psychiatry

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

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.

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.

21
OCT
2013

Resetting the Bar

I’m not a fan of competition. It brings out the worst in people, while trying to bring out the best. So of course I have difficulty understanding athletes using steroids or doping just to win a contest. These drugs have possible health consequences after all. For the athlete, I’m sure they believe it’s about achievement and maximized potential, but it’s driven by trying to be better than the other guy. The bar is set by another person.

With that drive they are willing to do “whatever it takes.” Train more. Work harder. We as spectators encourage it and set up an environment that doesn’t reward holding back. Those that hold back anything that might enhance their performance don’t last too long in competitive sports. Once someone else becomes the standard to be matched or exceeded, they determine the bar for “normal.” Anything less is unacceptable.

In society we have a name for functioning below the level of “normal.” We call it impairment. As a psychiatrist I am supposed to intervene when someone has a mental impairment. Physicians usually define normal as the range of functioning of the average person in society. Not having enough energy to get regular activities done is an impairment. As society pushes people to pursue one’s “full potential,” expectations shift up for “normal.” People view normal by unnaturally high standards, and feel disappointment if they don’t meet it. Performance enhancement becomes common, normal, and expected.

When I was twenty-two years old, I did my job with five hours sleep and little to eat. That was normal then. Now in my thirties I need three cups of coffee to get the same amount of work done if I’m sleep deprived. I view it as necessary and justified since the work needs to get done. It’s normal. In medicine we’ve trained ourselves to maximize functioning without sleep, because it’s expected of us.

While it’s possible that my medical training has skewed my view of athletes, college students don’t seem to find performance-enhancing drugs in athletes acceptable either. Last year, in a study in the journal Psychology of Addictive Behaviors, authors Dodge et al., found that college students viewed such athletes as “cheaters.” These same college students, though, believed it was all right to abuse stimulant medications (not prescribed) to do better academically. They did not consider that misuse of stimulants to be cheating. The more they themselves had abused stimulants, the more judgmental they felt about athletes. Stimulant abuse is rampant in colleges, with students attempting to enhance their academic performance. If their classmates are using them and scoring better on tests, the bar is raised, and a new “normal” is set.

I routinely have patients who come to me asking if they have ADHD. More of the time they insist that they have it. They insist because they’re sure they have attention problems. Or because they tried their friend’s Adderall and were “able to focus so much better.” In their minds, improvement on a drug must indicate a diagnosis and thus an explanation for the difficulties. I even have parents of patients who presume that the lack of A’s must indicate ADHD and insist on my prescribing stimulants. Two hundred years ago people weren’t expected to sit in a chair for eight hours a day. Today we have a diagnostic construct of ADHD. Now this isn’t to say to that ADHD doesn’t exist, as we have all seen children who really struggle with this condition.  But perhaps thinking about our expectations reveals the slippery slope that leads to overdiagnosis.

As we’ve stumbled upon many ways to “enhance” functioning, to maximize what we can do with our bodies and minds, the bar shifted on normal. We expect people to perform at that new level. If they can’t, it must indicate a deficit. Such a progression leads to less and less tolerance for any impairment, distress, or problem. In the end, this is really about performance at all costs, masked in the pretense of “treatment.” In 2008 a group of eminent scientists published a commentary in the journal Nature, calling for regulation to allow “cognitive enhancers,” namely open use of stimulants to improve brain function in the average person. Implicit in their argument is a goal to “call a spade a spade.” In that argument, people use drugs to do better at tasks, so let’s call it what it is. I reserve an opinion on the matter.

It’s easy to have perspective on something we ourselves are not doing. Once we have incorporated it into our routine, we develop rationale to justify it. I can understand how the college student thinks “athletes shouldn’t use drugs to win at sports, but keep your hands off my Adderall.” Personally I believe students shouldn’t use ADHD drugs they aren’t prescribed to do better on tests. It’s wrong for them to misuse drugs just to be able to take tests.

Just don’t take away my coffee. I need my coffee.

10
OCT
2013

On Balance in Relationships.

This isn’t just about balance.  Or how to stay connected.  Though it serves all of that.

I touched on this just a little bit in my post about burnout, but I want to get into Balance in Relationships.

We’re asked to care.  We’re asked to do something.  We’re asked to invest time and energy.  This is usually about a person.  Sometimes it could be a project.

John was a military vet.  He didn’t have to be.  He could have been my childhood friend, or a guy I made friends with in a coffee shop.  In this case I met him where I was his doctor, and he was my patient.  I sit down with him in clinic, and I see a long list of “problems,” from medical issues to PTSD and many notes about “personality” issues.

Two seconds after I sit down, he pulls out his own list, but these are things he wants from me.  Medication refills?  Easy enough.  Help with disability?  Let’s investigate.  Call his landlord and advocate for him to keep his apartment after causing problems?  Maybe I’ll help.  Call his parole office?  Hmm.  Prescribe him medical marijuana?  Well…

It isn’t long in this interaction before I start disconnecting emotionally.  It’s natural to want him to leave, because he is putting all the burden on me to fix his life.  To a tiny degree I understand that, as it’s supposed to be my role to “help” him with many of his problems.

So let’s say I spend a couple extra hours trying to help him with everything he asks.  At the next visit he comes back with new issues, and this time he wants me to write a letter for court saying he has PTSD and that he shouldn’t be held accountable for some things he’s done.

Now let’s pretend that John has other issues.  Maybe he’s an alcoholic, and my repeated pleas to get sober haven’t helped.  Or he’s my brother (I don’t have a brother) and asks me to loan him money for the tenth time.

All of these situations feel emotionally taxing on me, and a common response is to disconnect.  I feel tired pouring more energy into a situation that isn’t changing, and I want to just stop. Maybe at best I keep going through the motions.  For those in a role where we’re supposed to stay emotionally connected to people (such as healthcare), it’s helpful to not get apathetic.

So I happened upon two simple philosophies that have helped me to stay balanced, particularly when stressed.

1.  Don’t work harder than the other person.

As sad as it sounds, this is their problem, not yours.  If they’re bringing the issue to you, they need to be willing to meet you halfway.  Now halfway might be different for each person, but the idea of effort is what’s important.  If you find yourself over-investing, doing more or all of the work, that is a recipe for burnout.  Once you’re pouring yourself into something, if it fails, you feel jaded.  You then want to withdraw and not try again.

There’s a much longer discussion that can be had about how to get someone to invest.  Another time.  Here, though, not working harder than the other person can often feel like pulling back.  And if we pull back too much emotionally we can end up apathetic, not caring at all.  So then comes the other side of the coin –

2.  Cultivate a feeling of Detached Compassion.

I want to hammer both words in there.  DETACHED.  Meaning disconnected from the outcome.  Aim high, but don’t set up your emotional payoff on the win.  COMPASSION.  Meaning you still care about the person.  Stay connected to the person, but disconnected from the outcome.

Especially since a lot of the time people don’t want things fixed, they want someone present for them.

As you pay more and more attention to this balance of effort, investment, and connection, you’re really cultivating mindfulness.  Mindfulness (which needs its own posts), which I’ll simply define here as awareness, without reacting.

30
SEP
2013

How to Not Burn Out

“I just can’t do it anymore.”

People burnout everywhere, in every field. They burn out professionally. They burn out in taking care of others. I live in Los Angeles and I can understand how just driving a car can burn someone out in this level of traffic.

No one plans to burn out. Maybe they do have a little awareness that they’re going down that road, though.

We have a level of control over where we place our attention, as well as our effort. If you’re worried you’re burning out, consider preventing it.

There’s two parts, I believe, to preventing burnout.

For the first, I’d like to borrow from a simple model I first heard from Dr. Christine Moutier (a psychiatrist and former supervisor of mine at UCSD), modified a bit here. Imagine a gas tank. It’s feeding an engine. That engine is you. If the engine shuts down, you shut down.

dreamstime_m_30848081

This gas tank has a leak in it. It’s losing gas. Gas is pouring out. Eventually if we do nothing, the tank will be empty. When it’s empty, the engine stops. It doesn’t run anymore. The engine burns out.

We don’t want the engine to stop, so we need to fill the tank. It has to be filled faster than it’s losing gas. In life we each have our strategies to fill the tank. Sleep. Food. Socializing. Rest. Sex. Yoga. Watching TV. Meditation. Talking to people.  Exercise. Make a note of your ways to fill the tank, and note what others do, since one way might not be enough. One way might not be able to fill it fast enough.  It’s for your own well-being.

On the other side, look at the size of the hole that gas is leaking out of. This is the effort we put out into the world. We can try to narrow the hole, to hold back. That may be effective, to a degree. If done too much, it leads to apathy. The hole can’t ever be completely plugged up, in a normal life.

It’s not a particularly complex model, I’ll give you. Yet really smart people neglect themselves all the time. They think their tank will never run out, as if there’s a secret reservoir somewhere. Running on empty hurts the engine. So the first step is to keep the tank filled.

The second part of not burning out is to Not Overextend. We all have projects we’re asked to be involved in, whether that be something at work or even fixing up something in the house. Or maybe it’s arranging an event for family or friends. Presuming this is not a startup business that is your idea, ask yourself – how much am I putting into this? How much are the other people putting into it?

Here’s the key: If you’ve been asked to do this project by someone else, and you decide to invest a lot of time/energy in it, make sure the other person is as invested in it as you.  The plan, the approach, and if possible, the energy/time.  If you’re thinking up a lot of aspects of it, make sure the other person agrees along the way, or has as much skin in the game.

Let’s say I’m asked by my wife to plan a party for our friends. I put a lot of time into planning and arranging it, and then my wife tells me she doesn’t like what I did. I devoted hundreds of hours into the project, she devoted none. My response to any criticism she might have is anger and wanting to quit and disconnect. I would feel burned out. Such is the way when only one party in a group does most of the work, and the other critiques or doesn’t support it.

Now in many situations the division of labor is unavoidable. One side will do more work than the other. Chances have to be taken. When they are done with open eyes, though, the disappointment may be less.We can clarify the point, then, that the other party needs to buy into the plan at least. Don’t overdo it expecting the other party to be wowed by the amount of time you’ve put into it. What if they aren’t? You may end up apathetic and withdrawn. Check in with them frequently, to get their buy-in on the approach, so they won’t be surprised, and you won’t be surprised. And finally, try to discern endeavors that might not be worth the investment.

23
SEP
2013

In Brief for Those New to Therapy

If you ask ten different therapists what it is they do, you’ll get twenty answers. A therapist talks. A therapist listens. Using the term “therapy” implies only one thing, so for those who don’t know what therapy is, it’s hard to get a grasp on it. It’s even harder to understand that there’s many types of therapy.

So let me begin with a comparison to religion. Religion is similar to therapy, in that they both have belief systems. Therapy is usually based more on research and evidence, though, rather than faith. Trying to pretend that there is one “religion” doesn’t help to define what religion is, or to understand the different religions. Nor does understanding Catholicism tell you much about Buddhism. Understanding Catholicism does of course give you a frame of reference to understand other religions, but its minutiae don’t tell you about the minutiae of other religions.

I’ve studied and trained in a number of different psychotherapies. Psychodynamic, Gestalt, CBT, DBT, hypnotherapies, brief strategic therapy. Within that there are others such as supportive and insight oriented therapy. Maybe some of these are better fits for you as a patient than others. That’s fodder for a longer post, discussing what to expect from each therapy style. I’ll get to it. In the meantime I hope the idea can be seeded that no one therapy is absolute, and that change can come about in many different ways.

Let’s get to some myths and misunderstandings about therapy. Therapy isn’t simple. And it isn’t just listening or support. Or at least it shouldn’t be. It’s idealized from those outside. As if a little support is all that’s needed. As if people go to therapy to vent or complain about others, and somehow they come out “fixed.” That’s never how it works. Real therapy is more than that, and should be more than that.

Therapy is about change. This can be changing how you feel or think or function in life. It usually comes about through working with a therapist. A relationship is formed. Usually trust develops. This alone can help some people change.

Beyond this there are a number of strategies and theoretical systems. There’s simply talking about whatever comes to mind, developing a relationship with the therapist that can reflect other relationships, recognizing and changing thoughts to change feelings, changing behaviors or exercises that alter the way you feel. It can be about changing patterns in life.

Sometimes therapy feels good. Sometimes it involves a lot of effort. Both can be important.

There is not only one way to do therapy. Many therapists will become dogmatic about their approach, as if their way is the only way. I would again draw the comparison to religion. Many therapists become invested in the approach they learned first, just as many people stick with the religion in which they were raised. They may even push the belief that their approach is better proven than others. Other people wander and explore various approaches, for better or worse. The skinny on this is that different therapy styles may be a better fit for you as the patient (aka client or receiver of therapy). If you don’t feel like you’re making progress through therapy, perhaps it is a bad fit with the therapist or the style being used. Also it is possible that you’re not feeling a good fit because that which is being stirred up in therapy (bad feelings, annoyances, etc.), may be exactly what needs to be worked on in therapy.

Being told exactly what you want to hear is usually not that helpful in therapy. If that is all you want (to vent and be agreed with), then I’d suggest that therapy may not give you what you’re looking for.

Oh, don’t get me wrong. You may find someone to agree with you and allow you to vent the whole time. That alone may not lead to the change you want in your life, though.

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