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 ride 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.

Silver Lining Playbook - Propsychiatry?

I went to see this film today for a couple of reasons.  Several people recommended it to me as a “pro-psychiatry” movie.  And I saw Robert De Niro interviewed about this movie with some of the cast and he was overcome with emotion and attributed it to the main character of the story and what he apparently went through with bipolar disorder.  As a film the structure and pace of this are well done.  It is enjoyable to watch.  The ensemble cast of Bradley Cooper, Jennifer Lawrence, Robert DeNiro and Jackie Weaver are focused at times on how depression and bipolar disorder affect people and their families.  I think it is generally known that the film focuses on Cooper’s character Pat, at the outset.  We learn that he has been court ordered to a psychiatric hospital.  In one of the opening scenes his mother picks him up and drives him to home to Philadelphia where he is supposed to comply with court ordered therapy, medications, and the conditions of a restraining order that prohibits him from contacting his wife or coming within 500 feet of her.  A police officer shows up to encourage compliance with the restraining order.

The first question in evaluating the movie and my friends’ comments is whether this very entertaining and well acted film is psychiatrically plausible.  Could the Cooper character (Pat Solitano) assault someone with the vigor we see in the film and end up being diverted to what appears to be a low security state psychiatric facility.  My understanding is that the film is based on the novel The Silver Linings Playbook by Matthew Quick.   There seems to be a general consensus that the film version is a very loose adaptation so I suppose I would need to read the novel to see the way this part of the plot was framed.  In real life, assaultive behavior in most states is handled as a criminal matter rather than court ordered psychiatric treatment.  It is one of the reasons that county jails have become large psychiatric facilities.  In some cases there is psychiatric care provided in jail.  In more enlightened systems competency evaluations are provided in jail and that may result in diversion to mental health court rather than criminal court.  An insanity plea has a low likelihood of success and defense attorneys are reluctant to consider it because the length of stay in a psychiatric hospital may be longer than in jail.

In this case Pat has been in the hospital for about 8 months.  We are told his mother made some kind of a deal to get him out.  In the process, one of his fellow patients leaves in the same car illustrating that security is not a priority.  While he is in the hospital, Pat spits his medication out after a mouth check by a nurse and when he gets home he proclaims he is not taking the medication because it affects his mental clarity and gives him physical side effects.  He is intense, wakes his parents up in the middle of the night, and creates a high level of tension in their home.  His parents seem at a loss in terms of how they can help him and invariably end up reminding him about the conditions of his release.  His apparent mental illness peaks with a scene where the entire neighborhood is disrupted and he physically injures his parents.  He eventually begins taking the medication.

His relationship with Tiffany (Jennifer Lawrence) begins in parallel with his initial stability and proceeds as he is getting more stable.  She also discloses a significant depression associated with her husband’s death and some sexual promiscuity.  She is portrayed as a very intense and at times angry and agitated women who is aware of the controversial parts of her character and says she has accepted them.  She has several angry confrontations with Pat and a very animated confrontation with his family about whether or not she is good for their home team’s juju.  Her emotional relationship to Pat as he recovers is one of the most compelling parts of the film.

At various moments, Pat is seen with his psychiatrist Dr. Patel (Anupam Kher) who does a good job of engaging a hypomanic Pat in movie psychotherapy.  Dr. Patel did have qualities that most people would like to see in a physician.  He listened, he was engaged, and he was able to relate to Pat.  In the first clinic scene, we learn that Dr. Patel played some music (or said that he did) to see how Pat would react.  Pat trashed the magazine stand in the waiting area.  This is dramatic license rather than actual psychiatry.  I can’t imagine any reasonable psychiatrist who would be eager to provoke a reaction from a person with a history of aggression who has been conditionally released from a state psychiatric facility.  The reality of these appointments for people with severe mental illnesses is that most of the time is not focused on psychotherapy.  In most public or managed care clinics Dr. Patel would have about 20 minutes to see Pat, discuss his symptoms, discuss medication side effects, order and review labs, and do the necessary documentation.  A casual armchair conversation like the one portrayed in the movie can occur only in special circumstances.

After the initial sessions we next meet Dr. Patel tailgating in the parking lot outside of the Philadelphia Eagle’s game.  He embraces Pat and utters a word that I have never heard a psychiatrist say.  There is an ugly scene involving racism and Dr. Patel and his fellow Indians and some of the locals.  Pat is back in the middle of this fighting to protect his brother.  Although he is arrested they all (including Dr. Patel) end up back at Pat’s parents home – a significant boundary problem.

I think that it is pretty obvious that I don’t really see this as a “pro-psychiatry” movie.  Psychiatrists don’t really act like Dr. Patel and many of the scenes highlighting problems with mental illness are more probably affected by dramatic license.  Some of those scenes were well done in terms of the chaos, aggressive behavior, anger and stress associated with mental illness.  Critics have faulted the film for not going far enough diagnostically, being an antipsychiatry film in that it demonstrates the failures of medical psychiatry, and generally seeing it as a random display of neurosis without enough details.  I think the outlines are there, but let’s face it.  This is not a clinical exercise.  This is art.  When I go to the movies, I am looking for compelling characters and good acting.  It is even better if those characters are acting out a fantasy that I can identify with.  Cooper and Lawrence clearly have a level of intensity that you don’t see in many places these days.  So while this film was really not about psychiatry (certainly not “pro-psychiatry”) it was very entertaining and it captured a lot of the reasons why I go to the movies.

I would like to have read what Robert De Niro read that gave him insights into the pain of the main character.  From what I saw today, they only scratched the surface on that issue.

George Dawson, MD, DFAPA         

Historic WWII Era Film on PTSD

An historic film by John Huston on PTSD is available at: 

http://www.filmpreservation.org/preserved-films/screening-room/let-there-be-light-1946 

This is an actual film of veterans being treated. Very interesting film from an historic and psychiatric perspective. Also interesting from a propaganda perspective. One of my first teachers in psychiatry was a WWII psychiatrist who went through an expedited residency in order to treat combat neurosis.  The attached notes about the making of the films is also interesting in terms of the way it is structured, the total footage shot to get this final cut version and why this particular facility was used. 

As an example Huston comments on the treatment process at the hospital he chose for the film: " The hospital admitted two groups of 75 patients each week, and the goal was to restore these men physically, mentally and emotionally within six to eight weeks, to the point where they could be returned to civilian life in as good condition—or almost as good—as when they came into the Army…  "  Just doing the arithmetic, with what we know about the scale of WWII, that would suggest that most veterans with PTSD never got treated.

He also commented on the goal of the film: "[The purpose] was to show how men who suffered mental damage in the service should not be written off but could be helped by psychiatric treatment….".  That message seems to continuously escape the politicians responsible for war making and repairing the damage afterwards.

The original film was suppressed by the Army and the US Government who suggested that privacy considerations were the reason.  All the men in the film had signed releases for the filming, but at one point those releases disappeared.  During an attempted screening of the film, military police showed up and confiscated a copy.  The author of the Film Notes suggests a few reasons for the suppression of the film as well as discussing the innovative and artistic points.

From a psychiatric standpoint, the use of drug therapy by psychiatrists in film was cutting edge.  According to Gabbard and Gabbard the first film depictions of drug therapy occurred in 1947 (Possessed) and 1949 (The Home of the Brave).  In their book they mention Let There Be Light (1946) as the third depiction of narcosynthesis.  It  also reminded me of The Snake Pit (1948) in that the psychiatrists are portrayed as being generally effective.

From a cultural and political standpoint, the film and Huston’s intentions stand in contrast to the atmosphere today where psychiatrists are portrayed in the media as inept tools of pharmaceutical companies who thrive on prescribing ineffective treatments.  In the film notes section, Huston describes the transformation of some of the patients as “miraculous”.  At some level, there has to be skepticism on the treatment effort and outcomes.  For example, there is an overall lack of aggression and severe depression in the veterans filmed for this project.  In my experience in several different VA facilities those are common problems as a result of combat stress exposure.

As a kid walking 5 blocks to elementary school every day, I encountered veterans with clear problems that were explained to me at the time as being “due to the war.”  In some cases more specific etiologies were suggested like: “he got malaria in the war”.  That was in the late 1950s.

As a civilian, I had no idea what exposure to combat stress could do until I was a psychiatric resident working in a VA hospital.  By that time we had already been through the Vietnam War and any consideration of the impact that war had on veterans was secondary to the over-the-top politics associated with an unnecessary war.

Maybe things would have been a lot different if the Army had allowed a broad release of this film.

George Dawson, MD, DFAPA

Gabbard K, Gabbard GO.  Psychiatry and the Cinema. The University of Chicago Press, Chicago, (1987) p 70-71. 

Vision Quest "6 minutes" - Why We Watch Sports

Another clip that goes a long way toward explaining why we watch sports, go to concerts, read good books:

https://www.youtube.com/watch?v=TZeaZ3rZumg

In this clip Louden Swain, a high school wrestler preparing for the match of his career goes to see why Elmo the cook who he works with took the evening off of work to go to his wrestling match.  Elmo's soliloquy here about sports still strikes me as the best single reason why I watch sports.

I have never seen it studied, but it seems that there are several reason for why sports play a central role in society.  The social elements are apparent and many people see themselves as a larger community tied to a particular team.  I used to be  New York Yankee fan, despite the fact that I did not set foot in New York City (or the state of New York) until I was about 26 years old.  My father was a Yankee fan and so was I, so identification is important.  Somewhere in my late 20's I realized that a certain team winning was no longer important.  I started watching "This Week in Baseball" just to watch all of the best plays.  I tuned in to see Nolan Ryan pitch.  I watched the Tour de France and the Olympics to see the best athletes in the world compete.  I can still remember my excitement as I watched Johann Olav Koss in the 1,500, 5,000, and 10,000 meter events at Lillehammer. It was the first time that they had a motorized camera following the speedskaters. We learned that he had some last minute technical problems with the blade angle on his skates but Koss's form was perfect.  I was ecstatic.  I had become Elmo.

I have never seen a study that looked at the percentages of people who watch sports for the purposes of seeing a certain team win versus those who are looking for the best possible human performances.  But for the later - there is no better explanation than Elmo's soliloquy in this clip.

George Dawson, MD. DFAPA

Mad Men scene

The scene between characters Don Draper and Peggy Olson in AMC TVs award winning show Mad Men (as in Madison Avenue) has an excellent bit of advice that I have tried to impart at times.  In this scene, Peggy is in what appears to be a psychiatric hospital and she is bedridden. She has just gone through a major life crisis and tried to conceal her whereabouts from her boss Don Draper. Prior to this crisis she had impressed Draper to the point that he promoted her and he brings that up during this conversation.

Draper on the other hand, had a similar life crisis when he was in his early 20s that involved changing his identity to the identity of a soldier he was serving with during the Korean War. He has a significant amount of psychological trauma from his childhood. His advice in this scene captures the way he has dealt with his own problems but also captures a larger thread of developmental psychology and speaks to the fact that as we deal with more crises through our lives it affects us less and and we can recover from it more quickly. That basic concept of resilience is not talked about enough in assisting people with crises in their lives.