THE USE OF FILMS IN PSYCHOTHERAPY

THE USE OF FILMS IN PSYCHOTHERAPY* MIGUEL PRADOS, M.D. McGill University, Montreal

HE introduction of films as an aid in psychiatry has received consider- T able recognition during recent years. Films have been used for therapy, training and for educational purposes; but very little has been written about the ways and modes in which the film experience produces its effects upon the audience, although those who have been using this medium seem to be satisfied with the results obtained. An understanding of its dynamics is necessary as it will enable us to outline the theoretical principles upon which an appropriate technique for application of this method may be established.

Three years of film therapy have convinced us of the validity of this new technique in group psychotherapy and of the need for further development and standardization of the technique. We also believe that it is not enough to have a series of suitable films at our disposal. We must also know how to use them according to different needs. The therapist must know what he is doing, what is going on in the mind of the audience, what the emotional relationship of the audience is to what is shown on the screen, the impact the film produces, and the kind of reaction he may expect. It is the aim of this article to present an interpretation of the ways in which films may effect some beneficial influence upon patients.

As our experience has been limited to the use of films in therapy, we will discuss the dynamics of film therapy exclusively from a psychiatric angle.

A group of neurotic people who meet together of their own accord in order to find some relief from their symptoms or character difficulties is per se a group qualitatively different from other groups. The neurotic group is com- posed of individuals who suffer, who feel helpless and defenseless in the face of their own difficulties, and who ask and hope to be helped. They are people who have been unable to reach a reasonable degree of emotional maturity and who, in their personalities, show areas that have remained in a very early stage of development. In other words, they keep, to a larger degree than the average population, infantile ways of feeling, thinking and acting. A great understanding of the psychology of a therapeutic group can be gained when we keep in mind Freud’s statement that “Just as primitive man virtually survives in every individual, so the primal horde may arise once more out of any random crowd; insofar as men are habitually under the sway of group formation we recognize in it the survival of the primal horde.” This statement is of paramount importance particularly with therapeutic

* Presented at the 1950 Annual Meeting.

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groups, because their members, owing to their emotional immaturity, more than other people, retain trends and modes of behavior of the primitive individual and, for that matter, of the child.

A therapeutic group is a rather compact and solid type of group; its members are bound together through identification as the result of having substituted one and the same object for their ego ideal, in this case, the therapist. One can observe a restriction of their ego, a focusing of thoughts and feelings in one direction, and an emergence of the unconscious mental life with all the characteristics of the primary process with its loose organiza- tion, its symbolic ways of thinking, the magic and animistic interpretations and the primary type of object relationship.

In other words, there exists a considerable regression t o very primitive levels of the libidinal development with a breaking of the secondary narcissistic barriers. As a result, the type of object relationship between the members is based on identification and/or incorporation and introjection. Their mechanisms of defense are mostly projection, denial and displacement. There is also a tendency to immediate carrying out of intentions, as they emerge, in an acting out which it is very important to supervise closely.

Freud has compared the emotional situation of the members of a group of this kind to the state of hypnosis. “Hypnosis,” he says, “is based entirely upon sexual tendencies that are inhibited in their aims and substitutes the object for the ego-ideal. The group multiplies the process; it agrees with hypnosis in the nature of the instincts which hold it together, and in the replacement of the ego-ideal by the object; but t o this it adds identification with other individuals which was perhaps originally made possible by their having the same relationship to the object.”

This point is particularly true in our therapeutic groups. Before he joins the group each patient-member has a series of individual interviews with the therapist until a good rapport has been established; the patient is then quite willing to attend the meetings. In the group, the patient learns to share with the other members the attention of the therapist which he would like to have exclusively for himself. Because of what we know of the psychology of the group, this renunciation of the all-possessive and egotistic love of the therapist is accepted without much feeling of frustration. The patient learns that he cannot obtain what he desires, and the realization that the same thing is true for the other members forms the basis for his identification with them. In that way the emotional tie to the therapist is desexualized and the group is made cohesive.

One of the most important aims of psychotherapy is t o help the patient to gain insight into the nature of the emotional relationship between himself and his therapist; in group therapy, to gain insight into the nature of the relationship between himself, the other members and the therapist. H e must

38 THE USE OF FILMS IN PSYCHOTHERAPY

learn to feel that he is reliving, in what is supposed to be an adult therapeutic setting, his own infantile family situation, a result that has to be attained through a constant reality testing. Any awareness of this creates the strong- est type of resistances in the individual as in the group.

On the other hand, the individual in the group feels safe because his instincts have been inhibited in their aims, and this makes the relationship with the therapist and the other group members relatively free from instinctual anxiety. consequently, any attempt to bring insight into the real infantile libidinal or aggressive nature of the ties meets strong resistance.

It is precisely at this point that film therapy is of great value, according to our experience; that is, when well handled, the film experience helps the group to break through this kind of resistance to a large extent. This is due to the fact that the film experience effects a deep impact on the unconscious system by very efficiently shaking the barrier of repression. There is an ac- centuation of the regression of the group to still more infantile levels. The therapist ceases to be a father image only to become more like some kind of “loving mother.” The whole group regresses still further as a result of the complete change that takes place during the performance of the film.

This further regression that the group experiences is significant and may be of high therapeutic value if it is clearly understood and manipulated by the therapist, or it may become an obstacle to further progress and insight.

When the group is told that it will be shown a film, there is a great deal of excitement and cheerfulness among the members. They begin to ask ques- tions about the film, the producer and so on; they feel very impatient and extremely disappointed, resentful and angry with the therapist if, because of some unexpected difficulty, the film cannot be seen at that meeting. One can easily observe that the relationship to the therapist has changed completely; the whole group experiences a feeling of anticipation and expectation much akin to the forepleasure felt in any sort of love relationship. I n other words, the group becomes passive, receptive and demanding. At the same time it becomes very submissive with a kind of childlike compliance as though it has been promised a reward for good behavior.

This passivity and receptiveness is augmented by the external factors in- volved in every film performance. External stimuli are reduced to a mini- mum because of the darkness of the room and the silence. As with the individual who is going to be hypnotized, the attention of the group is concen- trated on the luminous screen. Without using words the group spontaneously submits t o this restriction of ego functioning. The therapist is almost for- gotten by the group because all the dependency has been shifted to the screen and temporarily removed from the personality of the leader. It seems as though the members, in becoming aware of the intensity and primitiveness of their instinctual impulses toward the therapist, attempt a defense of the

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ego by displacement of their attitude toward the therapist to the material on the screen. This shifting from therapist to screen is so complete because of the protection that it affords for the ego of the group which, as the result of the regression experienced, has become much weaker.

Another very decisive factor instrumental in the breaking through of the repressive barriers and the consequent intercommunication that takes place between the preconscious and the unconscious systems is specifically the “optic” or pictorial character of the images that stimulate the percep- tive end of the psychic apparatus of the group. It is known that visual images are much better able to establish contact with the unconscious, which is mostly pictorial and symbolic, in opposition to the preconscious, which is mostly verbal and conceptual. This explains the obvious fact t ha t the audience pays much more attention to the visual than to the auditory aspect of the film.

We can gain a considerable amount of understanding of the way in which film therapy acts by comparing the film to the dream experience. After all, the way in which the group prepares itself to see the film is very similar t o the way in which people prepare themselves to go to sleep. As in the subject who seeks sleep because of his inner needs, there is here a similar kind of narcissistic withdrawal. For in the group there is a hypnoticlike compliance because of the pressure of the therapist’s suggestion.

The latent content of the dream is based on old infantile memories which are striving for expression. These memories are mobilized by the daytime experiences of the individual, and from these experiences appropriate and useful elements are chosen for the dream work. If thoughts are transformed into visual images in the dream Freud thinks it is “because of the ‘attrac- tion’ exercised by the visually represented memory striving for resuscita- tion, upon the thoughts severed from consciousness and struggling for expression.” The visual, kinetic and auditory images of our special films facili- tate immensely this type of work on the unconscious, not only because of their “thought content” but mainly because of their sensorial, mostly pictorial character which, breaking through the preconscious system and its barriers, establishes contact with actual infantile memory traces which were barred from consciousness by repression.

On the screen, as in a dream, the individual “sees” thoughts and feeling pictorially. Envy, rivalry, jealousy, aggression and hostility, like love and affection, are no longer concepts or words that can easily be denuded of feeling, but concrete images in action as in the primary processes overcharged with instinctual energy. Moreover, in the group situation these images are “given” to the patient, offered to him with love as it were; and he is even encouraged to express himself similarly without restriction, prohibition or limitations of any kind.


The member of the group under the afore-mentioned conditions has re- gressed to a very early oral passive stage. Consequently, the images, seen and heard in the film, are incorporated through his eyes and ears which have become “oralized.” This incorporation is equally effected with the loved as with the hated object-image. H e absorbs the different characters of the film, loves and hates when the character loves and hates, and laughs with the image. This complete integration of himself and the image per- ceived helps him to become aware of identical emotions and impulses without feeling too much fear or guilt. It is also important in the mobilization of memories. The possibility of an acting out of affects would be much greater i f it were not for the fact that in using projection and displacement as mechanisms of defense, he lets the pictorial object act for him, and in this way he gratifies his id impulses vicariously and a t the same time feels safe against the danger of carrying them out. These two mechanisms also help the patient in the group to protect himself against the anxiety of the intensity of the impulses connected to the infantile memories that emerge so strongly during the performance. Of course there are other factors, such as the group setting and the identification with the other members, that help him to feel safe and reassured in spite of the stirring up of affects produced by the film experience.

Nevertheless, if the therapist does not proceed warily, there is a possibility that this experience may bring the patient and the whole group into difficulties. The group feels aggressive and hostile toward the therapist, especially after the film is finished. The feelings of the inembers of the group toward him are always ambivalent though they may be unaware of anything but devotion and compliance. We know that no psychotherapy can achieve final, permanent results unless the patient is able to become aware of the ambivalence of his feelings toward the therapist and has learned to accept it. Though this awareness of hostile feelings is absolutely necessary, the therapist must learn to detect it rapidly and watch its mani- festations in order to prevent the possible disruption of the group and thus endanger any chances of beneficial influence.

Once the performance of the movie is over and the lights are on again, the emotional situation of the group changes completely. The immediate reaction of the group is one of disappointment and resentment simply because their passive oral strivings are no longer satisfied. The therapist is no longer the motherly provider of narcissistic supplies and the group feels that now something is expected of them. As a rule, the hostility because of this frustration of the oral passive tendencies overlaps the still mild need of the members to live up to the expectations of their therapist. This period of transition before the group regains the prefilm-experience condition is mostly pervaded by hostility and aggressiveness. This is when the therapist,

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without endangering the beneficial effects of the insight that the members should gain by their hostility, must make use of his skill to prevent too much expression of hostility that might be group-disrupting. I t is particularly important to watch closely the behavior of those members who might be most group-disrupting, because of the possibilities that, if left completely free, the rest of the group would identify with them against the therapist. I t is not difficult, however, for the therapist to check the expression of these more or less destructive impulses.

Generally speaking, immediately after the film there is a period of silence. This silence is an expression of the perplexity of the ego which finds itself caught between new stimuli coming from without and a flood of old memories which have been recathected. Besides, like the individual who has awakened, the group feels frustrated at the end of the film. Just as the dream has the function of keeping the individual asleep, so in a similar way is the film performance gratifying for the group, and they feel upset and angry in being deprived of this gratification. The silence is secondarily used as the safest way to express resentment and hostility toward the therapist, who they feel is responsible for the frustration. After this period they usually begin by making statements dealing with the film in general from the standpoint of the film technique. A very common way to express hostility is to compare the film with commercial films or to criticize the photography and sound, etc. Complimentary remarks about the film generally express the individual’s feelings of guilt.

Hostility may also be expressed by trying to ignore completely both the film and the therapist during the discussion period. In this case, the material that the group brings into discussion is connected to the relationship with the parents or superiors, that is, related to a dreaded or hated infantile type of superego. In such instances the group is generally permitted to discuss this material freely, but toward the end of the meeting it is suggested to the group that the discussion may have been intended to express more or less repressed feelings of a similar nature toward the therapist. The results of this technique are generally very satisfactory. The group members always admit this interpretation of transference jokingly and with surprise, and they let themselves express their feelings openly without guilt or anxiety. Interpretations, explanations and justifications are given by the members: they were too upset by the film, it was not long enough, they were disappointed, they expected the therapist to make comments and so on. This is quite a constructive type of reaction which we frequently find in groups that are rather advanced in their therapy. It is important to insist upon the fact that in group as in individual psychotherapy, patients may try to avoid any situation of conflict with the therapist by using the parents as a resistance in the transference. Until this point is clearly understood by the patient one


cannot expect positive results. By talking the way “they are expected” the patients are trying to fool the therapist and actually are avoiding insight.

It is important, nevertheless, to keep in mind that the hostility toward the therapist persists, though in a latent state, throughout the whole period after the performance and may last for several days and even weeks. There- fore, in order to help the group release the material of memories which are striving for expression, the free expression of these feelings must not be thwarted. Deep interpretations may be necessary to enable the group to express hostility without its being disrupting, and the effect is much more beneficial when such interpretation is made by a member of the group rather than by the therapist. It is amazing to see with what readiness the patients accept interpretations made by a member, whereas they may resist those made by the therapist. We have found it a very good technique to ask one member of the group to interpret another member’s expression of hostility toward the therapist. In this way the member, identifying with the therapist, supports him and prevents the destructive effect without dim- inishing the possibilities of insight.

The therapist also has to be aware of the fact that if the hostility is not expressed, a feeling of guilt of varying degrees will persist and this may jeopardize any further expression of relevant material.

At this point we want to make a remark concerning the length of the film used for strictly therapeutic purposes. From what has been said, it is clear that the period of discussion after the performance is not only necessary, but that it must be long enough to help the patient abreact, inside the group situation, all the affects that have been stirred up by the film. Otherwise the whole experience will be useless from a therapeutic standpoint or will only intensify the resistances of the group. In our experience, we have found films lasting not more than thirty minutes the most suitable for the purpose. In this way, there is a t least one hour left for the discussion.

Another reason why the performance period should not be very long is that, as already mentioned, the film experience is rather id-gratifying for the patient and it stimulates regression and passivity. In other words, the patient’s own neuroticism is strongly stimulated. If the film is too long the group will become more and more demanding and more and more hostile, and the results can be therapeutically negative.

This acute period of hostility can be considered practically overcome when the members begin to make comments about the behavior of the different film characters. These comments are provoked by the identification of the patient with certain characters and may be either of a positive and/or a negative type. Both negative and positive feelings can be seen to be operating simultaneously when, for instance, one patient tries to justify

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the favorite character’s behavior by making another character responsible for it. This identification with a character is very upsetting for the patient! It stirs up a considerable amount of anxiety manifested in feelings of self- contempt, anger or self-pity, but it is rather constructive because it en- hances the determination to change as the result of this splitting of the ego so necessary in the psychotherapeutic process. The therapist must be very alert in order to help the patients see the constructive nature of these feelings and support their struggles in this important moment.

The patients begin to associate their own memories if the discussion lasts long enough or in the next meeting. These memories may be similar in nature to those seen in the film, but it also happens that they liberate all kinds of infantile memories stimulated by little pictorial details acting as stimulators for the unconscious in the identical way that the day experiences do in the dream work.

This point is of importance in the production of films for therapeutic use. The visual aspect of the film is much more important than the auditory one, including the dialogue and the comments. The visual and the auditory aspects operate a t different levels of the psychic apparatus, and the pictorial images of the screen travel directly to the unconscious system, charging the memory traces with instinctual energy.

The impact of the film on the patient’s unconscious lasts for a long time. As a matter of fact, we have a good deal of material collected on patients who, weeks and months after having seen the film, were able to utilize the mental representation of the film for an understanding of their own behavior in difficult life situations. Some typical examples are presented:

On the same evening that he had seen the film Overdependency, a patient had the following dream, which was obviously stimulated by the sequence of the tonsil operation.

“I dreamt I was at a group meeting in my own living room. It consisted of eight or ten people of both sexes, but all unidentified. I left the living room to go to the kitchen, and an unidentified doctor came in with a very old man in his arms. H e was poorly dressed and his shirt and pants were separated, showing his genitals. The doctor laid him on the table and said: ‘I can’t take him to the hospital in this condition for obvious reasons.’ The old man’s penis (very large) was all wrapped up in blood-stained rags, and I had the feeling that it was lacerated and scratched instead of having been cut. The doctor said: ‘Although he is 92 he insists on going out once a month and this always happens, and I have to fix him up.’ The next scene wasibackiin the living room, where a motion-picture projector and a screen had been set up, and the group was still there with Dr. Prados standing in front, and he announced he was going to lecture on and show a new film to show ‘how anxiety arises.’ ”


The discussion of this dream was extraordinarily important in helping the group to understand the castration anxiety and the role of the father and of the therapist. Consequently, the group was enabled to connect the past with the present therapeutic situation. During this meeting we were able to discuss and make very clear the mechanism of denial. When the patient described his dream in the group, another member immediately connected with it the afore-mentioned sequence of the film. He was interrupted by a third member who flatly denied that there was any operation seen on the screen. It was only when the whole group began to mention details about it that he could remember the scene. H e was amazed a t his not having paid any attention to it. It was a t this time that the mechanisms of denial and repression were clearly discussed and accepted. The same patient was able to bring a great deal of material related to it back to consciousness.

The next example demonstrates how a patient was able to solve an important situation in his life which had left him entangled for weeks without being able to make any constructive decision.

A male in his late thirties, suffering from stage fright and other conversion symptoms, decided, during the course of his therapy, to start practice in his former profession which he had given up several years previously. H e had been very successful a t the time but gave up because of his neurotic ambition. I n the meantime his older colleagues had set up a Society with certain standards and necessary qualifications of their own, which, though different, were obviously inferior to those of the patient who was a graduate of a highly qualified European school. They denied him his license. H e felt badly rejected, unjustly treated and very anxious, but behaved submissively and politely. H e could not take any action and was considering giving the whole thing up. H e did not mention any of these problems in the group meetings. One day the film Feeling of Rejection was shown to the group. Contrary to his usual custom, he was silent during the discussion. At the next group meeting a week later, he arrived feeling very happy and said, “Margaret [the name of the main character of the film] has cured me.” He then, for the first time, told the group about his worries in connection with his license. Then he said that when he had been worried, thinking about what action he should take in order to accomplish what he wanted, and not being able to find any suitable solution, a “flash” came to him of the scene in the film in which Margaret felt very rejected when a group of friends ignored her as she was passing by. He felt very sorry for her, when suddenly another picture came to his mind. This time it was a childhood memory of a rather similar kind, in which he was not accepted in a group of children who were playing and he remained alone, crying, and said, “They don’t want me to play with them.” H e then connected his present situation about the license and his actual reaction about it, and felt that he was reacting as

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he had when he was a child. “They don’t want me to practice.” H e felt very happy about the association, and this helped him to correct his behavior and act in an adult way. H e went to see a lawyer who wrote a letter to the president of the Society, with the result that they granted him his license immediately.

The following is a similar example as described by the patient herself in a letter to the therapist.

“Being a very visual person, I have found that looking a t pictures helps me to remember facts more easily. No amount of talking about m y jealousy of my sister and resentment of my mother could be as vivid as seeing the actions on the screen. ‘The Story of Margaret’ impressed me greatly. I could see myself as Margaret in so many scenes. My history does not coin- cide with Margaret’s in many parts, but certain situations shown on the screen ‘hit home’ with a terrific force. The picture has also served to pro- duce continuity of my memories. I have not seen the picture in many months. Yet last week when in the course of my therapy I discovered some hidden jealousy toward my sister, my thought was ‘Now I know how Mar- garet felt.’ Whenever I have a headache I visualize Margaret and her conflict between aggression and passivity. This usually produces a stream of consciousness which finally resolves itself in a satisfactory answer.”

These examples show very clearly that the film experience leaves a highly cathected memory trace which is easily and quickly mobilized by the daytime experiences and acts as a stimulus that reactivates a series of repressed memories which consequently become conscious. Insight takes place as the result of establishing a connection between the actual and the old repressed in fan tile thought.

A second showing of the same film some weeks or months later produces a somewhat different reaction. The group shows a tendency to interpret rather than to judge. Repression is softened not so much because of the ego’s being overwhelmed, but because there has been a rather strong diminution of countercathexis. The memories expressed are much deeper and in many instances they come from the very early years of life. One can see that patients, prone to developing autoplastic symptoms, can also make their own interpretations. During the discussion of the second showing of the film Hostility, a patient with neurotic depression and slight phobias, who was very preoccupied with bladder functioning as the result of an early and trau- matic bladder training, said, when she noticed strong perspiration on her hands, “Am I urinating with my hands. . . ? Perhaps I am wetting my bed. . . .

There is also less tendency toward identification and projection, and this detachment helps the patient pay greater attention to the film, finding numerous details which could not be seen in the first showing and which

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he interprets spontaneously without anxiety. For instance, a patient was able to make an interpretation of the symbolic meaning of a short sequence in the film Rejection, in which the little girl Margaret tries to saw off the screwdriver which her father is using in making repairs. Consequently, in order to obtain positive results, during the course of therapy it is advan- tageous to repeat the showing of the same film at least twice, with a long interval between showings. The resentment and disappointment felt by the group when they notice that they have already seen the film are expressed in hostility toward the therapist. The expression this time, however, is much less violent and is seldom disrupting.

As a result of our experience, we also believe that the same group should not be shown a new film until about three weeks after the showing of a previous one. Although actually the material mobilized by the group out of one film is difficult to exhaust in this short period, we nevertheless feel that after two or three weeks the group is prepared to see a new film, as during this interval there has been a certain cooling off of the film impact.

Our experience has thus far been limited to the use of three films which were originally produced for therapeutic and teaching purposes though they have also been used for educational ones. In these films emphasis has been mostly on certain mechanisms of defense. Concessions have had to be made especially in captions and comments, but also in accuracy. Practically nothing has been shown that could help in the understanding of the genetic libidinal development of the personality and the influence of the family constellation upon it. There has also been very little and only superficial presentation of symptom formation. The results obtained with these films are nevertheless rather interesting in our opinion and should encourage psychiatrists interested in group psychotherapy to promote the production of newer films in which the producer and the psychiatrist should cooperate closely without any restriction or concessions and with the only goal that of helping our patients.

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THE USE OF FILMS IN PSYCHOTHERAPY