The answer is, it seems, by fusing the genre with a period drama that celebrates the early days of cinema.
Co-written with Mia Goth, 'Pearl' fills in the back story of one of the characters the London born actress played in 'X'.
Pearl was an old woman in the previous instalment who unleashed an orgy of violence on a Texan farm in 1979 where Goth's other character Maxine was making a porn film.
A prequel to 'X,' 'Pearl' is not, however, your typical psycho movie.
It's a loving, knowing tribute to the Golden Age of cinema and another meditation by West on the lure of fame and the dangers of developing an unhealthy obsession with it.
'Pearl' begins with Goth's farm girl sporting a fine dress and dancing aeound her bedroom like a Disney character.
She's interrupted, however, by her stern mother, Tandi Wright's Ruth who orders her to take her head out of the clouds and do her chores.
Sporting dungarees, Pearl goes to the barn to feed the sheep and cattle and talks to them like 'Snow White', telling them of her dreams of becoming a movie star.
The year is 1918.
The world is emerging from the turmoil of the First World War and is living in fear of the Spanish Flu - no doubt chosen to play on the fears of post COVID pandemic audiences.
Ruth is especially fearful of the flu arriving at her door, with Pearl's father, played by Matthew Sunderland, confined to a wheelchair and unable to communicate.
Pearl's husband, Alistair Sewell's Howard is missing for much of the film, as he has been serving in the trenches of First World War Europe.
When she is not tending to the animals while her mother grows crops, Pearl cleans and feeds her father.
It's a grim existence made bearable by occasional errands into town to get her father's medicine from the local drugstore.
This enables her to sneak into the pictures.
Buzzing after one screening from watching dancers onscreen, Pearl is daydreaming in an alleyway when the local cinema projectionist, played by David Corenswet, spots her.
Offering her a cigarette, he complements Pearl, telling she has the looks of a movie star.
He invites her to her own personal screening in his projection room, gifting her a frame of the film she has just seen.
Opportunity knocks when Howard's pretty, well to do sister, Emma Jenkins-Purro's Mitsy visits the family farm and tells Pearl about auditions taking place in the local church for a dance troupe that will tour the state.
Ruth, though is alive to Pearl's plans and quickly squashes them, putting her foot down about her daughter attending the auditions.
This unleashes a ruthlessness and rage in Pearl that West gives us glimpses of early on in the film.
In 'X,' West peppered his audience with knowing nods to horror classics like 'Jaws,' 'Friday the 13th Part III,' 'The Shining' and especially 'Psycho'.
Here the references go beyond horror cinema to the picket fence paintings of Norman Rockwell to images from classic Disney and 'The Wizard of Oz'.
Whereas 'X' was shot in 4:3 aspect ratio on digital while aping the qualities of a 16mm 1970s porn film, West and his cinematographer Eliot Rockett adopt a more classical Technicolour look, shooting their film in a widescreen 2.35:1 Cinemascope aspect ratio.
Tyler Bates and Tim Williams' score is melodramatic and intrusive just like the music in a Hitchcock film or a Douglas Sirk melodrama.
Like Dorothy in 'The Wizard of Oz,' Pearl also dreams of escaping the grim reality of life on the farm, only to find her dreams are not as golden as she would hope.
While tipping their hats to classic Hollywood, West and Goth make some clever call backs to 'X'.
Pearl shares the dreams of the porn stars in the previous film of making it big and achieving fame.
While the porn film in 'X' goes by the name of 'The Farmers Daughters,' Pearl literally is a sexually frustrated farmer's daughter - as evidenced in a rather creepy scene with a scarecrow.
Martin Henderson's aspiring porn producer Wayne in 'X' and David Corenswet's projectionist in 'Pearl' are a type.
Both seek to cash in on a growing appetite for adult movies.
The former looks to cash in on the burgeoning home video market, while the latter talks about going to Europe to work on silent porn films shown at bachelor parties.
They also take advantage of their position - filling young women'a heads with promises of fame for sexual gratification.
The projectionist clandestinely screens Pearl a banned silent porn film and sleeps with her.
Wayne and the projectionist also use the phrase "X factor" to lure the women they exploit.
West even recreates a Simon Cowell style audition in a local church as 'Pearl,' like 'X,' uses its central character's obsession with fame to reflect on the same phenomenon today.
The influence of 'Psycho' looms as large as it did in 'X,' with a specific nod to Norman Bates submerging his victim's car in a nearby swamp.
The austere setting of the family farmhouse and the domineering, emotionally abusive mother figure in Pearl's home again acknowledges Hitchcock's classic.
Once again, the success of 'Pearl' hinges on Goth in a role that could easily be ruined by over the top eye rolling.
Goth navigates the lead role skilfully, balancing Pearl's head in the clouds naivete with some early glimpses of her shocking capacity for gruesome violence and cruelty.
A goose meets a particularly nasty and unfair end early on in the film at the end of a pitchfork.
Wright, Sunderland, Corenswet, Jenkins-Purro and Sewell make significant contributions too, heightening the sense of tragedy that pervades West's movie.
Tom Hammock's vibrant production design, Malgosia Turzanska's eye catching costumes, Ben Milsom's art direction and Thomas Salpietro's set decoration evoke the films of classic Hollywood.
Their work is so effective, it only accentuates the rather discombobulating effect of gruesome violence being unleashed on locations and sets that could be straight out of an old MGM or Disney movie.
All of these elements brilliantly morph into a wonderfully inventive, cine literate addition to the slasher movie genre.
While the violence is disturbing, it is to West's credit that he unleashes it in a more controlled and calculating way than 'X'.
This makes it all the more chilling.
With at least one more film in the series to come, Goth and West have recruited a more starry cast for the next instalment in LA, 'Maxxxine'.
With Elizabeth Debicki, Kevin Bacon, Michelle Monaghan, Bobby Cannavale, Lily Collins and Giancarlo Esposito are all on board, expectations for that movie are sky high.
But can Goth and West possibly live up to them?
Martin Scorsese admitted after watching 'Pearl" struggled to sleep after watching it.
The challenge with 'Maxxxine' is to make Scorsese and audiences so giddy with excitement and fear their sleeping patterns are disturbed once again.
('Pearl' was released in UK and Irish cinemas on March 17, 2023)
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