Out of Hiding
About 450 million people live with mental illness worldwide and nearly one million a year die of suicide. In “Hidden Pictures,” Seattle physician and documentary filmmaker Dr. Delaney Ruston reveals the human cost of our mental health crisis
Seattle has emerged as an epicenter for global health research as the home of the Bill & Melinda Gates Foundation as well as the University of Washington Department of Global Health, PATH, the Fred Hutchinson Cancer Research Center, the Seattle Biomedical Research Institute, the Washington Global Health Alliance and more.
Until recently, most global health initiatives have devoted resources to physical health and illnesses while mental health issues have been largely ignored. Yet, according to the World Health Organization, about 450 million people live with mental illness worldwide and almost one million a year die of suicide — mostly in low- and middle-income nations where as many as 85 percent of people with severe mental disorders receive no treatment.
Seattle physician and documentary producer Dr. Delaney Ruston has devoted her professional life to caring for underserved populations, and now she’s working to break the silence on global mental health. To spark an international discussion, the award-winning filmmaker produced the first full-length documentary on this overlooked issue, “Hidden Pictures.”
Over the course of five years, Ruston traveled from Seattle to India, China, South Africa and France, exploring the plight of the mentally ill: the heartrending lack of services, human rights violations and pernicious stigma in nations rich and poor.
More than 140 international organizations screened “Hidden Pictures” on Oct. 10, Mental Health Day, and reviewers, including actress and mental health advocate Glenn Close, have praised it. Among them are public radio health reporter Joanne Silberner who wrote: “It’s a deeply compelling documentary that exposes us to the harm caused by ignorance of these diseases, at the same time pointing out that the currently available approaches to care can make a real difference.”
Ruston has worked as a primary care physician at the Pike Market Medical Clinic and other clinics for the underserved in Seattle. She is a graduate of Stanford Medical School and has taught on the faculty in the Department of Medicine at the University of Washington. She studied filmmaking in San Francisco during her internal medicine residency, and she earned a Fellowship in Ethics and Communication at the University of California, San Francisco.
In her documentary, “Unlisted: A Story of Schizophrenia,” Ruston recounted her father’s struggle with mental illness, how she reconnected with him after hiding from him for 10 years, and his eventual suicide.
“Unlisted” was featured on PBS and honored with the Media Voice Award for Best Documentary by Mental Health America in 2011. Ruston’s other films include “Crisis in Control,” about psychiatric advance directives, and “Go Away Evil,” on mental illness in South Africa.
Ruston recently spent two years in Delhi, India, as a Fulbright Scholar making films about community mental health workers in India, which will be used to promote mental health services.
She sat down with me recently and spoke at length about filmmaking and her mental health advocacy.
You’re a physician and a prize-winning filmmaker. How did you decide to become a doctor?
My experience growing up with my dad and his schizophrenia influenced my wanting to go into the health profession. I planned to work in clinics for the underserved when I went into medicine.
After my training, when I started working in such clinics of course, I discovered that many people were facing mental health problems. Fortunately, my residency in primary care internal medicine taught us how to help treat many mental health conditions.
Even though my dad’s schizophrenia motivated me to go into medicine, I didn’t want to go into psychiatry. I think it just felt too close to home, but now I love helping people recover from mental illness. And now, for the past
10 years, I’ve been doing documentaries on mental health conditions, so I’ve come full circle.
And what inspired you to become a filmmaker?
Since I was young, realistic stories are the ones I gravitated to. When I was 11, my favorite film was “Small Change,” by [Françios] Truffaut. Meanwhile, I was fortunate to know documentary filmmakers growing up so I saw that doing this type of filmmaking was possible. The real clincher was seeing how filmmakers such as Judith Helfand (“Healthy Baby Girl;” “Blue Vinyl”) were able to elevate the impact of their films through multilayered filmmaking and collaboration-based awareness campaigns.
I realized I wanted to make documentaries that could inspire change for the better. The key is that for a film to create change it must touch us emotionally. If we feel guilt, we might want to apologize. If we feel shame, we might want to hide. And if we feel compassion, we may indeed want to act to improve a situation.
It’s surprising too that you’re the writer, director, narrator, producer and cinematographer of your films. And you’re a skilled storyteller with an artist’s eye for compelling images. Can you talk about doing all of that?
It’s been a curse and a blessing. It allows me a lot of freedom to not have to do as much fundraising when I can do certain parts myself but that, of course, comes at a cost and it makes the projects take longer. The upside is that I can get my gear and I’m all set to go.
In your film, “Unlisted,” on your dad’s struggle with schizophrenia, you recount how you hid from him for years, but then reconnected and produced the film. How did that come about?
I was in medical school and received a page that would completely change the course of my life. My neighbor said there was a man at the door screaming about Jesus and saying that he was my father. I was shocked because this was the first time my dad came 400 miles looking for me.
I took him to the [Stanford] psychiatric ER right where I was a medical student. They said that there was nothing they could do for him, and I tried to get him help other places. That brought up the painful cycle that many family members face.
When I disconnected with my father, I felt a lot of shame about it, but I had to move forward. Then, when I became a doctor, I saw how many families are disconnected because of silence in the family or not getting support from the medical system. I decided that when I reconnected with my father I would make a documentary.
That launched my becoming a mental health advocate and that’s how the film changed me. As I did it, so many people came forward and shared their stories. It’s only through talking about these things that we can learn the ways to get treatment and support.
How did you move from your dad’s story in “Unlisted” to your new film on global mental health, “Hidden Pictures?”
As I worked on the film about my father, it bothered me that there was no documentary on global mental health. There was a bizarre silence, particularly being based in Seattle, which is a mecca for global health.
I learned from the story about my father the power of honest storytelling to elicit conversation and compassion. And, as I grew up, I was very much interested in other cultures, so the combination made me interested in the topic.
Before starting the film, if I heard anything at all related to global mental health, it was about two main things. I heard that people [with mental illness] in low-income countries often do better because of extended families and inclusive communities. And I also heard that things are so different culturally that we can’t understand mental illness in these countries and vice-versa.
With that in mind, I headed to different countries, but ultimately the stories were incredibly hidden because the medical systems have almost no mental health care in them.
The shame experienced by families facing mental illness is often quite extreme in countries where I filmed, such as India and China, [and] families may even hide the presence of mental illness from extended family members. Meanwhile, unlike the U.S. and the U.K., there are no advocacy groups to educate and support such families. Therefore, it’s a world where the main message is that mental illness doesn’t exist. And if it does exist, it’s hidden. And as a government, as a society, we don’t have any responsibility to offer treatment or support.
In making “Hidden Pictures” you went from country to country and had extreme difficulty finding subjects. In India, after several refusals, you finally met Sonal, the daughter of a doctor, and you presented her story.
Yes. Again, they were not excited to be in the documentary. I ultimately found out that they had only recently revealed to their extended family that Sonal had significant mental illness — a form of schizophrenia. When they had family gatherings, they [said] that Sonal had to study, and that was a way they hid their secret for a couple of years. It was the antithesis of an extended, supportive family.
I heard this over and over. The stories I show are truly representative for what is happening for many people in these countries. In all of Delhi, a city of almost 20 million people, there were only three day treatment programs and only two supportive housing units I could find. That is shocking. Also shocking is [the] fact that there are only 4,000 psychiatrists in all of India [with a population of more than one billion].
And time and time again, I found that a complete lack of a community mental health system is the norm. It means that over and over one person — in Sonal’s case her mother — is doing all of the work and is not getting a break from the repetitive, difficult and challenging behaviors that come with serious mental illness.
In the China sequence, you mentioned that there’s only one residential mental health facility in Beijing, a city of 20 million people.
Exactly. I was told that the hospital where I filmed was the only one in Beijing [and] the only options for a mentally ill person are a big government hospital or home. To me, that lack of options is shocking.
The fact is that 60 percent of countries don’t have well-thought-out mental health legislation. I hope that [the World Health Organization] putting [mental health] high on its agenda will give voice to people and protect their human rights and stop discrimination.
Your subject “Jeff” in Beijing is confined to a mental hospital until his family agrees to release him, and there’s no legal review of his status. It seems he was misdiagnosed and displayed no signs of a mental disorder when you saw him. Your concern for him was palpable.
Whatever led Jeff’s father to [commit Jeff]— people speculate that it might have been Jeff’s sexual orientation — I was shocked that Jeff didn’t just leave. One thing is that his father had his identity card, and you really have to have it in China. Without this card, Jeff would have a hard time functioning in this society. I really was frustrated, but I appreciate that there’s so much that’s kept silent about hard issues in families in certain cultures.
You stress that housing creates stability and is very important in addressing mental illness.
There’s great evidence now that housing first works. Even in a poor mental state, getting housing and other supports can be transformational to the point where [the mentally ill] seek counseling and medication and the array of support.
To illustrate your point on housing, you tell the story of Patricia in the Seattle area. She met Jeff, a homeless man, and she took him into her home and provided a caring environment. How did you find that story?
I met them when they came into the Pike Market Medical Clinic [in Seattle]. She was so unassuming and so sweet [and] was very new in helping to care for him. For many years he had been homeless on the street, and he spent his days in the library. She’d also see him yelling into a phone, talking to no one, or pacing and agitated. He had extreme mental illness [but] he did come to live with her and was stable. Patricia is one of those angel people doing the work.
In your film, you mention programs in the schools to build this awareness of mental disorders and combat the stigma of mental illness.
It’s such a missed opportunity that most schools across the globe do not teach about mental health and mental illness. When I show my films in elementary and high schools, the level of curiosity of the human brain, of our behavior, and of mental illness is remarkable.
Teaching about mental health and mental illness in schools, using real life personal stories, can have a big impact, particularly in two areas. The first is to educate students to help themselves and their families and friends. And second, by teaching in a way that inspires compassion, students will develop empathy that can translate to a future inspired to help improve lives. As a science- driven country, why not incorporate education around mental health into the science curriculum?
Do you see hopeful developments?
I’m always looking for solutions. I’ve never been into making documentaries that just show hard reality.
I spent last year as a Fulbright Scholar in India doing stories on community mental health workers. Many nonprofit organizations are training people to be out in the community in India to find people and give them support around mental health.
What’s interesting recently is that [our] federal government also believes that we need more community mental health care workers and has given a lot of money for implementation research.
A few weeks ago, I met with one of the recipients in Seattle to learn about what care coordinators are doing here, and many of them use the counseling technique called behavioral activation for treating depression. I saw the same technique being used successfully in a village of India [and] research shows the tool is effective in all sorts of settings.
Indeed, one of my key take-home points from making “Hidden Pictures” is that, unlike the myth that our experiences globally are too diverse to understand and help, in fact, our experiences at the very core are much more similar than different, and global solutions are possible.