psychotherapy

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.  

—–

Return to index

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

21
FEB
2014

On Loneliness

There’s an emptiness that many of us feel every day. Sometimes we feel it when we’re away from someone. Sometimes we feel it when we’re surrounded by people.  It isn’t depression, per se. We have all experienced it. Unless you’re schizoid, of course.

Loneliness is a want. When we want, we create a gap between what we have, and what we don’t. That gap hurts. Commonly we try to distract ourselves so we don’t have to pay attention to that pain. We don’t want to feel it. We have this deep fear it will consume us. It is almost as if we feel a need to find another person to verify that we’re really here.

As I sit and contemplate this state, there’s even guilt over feeling this way. Why should there be guilt over feelings? You feel what you feel. Unless you start thinking about expectations (from society, on yourself), about what you’re “supposed” to feel. We’re supposed to be happy and buoyant and “perfect.” Wouldn’t that be nice.

Of course we can examine if there are things we do that perpetuate these feelings, which keep us stuck. That’s the process of psychotherapy, and becomes especially important when we start to take ownership over our own participation in our feelings. While I understand the explanation of the brain as a “chemical state,” and bad feelings as “brain chemistry,” it’s an explanatory model that lessens the idea of free will. Brain chemistry exists. When I eat something, or think something, or close my eyes, I’m changing my brain chemistry. So maybe there is a way that we perpetuate loneliness as well.

When we idealize the individual and celebrate “I,” we are celebrating the disconnect of that person, what makes them unique, what distinguishes them from everyone else. When we cherish our own uniqueness, we are isolating ourselves. Thus our American culture of rugged individuality and championing the loner, who is dependent on no one, leaves the next generation very alone when they try to embody such an ideal. The more we want to be unique and important, the more alone we feel. We want to be important, which requires other people recognizing us as unique. Paradoxically trying to be independent and important makes our self-esteem dependent on the attention of others. In our culture where narcissism is on the rise (google Narcissism america), perhaps the consequence of cultivating some amazing individuals is the emptiness of some achievements, and an epidemic of loneliness.

The alternatives to the individual have their own stigma and problems. There’s the group identity, whether that’s as part of a team or an organization. There can become camaraderie amongst members, which is a definite antidote to loneliness. Fear can set in though, fear of dependence. Really this is true for any relationship. We play with the romanticization of love as something that absorbs a whole person, ultimately. As beautiful of an image as that can be, it also leads to the risk of betrayal, co-dependence and loss of any ultimate purpose. I’m sure members of any group that went down a dark path (think of cults, nazis, etc.) at first felt a true sense of purpose when they joined. It gave them an identity, a sense of belonging, and thus lessened loneliness. Social psychologists discuss that this group mentality leads to loss of humanity and performing acts that go against the morals of the individuals (see the work of Phil Zimbardo). But that person doesn’t think about them because at that time they aren’t themselves — they’re just a member of the group.

Co-dependence isn’t any more healthy, though it has the temptation of escape, and the romanticization by our culture. As much of a fan as I am, Shakespeare didn’t help this idealization of collectively losing ourselves in love. It’s beautiful to lose ourselves in another, to need and be needed completely and wholly. Depending on your belief in the idea of a soul mate, you may have convinced yourself that this is meant to be one person. And maybe it is. But if that dynamic of needing and being needed by the world could be diffused, spread out to the world, maybe we’d realize that loneliness could be an illusion.

J Krishnamurti, an Indian philosopher, believed that we’re all inherently connected. He believed that we’re all made up of the same substance. He was probably referring to a spiritual belief within Eastern philosophies that we all come from a God, and made of God. Within that framework, we’re all connected, since we’re all part of the same network. In the belief system, loneliness is an illusion, based on the false idea that we are all separate. If you could let go of the idea of having to be separate, without losing a sense of self, and feel that we are all connected, then loneliness could fade away.

Or maybe not.

I’m online right now, looking over facebook and twitter. I feel the impulse to reach out and find connection to other people. The more I feel alone, the more I feel I have to reach out to find someone and get any validation I’m real or alive. It’s hard to be alone. There’s an emptiness to it, as if I might collapse. These “social media” sites feed an illusion of connection through technology, which can make us feel more alone.

But let’s just pretend I don’t have any internet. Let’s pretend I don’t have a phone. Let’s pretend there’s no way to distract myself. I’m stuck with just me. I could fight to find another way to distract myself. Or I could stay with the feeling. I might even feel like I’m collapsing. In the strangest way, staying with that feeling of collapsing (in Gestalt therapy called the implosive layer), can lead to a breakthrough. All the energy invested in holding back the fear [of being alone, etc] can be freed up.

Then we can see the world with new eyes. That’s a whole process (going through the Gestalt layers) that we’ll touch on in another post.

Until then, consider the possibility that you’ve never been alone.

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.

03
SEP
2013

10 Life Lessons from a Psychiatrist

I run into the same issues everywhere, from patients, co-workers, and friends. People are stuck, and not sure how to “un-stuck” themselves.

I’ve noticed some basic rules on how to live a more fulfilled life, to make life easier, and make you more effective.

Consider them like guideposts if you feel off track. Some may be obvious. Others, maybe not so much.

It’s not about knowing them.  It’s about where you put your attention and effort.

1. Be Polite

I’m not suggesting to be fake or disingenuous. Instead find the way to being kind to others. And if kindness can’t be found, then at least be civil.

You may get what you want by being rude, angry, or demanding. The squeaky wheel does get the grease. In the process, though, you’ll burn the bridge with the person you’re getting it from. They won’t respect you, and given the choice they wouldn’t help you in an accident. I’ve worked with plenty of people that steamroll over others to get what they want. A lot of the time they still get what they want, but no one likes them.

If people like you, they’re more likely to want to help. Create allies, and start by being nice to people. Especially when you have no reason to be nice to them.

2. Be Flexible

I’m not talking about doing yoga backbends. This isn’t about physical health.

This is the holy grail in functioning in life, IMHO. The way to mental health is to develop flexibility, being able to function in a variety of situations, to find appreciation wherever you are, to be a leader when a leader is needed and a follower when that is needed. And to find enjoyment in every role. To be able to see multiple sides of every issue, and appreciate the opinions of everyone. Even if you disagree with it. Even if its hateful, to be able to understand what led to that person having that opinion.

See #10 for more on this.

3. Pick Your Battles

Stand up for yourself when you can, and when it will help. Assert yourself to make positive changes, but not just to exert your will on others. Don’t let yourself be trodden down by others, but be smart about it. If it’s important to finally stand up to your boss, do you have a backup plan?

People have variable lengths to their fuses. Some will let themselves be beaten down their whole life, never speaking up for what they want or believe. Others snap violently at the tiniest provocation. Neither approach works to get your needs met. Think ahead and plan the next three steps after you stand up for yourself, and plan how to weather the worst possible consequences.

4. Be Open to New Data

Medicine has few certainties. During medical school the lesson was: “Twenty years from now, 50% of what we know is fact will be wrong.” In a field of explosive egos and paternalistically telling others how to live their lives, it’s hard to be able to admit fault. It’s absolutely necessary though.

I could be wrong about everything here. I know I don’t know anything for certain. Anyone that says they do is wrong. This is more than being humble. New information could arrive at any point, and if we choose to selectively ignore that information because it’s a blow to our ego to change our minds, then we’re living in a delusional world. We’re ignoring reality.

I very rarely get all the information on someone’s background to be able to even make a definite diagnosis. I get pieces, and I put together the best picture from that information. If new information comes in, I have to revise that picture.

Think about your own philosophy on life. Any one thing you take for granted. Would you be willing to admit you’re wrong if some new information came in that didn’t fit? Most likely you’d want to discredit it, unless it came from someone you trusted.

The better stance is to be open to any credible information, and to recognize any belief or idea is only as good as the data it is based on. This is also the way of science, usually. At least when politics aren’t involved.

5. Paradox is the answer to many puzzles

I could give a thousand examples of this. You get more by giving. When in the black hole of desire and want, feel better through focusing on gratitude. Strength comes through vulnerability not hardening the walls. Fears are broken through experiencing the fear, rather than numbing it. Giving is the best way to get people interested. You have to stop chasing a dream to get it to stop running away.

We are creatures of habit. We do things because they worked in some way, at some point in the past. So we keep trying to do them, stuck in the hammer-nail paradigm all the time. We do what we do because our approach makes sense. It fits common sense.

Sometimes what we intuitively do is very effective. But sometimes it doesn’t work at all. Conventional wisdom tells us to “fight harder” and do more of it.

If you’re stuck on a problem, consider trying the thing that doesn’t make sense. Oppose your intuition. Trying to keep things from getting worse sometimes just makes the problem last longer. We do it because common sense dictates that things would be worse if we did anything else.

When desperate for love, we’re in a place of want. We desire. We feel empty, as though there’s nothing to give. We want someone else to fill us with love. Yet giving without expectation may be the very thing that results in getting what you want.

You just have to accept the worst outcome as a possibility. Some of those worst outcomes may not be acceptable, no matter what. I can’t speak to the specifics in your life. Just think of these as guideposts. There are whole schools of psychotherapy (lesser known) devoted to this approach.

6. Growth (or change) Requires a Degree of Risk, But Not Pain

There’s always risk in doing something new. Because it’s new and unfamiliar. The pain that’s expected comes from fighting change, from swimming upstream against the current, from holding onto the past. In order to change it means letting go of something, even if only as the sole way of doing something.

Weigh the risks and benefits, and make a choice to try something different.

7. Your Heart Will Keep Ticking

Even if it feels like the end of the world. Even if you feel like your soul is dying. You will probably survive. The pain will pass, like a wave. And you will survive. Don’t give up just because the wave is rising, or because it’s scary. Fear won’t kill you (unless you have a heart condition).

In that vein, I always appreciated this quote:
“I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.”
― Frank Herbert, Dune

8. Balance is a Process, Not a State

No one is perfect. No one is at bliss twenty-four hours a day. Marketing (including by self-help marketers) sell you the idea of perfection. Or balance. Or happiness. Or Mindfulness. In truth that is not a maintainable state.

Stand on one foot. Even if you aren’t falling over, that’s because opposing muscles are working simultaneously. Balance isn’t about one thing only. It’s about finding the right amount of two things that might oppose each other, so you don’t fall over.

Find the balance between apathy and overinvestment. Being totally absorbed in anything is a recipe for burnout. In relationships or projects. Apathy isn’t living, but shielding yourself from any future risk, because it doesn’t seem worth it. Life is best lived in-between, in a state of mindfulness.

9. Everybody is Doing the Best They Can with the Tools They Have

Just sometimes their tools aren’t good enough. If that’s you, get more tools. Try new stuff. Shrugging your shoulders that you are the way you are doesn’t leave much of a path for your story.

If it’s someone else that is pushing your buttons, find some compassion. Whatever they’re doing, no matter how annoying, has served a purpose for them. They’re using what they believe is the best tools they have, even if it makes no sense to you.

10. Problems in Relationships Can Often Be Fixed by Trying Different Positions

Get your mind out of the gutter. I’m not talking about that.

Think about where you find yourself, in relationship to others. First, second, third positions.

First position (I) is looking at it through your own eyes. Some people literally cannot think for themselves, but are constantly caught in the needs of others.  They’re disconnected from their own needs and always put others first.

Second position (you), is about empathy and being able to imagine yourself as another person. Why they do what they do, and how they feel how they feel. Understanding that helps to understand how to deal with another person.

Third position (outside) is looking at the group from the outside, detached, and seeing the big picture. Seeing that when I push, he pushes back, which I might not be able to appreciate from the first or second positions. Each of these is like a muscle. Which of yours is underdeveloped?  Which is overdeveloped?

——

Now of course there’s lessons #11 – 20. But those will wait for another post.

Share this if you think it might benefit someone you know.

27
AUG
2013

Why I hate Xanax

A lot of people like Xanax. It’s given out like candy. People get it from their friends, from their primary care doctors, even from their psychiatrist. I hate it. I might go so far as to say it’s evil, though really it’s just bringing out the worst aspects of our nature. In my professional opinion, it’s bad for you.

But no one wants to hear that.

Yes, it feels good when you take it. People take it for anxiety. They feel less anxious (usually) after taking it. Must be working, logic would dictate. Unfortunately this is short-sighted, in the same way that we as a collective society (and medical establishment) view pain as something to annihilate.

Xanax makes you feel good. It brings on euphoria. Heroin feels pretty good too. Feeling good from it doesn’t mean it’s good for you. In fact it is this hedonistic approach of minimizing anything uncomfortable [painful] and maximizing pleasure that leads to more problems with both pain and anxiety. I’ll discuss pain in another post, particularly the overtreatment of pain as a phenomenon which is leading to a significant number of deaths from prescription pain pill abuse and misuse. Here Xanax needs to be addressed.

“My doctor prescribed it for me, so it must be safe.”

“The FDA approved it, so it must be safe.”

In truth nothing is absolutely safe. Water will kill you if you drink enough of it. Seriously. Every medication has its potential benefits and potential drawbacks. You are not guaranteed to get either the benefits or the drawbacks. It’s really a numbers game. Do the benefits outweigh the risks? In Xanax we both overestimate the benefits and underestimate the risks. And those that prescribe it like candy have a fundamental misunderstanding of how anxiety works, in my opinion.

Over and over again I hear –
“But you have to give me Xanax. It’s the only thing that works for my Anxiety.”

Really it doesn’t. It’s giving you the illusion that it’s helping, because it seems to give temporary relief. And it does. It works really fast. It gets into your system quickly, and feels really good really fast.

And then it’s gone.

The anxiety returns. Even worse, there may be withdrawal anxiety as the medication comes out of your system, bringing up all the feelings that your body and mind are out of control. So you turn to the same thing that seemed to help, even if temporarily: more Xanax. As you take it on a regular basis, possibly with increasing amounts, your body becomes tolerant to it. Tolerant means the same amount doesn’t have the effect it used to have. So again you need more of it. If you start to worry about the possibility of anxiety (anticipatory anxiety), you can then make yourself more anxious. Then you’d need a Xanax just to prevent the possibility of something bad happening.

I wish this was a fanciful diatribe with no grounding in reality. I’ve seen hundreds of these patients in my relatively brief career, caught in exactly this cycle.

The basics
Xanax is a benzodiazepine (aka benzo). It’s a tranquilizer. The same drug “family” includes clonazepam (klonopin), diazepam (valium), lorazepam (ativan), chlordiazepoxide (librium), and others. Xanax is notorious because it has such a short half-life, meaning it lasts in your system a brief amount of time. Surely the longer acting tranquilizers must be the better approach? Perhaps. Some people do function on benzo’s. That isn’t really in debate. The question is whether they function better with them than without them, in the long-term, and if there isn’t a safer alternative. In my opinion, they’re a third or fourth line approach, at best.

Anxiety is uncomfortable, and people in our culture don’t want to be uncomfortable. At all. Ever. So logic would dictate we should try to annihilate it. If something helps a little, use it a lot.

This is the rationale that actually leads to anxiety becoming an unremitting problem. Trying to keep it in check, to hide from it, or to hold it at bay, all feeds the problem. Fear is the problem. Psychotherapy figured out the truth: the way to lessen anxiety is to face it, not avoid it.

I had a patient once who had panic attacks. I think of panic attacks as the worst kind of anxiety, so severe it can feel like a heart attack or like you’re dying. He grew up on the streets (homeless for much of his life), coming from a tough childhood. He never had anyone he could trust. He got over his panic attacks without medication, and even without therapy. He had tried Xanax and other meds, and was on the slippery slope of trying to manage the anticipation of anxiety by using more and more benzo’s.  He would think about how bad anxiety could get, and would get anxious about that, and so would end up taking benzo’s just to prevent possible anxiety.  He was getting more and more addicted.

Then one day he got fed up. He was having a panic attack, and felt the fear of dying.

He shouted at himself, while beating his chest, “just fucking do it! Just fucking die already.”

He welcomed the worst possible consequence. And immediately the panic attack went away. The fear fed the panic. When he stopped fearing it, it deflated. It was still uncomfortable, but it didn’t build up the same way. He cured himself.  He doesn’t have panic attacks anymore.

If you want a medication for anxiety, look at the whole picture.

“I only want to take something as needed.” Your anxiety is all day, though. You have brief periods of it getting worse, but the rest of the time there’s some anxiety. So really you need something that works all day. You’re falling into the fear of chemicals while still wanting some chemicals. The issue is that the ones you’re asking for perpetuate or worsen the problem, rather than improve it. It’s a lot harder to treat anxiety in someone already addicted to benzodiazepines than someone not. Thus the slippery slope of good intentions and short-term outcomes.  And I believe medical providers with our good intentions cause more iatrogenic problems with this than we do help people.

The other risks
Unlike other medications for anxiety, the risks with benzodiazepines are much higher. Primarily the risks are seizures and death. If you take too much, you could get oversedated and die. If you mix it with anything that makes you sleepy (or pain medications), you could get oversedated and die. Withdrawing off of benzodiazepines can bring about increased anxiety, but more importantly the risk of seizures. Alternative medications like SSRI’s while not perfect, have far fewer risks to them, and are thus a much safer choice.

 

–postscript.  Yes, I float between the 1st/2nd/3rd person.

16
AUG
2013

Chemicals, Depression, and the Mythos of Natural

Usually by the time a depressed person comes in to see me, it’s because what they’re doing hasn’t been working.  Therapy hasn’t been helping, or they don’t have the time or finances to do therapy.  So as a psychiatrist, I offer an antidepressant.  And almost every day, people hesitate.  They don’t hesitate because they doubt whether the medications work (a separate debate).  They hesitate because they want to follow a “natural” lifestyle or philosophy.

Now I follow a principle of using as little medication as needed, recognizing a propensity in many colleagues to use more and chase every symptom with another medication.  But I disagree that “natural” means better in healthcare, as the foundation of a lifestyle of “natural” and “organic” is at its core shaky, particularly when it comes to depression.

Behind this lifestyle lies a bias against “chemicals,” as if all “chemicals” = “poison.”  As if there exists a homeostatic mechanism in humans that will protect them from disease if they remain “pure” enough.  This demonizes medicine and perpetuates a false model that the human system (body/mind) is inherently self-healing and self-correcting (a philosophy perpetuated in many alternative health models).  Disease occurs because the system isn’t working anymore, often despite a “natural” lifestyle.  And yet like anyone entrenched in a belief system, when something isn’t working anymore, rather than doing something else people just do more of the same.  More extreme of the same.

The “natural” lifestyle could be partially a backlash against the overmedicalization and overmedication of every condition.  I understand that.  I can only blame my own field, where the trend of using medications exclusively causes a distorted view of chemistry as a solution for everything.  This comes at the expense of what many seek in therapy, which is someone to listen.

The backlash against overuse is underuse.  Antidepressants are all too often given out for mild complaints, or temporary depression and anxiety.  This leads to the myth that antidepressants are useless, and even that “depression is natural.”  People get concerned about getting treatment for their catastrophic depression because “it’s natural to feel this bad in these bad circumstances.”  They hesitate because maybe depression is adaptive.  And it is, to a point.

There may be an evolutionary basis to depression (see research by Keller and Nesse).  Crying may have been selected for as a mechanism to help a person get social support.  The low energy and interest of depression may have been selected for as mechanisms to conserve energy in the face of an impossible goal that can’t be relinquished.  In the way having sickle cell trait (a single copy of the gene) appears to protect against malaria, some genetic developments help support life in a milder form.  But when the development is in a more extreme, it isn’t adaptive.  Sickle cell disease (a more severe type with two copies of the gene) isn’t more helpful than sickle trait against malaria.  A sickle cell crisis can even kill a person.   Similarly severe depression may be an out-of-control version of something originally adaptive or beneficial.  To follow a model of statistical normal distribution (the bell shaped curve), it’s an outlier, where the mechanism is causing harm rather than helping.

Of course there may be conditions that are environmentally caused.  That is not in debate.  Some cancers are definitively caused by chemical exposure.  What is less clear is if “purification” leads to remission from environmentally caused problems.  If it’s “stress,” can we realistically avoid all stress?  Probably not.  Avoidance with stress is almost never helpful.  Just as “bed rest” for back pain is in fact harmful, not helpful.  An alternative to avoidance should be to utilize alternative ways to handle the environmental problems.

Physicians, as a profession, are inherently anti-evolution, in its traditional sense.  Evolution occurs through natural selection, where environmental stressors kill off the “unfit” or weak.  Our job is to help those that might not function as well without help.  We’re a modern social invention to assist more of humanity to survive.  In the first world of plenty, there’s fewer selective pressures.  So apparently people are constructing their own, letting their ideals get in the way of their lives.

Everything is chemical.  The state of being depressed is chemical, in that there’s a chemical process going on in the brain.  Medications change those chemicals.  Therapy changes those chemicals.  Food has chemicals.  Herbs, often touted as “natural,” are just weak medications that are less regulated (so you don’t know how much you’re getting), and less studied (so we know even less if they help or hurt).  The idea of ingesting “foreign” or unnatural chemicals ignores the reason medication exists.  Medication does something for your body that it can’t do on its own.  An antibiotic, which is a foreign, unnatural chemical, that gets through your entire body often into your brain as well (thus its utility), is necessary when your own body can’t fight off an infection on its own.  Few people think twice about that.  It’s acceptable, most likely because it’s temporary.

I hear all the time in passing people present the rationale “well if cave men didn’t do it, it must not be healthy.”  Paleo diets, organic air fresheners.  The evidence actually isn’t that good as to the life expectancy of ancient man, but we can be sure of one thing now:  we’re living longer.  So we’re doing something right.  Modern medicine helps people live longer.

In primary care, usually people are unable or unwilling to make the necessary lifestyle changes to keep themselves healthy.  They won’t exercise or quit smoking.  In psychiatry it can be about the same issue, that of getting someone to admit that what they’re doing isn’t working, and that doing more of the same isn’t really a solution.  This is an issue throughout all of life, not just medicine.  If telling a patient to exercise more isn’t getting them to exercise at all, telling them more often isn’t going to make them do it.

If it can be done “naturally,” terrific.  Therapy is great.  I treat with psychotherapy as much as I do with medications.  But if you’re waiting to see if being natural will help with depression or any other medical problem, determine where the “point of no return” is, where it’ll be too late to take advantage of the treatments right in front of you.  Is it when death is near?  Is it when you’re hurting those around you?  Consider the point when following a lifestyle comes at the cost of your life.

05
AUG
2013

Well maybe it’s like physics. Kinda.

I was at a party once of non-medical people. A woman we’ll call Jill comes up to me. She’s a teacher, 28 years old, and talks to me about her teaching middle schoolers. I mention what I do, and I get a surprised look.

She’s intrigued, but then brings up all the complaints she’s heard. “My friend went to a psychiatrist, and they were horrible… And isn’t it true that the DSM is run by drug companies?” “So you’re pushing pills all day?” “Why can’t psychiatry figure it out better?”

Where do I start in addressing so many myths? Ultimately it’s hard to convey how difficult this field is.

In fact I hear critiques about my field (psychiatry) all the time. How it’s such a mystery. How it’s a soft science, and wondering why it can’t be more like cardiology. It would be nice for psychiatry and understanding the mind and brain to be finished. Nothing left to learn. But where’s the fun in that?

The truth is that the brain is the most complex “thing” on the planet, and with all we know (which is a lot), we still are only getting started. Mastering the information we do have is still a process, and it’s hard for those outside the field to comprehend how it’s not quite a linear process. It’s hard for them to understand that the brain can’t be understood linearly.

Understanding the mind/brain, as best I can find an analogy, is like learning physics.

At a grade school level, we learn a simple rule: nothing is smaller than an atom. We learn about how molecules are combined atoms, and the way they combine make up everything in the universe. That rule seems straightforward. And at that level it’s absolutely right.

Then as we grow older we learn that that rule wasn’t exactly true, and that really atoms are made of particles called neutrons, protons, and electrons. And the number of these in an atom determines what type of element it is, its weight, its charge, and so on. And we had to unlearn the first rule to accept the next. But in a way the first rule was a good foundation to move to the more complex. It’s easier to first learn about molecules when only thinking about atoms.

Then we continue, and we have to unlearn that electrons are particles. In fact they’re more like clouds, and don’t even exist in one place, but have “probabilities.” But being able to think about them like particles first was useful before unlearning the lesson, in order to understand them relative to protons and the net charge of an atom.

And with each step we learn a rule then unlearn it as we get more complex. Electrons aren’t even clouds, really. And then there’s quarks. And superstring theory. And so on. And it isn’t exactly that each rule was untrue, but just a simplified view was useful for that step of learning, to understand the larger picture, before moving into the more complex and detailed.

So it is with the mind/brain. But even less linear. At an early level is the DSM. It’s a guidebook, and its the best common language to describe illnesses so everyone can have some common language. But even the contributors know its far from the whole picture. It’s a fine starting point, so we can have a reference from which to deviate.

Then with each mental illness there is a body of research literature. Hundreds or thousands of published research papers on an individual topic. Every paper has data, some of it contradictory, that adds to the complexity of the picture. As each of us learns more, we learn to read between the lines in the research, to see some of the bias inherent in different papers. Often the data isn’t even applicable to the real world. Researchers each take different tacks on a specific question or dilemma. I’ll get into this more in future blogs, but suffice it to say that no one take is ever the whole picture. The more sophisticated we get, the better we can recognize which data is useful, and which isn’t.

And then there’s the brain models, from the ways the brain is wired in different conditions, to having larger areas of the brain in some conditions and not others, to more or less neurotransmitters in some conditions in some areas of the brain. And as interesting as it all is it doesn’t tell us enough. It tells us little aside from a hope it’ll pan out to something viable down the road.

Understanding the problem tells you very little as to how to change it. Reading the DSM tells us almost nothing about interventions (meds, therapy). So then comes training and incorporating various ways to actually deal with problems. The process of medication management of problems must incorporate what the pills are approved to do, what they do in addition, and everything else about them (research on them, side effects, how they affect other body systems). And then comes psychotherapy, from learning how to connect to a person, to the myriad of different therapy approaches (behaviorism, psychodynamic, CBT, DBT, IPT, and many many others).

In most ways understanding the mind/brain is not like physics. There’s not higher math. Physics is considered a “harder” science. But they both deal with the mundane, what’s right in front of us, and yet with the intangible. And the more complex aspects of physics and chemistry examine that which can’t be quantified with the senses alone.

So when people complain that the DSM seems incomplete, I agree. And when people tell me about bad psychiatrists, or therapists, I understand why. There’s a lot of information to “master,” and right now we do alright even with just simplistic uses of the information as a minimum.

We’re still looking for our grand unified theory to tie it all together.

12
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