brain disorders (APA, 1952). Then, in DSM-II, the concept of “dependence” was raised, and the disease was categorized under “Drug Dependence,” which was a diagnosis for patients who were “addicted to or dependent on drugs other than alcohol, tobacco, and ordinary caffeine-containing beverages” (APA, 1968, p. 45). For diagnosis, evidence for the habitual use of drug and withdrawal symptoms were started to be required (APA, 1968). DSM-III-R has brought the largest changes in classification and diagnostic criteria, in a way that it became a lot similar to the current ones in DSM-5. Andas we can notice, there are several significant changes in the classification, as similar disorders began to be clustered and categorized under the title of “Psychoactive Substance Use Disorders” together (APA, 1987). Firstly, the title of this disorder was changed to a more generalized term – “substance” – and alcohol was included into this category. Secondly, as the disorders were further specified based on the substance being used, the broader category of “opioid” was introduced to include all opium-like substances. And finally, the distinction between “Dependence” and “Abuse” was explicitly stated. In DSM-IV-TR, the name “Opioid Use Disorder” was first introduced (listed under “Substance-Related Disorders” in general), and the distinction between “Dependence” and “Abuse” was kept (APA, 2000). However, in DSM-5, the categories of “Substance Abuse” and “Substance Dependence” have been eliminated after multiple discussions and data analyses, as researchers have found this distinction to be not well-founded and practically useful (Hasin et al., 2013).
Risk Factors
Many factors have been suggested to be associated with higher risks in developing opioid use disorder, including both extrinsic, environmental factors and intrinsic, genetic factors.
According to research, extrinsic factors including but not limited to early antisocial behavior, anxiety level, low academic performance, socioeconomic status, psychiatric history, and religious involvements among adolescents can all potentially increase their risk of developing substance use disorder and increase their frequency of substance use (Kilpatrick et al., 2000; Ronel & Levy-Cahana, 2011; Tsuang et al., 1999). And as shown by Ronel & Levy-Cahana’s study (2011), adolescents growing up with a substance-dependent parent are more likely to have an early onset of drug use.
On the other hand, several family, twin, and adoption studies have consistently indicated the genetic factors involving in the development of SUD (Cadoret, 1986; Tsuang, Bar, Harley, & Lyons, 2001; Tsuang et al., 1998). According to the twin study (N =3372) conducted by Tsuang et al., using the common vulnerability model, they have estimated that “31% of the variance for the shared or common vulnerability was caused by additive genetic effects, 25% by family environmental effects, and 44% by non-family environmental effects”(Tsuang et al., 1998, p. 969)This result has not only indicated the significant contribution of genetic factors in leading to higher substance abuse risks, but also highlighted the importance of the complex interactions existing between genetic and environmental factors, as no single factor can be held fully responsible for this disorder.
Etiology and Mechanisms
Opioid use disorder is a disorder which involves certain neurochemical changes in the central nervous system (CNS) that can lead people to become dependent or addicted to the opioids and develop compulsive opioid use behaviors (Nguyen, Hahn, & Strakowski, 2013). According to research, these addictive drugs primarily act on neural circuits that are responsible for motivation and reward, for example, the well-known reward pathway (Chao & Nestler, 2004; Kalivas & Volkow, 2005). And as we can notice from multiple research studying the mechanism of SUD, functional changes within brain regions including nucleus accumbens (NA), orbitofrontal cortex (OFC), amygdala, hippocampus, and anterior cingulate gyrus (ACG) have been consistently reported to be related to drug dependence and addiction (Chao & Nestler, 2004; Kalivas & Volkow, 2005; Koob, 2006; Volkow, Fowler, & Wang, 2003). One thing important to mention is that, combining the fact that opioids can alter neural signal transmission by binding to opioid receptors and these receptors are highly abundant in aforementioned nucleus accumbens and amygdala (Mistry, Bawor, Desai, Marsh, & Samaan, 2014), we can see how the opioids are directly affecting the reward circuits in these patients’ brain, altering their normal regulation function by the prefrontal cortices (Bush et al., 2002; Jentsch & Taylor, 1999), and causing them to become dependent or addicted to these opioids.
Treatments
The treatments for patients with OUD generally involve 2 phases – the detoxification phase and the maintenance phase (van den Brink & Haasen, 2006). In the detoxification phase, there will usually be a reduction then termination of opioid use to deal with the acute physiological effects of opioid withdrawal; and in the maintenance phase, relapses will be prevented. For these two processes, drugs including full m-opioid receptor agonists (e.g. methadone), partial m-opioid receptor agonists (e.g. buprenorphine), and m-opioid receptor antagonists (e.g. naloxone, naltrexone) have been widely reported to be effective (Ayanga, Shorter, & Kosten, 2016; Berrettini, 2017; Nguyen et al., 2013). However, the drawback of these medicines is that there might be certain side effects associated with them. For example, methadone maintenance may have side effects including but not limited to “sedation, diaphoresis, constipation, insomnia, nausea, seizures, weight gain, and sexual dysfunction” (Nguyen et al., 2013, p. 291).
In addition to the treatments including these two phases, long-term treatment and care are typically required for these patients, aiming to reduce their potentially risky or harmful behaviors and improve their long-term physical and psychological health. As the emotional, cognitive, and social elements of recovery cannot be simply treated with medicines, certain forms of behavioral therapies might also be required. Although research explicitly investigating the effectiveness of cognitive-behavioral therapy (CBT) in treating OUD is relatively rare, in a recent study conducted by Barry et al. (2019), the preliminary efficacy of CBT has been supported with evidence. And as more and more studies being conducted, the relative effectiveness of different kinds of psychological and behavioral therapies might be empirically tested.
Ben Is Back: Portrayal of Opioid Use Disorder in Film
As discussed in the introduction, the film Ben Is Back was actually intentionally created to be an accurate and realistic depiction of OUD. Therefore, multiple signs of OUD have been either implicitly or explicitly presented by Ben and his families’ behaviors in the movie.
As this movie is depicting a young man who comes back from rehab, most of the symptoms directly presented in the film are withdrawal symptoms and conditioned responses to drug-related stimuli. After Ben comes back, his mother, Holly, chooses to hide all the drugs in the bathroom away to prevent Ben from being triggered by these stimuli. Using a close shot focusing on her facial expressions in the mirror, the audience can directly see her anxious feeling for Ben’s condition. However, at the same time, through her conversation with her daughter, she also seems to be positive and confident for Ben’s recovery, which is conflicting with her expressions. This struggling and uneasiness is a very realistic depiction for the emotional states that the families of addicts typically experience. And in a later scene, when Ben climbs up to the attic to get the Christmas ornaments, he sees the place where he used to secretly store his drugs and suddenly feels the stress comes with this stimulus. To present his unstable psychological state, a tilted high-angle shot is used when he looks down to his sister for help, which further highlights the extremely unstable psychological conditions of patients with OUD. Other similar scenes throughout the movie have all directly indicated Ben’s conditioned responses to drug-related stimuli.
Furthermore, through these triggers, other aspects of the consequences of his early addiction have also been indirectly implied, including his compulsive drug-taking behaviors, the enormous time and energy he spent to achieving these drugs, and his undesirable social activities and social relationships… And most importantly, with his confession to Holly that he has never felt safe, loved, alive, and whole, the reasons for his initial dependence and addiction for painkillers has been revealed, which has potentially offered a lesson to all the parents and families about the importance of love, attention, and feeling of safety.
Looking at all the scenes discussed above, the tone of this movie seems to be generally negative. However, there is also certain positivity involved in this movie, which really gives a “beacon of hope for addicts and those who love them” (Fairyington, 2018). Firstly, it offers hope for people because it suggests addiction is treatable and the people who used to suffer from OUD can be healed through a gradual process. But importantly, this process requires support from multiple aspects. As depicted in the movie, when Ben is feeling shaky, he decides to go to a meeting, to find people who are also suffering from these experiences and share their stories, which can potentially encourage and benefit each other mutually. Watching this scene and listening to his short speech, the audience are moved by the authenticity of his confession and self-reflection. While inducing our empathy for these people who are working hard to get out of their addiction, it is also providing certain kinds of advice for these patients and their families, making them realize the help of meetings and the power of groups, teaching them that sometimes, there are things that we cannot do alone (Fairyington, 2018).
Conclusion
As the producer Nina Jacobson once said in an interview, "for me this was a really personal script," she hopes this film can eventually lead to a more open dialogue and increased awareness of the effects of drug addiction (Lewis, 2018). While the film industry in the past is stigmatizing mental illnesses as “madness” and presenting them in typically horror ways (Haider, 2018), recent movies have been realizing this problem and shifting toward more accurate and realistic depictions of their symptoms and consequences. More importantly, instead of focusing on the negative aspects of the diseases, more and more films, including Ben Is Back, are written and produced in a way that conveys positivity through the screen. For both disease-related people (patients and their families) and common audience, the movies can provide something positive and new: new knowledge about the disease, new understanding of its symptoms, new cognitive and emotional responses, new ways of thinking, new possibilities of treatment, and new confidence for facing the challenges.
As we can see, the film industry is already changing to bring these positive impacts into our real life. With these attempts to gradually correct the misconceptions and stereotypes people possess, I believe there could be potential benefits for both psychiatry and the film industry. To a certain extent, we can even imagine a change in the epidemiology of the diseases when these films are powerful enough to shape the ideals of how families raise their children, how teachers offer hope and care for students, and how people can cope with different kinds of difficulties and live a positive life. Personally, I firmly believe that films are going to play an especially important role in promoting mental health awareness in the future.
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