07
APR
2015

Digesting Hannibal – Season 1, Ep5

Episode 5 – Coquilles

We open with Will walking barefoot down a two-lane highway, in only his underwear.  The stag walks behind him.  He’s sleepwalking.  A police car pulls up to him and the two officers question him.  He doesn’t know where he is, and still isn’t sure he’s really awake.  This tells us Will questions his own reality.  This doesn’t quite reach the point of Zhuangzi, but there’s clearly a similarity.  

Will visits Hannibal in his home, early the next morning.  Hannibal remarks that sleepwalking is less common in adults than children.  True.  Will wonders if it could be a seizure.  Hannibal suspects it’s PTSD, from the work they do.  He blames Jack, and that Jack “manipulated” Will into going back into the field.  Perhaps, though this is more likely Hannibal using “splitting,” by creating an alliance with Will while simultaneously creating a divide between Will and Jack.  If so, we would expect Hannibal to later do the same with Jack, badmouthing Will behind his back.  Hannibal hypothesizes that the intensity of the experiences have just overwhelmed Will’s defenses, leading to a “loss of control.”  He also says that sleepwalking is associated with difficulty handling aggression.  This was a finding when testing sleepwalkers using the MMPI (Minnesota Multiphasic Personality Inventory), and found an association with outwardly directed behavior patterns, suggestive of problems with aggression.  Hannibal continues to blame Jack as pushing Will too far, which presents Hannibal as Will’s ally, the only one who cares about his wellbeing.

Outside a motel, we meet a man scooping ice, trying to hide fear as he watches a couple walk by.  To him, this couple seems to be on fire.  He’s upset but not alarmed.  As if he’s seen this before.  Cut to Title Sequence.

We return to motel, with authorities investigating.  Jack presents the info they have — nondescript name, paid cash, no cameras.  Jack warns Will to prepare himself.  Will brushes it off.  Jack reiterates it to him.  This is not in line with Hannibal’s characterizations of Jack.  Jack seems to care about Will.  And the case.  

The couple previously on fire have been cut up and posed as praying angels.  The forensics team discusses similarities to other rituals, such as the vikings.  Will intuits that the killer did this to “transform them.”  As usual, we aren’t let in on the evidence he’s using to deduce that.  Katz notes that the killer slept there, leaving hairs and sweat.  She also finds vomit, and Jack deduces that he couldn’t stomach what he did.  Will believes the killer felt he was “elevating” his victims.  Will lays down on the bed to do his metronome regression.  He imagines that this killing is a way of helping the victims, and that it gives the killer a sense of peace.

Meanwhile, Hannibal brings out a carefully prepared dinner to Jack and his wife.  She declines the foie gras due to the cruelty to animals.  Hannibal relates that he uses an ethical butcher.  “No need for unnecessary suffering… Human emotion is a gift from our animal ancestors… Cruelty is a gift humanity has given itself.”  There isn’t quite a value judgment in that statement, but it implies that being cruel is something uniquely human.  As a psychopath this must help him to feel elevated from others, by the ability to cause suffering when he chooses.  Hannibal pours wine, and detects Bella’s perfume.  She notes his keen sense of smell.  Hannibal tells a story of being to smell that a teacher of his had cancer.  This may actually be legit.  http://www.nytimes.com/2013/11/24/magazine/what-does-cancer-smell-like.html  It is also a hint for the episode.  

The team performs autopsies.  They discuss whether the killer might be christian/religious.  They learn that the woman lived while she was cut up, and that the killer used vecuronium to paralyze her.  “They weren’t praying to him.  They were praying for him.”  Based on the drugs they found in the vomit (chemotherapy, steroids, and an antiepileptic [keppra]), the team deduces he has a brain tumor.  Will takes another leap that he is afraid of dying in his sleep.  This seems less substantiated.  Their guess about the medical condition at least makes sense.  As does the vomiting — brain tumors can cause nausea and vomiting from pressing on the vomition center of the brain, in the medulla.  “He’s making angels to watch over him.”  Now unless he has a particular religious preoccupation or a staunch belief system, few would attribute their problems to the devil, and even fewer could justify killing to create angels to protect themselves, unless perhaps they had a hallucination or delusion that pushes such a belief.  That a normal person could become both hyperreligious and kill to create angels to protect from dying would be a particularly bizarre delusional system.  

Bella goes to visit Hannibal for a session.  Typically this would not be done, especially by someone as psychodynamically oriented as Hannibal.  It would be considered a conflict of interest, and that Hannibal would have trouble being “neutral.”  Bella implies she’s having an affair, and doesn’t want to tell Jack.  Not clear why she would go to Hannibal for advice on this.  She questions whether there’s a conflict of interest, and Hannibal minimizes it as only “unorthodox.”  Unclear who requested the meeting.  She resents Jack and his work responsibilities.

Hannibal meets with Will, and relates that there’s no single center of the brain that’s religious.  Indeed.  Thus the unlikelihood that this symptomatology could come from only a single tumor.  “How do you profile someone who has an anomaly in their head changing the way they think?”  This is foreshadowing of what is to come for Will.  Hannibal believes it’s more likely due to a sense of mortality rather than hyperreligiosity.  Will believes the killer feels abandoned.  Hannibal attempts to direct this at Will, asking if he himself ever feels abandoned.  This could be a valid line of questioning.  Since we never see the evidence by which Will is making his deductions and leaps in logic, it’s quite possible for him to be projecting his own issues into the case.  By imagining himself in the shoes of a killer, he would likely bring in the issues that he himself suppresses or struggles with.  Hannibal continues to push that Jack has abandoned Will.  Will picks up on this — “Are you trying to alienate me from Jack Crawford?”  I’m surprised it took him this long to notice.  Hannibal evades, claiming he’s trying to help the profiling of the killer.

Jack tries to have a conversation with Bella, in bed.  She doesn’t want to talk.  He offers support, she declines and mainly wants to be left alone.  “I won’t insult you by asking if there’s someone else.”  A test.  He’s asking.  She evades and they pretend that everything will be fine without ever talking about it.

In Cleveland we see the killer in an alley, watching a security guard appear to be on fire.  We cut to after, when with Will seeing that same guard now posed as an angel and hung from a scaffolding.  They find human testicles, and deduce that the killer castrated himself.  They take this further to infer that the killer is now turning himself into an angel.  Which in my opinion doesn’t track with his supposed fear of death and need for protection, nor the ignoring of the religious consequences of murder.  If it was explained that his hallucination led to a belief that he’s killing demons, that might track.  But we aren’t shown that only some people are on fire.  Nor that he believes he’s saving souls.  So the logic jumps don’t make sense to me in their profile.  But they’ll get to that.  The writer is purposely withholding some information.  Will takes this further that he’s now accepting his impending death, or “bargaining.”  Not really clear to me how castrating himself becomes a bargain.  Jack asks for more, and Will pushes back, telling Jack to basically do his own profile if he doesn’t like Will’s.  Hannibal’s divisiveness is taking hold.  

Katz challenges Will on his backtalk to Jack.  Will admits he was out of line.  They find out that the dead couple were serial killers, and that the security guard was actually a felon.  He’s making demons into angels.  A twist on Frailty, a fantastic little movie with Bill Paxton.  Will states that the killer doesn’t need to know that his victims are demons, he just has to believe it.  That still leaves a hole in how he deduces who are demons.  Because somehow he knows.

Bella meets with Hannibal again, and she brings him up to speed on Jack’s suspicions.  Hannibal interprets that she feels more betrayed by Jack than her own body.  Bella reveals she has cancer, not that she’s having an affair.  And even moreso, it’s terminal.  Hannibal identifies that she holds Jack responsible somehow.  He also points out she’s withdrawing from Jack.

Elsewhere, Will has trouble sleeping in the middle of the night.  He blinks and finds himself on the roof of his house.  It’s morning.  Sleepwalking again.

Will tries to process this with Hannibal.  Hannibal goes back to the case, about how the “Angel Maker” chooses his victims.  Will sees a statue of a stag.  A hint as to who the stag symbolizes in Will’s mind.  Will carries the influence and manipulation of Hannibal with him all the time, even in his dreams.   Hannibal believes Will is similar to the killer, in that they both want peace.  Hannibal smells Will.  We now wonder what he smells on Will, namely his illness (to be revealed as season continues).  Hannibal asks about the headaches.  Hannibal clearly can tell that he’s sick.

The team identifies the killer, Elliot Budish.  Jack and Will interview the wife, who talks about how he withdrew, paralleling how Bella has been withdrawing from Jack.  They learn that Budish wasn’t religious, did have anger problems but not a history of violence, and had a near death experience when young, when he survived a fire as a child, and was told he must have had a guardian angel.

They go to the farm where this happened to investigate.  They find Budish hung up in the barn like an angel, just as he’d done to others.  I would presume he had an accomplice, since such a feat is difficult to do on one’s own.  It would be like nailing yourself to the cross (as poet Alan Dugan portrayed in his Pulitzer poetry).  Will remarks that he might not be useful much longer.   They argue, with Will conveying that it’s all taking a toll on him.  Jack rebuffs the role as his father, to tell him what to do.  Will still thinks he’s doing it.  Jack tells him that he won’t be able to stay away, when he knows he could prevent the next murder.  Jack tells him to go ahead and quit.

As Jack leaves, Budish stumbles up to him.  He says he can see who Will is on the inside (on fire).  But strangely this is all in Will’s imagination, as Budish is still strung up, dead.  Will is hallucinating while still awake.

Jack confronts Bella.  She admits she’s known for 3 months.  Lung cancer.  Stage four.  She doesn’t want chemotherapy.  Stage four means it has metastasized to a distant part of the body or the other lobe of the lung.  She still feels distant, and can’t let herself be comforted.

We end on Will offering Jack support.  In that way Bella served to keep Jack and Will together, despite Hannibal’s efforts. 

—–

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07
APR
2015

Digesting Hannibal – Season 1, Ep4

Episode 4 – Ouef

Warning: Wasn’t a big fan of the episode from a psych perspective, and may have vented a little.

We start with Will and Hannibal in therapy.  Will describes his house, and seeing it from a distance.  “It’s really the only time I feel safe.”  Hannibal pivots this to thinking about Hobbs and how Will knew him.  “Like a bloodhound.”  Will discloses that he tried very hard to understand him.  Hannibal furthers this to exploring how Will felt about finding the body of Marissa.  Will admits that he felt guilty, “because I felt like I killed her.”  Here we have the beginning seeds of Will losing his sense of self.  He imagines himself as other people so well, that he feels guilt over their actions.  He doesn’t naturally step back into himself.  I have seen this at times with some individuals with severe dissociative disorders, who might be quite out of their own body and forget their own perspective.  Will has lost himself in Hobbs even after he was dead.  The question of course being planted is whether this problem ultimately turns Will into a killer like Hobbs.  

Will immediately clarifies that he knows who he is, and he isn’t Hobbs.  All evidence to the contrary.  Will has seen Hobbs and seen himself AS Hobbs.  Which makes this statement that he isn’t Hobbs disingenuous, and perhaps Hannibal knows it.  Hannibal stiffens in response to this.  Hannibal might just know that Will is lying.  Even moreso, his statement is a challenge to Hannibal’s unspoken agenda to turn Will into a killer, even a psychopath.  And that might further irk Hannibal, that Will isn’t fully going with the program.  

Next we find a death scene, undisturbed.  Blood spatter on photos.  A whole family dead at the dinner table.  And of course Will is taking it all in.  Cue the metronome, as he reverse engineers the crime scene in his imagination.  This is one of the procedural elements of this show, recurring in many episodes.  He intuits that the killer wasn’t invited to the dinner, but that he forced it as an intruder.  In this scenario, the killer wanted control over this family, presumably to fulfill a fantasy.  He executed the children first, then the mother.  Will comes out of his imagination as Jack asks him what he sees.  “Family values.”  Jack asks “whose family values?”  Presumably it is the killer’s, enacted in his scenario.  

Interestingly [to me, I guess], this show chooses to illustrate each murder as somewhat constructed and orchestrated, “by design.”  In truth much violence is not that way, but instead an emotional act such as when in a rage or when feeling threatened.  Here, though, each of the killers are elevated psychopaths, calculated in their creation of each violent scenario.  

Hannibal pulls up to Will’s house in a Bentley.  He enters, feeding the dogs a snack, and snooping.  Will folds and rolls his clothes meticulously.  And apparently he keeps them in his living room.  He fixes a fishing lure, revealing his careful ability with a needle.  Hannibal was a surgeon before he was a psychiatrist, after all.  Anecdotally, I heard a story of a surgeon who decided to become a psychiatrist because “surgery wasn’t invasive enough.”  

Jack, Will, and CSI team [not them, people, that’s on a different network] review the victims and the crime scene.  Pillars of community yada yada.  Youngest son was probably kidnapped a year earlier.

Back at the psychiatric facility, Abigail Hobbs processes what happened with Alana Bloom.  Again, in the real world it’s highly unlikely that she would be kept in a psychiatric facility, as they wouldn’t be able to justify to an insurance company that she’s acutely ill enough to be in a hospital.  Abigail doesn’t like the other patients, as they talk like children or don’t say anything useful.  Alana gives some factoids [kinda] that “some traumas” can stunt vocal development.  Which really doesn’t address what Abigail was complaining about.  Alana also goes on to say some victims can “broadcast” their victimhood.  While this can absolutely be true, it’s a bit of a non-sequitur as it has nothing to do with what Abigail was talking about, and doesn’t bridge at all into anything relevant.  This is a device increasingly used on the show, making “insight” judgments that aren’t particularly grounded in what’s happening with the character or the scene, but seems to perhaps aim at steering the conversation in a certain direction.  Perhaps for plot purposes.

Abigail doesn’t feel that she broadcasts “victimhood.”  Alana disagrees, calling her [more or less] a famous victim.  This is also a jump in logic.  Broadcasting victimhood is a way someone portrays themselves to others, or a way they engage people.  Jumping to the celebrity angle as being the same thing is again an illogical jump.  When talking in somewhat more abstract terms, these conversations make illogical jumps.  Unlike many leaps in therapy, these just don’t make sense to me.  At best, they’re forced.

They talk about her lack of a home, and that Alana wants to help her find a new one.  More forced jumps.  They end with Alana encouraging her to find someone to “relate to in this experience.”  This is the plot point, to drive her back to Will or Hannibal.  They both understand her experience, and she’d rather do that.  The logic leading up to it… you get my point.

Alana shows up at Hannibal’s office, and we learn they have a relationship.  She drinks a beer, him wine.  Not many psychiatrists keep alcohol in their office, for obvious reasons.  As mentioned before, though, this is not your typical office.  Alana bemoans “professional neutrality,” and that ultimately she hates watching Abigail go “adrift.”  I haven’t really heard the term “professional neutrality” used in any psychiatric circles, though that doesn’t mean it isn’t.  Regardless, this is basically untrue for Alana to say.  First, she has clearly shown an agenda with Abigail on multiple occasions, and conveyed it, even in the scene just prior (telling her to go to support groups).  Secondly, neutrality doesn’t mean being neutral about caring about the person, as she’s implying.  You always side with the person.  Neutrality, when used, is about not taking sides in debates that someone is having.  It’s a particular belief in psychodynamic therapy, the particular kind of therapy conducted on this show.  I had a patient once who was torn on making a really basic decision on a small issue.  He pushed and pushed me to tell him what to do.  I told him what seemed to be the decision he was articulating, that he preferred one thing after another.  He did it, but then was stuck on believing that he should have made the other decision.  “I only did this because YOU told me to.”  

Furthermore, Abigail doesn’t seem to be “drifting.”  She has definitely been wounded, physically and mentally, and that takes time to come back from.  But C’MON!  If anyone should be cut some slack to be adrift for a little bit, it’s a girl who discovered her father was a serial killer and killed her mother and almost killed her.  Hannibal suggests she should be released from the psychiatric facility.  “Where?  Back into the wild?”  Again, this reflects an unrealistic ability of a psychiatrist to protect their patient from the world.  No hospital in the country (unless you pay a lot of money in cash) will keep someone inside for treatment indefinitely just to protect them from “the wild” of… basically… LIFE.  Hannibal pushes to get her back into the world, to learn how to survive in the real world.  I wholeheartedly agree.  Coddling people isn’t particularly useful, as it can foster a state of dependency.  Support should be aimed at developing independence and the ability to survive.  The only exception is if you really do believe the patient is so fragile that they’ll fall apart.  In which case all efforts should be aimed at getting them ready to be out in the world, rather than “protecting” them.  

Alana makes just this case, that Abigail is in “no condition…”  She even says that Abigail was very attached to her parents, and that Hannibal “stepping in as a surrogate would only serve as a crutch.”  First off, Hannibal never proposed doing anything himself.  Second — pot, kettle.  Alana is the one inadvertently being a crutch through trying to protect her.  Alana argues that Abigail should figure things out before leaving the facility.  This is a common belief system, but it always runs the risk of avoiding anything possibly overwhelming, which can worsen the anxiety through anticipatory anxiety and a progressive avoidance cycle.  See my other blog posts on this stuff.  Hannibal defers to her judgment, in a bit of a come on.

In the medical examiner’s office, they discuss guns and families.  Someone guesses that Will was an only child, because “family friction is a catalyst for personality development.”  This implies that Will doesn’t have a personality of his own.  Which isn’t exactly true.  Will has one, though much of what we’ve seen has been in response to his excessive empathy/TOM traits, to protect himself.  Otherwise, much of the factoids thrown out tend to be relatively true as to birth order.  They end with Jack pointing out that the mother lacked any defensive wounds, unlike the children.  “There’s a forgiveness.”  Indicating she’s forgiving her son, as a mother.  Again, a little bit of a leap in logic.  Acceptance, to me, makes more sense than forgiveness.  Forgiveness is after the fact.  Acceptance implies an allowing in of what’s happening.  But maybe that’s semantics.  The conclusion still makes sense, though, that a mother might accept her child.  Probably not in reality, but it’s an interesting clue to get us to the conclusion.  

Back to the Will-Hannibal dynamic.  Hannibal asks about his mother.  Will deflects through critiquing the strategy.  To me I have to wonder if the writer has been in therapy before.  While this reflects on cliches, it doesn’t transcend it very much.  Will inquires about Hannibal’s mother.  Hannibal actually discloses his history.  For most practitioners of psychoanalysis and psychodynamic therapy, this is a big no-no.  Self-disclosing isn’t a good idea since it turns the attention away from the patient.  The only exception might be if a little harmless disclosure might help the patient feel closer, and thus more willing to open up.  A skillsd therapist probably wouldn’t do it here, since this appears to be an attempt to evade, rather than an exploration of whether the therapist is trustworthy.  Further indications that the writer probably doesn’t have much experience with actual therapist.  Then again, there are a lot of bad therapists out there.  Hannibal describes his childhood as an orphan, followed by adoption by an uncle.  Will points out that this is a similarity to Abigail.  Hannibal mentions that Abigail is similar to both of them.  Again, the jumps in conversation don’t seem organic, but based on planned out story beats.  

Will discloses that he doesn’t relate to family, though he did create a family of strays.  We learn that he invited Hannibal to feed his dogs while he was away.  Will further divulges that his family was poor and blue collar, wandering around the south with his father, compared to the Turner family (the victims of the episode).  This could be fitting for Will who would have trouble attaching to others or building close relationships, as he would be moving around.  Just another reason in addition to his excessively developed ability at TOM (Theory of mind).  

Hannibal serves one of his decadent meals to Jack, at his home.  They joke about the rabbit they’re eating.  We see flashes though, indicating it’s really a person that Hannibal hunted in the woods.  They discuss Will as “haunted,” with nightmares, which Jack hypothesizes is about being wrong about Abigail.  Hannibal goes on to wax, in near gibberish cloaked as poetry.  “The tug of life.”  “That life is an anchor streamed behind him in heavy weather.”  I can think and speak on multiple levels, and even trained in some areas of using pure metaphor in therapy (Ericksonian), but this still doesn’t make much sense to me.  There are cleaner and even more poetic ways to say that he may get lost in his own childhood memories, and that that’s dangerous.  That’s the most sense I can glean from his statements.  And here I continue using up page space to try to rationalize it.  Simply put, Will getting lost in his childhood doesn’t clearly connect to what we’ve seen in the story, nor to any clear risks or stakes for his character.  

In the medical examiner lab, the team (Katz, Jimmy Price, Brian Zeller) discusses evidence such as shoes found whose wearer had uneven legs.  Lots of exposition.  The son (killer) is estimated to be so tall.  Fingerprints found on an Xbox controller.  Shoe prints.  They narrow it down.

In the lecture hall, Will teaches until Jack enters and prematurely ends the class.  He tells Will that the prints found came from a different missing kid.  So, ending the class abruptly and rudely (artificially dramatically) didn’t really spring up for any clear reason.  It was flash for flash’s sake.  It served no plot purpose, and doesn’t make sense with these characters.  Alas.  Jack takes him to the home of this other kid, where they expect another crime scene.

And there is one, decorated for christmas.  Many dead from gunshot wounds to the head.  Smelly.

The lab goes over these new bodies.  Similar killing order.  The mother had to be shot twice, because the first shot didn’t kill her.  The second was from a different gun, “to put her out of her misery.”  A burnt, unrecognizable body.  Will just guesses that it’s Connor Frist, the missing boy who they presumed went on this rampage.  He opines that he was “disowned” for screwing up.  This is another massive leap with no foundation.  Not only is there no hypotheses to weigh in here, there’s no emotional logic to reach this conclusion.  This could be anybody.  At least tell us there aren’t other children in the house.  There could be so many other ways to unfold this story of kidnapped children being brainwashed into murder and an artificial family.  None of this resonates or follows any emotional logic (for me).  Nor does it fit any psychological paradigms.  The factoids of the episode are disconnected from the plot and character.  If we do go to the actual script, there is slightly more information for guessing about Connor, regarding a goose-down pillow and compassion before killing him.  But this was edited out of the episode, apparently.  

In a diner, EVA (a kidnapper) sits with three young boys.  She works to convince them that they’re “making family,” and that Connor had to die because he couldn’t let go of his original family.  So these murder sprees are somehow intended to free these kids of their former family.  So again the show portrays a twisted psychopath attempting to have some type of basic human connection.  

Back in the lecture hall (apparently Will doesn’t have his own office), Will discusses his case with Katz.  He points out that the children were smaller and thinner for their age, and hypothesizes that this could be due to ADHD and use of stimulants.  This is a bit controversial, and not really representative of the research literature.  Most of the research these days has concluded that overall ADHD medications might at most slow growth (even that is arguable), but doesn’t change the overall height of the person.  This is therefore putting out inaccurate health information.  

Here’s some references to refute Will’s statements:  http://www.ncbi.nlm.nih.gov/pubmed/20605163http://www.ncbi.nlm.nih.gov/pubmed/25180281http://www.ncbi.nlm.nih.gov/pubmed/23216890.

Katz brings info about the ballistics.  Will continues the discussion with the team, including Jack.  This now helps them identify one of the other kids.  Not someone who seems like he has conduct disorder (some consider this the precursor to psychopathy/ASPD.  This scene feels like exposition, like something ripped out of Criminal Minds.  

In a convenience store Eva pays for something while a little boy Chris stands nearby, and the older boy CJ stares at Chris.  Chris wets his pants, and Eva is embarrassed.  Now this scene really really makes no sense.  We know that Eva, Chris, and CJ all know each other, because we saw them in the diner earlier.  In reviewing the script, it seems like this was originally supposed to precede the diner scene, but they reversed them and never course corrected the script.  This is indicated by Eva getting a descriptive sentence in this scene, usually reserved for when a character is first introduced.  So it makes little sense the way this plays out.  It would have been creepy if the diner scene wasn’t there.  Instead it’s just weird.

Will returns to Hannibal’s office.  He’s torn over a gift he bought for Abigail, but decided against giving it to her.  Again, their interaction in this episode departs from their usual interaction style, and doesn’t fit most forms of therapy.  Will is angry, and attributes it to not being able to help those boys, because he “can’t give back what they just gave away.”  This is very focused on external circumstances, that of family, which is so different than the usual internal preoccupation and sense of losing himself in other people.  It just isn’t consistent with the usual Will to this point.  The premise is that Will identifies with these boys, but it wasn’t very well established.  He wandered with his father a bit in his childhood.  That doesn’t seem to make it emotionally resonant to us as viewers (or again maybe it’s just me).  Hannibal offers that they can help the lost Abigail find her way, even if they can’t help these lost kidnapped boys.

Hannibal meets with Abigail.  “I don’t think I’m allowed to leave after I climb the fence.”  This is a curious sentence.  Is he telling her to climb the fence and run away?  And if so, then how permission play into it.  Hannibal appears to suggest that come his home and he makes her a meal.  This is again the adopting of the apprentice.  Abigail’s father taught her to hunt, and attempted to perhaps instill in her the “killer instinct,” perhaps even trying to turn her into a psychopath like him.  Hannibal up until this episode has been attempting to do the same with Will, just without Will’s knowledge or permission.  Here now he’s bringing Abigail under his wing as well.  Abigail asks to spend the night there, since she doesn’t like the institute and has bad dreams there.  He asks her to tell him about the dreams.  Since when is he her therapist?  This is a transition in the relationship, in line with his “tell them I’m one of your guardians” role.  

She describes a dream of Marissa sending her crime scene photos of Nicholas Boyle, dead.  She describes the fear that others will find out that she killed him, and think she’s like her father.  She relates that in her dream she has fear that she won’t be able to live with herself, and while awake she knows she can live with it.  “Does that make me a sociopath?”  Hannibal tells her it makes her a survivor.  Dreams for many represent the message we don’t allow ourselves to be aware of when we’re awake.  It’s about a forbidden message or image of ourselves.  Or at least that’s one possibility.  In this case the dream could make sense in the context of Hannibal’s manipulation.  He’s making her believe that she’s a killer, and that that’s acceptable.  The part of her with a conscience is screaming out against it, but can only find voice in her dreams.  She’s not a sociopath, though Hannibal is trying to help shape her into one.

Hannibal preps a meal, and inquires with her about if she’s applied for schools.  She counters that her father killed girls at each school she applied to.  She baits that she wants to work for the FBI, but that they wouldn’t let her because of her father.  Hannibal mentions that they wouldn’t let her if they believe she’s like her father, in her nature.  “Nature vs. Nurture.”  He reassures her that “you aren’t your father’s daughter anymore.”  No.  She has a new surrogate father.  Hannibal offers the idea of making the memory of her father less painful.  Again, through destigmatizing her father, it becomes acceptable to become like him.  He introduces the idea of Psilocybin.  Hallucinogenic mushrooms.  He made her a special tea with it in it.  He mentions that there are psychiatrists who believe hallucinogens can be used to access traumatic memories.  This is actually true, though it has mostly been a fringe area of the field.  Research going back to the 1960s, including with LSD in research settings such as with Timothy Leary (a psychologist).  Don’t be fooled, though.  It’s still schedule I in the US (schedule III in CA).  She takes it.

Will, Jack, and the team, attempt to trace the geographical pattern on the map.  500 miles apart.  Middle children from affluent families.  Will hypothesizes that this is all due to capture bonding.  That’s a fancy way to reference stockholm syndrome.  The idea being that there’s an evolutionary advantage to bonding with your captor, probably descended from women in “cave man” times who were kidnapped.  If they could bond with their captors, they were more likely to survive.  This doesn’t really have anything to do with the “WHY” of these children, or the 500 miles, or any of that.  It’s a technical concept that explains why these kids would participate, but doesn’t fit the rest of the profile they’ve created for these kids.  I suppose their rationale that middle children have more difficulty fitting it makes them more vulnerable to Stockholm Syndrome is interesting, but it’s not like the kidnapper would know that if they weren’t a mental health expert.  Nor am I aware of any research data to support this.  It might as well be the oldest kid who wants to excel, and thus prove themselves to the kidnapper.  

Abigail’s trip isn’t going so well.  Hannibal cooks for her.  She’s remembering hunting deer, gutting it, and gutting Nicholas.  She asks if Alana approved this, and Hannibal admits they have a differing opinion.  Umm.  Yeah.  He offers that psilocybin during therapy can be beneficial, as it gives back power to those that have felt powerless.  Subjective sense of powerlessness can be a part of many psychological issues, including depression and anxiety.  I wouldn’t say that hallucinogens are necessarily the way out of that, though.  Her trip isn’t going well.  He reassures her to let in the experience.  She identifies he’s making the same breakfast for her that was the last meal she had with her parents.  Again this can all be viewed as steps in him manipulating her into bonding with him, in this twisted apprenticeship system of encouraging someone to become a psychopath.  

Will, Katz, and Alana go through profiles of missing kids, to find the next kid and next victim’s home.  Will speaks of the profile.  An outsider who doesn’t look like one.  Again, not certain from what data he’s drawing this profile.  “He’d have a vocation, something inventive or mechanical.”  I challenge my readers to find data to support that one.  Seems out of nowhere to me.  Will brings part of the profile to Jack, that he believes the kidnapper is a woman, playing a mother since they’re killing mothers last.  Jack contributes to the profile.  These scenes have no contrast or conflict.  Since they don’t even seem technically based on anything, they’re tough for me to watch.  They find a good suspect of CHRIS, the next kid.

We see Chris ringing his doorbell.  We know what’s coming.  The FBI arrives just in time.  Chris runs away.  Will calls him, and he pulls a gun on Will.  Eva steps up and holds him, telling him to kill Will.  Katz shoots Eva in the shoulder.

Jack sits with Chris in the car.  Chris asks to go home.  Jack says that’s not going to happen, since all that anyone knows is he came to kill his family, then that’s what they’re going to believe.  This is probably intended to echo Abigail’s situation, where people’s perceptions of her as a possible killer will haunt her for a long time.  

Alana rails at Hannibal for taking Abigail out of the hospital, since she’s her patient.  He apologizes, and mentions that she’s in the dining room.  He tells Alana that he gave Abigail a bit of valium.  We know better.  She goes in and joins them at the table, sitting down for a meal.  “Breakfast for dinner.”  And the picture is complete.  Mom and Dad at the table.  Dad is a killer.  Mom is innocent.  Rebuilding her family.  A twisted corrective emotional experience.  Hannibal has solidified his bond with her.  

At home, Jack sees his wife join him in bed.  He inquires if it’s too late to have kids.  “It is for me.”  Will sleeps in bed, alone.  Tossing and turning.  He’s the only one without a family now.  

—–

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07
APR
2015

Digesting Hannibal – Season 1, Ep3

Episode 3 – Potage

We open with Garrett Jacob Hobbs and Abigail Hobbs observing a deer. They’re hunting together. She misses the first time, but succeeds the second. Yet she’s distressed over killing it. She’s internally conflicted about killing, while her father is happy. She tells her father about how amazing deers are supposed to be, with regret. Her father one-ups her on each statement; they’re still beautiful and smart, even in death. He has the plan to “honor her” and use all of her parts, but have his daughter do the cutting with a knife. She’s distressed. He’s desensitizing her to what she doesn’t want to do: the horror of taking a life and the gory reality of the body afterwards. “Eating her is honoring her. Otherwise it’s just… murder.” She cuts the deer and runs her hand through its fur, flashing to the hair and body of a victim of her father.

She wakes up in the hospital, her intubation tube still in place. She’s haunted by what she did with her father. It comes out in her dreams. Many dream theories, going back to Freud, believe we compartmentalize or hide away things that are unacceptable. Yet they sneak out in our dreams, often disguised. Maybe this is because only when disguised can they get close enough to our conscious awareness that we won’t try to shove them back down out of fear/shame/etc. 

We move to Will’s home, where he’s letting his dogs out. Alana Bloom shows up on his lawn to tell him Abigail has woken up. Will seems a bit shaken, and Alana presses them to sit down for coffee. She noticed that Will is shaken, and she presses him to take a pause before diving in. She’s fulfulling a basic role: protecting him when he doesn’t think to protect himself. His impulse is to dive in. They sit silently with their coffee as Jack calls on the phone. Alana conveys that Jack believes Abigail was an accomplice. Will wants to help her. Alana wants to protect him from having to “save her.” They agree to have Alana be the one to talk to Abigail. Alana posits that the first person to talk to Abigail shouldn’t be someone who was there. Another might argue that she would feel more understood by someone who was there. It would definitely complicate things for someone who has a tendency to over-empathize, though. Will needs distance. He needs boundaries.

Alana goes to meet Abigail, introducing herself. Alana says “not medicine… I’m a psychiatrist.” It’s a funny distinction. Psychiatrists are medical doctors. We go to medical school. Then we specialize in the mind/brain and behavior. The reason this is important is many people don’t know the difference between a psychologist and a psychiatrist. Both have doctorates, but in a medical setting some people believe it to misleading to call yourself a doctor without an MD (or DO – more on that another time). More often a psychiatrist will say “my specialty is psychiatry,” or “not internal medicine.” Things like that. Alana says that she specializes in “Family Trauma.” Psychiatrists do subspecialize. Technically psychiatry is the specialty (like surgery is the specialty of surgeons), and then a subspecialty can be practiced such as forensic psychiatry (presumably one of Bloom’s real subspecialties), or cardiothoracic surgery for a surgeon.

All the more interesting is Abigail being treated at the Port Haven psychiatric facility. This is never explained. People are psychiatrically hospitalized for only a few reasons — because they are suicidal, psychotic, or manic. Few other reasons are typical, aside from an occasional drug detox. For Abigail we’ve been given zero reasons for her to be hospitalized. We could presume a rationale such as concern for trauma and PTSD, but these aren’t reasons to hospitalize someone, usually.

Abigail notes that she knows her parents are dead, and Alana seems to have information. They’re dead. They haven’t been buried. Abigail’s mother was cremated. Her father “is more complicated.” Abigail admits she knows her father was “crazy.” Alana challenges that Abigail had told the nurses she didn’t remember. “I remember, I just didn’t want to talk to them about it.” Now this is an incredibly revealing moment. For one, it’s real. People don’t talk about everything with every person. More importantly, it reveals that Abigail can be duplicitous, and lie to people she doesn’t want to talk to. It further means that no one aside from her will really know what happened unless she chooses to disclose it. 

Abigail states she wants to sell her family house. Alana watches, with the faintest airs of surprise and suspicion. Wanting to sell the house might be an effort to distance herself from the horrors of her father. We’re not sure. Alana brought her clothes, in a very sweet and motherly way. In this way Bloom is mixing roles. If she’s a forensic psychiatrist, often her job is assessment for the court, not treatment. Forensic evaluators don’t have to maintain confidentiality, and spell that out up front. Bloom, though, is presenting herself more clinically. She’s playing the role of a caregiver, presumably to get Abigail to trust and open up. She has not spelled out her role though with her, as a clinician or evaluator. And for the drama it’s more interesting to leave it ambiguous.

Alana goes on to offer her music as well, and discloses that she has a “problem” redeeming gift cards. It’s a subtle personal disclosure, for the purpose of trying to form a relationship. “By telling something about me, maybe you’ll trust me enough to tell me about you.” Abigail takes the bait. “Probably says something about you.”

Back at the BAU (Behavioral Analysis Unit), Jack sits down with Hannibal and Alana. He emphasizes the urgency of getting info from Abigail. Alana in turn emphasizes the need to create a safe space for her to get her to open up. This is a particularly self-psychology approach, a branch of psychoanalysis. Jack mistakenly views this as her being empathic and trying to protect Abigail. Alana reveals she questions her state of mind, believes she’s hiding something, yet doubts she could have really assisted the murders physically. She and Hannibal end up taking different sides, with Hannibal suggesting she might just be hiding the trauma, and Alana noting her history of manipulation. This is a common bias that health professionals of all kinds see: withholding of information is manipulative, and thus nefarious. In this context we don’t really know her ulterior motives, and the presence of selectively disclosing information is no more nefarious than openly disclosing everything is naïve. Jack wants Will to see her. Alana wants to protect Will, but Jack clarifies that Hannibal is Will’s psychiatrist. This hadn’t officially been spelled out before. Hannibal was at most an evaluator, rather than someone who focused on treating Will’s state of mind. 

Back in the lecture hall, Will lectures on Hobbs and his copycat. Jack and Hannibal step in and listen as Will describes the copycat (ie Hannibal): An intelligent sociopath who will be hard to catch, as he won’t murder this way again. He’s an avid reader of Freddie Lounds, and had intimate knowledge of everything of Hobbs (motive, procedure, etc). This is a fantastic device in continuing the cat-mouse dynamic of Will and Hannibal, which is played out on multiple levels. Will even opines that the mystery caller to Hobbs before his death was the copycat. The real drama in the scene is not Will, but Hannibal’s response to his own profile. The Act ends with Hannibal smiling, an uncommon act out.

At the psychiatric facility, Abigail [skeptically] talks with Freddie Lounds. It’s a game of manipulation. Freddie attempts to convince Abigail she’s worth disclosing her story to. Abigail is cautious and calculated. She gets Freddie to spill what she knows. “Your father was sick.” “Does that mean I’m sick, too?” Abigail works hard to hide the emotions, but lets slip the concern that she’s a psychopath like her father. In so many ways this parallels Will and Hannibal, with Will being the unwitting apprentice. 

Most courts do not consider psychopathy or its many forms (sociopathy, antisocial personality disorder, psychopathic personality disorder) to be a “mental illness” in the form that would qualify for exculpation. Typically the term is NGRI (not guilty by reason of insanity). There’s a whole history to this, but in short psychopaths aren’t considered “insane” in the legal sense, and thus are responsible for their actions. Furthermore there is little evidence that treatment by psychiatric hospitalization is helpful, though some select countries like the UK have tried. 

Freddie makes the case that the public will perceive Abigail as being like her father, so she needs to protect against that by controlling the information she gets out. Abigail counters that she doesn’t care what other people think. This is further revealing about her state, that if she doesn’t care then her reasons for withholding information from the nurses isn’t because of shame. Or at least that’s the profile she wants to portray to Freddie. Abigail asks how her father got caught, and Freddie describes Will (as he’s walking in) as a man who catches the insane because he can think like them, because he himself is insane. What an introduction!

Abigail admits that she remembers Will as the person who killed her father. Not a great place to start engaging with someone. They go for a walk and discuss her parents. “He was loving right up to the moment he wasn’t.” Such an experience would have to shake someone’s ability to trust ever again. Anyone in the future who appears trustworthy could turn on her. Will tells her she isn’t the same as him, and that the good she saw in him must have been because of her. She admits fearing the future— her own nightmares, the psychological effects of it all. Hannibal promises “we” will help. Will normalizes her experience, that there’s no “getting used to” it. He even discloses that he fears his own nightmares over killing, calling the experience “the ugliest thing in the world.” Hannibal watches. This is undoing his agenda to transform Will. 

On the way out they run into Freddie, who attempts to manipulate Will. She offers to undo the statements about Will she made to Abigail. “I can also make them a lot worse.” Will responds with a threat, that one shouldn’t piss off someone who thinks about killing people for a living. This of course actually proves her slanderous statements that he’s dangerous. Jack of course scolds them, including Hannibal for letting him say this. Hannibal furthers his connection to Will by “trusting him to speak for himself.”

Jack wants to let Abigail go home. Alana thinks it’s reckless, and that she doesn’t appreciate the dangers of going home, as well as the risks of taking her out of a controlled environment. Again, the psychiatric system, most specifically dictated by insurance companies, doesn’t hold people because it’s risky to go home. They usually have to justify keeping someone by something they’re actively doing in the hospital, some kind of treatment. Jack inquires “you said she was practical.” Will offers “That could just mean she has a dissociative disorder.” This seems like a leap in logic. A dissociative disorder, which usually manifests as a splitting off of a part of functioning, or feeling out of one’s body, doesn’t seem connected at all to her issues. And yet, maybe it does. Many people dissociate as a way of dealing with extreme emotions such as experienced during a trauma. They leave their body a little. There’s probably a PTSD subtype where this is the response (vs. the hypervigilance subtype). In which case if she’s dissociated she might not be able to appreciate the emotions and dangers there. More commonly people would avoid the triggers of the emotions, just as dissociating it away is a way to keep the emotions at bay and not have to experience them. In this case, Abigail has shown visibly having to suppress emotions, which makes a dissociative disorder much less likely.

Alana hypothesizes about the bad outcomes of letting Abigail return to her home, including re-traumatizing her. Jack reaches to Hannibal for his opinion, who sides with Alana but notes that there’s an opportunity to use the experience to heal her. Jack openly states he’ll go with the opinion that serves his agenda. As usual, it’s an interesting power dynamic to watch play out. As usual Hannibal is the most successful at being strategic: he has his own endgame he’s working, now on Abigail as well. 

Freddie talks with NICHOLAS BOYLE, the brother of one of the victims (actually the victim of the copycat). He’s still upset over the brutality of her death. Freddie feeds him the bait that Abigail came of her coma. She is setting into motion a new antagonist.

Hannibal, Will and Alana accompany Abigail to her home, where they find graffiti covering the house, with “CANNIBALS” written everywhere. Abigail goes step-by-step through the house. Where her mother died. Where her father was killed. All cleaned up. She doesn’t seem to have any emotional response to the situation. We don’t know if this is because of her being a psychopath, or because she’s detached. Based on the earlier emotions we’ve witnessed her having, detachment (dissociation) is much more likely. Abigail asks Will about his process of pretending to be others, like her Dad. This leads back to the copycat. She talked to him briefly on the phone, before he warned her father. Does she remember his voice? This is a fantastic bit of tension building. Abigail asks whether you can “catch someone’s crazy.” Alana responds that it’s called “Folie a deux.” Technically that’s incorrect. Folie a deux is a shared delusion (a false belief). Such as if you and your partner both believe the neighbors are poisoning you. Distinguish this from the “crazy” they’re referring to, which is psychopathy. Psychopathy isn’t contagious. Though situations like cults seem to open up the possibility of violence and even enjoying violence amongst people who are suggestible but not psychopaths. Oh, and no one uses the word “crazy” in legal or psychiatric circles. At least not officially. Hannibal further clarifies that false beliefs aren’t “delusions” if they’re accepted in their culture.

Abigail mentions her father was a perfectionist. Will agrees, noting there was little evidence. She jumps on this as the reason they let her come home, questioning if it was to find evidence. As if it wasn’t her idea in the first place. Though she ask about “letting her” come home vs. bringing it up in the first place. Abigail takes it a step further, excitedly wanting to re-enact the crime, making Will play her Dad, Alana her Mom, and Hannibal “the man on the phone.” Chilling. Does she know? Probably. We aren’t sure, but her decisive ending pointing to Hannibal seems to be her not-so-covert way of telling him that she knows it was him. Not covert to us, at least. She stares at Hannibal, trying to get a reaction, but without a response aside from him walking away.

MARISSA SCHURR, a classmate of Abigail’s, shows up to talk. She tells Abigail that everyone thinks she participated in the murders. This brings home the reality that public perception is important for her. Nicholas Boyle steps up from the woods and calls out Abigail as being the bait that got his sister killed. They scare him away, including by Elise throwing rocks at him. When Hannibal and Will catch up, Hannibal conceals a bloody rock. He’s trying to protect Abigail, or perhaps just form an alliance with her to protect himself.

Will dreams of a stag, and of himself as Hobbs, slitting Abigail’s throat. For him it’s a nightmare.

Abigail leads the group back into her father’s cabin. It’s quite clean. She recognizes now that what appeared to be a philosophy about life and hunting — “no parts went to waste, or else it was murder” — might actually be his way of preventing getting caught, leaving no evidence. She even realizes that he was probably feeding parts of the victims to his family. As she tells them about his confession, that he murdered other girls so as not to murder her, blood drips onto her, leading her to find her friend Marissa murdered upstairs. Abigail is shocked, legitimately. This doesn’t track with any level of psychopathy unless she’s a very very good actress. Abigail, that is, not Kacey Rohl, the actress who plays Abigail, who obviously is very talented.

The presumption is that the same copycat (we believe to be Hannibal) killed Marissa. Jack shows up questioning Will’s profile about the copycat, which even Will is now questioning. Hannibal makes the prediction that Nicholas Boyle killed Marissa, as well as his own sister. Hannibal has a possible scapegoat for his crime, and he’s seizing the opportunity. 

Will doesn’t think Abigail had anything to do with either murder. Jack questions this, wondering if Abigail is manipulating Will. I see no evidence of this based on the evidence in the episodes. Abigail’s “manipulations” are fully explainable within a normal personality structure, considering the circumstances. But of course we only know as much as the show chooses to reveal at this moment.

Will and Hannibal conclude that the copycat killer must have done both murders, since the wound patterns are the same. At this point there seems to be very little evidence connecting this directly to Nicholas, though. Hannibal tells Jack that Abigail isn’t responsible, but she may be a target. Jack instructs Hannibal to take Abigail out of Minnesota. We aren’t given any evidence to explain why Nicholas would be a suspect aside from his approaching them angrily the day before. It doesn’t explain at all why he would kill his own sister. In short, their profile of him is kinda weak. One could see, though, that the picture is confusing Will and Hannibal might be capitalizing on that by putting in a new explanation. 

As Abigail is escorted back to her house, Marissa’s mother breaks through the police, accusing Abigail of murdering her daughter. Hannibal escorts her away. Freddie Lounds appears, wanting to talk to Abigail. This plants the possibility that a predatory reporter might even be responsible. Is she so desperate for a story that she’d kill? She has no scruples, but we haven’t seen any violent history. 

Hannibal and Alana stay outside with the police. Abigail sits in the house. She visibly shakes, shocked and emotional. This is further evidence that she is really shocked and not acting. Aside from us as audience members, she doesn’t believe anyone is watching. She remembers the “not wasting” any part of the hunted, and cuts open a pillow to find it stuffed with hair.

Suddenly Nicholas appears, telling her he didn’t kill Marissa. Abigail tries to run but Nicholas grabs her and slams her against the wall. She stabs him in self defense, shocked at what she has done. As she heads up the stairs with bloody hands, Hannibal sees this. He knocks out Alana to prevent her from seeing, and instructs Abigail to show him what happened.

They go down to see the body, and kneel next to him. In a shocked, suggestible state, Abigail is vulnerable. Hannibal says this doesn’t look like self-defense, but butchery, and that they will now assume she was an accessory to her father’s murders. This gives Hannibal a point of leverage to manipulate her. She knows about him on the phone. This gives him a way to manipulate her. “I’ll keep your secret and protect you [if you keep mine].” Though it’s not stated as such. Yet.

Hannibal offers to help her, at risk to himself. He offers to help her hide the body, something that would never occur to her. We move to Will, Alana, and Jack outside at the ambulance. They’ve created a narrative that Nicholas attacked them, and Abigail was able to scratch him as he fled. This fits the picture that he’s a killer. Though we know better. The blood remaining of Nicholas matched the tissue found on Marissa, further confirming the frame job. We know Hannibal probably got it off the bloody rock that he hid.

We find Hannibal back in his spacious office. Admittedly I’m a little jealous of his office. I know no psychiatrists of therapists with anything like this. Abigail has snuck in, and he welcomes her. She’s afraid to sleep, and he knows it’s about her dreams. She believes that because she didn’t “honor” him by using his parts, it’s just murder. He reassures that it was probably self-defense. This of course goes contrary to his earlier manipulative rationale. Now he’s admitting what it was. 

She identifies that he called the house. Hannibal lies, stating he only asked if her father was free for an interview. She sees the truth, though, calling him out as a serial killer calling another serial killer. He denies it. “I’m nothing like your father… I made a mistake… like yourself.” And he offers to keep her secret.

—–

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06
APR
2015

Digesting Hannibal – Season 1, Ep2

Episode 2 – Amuse-Bouche

We open on bullet shells hitting the ground. Will at the firing range. He’s haunted by Garrett Jacob Hobbs. Even in his dreams. He awakens to entering a crime scene with Jack, the attic of Hobbs, filled with mounted antlers. Jack maintains that his daughter, Abigail, could be an accomplice in the prior murders. “Hobbs killed alone.” As usual, Will is very certain. But someone else was there in that attic. Someone with red hair. We meet FREDDIE LOUNDS, an online tabloid reporter.

Will stands in his classroom teaching his students. And yet he is still haunted by the experience of shooting Hobbs, to the point of having apparent intrusive memories. This is a classic symptom of PTSD, aka Post Traumatic Stress Disorder. If we follow the textbook, a traumatic experience is a single scary event with threat of death or bodily harm, or witnessed threat to someone else. Though at this early stage it would at most be Acute Stress Disorder.

Will alludes that there is a copycat killer already, opening up the question as to who is it? Alana and Jack talk with Will after class, letting him know he’s free to return to the field, but that he needs to have a psych eval done, with Hannibal or Alana. Will clarifies that it’s mandated, and attempts to dismiss it by stating “Therapy doesn’t work on me. I know all the tricks.”

Of note, Jack wasn’t proposing that Will go in for therapy. He proposed he go for a psych evaluation. In the clinical and forensic worlds, evaluations are usually for the purpose of assessment and diagnosis, rather than treatment. So really therapy would be irrelevant. A better twist might be mandated regular counseling or therapy while in the field. But maybe I’m just being nitpicky. 

Hannibal immediately “rubber stamps” Will, for the purpose of moving on to therapy. Getting on with it. And the banter begins. Hannibal alludes to Will feeling obligated to Abigail (Hobb’s daughter). Hannibal states he too is obligated to her. In their dynamic, Hannibal asks a question and Will pushes back without answering. So Hannibal answers instead. This can be a therapeutic strategy to get a patient out of a defensive position, which Will definitely was in. And it works. Those in classic psychoanalytic practices would not use this technique, because it challenges the “blank slate” of the therapist. 

Deep in a wood in Maryland, three boys hike and find a dead body, in fact a whole garden of dead bodies and mushrooms.

Meanwhile, Will is back at the shooting range. Beverly Katz joins him, critiquing his stance and his need to practice. Will reveals that he was stabbed when he was a cop. This is presumably in line with the history of Will from the books, where he was a homicide detective in New Orleans prior to going to grad school for forensic science.

Back at the grave garden, Will examines the scene with Jack. Nine bodies, all buried alive and kept alive with IV fluids, to feed the mushrooms. At the periphery, Freddie Lounds covertly questions a cop. And Will does his metronome trick, imagining the scene from the beginning, again in the shoes of the killer. As he imagines this though, he continues to be haunted by Hobbs. One of the grave bodies also grabs Will’s arm, still alive. Good scare moment, author.

Will returns to Hannibal, handing back the clearance letter. He’s admitting he needs help, which is usually (but not always) where therapy begins. Will admits to having a “hallucination” of Hobbs in a grave. Hannibal attributes it to stress, yet continues his slow seeding of making Will into a serial killer, by calling Hobbs Will’s victim.

If I had to hypothesize a strategy that Hannibal is taking, he’s beginning by desensitizing Will to the process of being a killer. He has fed him presumably human remains as sausage, and now he talks to him as a killer, which Will dislikes. Will admits he doesn’t like putting himself in the shoes of a killer.

They discuss the case, and like many of the frankly bizarre murders on this show, has a deeper meaning. Each murder seems to be a metaphorical process for the killer to find a basic human need, such as connection or as a twisted cure for loneliness. 

Freddie Lounds pretends to be a patient to get to meet Hannibal, even using a pseudonym. Hannibal calls her on quickly. This is a fantastically tense scene. What might he do to her?

Jack and Hannibal dine together, eating a beautifully prepped loin dish. We’re clearly intended to wonder if they are eating Miss Lounds. They have a friendly relationship, and Hannibal clearly digs psychologically with most people he know socially.

Will in the lab, discussing the case with the techs and doctors. They deduce that since the killer was feeding the bodies sugar water (dextrose solution), that they were likely diabetic. Will presumes it was from changing their medications that he was able to make them hyperglycemic. And we follow that logic in to a pharmacy, where GRETCHEN SPECK-HOROWITZ shows up to pick up her medication.

Gretchen is the only crossover character (and second actor) from my favorite Bryan Fuller show, Wonderfalls. I encourage everyone to pick up the dvds for that brilliant but short-lived show. Apparently Gretchen moved from Niagara Falls to the Maryland area. 

Physiologically this makes sense. Diabetes Type I involves the body not being able to make insulin. Insulin helps sugar get taken up into muscle (and other areas of the body). If a pharmacist swapped insulin for saline, then blood sugar levels rise steadily, which severely dehydrates a person. Without the sugar being usable by cells of the body, fat is broken down releasing ketones. The complications of all of this is Diabetic Ketoacidosis (DKA). 

The FBI raids a pharmacy, trying to catch the killer, ELDON STAMMETS. But he has escaped, leaving a body in the trunk. A story is released by Freddie Lounds about Will, with excessive detail. She worked another FBI agent for info though, leaving us wondering how much she got from Hannibal, if anything.

Will sleeps in Abigail’s hospital room. As he hears Alana walking through the hallway in heels, he dreams about a giant stag walking through the hospital. He awakens to find Alana reading to Abigail. They have a warming conversation. “I feel… good.” Will exclaims this, almost with confusion.

Freddie leaves her motel, to be confronted by Detective Pascal (who she tricked into giving up info earlier). It’s clear she’s a shark, willing to steamroll over people to get what she wants, but is willing to help others afterwards. Until Stammets walks up and kills Pascal, point blank. With blood spatter on her, he demands she tell him about Will. He’s looking for someone that can understand him.

Freddie Lounds informs Jack that Stammets is going to go find Will. “He wants to help Will Graham coonect to Abigail… he’s going to bury her.”

Now this type of thinking that burying someone to make a personal connection to them via fungus and plant interconnectivity, I would venture to fall into the realm of magical thinking. Magical thinking, when believed literally and outside of fairy tales, is considered a form of psychosis. So here again we have evidence that this man is as much psychotic as he is psychopathic. Some might argue that he’s a psychopath because he’s willing to hurt people without any apparent remorse, though in his delusional system (his false belief system that burying people helps to connect them through plant life) it’s not for any goal of cruelty or torture. So the evidence that Stammets is a psychopath can be challenged.

We follow Stammets going into the hospital where Abigail is admitted, and changing into scrubs and hospital garb. We move on to Will entering the hospital as if any other day, but then gets a warning call from Jack that Stammets knows about Abigail. Will draws his gun and switches into game mode. He finds that Abigail isn’t in her bed, and that the nurse believes she was “taken for tests.” We don’t really need any more medical specificity than this. Tests is enough for the plot point, because we’re caught up in the chase. Will finds Stammets and shoots him in the shoulder. Stammets continues on his psychotic delusion that by burying her “she’d be able to reach back.”

A fascinating belief, but quite detached from what many would consider reality. Furthermore the emphasis on “connection” seems to weigh against psychopathy, as psychopaths are considered less interested in helping or connecting to others. They’re both kind of selfish. In that way narcissism and psychopathy are considered connected, Otto Kernberg, and psychoanalyst, wrote about a spectrum of pathological narcissism, and that psychopathy and what we now would call narcissistic personality disorder all exist on it.

Hannibal questions who Will saw when he killed Stammets, and Will replies that he didn’t see Hobbs. Hannibal continues his psychodynamic therapy through interpretation. Interpretation is a tool in primarily psychoanalytic/psychodynamic therapies, to “interpret” what is happening and give “insight” into the person’s unconscious process. Hannibal makes an interpretation – that Will isn’t haunted by Hobbs but by the “inevitability” that eventually someone will be so bad that Will will (pun intended) enjoy killing him. Here again Hannibal is making a suggestion and couching it as a psychodynamic interpretation. As if he has great insight into Will, and when Will considers it, it has an impact. Hannibal has thus implanted the possibility that Will could enjoy killing. It’s a very subtle and slow psychological manipulation. 

Will doesn’t buy it, distinguishing that he felt “just” when he killed Hobbs, and that he didn’t even kill Stammets. Though he might have had the intention to kill him. Maybe. Hannibal furthers his manipulation through interpretation, stating that if Will intended to kill Stammets, it’s because he understands why Stammets killed. “It’s beautiful in its own way.”

Hannibal is furthering the manipulation, lessening the stigma behind killing through these suggestions. He’s developing Will’s empathy (caring) for killers, rather than just his ability to think like them. In that vein he’s also desensitizing Will to the process of murder. Again, it’s a subtle slow manipulation, presumably to turn Will into a killer who enjoys killing. Every time he gets Will to consider that he himself might be like a psychopath, Will explores whether it’s true and accepts it a little more as possible, eventually as true.

Hannibal furthers the interpretation – “did you really feel so bad because killing [Hobbs] felt so good?” Will admits that he liked killing Hobbs.

And we move into the closing of their “therapy” session, where Hannibal compares man to God. God must enjoy killing since he does it so often. He killed a church of his followers during worship. Will counters “did God feel good about that?” Hannibal “He felt powerful.”

Visually this ending really illustrates the difference between Will and Hannibal. Hannibal is calm and emotionless. Will is shaky and scared. From this alone, we can see that Hannibal fits the picture of a psychopath, and Will is scared to explore that world, but will do it when led by Hannibal. The manipulation continues.

—–

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06
APR
2015

Digesting Hannibal – Season 1, Ep1

Episode 1 – Apertif

We begin with a murder scene. A man and a woman killed. We meet WILL GRAHAM, an FBI teacher and profiler. He’s assessing the scene, and through a metronome device we watch time rewind to before the murder. Will has the ability to imagine himself in the killer’s place, conducting the murder himself, and understand the murder through this process. We watch him kill the couple, and learn about the killer in the process.

The story cuts to him lecturing a class on the murder. He’s approached by JACK CRAWFORD, the head of the Behavioral Science unit (think Criminal Minds). Jack asks Will where he lies on the spectrum (referring to the Autism Spectrum Disorder). Will states that he’s closer to Asperger’s, with difficulty in social engagement, and so he prefers teaching. And yet he has the capability of empathizing with anyone, including sociopaths.

The show creates an unusual character in Will. He’s compelling partly because he’s tortured, and he must stay tortured to do the good work that he does. But most experts would say this isn’t in the Autism Spectrum, since those in the Autism Spectrum tend to have problems with empathy, rather than have it overdeveloped as Will Graham does. He’s basically supposed to be an empathy savant, which would be difficult for someone with ASD. Even first degree relatives of people with autism, who can have an ultra-mild form called “Broader Autism Phenotype” have significant impairment in empathy. There’s a good amount of research to support this. Which makes the existence of a Will Graham improbable, at least as explained as existing on the Autism Spectrum. 

There is a hypothesis (primarily put out by those diagnosed with ASD) that those with Autism actually have plenty of empathy, but just are too easily overstimulated by social interaction, so avoid it to avoid the stimulation. This model might fit the picture for Will, which could make it all the more difficult for him to use his gift. The more he uses it, the more overwhelmed he gets. Of course they never explain it, but the drama works well as it is if you can suspend disbelief. 

Some additional research may help this discussion, examining the idea of Theory of Mind (TOM). Theory of Mind is the ability to know that others have beliefs and thoughts different than yours. Technically this is different than empathy, which focuses on the feelings of another person. Some research has found that those with Autism have an impaired Theory of Mind, and impaired empathy. Other research, particularly in children, found that they can have intact TOM while empathy might still be impaired (in those on the spectrum). http://www.ncbi.nlm.nih.gov/pubmed/24875777

In short, TOM is the ability to consider how another person thinks, believes, and what they want. This is closer to the nature of Will’s ability, particularly in being able to understand another, without necessarily having to feel what they feel. Research seems to indicate that those with full autism have severe impairments in TOM, but that those on the spectrum vary. So it’s plausible that Will could have intact TOM. Pain empathy also seems to be intact in ASD. Empathy is distinguished by the ability to resonate with the emotions of others.

Jack brings Will in on a case of multiple presumed kidnappings, all of girls similar in appearance. They’re looking for the standout case that tells them what the killer is really looking for. They go to the family home of the most recently disappeared girl. Will deduces that because the cat was fed, that she was at home, and that she must be in the house. He finds her body. We meet Beverly Katz, apparently a pathologist who was examining the body and found Antler velvet in the wounds of the dead body. Will thus deduces that the Antler velvet was used for healing, and thus that the killer was trying to undo what he has done. “This is an apology.”

These deductions by Will mark a clear procedural approach on the show. Will deduces from scant evidence, and we suspend out disbelief and follow him on it. Primarily because we’ve seen his process (in the opening), and that up until now he hasn’t been wrong. It’s fantastical, and thus fun to watch, even if the leaps in logic seem large at times. 

We follow Will traveling home, where he sees a lost dog running in the street. He takes a lot of time to bring the dog in and help it. We’ve learned that he cares about animals, and that actually he’s an animal rescuer.

While this might be a device to make Will more likable, it also reveals that the character connects well with animals even if he doesn’t with people. This fits with Autism Spectrum Disorders as well. 

Will has nightmares of the murder, even to the point of night sweats. He’s haunted by the murders he sees.

This is consistent with the idea of those with ASD being overstimulated because they can’t filter their empathy. 

Jack confronts Will about the case, and whether the killer is a psychopath. Will deduces that the killer loves one of the girls he kidnapped, and therefore shows special care with her corpse. The Sensitive Psychopath.

Next Jack meets with Alana Bloom, a forensic psychiatrist and lecturer with the FBI. Jack wants clearance to have Will in the field. Alana worries about him.

During the autopsy, Will has the visual that the girl (victim) was mounted on the antlers, “like a hook.” Her liver was cut out but put back because she has liver cancer. Will deduces that the killer is eating the livers.

Now in a traditional scientific approach, information is gathered, and multiple hypotheses are developed. Maybe one is more likely than others. More data/evidence/information is gathered to support one hypothesis over another. That one is then pursued. It happens with detective work. It also happens with medicine. If someone comes into the hospital with shortness of breath (information), a doctor has a list of possibilities for that, such as pneumonia or heart failure. A history and physical exam is conducted to gather more data to narrow the possibilities (hypotheses). Will Graham doesn’t do that. He makes large leaps in his hypotheses, and he’s always quite certain of it. How does antlers goring someone, plus removing livers in someone that cares about the victim lead to the conclusion that the killer is eating organs? I know of no precedence in psychopathology, and no clear evidence that they presented witth the case to make that leap. Yet we as viewers are willing to follow this logic. It moves the story forward, and we’ll suspend our disbelief because Will is not your average detective. He must know something we don’t. 

And of course this leads us to HANNIBAL. Hannibal the Cannibal. We join Hannibal Lecter with Franklin (a patient), a man who’s crying and complains about being too neurotic. Hannibal replies that if he wasn’t neurotic he’d be something much worse.

This likely refers to an old psychoanalytic system of thinking (originally Freudian) that people exist on a spectrum between neurosis and psychosis. Hannibal is implying that if the patient wasn’t neurotic, he’d be psychotic. This is also the origin of the term borderline (personality disorder), referring to the borderline between neurosis and psychosis. Nowadays if we use the word neurotic at all (most practicing therapists don’t), it’s in reference to a trait of the personality, but only one of many traits. This is a source for a much longer blog about personality and the different ways of understanding it, from DSM to the five factor model. 

“Our brain is designed to experience anxiety in short bursts, not the prolonged duress that your neurosis seems to enjoy.”

A great quote, reflecting the nature of an anxiety disorder. It is in simple terms, the fight-or-flight mechanism turned on for what feels life threatening, yet isn’t.”

“It’s why you feel as if a lion were on the verge of devouring you… You have to convince yourself that the lion is not in the room.”

This reflects a simple approach to therapy. Which for the purposes of such a small scene is needed. Hannibal generally uses Psychodynamic Therapy as his particular brand of psychotherapy, kind of like psychoanalysis lite. Psychodynamic therapy of uses the relationship with the therapist as an tool of change, and can use “interpretations” also, working to make a patient aware of things they’re doing automatically (unconsciously) and might not be aware of.

Jack approaches Hannibal for help. In their conversation we learn that Hannibal had his internship at Johns Hopkins (fitting since much of the show takes place in the DMV — DC, Maryland, Virginia). Jack asks to come in, and Hannibal tells him he can wait in the waiting room. We see an early display of who is in charge in this setting. This is Hannibal’s turf. Jack goes on to humble himself, calling himself a layman in Hannibal’s company. Hannibal deflects the role of expert at first, appearing humble. He then even goes on to point out Jack’s attempt to flatter with use of the term layman, but ultimately allows it. Jack proved worthy.

It’s an interesting first exchange, if you really think about it.

Now the reason I chose to get into such detail of this one conversation, is the idea of psychopaths having a place in society. They are considered to be “intraspecies predators,” and maybe served a purpose in tribes of being the soldier or hunter. It’s exciting to them to kill, and in tribal warware it’s beneficial to the society to have them do that, to protect the tribe. We might expect, though, a need for domination or power in other social circumstances. Here Hannibal wants the power, but he doesn’t want it as part of a manipulation by Jack. He wants the offering to be legitimate. 

Jack asks for Hannibal’s help in making a psychological profile. We don’t know if it’s about Will or the killer, and we’re left wondering. Hannibal examines the crime photos, as a guise presumably to get in the room to examine Will. He challenges Will about his poor eye contact. Hannibal makes leaps in his logic, and Will makes the correct assessment that Hannibal is there to profile him. “Don’t psychoanalyze me, you won’t like me when I’m psychoanalyzed.” A Bruce Banner moment which I love. Hannibal tipped his hand a little. In the process he developed the formulation that Will is “pure empathy.”

A Paper that Hannibal authored is mentioned – “Evolutionary origins of social exclusion.”

Social exclusion refers to a social disadvantage, where a group (or person) is relegated to being an outsider in a society. In the US this might be based on race, or sexual orientation, for example. In other countries it might be based on religion. Of the few papers published on this type of topic, the hypothesis is that stigma/exclusion serves a purpose for the benefit/survival of a group, and in keeping out those that can’t conform to the agreed upon rules of functioning for a group. http://www.ncbi.nlm.nih.gov/pubmed/11316010

We move to the finding of the next body, of a girl impaled on a stag head. The killer has a name now – “The Minnesota Shrike.” We get a full definition of a shrike in the episode. Will concludes that the killer is mocking her.

In some ways Will seems to see each murder as a conscious expression by a killer, as if he’s trying to communicate something to others or to the victim. Some therapists view all behaviors like this, as an expression of something. Others might just say a cigar is just a cigar.

Will can conclude that the emotion is so different that it must be a different killer. We move to see Hannibal cutting up lungs, which were missing from the victim. Will makes a distinction in the twisted intentions between two killers. One wants to consume women as food, as he would an animal. The other wants to consume them as a tribute. I am not aware of any documented cases of psychopaths fitting the latter category, but one could hypothesize that ritual human sacrifice might have arisen from such human inclinations. At least it’s a fun thought experiment.

Will makes further leaps that the Shrike is really a father with a daughter who matches all the murdered girls, and that he’s afraid to lose her when she leaves for school soon. This is a very human concern, and a very abnormal way to express it. Others would more likely try to control their daughter, or seek affection elsewhere. Instead this person kills women and eats part of them, to somehow honor his bond to his daughter? It’s a strange leap, but we follow it because with Will we’re able to suspend most of our disbelief. It doesn’t necessarily fit with the girl that was put back to bed, or the other missing girls. 

The copycat killer he identifies as an intelligent psychopath, without clear motive. He knows they can be near impossible to catch. Which sets the stage for the dance between Will and Hannibal. Will Hannibal ever get caught?

Will is haunted by images of the stag. Hannibal shows up and brings breakfast, including a “protein scramble.” This is the beginning of Hannibal feeding Will his way of thinking. And it comes symbolically through eating as a cannibal, without even knowing it. We are what we eat, after all. There’s another exchange, where Hannibal attempts to qualify his inquiries as just the way they will relate. Will shuts him down with “I don’t find you that interesting.” That was almost a challenge to Hannibal, I suspect. 

“How do you see me?”

“The mongoose that went under the house when the snake slithered by.”

Cryptic, and as usual requires multiple leaps in logic before it slips away like a Zen koan.

They investigate a construction site and Will goes through the files, finding a suspect. Hannibal secretly calls him to warn him, as a “courtesy call.” We see Will with blood spatter, but he metronomes back in time to before the incident. He takes some kind of a pill. The killer (Garrett Jacob Hobbs) steps out the front door and throws his wife out, her throat cut and dying. Hannibal observes her body with at most a detached curiosity. He finds Hobbs holding his daughter at knifepoint. He slices, and Will shoots him repeatedly. He trembles as he tries to clamp her throat. Hannibal removes his hand calmly and takes over. A bonding experience, constructed to a degree by Hannibal.

Will heads to the hospital to see the daughter. He finds her intubated and unconscious. Next to her, Hannibal sits by her side, asleep in a chair.

And we finish Apertif (title of episode), the drink before the meal.

—–

Return to index

29
DEC
2014

Perspective on Eating and Overeating

Overeating permeates our society. At the holidays, but really all year long. The strategies that spring up, such as calorie or portion control, weight watchers, focus on an external system. Eating healthier is also important. I’ll admit I have binged on some ice cream now and again as well.

Other wisdom about eating tells us that sometimes we’re eating for comfort, for distraction, or mindlessly (while watching TV), or out of boredom. Of course we are. That doesn’t quite tell us the how to eat differently, though. Aside from maybe not while watching TV.

I was in the middle of a session with a patient, discussing food. A novel thought came in. Well, it was novel to me. To “naturally” skinny people there is probably nothing new about the idea.

There are signals built into us that are absolutely clear on when to start eating, and definitely when to stop. The clear start signal includes hunger pangs, that gnawing feeling of hunger in the stomach, or it might show up as weakness. There’s no doubt that’s the right signal to start eating.

The time to definitely stop eating is the feeling of “fullness.” For many of us, this is the point of “I have no more room.” Some people even eat past that point, especially if eating for other reasons than hunger.

But what if the trick was not calorie counting, but just retuning the signals. WHAT IF the correct STOP signal was just the ABSENCE of the START signal. Once the pangs are gone, STOP.

Now of course food takes some time to digest, and once the start signal goes we may get so desperate to eat a lot. So the portion control comes to asking – “Is this amount enough to turn off the start signal?”  And have you given yourself a little time to let that signal go away?

And then there’s the “I just will eat until I’ve finished this box/pint/cookie/etc.” This seems to stir a sense of scarcity internally that if it doesn’t get eaten now, it might be wasted or the last of the junk food to be savored.

To which I remind you to remind yourself:

There’s always more junk food available tomorrow. We’re not going to run out anytime soon.

28
NOV
2014

Fear of Mental Illness

The fear behind mental illness reflects the nature of fear itself: We fear what we don’t know. We can never truly know what is happening inside the mind of another person. We as people follow fixed rules most of the time. Drive through an intersection when the light is green. Wear some amount of clothing outdoors. Don’t cross the double yellow line. So many rules.

When rules are broken, it is jarring to us as bystanders. Perhaps that rule breaker is innovative. Perhaps that rule breaker is a genius. Or perhaps that rule breaker is sick. The more bizarre the behavior, as in something so unorthodox that we cannot construct a rationale to make the behavior make sense, the scarier it is. That person no longer fits the parameters of normal, and thus cannot be understood. Except they can be understood. Once the parameters are broadened, and we understand what is happening inside the mind of a “crazy” person, then they become just as human as anyone.

The typical example is a psychotic man. They may do “strange” or bizarre things. People are afraid of them. They may mumble to themselves all day long, or talk to people that aren’t there. They might run around naked. They might hide in unusual places. These activities don’t seem “rational” by traditional standards. We can’t understand it, and the easiest label is “crazy.” By categorizing these people as crazy, we know they’re not us. And yet with that comes stigma, because there is still no understanding in that label.

The way to destigmatize these conditions is not just to educate the public that these are people with illnesses, but to take it a step further and understand the process that led to them doing this.

An individual with psychosis (schizophrenia, for example) is having a break from reality. That is a definition for psychosis. This might involve hearing things that aren’t there (auditory hallucinations), having paranoia or bizarre thoughts (such as that aliens will be imbuing them with special powers). There are commonly occurring forms of psychosis, and people with psychotic symptoms often fit into one of these categories.

How does this happen? The short answer is it’s a brain malfunction, and they are thinking things that are fundamentally disconnected from reality. Some paranoid beliefs or delusions might pop into their heads. This is like what happens in a dream, when you know something without having any idea why you know it.

If you could imagine hearing a voice that no one else hears which whispers in your ear, making you question everyone and everything you trust, then you might start to understand the difficulties of someone with psychosis. I myself can only imagine, having never lived with it myself.

So this brain malfunction leads to this false information, until they don’t know what’s true and what isn’t. Within this world of misinformation, though, they’re acting as best they can. If the voice is telling them they are in danger, they might strike out at anyone approaching them. This is not because they’re evil, but to protect themselves. I once had a patient who stripped off his clothes because his voice told him it would help him outrun the devil. He believed it. It’s often hard, even if they know it’s not true, to completely discount this false information they are getting. Even worse than our attempts to filter mass media messages about what we should buy or think, the false information in someone with psychosis is coming from their own brains. It’s hard to learn to NOT trust yourself. That’s why they need our help and understanding.  When we can understand what’s happening, then it’s easier to remember they are people.

Psychosis feels especially scary since there appears to be a level of unpredictability, and thus dangerousness. Research has never shown psychotic individuals to be more violent than the general population. But we’ll get to more on understanding the nature of violence in an upcoming post.

25
NOV
2014

Positive Psychology, Lindsay Doran, and Story

Many months ago I attended a lecture by Lindsay Doran on Psychology as an approach to understanding story. It was hosted by the Blacklist.  For anyone interested, her Ted Talk covers much of the same material.

Ms. Doran is a studio executive that has helped in the development of a number of films, including recently The Lego Movie. She also has a fondness for Positive Psychology. For those not familiar, the wiki page is actually pretty good on the subject. In short, it’s an approach to human psychology that focuses on the positive side of functioning, such as how to become optimistic, or what helps someone thrive rather than removing a problem or deficit.

I believe this is a valuable approach to understanding the human condition, and adds a necessary perspective to a world very preoccupied with pathology and problems. Dr. Martin Seligman is one of the most influential leaders in Positive Psychology, authoring such books as “Learned Optimism,” and “Flourish.” In a world so focused on tragedy all the time, turning our attention to developing the good things makes complete sense to me.

Doran went on to reference Seligman’s core components of well-being, namely PERMA:
Positive Emotion – Simply, about feeling good.
Engagement – Being absorbed in a process or activity.
Relationships – Feeling connected and involved with others
Meaning – Finding purposeful existence
Accomplishment – Achievement as a form of success

Seligman identifies these as the components of having a fulfilled life. Doran believes they are the key to what makes certain movies successful.

Doran even uses these ideas (PERMA) as a lens to identify what makes films inspiring or uplifting. She further draws conclusions about the movie industry going too dark, and that just as positive psychology redirected therapy towards the positive, lighthearted films without tragedy (like Airplane, Young Frankenstein) are fun for fun’s sake. She believes there should be more of these lighthearted fun comedies that help us to vicariously just have a joyful experience.

I agree with much of her message, though I believe she might be missing some points.

Regarding PERMA, Doran references an audience researcher who stated that he knew that people don’t really care about accomplishments. So even though we can be fixated on an achievement appearing to be the entire point of a story, we only care about it when it is tied to other things in the life of the character. So the A of PERMA seems less important.

Positive emotions obviously have their own point, and I would agree that lighthearted films serve a great purpose. Laughing feels good. Sometimes we just feel like a comedy for ninety minutes.

On the other hand, positive emotions on their own lack context. Sometimes what makes comedy so wonderful is that it is “comic relief,” as in relief from heavier topics. A comedic movie is really our comic relief from the heaviness of everyday life.

Movies serve a greater purpose than simply to entertain or distract. They serve a purpose in reflecting on the world, and in helping us gain perspective on how to live. Doran herself states that one of the purposes of movies is to answer the question of how we should live.

It is in that question that I believe Doran loses focus. She emphasizes the Positive Emotion of PERMA, while not sufficiently emphasizing the Meaning. I think she nails it with the importance of relationships, and has a direct point that women want to watch movies about relationships, and that men can only handle the relationships indirectly. Accomplishment in movies only feel good when it’s shared with someone.

This focus though on accomplishment and relationships, as well as on the positive, misses the reason that the industry has turned dark. We suffer. People feel a sense of suffering every day, and they are looking for some way to understand that. They are looking for meaning from it. And in the absence of meaning, they at least want to not feel alone in it. They want resonance, and portraying a dark theme that matches what they feel about the world resonates with them.

I posit the idea of suffering and sacrifice as being important values. In writing we set up stakes for protagonists, and often put them through hell to earn their accomplishment. That protagonist suffers and sacrifices, and what they do with that suffering and sacrifice gives meaning.

In that way it is the transformation of negative into positive that we want. We want ways to get through our own suffering, whether that be light movies (respite), or darker movies finding meaning (transforms suffering into something useful). Dark movies can masquerade as jaded, when really they may be vicarious relationship movies, where we can feel connected to someone who has suffered the way we’ve suffered. Which comes back to the idea of not wanting to feel alone. We connect to a character. We don’t want them to die because we want to stay connected to them.

Of course I agree with the point made by many (including Doran) that our fascination with pathology and problems, with what’s “wrong” can miss the larger picture. That process can even result in getting stuck in bad emotions, such as wallowing. Yet a focus on the Positive Emotions of positive psychology seems to neglect the real human suffering that occurs.

We become whole not through avoiding the negative but through owning it and transforming it.

Doran pulls many references from the AFI list of top 100 films to explore her hypothesis.

I’d like to look at a different movie, that of Cast Away.

At the surface it’s a story about survival. Chuck Noland (Tom Hanks) gets deserted on an island, away from the love of his life. He suffers. He learns to survive. He becomes so lonely he makes a relationship with a volleyball to have a friend. He builds himself a boat and gets away. We feel for him throughout. It’s primal. We see him cling to the last remnants of civilization in a beautiful butterfly on a box. He gets home, and he loses again. The love of his life has married someone else.

I love this movie. It was a massive success in the US and internationally. It doesn’t have many positive emotions at all. He loses his fiancee. He doesn’t accomplish anything but survival. His relationships are almost nil. He loses his entire identity. So it should be depressing. And yet there’s a transformative hope built into the film. We watch him suffer, and he finds a way out of it. There’s a lovely monologue of him talking about his loneliness and despair, and how he just remembers to keep breathing. A message for us all.

Finally he delivers this box that had kept him inspired. He meets a woman and we have a glimpse of hope. Maybe he was meant to meet her all along. Or maybe that’s my interpretation of it.

It’s a beautiful story of survival.

Viktor Frankl pioneered his own approach to therapy long before Seligman, which focused on meaning. I recommend everyone should read his book Man’s Search for Meaning. It’s a quick read. He was a psychiatrist who survived the concentration camps. At the time the wisdom was that when men have enough taken away from them, they’ll revert to animals. His experience was that people could be incredibly kind, and that those who survived had a reason to live. They found meaning and purpose in their suffering, even if it was just to survive to fulfill their purpose.

Now I don’t want to pretend that suffering, sacrifice, and transforming it into meaning is the key to what makes all movies powerful. Doran has clearly broke some great conceptual ground in thinking about films with a lens other than traditional formulas.  But the Meaning component seems underemphasized by Doran.  I heard many that night say that it was a transformational experience for them, yet in the vein that I hear so many emphasize “positive thinking” as a solution to the parts of themselves they dislike.

When we overvalue any one side, we miss the whole picture.

15
JUN
2014

Haystacks: How to Improve EHR and the Healthcare System

I woke up today to a request on LinkedIn from someone at Harvard for a healthcare startup that seemed on its surface anything but innovative. The only interesting thing about it was the word “Harvard.” Another “me too” wellness program. I declined and went on to click on a story in the NY Times about Tim Cook, and how he’s shaping Apple and maybe moving into some more healthcare applications.

I flashed back to 5 years ago (2009).

I was a resident and could see so many problems with the healthcare system, including the attempts at creating a good Electronic Health Record (EHR). I knew I could do better, and sketched out some ideas. After creating my first iphone app, I pulled in a friend and colleague Sanjai Rao (also a psychiatrist who’s interested in technology and innovative thinking). We created a business plan and even mockups for a new startup called Haystacks.

It was bold. It was a big idea.

It solved many of the issues that EHR was banging its head against, and still is. It would improve lives for patients and for doctors.

We met with some other startups who told us to quit, because it couldn’t be done. It was too big and we were nobodies.

That didn’t stop us from believing we had good ideas. It did make us realize that it would take years of focusing only on this (with our limited resources) to develop a company. Giving up the rest of our careers and lives for this idea.

We didn’t stick with it, because other interests took precedent. I was focused on being a great therapist and to develop my work as a writer. It would be hard to do those and run a startup.

So we stuck it in a drawer.

Jumping to present day, things have only mildly improved. EHRs have begun to incorporate some of these ideas, but not all, and not enough to solve the ongoing issues. So I decided the ideas should be put out there. Maybe someone with more resources and manpower can utilize these ideas in their companies, and actually improve the products out there.  Maybe they’ll just inspire to think outside the usual paradigms.   I could of course also be naive and uniformed, and this could all be in the works already.  But just in case…

If you think this might be useful or interesting to someone in healthcare or tech, PLEASE SHARE IT.

Today being Father’s Day, I’m dedicating this idea to my father. He is an engineer turned entrepreneur, and has inspired me to think about problems as creative opportunities to come up with elegant solutions. Work Smarter, Not Harder.

 

So onto Haystacks:

jump to bullet point summary–

An Electronic Health Record is a digital version of the patient information. It’s essentially a digital version of the old paper chart your doctor kept in a file drawer. And that has essentially been all it is used for.

Everyone (including the president) talked about EHR saving time and money, and it hasn’t really done either. Doctors end up spending more time typing up notes and clicking hundreds of boxes and popup windows, rather than handwriting the notes. It’s not why doctors got into medicine. This also takes away time from being with the patient. Patients feel shortchanged on time with their doctor, feeling like just another widget being pumped out of the factory.

So EHR doesn’t save time.

Patients also move between doctors, and often have difficulty getting ahold of their records from their last doctor or hospital visit. The hospital or medical office is holding these records, even though technically the patient “owns” their own health records. This is a massive barrier to integrating care across the system. Even if the patient can get ahold of the right people at the hospital, there’s a weeklong delay to get ahold of the records. That’s not particularly useful if you had to go to an emergency room or an urgent care that wasn’t part of your original clinic.

And even then the records that get sent aren’t often useful. They’re blurry faxes of page upon page of useless information (I got a 900 page medical record sent to me recently, much of which was worthless), or a summary that often leaves out important information.

Patients just want to know their doctor (wherever) can get access to their information to give them good care, and that the information is safe.

So EHR isn’t useful to doctors, isn’t portable as it should be between providers, and still leaves massive gaps in communication between providers.

These gaps in care also mean patients get repeated tests which are expensive, and some even have health consequences (like X-rays).

EHR hasn’t really solved most of these issues, because every medical practice uses a different system.

So EHR doesn’t help the portability of records. Much.

There are some better EHRs out there, but they’re usually designed for large hospital systems. And they’re expensive. Which doesn’t help when a patient shows up to a random emergency room, or a new doctor.

To summarize: 

The Problems:

  • Current Medical Records systems are fragmented, inefficient, difficult to access, costly, and paradoxically take up more time for the providers than using paper charts
  • Current systems have some useful components, but lack many of the real benefits of making a medical record system electronic
  • Most currently available systems are designed for hospitals or large practices
  • What EHRs seem to help with now is portability. Doctors can pull up information on a computer anywhere, but only for their home clinic. Well, not anywhere, but closer to it.
  • Medical errors are a major cause of death, and much of it is due to inefficiency and lack of information to the people that need it when they need it.

 

Who cares about these issues– 

Patients

  • Want to know their records are safe and accessible to future physicians
  • The current standard of transfer of care is abbreviated summaries or blurry delayed faxes

Physicians

  • Want ease of use, improvement in level of care, low cost, better efficiency
  • Little investment in keeping own medical records system
  • EHRs can cost thousands of dollars for a practice
  • Small providers can’t afford this, and can’t communicate with the bigwigs
  • If it could make them better at their job, that’s ideal

 

The Main Goals of an EHR could be:

  • An integrated cloud-based EHR system
  • Multiple points of access (phone, tablet, browser)
  • Appealing features to physicians and patients
  • Minimal set-up time
  • Intuitive interface with minimal training required
  • Minimal installation costs for small physician practices

 

HAYSTACKS — a Multi-tiered EHR – from individual to systemic 

  • Mobile Record Entry and Storage (smartphone based)
    • Patient enters own basic data
    • Begins a grassroots system and concept of patient ownership of their record
    • Available wherever they go (ED’s, other doctors)
    • Available during an emergency
    • Can have online backup (Centralized storage), accessible for a registered, verified physician.
    • Every access of a patient record is logged.
  • Tablet
    • Data entry and Retrieval of notes
    • A quick entry system of note-taking to improve efficiency for physicians and other providers
    • Involves sliders and radio buttons to quantify symptoms and their history -
      • Ultimately trackable and usable
    • Can add a text entry
    • Can incorporate dictation features for certain elements
    • An intelligent user interface that prompts questions based on presenting symptoms
    • On-the-go data entry and retrieval of information to access and update a chart and note along the way
    • Quantifies data as variables that improves tracking and patient outcome
    • Historically tracked data (blood pressure, pain, medication dose) are viewable in graphed form at multiple scales [pinch-zoom], overlaid, allowing for simplified scanning of records
    • Integrates with centralized record system as a whole
  • Browser-based EHR
    • Includes tablet features for viewing records and data entry
    • Could use citrix or other means to access browser-based records
    • Set up customized templates for record viewing and record entry
      • Example: An emergency room physician may have a preferred workup for vomiting that he can make auto-populated.
    • The system can begin with workup and management recommendations, further able to be edited by provider
    • Access point for an emergency physician to view centralized records without having our EHR as their primary EHR
    • Patients may then request data entry by ED physician into centralized EHR so their PCP can have access, furthering a buy-in by the healthcare system and integration
  • “Cloud-based” database of all records
    • A centralized backup of records from all other entry (mobile, tablet, browser)
    • Bypasses bureaucratic hurdles of records departments, blurry faxes, wait times, and useless information
    • “Bank-level security”
    • Storage of records from each site/clinic/hospital, accessible for any registered physician
    • Indexed records including all keywords, akin to a “spotlight” on your records
    • Scanning feature of old records into pdf +/or OCR to make documents searchable
    • An offline mode
      • A clinic can download the cloud data, alter it during a visit, then transmit the update back to the main server after visit is complete
  • Additional modules (necessary, less unique)
    • Billing
    • e-Prescriptions
    • Scheduling
    • Patient reminders using push notification
    • Premium features for physicians/practices
    • Importing ability from other EHRs

With modern software technology, none of the current issues are necessary. It would require some leaps in thinking and practice, of course.

Current EHRs are often designed by software engineers, who don’t really understand how physicians or other healthcare providers think and work. Physicians, all too often, just want to be left alone. They are creatures of habit. They want to do things the way they learned to do them. They have difficulty imagining how an EHR could be helpful. When asked what they want, many physicians respond “let me do what I do now [writing a paragraph on a piece of paper] on a computer.” So many EHRs are more or less exactly that. Blank pages where doctors type information. They may be able to pull up lab results and information like that, but that’s the extent of the “innovation.”

So the solutions in the idea of Haystacks comes in the form of multiple tiers. It’s not one solution, but many solutions that work together. There’s the top tier (a backbone or system level), then a desktop/browser tier, a tablet tier, and even a mobile phone level. Some of these have started to be developed in modern companies.

The backbone of Haystacks would be a centralized server, essentially a cloud EHR for the whole country and beyond. If the patient owns their own record, then they should be able to choose where their information is stored. Right now every medical practice or hospital keeps their own records. There’s little exchange of information between sites. Centralizing it all removes the blurry faxes and the long delays. Now of course there would have to be an incentive for organizations to adopt such a system, and that might take many forms, from the ease of the UI to universal accessibility to the promise of actually making data useful to physicians. This would involve bank-level security, but make records available to any licensed physician who registers with the system. Patients could know who has ever accessed their records, including a timestamp for every access. This would allow a patient to walk into any clinic or hospital and basically take their whole medical record with them, as it’s all available on the cloud to their new doctor. Even moreso any emergency room physician could access outside records so that they know the entire background of a person. In an emergency, there’s no time to request outside information.

Now of course there would need to be innovations, and this is about making this specific EHR useful to physicians, in a way that makes their job easier. And this improvement is in the use of data. Physicians really want specific pieces of information, and much of this can be quantified. Besides lab results, there’s reason for each visit, symptoms at that visit, medications taken and doses. There’s a large amount of quantifiable data that physicians look for. It should be organized in a way that is useful for physicians, such as overlapping timelines that could be scrolled through and zoomed in/out, such as a timeline for types of visit, med dose at that time, and lab results. Having the useful data quickly accessible and organized, rather than having to comb through hundreds of verbose notes is the real goldmine for EHR. Once the data is digitized, it needs to be organized and indexed. Much like “spotlight” on a mac, each person’s medical record should be indexed and easily searchable. Information should be findable quickly. Even old notes could be scanned into pdf format and converted with OCR (or hand-converted into typed notes) to get useful data points from each medical visit. This is all systems-level aspects of Haystacks.

Every level of Haystacks offers unique innovations, fitting unmet needs within that level of healthcare, and leveraging the available technology and convenience to improve data entry, use, and patient care.

The better and more efficiently information is entered and used, the more time and money are saved. More importantly, that car accident victim that doesn’t remember their medication list, will be less likely to die from a medical error if all their records are easily available in the emergency room. This could be the way to make that happen.

Now of course I could write at some length about this project, and am happy to do so. For a Father’s day post about my dreams for how to clean up one area of the healthcare system, this post is a good start. I may clean it up in the future, if people are so interested.

08
JUN
2014

Your Partnership is a Fantasy

Yes, I’m being dramatic and the title probably borders on clickbait. And yet it’s true. When I refer to partnership, I mean the idea that two people join equally at all times, make decisions equally in all things, and that no one ever dominates. It’s a beautiful utopian idea, post-modern gender roles, where neither “partner” does more than the other. It just doesn’t exist in reality. For the purposes of illustration, I write about roles here in a heterosexual male/female relationship, though this is all easily applicable to same-sex couples.

Perhaps there are moments when two people are in absolute sync, thinking and functioning as one, and do things at the same time. But that’s something else, rather than a partnership.

A partnership doesn’t involve two people “equally” making decisions. To illustrate how a partnership really works, let’s look at the image we hold (or maybe just I hold) of the 1950’s stereotyped household. The husband earns money via his job, the wife takes care of the home. In this model, the man is authoritative, the wife somewhat submissive. Really this somewhat suppressive dynamic existed through a lot of history, even in hunter/gatherer and child rearing roles. It was functional. It served its purpose. For a time, both sides knew their place in the dynamic. In modern society though we have higher standards for a relationship. It becomes uncomfortable to be stuck in a single dynamic permanently.

In reality there is always someone dominant, or someone taking the lead in a situation.

This person is the more active member of the dynamic. Watzlawick talked about this role as the “one-up.” The complementary role would be the “one-down,” or passive role in a relationship.

The giver and the taker. The giver and the receiver. The leader and the follower. The dominant and submissive. The talker and the listener. The caregiver and the sick one. The rescuer and the vulnerable. The leader and the participant. I could go on for quite a while about how these dynamics help us to have purpose, and how we may stumble upon these in our youth. Maybe we began this with our parents or someone else, and then get pulled emotionally into them again and again in other relationships. They become comfortable for us. We know how to function in them. It’s a functional dynamic, in that it works.

In a healthy relationship, though, one person will not be the active or dominant person in the relationship all the time, in all areas. There has to be switching, ways for people to have time in both the active and passive roles.

In a conversation, for example, there could be a designated talker and listener. That’s a functional dynamic. It can work for a while. Eventually there needs to be a switch, though. The listener needs to have time to speak. That’s what makes it a real conversation and not a monologue. That’s what makes it a healthy relationship.

So here lies the distinction between a functional dynamic and healthy partnership. A functional dynamic involves two people taking their two sides, the one-up and one-down in some area. Both people know their place and can engage in that. They work well together in this single situation. It’s functional in that they cooperate to get things done. If this is fixed and pervasive, though, then it becomes unhealthy.

What if there was literally a dominant and submissive role at play here. The “wife” who manages the house goes shopping and she has to get approval for every little thing she buys at the store. What kind of eggs. Whether to buy milk or not. Everything. While this seems to continue the stable dynamic of her being submissive, its pervasiveness could be stifling to the wife. It might be equally be exhausting the husband, to have to make every decision for her. She has to have some room for freedom. She has to have an area where she can be active and in the “one-up” role.

So a healthy relationship often has designated areas of responsibility. Separate areas where each person is the more active member, and their partner becomes passive in this area. And then there’s role reversal. This is a particularly healthy strategy for a partnership, when both have some investment in an area and want to participate actively. It’s simply to take turns, as in a conversation. In the first instance the husband takes the lead, in the second the wife takes the lead.

An easy way to illustrate this whole process is in sex. While it’s beautifully (or tantalizingly) portrayed in movies that when two people have sex they’re enmeshed, they both feel all the pleasure at seemingly the same time, and they climax simultaneously, reality is much more clunky. In a heterosexual relationship, if the man orgasms first, the woman may never achieve an orgasm. This is a stable dynamic (meaning some people do this for years), with one side basically taking and the other side giving. It leaves the woman unsatisfied. He may even be oblivious to this. An alternative could be making sure that the woman orgasms first, and then the man. They take turns, to make sure both receives what they want. Now of course this requires each person to be willing to take their turn “being selfish.” With oral sex this is even clearer. One person receives and the other gives. The receiver is allowed to be selfish during that period, knowing that the roles will be reversed in the future.

Now let me add one additional layer. No dynamic is ever fully one or the other, but can have both sides co-existing. The man giving oral sex to his female partner is giving rather than receiving, but can take satisfaction in the process of giving, in causing pleasure in his partner. The partner who is receiving may feel guilty about receiving, about being “selfish” and just feeling pleasure for what it is. The receiving partner can know though that while they are receiving, they are serving their giving partner by allowing their giving partner to feel good about giving. Giving can feel good all on its own. We’ve all met people who are seemingly selfless in a relationship. That can be nice for a time, but ultimately a source of burnout if it isn’t reciprocated.

Because in truth a single dynamic never serves all the sides of someone. A dynamic can be stable, for a time. But if there is never any changeover, it will become fixed and thus prone to break should any outside pressures get involved. What happens if the active gets in an accident? If the passive member of the relationship has never had to be active ever, they might fall apart. We want to encourage opportunities to experience both sides.

The more we’re stuck in only one dynamic, and unable to try out reversing roles in some contexts, the more fragile the relationship. This is usually not about subverting or taking advantage of the other person. Not usually. As long as the needs of both individuals get met, and the roles are not especially rigid.

So having a “healthy partnership” really involves some agreed upon designated responsibilities for each, where each person is the more active in that area, and there are times set aside for taking turns in other cooperative areas. When full agreement has to occur in an area of conflict, it’s important both sides can feel they’ve had a turn at the active role. Both people have had the opportunity to talk and have the other side listen.

The dysfunctional alternatives not mentioned are when both sides try to be active (or dominant). This leads to a continual escalation to try to assert authority. It becomes a competition, rather than a partnership. Or just as bad no one makes a decision or takes an active role, and the couple is paralyzed by inactivity.

Keep an eye out for this in your relationships with friends, family, and even professional relationships. How could the partnership be shifted to make sure everyone feels like they have had their equal time and roles in the relationship? Is your partner uncomfortable taking the other position in an area? Might they secretly like to take turns in something? Just more food for thought about relationships.

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