Primal Fear - Movie Analysis

Primal Fear: "Sooner or Later a man who wears two faces forgets which one is real".

Marty: So there never was a Roy?

Aaron: Jesus Christ, Marty. If that’s what you think, I’m disappointed in you. There never was an Aaron, counsellor.

The movie Primal Fear is a 1996 film featuring the mental disorder, Dissociative Identity Disorder, previously known as Multiple Personality Disorder. Martin plays the defence attorney for the murder of Chicago’s Archbishop, where the alter boy, Aaron is suspect. Aaron was seen fleeing from the crime scene with blood spluttered across his clothes, however he has no recollection of being at the crime scene as he ‘blacked out’.

This movie was captivating. The character of Aaron was extremely well scripted and the actor falls into my top 3 best actors, after watching this film.

I am now going to analyse the film and how in reality it would be impossible. However, this is only in the eyes of a student health professional, required to research the film. The average individual walks away flabbergasted and in awe of its story line.

Here is a critical analysis of the client’s diagnosis. A psychiatrist interviews Aaron throughout the film. When past experiences are brought up which have made him angry, Aaron often switches into the character of Roy. Roy is ill-tempered – becoming physically and verbally aggressive. The psychiatrist and lawyer soon realize it wasn’t Aaron that killed the Archbishop, but rather Roy. When coming out of Roy’s character Aaron blacks out and cannot remember those moments.

The psychiatrist diagnoses Aaron with DID as he suits the following criteria according to the DSM V: (a) a sudden transformation from one personality to the other (b) an alter personality representing different ways of acting to others (c) alter ego is a protector or avenger. However, Aaron reveals at the end of the movie to Martin, his lawyer, that there never was an Aaron. He has always been Roy and was malingering the DID in order to escape the death penalty in the court case.

This would never occur in reality as DID is present from childhood and reports of his DID would have been found in medical history files. If this was a case, even a single interview from one of the client’s friends would have explicitly uncovered the fact that his true personality is that of Roy.

Roy’s impeccable acting skills also made me question whether his stuttering and ‘black outs’, as Aaron, could have been so perfectly demonstrated for the pure purpose of malingering.

The DSM V does not consider malingering to be a mental disorder, but does note that malingering is often suspected in the presence of an anti-social Personality disorder. When Roy (Aaron) reveals to Martin that he was faking the DID he makes further claim that he killed his girlfriend Linda, because “she deserved it” and states that cutting up the Archbishop was a “work of art”. This is the first time we learn that Aaron also killed Linda and he clearly shows pride and pleasure in admitting to these heinous acts with no signs of remorse.

The correct diagnosis according to the DSM V would have been: Anti-social Personality Disorder. Aaron obviously fits many criteria for this disorder, including (a) failure to adhere to legal codes (b) aggressive and hostile behaviour (c) lack of truthfulness & (d) lack of remorse for good deeds.

Primal fear is another example of Hollywood filmmaking looking to make a psychological thriller, with a twist at the end – a common template for this type of movie. It works well, captivating a naïve audience who cannot help but fall in love with the patient’s intelligence to get away with murder. A review stated that the film would have been better if Marty had found out about the malingering earlier and was placed in a position of moral crisis. Nevertheless, it was an extremely interesting plot and is one of my new favourite films.

This film also made me question the diagnosis of the boy, which was discussed in an MDT meeting on our first day of prac at King Dinizulu Hospital. It was mentioned that the boy is a genius and that he states he puts on his different personas to become ‘ill’ and get rid of his mom’s boyfriends that he strongly dislikes. It was also stated that he has made strong suggestions of killing the boyfriend too. He always succeeds at getting rid of the disliked boyfriends. After watching the film, this patient sounds like he could be given the diagnosis of Antisocial Personality disorder and this was not uncovered as an option when discussing his case.

Primal fear film can be of use to students as it clearly demonstrates traits of DID, malingering and Antisocial Personality Disorder. I feel a main message for me that came from the film is that one must always be objective, unbiased and thorough in making a diagnosis, especially in such serious cases as murder trials. I believe this does relate to our profession as we do need to be aware of the fact that a diagnosis may be misconstrued and because medico-legal OT’s perform multiple assessments for court trials, which can impact greatly on a case outcome.

References:

1 Webermann, A. R., & Brand, B. L. (2017). Mental illness and violent behavior: the role of dissociation. Retrieved from https://bpded.biomedcentral.com/articles/10.1186/ on 30/08/19.

2 Wrobel, B. (2017). Primal Fear – Blog. Retrieved from     https://psychopathologyinfilmblog.wordpress.com/2017/10/06/primal-fear-1996/ on 29/08/19. 

3 IMDb image. (1996). Movie review website ( Primal Fear). Retrieved from https://www.imdb.com/title/tt0117381/mediaviewer/rm2713459712 on 31/08/19. 

4  Dorwart, E. (2019). Analysis of Primal Fear – Mistakes and Misdiagnosis. Retrieved from https://www.academia.edu/32654547/Analysis_of_Primal_Fear_Mistakes_and_Misdiagnoses on 29/08/19. 

                                                                                      Roy

Aaron

Treatment on the Go

As I lie in bed trying to rest to eliminate my bad flu, I am contemplating going to the doctor to medicate me before this overloaded week of: client demo, a clinical science test and our presentation. I am also contemplating whether it is just a virus and not wasting my parent’s money. But with my tight chest, sore throat and weakness I do not feel my immunity will handle the stress of the upcoming week. My arms ache as I type this and all I want to do sleep. ‘Sleep’ that I won’t get much of this week. ‘Rest and Sleep’ – an important area we treat as students, but fail to achieve ourselves.

My interviewing and assessment skills definitely require work. I feel as though I should not need the file to identify the most important areas of treatment. However, I should not put myself down too much considering the complexity of Schizophrenia cases and the clients’ change in approach of answers, as they hear the words “Pass Out” and “Discharge”. For example, I know that medication compliance is often a problem in Schizophrenia patients and is a very important aspect of relapse prevention. When a client has been given his medication for months in an institution, he will certainly reply that he complies with it. However, when reading his file, non-compliance was his main reason for submission and when talking to the client’s nephew, the client believes the injection he receives poisons him.

I titled this Blog ‘Treatment on the Go’ after I treated my client on his walk from P4 to the car park upon discharge. I did this to try my best to alter his thoughts towards his medication with my words, as well as imply that he should listen to his extended family as they only want what is best for him. His nephew smiled as I did this, knowing the client displays a completely different persona in the hospital and towards me and that he will become the moody, ill-tempered, disobedient uncle as soon as he climbs into the car again. The nephew has dealt with him for many years; tying up his hands and legs to carry him over his shoulder when hospitalization is necessary, once again.

Whilst my client described the visions and delusions he experienced; I would prompt him to tell me more. I need to learn to prompt during the most important aspects, which I may be afraid to ask. For example, when the client explained to me that the ‘Tamils have been poisoning him’, I did not prompt him to explain further. This may be the reason he does not comply with his injection and medication, as he believes it is the Tamils poisoning him. Had I realized this without needing the nephew’s input and the files, my title would not need to be ‘Treatment on the go’, as a result of only recognizing important treatment aspects last minute - upon client discharge.

After flipping through the file and discussing the client with his nephew, I realized the most important aspects of treatment. My two treatment sessions would have definitely prioritized Medication compliance and Substance abuse to prevent relapse, rather than social skills and leisure.

I feel as though my treatment skills have improved since my first attempt, using an icing activity. My second attempt at treatment was leisure, because the client does not have a job and poorly uses his time, most liekly resulting in drug abuse. I therefore discussed the opportunity for different leisure outlets which can make his days more interesting and hopefully reduce temptation for drug use.

On Friday I treated my P2 client for the first time. I could tell he really enjoyed the session. This made me happy. The client was required to answer yes or no statements and I tried my best to pronounce the Zulu sentences I had translated for him. The client participated actively, motivated to beat his previous time and answered most social judgement or insight questions with the correct yes/no answer before shooting at the goals. When we reviewed the session, I realized the importance of this in treatment. The client had answered some questions correctly but with a different thought process than the student therapist's. For example: “I should only take my medication every third day”, this was correctly answered: No. However, his explanation for this during the review was that it was because he feels he does not need to take his medication at all. I therefore provided him with intellectual insight about his diagnosis and plan to do a medication compliance chart with the client on Tuesday. Anger management also requires attention after discussing the social judgement and insight questions.

I am now sat finishing off this blog in the doctors waiting room. My thoughts trailing about how I am going translate my entire demo into isiZulu... I seriously need to start my case study and find time to study for the test.

I am learning how to perform treatment better each day, evaluating my poorer sessions from my better ones and I know that my skills will improve in time. I am finding this semester very interesting and am grateful for my opportunity to learn in an acute setting, despite the added stress this may cause.

An OT is Born

I have always pondered over the importance of employment in psych OT, knowing its value but doubting the strength I would have as an OT to guarantee my patient to be re-employed post-discharge. I understand that a person with a physical disability deserves their place again in their work space and how this can be achieved through environmental accommodations to be made etc. However, trying to convince an employer to take back their patient with a diagnosis, such as schizophrenia or bipolar, seems to be a difficult task in my mind. I therefore wanted to explore this topic further by reading an article. I have come across clients that have been unemployed for many years or are in a sheltered workshop, such as Durban-North challenge. My mind is now exploring options for young, acute clients who may wish to work, as I am now experiencing this with my 22 year old client.

Occupational therapists have skill in the employment service area because occupation is central to the frame of reference of occupational therapy, and this includes work. Therefore, occupational therapists have the expertise to holistically consider the persons physical, behavioural, cognitive, social and emotional capacity in relation to employment. Task analysis is a core skill of occupational therapy and allows barriers and enablers to be identified. Subsequently, occupational therapists are able to determine the necessary interventions to enhance the job-person fit.

Occupational therapists have many assessment tools such as the occupational performance history interview, the occupational self-assessment, the volitional questionnaire, the worker role interview and the work environment impact scale that they are informed of and trained to use to accurately recognize strengths and barriers to employment. Occupational therapists possess the expertise to adapt the job demands and environment together with the person to achieve their maximum capacity for work.

I am now going to list examples of modifications which can be made in mental health accommodation for return to work, according to (Bezdikian, 2017). The OT should develop a detailed return to work plan. Accommodations should be agreed as well as expectations of responsibilities and consequences of not meeting performance standards should be discussed. This plan should also include a crisis plan of how one should respond in the event of client relapse and support or resources. Modifications can be made by use of written instructions for greater clarity and the employee’s ability to recall details, include more frequent breaks e.g. Six 5 minute breaks and not two 15 minute breaks and possible exchange of tasks. The client should have weekly meetings with the supervisor to discuss his work ethic, struggles and receive feedback. Co-workers should be educated on the diagnosis too. More examples include: quality work training, breakdown of large tasks into smaller steps, use of technologically advanced equipment, use of checklists or possible counselling.

Meaningful employment has been shown to improve self-esteem, increase personal empowerment and social contact, social identity and status, reduce clinical symptoms, development of personal wellbeing and higher levels of functioning.

OT’s use activity analysis to break down skills so that they can be gradually mastered and help people resume past roles or adopt new ones. It was suggested that occupational therapists should continue to focus their attention on listening to their clients to understand where they are on their recovery journey. Occupational therapists are able to provide a range of different vocational services to people with a mental illness. Treatment in social skills training, stress management and time management skills are also key strategies.

The article gave me the confidence in our role as professionals to strive for patients’ opportunity in the work place and empowered me to advocate for our psych clients. It frightened me to think of how I could powerfully impact someone’s life someday by promoting their return to work and I struggled to understand my capability when it came to Work in the psych field. I have also realized the need to do further research in the area of vocational employment and the formal assessments we use as OT’s to be more competent in this area. Occupation in the form of work provides much meaning and value to peoples’ lives and therefore, whether it be in a supported or open labour market, it is vital for us to address it and creatively discover treatment options to make recommendations for the clients’ return to work. 

References:

1.       Machingura, T. and Lloyd, C. (2017), "Mental health occupational therapy and supported employment", Irish Journal of Occupational Therapy, Vol. 45 No. 1, pp. 52-57. Retrieved from https://doi.org/10.1108/IJOT-02-2017-0004 on the 7/08/2019

2.       Bezdikian, D. (2017). Workplace Strategies for Mental Health. Accommodation Strategies. Retrieved from www.workplacestrategiesformentalhealth.com on the 8/08/2019

3.       Mental Health Treatment. Then and Now. (2019). Retrieved from https://courses.lumenlearning.com/wmopen-psychology/chapter/introduction-to-mental-health/  on the 10/08/2019

My experience of Prac Prep and first week at King Dinizulu Hospital:

A war zone at varsity became the norm during the week of prac prep. It’s strange that I became accustomed to a group of AK47 men, with extremely large guns and bullet proof vests who greeted me as I took my usual route into campus. A gas bomb exploding when I walked towards the cafeteria did not even frighten me. I was picking up the rubber bullets scattered along the corridor leading to the bathroom. An environment can change so suddenly for students and we adapt very easily to the conditions, despite the consequences on our study efforts. There’s no other option.

I will be honest. I am accustomed to these conditions, but that does not make me brave. I was tense the whole of prac prep, observing and listening to every sound and watching the door be opened hesitantly each time a student came back in. The fact that striking students could come banging on the door, shouting with possible weapons during prac prep was far from a crazy thought. Shutting the windows so that tear gas did not cause the already nervous students to cry… hysterically, was a necessity at one stage. Is this a conducive learning environment for preparing to treat our psych patients, I ask myself? No, but it is only our REALITY.

I felt sufficiently prepared after prac prep – Feeling a bit uncertain of how to decide on a psych theoretical framework. However, I am feeling more equipped for that after going through our assigned case studies at King Dinizulu. After printing the necessities and creating multiple files, I finally began organizing the piles of dusty notes lying in the corner of my room from the previous semester. Fresh start.

This week has consisted of two psychology group sessions. I’ve seen the anxiety levels and the stress build up in the students’ emotions, as they account for things they have experienced. An overall feeling of helplessness and vulnerability is the atmosphere in these hour sessions. With minimal solutions made and an environment filled with tense, drained students, the sessions have been exhausting.

Emotions were also shed during the role play sessions and team building warm ups with Debbie. Not only did this make our class closer, but I also realised the therapeutic value of these tasks for the first time.

Psych prac has been extremely interesting and slightly overwhelming. I definitely need to regain the theory behind the assessments a lot quicker than I currently am. I have forgotten many of the descriptive psychotic words, after a year of focussing on Physical. Going through the MSE definitions is a task I have made for myself this weekend.

I have been given a client with a Schizophrenia diagnosis. I researched more into how an OT should treat this diagnosis. According to Hayes, R. (2008), a review of Occupational Therapy literature on the treatment of schizophrenia identified four loosely defined treatment categories: (1) sensory integration, (2) activity groups, (3) social skills training, and (4) living skills training. From their available data it proved that sensory integration therapy has been able to improve the motivation and affect of schizophrenic patients and structured activity programs can contribute to a reduction in positive symptomatology. Social and living skills training can be used as treatment methods to promote the community functioning of this population.

I’m also feeling anxious by the time bound reality. Will my client be discharged soon? I felt helplessly frustrated when I was unable to do my treatment session on Friday, after arriving with packets of ingredients and setting it all up. I have decided that between 9-10am is the best time to do my treatment sessions in the future. This factor puts me behind by a week in treatment, as I cannot focus on a new treatment session on Tuesday.

A different client who is more low functioning than my current client loves to join in my sessions. I have become creative in my ways of coping with him. For instance, when I needed to personally interview my client, I gave the low-functioning client some paper on Friday and asked him if he would like to draw at another table. He was content with this task, enjoying it for the next 40 minutes without disturbing me and allowing us privacy. His artistic drawings were impressive when he showed me his final product.

I gained insight into my client’s delusions on Friday. I was trying to comprehend the words that came out of his mouth, whilst keeping a therapeutic face. He sounded so convincing and to be honest I could not tell what may be true and what couldn’t be. I will need to dive into the meaning behind certain characters or images he plays out a bit further.

I will conclude with this quote by Stuart Sorenson: “Always keep in mind that the psychotic experience is real to the patient. As a rule they will be as convinced of their perception of reality as you are of yours”. I need to be mindful of my reactions, facial expressions and response when discussing the client’s thoughts in their mind. According to (Sorenson, S. 2019), it’s extremely important never to ‘enter the delusion’. This means never agreeing with the delusion or behaving in ways which imply agreement. This will be a challenge working with these patients. Schizophrenia is an interesting diagnosis which I am excited to learn more about and understand how to treat holistically.

References:

1.      Sorenson, S. (2019) MH Today. Talking with Psychotic Patients. http://mental-health-today.com/clinicians/psychotic.htm

2.       Hayes, R. (2008). Occupational Therapy in the Treatment of Schizophrenia. https://www.tandfonline.com/doi/abs/10.1300/J004v09n03_05

3.       Vivaelpato. (2019). Pinterest. Schizophrenia. https://www.deviantart.com/vivaelpato/art/Schizophrenia-553692583