Alan A. Stone, MD

by Joanna Breyer
	New York: TarcherPerigee-Penquin Random House, 2018
	448 pages • $16.00 (paperback)

 is the work of psychologist Joanna Hare Breyer, PhD, she is the wife of Supreme Court Justice Stephen Breyer. Her professional career has followed the less public path of compassion, empathy, and helping children and their families deal with the demon of cancer. Upon her retirement, instead of a memoir, she set out to distill and pass on everything she had learned. Who would have thought it possible to sum up such a career in a handbook that provides guidance to everyone involved with sick children?

Dr Breyer’s writing aims at parents, but her reach touches every person and professional involved in the care of very sick children. Hospitals that treat children with cancer are divided among many subspecialties each with its own teams and technicians so that fragmented care seems inevitable. This is surely bewildering to children and their families when life threatening illness strikes and all that high powered medical science has to offer is brought to bear. Dr Breyer, untrained in medicine, has managed to understand it all and translated it into a language that can be understood. One is reminded as one reads her book of Emerson’s well-known quote, “Common sense is genius dressed in work clothes.”

A diagnosis of cancer in a child breeds helplessness, bewilderment, and desperation. If there is a red thread in this deeply informative book it is the many pragmatic and creative ways Dr Breyer has devised to help children and their families overcome those feelings of helplessness and despair. Dr Breyer has the skills, empathic and professional, to grasp all the parameters of treatment and help the family to understand, to cope, and to participate in the treatment.

She calls herself a psycho-social counselor, but she is more than that. She knows every resource that can support the family and every psychological device that can help the child cope with pain, disfigurement, and even suicidal despair. Working with children in pain who fear the next procedure, she finds ways to give them a sense of mastery.

Each chapter has a case example that explains what she does. In a particularly touching example, she created a game to help a suicidal ten-year-old cope with self-destructive impulses. At a certain point in the game the child smiled at her and said, “I know what you’re doing, but I like it.” What an enviable account of a therapeutic alliance in a desperate situation.

Dr Breyer goes on to describe coping techniques: breathing and relaxation, guided imagery, hypnosis, auto-hypnosis, and many others. There is practical guidance at every turn to ease suffering and promote mastery and resiliency. The book has no theoretical pretense, every chapter describes where the “rubber hits the road.”

This is a book that should be put in the hands of every family bringing a child with cancer to a hospital and every professional involved in the care of these children. But it is also a book for mental health professionals to read, to learn, and to admire a vocation of caring in the presence of death. Dr Breyer has repeatedly faced death with children. What does one answer when a child asks, “Am I going to die?” She offers suggestions for children at different developmental ages and for their parents. It is a book I wish I had read in medical school. Here is wisdom about mortality and the human condition without pretense or posturing. Here is a selfless portrait of a vocation.

Dr Stone is Touroff-Glueck Professor of Law and Psychiatry, Faculty of Law and the Faculty of Medicine, Emeritus, Harvard University.

Articles

One is reminded as one reads this book of Emerson’s well-known quote, “Common sense is genius dressed in work clothes.”

When Your Child Is Sick

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, the first feature film of the French auteur Alice Winocour, premiered at Cannes during La Semaine de la Critique, the week of screenings meant to encourage new filmmakers. It was warmly received and subsequently earned a coveted CÃ©sar nomination for best first film. American film critics also applauded it as a polished cinematic jewel with a welcome feminist perspective that exposed the greatest French physician of the 19th century variously as a charlatan, a misogynist, a sadist, and someone who violated his Hippocratic Oath to have sex with a teenage patient. Although there were one or two skeptical voices, most of the film critics believed what they saw. It is indeed a beautiful movie, but for those who know something about the history on which it is supposedly based, its flaws are painfully obvious.

The film, a costume drama set in the 19th century’s Belle Ãpoque, claims to tell the story of the relationship between the preeminent clinician of that era, Jean-Martin Charcot (Vincent Lindon) who presided over the Salpetriere Asylum, and his hysterical patient, the kitchen maid Augustine (Soko). In Winocour’s screenplay, and in the mantra of the film’s marketing campaign, “the object of study becomes the object of desire.”

In fact, Winocour knows virtually nothing about the actual relationship between Charcot and Augustine, if indeed there ever was one. She made the doctor-patient story up out of whole cloth.

Charcot was in fact famously remote from the Salpetriere patients. His assistant, Dr D. M. Bourneville, was responsible for Augustine’s care and compiled her history. Winocour not only invented the erotic relationship between Charcot and Augustine, but she also misrepresented the unfortunate young woman’s history. We know from Bourneville’s medical records that when she first entered the Salpetriere with her “hysterical symptoms,” Augustine was 14 or 15 years old and had recently been brutally sexual abused. Winocour’s Augustine is instead a surprisingly self-confident 19-year-old woman who suffers from hysterical fits but has no psychological past.

Winocour, while she was still in film school, had done some reading about Charcot and the Salpetriere, and she learned about his research on hysteria-a poorly understood illness that at the time most doctors thought afflicted only women-and the famous Tuesday clinics at which patients were presented to doctors from around the world and to interested Parisians as well. Charcot had reintroduced Mesmer’s hypnosis as a diagnostic and clinical tool, and hysterical patients would be hypnotized so that assembled audiences at his Tuesday clinics could witness the natural course of hysterical seizures.

Much had been written about Charcot and his hysterics whose seizures often had sexual overtones. But Winocour was looking for her own way into this material. She read in the Salpetriere records that Augustine had escaped from the hospital dressed in a man’s clothes, and she saw this as a woman liberating herself. But what really intrigued her was that in all the hospital records, there was nothing about the doctor-patient relationships-she decided to fill in that void from her imagination. In the course of her interviews at French Film Festivals all over North America, where audiences and critics believed what they saw, she became less and less candid about how she had actually dreamed up the doctor-patient relationship.

As Winocour had acknowledged, she tried to forget what she had read and to think cinematically, and what came to mind is Dario Argento’s exotic Italian thrillers and Cronenberg’s horror films and supernatural exorcism films. But she also had literary thoughts-gothic love stories, Jane Eyre, and the Bronte sisters. And she imagined the art of her cinema in the style of the Pre-Raphaelites.

Winocour had no interest in making a docudrama or a biopic. She wanted her film to be sensual, and she directed it with a sexual subtext. As she explained in interviews, Charcot’s Tuesday lessons were a “peep show,” a scene where Charcot feeds Augustine soup is “a blowjob,” when Charcot lets Augustine pat his pet gibbon it is “foreplay.” Only when doctor and patient give in to their aroused passion and have intercourse is it not sexual-it is their farewell scene. When Augustine has her hysterogenic seizures, each of the four becomes more obviously sexual-simulations of intense female orgasms. Winocour imagines Charcot as a fascinated little boy aroused and frightened by the spectacle of the woman’s overflowing sexuality.

Winocour wanted to tell a feminist story about Augustine. In her version, feminism is a story about personal autonomy and sexual empowerment. Hysteria is the language of the woman’s rebelling body expressing its repressed pain and sexuality. She thought of hysteria as a form of feminine protest that continues today with different symptoms: anorexia, self-cutting, etc.

Taking a page out of Charcot’s Tuesday clinics, she enlisted real female psychiatric patients of today, dressed them in 19th century costumes, and filmed them describing their symptoms. In her discussions about hysteria and protest, she likes to quote Lacan: “A hysteric is a slave in search of a master to rule.” And Augustine goes from lowly servant to a woman who understands herself and her sexual power and conquers the great doctor. This gothic love story is less about love than about lust; more a battle of the sexes in which the young woman wins and the famous doctor is shamed. I warrant it tells us more about sexual mores in Paris today than about what happened during the Belle Ãpoque in the Salpetriere.

In one of her many interviews, Winocour described how she thought about what happened at the Salpetriere. It was men in 3-piece suits looking at women in nightgowns-the male gaze-the subtext of all male-directed films.

Inverting that gaze, everything in her film is seen from the perspective of Augustine, and from the very first scene we identify with this distraught young woman. She is a kitchen maid serving dinner to a large bourgeois gathering. Her hands begin to shake as she pours the white wine then suddenly she reflexively grabs the tablecloth falling back in a fit and pulling everything off the table with her. This fit is meant to look like the cinematic depictions of exorcism in which the body is an independent presence separate from the conscious self and does things no human being could intentionally do. It was achieved by ropes that were attached to Augustine’s body, pulled in different directions, and then removed in editing. In a brilliant stroke, the dinner party guests stand and look on in silence, one woman crosses herself-exorcism-and the hostess pours a pitcher of water in her servant’s face, treating Augustine like an animal. It was originally Winocour’s intention that the fit be precipitated by a male gaze, a look from a dinner guest who had raped Augustine. That idea was discarded at some point, but an unidentified man still mysteriously gazes into the camera before the fit.

Augustine recovers from her seizure with one eye permanently closed, and the next day she is off to the Salpetriere. She soon realizes that Charcot is the god of the Salpetriere, and if she has prayers about being cured, they should be directed at him. As it turns out, Charcot is too busy even to examine her, but when he tours the living quarters, she conveniently has another seizure that commands his attention. This second fit has more erotic overtones and Augustine becomes Charcot’s favorite patient. She gets his full attention as stripped naked he examines her body and draws lines on it. His attitude denies any erotic interest and yet that is undeniably what we see. Adding to her empowerment over him, Augustine is the archetypal case Charcot desperately needs to present to the influential Academy that might fund his work. She is moved to a private room, takes walks alone with Charcot in a garden, and a human-erotic connection begins.

French neurologists decrying the factual inaccuracies of the film assure us that none of this special treatment ever happened. There were no private rooms and no such garden. In fact, the Salpetriere was originally more hospice than hospital. Incurable women were sent there to die along with homeless women. Most of them were geriatric patients. Charcot began to develop case histories and hospital records for all these abandoned women.

In this neglected warehoused population, Charcot, almost single handedly, invented modern clinical neurology, showing the relation between lesions of the brain and symptoms of the patients. That is what brought doctors from all over the world-including Sigmund Freud and Harvard’s William James-to Charcot’s Tuesday lessons, not just prurient curiosity.

All kinds of medical conditions were demonstrated, and new cases were presented to Charcot for diagnosis. Of course, this was an era of medicine in which there were few efficacious treatments. But Charcot was the greatest clinician and teacher of his time. Students flocked to his clinics and lectures; among them were the future leaders of clinical neurology: Babinski and Tourette. Rich and famous private patients came from all over the world seeking his advice.

In the final scene, the fictional Augustine falls down a stairway and her hysterical symptoms all disappear without medical assistance. When Charcot tries to present her to the assembled Academy at the crucial Tuesday clinic, she whispers to him that she is cured. When he tries to hypnotize her, he is unable. He turns to the assembled amphitheatre and is about to admit defeat when Augustine takes pity on him and feigns a seizure. This time the sexual overtones are all too obvious and she knowingly looks up at Charcot so that he realizes this show of hysteria is performed for him.

Charcot had argued throughout his career that the symptoms of hysteria were not feigned, that the women burned at the stake during the inquisition were suffering from hysterical symptoms. Now in what was to be his moment of triumph, he knows that his patient is faking it. When Augustine’s performance is complete and Charcot’s sense of integrity is demolished, the dignitaries of the Academy, totally taken in, erupt in applause. Charcot and Augustine repair to his office, where she greets him with an open-mouthed kiss and lifts her skirt, and the doctor succumbs to the passion she has inspired.

At the reception for the Academy that follows, a bewildered Charcot is showered with compliments and then we see Augustine with a hood pulled over her head. She is walking through the reception and out the door: cured, sexually triumphant, and now liberated.

Soko, the single-named singer-actress, is superb in the role. She seems to become Augustine rather than acting a part. Vincent Lindon, a great French actor, is quite convincing as Winocour’s Charcot. The haunting score by Jocelyn Pook will remind you of Philip Glass; it echoes the emotions of the narrative. The cinematography is done with a painterly sensibility in the style of tenebrism or chiaroscuro. All this is what gives the film its jewel-like quality.

But what Winocour has done with Augustine’s own story is the greatest flaw of the jewel. At age 13, Augustine, who had been raised with cruel discipline in a nunnery, was handed over by her mother to her employer and lover who brutally raped the young girl. Then her older brother offered her to his friends. These ghastly experiences brought her to the Salpetriere at age 14.

It is clear from a 21st century psychiatric perspective that Augustine was suffering from PTSD. D. M. Bourneville’s case history amply documents that diagnosis. Charcot did not invent the human suffering that he called hysteria, he just gave it the wrong name. It is worth noting that in his time, Charcot was derided by British and German doctors for insisting that male hysteria was not an oxymoron but a reality. Charcot described it in men who had been traumatized in railroad accidents and in war.

In the history of PTSD, Jean-Martin Charcot deserves a place as he does in a host of other conditions, many of which bear his name. Charcot had his faults, but they were not those portrayed in Winocour’s film. And Augustine was victimized in ways far more horrific than Winocour revealed. Horror thrillers and gothic romance, the stuff of Winocour’s imagination, feed the emotional brain and provide the audience escapist fantasies that insulate them against the painful realities.

It is clear from a 21st century psychiatric perspective that Augustine was suffering from PTSD, but Augustine was victimized in ways far more horrific than filmmaker Alice Wincour revealed. More in this film review by Alan Stone, MD.

Augustine

The ancient Greek dramas of Aeschylus, Sophocles, and Euripides gave Western civilization its foundational myths: Prometheus, Oedipus, Antigone, and the Oresteia. Two thousand years passed until Shakespeare arrived and, according to literary critics, achieved something perhaps more important: he “invented the human!”

 I think of this invention as the secular conception of the human condition. Yes secular! it is a vision of the moral adventure of life constrained by no religious orthodoxy.

Scholars debate whether Shakespeare was Catholic or Protestant. He often draws on both the Old and New Testaments of the Bible and the Book of Common Prayer, but God is missing from his greatest plays. Nonetheless, to paraphrase Simon Russell Beale, the great British actor, to perform in those plays is to experience “redemption and transcendence.” Shakespeare’s understanding of the human condition miraculously transcends his culture, time, and place.

 is an empowered woman; Othello, a blackamoor, commands the fleets of Venice; and Shylock, Shakespeare’s Jew, bleeds like a Christian when he is pricked. Even today in our era of cultural diversity, Shakespeare (the dead white male) remains the greatest figure of world literature, performed on every continent, surviving translation. During the recent London Olympics, Shakespeare’s 37 plays were performed by casts from around the world in 37 languages. The Bard’s “vitality seems to be impervious to adaptation.”

These are the pronouncements of Shakespeare scholars, but they are not alone in these judgments. American psychiatrists have enthused about Shakespeare from the very beginning of their profession. The early issues of the 

) contain more than a dozen articles on Shakespeare.

 Isaac Ray, a president of the American Psychiatric Association (APA) who pioneered 

 in America, thought Shakespeare was essential professional education: “few men [I add women] . . . are so familiar with those adversities of mental character that are in any degree the result of disease, as not to find the spheres of their ideas on this subject somewhat enlarged by the careful study of Shakespeare.”

 I emphasize the enthusiasm of Ray and his colleagues, but I agree with medical historians that their psychiatric readings of the Bard were almost totally mistaken.

British psychiatrists, as one might expect, had long been interested in the plays of Shakespeare, and 

. A school of Shakespeare criticism that began in the 18th century looked at the characters in the plays as though they were real people. Physicians, many of them learned in literature as well as the psychiatry of their day, joined the dialogue. The first medical commentator in this tradition was Mark Akenside (1721-1770), a physician and a poet. He was asked about the character of Hamlet. George Steevens (1736-1800), then editing the plays, had questioned Hamlet’s heroic stature, pointing out what he took to be immoral tendencies, eg, his get thee to a nunnery rejection of Ophelia and his sending his schoolmates Rosencrantz and Guildenstern to their death without a pang of conscience.

Akenside made no precise diagnosis, but he thought Hamlet could be forgiven because he “was impaired by his own misfortunes: by the death of his father, the loss of expected sovereignty, and a sense of shame resulting from the hasty and incestuous marriage of his mother.”

 Akenside’s compassionate understanding of the Prince of Denmark’s emotional devastation and his perilous personal and political situation was unrivaled by succeeding psychiatric commentators who were so intent on finding a diagnosis for Hamlet that they lifted the character out of context.

Perhaps the most important intervention in Hamlet dramaturgy was made by the physician to George III. The learned Sir Henry Halford (1776-1844) was “lost in astonishment” at Shakespeare’s knowledge of Burton’s 

 “so exactly did he portray in Hamlet the symptoms described by Burton.”

 Many subsequent productions down through the ages have emphasized Halford’s Burton connection and made Hamlet a “melancholic” figure. It was Winfred Overholser,

 an APA president, who pointed out in 1959 that Burton’s 

 had not been published until 5 years after Shakespeare’s death and long after 

 was written. Actually, Hamlet describes himself as 

, but whether Halford got it right or wrong, he stands as an example of the profound influence medical commentators have had on directors and literary critics of Shakespeare.

 I can only say that it defies modern diagnostic understanding. My guess is that the term “melancholy” might have been the 17th century catch-all equivalent of the 20th century neurosis.

The famous Henry Maudsley (1835-1918), for whom the London hospital is named, had a deep literary understanding of Hamlet but, in my view, thoroughly distorted by his classist English ideas about family heritage represented as the clinical wisdom of psychiatry. He dissected Hamlet’s character as derived from his poor family heritage, including a “taint from his mother” (Queen Gertrude) who, in Maudsley’s reading, was either in on the killing of her husband, the King, “or was just as bad.” And, Maudsley opined, Hamlet was the “nephew of the bloody bawdy villain,” the fratricidal Claudius. His conclusion, “dissimulation is Hamlet’s inherited disposition.”

Maudsley is an example of what I take to be an unfortunate tradition. Instead of learning from Shakespeare’s understanding of the human condition, psychiatrists began to apply what they thought was the science of psychiatry to dissect and diagnose his characters. Or as Isaac Ray and his colleagues did, they found their diagnostic categories and nosological theories confirmed by Shakespeare. The Variorum edition of 

 catalogs a centuries-long psychiatric debate: “Is Hamlet’s insanity real or feigned?”

 That debate continues today in mock trials about which I shall have more to say.

Sigmund Freud was never very interested in Kraepelinian diagnoses or legal definitions of insanity. He launched the practice of psychoanalyzing Shakespeare’s characters with his observations on Hamlet in the 

 (Freud’s biographer) that when Freud was 8, he was already reading Shakespeare and reciting in near perfect English some of the famous lines. There are quotes from Shakespeare scattered throughout the collected works, and in perhaps his most important insight, Freud recognized Shakespeare’s Hamlet in Sophocles’ Oedipus and formulated the Oedipus complex-the cornerstone of psychoanalysis and of his personal self-analysis.

 one of Freud’s most loyal adherents (and the author of his own erudite study of 

) believed that Freud got more of his ideas from Shakespeare than from his patients. That seems to me entirely believable. In my own retrospective judgment, once one gets past the Interpretation of Dreams and the 

, it is fair to say that Shakespeare saw more deeply and broadly into the human condition than Freud.

Nonetheless, Freud’s Oedipus complex dominated productions of 

 in the second half of the 20th century as the 

 had before then. Laurence Olivier, in planning his Hamlet performance, famously consulted with Ernest Jones,

 Freud’s acolyte and biographer, who had expanded Freud’s insights into a book about the Danish Prince. Under Jones’ tutelage, the scene in which Hamlet finally accuses his mother (“As bad, good mother as kill a King and marry with his brother,” Act III, Scene IV, Line 27-28) takes place during an eroticized wrestling match in Queen Gertrude’s bed. Olivier’s 1948 film version of 

, emphasizing the mother-son sexual attraction, earned him Academy Awards for Best Picture and Best Actor. In 1990, Zefirelli directed Mel Gibson in an even more explicitly Oedipal version of the play. But, although that blatant emphasis is gone from recent productions, Freud’s ghost still haunts the castles of Elsinore on stage and screen. Sex has become an explicit part of the plot, graphically depicted in Ophelia’s madness. And during rehearsals and workshops in preparation for 

, it is not uncommon for directors and performers to explore the unconscious of the characters (and their own), often with the help of psychoanalysts.

Freudian interpretations of Shakespeare, although now on the wane, also flourished in the groves of academe during the second half of the 20th century. Many of the leading scholars in Shakespeare criticism relied either on Freud himself or on Lacan as a framework for their interpretations.

 is, as one might expect, recondite and abstruse but strays very far from the text and into Lacan’s own phallocentric imagination and theory of desire.

Although no contemporary psychiatrist or psychiatric theory plays a dominant role in Hamlet dramaturgy, Justice Anthony Kennedy of the Supreme Court created a prominent public role for psychiatrists in his mock trial of Hamlet. First staged at the Supreme Court in 1996 to raise money for the Shakespeare Company of the District of Columbia, it has had 3 iterations in other venues in which I participated as 1 of the 2 expert witnesses. Justice Kennedy resurrected the debate cataloged in the Variorum edition of 

: is Hamlet’s insanity real or feigned?

Justice Kennedy concocted a scenario that narrowed the question as appropriate in law. He posited that all of the characters who died in the final scene by poisoning-Queen Gertrude, King Claudius, Laertes, and Hamlet-had all miraculously recovered. Only Polonius whom Hamlet had stabbed in Act IIi, Scene IV was dead. Hamlet was charged with the murder of Polonius, and the only question to be decided at trial was whether Hamlet was sane or insane at the time of that crime. The only witnesses were to be 2 psychiatrists.

The American Law institute’s formulation of the insanity defense would apply. The basis of the psychiatric testimony was to be any statement in the text of the Folger edition of the play.

The expert for the defense was a leading forensic psychiatrist with experience in many trials. I was the witness for the prosecution, and although I have been a Professor of Law and Psychiatry at Harvard for more than 4 decades, I had no experience as a forensic psychiatrist. My former student and friend Joel Klein, then a lawyer in the Clinton White House, convinced me to participate. He knew that I taught 

 in my law and literature seminar, and he understood my principled objections to forensic psychiatry.

 I was quite convinced that Hamlet had no serious mental disorder. And Joel Klein assured me I would testify only for the state whose lawyers would argue that Hamlet was not insane. Preparation for the trial at the Supreme Court caused me to dig deeper into the play and the literature of 

Two famous lawyers met with me before the trial to work out a strategy. They were superb in their craft but not steeped in the study of 

. My first task was to convince them we believed in ghosts. Or at least that the guards of the watch, Bernardo and Marcellus, and Hamlet’s friend Horatio had all seen the ghost of Hamlet’s father before Hamlet had and thus this was not a textbook hallucination.

My understanding of Hamlet was most influenced by a single defining performance. In 1989, Derek Jacobi directed then 27-year-old Kenneth Branagh in a brilliant 

 staged on the grounds of what is supposed to be the actual Elsinore Castle in Denmark. The bare-bones outdoor production bore no resemblance to the inward-looking Oedipal or melancholic versions of the play. The eerie appearance of the ghost on the battlements of the castle to begin the first act left no doubt that this was a supernatural phenomenon, not Hamlet’s hallucination. King Claudius was a Machiavellian usurper who kept his nephew under surveillance, ready to dispatch or poison him as he had his father.

Branagh’s vibrant youthfulness changed the emotional tone of every interchange. His prince was passionate, impetuous, defiant, struggling to control his emotions, barely able to contain his outbursts of resentment and contempt. Indeed, he was a brilliant young student of philosophy, not a man of action, caught up in a moral and political predicament and feigning madness only when watched by Claudius’s subalterns. My opinion of Hamlet was much like that of Akenside in the 18th century. Hamlet was a troubled man in a difficult situation who “put on an antic disposition” just as he had said he would in Act I. I thought of his psychiatric problems as a complicated grief reaction and testified that he was not insane when he killed Polonius.

The forensic expert’s opinion was based on DSM and the Folger text of 

 both of which he seemed to have committed to memory. He concluded that Hamlet suffered from rapid cycling bipolar disorder, and he retrieved from the text exact quotes that met DSM criteria and substantiated his view that Hamlet was insane. The jury, which included Justice Ruth Bader Ginsburg, found Hamlet sane. I am told that forensic experts reviewing the testimony from their professional perspective considered that result inexplicable.

Since the entire trial was broadcast by C-SPAN and is still available online, any reader who is truly curious can examine the record.

 I am confident that the defense expert is a better forensic psychiatrist than I and a more experienced clinician. But a forensic psychiatrist who fits Hamlet into a DSM category and pronounces him insane has in my opinion cut pieces out of the greatest portrait of a character in the greatest play ever written.

I have revisited the trial of Hamlet in a class I teach with Professor Alan Dershowitz-Justice and Morality in the Plays of Shakespeare. Again in a mock trial, I testified that Hamlet was sane. On this occasion, however, I saw the basis for my testimony in a completely different light than I had in the several previous public trials. Hamlet has 7 soliloquies in which he shares his innermost thoughts and feelings with the audience. It suddenly occurred to me that those soliloquies were as good or better than the information I or any other psychiatrist could obtain in prolonged anamnestic interviews. The soliloquies reveal the kind of insight, judgment, and reality testing we do not expect from patients with serious mental disorders. My friend, Fuller Torrey,

 likes to use the term “anosognosia,” suggesting a neural mechanism for the cardinal symptom of serious mental disorder. Whatever term psychiatrists use to indicate lack of insight, it clearly does not describe the Hamlet of the soliloquies.

Despite all this, I now consider my certitude about Hamlet an example of hubris. A mock trial it now seems to me is an invitation to narrow one’s perspective both on Shakespeare and on Hamlet. I recognized my failings in another defining performance of Hamlet. This one starring Michael Sheen and directed by Ian Rickson at the Young Vic in London. It was the first Shakespeare play Rickson had directed and his intentionally radical interpretation went against everything I believed. Denmark was a secure psychiatric hospital, Claudius was the nefarious superintendent, Polonius was a bumbling psychiatrist, and Hamlet was a disturbed mental patient. In the ghost scene, Hamlet lies down on the floor and out of his mouth comes the sepulchral voice of his dead father. Rickson had gone back to the psychological Hamlet, this time inspired by RD Laing

And Rickson’s idea of what is “rotten in the state of Denmark” is inspired by the 1975 film 

. Hamlet is being tormented under the aegis of psychiatry. Sheen and Rickson spent months brainstorming about the play, opting to abandon the “revenge Hamlet” and creating a new family dynamic conception. Their Hamlet hates his dead father but is locked in grief and projects his hatred onto his Uncle Claudius. They brought in psychoanalysts to help them think through all of the characters and their dynamic interactions.

It is tempting to simply dismiss this Young Vic version of 

 as aberrant, and many critics did. And I was certainly inclined to do the same. The production both attacked my understanding of the play and made psychiatry the evil force of oppression. But Sheen was brilliant as a mad Hamlet, and the soliloquies took on a new and different meaning. It was a stunning performance. This 21st century Hamlet demonstrated, once again, that there is no ultimate truth of the matter in Shakespeare. Hamlet says of Yorick, “A man of infinite jest.” Perhaps we can say of Shakespeare, a man of infinite human understanding and empathy.

 Reiss B. Bardolatry in bedlam: Shakespeare, psychiatry, and cultural authority in nineteenth-century America. 

Amariah Brigham, isaac Ray and Shakespeare. 

 Overholser W. Shakespeare’s psychiatry-and after. 

 1959;10(3):335-352. http://www.jstor.org/discover/10.2307/2866854?uid=3739832&uid=2&uid=4&uid=3739256&sid=21101579500523. Accessed January 25, 2013.

 1621. http://danassays.wordpress.com/encyclopedia-of-the-essay/the-anatomy-of-melancholy-by-robert-burton-1621. Accessed January 25, 2013.

 http://www.hermetics.org/pdf/Sigmund_Freud_-_The_Interpretation_of_Dreams.pdf. Accessed January 25, 2013.

Discourse on Hamlet and Hamlet: A Psychoanalytic Inquiry.

 New York: international Universities Press; 1971.

(Folger edition). New York: Washington Square Press; 1992.

 Stone AA. The ethical boundaries of forensic psychiatry: a view from the ivory tower. 

 March 17, 1994. http://www.c-spanvideo.org/program/55363-1. Accessed January 25, 2013.

The insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens.

 New York: WW Norton & Company, Inc; 2012.

Shakespeare's understanding of the human condition miraculously transcends his culture, time, and place.

Shakespeare and Psychiatry: A Personal Meditation

 tells the story of the relationship between Freud (Viggo Mortensen) and Jung (Michael Fassbender) and a woman named Sabina (Keira Knightley) who had a considerable influence on both of them. © Sony Pictures Classics

A century after it happened, the clash of the Titans of psychoanalysis, Freud and Jung, has made its way into the cineplex in David Cronenberg’s new film,

 The critics are giving it thumbs up for its achievement in bringing a moment in intellectual history to life for general audiences. And disciples of both men will have to admit that it’s not the muck-raking expos it could have been. There is, for example, no mention of Freud’s adventure with cocaine, nor Jung’s early ideas about a racial unconscious.

What supplies the melodrama required for film is Sabina Spielrein (Keira Knightley) who, as it turns out, was an important player in the clash between the great men. Spielrein was virtually unknown until the 1970s, when her papers were discovered in an archive in Geneva. She was psychoanalyzed by Jung (Michael Fassbender), consulted with Freud (Viggo Mortensen), and became a leading psychoanalyst in the Soviet Union, where she and her daughters were murdered by the Nazis. Her papers suggested that she made unacknowledged contributions to both of the great men’s theories. But what sent shock waves through the psychoanalytic community, reeling in the 1970s from accusations of patient sexual abuse, was the revelation that Jung had a prolonged affair with her.

Spielrein, the daughter of a wealthy Russian Jewish family, had been admitted to Bleuler’s famous Burghlzli psychiatric clinic in Zurich at age 18 with the diagnosis of hysterical psychosis. There she came under the care of Jung, who decided to employ for the first time Freud’s dangerous method-The Talking Cure. Dangerous because the intimate fantasies and feelings explored in the treatment can stir up sexual longings in the unwary therapist as well as the patient. That is apparently what occurred in Jung’s first analysis, and he succumbed to the temptation. Freud had anointed Jung as his apostle, “his son and heir,” hoping that the Swiss Protestant psychiatrist, the son of a pastor, would add respectability to what his detractors called the “Jewish Science.” One can only wonder how Freud must have felt when he learned that his prized Christian disciple was having sex with his young Jewish patient. Cronenberg’s film tells the story of Sabina Spielrein’s crucial role in making and breaking the Freud/Jung relationship.

The Spielrein revelations produced a cottage industry of professional articles, plays, and films, and a book by psychologist John Kerr, 

. Christopher Hampton-who had with stunning success adapted the classic French novel 

 for the stage and then for the screen-used Kerr’s book and the Freud/Jung correspondence to construct 

 a play that opened in 2002 in London’s National Theatre. He would then create the screenplay filmed by Cronenberg in 2011.

Hampton is a gifted dramatist, and something should be said about the theatrical version. Disaster struck during rehearsal when the actor who was to play the part of Freud died and a young understudy who lacked gravitas was pressed into service. Ralph Fiennes as Jung towered over the Freud character. Fiennes’ Jung owed much to his Count Laszlo de Almsy, the passionate doomed lover in 

-the role that made him an international star. His Jung was also the Nietzschean Ubermensch to whom middle-class morality does not apply, a man destined for greatness and the bout of madness he chronicled in his 

. The seduction of his patient seemed a Dionysian happening rather than a boundary violation. Fiennes made it an unforgettable night at the theater, but the cogency and cunning of Hampton’s dramatic adaptation was lost in the bravura. Critics who stopped to think about the play were not impressed by the dramatic urgency of the lines, some of them taken directly from the Freud/Jung correspondence, and wondered what to make of the argument between the two men today when the theories of both have long since been discredited by serious psychologists. Obviously, the play as performed conveyed no sense of the cultural sig-nificance of Freud and Jung, who may not have been scientists but who did transform the 20th century’s understanding of the human condition.

Almost a decade later, Hampton gets a second chance. The film re-titled 

 is brought to us in a beautifully crafted costume dra-ma that features wide-angle close-ups in which every shot is a work of art, Jung and Freud are iconic, and Hampton’s screenplay is fully realized. David Cronenberg was an unexpected choice to direct the film. Cronenberg, a Canadian, cut his teeth as an auteur making low-budget horror films. He is known for a mix of sci-fi and grotesque violence, exploding heads being only one extreme example. He also seems to be drawn to the sexually perverse, as in 

. Not the bland Oscar-winning film with the same title, but a nightmarish portrayal of people who can only get sexually aroused by violent automobile collisions. It is a cult classic of sadomasochism that gives new meaning to the term “autoeroticism.” His recent films, 

 featuring Viggo Mortensen, are more mainstream, but there is still something perversely erotic-even orgiastic-in the violent encounters. Sadomasochism is Sabina Spielrein’s sexual fixation, and so Cronenberg is on familiar ground.

Christopher Hampton’s screenplay places Sabina Spielrein at the apex of the triangle with Jung and Freud. She is the demonic force. The opening scene has her being dragged from a horse and carriage kicking, screaming, and laughing hysterically. Keira Knightley was chosen to play the role and her performance has been a lightning rod for critical reaction. Many are put off by the opening scenes, the grimacing, the writhing of the limbs, the spasmodic speech, and the desperate protrusion of her naturally long jaw. The most mistaken response is that “the woman” cannot act. In fact, this may be the remarkable actress’s bravest performance. She studied the Burghlzli’s medical records of Spielrein’s symptoms and attempted to simulate them. She willingly made herself look repulsive in order to inhabit Sabina Spielrein-a “hysterical psychotic” in 1904. Psychiatrists know that the way mental illness expresses itself changes with time and place. Knightley is true to the clinical description of that earlier time, although grotesque and alien when seen through the lens of contemporary sensibility. Her sexual thoughts and feelings disgust her-they make her nauseous-and those inner feelings are “converted” into facial contortions (the protruding jaw) as though she were retching. And Cronenberg, as he told an interviewer, encouraged Knightley in this “conversion,” “the words are trying to come up . . . you can’t allow them to come out.”

The real Spielrein had overactive emotional reactions, but she was also a well-educated and brilliant woman. In Hampton’s screenplay, she is more psychologically minded than Jung and understands him better than he does himself. Hampton adroitly puts one of Jung’s famous ideas into one of Spielrein’s spontaneous lines. When Jung succumbs to temptation and accepts her invitation to a tryst, she welcomes him into the room and kisses him on the lips. He backs away and with a conventional reaction asks her, “Don’t you think the man should take the initiative?” With a knowing smile she responds, “Don’t you think there is something of the man in every woman and something of the woman in every man?” Jung looks quizzical as if he never thought of that idea. It would become one his most basic archetypal theories, Latinized by him as the Anima and the Animus.

I credit Hampton for knowing that most of his audience would miss the deeper significance of this exchange, but those steeped in psychoanalytic theory would not. I also assume that in his depiction of Jung and Freud, he was speaking both to his general audience and to those still invested in their disputes. For the general audiences, Jung is the cowboy in the white hat and Freud is wearing the black hat. If Ralph Fiennes’ Jung was Nietzschean man, a genius in statu nascendi, Michael Fassbender’s Jung is Candide: too innocent to seduce anyone . . . indeed too innocent to blame for his violation of his Hippocratic Oath.

As Hampton has crafted Jung and as Fassbender plays him, his main quality is his innate decency. There is no trace of the mystical leaning that already preoccupied Jung; if anything, he is the archetype of the good doctor and budding scientist. From his first friendly encounter with Spielrein, he treats her as an equal, with consideration and respect. She responds to that decency at least as much as to the erotic longings released by the abreaction of her masochistic fixation. Those in the profession will recognize that Hampton’s Jung is trying to create what is called today a therapeutic alliance. The movie foregrounds the perverse contents of the therapy; when as a child her father spanked her naked bottom, she became sexually excited. That is the perverse core of her neurotic conflict, revulsion and excitement are almost inextricably linked in her psyche. Painful humiliation is her aphrodisiac, and she despises herself for this. As often happens in actual therapy, as she abreacts all this to the supportive and friendly Jung, she falls madly in love with him.

It was during this honeymoon stage of the therapy that Jung began his friendly-indeed adulatory-correspondence with Freud. Meanwhile, Speilrein was doing everything in her power to seduce Jung, and the thoroughly decent Swiss Protestant resisted. He was married and believed in monogamy. He had a very wealthy and very doting wife who seemed to understand better than he what was happening to him in his treatment of Spielrein.

In Christopher Hampton’s telling, what sends Jung over the edge is the arrival of a new patient, Otto Gross (Vincent Cassel), sent to him by Freud. Gross has a place in the official history of psychoanalysis. The son of Austria’s most famous criminologist, he was a brilliant physician and one of the first psychoanalysts. Yet he was hopelessly addicted to narcotics. Freud sent him to the Burghlzli in the hope that he could break his addiction and come back to Vienna for analysis with him. Gross had already been practicing analysis and, as he tells Jung, has been sleeping with all his women patients. His basic premise is that all repression is bad and that Freud is obsessed with sex because he is not getting any.

Hampton, preserving Jung’s good guy Adam before the fall persona, introduces Gross as the serpent in the garden. Gross was radical in his views about sexual repression, but he was also a political radical-an anarchist. Hampton gives us Gross with the politics left out; but in their therapeutic sessions, he is more Jung’s doctor than his patient, and when he elopes from the hospital he leaves a written prescription: sex with Spielrein. And Jung takes the medicine.

There is something childlike about Fassbender’s Jung that keeps his white hat in place even as he is enacting Spielrein’s masturbation fantasy and spanking her buttocks. Having sex with a patient is a serious ethical violation, destructive if not ruinous to the patient akin to the damage caused by incest. That is the prevailing view of contemporary experts. But Spielrein prospers, decides to go to medical school, and becomes a psychiatrist and a psychoanalyst. She is unhappy only when Jung breaks off the affair. For the general audience, Jung’s innocent childlike persona and her aggressive sexual overtures take most of the sting out of the offense. There is, I believe, a deeper argument also being made by Hampton against the certitude of contemporary experts.

When the Titans went their separate ways, Jung developed his own theory of how analysis cured. The person had to do more than come to understand himself: he had to discover what he could be . . . he had to create a sense of what he might become. This is what Spielrein explains to Freud in the film when they meet and he rejects it out of hand. But for Hampton, the transformative Jungian cure is the basis of his deeper argument and central to the underlying, more sophisticated narrative. Jung gives Spielrein the sense that she, “an insane patient,” can become a psychoanalyst in her own right. That sense of what she can become is her cure! Jung is very much her patient as well as her doctor, and she shows him what he can become. Their adulterous affair not only was good for her, but also it empowers him, unlocks his genius, and helps him break out of the straightjacket of conventional wisdom. Hampton’s Jung underlines this, telling Spielrein she was the most important love of his life. She gave him a sense of what he could become. They have cured each other and the illicit affair was part of that cure. With Wagner’s Siegfried’s Idyll playing in the background (Siegfried is the heroic offspring of the incestuous affair between Sigmund and Sieglinde in the 

), Spielrein assures Jung that good things can come out of bad, that perhaps true creativity requires such boundary violations.

Jung’s therapy of “salvation,” as it is called by Philip Rieff, has captured the imagination of contemporary new wave psychology that embraces Jung’s mysticism. Jungians also claim credit for the spiritual element in all of the 12-step programs that play such an important role in contemporary therapeutic endeavors. But most American psychiatrists know almost nothing about Carl Jung. 

There is another mystical Jungian element that general audiences might not fully register. Jung believed that dreams (and particularly his own dreams) could be prophetic. In the last scene of the film, a pregnant Spielrein, now married to a “kind” Jewish doctor, visits Jung. He is troubled, not sleeping at night, and on the verge of his “nervous breakdown.” Spielrein was his guide and mistress on his first empowering journey, and Toni Wolff, another analysand and mistress, would steer him through his impending psychosis and help him record it in 

. Spielrein extracts Jung’s confession about his new mistress whom she emphasizes is like her, an analysand and half Jewish. Neither agreeing nor disagreeing with Spielrein’s observation, he responds, “My wife is the foundation of my house, Toni perfumes the air.” He is no longer a monogamist; in fact, both women, like Spielrein, went on to be Jungian analysts and found a new identity sharing the great man’s life.

Jung tells Spielrein the dream that is waking him at night. A flood is sweeping over Europe and it reaches Switzerland as an avalanche of blood. Spielrein asks him what the dream means; he answers that he doesn’t know unless “It’s about to happen.” It is 1913 and his dream on the eve of the First World War is prophecy. Hampton’s Jung is not just a genius: he is a divine.

I have said nothing about Viggo Mortensen’s Freud. Mortensen is an actor of great talent and charisma, and certainly on screen he is a match for Fassbender and his resemblance to Freud is uncanny. But speaking Hampton’s lines, his Freud is small-minded, reductive, doctrinaire, and manipulative. There is no sign of the mind that gave birth to the 

the book that earned the real Jung’s unqualified admiration. Freud opened a road into the world of the unconscious that Jung traveled for the rest of his life, and where he found his archetypes.

The film does not have a happy ending, but for Sabina Spielrein and the “spirit” of Carl Jung it is a vindication. Other mental health professionals may well interpret this film quite differently, but anyone interested in psychoanalysis or analytical therapy owes it to himself or herself to see and discuss 

 David Cronenberg’s film "A Dangerous Method" tells the story of the relationship between Freud and Jung and a woman named Sabina who had a considerable influence on both of them.

A Dangerous Method

Film blogs report that in multiplexes around the United States, during the first week of 

 screenings, irate patrons would get up and leave. One grumbling critic got it exactly right: “It feels like Malick made this film for himself rather than for an audience.” Surely that description applies equally to any visionary artist who breaks and transcends the settled conventions of a medium.

 is not easy entertainment, but for psychiatrists who might welcome an encounter with a brilliant, uncompromising mind and are willing to embrace the dazzling cascade of unexpected images, 

 is enthralling. It is the most intellectually and artistically ambitious film of the 21st century. To understand this film, to get beyond that dazzled state, a second viewing is required. I have now seen it 3 times, each time bringing greater satisfaction and more appreciation of its psychological dimensions.

According to the avant-garde British director Peter Greenaway, the film’s original ambition was to be a great visual art, but as the narrative element has grown to dominate the medium, even the most creative cinematography has been subordinated to the story. Movies, Greenaway laments, have become the art form of the Philistines.

If Greenaway correctly diagnosed the aesthetic crisis of modern film, 

 is the solution. Malick seems to intend that visual images dominate the first viewing experience-the mind has time to register the cascade of images but not to comprehend, to reflect, or to anticipate. The marketing describes the construction of the film as impressionistic. This might suggest that one impression leads to the next, a sort of free association. But there is nothing free in the associations: every link has been chosen carefully. Malick spent 30 years thinking about this film. And after shooting footage, he devoted another 3 years to editing; 5 co-editors are acknowledged in the credits. They seem to have invented a poetic rhythm, a visual music, which has more in common with a symphony than a novel (and, indeed, the music lifts your soul and sends chills down your spine). The images carry the creative trajectory.

A rough approximation of what a psychiatrist might see in the movie is a family, the O’Briens, dealing with the psychological trauma of an unexpected death of one of their own. Then before we can be certain of our psychological bearings, Malick takes us from the human to the cosmic and nothing less than a depiction of the creation of the universe and the evolution of life on earth. Having shown us our insignificance, suddenly the director brings us back to psychology and a troubled boy coming of age in the traditional family where father rules, mother loves, and Oedipus stirs. The film ends with a vision of the afterlife.

 as a philosophical exploration of the meaning of life. In fact, Malick is one of a surprising number of contemporary filmmakers who began in philosophy. He taught and translated Heidegger before deciding he was not an academic.

But with his background and the lack of a clear narrative, it’s not surprising that some would see his film as dealing with philosophical questions. Be that as it may, Malick has given his film an epigraph, a quote from the Book of Job, that suggests something different: “Where were you when I laid the foundations of the Earth . . . when the morning stars sang together and all the sons of God shouted for Joy!”

The traditional understanding of those lines suggests the humbling of Job, a good man put to a test of faith by a compassionless God. The sense of the quote can be understood to represent the essence of Malick’s project itself, a dialectic of grand ambition and abject humility. On the one hand, he audaciously depicts creation-we are there when all the sons of God shout for joy. On the other, he shows us a father, a mother, and their 3 sons, who, like all humanity, inevitably endure profound humbling.

This is not a philosophical project . . . it is simply posing questions about the meaning of life. Malick has an answer in his film’s exploration and embrace of faith, even in the compassionless God of Job. He will show us the afterlife, where an angelic mother who still grieves for her beloved son joyously proclaims to God, “I give him to you, I give you my son,” and finds ecstatic salvation.

That mother and the world Malick creates for us belong neither to everyday reality nor to the realm of dreams. 

 gives us the spiritual world in which God is present. The mother (Jessica Chastain) walks into the woods, and the trees become a cathedral. She points to the sky and tells her child, “That’s where God lives.” In every scene she is the Madonna. Throughout the film, mother and son whisper to God in voiceovers. Some take these as prayers, although they are not those one finds in prayer books. This is the lonely inner voice of faith that speaks directly to God, or of shaken faith that wants God to demonstrate his presence. The miracle of Malick’s cinematography is that, like the greatest religious art of the Renaissance, it conveys the presence of God even to nonbelievers. But Malick and his cinematographer, Emmanuel Lubezki, achieve this in an entirely contemporary way.

Chastain as the mother is eerily beautiful, the embodiment of sacred innocence. Far from the typical Hollywood actress, she has red hair and a pale complexion and conveys vulnerability. When she asked Malick how he wanted her to play the part, he suggested she visit the Metropolitan Museum of Art and study the paintings of the Virgin Mary. Remember, “I give you my son.”

Malick’s instruction is another key to his project. He did not ask or expect her to reveal her character over time as one might expect in a linear narrative. There does come a moment when she stands up to her tyrannical husband’s cruel discipline of her sons, and there are moments of heartrending grief and empathic loving of her sons. Early in the film, Chastain’s character speaks of the way of nature and the way of grace. The way of nature is Hobbesian self-interest-it only cares for itself. The way of grace is selflessness, love, and forgiveness. Then she gets a letter telling her that her 19-year-old son is dead. That is her test of faith. Heartbroken but conforming to the way of grace, she transcends her human grief and offers up her son as an ecstatic gift to God.

 in my interpretation/conjecture is Malick’s meditation on his own life: an account of his struggle for faith in Job’s compassionless God.

Malick is both reclusive and secretive. He never allows interviews; he refuses public appearances; and he avoids appearing on television, being photographed, and saying anything about his private life. Enough is known about him to suggest that this film is deeply autobiographical. Like Jack O’Brien-the film’s main character, played in his youth by Hunter McCracken and in adulthood by Sean Penn-Malick is the oldest of 3 brothers. His younger brother Larry, like R.L. (Laramie Eppler) in the film, played classical guitar. Larry studied with Segovia in Spain and committed suicide as a young man. The third brother was severely burned in a fiery car crash and scarred for life. In the film, one of Jack’s friends bears the scars of a burn across the side of his scalp. The camera repeatedly comes to rest on that scar, asking Jack’s question . . . “God, how could you let that happen?”

The O’Briens are not identical to the Malicks but there are striking similarities. Malick’s father was of Lebanese descent, a geologist and a self-made man who became an executive at Phillips Petroleum. As the driven Mr O’Brien, Brad Pitt astonishes. Who would have thought that Pitt might be one of the most talented actors of his generation? Actors have apparently long known of Malick’s ability to bring out the best in them. Still, Pitt’s character, like Chastain’s, is an archetype, not a psychologically nuanced individual who evolves over time. One might think of them not as actual people, but as figures who exist in their son’s selective memory of his childhood. Jack’s early childhood, in the same way, is presented as the distillate of his memories, the experience of childhood from the child’s point of view. Malick does this as well as it has ever been done in film.

Malick’s depiction of Jack’s coming of age has much in common with Freud’s description of the Oedipus complex and superego formation. It may be set in 1950s Waco, Tex, but this family’s dynamics were known in circa 1900 Vienna. Young Jack is at war with his father. Jack contemplates killing him, and he calls on God to do it for him. God is the alternative father-authority with whom he struggles. Why does this omnipotent and omniscient God let a child die, let a child be burned, let a man be crippled? Jack is painfully alone in the world. God is not watching over him.

Malick shows us a church service in which the priest warns that the congregation cannot expect God’s help or protection. In his rebellion against his father and his disappointment in God, Jack tests the limits of his rage by torturing animals and his brother, the beloved guitar-playing R.L. Jack seems to be moving along the path to delinquency and bullying. (This is what the Ericksonians would describe as a negative identity, an antisocial personality that emerges from adolescent rebellion, crisis, and confusion.)

Jack’s erotic longing for his mother is displaced onto a neighbor, whom he peeps on through her windows at night. Later he watches her drive away in her car. He enters her home, rummages through her bureau, pauses over her jewelry, and steals her slip. We see him lay it out on her bed as if some fantasy is to be enacted, and suddenly he is running frantically along the riverside with the stolen slip in his hand. He hides it under a piece of wood, thinks better of it, and sets it in the river to be carried away by the current.

As though to remind us of the true object of Jack’s lust, Malick then shows us the boy watching his mother walk through the house in her nightgown. The wish for the tyrannical father’s death, the erotic desire for the saintly mother, and the sadism toward the beloved younger brother are palpable. Freud could not ask for anything more, and then Malick gives us Freud’s resolution of the Oedipus complex: identification with the father: “I’m more like you than her,” a reconciled Jack tells his father.

Jack’s coming of age is the most linear sequence in the film, but the future haunts the present in Malick’s rendering. All this takes place chronologically before R.L.’s death at 19, which we learned about at the beginning of the film. And the grown-up Jack will be forever troubled by his bullying of his brother. If Pitt gives a superb performance, then one must say that McCracken as young Jack is spectacular; this has to be among the few greatest performances in living memory. He does not look like an actor playing a part; he is young Jack. His cruelty to R.L., a touching performance in its own right, tests our sympathy. He is the most psychologically real character in the film and, most likely, he is Malick’s memory of himself.

 and in his previous 4 films, Malick never depicts prosaic present-day reality. This is one of Malick’s ways of keeping us suspended in the world of the spiritual. There are also scenes of the adult Jack (Sean Penn) wandering in the wilderness-psychologically, a troubled man; spiritually, a tortured soul. And finally, Jack walks in the shallows of an ocean. We are in the afterlife, and Jack is reunited with the brothers of his memory, including himself. His mother gives her son to God, and Jack falls to his knees in humility, accepting authority and kissing the feet of someone whose face we never see. The last image is of a long bridge out of which swoops a single sea bird. The O’Briens have all found salvation through the way of grace.

But don’t take my word for it. After seeing the film for a third time, I believe that any verbal interpretation, right or wrong, could not be aesthetically faithful to Malick’s awe-inspiring visual masterpiece.

 Terrence Malick’s The Tree of Life is not easy entertainment, but for psychiatrists who might welcome an encounter with a brilliant, uncompromising mind, The Tree of Life is enthralling.

The Tree of Life

Marco Bellocchio, one of the most psychoanalytically oriented filmmakers of his generation, entered the annals of Italian cinema in the 1960s to almost universal acclaim from critics at home and abroad. An intellectual wunderkind, he had abandoned the academic study of philosophy for a creative career as an auteur. At age 27, with money borrowed from his family, he made his first film,

(1964). Filmed in black and white with a score by the great composer Ennio Morricone, 

 was a polemic against bourgeois conventions. As a creature of the 60s with the radical convictions that were to produce Europe’s cultural revolution of 1968, Bellocchio believed that the transformation of the bourgeois would have to take place on 2 levels, both in the public sphere of the political and in the private sphere of the personal. The family is where those 2 spheres intersect, and Bellocchio’s 

 was an unsparing psychological assault on a grotesque Italian clan.

Critics compared the surreal elements of the film to Bunuel who, along with Salvador Dali, had been inspired by Freud’s 

. Bellocchio’s psychological inspiration seems to have been drawn from Freud’s radical disciple Wilhelm Reich and from R. D. Laing’s

 was burdened by epilepsy, blindness, and almost psychotic hatred-its family ties were toxic bonds. Cineastes agreed that whatever it all meant, Bellocchio was a brilliant Italian original.

 (1967), another radical polemic, Pauline Kael, in her waspish style declared his filmmaking “so distinctive that it already

genius” (emphasis added) and she saw in the quality of his work “an outgrowth of the hybrid art of opera.” Kael is almost 10 years dead and Bellocchio is now 70 years old, but with 

 (2009)-a film about a woman who loved Mussolini-he has at last fulfilled his youthful promise.

 (pronounced VEEN-cheh´-reh) is a critical success at home and abroad, it is a grand opera filled with the public passion of politics and the private passion of erotic surrender. It is by no means realistic in any documentary sense-it does not want to be. . . . still, it creates an invaluable picture of the rise of Mussolini, particularly for Americans who think of Mussolini as Hitler’s stooge. Bellocchio’s portrait of Mussolini, brought to life by the extraordinary performance of Filippo Timi, allows us to reassess the man who spoke fluent German, read Nietzsche, believed God was dead, called on Italians to strangle King Emmanuel in the guts of the last pope, and made himself into the Fascist Ubermensch-Il Duce.

Vincere, however, is not so much about Mussolini and fascism as it is about Italy’s rediscovery of a forgotten woman, Ida Dalser, whose love for Mussolini was like a madness and who, like the heroine of a great opera, embodies much more than herself. She is a metaphor for the passion of the Italian nation who surrendered themselves to Il Duce, believing they would be lifted up and exalted in his arms and instead were ruined by him. For psychiatrists, Ida Dalser presents a diagnostic puzzle. Does she have a delusional disorder, erotomania-the diagnosis film critic Roger Ebert suggested? Or is she a classic example of the human condition described by Congreve’s “(nor) hell a fury like a woman scorned”? And Dalser’s experiences in mental hospitals present all of the political misuse of psychiatry issues. Does she belong in a mental hospital or is she a victim of Mussolini’s determination to deny her existence?

 the preoccupations and the artistic struggles that have characterized Bellocchio’s long trek to this artistic triumph. Back when Kael was finding opera in Bellocchio, other critics saw Antonin Artaud’s theater of cruelty. His sympathies were with the Red Brigade. He may have borrowed money from his own parents, but he was merciless in his depiction of families in his films. Typical and unforgettable is the beginning of his In the Name of the Father (1971). It opens with an older and younger man coming toward us from the shadows. Suddenly the older one begins to shout “respect me, respect me” as he beats the younger who more than returns his blows. It is a father and son, and Bellocchio’s scene chooses to show the power impasse of the Oedipal struggle. Every kind of patriarchal authority was attacked in his films: political, military, religious, and academic, and every kind of sexual repression as well. Bellocchio’s cinema does not spare women: most of them are mad or masochistic-or both.

Bellocchio’s preoccupations turned increasingly from the public space to the private space of the mind. His films lost their narrative clarity and became oneiric. His cinema was a series of arresting images connected by his own free associations. It was like watching someone else’s nightmares. In his own personal life, Bellocchio seems to have been searching for a way out of the limitations of his own consciousness. Many of his contemporaries in the 60s joined communes and experimented with consciousness-expanding LSD. Bellocchio sacrificed his own auteur’s voice and tried to merge creatively with others making communal films. He came under the spell of the psychoanalytic guru Massimo Fagioli, and joined his cult of group analysis in which scores of people would take part in a single session analyzing a dream together. He surrendered his creative autonomy to the will of Fagioli and collaborated on 4 films with him, most notoriously, 

Bellocchio had always been interested in sex and power; which he understood as the psychoanalytic building blocks of all human relationships. But he was also fascinated with madness, and with Fagioli he explored these subjects in an almost clinical style. 

 was a “succes de scandale” as the first art film with a depiction of fellatio. The protagonist Giulia (played by the Dutch actress Maruschka Detmers) is a woman with a spectacular body. In this film, however, she seems more feral creature than erotic woman; sex is her symptom, not her pleasure. She is acting out her transference and having an affair with her psychoanalyst’s son, a high school senior. He is the person on whom she performs brief and tentative fellatio. This and other sexual scenes leave us with the sense that Giulia is more a puppet acting out the Bellocchio-Fagioli imaginings of her masochistic sexual impulses than a woman experiencing and revealing her own sexuality. Despite its commercial success, this was hardly a high point in Bellocchio’s career.

 the same preoccupation with sex, power, and madness as we saw in 

. But in this film, Bellocchio has regained his creative autonomy. The great actress Giovanna Mezzogiorno makes us believe her erotic passion as Ida Dalser, and Timi’s Mussolini is the ultimate example of power as narcissistic entitlement. 

 will trace Ida’s trajectory from “mad love” to “madness.”

Yes, Ida, too, is a masochistic woman. She falls in love with Mussolini and his aura of brazen power. When others are shocked by his public Nietzschean pronouncement that God is dead, she is thrilled. And she loves him even more when he rejects peace, parts with the socialists, and embraces nationalism. She is drawn to the firebrand and is eager to surrender to him. Unlike 

 are a compelling revelation of who these people are. Ida wants to experience complete submissive love. She gives herself to Mussolini in her search for intimacy, orgasm, and reciprocity. We witness her pleasure and her fulfillment in surrender. While Mussolini, his eyes gleaming and fixed on some personal horizon, mounts her body for his own gratification and fulfills his sense of power.

Ida not only surrenders her body and soul to Mussolini, she sells everything she owns to support the publishing venture that launches his national political career. Bellocchio shows her waiting for Mussolini naked on the bed in her empty apartment, her body and the cash an offering to him. He takes it all but never gives her the love she wants as her reward. We sense, however, even at the height of their affair, that for Mussolini, Ida is only a conquest. He is incapable of love. Ida bears Mussolini a son, but he betrays her and rejects them both.

The heart of the film is a portrayal of Ida’s attempts to deal with that rejection. Filippo Timi disappears and the actual Il Duce now looks out at us from newsreels woven into the film. This helps convey the reality of the emotional distance that Ida denies. First she is sent off to live with relatives. But she refuses to give her Mussolini up. She writes letters to the Pope, to the King, to the authorities insisting that her relationship to Mussolini is real. For this she is sent off to a mental hospital and separated from her son.

Marco Bellocchio, one of the most psychoanalytically oriented filmmakers of his generation, entered the annals of Italian cinema in the 1960s to almost universal acclaim from critics at home and abroad.