Psychosis in Black Swan Movie
A film that helps us see the importance of the social context in mental illness
The biomedical vision of mental illness, specifically in psychosis, is obsolete.
In Black Swan, we have the perfect example of how the family and closest environment has a crucial role in aggravating, improving, or even precipitating psychosis.
For me, it was one of the first blockbuster movies that managed to go beyond flashy hallucinations on the big screen, to begin to raise awareness about what lies behind them. With movies like that, I expect someday cinema to move away from the image of the cool and dangerous psychotic.
Beyond the Double Swan leading role
Black Swan movie, starring Natalie Portman (V for Vendetta, Annihilation) and directed by Darren Aronofsky (Requiem for a Dream, The Fountain) deals with many possible mental illnesses of a professional ballet dancer: dissociative identity disorder, obsessive-compulsive disorder, eating disorders, and schizophrenia.
Among these, Nina's delusions and hallucinations are possibly the most striking symptoms. There are many articles explaining the schizophrenia that she suffers from, but what I’m more interested in exploring is her personal history.
A scene worth analyzing: Nina and her mother's cake
Here we see an example that is sadly very common in families of psychotics: the double bind in communication.
Her mother (Erica) smilingly makes her seem concerned about her by wanting to celebrate her new role with a cake, but when Nina expresses her concern about eating it, she begins to manipulate her with her words, sending a double message.
On the one hand, he tells her that it's okay and that she will throw it away. But his face and his tone of voice do not express acceptance, but anger. Nina has no choice but to accept the cake to avoid her mother's wrath. And it is not the only example of the film.
Erica overprotects and infantilizes Nina to the point of absurdity (you only need to see her bedroom), but then she blames her for having been the reason for not succeeding in her professional career. Furthermore, it's implied that Nina’s mother has her own mental illness, although it’s not clear the extension of it.
The problem is expecting your family member to process such abuse, and to be able to manage their anger towards you correctly. It is an impossible mission. And most likely, an ambivalent attachment that dates back to childhood.
The infantilized Nina lives a late puberty in which she tries to individualize herself as an adult and in an abnormal situation, being consumed by her psychosis. These patterns are reflected in the social environment of Nina, who has no friends and is abused by her boss at work. And her only friend and antagonist in the film, Lily, could be real or a product of her psychosis.
The failed relationships with the people around her are nothing more than a reflection of the relationship she has with herself. And without a healthy family and social support network, it’s very difficult to endure such mental problems alone. That’s precisely the root of systemic theories (Brown, Monck & Carstairs, 1962).
For this reason, many of the traditional treatments for psychosis are based on psychoeducation with the family. As well as other newer ones focused on first psychotic episodes, continue to maintain family therapy among its central components.
Finally, we understand that the focus should not be only on the patient.
Other examples of cinema
Besides Black Swan, we have a lot of examples of psychosis in the cinema. The problem that I always detect is that they focus on the most striking, most “visual” symptoms and do not delve into the suffering and causes of the disease. Films like The Joker and A Beautiful Mind are exceptions with an interesting vision.
The Joker presents a more harrowing vision than the Black Swan. It leaves the viewer with a "can't do anything" feeling. It victimizes the protagonist to the point of championing his illness and making it his only identity. It is a masterly critique of the system, but it does not lead to a healthy acceptance of the disease, but rather to frustrated resignation. The Joker only has to show the monster that society made of him.
A Beautiful Mind is an opposite case. It shows a patient with a wonderful social network, which helps him get on with life. In fact, I have always believed that the real hero of this history is his wife (played by Jennifer Connelly). And this is nice but very unreal — despite being based on the life of a real person (the mathematician John Forbes Nash) —. Most people with a psychotic familiar neither understand nor accept the illness.
Black Swan is the turning point between the extreme cases of the Joker and A Beautiful Mind. What would happen to Nina's life if she woke up? That is why it is my favorite because it makes us reflect on why a person like Nina has reached this point and makes us imagine what will happen once she begins treatment, with the social network she has.
New ways of understanding psychosis
The stress-vulnerability model (Zubin et al., 1977) it’s currently the predominant one and proposes the interaction between individual vulnerability and stress suffered by the subject.
We must never forget that the correlation between two variables does not imply causality.
X can be related to Y, but not be the definite cause. Therefore, we do not say that the family and the social context cause psychosis, but we do say that it’s one of its multiple precipitants, as epigenetics begin to explain.
Mental illness has a biological basis, but we no longer assume that this is the cause of it. Instead, human relationships — and most of all, the attachment relationships that we form in childhood and later on — are what create our worldview and shape our psyche.
This is important because we start from biological theories that accept certain deregulations in the brain. The most important is the dopaminergic hypothesis, which explains the hyperactivity of dopaminergic neurons in some brain areas (mesolimbic, mesocortical, and nigrostriatal) and specifically in the S2/D3 receptors.
But recently, investigators McCutcheon, Merritt, & Howes (2021) published an interesting paper that will change our vision — of which little echo has been made in the media.
They systematically reviewed and meta-analyzed studies that have used neuroimaging to investigate dopamine and glutamate function in individuals at increased clinical or genetic risk for psychosis.
That is, the hypothesis that individuals at high risk for developing schizophrenia have dopamine or glutamate dysfunction before the onset of the mental disorder is not supported by the data in this review. It’s a very important statement because changes all we know and gives more relevance to the biopsychosocial paradigm.
This shift has been reflected in initiatives as beautiful as the Hearing Voices movement, whose information you can consult in the link below. This movement proposes that the phenomenon of hearing voices and experimenting with other unusual perceptions is something much more common and natural than is thought.
The Hearing Voices Movement makes explicit on its website how the focus is helping to create respectful and empowering spaces, whilst challenging the inequalities & oppressive practices that hold people back. Raise awareness of the diversity of voices, visions and similar experiences.
Nevertheless, we shouldn’t forget the importance of medication: adherence is one of the most important factors. In fact, in acute phases, it’s the treatment of choice and the fastest. It helps us stabilize the patient, and from there, work with psychological programs with a more attenuated baseline.
But there’s much more beyond chemicals.
Black Swan End
When I saw the movie for the first time, I believed that Nina was committing suicide, absorbed by her madness. In the last scene, the camera closes with a subtle "I was perfect", which the viewer can interpret as the latest extension of her obsession with perfection.
But over time, I’ve changed my mind. Now I believe she doesn’t die. What dies is a dichotomy of imperfection-perfection and black-white. What becomes “perfect” for her is to be authentic and human. Stop intellectualizing her dance movements, and start feeling. Also accepting darkness and leaving innocence behind. Even so, it’s an open ending to the viewer's imagination.
Going back to schizophrenia and what I’ve written here, it makes more and more sense to me. Perhaps Nina understands that she’s more than just a walking disease, at the end of the movie.
At least, I wish Nina and any other psychotic understand that they didn’t win the worst lottery nor are they guilty of reacting like that in order to live.
There are many ways to react to difficulties and traumas. Some people yell and cry, and others internalize their emotions so much that they become apathetic. The psychotic breaks logic to pieces. There’s no more.
So let’s stop cursing biology and look more at the precarious society that doesn’t protect us and doesn’t give us healthy tools, as well as our families, the first filter of social support.
Is psychosis a failure of the brain, or rather a strange mechanism to deal with traumatic situations and fight against a precarious society?
We are a psyche experiencing the material and emotional existence of the planet, trying to integrate all of our spheres. And, whether or not we have a mental illness, no one has the right to reduce us into a malfunctioning synapse because we are as vast as the universe itself.
References:
- Brown, G.W., Monck, E.M., Carstairs, G.M. & Wing, J. K. (1962) Influence of family life on the course of schizophrenic illness. Br J Prev Soc Med 16: 55–68. Link in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1058855/pdf/brjprevsmed00066-0001.pdf
- McCutcheon, R. A., Merritt, K., & Howes, O. D. (2021). Dopamine and glutamate in individuals at high risk for psychosis: A meta-analysis of in vivo imaging findings and their variability compared to controls. World Psychiatry, 20(3), 405–416. Link in https://pubmed.ncbi.nlm.nih.gov/34505389/
- Zubin, J., & Spring, B. (1977). Vulnerability: A new view of schizophrenia. Journal of Abnormal Psychology, 86(2), 103–126. https://doi.org/10.1037/0021-843X.86.2.103
