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Medical Education: Addiction and the Cinema (Drugs and gambling as a search for happiness)

António Pais de Lacerda

UCI Polivalente. Servicio de Medicina Intensiva, Hospital de Santa Maria. Lisboa (Portugal).

Correspondence: António Pais de Lacerda. UCI Polivalente. Servicio de Medicina Intensiva, Hospital de Santa Maria, 1649-035 Lisboa (Portugal).

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Received 7 july 2005; accepted 13 september 2005


Summary

Originating from diverse backgrounds, medical students have their own cultural understanding and feelings about social diversity. Dealing with human beings, they must be prepared to face the infinity of human behaviors without prejudice.

Our aim was to assess the usefulness of using scenes of commercial movies (“Trainspotting”, “Requiem for a dream”, “Leaving Las Vegas”, “Kids” and “Rounders”) for educational purposes, during an optional one-day course on “Addictions” for 4th and 5th year medical students (Faculty of Medicine of Lisbon.

Following discussions, each theme was approached with student participation and interaction, allowing students to bring out their prior perceptions and misconceptions, and trying to solve case-based medical problems.

The use of scenes from movies was considered to be motivating and useful for promoting and explore a wider vision of addicted’s social and medical problems. They may also trigger some personal changes about the understanding of “what substance/gambling abusers feel inside”.

Keywords: Medical education, Movies, Addiction, Heroin, Alcohol dependence, Pathological gambling.


“We can not escape who we are, our destiny chooses us.”

(Abe Petrovsky in Rounders 1998, directed by John Dahl)


Introduction: Five movies about addiction and life

When thinking about addiction, there arises sudden degrading images of desperation that are associated with multiple emotions, generally unpleasant. These raise questions about what is addictive and about the relative importance of the physical symptoms and/or the psychology of dependence. As well, these images cause us to think about whether or not symptoms of abstinence will appear when the individual suspends the addictive activity.

Generally, we put aside alcohol and nicotine addiction because these psychoactive substances are acceptable by societies in western countries. We also do not think about certain compulsive behaviors either such as addiction to sex, gambling, work, or shopping. In the last example, the individual spends compulsively in an uncontrollable manner, with or within his or her means. In all cases there exists a common factor, independent of whether or not symptoms of abstinence exist, which will possibly be treated with a suitable medication. What is truly common to all addictions is the loss of control, the compulsive necessity to obtain a substance or to carry out a determined activity, despite knowing the consequences of said behavior, which is typically considered as having adverse effects on the individual or for society.

In the moment of necessity, there is nothing more important than the addiction itself, and all worries, if they ever existed, disappear when the risks of the behavior are ignored. The fixation on sex for the sake of sex itself is a good example. In Kids, (1995) directed by Larry Clark, Telly says that “When you're young. Not much matters. When you find something that you care about, then that's all you got. When at night you go to bed, you dream of pussy. When you wake up, it´s the same thing. (…) Sometimes the only option that you have is to do it. It´s only that, having sex is what I adore. Take it away from me and I have nothing. ”

The consideration of an addictive behaviour depends not only on the individual who passes from having a habit to developing an incontrollable situation, but also that of his or her socio-cultural acceptance.

This vision of addiction as a compulsive and incontrollable need to establish a privileged relation with a determined substance or behaviour, in order to suppress an inner hunger and to obtain satiety, helps to clarify the nature of addictions and to create a perspective of the therapeutic possibilities that reach beyond the resolution of the symptoms of desire.

Treatment should return to the individual the self confidence to control cravings in order to achieve happiness.

In fact, all individuals look for happiness and spiritual peace. In the day to day of social life, not everything is pleasant and there exists cyclically moments of failure/emptiness, depression/mourning, solitude/incomprehension, misery/vulnerability, that have to be overcome through multiple psychological and/or social mechanisms to achieve one´s own personal realization.

“You´ve never had the sensation that the world was escaping you, leaving you behind? You never had the sensation of nearly losing your mind? You look at the turn of every corner with the hope that she will be there. You intend to be strong, fake that it is not important to you. But that does not serve anything. You must seek until you find. Or you will never find peace.” (In Leaving Las Vegas (1995) by Mike Figgis).

Any situation of addiction will intend to resolve these moments producing a modification of the state of spirit, creating, in a fictitious form, notions of plentitude, company, grandeur, peace of spirit, and an end in happiness through a relationship with an object or action. The relationships with the world for these people are too complex and don´t come about with as much ease as those with aforementioned objects.

As Renton says in Trainspotting (1996) by Danny Boyle: “…I chose not to choose life, I chose another thing…And the reasons?... There are no reasons. Who needs reasons when you have heroin?”

An alcoholic experience causes a total change of state, even in the early hours of the morning, as can be seen, for example in the complete change in the behavior of Ben Sanderson (in a bank where he will take out money) immediately after the ingestion of an alcoholic beverage (Leaving Las Vegas).

A heroin addict, along the same lines, can only think of the recuperation of his or her own serenity with the introduction of an opiate into his or her body. In Trainspotting, Mark Renton gets into a filthy toilet and it appears as nothing more than a clean ocean with rocks at the bottom when he tries to recuperate a supposed “repairer” that he had lost.

The sex addict forgets all of his or her problems when he or she marvels in a store of pornographic articles or passes slowly through zones of prostitution.

The workaholic only feels stable when he or she stays in his or her place of work doing whatever type of task (although it does not have to be done that same day) when the addict knows that there are things that need to be resolved at home.

These different states of spirit realized in an impulse of pleasure introduce to the addict an excitation, satiety, or dream which purports the notion of another reality. “…People believe that this is no more than misery and desperation and death and all that shit that we can´t forget…, but they forget that the pleasure that it supposes…, …on the contrary that we wouldn´t do…,…after all we aren´t dickheads, fuck!, well at least not so much dickheads,” says Mark Renton in Trainspotting (1996) by Danny Boyle.

The excitation (the initial period of the ingestion of alcoholic beverages, cocaine, ecstasy, or the act of gambling, sexual seduction) makes the addict happy, feeling replete with power. But to maintain these feelings, it will be necessary to return to the object or the relational situation that triggered the use, and in this manner they become dependent.

Each relationship with the addictive element will be felt by the individual as a true alleviation from a real life that brings with it another emotion.

“You said that you felt alive for the first time while playing the card table. What do you want me to understand?”comments Joe, when he terminates his relationship with Mike in Rounders (1998) by John Dahl.

The previously mentioned emotion also produces satiety. This sensation can refer not only a consequence of an excess of food consumption, but also of consumption of heroin, alcohol, or gambling on slot machines or watching television. In Requiem for a dream (2000) by Darren Aronofsky, there exists a similarity between the various scenes of addictive representations of the consumption of the injected or orally taken substances as well as other addictions such as television overconsumption. Pain and all worries disappear, buy they return when the addictive behaviour is interrupted. In this phase of desperation, it is important for the addict to return to or come in contact again with the chosen substance or with the addictive activity, to push to the limit of well being by way of the behaviour.

Finally the addict has a feeling of being close to his or her surroundings, living in two worlds simultaneously, sometimes without out realizing the change between the addictive and real worlds (which of the two feels more real?). He or she ceases feeling any guilt or shame, finds special laws to live “on the other side,” and tastes a demonstrated power or control. The compulsive gambler learns to observe the most unperceivable reactions of the other gamblers, feeling that he or she has a superior intelligence, the rest of the world can revolve around him or her, as can be observed in Rounders.

We live in a world of immediate and individual pleasures, putting in second place the values of responsibility, family or community, and the interpersonal implications as well as social intervention. Everyone has an enormous potential to establish addictive relationships or dependence on a series of objects, sometimes on people, in moments of anxiety and/or depression, with the hope of obtaining the needed relief. All individuals can find that the processes of seduction that permits them to evade reality can momentarily resolve their problems. The addict ceases engaging in a certain type of life, losing control over the use of objects and happenings pertaining to reality, self feeding on the addiction, which becomes the fundamental reason for his or her existence. Slowly the addict returns again and again, isolating the rest of the world. As the illness of addiction progresses, the addict loses fundamental relationships with others, which will become, in general, used and manipulated as a function of the dependence. Harry, in Requiem for a dream, says “Mom…mom. Why you have to become a monster with seven heads? Mom? (…) Why do you always have to make me feel so guilty? (…) What are you intending to do with your own son…you own blood? Why do you always have to play with me? Do you see how you always have to bother me? (…) Mom? Mom, please, mom!...Go fuck yourself!”   

Mankind has always utilized diverse chemical substances and activities to modify his states of being, escape from his temporal conflicts, defy authority, look for new feelings, increase stimuli and sexual activity, or for simply pure pleasure. The types of substances and the forms of consuming them, just as the types of addictive activities (ie the Internet) have varied in type and availability of new products and technologies. --“Every place has its own venom” affirms Goethe in Faust.

Although the initiation of the relationship with the determined object or psychoactive substance is voluntary, the repetition of this action becomes involuntary and produces a compulsive “hunger” that must be carried out constantly. This compulsion is due to a series of cerebral modifications, different at the individual level, under the genetic influence and that of the surrounding environment, which it causes. In the formation of the addiction, the cerebral structure is altered functionally and biochemically, and new avenues of interactions of neurotransmitters are established that rapidly drive the disenchantment with the systems of pleasure stimulation. Some individuals have a stronger disposition of becoming imprisoned by the whim of pleasure, thus becoming addicts quicker.

Afterwards, all of the small alterations that are produced, from the molecular scale to the more elevated cerebral functions, are combined in such as way that produces the motivation of compulsion; the addictive behavior surges, and in this way, is a true cerebral affectation. These changes to the cerebral regulation, which justify the continuation of the addictive relationship, persist a long time after the individual has chosen to overcome his or her addiction, facilitating relapses. The cerebral function of reward is at the same time compromised by that of neurotransmission, which stress can exaggerate. Whatever stimulus that reaches the vicinity of the individual or whatever interior psychological modification can, in this way, constitute a sure path, without a margin for other choices, if there is not adequate psychological support, for the re-initiation of the behavior of pleasure1.

An ancient Chinese refrain affirms that “when you want to forget all preoccupations, use tight shoes.” In this way, some people resort to different procedures, in spite of the fact that they know they to be harmful, with the purpose of aliviating a monotonous, deserted, and problematic existence. “Reality, says Irvine Welse, author of the novel Trainspotting, in an interview, “sometimes should show itself to exist. When youths consume drugs in order to distance themselves from the horror and the mediocrity of life, it is terrible. There are many youths, and here the debate should be centered, who think that a life acheived tranquilly in society has nothing to offer.”

“So, why do I do it? I could offer you all a million answers, all false. What is certain is that I am a bad person, but this will change, I will change, it is the last time that I will do something like this, now I will reform myself and leave this behind, to go on the good road and choose life. I am desiring; I will be the same as  you all are: work, familiy, a big television to watch, a washer, a car, a compact disk player and an electric can opener, good health, low cholesterol, dental insurance, a mortgage, a rented flat, sporty clothing, band name suits, do-it-yourself, tele-courses, junk food, Kids, walks in parks, 9 to 5 work days, good golf games, washed cars, elegant jerseys, Christmases with family, pension plans, fiscal tax relief, to go pulling, looking ahead until the day of death,” coments Mark Renton in Trainspotting (1996) by Danny Boyle.

We still have time to re-evaluate the points of interest of our day, to intend to comprehend our addictions so many times at the unconscious level, to better stimulate our intrafamiliar and interpersonal relationships, learning to value and love every second of life.


The cinema in medical teaching about dependency

Medical students, who come from the most diverse socio-economic and cultural strata, have their own ways of understanding, or not, of confronting, accepting or negating, or only speculating about these types of social experiences, engaging with diverse feelings and ideologies related to the use/abuse of psychoactive substances or about addictive behaviors more or less accepted or tolerated by society.

Nevertheless, the necessity of having to treat these types of patients, with their multiple behaviors, obligates the medical students to take a position on the presented situation which necesitates comprension and efficient treatments carried our with profesionality and without prejudice. In this sense, it is important that in the faculties of Medicine there exists a curricular space where there enters the discussion of behaviors of certain social subgroups for a better compresion of all the problematic social/economic/medical/legal factors related with them.

In the cinema, as a mirror of quotidian reality, is an excellent educational resourse because it presents situations as if they are lived by the protagonists, mimicking social reality, with the advantage of the power to re-observe the scenes when necessary. It is possible afterwards to have a discussion and theoretical development in the same space as the teaching.


An optical course about “dependencies”

It has been out method to utilize certain scenes of commercial movies, adequately selected, to introduce determined social behaviors in the teaching of medicine.

One of these areas of this utilization is with addictive behavior. In general, their human aspects are rarely tackled, usually only contemplated in the psychologic-psychiatric field or in relation to medical complications, concretely infectious endocarditis, viral hepatitis, HIV infection, myocardial infarctions, cerebral vascular accidents in youth or the multi-organ dysfunctions recently provoked by the use of ecstasy.

To overcome this oversight, there was organized, in an extra-curricular atmosphere, a one-day course about addictions, open to students in the fourth or fifth year of the Faculty of Medicine of Lisbon.

Thirty five students attended this class and explained that their principal preoccupation was the lack of confidence they possessed in confronting medical questions associated with dependencies, in particular with that of heroin. Also, it was interesting to point out that that alcoholic dependence, as deleterious as well in social and medical fields, is rarely “felt” as a “problem,” maybe because there exists a different social vision in relation to this addiction.

Every session of the course had as an introduction the projection of a sequence of a commercial movie. With this we tried to stimulate the feelings and emotions of the students, to make them remember their own experiences and subsequently to be able to discuss the more correct mode of treating each situation, considering the diverse individual, social, and medical aspects.

Given the motivation for the course, each theme was tackled in an interactive manner; ambiguities were identified; the conscience of the grand variety of pre-established and erroneous notions of global form were heightened and real clinical situations were simulated. The movies carry implicitly potentials of such density, dimension and richness that can be converted into true experiences for the students/spectators, who see themselves as if they were in the skin of the protagonists.

In addition to the discussion of the phenomenon of dependence in general, the consumption of opiates, overdose, detoxification and the syndrome opiate abstinence, the classification of psychoactive substances utilized as drugs, for their sedation effect, stimulant or modifier of the perception of stimulus, modes of consumption and secondary effects, the medical complications of consumption intravenously, alcoholism, the alcoholic deprivation and other dependencies such as sex and compulsive were addressed.

To illustrate these themes that are projected in scenes of the movie collections in Table 1.


Table 1: Useful movies for teaching about dependencies and addictive behaviors

Movies (year)

Director/Screenwriter (Commentaries)

Topics for discussion

Trainspotting (1996)       

Danny Boyle/ Irvine Welsh & John Hodge

(A “generation  movie”; very realistic; appropriate soundtrack)

Causes of drug dependence, individual vulnerabilities, acute opiate intoxication (overdose), withdrawal state, detoxification, AIDS

Requiem for a dream (2000)        

Darren Aronofsky/ Hubert Selby Jr. & Darren Aronofsky

(An expressionistic “feeling” of the mental states of  addicts; brutal, honest, powerful)

Compulsive behaviour, gambling, complications of drug abuse, progressive deterioration of addicts

Leaving Las Vegas (1995)

Mike Figgis/ John O’Brien & Mike Figgis  

(An emotionally charged experience; no moral judgments)

Disrespect and depression in heavy alcohol dependent lives, adverse effects of problem drinking, alcohol withdrawal syndrome (delirium tremens), supporting alcoholics

Kids (1995)          

Larry Clark/ Larry Clark, Harmony Corine & Jim Lewis

(A "wake-up call"; a realistic depiction of a certain dark, dangerous and seductive youth subculture of contemporary society)

“Do you know anyone like the Kids in the movie?”, youth behavioural patterns - sex and drug culture:  how to  prevent HIV transmition, preparations and effects of cannabis - amotivational syndrome

Rounders (1998)      

John Dahl/ David Levien & Brian Koppelman

(Interesting vision of the world of gambling, in particular that of poker, the mind of a gambler, and the loss of reality)

The deconstructive power of addiction: the importance of gambling before the rest of life, the nature of addiction, and the attempts at rationalization.


Evaluation

The class learning was evaluated with a multiple choice questionnaire. To assess the value or grade of utility of this educational methodology (introduction to the scenes of commercial movies to tackle real medical situations in the context of Medical education about addiction), the questionnaire was created in such a way that the answers of the students were presented according to a scale of opinion (1-5)2, and we created a space for open ended answers. The obtained results appear in Table 2.


Table 2: Evaluation of the teaching. Student perceptions about the introduction to the selected scenes of the comercial movies in the process of teaching/learning. (n = 35)

Affirmations

Mean

>

Mode

1 – The objectives of learning were not clean to me

1.68

2

2 – The objectives of the curse responded to what I though they would be

4.57

5

3 – The scenes motivated me to participate in the discussion

4.37

5

4 – The teaching was well oriented

4.45

4

5 – The teaching was stimulating

4.57

5

6 – The lesson centered on the student (learning)

4.60

5

7 –  Learning was centered on the professor (teaching)

3.74

3

8 – The scenes called attention to the object of learning

1.97

2

9 – I stayed very interested during the sessions

4.57

5

10 – The visualization altered completely my attitude about drug addiction

4.14

4

11 – The majority of the scenes appeared relevant to my for my development as a doctor

4.57

5

12 – The scenes were irrelevant for the objectives of the course

1.37

1


It can be concluded from these results that for the majority of the students the visualization of certain scenes of commercial movies, adequately chosen relating to the treated themes, stimulated discussion, cultivated their interest, addressed themes relevant for their professional activities, and allowed for a process of change about dependencies in society.

Some students also added some opinions that better specified their sentiments and emotions and which valued even more this type of teaching/learning (their comments are below):

-By watching these scenes, I learned a lot about addictive behaviors. Nothing that I had read helped to show how reality truthfully is.

-Before, I never had been able to comprehend just how addiction was.

-We should have more basic education that uses movie scenes because they are very motivating and our emotions facilitate the comprehension of the different forms of living.

-I had to see these movies in their totality to learn to perceive these perturbed lives; I feel that they will help me in my profession.

-What, initially, appeared to me as insignificant, ended up being as important as other medical themes I learned about.

-Before, I did not want to know anything about drug addicts, but, after this experience, I am more comprehensive in my treatment of them and will be much more attend to their problems.


Conclusion

Interest is a force that facilitates the focus on conceptual comprehension and efficient learning. Some adequately chosen scenes from commercial movies can unleash interest and motivation of students and can be utilized as educational supports, in particular in the medical teaching of situations with a basis in behavior. Movies are examples of the real world that illustrate social and medical acts, being especially useful when related with the behaviors of minority population groups. The analysis of these living examples in the course is relevant for their future as medical professionals.   

The utilization of scenes of movies was considered as a motivator and useful in the promotion and the exploration of a more ample vision of medical and social problems of the addicts (concretely the comprehension of behaviors where appear irrational during abstinence). They also help stimulate modifications of personal attitudes about “what people feel inside,” given the diversity of human behaviors, without pre-established conceptions.


References

  1. Rolls ET. The Brain and emotion. Oxford: Oxford University Press; 1999. p. 148-200.
  2. Henerson ME, Morris LL, Fitz-Gibbon CT. How to measure attitudes. 2nd ed. California: Sage Publications Inc.; 1987. p. 84-92.
  3. * Opinion scale: 1-5, in that: 1 = total disagreement and 5 = total agreement

Acknowledgments

To the doctors, María de la Lastra Iglesias and Eugenio Vargas-Machuca Díaz, Spanish colleagues in rotation in Hospital of Santa Maria, in Lisbon, for the translation of the article into Spanish from Portuguese, not always an easy task.

Acknowledgment

International Studies Abroad (I.S.A.)

link 


Translated by: C. William Carspecken

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