brains

Happily ever after: Some thoughts on trauma in the movies

I watched a romantic drama this evening in which a man and a woman who has a child from her past relationship fall in love. The ex-boyfriend is controlling, threatening and manipulative and tries to sabotage the relationship. He is shown getting drunk and grabbing the woman’s arm tightly to stop her leaving twice, and at another point he threatens the man with a weapon. Towards the end of the film the ex-boyfriend is drunk and upset. He threatens to take the child, who runs away and falls into a river. The ex-boyfriend rescues the child at the cost of his own life, and the mother and child witness him meeting a sudden grizzly death. Then the couple get together, become a family with the child and the film ends, leaving them to live happily ever after.

Having watched a set of characters for an hour and a half that were portrayed sympathetically and realistically enough to feel invested in, this seemed like a weird ending. I was left with this really disconcerting feeling that the writers, producers and large numbers of reviewers of this film (who gave it respectable scores on Amazon and IMDB) thought that this climactic scene tied up the ends neatly and left us with the uplifting moral righteousness of the baddie getting his just deserts, the couple unimpeded in their romance and a perfect nuclear family.

But how could a child who just witnessed his father’s death (and probably felt responsible for it) not have any emotional reaction to that? Would it not be yet another loss of a close male relationship for this young child, who had already lost others as part of the back-story? How could the mother not have complex feelings about the death of a guy who has been emotionally and potentially physically abusing her for five years? Would her relief perhaps be tinged with guilt that her new romance triggered these events, or at being relieved to see the back of him? Would a mother not feel sadness in empathy for her child’s experience of trauma and loss? Would she not feel echoes of the loss of her own father in childhood, or her brother the previous year? Perhaps their different ways of dealing with grief and loss would challenge the romantic relationship? How about our leading man, who was mourning lost friends and showing signs of PTSD at the beginning of the film. Would it not re-awaken all the unresolved grief he is repressing? And what of the ex-boyfriend’s parents and their stoical thanks to those that tried to rescue him? Does nobody cry for this man, who gave his life up to save his child? Was his inept handling of the relationship that resulted from an unplanned pregnancy in his teens so bad that he deserved to die?

Why couldn’t the film have been one that illustrated the reality and complexity of modern family relationships? Surely the alternative was for the father to have shown his priority was the wellbeing of the child, during the rescue scene, but to have survived and been part of a renegotiated family configuration in which the child was able to have both a positive experience of contact with him and to live in the new family unit with Mum and step-Dad? As I often tell children who feel that any affection to foster or adoptive carers is disloyal to their birth family, love is not like a cake where you have a finite amount to share out between all your relationships, love is like candles where using your fire to light others just creates more brightness for everyone. But if the father had to die, then they needed to show the emotional fallout of that. They can’t have one without the other, any more than they could show a person standing in sunshine without showing their shadow.

As it stood, the film profoundly failed to acknowledge the impact of trauma on the different characters. And this film was far from alone in that. So many traumas occur in films and TV shows that it seems they are very much part of the expectation nowadays. In every vampire franchise I’ve seen the head counts of characters close to the main protagonists who die are extraordinary, and yet they briefly mourn and then move on. In Vampire Diaries, an average of 19 characters shown on screen die per episode, and the main character, Elena, has lost almost every living relative and most of her friends, as well as dying herself, twice! Many other shows track medical emergencies, murderers, serious crimes, drug dealing and power battles, yet they are dealt with in an entirely sanitised, emotion-free way. Sure, a pathologist would be well-used to the physical nature of human corpses, but even in the most hardened professionals some cases creep through the cracks into your psyche. The person that looks a little like someone you know, or reminds you of something in your past. The tragic story that becomes apparent from the cause of death, or the untimely demise of a child. We are not robots analysing data, surely we recognise that people are like us and the people we care about?

The latest Star Wars film showed planet-scale genocide without that even being acknowledged by the cast. It’s a really good film otherwise, and I really enjoyed it, but the scriptwriters chose to show genocide as shorthand to make the baddies bad. It could equally have done so through less wide-scale slaughter, or by showing the snatching of children to indoctrinate as stormtroopers or many other plot devices. Including the slaughter of millions of people was a plot choice, and given that the film is part of a historical franchise that is pitched to the whole family and used to market toys to children, that is a pretty weird choice of plot. To then skim over making light of it makes that more disturbing, rather than less, once you think about it. I’m not saying the main characters should have processed the emotional impact there and then; I’m sure if you are busy fighting for your life or have 20 minutes to save the world and see some planets blow up, that isn’t the moment you down tools, lie down and cry. But even an extra second of footage showing sad faces, one person humanising the loss by mention of having lost individuals there, or an additional comment about how awful that loss was, would have given some hint of the emotional connections of all the people whose lives were extinguished in an instant. In the original trilogy when Alderaan was destroyed they used the change in the force to acknowledge how monstrous it was. I still remember the scale and momentousness given by the line “I felt a great disturbance in the Force, as if millions of voices suddenly cried out in terror, and were suddenly silenced. I fear something terrible has happened.” And this is what was missing in The Force Awakens.

But I think this lack of acknowledgement of millions of deaths was also illustrating something very poignant about human processing of events; we identify much more emotionally with death or distress at the individual scale than we do at a population level. Think of how the discovery of the body of young Aylan Kurdi humanised the treatment of Syrian refugees in the news narratives, for example. Prior to that point, they were treated like an invading army of ants, but in the weeks immediately afterwards some individual stories were told and people felt more sympathetic and we were shown footage of refugees being welcomed into various European countries. I think that change in response according to the scale of deaths is part of human nature, as is our ability to shut off from suffering and get on with life, if that is necessary to our survival. At the extreme end, people living through wars or in areas of high risk or conflict are probably coping by living in “survival mode” and using more primitive parts of the brain in favour of the prefrontal cortex, which has reduced activity under threat. It makes sense, logically, as we do have to compartmentalise awful stuff to just keep on going sometimes. I think back to all the life events that happened whilst I was pregnant (including a car accident, my granddad dying, a close colleague dying unexpectedly, my job being placed at risk, my babies being born very prematurely) and think I only coped with everything I couldn’t avoid by going into a psychological bubble and putting all that bad news aside to deal with later.

Maybe these fictional narratives of unacknowledged loss that have become so prevalent in TV and film are using this tendency – our ability to put emotional distance between ourselves and tragedy through various forms of displacement. If something awful happens far away, or it happened in the past, or in a different cultural context, or in fiction, then we are able to distance ourselves from it and deal with it at a purely cognitive level. We think about it but don’t feel it. The shame is that this seems to be how many politicians and decision makers deal with the problems affecting people in our day to day lives. Although it is ‘psychologically expensive’ to allow emotions in, it is only with empathy that we can really make informed decisions. So in real life as well as in fiction, I think a bit more feeling would be a good thing.

Video games and violence

The relationship between playing video games and violent behaviour isn’t as black and white as most people assume. There is neither the causal evidence that would support the tabloid alarmist headlines that blame Mass Effect, Call of Duty or World of Warcraft for mass shootings nor the evidence that video games are entirely benign.

We know from research that trauma has a significant and lasting impact on the brain, a pattern widely accepted across numerous studies. For those who have already been traumatised and/or have maladaptive social skills, that increase in arousal sensitises the brain to further threat. It also makes them more likely to respond with anger or fear to a neutral stimulus, perceiving it as a threat. We also know from research that when the threat sensor in the the brain is activated (the amygdala and limbic system) the prefrontal cortex pretty much goes off-line until the threat is resolved. That significantly reduces the person’s capacity for empathy, complex reasoning, social skills and ability to be aware of the impact of your own behaviour on others. This effect is amplified where there is an absence of healthy real life relationships and/or physical exercise (which produce oxytocin, and help to mediate cortisol and adrenaline). And of course we know that people who have raised arousal levels deliberately seek out experiences that match or use that level of arousal, so they are often much more interested in violence and gore than their peers.

That’s all well established neuroscience. We also know that these brain changes can be perpetuated by exposure to violence or the representations of violence in our daily lives or the media we consume. Exposure to violence is an unseen public health epidemic. We also know that this pattern of being over-sensitised to threat and in a heightened state of physiological arousal gets ‘stuck’ for a proportion of maltreated children, particularly where there is an absence of secure attachment figures, and that ‘acting out’ with violence in this group is much more common. The neurological basis for moral reasoning and antisocial behaviour implicate similar brain regions. Similar areas are also implicated in violent behaviour when this is related to a lesion, dementia or atrophy.

Having reviewed the evidence, I think it is clear that video games do not in themselves cause violence. But playing violent video games increases physiological arousal levels (readiness for fight or flight) just as we know is the case for exposure to real life conflict such as domestic violence within the family. This can create a lasting effect which shows in MRI scans. But the effect is quite specific. We know that MRI studies show differences in the brain when people play violent video games but not when the video games do not involve aggression. We also know that it is dependent on the social acceptability of the behaviours chosen in the game.

It seems likely that watching films or TV can similarly cause an increase in physiological arousal, but this would only be the case with a high level of violence/action/drama, something which is not normally sustained for hours upon end the way it can be in some video games. Also, video games are more immersive because they are interactive, and I suspect you don’t become as habituated to them because of the fact that there is variation on every presentation of the stimulus, whereas rewatching the same film gets dull and predictable and no longer gives us that visceral response. Thus I think that it is reasonable to consider violent video games as a particularly concentrated form of this stimulus.

It seems from the meta-analysis that a small scale shift towards higher readiness for fight or flight and lower empathy/insight/reasoning is happening all over the place amongst people who play a large volume of violent video games with the result of small but measureable increases in the risk of aggressive behaviour. I’d extrapolate from this to what is currently happening with the threats and harrassments towards women and minorities in the gaming space, to suggest that this combination of lack of nurture and exposure to violent material may be contributing to the lack of empathy and insight into the impact of their behaviour amongst people involved. But I suspect that the impact of video game play on real life aggressive behaviour is only a significant issue at the individual level where this is combined with the presence of trauma and/or the absence of nurture. After all, the move from enacting violence in a video game to doing so over social media is much smaller than the move to take actions outside of home technology where you can see the impact on the recipient.

It is only in the extreme examples, where you combine violent video game use with people with horrendous histories, a lack of secure attachment relationships and/or who have entrenched extreme views (eg about women), nothing else in their lives to constrain them, an echo-chamber of harmful views including incitement to violence, and perhaps mental health problems on top that the mixture becomes truly toxic. Amongst this group a small proportion take the threat-talk that is so prolific online and in video game spaces into horrific real life actions.

I can’t see that being so different to the proposed mechanism for lots of other phenomena. As with the relationship between cannabis use and psychosis, or alcohol consumption and suicide, the former is something most people consume without harm so it cannot be causal in isolation, but for a much smaller number of  people with increased vulnerability (genetic, epigenetic or experiential) it can be a contributory factor towards a more negative outcome.

High on scare, low on science: a tale of charity, politics and dodgy neuroscience

In 2011 when I took a voluntary redundancy from the NHS I was asked to help set up a parenting charity* focusing on the period from conception to age 2. I agreed to be the founding Clinical Director and to help them set policies, sort out pathways of treatment and recruit staff. I worked for them one day per week. After less than six months it was clear that there was a divergence between what I felt was most clinically helpful to say about supporting parents in this critical period and the primary goals of the charity**. This was particularly evident in what was being said to promote the launch event of the charity. The title of the launch conference was the dramatic and pessimistic pronouncement, “Two is too late”. This title was cast in stone despite my repeated protests that parents would feel blamed and might think that there was nothing they could do beyond the age of two if they had not had a perfect attachment relationship before this point (when the evidence suggests that there are in fact many effective strategies for enhancing attachment relationships beyond this point, and many therapies for helping children and even adults to learn to emotionally regulate, mentalise and have successful relationships, even where there has been poor attachments, neglect or maltreatment).

The media were given soundbites to promote the event that suggested a baby is born with only one third of their brain active, and the rest relies on the quality of parenting received to grow. The news coverage in the Telegraph*** said that “a failure to help troubled mothers bond with their babies can stunt the development of the children’s brains”. The BBC coverage*** stated “a growing body of research suggests that the amount a baby is loved in the first few months of its life determines to a large extent its future chances” (when love and the quality of the attachment a parent is able to provide are quite different things, the most critical period is usually cited as 6-18 months of age, and the change in prognosis is most impacted by significant maltreatment).

Although our tiny pilot had kept 5 children out of 6 at home with parents successfully, despite them being referred on the edge of care, I had some misgivings about the marketing messages. We had feedback from service users and user groups that they felt stigmatised by some of these messages, but the organisation was unwilling to hear that. I am passionate about the value of improving attachment relationships and I had written a brief literature review on the impact of poor early care to ensure that the project was informed by the evidence. I was also writing a book about attachment and the impact of maltreatment, but I couldn’t match my views up with the politics of the organisation. I felt that to stay would conflict with my professional ethics, and my desire to honour the evidence base and respect the people who needed the service, so I quit before the launch. My colleague decided it would be unsafe to practise in my absence and left at the same time, leaving the charity with no clinical staff. Nonetheless, they decided to make a very big launch event, that I could only describe as one third professional conference, one third stately home wedding and one third party political broadcast for the blue party. It sold 500 tickets to health professionals and other interested parties, and I went along to see the show.

The speakers included a Conservative Peer, Ian Duncan Smith and Andrea Leadsom, along with Dr Amanda Jones (who shared a case study of parent infant psychotherapy). The fantastic Camilla Batmanghelidjh was also present (and made a good job of challenging the lack of empathy from politicians for the people they serve and quipping that this reflects their avoidant attachment styles). I had invited Dr Michael Galbraith (a Consultant Clinical Psychologist who has run community children’s services in Liverpool for many years) to talk about the health economics of early intervention. He did so persuasively and he also challenged the politics that came before his talk (with genuine zeal, as his entire service had been closed in a cost-saving ‘reorganisation’ a few weeks prior to the conference). But the biggest draw was that Baroness Susan Greenfield was invited to talk about the epigenetic effects of early attachment experience on the infant’s developing brain****. As I had not heard of her work prior to this event I was intrigued.

The talk that Prof Greenfield gave was baffling from the off. It massively overran her time-slot, and the program was rearranged to give her a second slot in the afternoon to complete what she wanted to say. My recollection was of a chaotic set of shock images and headlines, with provocative statements which appeared to contradict my knowledge of the literature, despite the fact she claimed they were scientifically founded in hard neuroscience research. Thankfully the pdf of the PowerPoint she used was circulated after the event, so you can see the content for yourself (zip file to download here).

Her title was “The mind of the 21st Century Infant” overlaid on a stock photograph of a baby using a computer. She immediately moved on to dramatic images of a youth celebrating in front of a fire during the recent riots, blaming the riots on the lack of attachment young people have grown up with, which she said had been replaced by technology. She then showed scary images of “artificial intelligence” before trying to define the mind. Then she made a knight’s move to demonstrate that “environment trumps genes” through a single study of rats given genes that cause Huntingdon’s Chorea which had less symptoms if they lived in a more stimulating environment. Then back to human babies, and images of how neurones proliferate during the first 2 years of life. Then a study showing that the Hippocampi of taxi drivers are enhanced, and then some blobs designed to indicate that mental practise of piano also activates the brain like physical practise. Then back to rats, showing more neural connections in a richer environment than when rats are isolated in boring cages. Then a description of how the mind shifts during development, from sensory processing to cognitive experience and gives greater meaning over time, with the view this is driven by experience.

She then claimed the mind might be “changing in unprecedented ways” due to interaction with technology, and showed alarming headlines circled in red, and book titles reflecting her view that internet use is changing our brains.

Prof Greenfield then showed a study counting children’s hours of screen time reported by parents, according to the child’s age. The source cited turns out to be a report saying that children have always used whatever media is current, mostly watching TV (which has been on for 7 hours per day since the 1970s) and although digital media is rapidly proliferating including learning toys, music and phones, total media use by white children had only increased by 38 minutes between 2004 and 2010, though it was more prevalent in low income families and had increased more in BME families. It states there is no evidence yet about how much is too much when it comes to media consumption but states that “media platforms by themselves are neutral; what matters most are the choices made by parents, educators, educational production companies, and other content providers in order to encourage a balanced pattern of consumption” using the metaphor of needing a balanced diet. This was not reflected in Prof Greenfield’s narrative about this amount of media being harmful, and it is unclear how she extrapolated the figures in her table.

Another leap, and we were onto how dopamine is the reward chemical and behind all addictive behaviour. Prof Greenfield said that it changes neural activity, inhibiting the frontal lobes. This is why children are becoming fat, sedentary and obsessed with technology. They are all addictions, and disrupt our frontal functioning. Then a leap to schizophrenia not having sufficient frontal lobe activity, and reverting the brain to sensory processing which is fragmented and without meaning. Another slide full of brains: The prefrontal cortex is not mature until your 20s. Then a claim that schizophrenia, gambling, over-use of screen technology and over-eating have a common pattern of prioritising our senses over reason, due to dopamine making us mindless rather than able to synthesise meaning. It felt very alarming to have schizophrenia and addictions linked to the same pathways as attachment difficulties and technology use. The implication was that parents could cause these difficulties in how they parented babies, or by allowing children to use digital media. These are claims for which I have never read any scientific evidence, despite being a clinician working in this area and trying to keep abreast of the research literature.

Another leap to social media and how it makes us “alone together”. Prof Greenfield told us how real communication is three dimensional, and little of the meaning is conveyed in the words, whilst 90% is in eye contact, body language, tone of voice, perhaps even touch and pheromones. But online we have only the words. According to her, this is why empathy has dropped over the last 30 years (another newspaper headline, not a scientific study, and with no reflection on the socio-political changes that might explain this). The lack of empathy required is why people with autism are so at home with technology and on the internet. People also have reduced identity, so they have to record their existence online. Prof Greenfield characterised the development of online communication as going from describing your cat sneezing on Blogger, to putting up a photo on Flickr, to a video on YouTube, to live Tweeting the action, saying that such activities reflected the author as a disconnected “nobody” who needs to prove they exist. She postulated that a rise in social networking is the cause of reduced empathy and people having a less robust identity, but it seems to me that even if these two things co-occur the direction of causality could be the reverse.

She then skipped on to the evils of video games, inserting a slide with MRI scans to show reduced listening when looking at something else, before blaming video games for the increase in methylphenidate prescriptions. Prof Greenfield claimed ADHD could be caused by video games because they lead to “fragmented attention, shorter attention span and increased recklessness” because they activate the dopamine system. Another headline in a red circle saying children who love video games have “brains like gamblers”. Then she showed us her own work bringing this together: a proposed cycle of how the intense stimulation and immediate feedback lead to high arousal and dopamine release, reward seeking behaviour and this makes brain changes which cause “conditions of childhood, schizophrenia, obesity” and a drive for sensation over cognition increasing the appeal of screen based stimulation in a continuous cycle. Again, I don’t believe any of these claims have appeared in peer reviewed publications or have any evidence to substantiate them, and even if there was evidence of co-occurrence the direction of causality is far from certain. There is however a growing body of evidence that some symptoms that could be interpreted as ADHD-like are caused by early trauma and maltreatment having an impact on neural development. To end that section, Prof Greenfield juxtaposed the “mindless” brain slide with a shot of World of Warcraft and mocked the lifestyle she believed was typical of those who play the game.

Then Prof Greenfield turned her attention to search engines, claiming they give fragmented information but nothing about meaning. By way of example she claimed that you can’t possibly understand what honour is from the search engine results produced by that term. Again, she claimed digital media is all fragmented content, lacking metaphor, depth and meaning. She strongly asserted that nobody could care about a character in a video game like you care about characters in a novel. Again, I would disagree with this. Like any media, video games are very diverse in style and quality and you pick ones that fit your taste, just as you would with a book or a film. If you don’t like violence, don’t pick a violent one. You don’t have the same expectations for the latest chick lit/flick as you do a weighty classic. Some examples are also of better quality than others, some focus on special effects over plot, others are low budget and whimsical. In my opinion if you feel immersed and the story is told well it feels like time well spent and you care about the characters and outcomes, whether the media is a video game, a book or a film. Its disingenuous of her to pick a random game she has probably never played and say nobody could care about a character in it as much as one in War and Peace.

Prof Greenfield then talked a little about the benefits for children of reading with a parent, and how we need to “make up our own minds”. She finished by advertising her books, and claiming that “mind change is the new climate change, the biggest issue facing us in the 21st century”. I’d share the comments on this claim raised here.

The whole felt to me like a mishmash of pseudoscience, headlines and speculation that didn’t even address the topic of the conference. Even if there was persuasive scientific research about the impact of using digital media (which I wasn’t persuaded), it wasn’t relevant to the conference as babies don’t use it. Her talk wasn’t about the importance of relationships between conception and two, which was what the conference was designed to highlight. She had come with a single agenda to sell. And it was clear that she was very much an outsider looking in when it comes to technology; judging it with minimal knowledge of social media, the internet, or video games.

As someone fairly immersed in that world, I could pick out numerous examples of violence in TV, film and video games, particularly violence against women and children. I might even be able to make a prima facie case that we are being desensitised to human suffering (and violence and sexism is being normalised). It is possible that the manufacturers of such products are buying into various ‘exciting’ neurochemical pathways that deal with arousal and reward (cortisol, adrenalin, dopamine), over those that deal with relationships, empathy, love and the ability to soothe (oxytocin and the work of the prefrontal cortex). But I think Susan Greenfield is making a huge correlation-causality error when she blames new media for people becoming isolated and lacking social skills and healthy relationships. I think there is much more evidence that real life experiences of maltreatment prime certain brain changes that make people more sensitive to later triggers and confer vulnerability for later mental health problems (see the work of Prof Eamon McCrory, for example) than that digital media is the cause of the problem.

I do think that if people lack templates for how to do real relationships in a healthy way, and haven’t learnt empathy and self-soothing skills, then these kind of media have a stronger attraction and a different effect on their brain, and can perpetuate rather than ameliorate this pattern. However, in the end I figure that people can always fill their time with something that disconnects them from others, or anaesthetises their pain. In other words, it isn’t the availability of the internet or video games that is the problem (any more than the presence of cheap alcohol, or drugs), it is the unhappiness and isolation that creates the void people want to fill with those things. And that has much more complex solutions, though it might generate less click-bait headlines.

* It is now nearly 3 years on, and I am confident that the clinicians recruited after I left have been able to establish a high quality service, so I would not wish to imply any concern about the services they provide.

** I felt, cynically perhaps, that there was a second agenda designed to promote the MP who founded the project and her political party which was of more importance than our clinical goals, although this was never explicit.

*** http://www.telegraph.co.uk/women/mother-tongue/familyvideo/9273569/New-post-natal-depression-charity-will-address-huge-gap-in-provision.html

http://www.bbc.co.uk/news/uk-england-northamptonshire-18117945

****The promotional flyer for the event said “We are honoured to announce that Baroness Susan Greenfield, Professor of Synaptic Pharmacology at Oxford University, whose speciality is physiology of the brain will bring you up to date on the Science, Neuroscience and Epigenetics”.