Clinical Psychiatry News
Dr. Roland Atkinson

... Another film that reprises the themes in King of Hearts has arrived from Russia. House of Fools, an anti-war film written and directed by Andrei Konchalovsky, tells a story loosely based on real events in 1996 at a psychiatric facility somewhere on the Chechnya-Russia border, shortly before the first cease-fire in the war between these forces. The hospital is old and understaffed, run by a kindly, diligent psychiatrist. The patients are a mix of actors and authentic chronic inpatients: a wheelchair-bound man with severe cerebral palsy; another with severe contractures from sitting neglected for too many years, who hobbles along in a near-seated posture; a woman with Down syndrome; an old man with psychotic depression who needs tube feedings; and sundry others.

Three of the actors stand out. Vika (Marina Politseimako) is a stout older woman, a communist of the old school, a somewhat manicky, officious sort who loves to bully others. The two central patient characters are Janna and Ali. Janna (Iuliya Vysotskaya) loves music. When she plays her accordion, often at times of tension on the ward, the music ignites her fantasies: The ambient light glows warmly sunny, and she imagines everyone singing and dancing gaily around her. She also has a fantasized love relationship with her favorite pop singer, Canadian Bryan Adams. Adams (playing himself) often appears to Janna – whether these are internal fantasies or frank visual hallucinations is uncertain. Janna also helps look after other patients in her nervous, hummingbird style. Ali (Stanislav Varkki) is a diffident, blunt schizophrenic poet. But he is also a respected natural leader among the patients; even the formidable Vika demurs to Ali's orders. Life clamors along, never dull but, given the patterned eccentricities of its citizens, more or less routine and predictable, as befits a typical chronic ward.

And then one day all hell breaks loose. The trains stop and the phone goes dead. Both nurses flee to their homes. The doctor goes off in search of buses to evacuate the patients. Artillery explosions rock the hospital. War between Muslim rebels and the Russians has arrived, uninvited. Rebels occupy the hospital. The patients are scared witless, but then things quiet down. The soldiers now simply dig in to rest and wait. They are mainly good-natured. As in most films about the Bosnian war, small ironies abound. One rebel wears a Calvin Klein logo T-shirt under his flak jacket. Two others trade marijuana for ammunition in a deal with Russian soldiers during a temporary truce. The rebel commander and a Russian tank officer discover that they had fought together in Afghanistan. A running joke develops among the rebels that one of them, Ahmed (Sultan Islamov), wants to marry the attractive Janna, who takes this notion seriously, anguished at having to renounce her (imagined) betrothal to Bryan Adams in order to give herself to Ahmed.

After a few days, a Russian counterattack erupts. Artillery, a helicopter gunship, and tank and foot soldiers invade the hospital grounds. The rebels scatter: Most leave, a few hide inside. Janna, histrionic, joins other patients hiding in the basement. The doctor finally returns. He restores order and also treats a Russian captain for acute stress disorder. (The captain swears the doctor to secrecy about his need for help.) At the end Ahmed – the only rebel still alive on the grounds – turns up in the dining room, masquerading as a patient to avoid detection (a ploy Pvt. Plumpick had also used). The others provide him cover. He is safe. Janna is pleased. No patient has died.

When used in a geopolitical context, the term "asylum" has always carried a positive meaning of safe refuge. When we speak of asylum for the mentally ill, however, different images come to mind. Whether positive or (much more typically) negative, most views are simplistic. The theme implicit in King of Hearts – that mental illness is an eccentric yet sane strategy to cope with dangerous forces set loose in the world – was thoroughly worked over in novels, plays, and movies, as well as in the professional literature, throughout the 1960s and beyond – to the point of becoming cliched by the end of the '70s.

For example, Mike Nichols' 1970 film Catch-22, based on Joseph Heller's 1961 best-selling novel about airmen in World War II, pushed an ironic idea to its logical extreme. At a time when there were insufficient forces available (shades of Iraq), soldiers were becoming mentally unhinged from the stress of flying combat missions too frequently; at the same time, anyone who asked for hospitalization, for treatment, obviously displayed good judgment, proving he was not mentally ill and thus capable of continuing flight duty. Sidney Lumet's 1977 film Equus, adapted from Peter Shaffer's 1973 play, extended this notion to the everyday world: Richard Burton, as the psychiatrist, laments the insane world that drives his young patient to seek refuge in mental illness, a saner alternative as Burton's psychiatrist sees it. The idea of illness as a twisted strategy to maintain sanity among even more irrational family members had been introduced in the 1960s, in the writings of the maverick British psychoanalyst Ronald Laing.

On the other side of the argument, Milos Forman's 1975 hit movie One Flew Over the Cuckoo's Nest, based on Ken Kesey's novel, suggests that some patients seem all too ready to voluntarily abandon their freedom for the security of the asylum, paying a stiff price in the bargain: loss of individual initiative and entrenchment of disability. Still others remain confined without any say in the matter. Years earlier, in an inversion of the theme in King of Hearts, when German bombing destroyed parts of several British mental hospitals early in World War II, many patients went unaccounted for. They didn't show up at other hospitals, injured or otherwise, or on lists of the dead. After the war a research team sought to track them down. Most were indeed still living and doing well enough, thank you. They had adjusted to life away from the hospital, first out of necessity, later because they felt sufficiently satisfied living in the community.

Such findings lent credence to a trend in psychiatric thought that gathered strength during the 1950s and '60s: in many cases, prolonged hospitalization was often both unnecessary and deleterious. Yet we've learned subsequently that simply closing public asylums for the mentally ill without properly funding decent alternatives has too often led merely to newer forms of warehousing: in bleak group homes and even bleaker jails.

Compared with King of Hearts, House of Fools offers a far more starkly realistic view of both the handicaps of the chronic mentally ill and the harshness of war. This is a sharp-edged film, better suited to contemporary sensibilities than the parfait served up in King of Hearts. In House of Fools, clear and simple boundaries no longer exist. War bursts into the hospital. A commanding officer becomes a furtive patient. Soldiers on the two sides can instantly become comrades during a moment of truce. Sanity and madness coexist at every hand. In a convoluted world, regarding war or mental illness, simple categories and cliches do not serve us well.