With the Oscars just days away, the films that are nominated as the best of the year can illustrate much of the work we face each day as psychiatrists.
Due to its pervasiveness, the leaching landscape of substance abuse provides fertile ground to cultivate the dangerous seeds of co-dependency. As professionals who chose to dive headfirst into all makes of dysfunction, psychiatrists and other mental health professionals likely encounter this behavioral and emotional phenomenon often. It may present itself as the overly avoidant patient who’s loved ones enable their misanthropic tendencies. Or perhaps you have enough self-awareness to recognize the patterns of co-dependency in your own life? Unfortunately, if we look at one particular subset of the population, it is obvious that the number of people who find themselves in such a dyad, far surpasses the number of mental health professionals there will ever be at one time. According to the WHO, some 31 million people suffer from some form of substance abuse. Of that 31 million, it is estimated that about 4 million of them suffer from alcohol use disorder.
As you can imagine the with diversity that exists amongst the millions of people who suffer from the disease, alcoholism can look different depending who you talk to. The illness can run the gamut from fairly inconspicuous to severely debilitating. While the media does not always do a good job at portraying the many facets of the illness, even fewer outlets do so while being honest and disturbingly entertaining. A Star Is Born, a film produced and directed by Bradley Cooper and starring himself and Lady GaGa, manages to do just that. This is the fourth remake of the film, which was first released in 1937 and originally starred Janet Gaynor and Frederic March. The 1954 versions cast Judy Garland opposite James Mason, and a later much acclaimed version starred musical powerhouses Barbra Streisand and Kris Kristofferson in 1976.
This version, however, feels more befitting for our time. Not only does the film give us a front seat to the wild ride that is a viral rise to fame, but it also poignantly illustrates the mosaic of tenderness and cruelty that sustains co-dependent relationships. Although the term co-dependency is now broadly used to describe any type of unhealthy relationship that people can share with those close to them, it initially was reserved for partners of chemically dependent persons. Although prior versions of the film touched on the issue of alcoholism, Cooper's film does so whilst acknowledging its place in the broader landscape of substances, specifically pharmaceutical drugs in the form of sedatives, hypnotics, and painkillers. According to the National Institute of Drug Abuse, eight to 12 percent of those who are prescribed an opioid will develop an opioid use disorder. Due to their similarly sedating effects, it is common to find the abuse of alcohol and pharmaceutical drugs in the same users. As the current opioid crisis has unfortunately reminded us, an individual's relationship to substances of abuse often start as a legitimate therapeutic modality. So is the backdrop of Bradley Cooper's character Jackson Maine, a now fading country music star who suffers from the untended emotional scars of generational trauma, and the physical scars of chronic pain and premature hearing loss. Littered throughout the film are a deluge of drug paraphernalia and problematic behaviors. Jackson maintains his limp grasp of fame on a regimen of alcohol, steroid injections, prescription pills, and self-loathing.
A brief, but memorable moment, was when Bradley's character Jackson Maine used the weathered heel of his cowboy boot to crush an assortment of pills, which he promptly snorted, before sprinkling its remnants into a glass of dark spirit. Whilst the scene had the desired effect, I realized later the shock I felt was misplaced. His behaviors are neither far-fetched or uncommon, and as physicians we try to approach that cognizance without judgment. Similarly common, was a scene where for the first time Ally sees an inebriated Jackson black out drunk. The man who a moment ago was charming and quick witted, became pathetic and sad. It was foreboding. It should have served as a warning for her—every fiber in me wanted to grab Ally and yell RUN!
But she didn't run. And I can't tell you exactly why. Of course, there are beautiful moments, like when Jackson coaches Ally through the jitters of her first recording studio session, or when he nursed her swollen fist with frozen packs of vegetables. But accompanying the tenderness was also darkness. While there was no instance of physical violence between them in the film, the trauma was there. It took the form of jealousy, self-sabotage, enabling and denial. Like many partners of people suffering from chemical dependency, Ally finds that an integral part of her identity and her happiness, are tied to Jackson. This fact can be lost on physicians, that addiction treatment must not only consider what the addiction does for the addict, but also what it can do for the recurring key players in an addict's life.
As I said, I could not tell you exactly what Ally was thinking. But I can tell you that whatever she was thinking, it would have helped her to share those thoughts with someone. Psychotherapy, while almost globally recommended for those who suffer from substance use disorders, is often overlooked as a resource to their partners. In an environment where healthcare is not universal, assuring that these resources are affordable and accessible to populations that need them, is nearly impossible. Every effort should be made to offer resources and referrals that are not only clinically appropriate, but also economically feasible. Though we are not treating the family, frequently the notion of family or individualized therapy should be raised for partners and immediate family, as our patients are better served by a network of individuals that are themselves mentally robust and supported. In the film, the music seems to serve as a poor replacement for therapy for both of the main characters, with unfortunate consequences, reminding us that the movies are not always what we want to see in real life.