A Child Psychiatrist's Review of Pixar's Inside Out

I finally watched Disney/Pixar's Inside Out, and I agree with the consensus opinion that Pixar has done it again, making a movie that's both fun and poignant, with a narrative that young children can understand while containing deeper messages for adults. Read on for more of my thoughts, but be aware that MAJOR SPOILERS FOLLOW, since it is hard to discuss my thoughts as a child psychiatrist on the movie's depiction of emotions without going into the details.

The main characters: Fear, Disgust, Joy, Anger, and (sigh) Sadness.

The plot of Inside Out is fairly straightforward: a preteen girl named Riley moves with her parents from Minnesota to San Francisco, and she experiences a crisis in her emotional state, in her relationship with her parents, and in her concept of herself. Most of the action takes place inside Riley's head, where 5 different emotions (Joy, Sadness, Anger, Disgust, and Fear) take turns at the control center of the brain's headquarters, directing Riley's actions depending on which emotion is at the controls. Joy is the energetic (cheer)leader who attempts to remain in control as much as possible, especially over Sadness. The crux of the movie is about Joy going on a journey in which she (and everyone else) learns to value Sadness.

How the Pixar filmmakers takes us on the journey, though, is where they show off their delightful imagination and remarkably decent grasp of psychology. Here are my thoughts on the aspects of Inside Out that delighted me the most:

• The movie demonstrates the inner workings of memory in a visually coherent and fairly accurate way. I especially like how Riley's incoming memories, which look like softball-sized glowing orbs, are temporarily kept at headquarters until Riley sleeps, at which point they are sent into long term memory. They also find a way to neatly show core aspects of Riley's identity/personality as floating islands that serve as repositories of concepts such as Family, Honesty, and Goofiness.
• The depiction of the weight of parental expectations is very well-done. When Riley becomes upset after the move, her parents say to her: "Where's my happy girl?", clearly indicating their preference for how she should feel. This is one way that parents insidiously and inadvertently tell their children it's not OK to be sad, and the fact that (if I recall correctly) each parent says this to Riley on separate occasions shows that Pixar is emphasizing the harm that this sort of communication can do.
• A critical scene that works incredibly well both as a turning point in the plot and a learning opportunity is when Sadness convinces a character to do something that Joy could not, simply by listening and showing empathy for that character's feelings. This teaches Joy (and us) the importance of validating another person's emotions.
• Some of my favorite moments in the movie are when it delves into the minds of characters other than Riley. I really enjoyed how each character has a different predominant emotion, and the emotions work together in different ways depending on the individual. For example, inside the head of Riley's mother, the different emotions sit around like a committee with Sadness presiding, while a teen boy's mind is dominated by fear, with all his emotions running amok.
• When Riley and her father get into an argument during dinner, the camera dives into each person's mind and clearly shows how Anger in one person leads to escalating Anger in the other, in a mutually assured destruction kind of way. This is a good example of an amygdala hijack, which comes up frequently when I discuss family conflict with patients.
• Despite being a primary emotion, each of the emotion characters are capable of expressing other emotions. This helps make them more interesting and less one-dimensional; it also helps subtly reinforce the point that having one emotion dominate all the time may not be desirable.
• Initially, each of Riley's memories passing through the control center is a distinct color, corresponding to the emotion associated with the memory. By the end of the movie, memories have become multi-hued, nicely illustrating Riley reaching a developmental stage where she is capable of more emotional nuance.

However, I do have one major criticism, and that is the portrayal of Sadness as short, rotund, and bespectacled. How…sad that Pixar uses such obvious stereotypes to depict her appearance! Sure, this may get more laughs from the audience and fit the look of the actress supplying the voice, and the movie does try to redeem itself by turning Sadness into a heroine. But how would kids fitting that description feel inside early on, even if they're laughing along with everyone else on the outside? I wish Pixar had simply portrayed Sadness on the basis of her facial expressions and body language without adhering to our cultural norms regarding the physical characteristics of a sad person; they're good enough animators to be capable of that. A few of other nitpicks:

• A scary clown is locked away in Riley's subconscious, visually depicted as a vault in a deep cavern. I'm not sure if even the psychoanalysts still use the term "subconscious," yet it persists in the popular culture, perhaps because it's so easy to conjure up that visual image of something deeply buried.
• Memories, of course, are not accurate recordings preserved in amber, but are malleable and often unreliable. While it would have been nice for the movie to show this, I understand that it would probably overcomplicate things. Similarly, expanding beyond just the 5 emotions featured would have been nice but too complicated.
• Though dramatic, I do not feel that the scene of Riley taking a credit card from her mother's wallet and getting on a bus back to Minnesota is very believable. Given her generally good relationship with her parents in the past, it would take much more than a couple of arguments to make a kid who did not have previous conduct problems steal and run away from home.

Despite my criticisms, Inside Out is easily one of my three favorite Pixar movies of all time, along with Wall-E and Ratatouille. I can even envision it being useful in therapy. Asking a child to think about a situation and consider what Joy would say versus what Sadness or Fear would say about it might help make cognitive-behavior therapy more engaging and fun. If you're a child therapist/psychologist/psychiatrist and haven't seen it yet, what are you waiting for? It's the only Pixar movie where I'm eagerly anticipating a sequel, given the portents at the end about Riley turning 12. I'd love to see what Pixar does with the even more tangled emotions and relationships of adolescence.

Why I Love Wall-E (and Question the ACA)

Spoiler warning: If you haven't seen Wall-E yet, why not? See it first before reading this post if you don't want certain aspects of the plot revealed.

Let me tell you why Wall-E is my favorite Pixar move. The title protagonist begins the movie as a humble robot, programmed with a very specific purpose: to pick up garbage, compress it, and stack it in neat, towering piles. In Wall-E's world, man-made trash overwhelmed the earth generations ago, smothering all plant life. The humans escaped in giant spaceships, leaving robots behind to clean up the mess. Over time, all of the other robots broke down, with Wall-E the sole survivor living a repetitive, lonely existence. Yet Wall-E somehow transcends his programming and develops a sense of curiosity about the world. What were those humans like? What are these relics that they left behind? What's that green thing growing amongst the trash?

After a series of improbable but exciting events, Wall-E finds himself on board one of those giant spaceships. There, he encounters real, live humans and the robots that serve their needs. The people were uniformly plump with adiposity, reclining comfortably on mobility chairs while sipping futuristic Big Gulps™ and fixated on screens. Wall-E was aghast, eventually discovering that the villainous AI of the ship was trying to keep the humans confined to their blissful but vacuous existence. Wall-E finds a way to rally the other robots and spread the news that plant life was growing on earth once again. The movie ends on a hopeful note, with the ship returning home and the humans taking small, earthbound steps that feel like giant leaps. I love that Wall-E acted in humanity's long term interests instead of either rejecting these disappointing humans or attending only to their short term comfort.

Recently, I was reminded of Wall-E when I attended a session at AACAP's Annual Meeting in San Diego titled: "The Affordable Care Act [ACA] and How We Think About Systems, Care, Quality, and Ethics." The discussants covered various aspects of the ACA (for an overview of the ACA, see this recent post from Psych Practice). What interested me most was the talk by Dr. Michael Houston on how the ACA relates to child and adolescent psychiatrists. Dr. Houston discussed the ethical underpinnings of the ACA, namely how it seeks to institute a more egalitarian and less libertarian health care system. The law lays the groundwork for transitioning us from a fee-for-service system in which doctors have a financial incentive to do lots of procedures to a system in which both patients and doctors have a responsibility to society to contain costs.

Clearly, one of the goals of the ACA is to make doctors provide more efficient care. One of the justifications for why we need this is the chart above (from this HuffPo article) showing how, despite spending way more than any other country on health care per capita, the U.S. trails most other developed nations in life expectancy. The logic seems to be that since we're not getting good bang for our buck, the health care delivery system must be streamlined.

This focus on efficiency would have an especially high impact on child psychiatrists, given how relatively few of us there are compared to the high numbers of patients. Here's an old article from 2006 about the shortage, and not much has changed since, except that even more children are being diagnosed with conditions like ADHD and taking multiple medications, putting further strains on the health care system. Last year, AACAP published a document describing how the ACA will impact the practice of child and adolescent psychiatry. More mental health care will be delivered by pediatricians and care managers, with psychiatrists overseeing cases but not seeing patients directly unless they were especially complicated.

To me, this seems like a herculean effort to create ever more efficient Wall-Es, without trying to address why there was so much for Wall-E to clean up in the first place. Instead of just focusing on the shortage of child psychiatrists, why are we not doing more about the over-abundance of patients? After the session, I asked one of the speakers this very question. Her answer was sobering: she had thought about this issue herself, but when she tried to a submit a paper on the prevention of mental disorders in children, no child psychiatry journal would accept it. She thinks that is just not our mindset, just not what we are trained or paid to do. It reminded me of the old adage by Upton Sinclair, "It is difficult to get a man to understand something, when his salary depends on his not understanding it."

Don't get me wrong, I believe in universal health care. I just don't think that the ACA is going to successfully address the mental health issues of children in this country, just as it won't address the obesity epidemic by making obesity treatment more streamlined. For example, today's NYTimes article that I linked to earlier profiled a California mother who has a child with ADHD and severe behavioral issues. Here's the crucial paragraph:

Some would consider Matthias a textbook candidate for combined treatment. His rages have overwhelmed schools and child care programs for years, and he is already struggling in first grade. He and his mother — a medical technician whose typical workday drawing blood lasts from 7 in the morning until 4 p.m. — share a cramped and clamorous three-bedroom ranch house with her sister and brother-in-law and their spirited children, ages 3 and 6 months. Matthias is having nightmares and bladder-control issues.

I'm not sure that any amount of meds or access to a child psychiatrist would help this child as much as having a less stressful home environment. I don't claim to know what the best solution for our society as a whole would be, but I do think we need to put more effort into investigating what can be done to better support children and families, and not just from a medical/health care system point of view.

I hope that more of us in the child psychiatry field can be a bit more like Wall-E: a bit more curious about the world we find ourselves in and how it became that way, a bit more willing to ponder what can change things for the better. Let's not continue to just put our heads down in order to squeeze ever more efficiency and productivity out of our days.

Boyhood Movie Review

Putin. Gaza. Ebola. ISIS. Ferguson. Robin Williams. This has been one of the more unsettling summers in recently memory. However, as we head towards Labor Day and I look back on the last couple of months, what I recall most clearly and fondly (besides some personal and family matters that are irrelevant here) is watching Boyhood, by director Richard Linklater.

The film stars Ellar Coltrane as Mason, who is 6 at the beginning of the story. We watch as he grows year by year into an 18 year-old young man. Forget all those gimmicky 3D movies; this is a 4D film, where the genuine passage of 12 years of time adds an extra dimension that cannot be faked by CG.

Boyhood succeeds in capturing something about the essence of our times when it comes to parenting and childhood. The parents have split, and the dad, played by Ethan Hawke, is barely around initially, only occasionally swooping into his kids lives like a tornado of fun. Meanwhile, the mom (Patricia Arquette) struggles to raise her children while trying to go back to school so her family could break free from the struggles of low-wage America.

Amazingly, the director found a young actor in Coltrane who was able to deliver a consistently convincing performance from childhood to adolescence. The film opens with him lying on the grass staring into the sky, leaving us to wonder what he makes of life. Coltrane was able to project this introspective nature throughout, and as a young man engages in the kind of philosophical discussions that Linklater's characters are known to do.

However, Boyhood is as much a coming of age movie about Mason's parents as it is about Mason's own journey. I found it interesting that the adults seemed to be engaged in a search for identity as much or more so than the children. The character who evolves the most over the 12 years is Mason's father, who becomes a minivan-driving, church-going actuary in middle age. Mason's mother ends up as a somewhat tragic figure who has to balance her career with parenting while dealing with a string of bad relationships. Our culture really is harder on women, and this film reflects that reality.

Boyhood has been the best reviewed movie of the summer and deservedly so. One may look at the box office receipts for the latest Transformers assault on the senses ($243.8M) vs. Boyhood ($16.3M) and despair; I choose to see the fact that this movie was made at all as a sign that there is still hope.

Brooklyn Castle Movie Review

I recently had the pleasure of watching Brooklyn Castle, one of the most delightful and moving documentaries that I have ever seen. It follows a group of students on the chess team of Intermediate School (I.S.) 318 in Brooklyn, which is perennially one of the best in the country, even though I.S. 318 is a public school where over 60% of families in the district are living below the poverty line. The New York Times review introduces us to the documentary's young subjects:

Rochelle Ballantyne dreams of being the first female African-American chess master; Alexis Paredes hopes to be a lawyer or doctor so he can ease the burdens of his immigrant parents. The dreadlocked newcomer, Justus Williams, might be a chess genius; Patrick Johnston, who has attention issues, just wants to raise his ranking. Pobo Efekoro helps his mother with her day care business.

Dovetailing with my last post, this film illustrates the importance of having caring adults involved in the lives of children and adolescents. Other reviews have highlighted the important roles that chess teacher Elizabeth Vicary and assistant principle John Galvin play in their students' lives, as well as how budget cuts threaten important programs like I.S. 318's chess team. Here, I would like to highlight another aspect of Brooklyn Castle that was striking to me, and that is the interaction between these students and their parents.

As a child psychiatry trainee, I attended multiple lectures on the importance of authoritative parenting, which refers to parents who have a warm relationship with their children but also set reasonable limits; who have high expectations and try to provide their children with the tools to succeed. The parts of this film that show the students interacting with their parents, while brief, are wonderful illustrations of the authoritative approach.

On more than one occasion, the film shows families sitting at a meal together having a conversation, which by itself is an important protective factor. Rochelle's mother repeatedly emphasizes the importance of her having an education. Alexis's mother reassures him that he does not have to find a job after high school, that he can go to college because that is why she and his father work so hard. She cries tears of joy when she finds out that Alexis had been accepted to a good high school. Pobo, who lost his father at a young age, shoulders his responsibilities at home without complaint. Patrick's mother acknowledges how hard things must be for him and participates in a fund drive to raise money for the chess team.

My favorite moment came when Justus lost a match and called his mother on the phone. He says hesitantly, "I lost a pawn, and then I just…fell apart after." She clearly hears how upset he is, and she validates what he is feeling, saying, "You're upset, right?" When he answers in the affirmative, she reassures him and encourages him to persevere: "Yeah, I can tell. That's ok. Just pick yourself up, it happened." She then says, "Boy, I feel down too I'm not gonna lie." She says this in such a way that is not blaming him for making her feel bad, but to share with him that she understands what he is feeling. This conversation, which lasts less than 30 seconds, can be used in a instructional video to show parents how they should approach their children who are upset.

As a whole, Brooklyn Castle is uplifting and joyous, but also a reminder of the dedication and effort that it takes to help children succeed. Just one last random nugget that I loved: where else are you going to see a kid rap about conquering his opponents in a chess match?

Movie Review: The Bling Ring

Sofia Coppola's The Bling Ring is one of my favorite movies of the year. Set in 2009 and "based on actual events," it tells the tale of a group of SoCal teens obsessed with celebrities and their bling, who end up stealing millions from the homes of Paris Hilton, Lindsay Lohan, Audrina Patridge, Orlando Bloom, etc. The ringleader Rebecca (played by Katie Chang) is fearless and quite possibly a psychopath. The closest thing to a protagonist in movie is Marc (Israel Broussard), a social outcast whose fortunes rise after he meets Rebecca at his new school. Also part of the group are best friends Nicki (Emma Watson) and Sam (Taissa Farmiga), and Rebecca's friend Chloe (Claire Julien).

Although the acting is fantastic, many professional film critics were lukewarm about the movie as a whole, as exemplified by the concluding paragraph of A. O. Scott's New York Times review:

“The Bling Ring” occupies a vertiginous middle ground between banality and transcendence, and its refusal to commit to one or the other is both a mark of integrity and a source of frustration. The audience is neither inside the experience of the characters nor at a safe distance from them. We don’t know how (or if) they think, and we don’t know quite what to think of them. Are they empty, depraved or opaque? Which would be worse?

Ignatiy Vishnevetsky has a similar conclusion in his review at rogerebert.com:

[...] Coppola neither makes a case for her characters nor places them inside of some kind of moral or critical framework; they simply pass through the frame, listing off name brands and staring at their phones. About an hour into the film, one starts to get the nagging feeling that Coppola's "neutrality" is a dodge; she avoids moral commitment, thereby creating a movie ambiguous enough to be interpreted in several ways, but too vague to have much meaning in any interpretation.

I disagree completely. I don't believe the movie is neutral or uncomitted at all; it is a satire aimed at not just the adolescents who browse TMZ, but also at their parents and society as well. Certainly, how I interpret the movie is a reflection of my own experiences working with families in which parents are at a loss as to how to rein in their teen's behavior. When I suggest setting some sensible limits, like no electronics after 10pm, I sometimes hear parents say things like: "That wouldn't work. He's like water, he always finds a way around things." Well, that's completely normal! The job of a teenager is to test the limits, to see what they can get away with. What's not normal is parents who cannot set limits or teach the teenager about acceptable behavior. The more the teen is like water, the more the parent needs to be like a vessel that can provide structure for the water.

In The Bling Ring, we see what happens when there is no such water container. For most of the main characters, we only get brief glimpses of their interactions with their parents, which I think was intentional, to reflect the fact that their parents are just not very involved. Katie's parents are divorced and her father lives in another state. Marc's father is often away on business. Chloe's parents are around but barely involved: there is a great shot of Chloe and her parents at breakfast, each separated from the others by the maximal distance that would allow them to still be in the same room. Sam was abandoned by her parents and adopted by Laurie, Nicki's mother. Laurie is the parent who gets the most screen time. Though she means well, she is portrayed as clueless and ineffective, a dispenser of Adderall who tries to teach her children lessons about character using a collage of Angelina Jolie photos. Instead of chastising her daughter after the teens are arrested, she tries to steal the limelight when a reporter interviews Nicki at their home.

In his review, Vishnevetsky's found the movie's use of celebrity cameos problematic:

[...] Paris Hilton and Kirsten Dunst have non-speaking cameos as themselves; more importantly, Hilton's real house is used throughout the film. The characters gawk at Hilton's real possessions and rifle through her real closets.

This points to the movie's most serious problem: the "impartial" viewpoint. Is "The Bling Ring" a movie about characters ogling at celebrities, or is it an excuse for the audience to ogle along with them? [...]

I really believe that Coppola was being subversive in her use of Paris Hilton's mansion. Sure, filming in Paris Hilton's home causes the audience to ogle, but my impression is that Coppola's goal was to show how ridiculous the place was, with its overstuffed glitz and wall-to-wall monuments to Paris herself. She returned to that location repeatedly, I believe, as a way of evoking disgust in the audience. After forming this opinion, I came across an interview that Coppola gave in which she was asked about the experience of filming at Paris Hilton's house (starting at 3:25). Here's what she had to say: "When we first got to see Paris Hilton's real house, it was like nothing I've ever seen before, and I had heard that she had a nightclub room, but then to really see it, and just all her pictures, and the pillows, with her pictures and stuff, it was very, um...exotic [shrugs]. I really appreciate how she let us into her, you know, real private world [smiles]." All that was missing was a wink.

The Bling Ring may not be a Great Movie, but it is certainly an important and alarming one. It's unfortunate that so many missed its subtly, and only 47% of film-goers on Rotten Tomatoes liked it. However, I do wonder about the reasons for audience members not liking the movie. Did it make them feel uncomfortable with themselves? If so, then perhaps Sofia Coppola has achieved her desired effect.

Movie Review: The Perks of Being a Wallflower

I recently watched The Perks of Being a Wallflower, and it is one of the best depictions I have ever seen of an adolescent's struggles with trauma and grief. The protagonist is Charlie, played convincingly by Logan Lerman as a quiet teen entering his freshman year. He is utterly friendless at the start of the movie, and the details of his past experiences are only gradually revealed, bit by bit.

Here's what I loved about the movie, and why I think all psychiatrists should see it: Charlie is never treated like a psychiatric label. In fact, no terms like "depression" are used at all in the movie. He, like most of the patients I see, has been through some pretty terrible things. He suffers from a mix of sadness, grief, guilt, anger, and dissociative tendencies,  yet he probably does not fit neatly into one specific DSM category. Most importantly, his life is not defined by those symptoms. He likes music and writing, he has hopelessly fallen for a girl named Sam (Emma Watson), and he is a loving brother to two older siblings. The best scenes involve him becoming friends with the school's band of misfits, led by Sam and Patrick (Ezra Miller, in a wonderful performance). We clearly see how these relationships give Charlie joy and a sense of identity.

I also thought the depiction of Charlie's psychiatric hospitalization was very well done. The movie takes place in the early 90's, shortly before the DSM-IV era of psychiatry. Back then, the average length of stay on child and adolescent psychiatry units was on the order of weeks to months, rather than the under one week stays that are so common today. Though the movie does not show how much time elapsed in the hospital, it does give the sense that Charlie was moving into his room for a while. The psychiatrist Dr. Burton (Joan Cusack) appears only briefly, but even so, her concern for Charlie comes through. She is not running down a symptom checklist, spewing psychiatric diagnoses, or pushing pills; rather, she tries to engage Charlie as a person first and foremost, hoping to gain his trust so he would feel safe sharing his most hidden secrets.

The story was certainly clichéd in places: There's the obligatory scene of getting high for the first time, and Charlie's English teacher (Paul Rudd) gives Charlie his treasured copy of The Catcher in the Rye. Are there no other books about teenage alienation? Also, Sam seems remarkably well adjusted given her chaotic backstory. Never once did the movie convince me that her character was someone who would have trouble getting into Penn State.

Still, the brilliance of the actors and the compelling story makes this one of the great coming-of-age tales.