“I’m going to outlive you. Both of you.”
“In fact I’m going to make a point about it. I’m going to inherit from her and not the other way around.”
“And the day of her funeral, I shall give a little speech. To remind everyone how heartless and manipulative she was.”
Anthony to his daughter Anne, The Father (2020)
These excerpts, although appear as perhaps a wronged father ranting about his daughter’s misgivings at the first glance, are a much more acute and guttural peek inside the failing mind of an old man whose fabric of reality twists into a muddled knot with every turn of the phrase. First-time director Florian Zeller who also co-wrote the screenplay, drawing from his own experiences of his grandmother’s illness, paints a brutally alive and utterly chaotic picture of what it means to suffer from dementia, a disease of memory, thoughts, and other higher-order brain functions.
There have been quite a few movies depicting this devastating condition: The Notebook (2004), Away from Her (2007), Still Alice (2015), Elizabeth is Missing (2019) to name a few, which took an honest but somewhat narrowed and diluted view of the condition. That is where this movie punches out a refreshing narrative by stepping right into the pinching shoes of the sufferer himself. Maybe, for the first time in cinematic history, the viewer gets a first-person experience of the sense of bleak obscurity this disease entails. For a certain time, the audience feels as dazed and confused as the character on the screen who is gradually losing his “clarity of thought” due to dementia. The viewer experiences the character who is suffering from the erosion of memories. For some time at least—the audience, the actor, the character, the lives and living are all but one. There is no telling them apart and that is where “The Father” really stands out. As the intricate screenplay takes a non-linear narrative, the reality and fading memories of the protagonist get blurred, with recurrence of events and conversation, something so common in our clinical assessments of neurocognitive disorders. In the words of the Guardian, “Hopkins gives a moving, Oscar-winning turn as a man with dementia in a film full of intelligent performances, disorienting time slips, and powerful theatrical effects. It results in a picture that peers into unexplored social corners of a devastating illness.
From the medical viewpoint as well, this movie ticks most of the boxes. Besides the obvious forgetfulness and confusion that is running in the backdrop for the entirety of the movie, the character goes on to display the whole gamut of human emotions and behavior. From extreme apathy toward his only surviving and caring daughter to begging her not to abandon him, from violent outbursts of anger to crying out in abject helplessness, from utter disgust toward his son-in-law to a fervent paranoia toward everyone in vicinity—none of the colors in the dementia palette are left untouched. We easily recall the symptom dimensions of behavioral and psychological symptoms of dementia (BPSD), not just as a checklist used in rating scales but as a lively portrayal of how debilitating they can be! The sudden jarring shifts in the persona are the lessons to behold—a pompous, grandiloquent octogenarian turns into a tearful, babbling toddler asking for his mother to come to fetch him. Conspicuously woven into the story are his affable confabulations—from being a tap dancer to being a performer of note in the circus. With any lesser director at the helm, the plot could have been easily subverted. Of course, to avoid complexities, the movie has not gone into the diagnostic nitty–gritty though from the course of progression and predominant involvement of learning and memory, “The Father” was likely suffering from Alzheimer’s disease. Importantly, the individual living with dementia in this movie takes us beyond the categorical diagnostic classifications of psychiatric disorders to a continuum of the evolution of the symptoms and how they influenced his “social identity” and the lives of his family.
The movie craftily combines mystery and psychodrama to depict the “leaves falling apart” in the protagonist’s life due to the progression of dementia. People, surroundings, environment, and time itself become confusing and slippery. Although both the audience and the Father attempt to piece the puzzle together, Zeller’s subjective approach weaves the story through the protagonist’s distorted memories. It is a scary, brutal yet simple narrative backed by a unique product design that manipulates “when, where, who” of the Father’s cognitive abilities. This takes us through the different stages of dementia and the challenges faced by the individual and his family.
The obvious first-person camera tricks also put us inside the main character’s head. The dichotomy between reality and conversation becomes increasingly apparent through time. The identity of people gets muddled (the protagonist sees his deceased daughter in carer), situations get elided, furniture of the apartment changes (illusions/hallucinations), sudden mood swings and fits of temper ensue (delusions and other behavior problems), and sequence of events appear to reverse. The theatrical portrayal of the protagonist’s life and his relationship with family members are powerfully achieved. Coupled with superb cinematic performances, this makes Father a narrative of grief; grief related to the loss of memories, identity, autonomy, and independence, even when the individual is alive but slowly “falling apart.”
This movie also throws up many pertinent but unanswered questions and dilemmas. How does one deal with such a catastrophic malady? There are a few medications such as cholinesterase inhibitors that are found to be useful in the early periods of the disease but with an advanced condition, the medications are not that helpful. And the next question arises about dealing with the frequent anger outbursts, the lability of emotions, the paranoid and suspicious behavior that mars the daily life of these patients. There are certain antipsychotics and mood-stabilizing drugs that are available to control such symptoms, but they come with their own specific sets of hazards. They increase the chances of patients developing metabolic disorders (such as diabetes) or worsening them if they had one, to begin with. They are known to increase the morbidity in such patients by directly causing cerebrovascular accidents. They are also known to lead to frequent falls in this age group and may prove to be counterintuitive. These drugs are also sedating in nature, so they may lead to increased lethargy and sleepiness, leading to more confusion and disorientation. Thus, each case is unique and the drugs are prescribed according to their tailored risk-to-benefit ratio. Environmental, ecological, and behavioral modifications along with dignified care, advance care planning, and empathy have been proven to bring some respite in most individuals living with dementia. The management strategies shown in the movie are well-researched and evidence-based, in-keeping with the recent National Institute of Clinical Excellence (NICE) 2018 guidelines where non-pharmacological measures have been recommended as the first-line for dealing with BPSD and medications are to be tried only when the behavioral symptoms lead to significant risk to the self or other and are sufficiently distressing. The plot of “The Father” reinforces that and enables us to see the “individual” with the illness besides the “patient.” Dignity and autonomy, important constructs for an individual living with dementia are reflected in The Father’s constant efforts to retain his identity. Hopkins (the protagonist) comments, “I don’t need any help from anyone. And I’m not going to leave my flat. All I want is for everyone to move off. Having said that… it’s been a great pleasure. Au revoir. Toodle-oo.”
The movie also throws the patient and the caregiver relationship into the ring. Olivia Colman as Anne brilliantly manifests for all to see—the painstaking job of keeping up with the taciturn behaviors of patients with dementia. The double jeopardy of “losing the identity of an individual while still living” along with the burden of BPSD can estrange the caregiver, which is considered a potential risk for decreased care, worsening cognitive decline, and abuse. As the worsening of “The Father’s” mood in the movie, most studies have shown that BPSD predicts cognitive outcomes in dementia as well as caregiver stress and mental well-being scores. It can wreak havoc on the caregivers’ personal and professional lives, ultimately leading to complete burnout and total breakdown of the family structure. There are several studies on caregiver burnout, testifying to this debilitating phenomenon. As a result, these caregivers are still grappling with severe mental and physical health issues while battling an already uphill task. Also, this brings forth the moral conundrum of banishing one’s affected parent or family member to institutional care or keeping them at home and risking a turbulent house atmosphere. End-of-life care and dilemmas are the other offshoots. The decision is not an easy one to make even for the most erudite and rational of the persons. As in the case with this movie, due to limited or poor insight into this progressive disease, patients do not feel that anything is wrong with them. They just want to lead a normal retired life at home and are often stubborn and traumatized with the question of being institutionalized. They are very reticent and rigid about asking for help lest it conveys some form of weakness and subordination on their part. But sadly, sometimes this is the only option to consider taking into account, its toll on the family and the caregivers. Once again, in line with several treatment guidelines, the movie upholds the need for caregiver support, empathy, education, and training.
It is quite true that any form of art is a product of its time. The same holds true for this piece of intricate workmanship. There has never been a more honest and lucid portrayal of this debilitating infirmity. Anthony Hopkins as the retired and amnesic engineer (the protagonist) delivers a virtuoso performance that is almost as epiphanic as banal. He is delightful and despairing in equal measures. Be it light-hearted tap dancing or his quirky obsession with his watch—he seamlessly transfigures between his actions and obsessions. His Oscar-winning feat will hopefully serve as a prelude to the gory realizations of the trials and tribulations of all the people suffering from this condition and hopefully, we can find some effective manner of mitigation. As mental health professionals, we are also hopeful that “The Father” will foster awareness, fight stigma, and help the public get near the truth of “living with dementia.” Hopefully, this movie will go down in the annals of cinema as one with a mighty heart and a moving deliverance.
In line with the World Health Organization (WHO) Global Action Plan on the public health response to dementia 2017–2025, holistic care is warranted for individuals living with this debilitating illness and their carers based on rights, empowerment, evidence-based practice, equity, universal health coverage, prompt attention, and multi-sectoral collaboration. Individuals living with dementia deserve healthcare on the principles of dignity, respect, autonomy, and human rights—free from stigma, discrimination, and abuse. Considering dementia as a public health priority, information systems and dementia awareness/friendliness are central to this approach. On the background of such a global approach and the predicted worldwide dementia prevalence to triple by 2050, this movie brings in an empathetic, lively, touching yet realistic understanding of living with dementia as well as dementia care, both for the general public and medical fraternity alike.
Anthony as “The Father,” even while forgetting, best sums up his affection and plight in his own profound words: Anthony: I feel as if I’m losing all my leaves.
The Woman: Your leaves?
The Woman: What do you mean?
Anthony: The branches and the wind and the rain. I don’t know what’s happening anymore. Do you know what’s happening?
As physicians, mental health professionals or caregivers of individuals living with dementia, we cannot resonate more.
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