Introduction

A compelling portrayal of the individual experience of schizophrenia, a denunciation of the brutality that systematically accompanies its medical treatment, and perhaps something of an apology for our collective failure to bridge the distance between the cognitively-abled and those living with this illness—Una cierta verdad is all of these things.

Born in Barcelona in 1975, director Abel García Roure studied filmmaking with Joaquim Jordà at the Universitat Pompeu Fabra de Barcelona, and counts among his accomplishments positions as assistant director on the films En construcción [Work in Progress] (2000), directed by José Luis Guerín, and El cielo gira [The Sky Turns] (2004), directed by Mercedes Álvarez. This, his first long-form cinematic product, is a highly nuanced documentary prioritizing the interplay between the film's two privileged groups: providers and patients. The battle of voices we watch unfold on screen, then, is not constituted by the medicalized self-talk of the person with schizophrenia, 1 but is instead a social dialogue between these two polarized groups of actors.

This dialogue—one that is simultaneously clinical and social—is pushed forward by two sets of goals so deeply divergent that conflict is unavoidable. To put this into terms that are far too stark to match the director's perspective, but that illustrate the crux of the matter nonetheless: providers focus on the disease, abstracting it from the patient, who becomes a mere residue or afterthought; on the other hand, patients yearn for a quality of life whose elusiveness is frequently compounded by the imprecise doses or debilitating effects of medications they are forced to suffer. The potential resolution of this conflict—in this Disability Studies reading of García Roure's film—seemingly lies outside of the clinical institutions into which we are drawn along with these necessarily social actors. Ultimately, the film suggests that it is the clinical paradigm's low tolerance for nuance and lack of precise tools that in fact perpetuates this ongoing battle of voices. The resulting picture emphasizes schizophrenia as a psychiatric disability that must be understood simultaneously as a social relation.

The release of Una cierta verdad in 2008 is best understood as part of a longer history of attempts to draw attention to the needs of people with schizophrenia living within the Spanish state. It is important to acknowledge that contributions from not only the social and medical but also the cultural/artistic spheres have figured in that longer history. The references here to the Spanish state are a stand-in for an historically and contemporarily heterogeneous grouping of distinct language and culture groups (including also Catalan, Galician and Basque, for example). Here I attend to García Roure's focus on Barcelona and his inclusion of dialogue in both Spanish and Catalan, but readers should be aware that films emanating from a specific linguistic and cultural tradition are likely to be viewed by audiences throughout the Spanish state. With this in mind, the Spanish Transition toward democracy, following the death of dictator Francisco Franco on November 20, 1975, offered new opportunities to address mental health issues through community frameworks, but also created new hurdles:

The development of a system of comprehensive community services and the deinstitutionalization process started in Barcelona at the beginning of the 1980s […] Before deinstitutionalization, patients with severe schizophrenia lived in hospitals and most of their basic needs were met by the institutions. Nowadays in Spain, with admission to long-stay inpatient units very uncommon, patients live in the community. (Ochoa et al. 201, 202)

A highly relevant study from 2001 noted that the patients in the Catalan context continued to have insufficient access to community-based psychiatric services even in the twenty-first century. 2 In addition, it must be considered that people with schizophrenia living in the community have needs that are not always seen in the same way by patients themselves and by outpatient program staff. While psychotic symptoms were the most frequent need identified by patients taking part in the above study (Ochoa et al. 206), only the relatively low rating of "fair agreement" on needs regarding drugs and psychotic symptoms was reported among both patient and staff populations (Ochoa et al. 205). 3 Moreover, another study carried out by a large collective of researchers drawn from locations across the Spanish Sate—including those in Barcelona, Madrid, Asturias, Valencia and Málaga—validated the concerns expressed by some that antipsychotic drugs carry additional health risks that are not fully understood (Bobes et al. 171). 4

Cultural products have worked to bring these interrelated issues concerning treatment for schizophrenia to the forefront of public discourse, and—contrasted with specialized research articles—have the benefit of reaching a much wider audience. For example, the informational documentary 1% esquizofrenia [1% Schizophrenia] (2006), directed by Ione Hernández and produced by Julio Medem, was a high-profile attempt to draw attention to the existence of this psychiatric disability as well as to the social dynamics implicated in its post-Transition treatment. Compared with Hernández and Medem's film, which was released two years earlier than García Roure's film, Una cierta verdad is a much more challenging cinematic text. This is, in part, because it raises important questions regarding the role patients have in directing their treatment—the social inequity that compels them, through threat of violence and in fact through brute force, to accept medications with debilitating side effects whose risks are not completely understood. But Una cierta verdad's artistic composition and narrative structure also require more of viewers. All documentaries are by their very nature artistic constructions, even though the wider public may take them to be mere reflections of an extra-filmic reality. Though García Roure's film is a documentary, the specific artistic decisions that have been made—the shots captured, camera positions, editing and pacing, costuming, and prop symbolism—all play a role in emphasizing the limitations of a contemporary clinical paradigm whose current approach to schizophrenia relies more on power than knowledge, on force rather than precision. Instead of grouping analysis of such representational strategies into one of the article's sections, these are in fact explored in all three.

In the first section titled "Madness, Cognitive Disability, Film," this article explores three crucial points of reference that contextualize the present analysis of García Roure's film: the growing interest in the historical separation between madness and reason, the cognitive and the global turns in Disability Studies, and of course the representation of cognitive disability in film specifically. Next, in the section "Una cierta verdad as Cinematic Window: Perspective, Commitment and Dialogue," it introduces readers to the major characters and enduring patient-provider conflict presented therein. Here the article asserts the director's social commitment, introduces the documentary's major protagonists, and continues to assert the imprecision of psychiatric clinical practice as a major theme. Then, in "Beyond the Parc Taulí towards the Community" the visual narrative's spatial dimensions take center stage. That is, the Parc Taulí hospital in Sabadell (Barcelona) is portrayed as the site of an emanating material and discursive power that impacts patients far beyond the limits of its walls. And finally the brief conclusion returns to the film's title and closing sequence—which drives home the central insight and social commitment of García Roure's captivating cinematic essay.

Madness, Cognitive Disability, Film

Whether we understand schizophrenia as mental illness, cognitive disability, or both at once, I assert that there are three requisite points of reference for approaching its filmic representation. Though it will not be possible to engage each of these points in sufficient depth here—given that space is limited by proscriptions of format and that the main concern in this article is to address representation of schizophrenia in a specific cultural product—a concise presentation will nevertheless set the stage for the filmic analysis to follow.

First, there is perhaps no work as significant on the general topic as Michel Foucault's labyrinthine History of Madness, 5 which—together with The Birth of the Clinic, of course—traces the distinction between madness and reason as progressively produced through historical developments, discursive and material power structures and both tangible and less-tangible social institutions. The portion of History of Madness that appears under the subtitle "Doctors and Patients" (part II, section IV) in particular engages that persistent, elusive and ever-so-blurry notion of a 'cure' for madness. At the same time, it explores the chaos and disorganization that were so central to an important pre-history of our modern clinical approaches and institutions. Therein Foucault writes,

Medical thought and practice in the seventeenth and eighteenth centuries do not have the unity or at least the coherence that we presently associate with them. The world of the cure is organised along principles which are in a certain sense peculiar to it, and which medical theory, physiological analysis and even the observation of symptoms do not always control perfectly. We saw earlier how hospitalisation and internment were independent of medicine, but even within medicine itself, theory and therapy only communicate in an imperfect reciprocity. (297)

Of course, this description of what readers may want to see as an historical age gone-by seems to echo visually throughout Una cierta verdad. For example, the first set of images we see in the film encapsulates its central critique of the imprecision of the clinical gaze. In the first minute of the film—after a fade-in from black—a blurry security-camera monitor displays patients seated in the hospital waiting area. 6 Horizontal two-tone bars obscure their images at the same time that they mediate those images for us: enacting for viewers a connection that simultaneously enacts a distancing. Almost as a reminder of the Foucauldian critique of the medical gaze, these and the other monitor-images that reoccur throughout the documentary become powerful symbols of the persisting imprecise nature of contemporary clinical thought and practice.

García Roure also uses this blurry display monitor as a way of symbolizing the thin line between reason and madness—certainly a hallmark theme of cultural production in Spain going back to the Quijote. 7 It can be difficult to distinguish, for example, just who is mad and who is sane when both are caught up in complicating social power struggles. In reality, as with Cervantes' protagonists, both the patients and the providers of Una cierta verdad are well-matched counterparts: though patients can suffer infrequent episodes of psychosis with disastrous consequences for themselves and for others, they seek the better quality of life they experience when not taking imprecisely dosed meds that force them into slumber; 8 and though providers can have the best interests of patients at heart, 9 these frequently conflict with the best interests of society or of clinical practice, which prefers patient slumber to patient violence and struggles to find a solution that does not rely on brute force. These options are extreme ones, to be sure, but admitting that treatment must extend beyond the walls of the institution for those living in the community, contemporary clinical practice has struggled to find sustainable social solutions outside of this polarized conundrum. Beyond merely symbolizing social distance and hazy solutions, then, the monitor feed additionally signals that social and medical power only moves in one direction: the patient is the object, and clinical observation an imprecise instrument.

The inevitable result of imprecise observation is that the provider's intent to arrive at the 'truth' of disease leads intermittently to the blunt instrument of forced medication (see Valverde 8). Hovering over the patients we see in the documentary is the threat of force, marshaled by social institutions and meted out in imprecise doses. One key difference between the historical context explored by Foucault (above), on one hand, and its restaging in contemporary form, on the other, seems to be the integration of the hospital and medicine, or rather, the complication or even the collapse of their independence. And if we follow the director's suggestion, the contemporary hospital as an institution has not brought control, unity or organization to the treatment of madness but instead additional chaos, confusion and imperfection. A primary concern of Una cierta verdad, then, is the representation of this imperfection, and the impact it has on the lives of the patients García Roure followed for two years while making the film.

Second, it is significant and in some sense lamentable that Disability Studies proper—as a more-or-less coherent if still emerging interdisciplinary framework—has tended to overlook cognitive disability in general, and psychiatric disability perhaps even more so. In a book published by pioneering scholars in 2000 that has become a touchstone for the field, David T. Mitchell and Sharon L. Snyder wrote that "While most of the work in the humanities to date has centered upon physical disability as its grounding object of study, one of the major new areas of research in disability studies will need to be that of cognitive disabilities" (Narrative Prosthesis 39). Between 2000 and 2015, significant work on cognitive disability has indeed been published. While not the sole example of this trend, feminist philosopher Licia Carlson has been particularly important in this regard (see Carlson "Cognitive Ableism," Faces; Carlson and Kittay). In addition, a growing body of work investigating films outside of the Spanish context has explored the representation of both physical and cognitive disabilities on film (see Chivers; Chivers and Markotić; Enns and Smit; Mogk; Pointon and Davies; Riley), going beyond the primarily physical focus of Martin Norden's foundational title The Cinema of Isolation: A History of Physical Disability in the Movies (1994). Yet on the whole, the literature on psychiatric disability written from a Disability Studies perspective—i.e. a paradigm that prioritizes the disabling character of the social environment—has tended to be eclipsed by medical approaches that essentialize disability and situate it ontologically inside the disabled body (and in this case, simultaneously within the disabled mind). 10 Study of psychiatric disability and its cultural representations, however—and the questions posed by its cultural representation, as in Una cierta verdad—has the potential to reveal just as much about our disabling social environment as do other areas of this growing interdisciplinary field.

And third, at the same time that scholars in Disability Studies have been calling for a more global and international approach (Mitchell and Snyder, "Geo-Politics"; Murray and Barker), studies of disability in film from Spain have been steadily increasing as if responding to that call. Though there are still only a handful of scholars working in this subfield, it is significant that studies of cognitive disability in film (in this one author's review of the literature) exist in greater proportion to those of physical disability when compared with studies of disability in film contexts outside of the Spanish state. Two books with a strong cognitive focus—Benjamin Fraser's Disability Studies and Spanish Culture (2013) and Matthew Marr's The Politics of Age and Disability in Spanish Film (2013)—stand out as the only single-authored monographs on disability in the Spanish state to date, while a range of scholars have contributed important articles and edited collections (see, for example, Conway; Fraser, "Toward," "Work," "Senescence," Cultures; Juárez Almendros; Minich; Prout; Rivera-Cordero, "Rebuilding," "Self"). It is significant in studies of film from the Spanish state—just as it is in other Disability Studies contexts—that there is a longstanding filmic tradition of disabled characters in cinema even where they have not yet been analyzed from a Disability Studies disciplinary perspective. 11 One must consider that Tobin Siebers's lucid remarks about the fundamental role of disability in modern aesthetics may warrant exploration in the medium of filmic representation specifically. That is, "disability," he wrote in Disability Aesthetics (2010), was present even if "rarely recognized as such" throughout the history of modern art, where the presence of disability—of "strangeness" and the "convulsive"; of "misshapen and twisted bodies"—allowed "the beauty of an artwork to endure over time" (4-5; see also Siebers, Disability Theory). Una cierta verdad is not the only recent film from the Spanish state to deal with disability, of course, but despite debuting in 2008, its message is still underappreciated: there is not a single scholarly article devoted to its in-depth exploration.

Una cierta verdad as Cinematic Window: Perspective, Commitment and Dialogue

As viewers should expect, Una cierta verdad functions as a window into the textures of everyday experience for those people living with schizophrenia. The director has stated that his intention was to provide a more even treatment of the theme of psychosis than one usually finds in media representations:

He partido de la idea de que hay un estigma muy fuerte respecto al tema; tras analizar la aproximación que se ha hecho desde el cine a la psicosis [trastorno mental en el que se incluye la esquizofrenia y la paranoia], o bien excesivamente romántica, o bien marcadamente antipsiquiátrica, he tratado de iluminar el tema desde la experiencia real del enfermo, de su relación con la enfermedad, explicar su sufrimiento, y contar las distintas evoluciones que puede tener. (de la Rosa)

[I began with the idea that there is a very strong stigma about it; after analyzing how cinema has approached psychosis (a type of mental disturbance that includes schizophrenia and paranoia) either from an excessively romanticized or a markedly anti-psychiatric viewpoint, I tried to shed light on the topic from the real experience of the patients, of their relation with the illness, to explain their suffering, and to portray the different paths it can take.] (Author Translation)

In yet another interview he describes his own perspective as "humana [human]," "cotidiana [everyday]," and "íntima [intimate]" (Vázquez 18). There is, of course, a strong link between the clinical paradigm and the cinema—both are grounded in the practice of observation. The cinematic window provided by García Roure, however, is a perspective mid-way between that of clinical observation and that of patient experience, regarding which it remains neither fully committed nor fully dismissive. 12

Representing both aural and visual data, cinema here is a perfect vehicle for exploring the superimposition of two historical stages in the evolution of the clinical paradigm. Foucault writes of the historical shift from a linguistic (technical/aural) to a sensory (aesthetic/visual) form of clinical practice (Birth, ch. 7 "Seeing and Knowing"). Dialogue with the patient still has a place in the newer observational paradigm, but it is the visual that becomes primary with the arrival of the concept of pathological anatomy. These historical developments

freed medical perception from the play of essence and symptoms, and from the less ambiguous play of species and individuals: the figure disappeared by which the visible and invisible were pivoted in accordance with the principle that the patient both conceals and reveals the specificity of his disease. A domain of clear visibility was opened up to the gaze. (Foucault, Birth 105)

This shift diminished the need for observation through language, through dialogue, through time and understanding, and replaced it with the possibility of a more immediate discovery of a truth that lay visible in the material world. As a film very much concerned with an illness whose expression is still not immediately visible, Una cierta verdad screens the inadequacies of the modern practice of psychiatry as it tries to navigate the superimposed paradigms of linguistic and sensory truth at once. Unable to ground itself purely in the "domain of clear visibility" opened up by the modern clinical gaze, its investigation of the relatively invisible realm of the mind must rely more on an older model of spoken probing, a questioning of the patient through dialogue, rather than on newer forms of clinical practice that potentially unite the visible and the expressible. 13 The film works to draw attention to this central character of psychiatric practice—it is a narrative and dialogic art just as much as it is a science. García Roure thus draws us into the fundamental interplay of language and power at the heart of this clinical practice—staging for us the battling voices with which any provider and patient are familiar.

The film's setting, as detailed below, is that of a teaching hospital and not a mental institution in the classical sense, and so unlike the protagonists of Jordà's Monos como Becky, for example, Una cierta verdad's social actors are community members who require intermittent and not continual observation. It is tempting here, as with many documentaries, to presume that there is no point of view—that the documentary film is merely an objective window into human experience. 14 But make no mistake, here, too—just as in the case of the films of García Roure's mentor Jordà—we similarly have an expressly social commitment on the part of the director. 15 One scholar has indicated that the film is implicated in a tradition of cultural production dedicated to "eliminar los tabúes existentes y la imagen siniestra de la enfermedad [eliminate the existing taboos and the sinister image of the illness]" (Real-Najarro 184). This commitment is expressed through attempts to push viewers to adopt another subjective experience of the world than their own. 16 The frequency of camerawork that lingers on windows and doorways combined with footage of security monitors, reinforces this theme of how we look—what and who we see when we observe people with mental illness. Together with the persistent appearance of the interstitial institutional corridors we traverse with the camera crew and hospital staff, this emphasis suggests the importance of positioning and perspective—where it is we look from, and how viewers who might tend to be both cognitively abled and relatively unfamiliar with healthcare institutions will access these patient stories, and whether they will understand them.

Perhaps the key protagonist of the film is Javier Sánchez (aged 58), whose diagnosis presumably goes back some twenty years. 17 Javier lives independently and receives visits from Josep Manel Santos, a psychologist working in the hospital's PSI (Plan de Seguimiento Individualizado [Plan of Individualized Support]) outpatient program. Their discussion ranges over topics of personal, artistic, philosophical, intellectual, and medical interest—and over the indoor spaces of his apartment and various outdoor spaces presumably near his residence—with a struggle gradually emerging as the pair's opinions increasingly diverge concerning the downside of imprecisely prescribed medication and the value of the energy, creativity and autonomy Javier enjoys when not on his currently prescribed dosage. The result is that Javier is eventually forcibly interned for observation. Viewers watch as he is abruptly brought from his apartment to the Taulí by police. Another key patient, Rosario Hernández Manzano, insists that she is bewitched and that she is only able to speak of the voice in her head when receiving prescriptions at her hospital appointment. If Javier's scenes are dialogic and conversational, Rosario's filmed appearances tend more toward confessional monologues. Against the clear symptoms of schizophrenia and paranoia manifested in Javier's and Rosario's appearances, the state of mind of a third protagonist, Bernat Pérez Acero, is comparatively lucid and thus provides a third model of patient-provider interactions, one not as immediately turbulent as those of Javier and Rosario. 18

We never come to learn much of first named patient appearing after the opening sequences, Alberto R. P., who is systematically distanced from viewing audiences beginning with his arrival to the emergency clinic at the Parc Taulí hospital in Sabadell (Barcelona). But he is crucial to the film's message nonetheless. He hardly speaks when questioned by Dr. Agustín, and when he does he speaks in short phrases delivered in a volume barely above a whisper. 19 We never clearly see his face. Instead, the camera shoots him from behind when in the same room or from the hallway when outside of a room; he is regularly captured shrouded in his hoodie, isolating himself in the sounds emanating from his earphones. 20 Moreover, in one particularly uncomfortable scene we are embedded with five hospital staff who move into what viewers might reasonably presume is Alberto's room to force his meds on him. With hoodie over his head and earphones plugged in, he stares out of a window—the efficiency and brutality of the event follow logically from the inadequate dialogue between the provider and the patient. During the operation, which is over as quickly as it begins, the camera hovers in the hallway, peering into the room as it captures the interned patient in a long shot that reaffirms his simultaneously medical and social marginalization.

The fact that we do not have early or sustained access to Alberto's face 21 is a clear expression of the director's vision, which is to move gradually from a medicalized view to a social view of schizophrenia. It has been observed elsewhere that the film's narrative arc is structured by two moments: the first, privileging the doctors and marginalizing the patients; and the second, shifting focus away from the doctors toward humanizing the patients.

En este primer segmento de la película, los protagonistas son indiscutiblemente los médicos (o más bien, la institución médica), puesto que Roure les confiere un rostro y una presencia definida, mientras que los pacientes son presentados como grupo, no con como individuos, desprovistos de un rostro que los singularice […] Este primer planteamiento de la película se disipa al iniciarse el segundo segmento puesto que Roure empieza a introducirnos en las historias personales de tres pacientes que padecen diversos grados de psicosis (esquizofrenia, paranoia, etc.). En esta parte los enfermos empiezan a tener rostro, a ser visibles, y a singularizarse delante de la cámara. (Petrus)

[In this first segment of the film, the protagonists are unquestioningly the doctors (or better said, the medical institution), given that Roure gives them a face and a defined presence, while the patients are presented as a group, not as individuals, deprived of a face that might individualize them (…) This (character of the) first part of the film evaporates with the beginning of the second segment given that Roure begins to introduce us to the personal histories of three patients who suffer varying degrees of psychosis (schizophrenia, paranoia, etc.). In this part the patients begin to have a face, to become visible, and to individualize themselves before the camera] (Author's Translation)

The director has a clear preference for representing each side of this social battle through a multiplicity of voices, such that the effect is one of two competing 'teams,'each with their own set of messages. 22 These teams—of doctors on one side and patients on the other—are placed in dialogue with each other throughout the film, and even up through the beginning of the end credits. Interestingly, the editing of the film privileges the cut—and uses cross-cutting as a pervasive technique 23 to emphasize the dialogic nature of the clinical enterprise—and in many instances as a way of breaking these dialogues up strategically. In one case as Javier's logic becomes recognizably schizophrenic, the film cuts to a psychiatrist's concise description of the disease, and in another case, the cut comes just as Javier has made a lucid critique of the forced and imprecise medicalization of people with schizophrenia, potentially emphasizing the power of his words. 24 In a sense, both teams are right. But as the film makes clear, there is an inequity in how the distance between them is resolved socially.

Beyond the Parc Taulí to the Community

It is important to note that Una cierta verdad's shift toward privileging patient experiences (the progression toward patient narration identified above) occurs along with a clear shift in the spatial exposition of the film. The primary anchor for the film's often competing and certainly overlapping perspectives is the physical and clinical environment of the Parc Taulí, the teaching hospital of the Universitat Autònoma de Barcelona. The Taulí appears as an exterior in Una cierta verdad's first scene, one that is echoed throughout the film as we repeatedly cross its threshold; 25 it is captured from within in in the first of the two cinematic movements identified above and it is progressively overshadowed as director García Roure spends more time with patients in the community during the second half of the film.

The disparity in how patients and providers enter the hospital becomes a metaphor for access to power. Patients are brought in by ambulant vehicles, or enter through the emergency waiting room, where the camera and editing repeatedly frame them as outsiders with little access to the power structure represented by the inner core of the hospital. As patients wait in the entry area, we routinely observe them from inside the provider area, peering out through automated glass doorways and glass walls via long shots that identify them with the outside and assure their figures are small on the screen, as if a metaphor for their lack of both clinical and social power. In addition, how both doctors and patients are shot in the film in relation to the hospital space is significant. While the film's main patient protagonists are shot both inside and outside of the hospital (Rosario, walking during the daytime, riding the bus, walking at dusk; Javier at a variety of times and in numerous settings), its doctors are shot purely inside the walls of the Taulí. In this sense they appear to be manifestations of its material environment or internal architecture: they thus become synonymous with the clinical gaze. They are unable to observe the patients in their own environments and by implication they may be unable to see the patients as human beings. The exception is the liminal figure Josep Manel, whom we see both inside and outside of the hospital. In the twenty-third minute of the film, a figure that appears to be Josep enters the Taulí through what comes off as a secret passage into the very heart of the hospital. The use of a tracking shot for this method of entry is in marked contrast with the cut-based transitions from exterior to interior scenes usually employed in the documentary. That is, we never visually accompany protagonists such as patients Javier and Rosario as they enter or exit the hospital, such that the film effects a separation between the treatment they are able to receive in the community and what goes on inside the Taulí.

Javier's story is by far the most compelling storyline in Una cierta verdad, and the considerable time he spends speaking with Josep in his own apartment is the film's emotional and critical core. Their conversations form a thin connecting thread linking the discursive and material power of the hospital with the lives of people with schizophrenia living in the community. As the film traces that thread, it illustrates both the reach of clinical power and the limits of its reasoning.

At one crucial point, an interesting use of editing connects the extramural interactions between Javier and Josep with a cinematic metaphor. After Javier expounds his "ideas sobre la cohesión de la materia (ideas on the cohesion of matter)," showing Josep two pieces of art he has made that illustrate vectors emanating from a cube and a sphere, the editing cuts from interactions in Javier's home to shots of information traveling through a pneumatic tube. 26 These shots are static, and capture the parcel at various moments during its passage through the pneumatic tubing. The editing between the cuts is such that the relationship between each static shot and the next obscures any sense of directionality or of the totality of the tubing system. As viewers we cannot connect one section of tubing with any of the others. There is a dual meaning to the cut that takes us from this patient's home to the hospital. On one hand, the crisscrossing sections of pneumatic tubing can be seen as a clear metaphor for signals in the brain of a schizophrenic patient that are disrupted and prone to crisis. 27 But on the other, this sequence is also clear metaphor for the imprecision of clinical observation—the information of the pneumatic tube systems viewers glean visually from these shots is necessarily incomplete. One cannot form an impression of how the complete system works purely from vision alone. Both of these points are made simultaneously by the director, which reinforces the theme of polarized actors who appear as battling voices. The dual message is this: Javier's psychiatric disability creates symptoms that need to be addressed, just as the imprecision of clinical observation and the blunt instrument of medication cannot take the place of more sustainable social solutions.

What the extramural conversations between Josep and Javier reveal most, as they take up a greater part of the film's duration in the second half, is the ineffectiveness of the communication between the two. In a particularly concise period of time, Javier makes a number of important declarations to his assigned outreach psychiatrist that are, in reality, repetitions of previous remarks. Javier expresses the importance of his attempt to get better and states that his life would be more meaningful if he only had time to do some drawings. He worries about the side effects of meds, stating the possibility that patients can be prescribed medications that can give them a stroke. 28 The outreach worker crafts and sustains clunky metaphors for Javier's need to submit to internment despite the fact he has not done anything (e.g., to paraphrase Josep's comments: a car needs to be fixed routinely or they take it away), to which Javier responds either with reluctant and resigned loud sighs or with attempts for playful banter that addresses the car metaphor but returns to the issue of his quality of life. Javier puts it most accurately and lucidly when he admits the distance between the pair's divergent set of goals: "Tú tienes tu idea, yo tengo la mía [You have your idea, and I have mine]." 29 Josep's one concern throughout is to focus on the power the hospital has to intern Javier, not to address his concerns. The link between the hospital and the community liaison program ends up being characterized only by control, and not by communication. 30 Ultimately the conversation between Javier and Josep is the same as those he has with psychiatrists in the Taulí: he has the same concerns, the providers have the same answers, and he is not being heard. Whether inside or outside of the hospital, the social battle is, in this case, always tilted toward the side of clinical power.

Returning to the historical paradigm discussed by Foucault, it can be said that psychiatry perpetuates a much older clinical paradigm than does pathological anatomy, one that lacks precise instruments for diagnosis, treatment and cure, and one in which the lack of meaningful dialogue between provider and patient recapitulates the irreconcilable gap between what is observed and what is known, between spoken and observed truths. The only middle ground that can be inhabited, which García Roure's film presents for all to see, is one clothed in the half-light of necessarily partial truths. Exploring this murky terrain, without the ability to establish and sustain effective resources for patients living in the community, contemporary psychiatry inevitably fails to cleanly isolate elements of schizophrenia and abstract them from the total person. The only options available to this confused and still primitive practice are clinical imprecision and the ever-present threat of violence.

What Abel García Roure's documentary has accomplished is to resolve, through artistic production—expanding the concerns of clinical paradigm to implicate the whole of social practice—the questions that originally drove the clinical paradigm's transition from audio and dialogic narrative toward visual and spatial observation as identified by Foucault:

The theoretical and practical problem confronting the clinicians was to know whether it would be possible to introduce into a spatially legible and conceptually coherent representation that element in the disease that belongs to a visible symptomatology and that which belongs to a verbal analysis. The problem was revealed in a technical difficulty that was very revealing of the demands of clinical thinking: the picture. Is it possible to integrate into a picture, that is, into a structure that is at the same time visible and legible, spatial and verbal, that which is perceived on the surface of the body by the clinician's eye, and that which is heard by that same clinician in the essential language of the disease? (Birth 112, original emphasis)

But as Foucault remarks, this balance between the visible and the legible, the spatial and the verbal, is more of a dream than a reality. 31 Facing the difficulty of observing psychiatric disability visually/spatially, and with little time and resources to put into language, narrative, and listening to patients on their own terms, the Taulí is forced into a poor solution. The result is a disproportionate emphasis on the quick fix of internship, of forced medication in imprecise doses. Even though it may be a dream for clinical practice to balance the visible and the legible, it seems that Roure's cinematic essay has been able to make this an artistic reality.

Conclusion

The last words of the film—voiced by Javier, who in the final sequence becomes unquestioningly its central character—are a punctuating call to arms. A psychiatrist asks more than once into the origins of Javier's schizophrenia, which he connects with a time during which he is beginning to think that his children are not his own. When the psychiatrist suggests to him that this "es una inquietud, ¿no? [that is an anxiety]" he responds tellingly "o, una cierta verdad [a certain truth]." The privileged positioning of this sequence as the very last dialogue in the film, which in fact unfolds on the screen after the first end titles and corresponding music have begun, seems intended to give Javier the last word. More than that, however, we see in this conversation the distilled kernel of conflict between providers and patients, or put another way between a clinical paradigm and a social paradigm of mental illness. Dialogue between these two polarized social actors is propelled forward through time by the clinical view of schizophrenia as a problem to be solved, on one hand, and by the first-person acceptance of this perceived problem as a situation to be lived with, endured and experienced. As staged by the director, this is a battle between forced medication and its effects on the body on one hand and creativity, energy and quality of life on the other. Questions of individual autonomy and rights are brought into contact with social and discursive force, employed in the name of society against a disruption that can never be cured, only marginalized—all against a background where institutional and rhetorical claims to truth are inequitably distributed in society.