Sunday, August 3, 2014

Jimmy P. - The Psychotherapy of a Plains Indian

Every now and then Netflix surprises me and seems to include come content of interest to psychiatrists.  I watch a lot of Netflix basically because I have a WiFi ready TV planted in front of my ergometer.  I rid an ergometer at least 4 times a week and as anyone who has ridden indoor cycling trainers can attest, that can be painful activity without some diversion.  I had just finished watching a biographical piece about Harry Dean Stanton and found the movie Jimmie P.  It starred Benicio Del Toro and I started watching it on that basis rather than the description that had something to do about psychoanalysis.  Del Toro stars as Jimmie P. or Jimmie Picard a Blackfoot Indian who also happens to be a returning World War II veteran.  We subsequently learn he was a sniper in the war but never shot anyone.  We see a scene where he falls out of the back of a transport truck and sustains a severe head injury.  It is that head injury that sets the story line for the film, the story develops through flashbacks.

I decided to start watch this film based on two things.  The word "psychoanalysis" and the name "Del Toro".  I am not a psychoanalyst, but I have been trained in psychotherapy, have done psychotherapy, and have had a great deal of success with psychotherapeutic interventions.  At the time I was trained all residents did psychotherapy training and were supervised intensively.  One hour of supervision for every hour of patient contact.  A lot of that  supervision was painstaking.  Reviews of audio tapes, video tapes and process notes.  I was intensively supervised on 3 extended psychotherapy patients per week so that was 150 hours per year for three years.  There were also group seminars, group supervision and seminars that consisted of case discussions.  Much of the supervision I had was done by psychoanalysts or psychodynamically oriented psychotherapists.  There were also existentialists, cognitive behavioral therapists, and marriage and family therapists.   My experience with these supervisors was generally positive,  but as you might imagine it was also a grind at times.  At  times, I felt like I was too physically, mentally, and emotionally drained to go into these sessions, but I made them all.  I include this information to illustrate a potential bias in my viewing a psychotherapy movie.

Benicio Del Toro always piques my interest.  I don't think there is any other contemporary actor who can play the conflicted bad man as well as he can.  He is visually interesting to watch and has huge screen presence.  He is one of the few actors that will prompt me to watch a  film cold without much knowledge ahead of time.  In this film he shows his range in his portrayal of a very real guy coming back from the war.  He is a conflicted good man and in fact he is too good at times.  When I was a kid growing up there were many uncles who came back from the war, and as I grew up it was common to hear that a particular person was "never the same" after they came back from the war.   I am old enough to have observed that effect of war on another three generations.  Jimmy P. was one of those guys.

I didn't think of it at the time, but I also have in interest in Native Americans and their culture.  I was born and raised between two reservations.  I note that some of these reservations have been renamed as tribal homelands.  I went to school with folks from these reservations and played sports with them.   My uncle and I were fortunate enough to be on a baseball team that was predominately Native American ball players.  My grandfather and I fished on the reservation, almost exclusively.  Even though those experiences were always positive, the most instructive aspect about knowing about Native Americans and some of their personal situations was the development of biases against them.  Over the last thirty years, they have been more assertive and in some cases more successful.  They have been granted rights that are viewed as controversial by non-native groups, specifically fishing rights.  The backlash has been significant enough to lead any objective observer to conclude that relationships with the native population is actually worse than when I was sitting in a boat on Bad River with my grandfather.

These first four paragraphs are a good indication that there psychodynamic influences in the very decision to select a film.  Getting back to the movie - we first see Jimmie P. at his sisters home.  He is having difficulty functioning.  He is sleeping late, but also has debilitating headaches and a sense of dysequilibrium.  At times he collapses with headaches, chest pains and is sweating through his clothing.  We learn that he has already been medically assessed and that he has a significant scar on the top of his head.  He is eventually admitted to a VA facility that is headed by Karl Menninger.  The focus of the admission is to determine whether or not there are any organic factors involved in the presentation or whether a functional illness is present that can be treated with psychotherapy.  The diagnostic interventions are vague and understandably crude.   For some reason a pneumoencephalogram was postponed until near the end of the film and we learn that the goal was to rule out a cholesteatoma!

At the end of the initial evaluation Dr. Menninger's team is coming up with no medical explanations for Jimmy's symptoms.  Dr. Menninger places a call to Georges Devereux, who is identified initially as an anthropologist with a knowledge of Native Americans.  He convinces Devereux to come to the hospital and do an assessment on Picard.  It was unclear to me about his professional orientation apart from his qualification as an anthropologist but it became apparent that he was also functioning as a psychoanalyst and getting his own analysis from faculty at the hospital.  After several interviews he presents his formulation to Menninger and colleagues and they like what they hear.  They ask him to stay on and engage Picard in psychotherapy.   The bulk of the film is a detailed psychotherapeutic conversation between Devereux and Picard.

That is where the real work for the viewer comes in.  My speculation is that whether the viewer does stay engaged depends on their psychological mindedness or ability to stay interested in the narrative.  That narrative that is built on Devereux's interpretations and clarifications and flashbacks that are designed to elaborate on what Picard is describing in the sessions.  There are several indirect discussions and enactments of transference and countertransference in the film.  In one very good scene Picard gets angry with Devereux and they discuss the importance of discussing the anger and associated events with the therapist.  There were also many good examples of real situations and how they are handled well but at times imperfectly in therapy sessions.   Scenes like this can lead experts to take issue with the way they are portrayed in the cinema.  My usual standard for cinema is that it is well executed from a technical cinematic standpoint, that it is entertaining and that I like it as art.   It certainly passes that standard.   Since we are dealing with just fragments of therapy sessions, any errors are difficult to assess.  I found myself thinking about taking too many notes early in the course of therapy as a possible example.   Therapy was also portrayed as hard work that results in somewhat erratic progress.  The necessary relationship  for therapy and a working therapeutic alliance seemed to be emphasized in the film, but over the course of the film it seemed like Devereux became more distant.  It may have been written that way to show the effect of termination and possibly supervision on the part of the analyst.

Devereux's personal life is also a focus in the movie.  He is having an affair with a married lover Madeleine.  Many critics see this a a diversion away from the main text of the film, but I saw it as more important than that.  In many ways Madeleine is an idealized lover.  She is bright, very attractive, likeable, and at times dotes on Georges.   In my observation of Georges, he just does not seem to have a lot going for him.  He seems to spend a lot of time on anthropological junkets, is somewhat of a nerd, does not seem emotionally resonant with Madeline, and seems fairly indifferent when it is time for her to leave.  Madeline also has a statement and a soliloquy in the film that I saw as critical.  One is an overview of how the brain is the central organ in the body and the role of psychoanalysis in psychosomatics.  The other has to do with the impact that an idealized lover has on a person, why they do not need to be forgotten, and the ongoing impact on one's  life.   I think that she also provides contrast between the advice that the analyst gives his patient and how he runs his own life.  That is an interesting thought in a movie that includes Karl Menninger.   One of Menninger's theories is that there is not much difference between people with mental illness and people who don't have mental illness.   Jimmy P. is a great illustration of that idea extended to include the fact that there is really no difference between Native Americans and the rest of us.  People seeing this film can probably identify with many of the themes and conflicts that Jimmie P. had to deal with.

I had the usual associations to the film.  I have treated many people with psychosomatic problems like Jimmy P.  These days most of the work has to go in to the idea that there is not a pill for these problems, but that other strategies can be useful.  It is very probable in modern times that the correct treatment of these serious psychosomatic symptoms gets buried under a long series of "medication trials."  I could see Jimmy being diagnosed with Post Traumatic Stress Disorder, Panic Disorder, Major Depression, and possibly an alcohol use disorder.  I can see all of that happening in one 20 minute session by a nonpsychiatrist.  I could see him walking out of that first session with an SSRI, a benzodiazepine, and possibly prazosin - all medications high up on the PTSD algorithm.   The issue of diagnosis came up in the last meeting between Picard and Devereux.  After discussing the pneumoencephalogram results, Devereux asks whether Picard would like to know his diagnosis.   He hands him a piece of paper with the diagnosis "Psychic Trauma".

That's my initial review.  There are some addition reference materials I would like to look at including a suggested book and the actual script.  A script with dialogue this intensive probably requires an additional read or two.  There is a lot of information contained in the dialogue between Picard and Devereux.  As far as I know there are no good models or methods for analyzing the information content in therapeutic sessions and how that information is used.  I ended up rating the film 5 stars on Netflix.  But keep in mind that rating is from a guy who has talked to people at least 6-7 hours per day for the past thirty years.

George Dawson, MD, DFAPA

Matt Zoller Seitz.  Jimmy P.  This is a good review by a professional reviewer who thought this was a good film and has opinions about it that contrast with mine.
  

Supplementary 1:   Given my comments about psychotherapy and psychopharmacology it is easy to see how those issues can be politicized and how discussions about both of those modalities can be very polarized.  The fact that a person with complex problems is more likely to see a psychopharmacologist first should not mean that they are not receiving psychotherapy informed treatment.  One of the most striking examples that I can think of is a psychopharmacologist I worked with for many years.  He started and ran a psychopharmacology specialty clinic.  The people who saw him had a uniformly positive experience based on their relationship with him and what how he discussed problems with them.  He was and is certainly an expert in psychopharmacology but he was providing a lot more than that.

I think we are past the time where there needs to be an open discussion and guidelines about psychotherapeutically informed psychopharmacology.  That would include a focus on the relationship, a discussion about that fact that there are probably other things that need work in addition to the medication, and a discussion of the meaning of the diagnosis and meaningfulness in general in a persons life.

These ideas have obvious implications for the stilted billing and coding system and the idea that anybody can prescribe psychiatric medications.  Expert prescribing requires knowing about what is going on in addition to the diagnostic criteria and algorithms and what else can be done.



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