Review of "Century of the Self" (BBC documentary)

It may have been a patient (I can't recall) who suggested I search online for the 2002 BBC documentary by Adam Curtis called Century of the Self.  It turns out the video is freely available at several sites; the full four-hour documentary can be viewed or downloaded here, or each of the hour-long installments here.  In briefest outline, Century of the Self advances the thesis that Freud's views of the unconscious set the stage for corporations, and later politicians, to market to our unconscious fears and desires.  It's gripping, it explains a lot, and it reminds me of The Matrix in the way it portrays an ugly dystopian truth hidden behind bland normality.  Except Century of the Self is real, not science fiction.

One reviewer offers: "There are very few movies I wish I could force my friends to watch, that I feel encapsulate a feeling that I've had but have been unable to articulate."  Indeed, Century of the Self ties together several observations I myself have made over the years about corporate marketing — and then it goes much further, placing those observations in a broad context.  For example, in my youth I found it odd that any products at all could be marketed to hippies, those bastions of non-materialism.  Yet by the early 1970s the signature unkempt long hair became a "style" featured in fashion magazines and offered in hair salons, and blowdryers were widely sold to cater to this new look.  Less than a decade later, punk rockers pierced their clothes with rows of safety pins, and it wasn't long before Macy's sold brand new clothes with safety pins already inserted.  Goth, grunge, hip-hop, or hipster, it doesn't matter.  Products will be sold.  As the Borg say: "You will be assimilated.  Resistance is futile."

I noticed something similar at the other end of the materialism continuum as well.  By the 1980s, expensive, formerly niche products were being avidly marketed to ordinary consumers.  Regular cooks bought restaurant-grade pots and pans, average shutterbugs purchased advanced cameras, families who never left the suburbs drove SUVs that could go off-road and up mountainsides.  What motivated people to spend their hard-earned money on features they'd never use and quality they'd never fully appreciate?  Again, it was hard to escape the conclusion that corporations sold self-image and emotional aspirations, not rational goods and services.

I'm old enough to remember when "lifestyle" was first popularized as a sales term, and when pitches aimed at self-image were still a little ham-handed and obvious (e.g., "What sort of man reads Playboy?").  Now we fail to notice that it is literally impossible to sell a new car, or prescription medications to the public, with an appeal to rationality. No one even tries.  Back in the mid-1970s it was novel and slightly jarring when gasoline companies ran ads not (directly) to sell gas, but to improve their corporate image.  We've come to accept that as routine nearly 40 years later.

It hasn't always been so.  Century of the Self shows how advertising once aimed to influence rational choice.  This gave way in the early 20th century to advertising aimed to connect feelings with a product.  Amazingly enough, at the root of this change was Sigmund Freud's nephew, Edward Bernays.  Bernays, an American propagandist in WWI, applied his wartime experience and his uncle's theories of the unconscious to peacetime commerce.  He invented the field of public relations, popularized press releases and product tie-ins, and changed public opinion about matters ranging from women smoking to the use of paper cups — all to increase sales.  Viewing politics as just another product to sell, Bernays also helped Calvin Coolidge stage one of the first overt media acts for a president, and helped engineer the 1954 coup in Guatemala on behalf of his client the United Fruit Company, by painting their democratically elected leader as communist.

This and more happens in just the first hour of the documentary, titled "Happiness Machines."  The second hour, the weakest in my view, is called "The Engineering of Consent" and focuses on the ascendancy of psychoanalysis and Anna Freud's consolidation of power.  The point here is that the unconscious was seen as a dangerous menace that needed to be kept under lock and key.  Rational choice, especially by crowds, was unreliable under its influence, so "guidance from above" (in Bernays' words) was needed from political leaders and corporations for the public good.  The conformity and mass-marketing of the 1950s reflects this view of a public that cannot be trusted to think for itself.  The pendulum swings the other way in the third and best installment, "There is a Policeman Inside All Our Heads [and] He Must be Destroyed."  By the 1960s the human potential movement urged the expression of impulses instead of their repression.  Business was eager to help.  By marketing products as a means of self-expression, business turned from channeling public impulses to pandering to them.  There is a fascinating discussion in the film about political activism being co-opted in this process: making the world a better place gave way to making oneself better in ways that, not coincidentally, required buying more goods and services.  The final segment, called "Eight People Sipping Wine in Kettering," follows this impulse-pandering into politics.  Instead of political leadership, we now have politics led by focus groups.  The public gets what it asks for (V-chips and populist slogans), not what it needs (healthcare and infrastructure improvements).

Freud himself is treated ambiguously in the documentary.  Although he benefitted by his nephew's promotion of his writing, one gathers he was uncomfortable with commercial exploitation of his ideas.  Enigmatically, the final camera shot zooms in on Freud's tombstone.  Perhaps we are to imagine him turning over in his grave.

How can democracy work best, given that our choices are inevitably swayed by irrational unconscious forces?  Curtis isn't explicit, but implies that treating people as rational tends to make them moreso.  Even as a firm believer in the dynamic unconscious, I find this a hopeful point of view.  It also occurs to me that it is a researchable hypothesis, and that such research may in some measure counterbalance commercial and political profiteering from research on unconscious influence.  The ethical implications of powerful social institutions exerting covert influence are only telegraphed in the documentary; they deserve a detailed analysis in their own right.

Century of the Self has engaging interviews, rare archival footage, a sweeping view of recent history, and, alas, somewhat irritating music.  It was reviewed quite positively when it came out, and despite being over ten years old, still has a great deal to offer.  I don't wish to force anyone to watch it, but I do highly recommend it.

The APA annual meeting: a photo essay

As posted previously, last month I attended the American Psychiatric Association's (APA's) annual conference.  Straying from my usual format, I thought I'd post pictures from the meeting and, of course, offer comments. The meeting took place in Moscone Center, a conference center complex located just south of Market Street in downtown San Francisco.  Depicted here are anti-psychiatry protesters who held a rally in front of the main entrance at noon on the first day.  There was also an exhibit of psychiatry's cruelties (psychosurgery, shock treatment, inhumane conditions in asylums, etc) running all five days in a tent across the street from the conference.   The conference was also a block from Yerba Buena Gardens, where I caught a very pleasant Balinese gamelan concert at the same time as the protest rally. This simultaneity — two events scheduled to coincide, forcing a choice — was a constant in the conference as well. The "scientific program" consisted of  numerous overlapping talks, such that attending any presentation meant missing five or more other good ones.  I'm not sure why the APA opted for such frustrating redundancy.  Nor can I explain why predictably popular talks were scheduled into small rooms, with the result that dozens of registrants were turned away once the room filled.  For instance, the crowd for Otto Kernberg's psychoanalytic talk on love and aggression was several times larger than the assigned room.  In this unusual case we were all moved to a cavernous hall at the last moment, where Dr. Kernberg gave a warm and very engaging presentation on the necessity and creative consequences of aggression in romantic love.  (I like how this photo depicts the renowned psychoanalyst Kernberg representing the APA in an era of biological ascendancy.)

The same huge auditorium was to hold the keynote address by Bill Clinton.  However, Mr. Clinton was ill and could not be there in person.  Several hundred (a couple thousand?) conference-goers nonetheless waited over an hour to see him on video.  Mr. Clinton was pleasant, thoughtful, and charismatic, but didn't offer much specifically about psychiatry or mental health.  Mostly he spoke about public health needs in general.

I didn't take many photos in the talks themselves.  Officially it was forbidden, although this rule was routinely ignored by attendees.  The quality of the presentations was high — I mostly chose "mainstream" ones this time, not the many off-beat and generally smaller meetings.  I attended presentations on suicide, personality disorders, PTSD, sexual compulsions, DSM-5 and mood disorders, the controversy over antidepressant efficacy, psychiatrists writing and blogging for the general public, teaching psychotherapy to residents, and assessing the capacity of demented patients to make medical decisions for themselves.  There were dozens of others I would have liked to attend, had they not coincided with the ones I chose.

I skipped the industry-sponsored, free lunch or dinner, non-CME presentations.  But I did wander through the exhibit hall, both to see the "new investigator" scientific posters, and to peruse the brand-new DSM-5. In contrast to the last time I went to this conference, the industry booths seemed less garish and "over the top."  Of course, there were still a lot of them.  Several had raffles where valuable prizes such as an iPad Mini could be won by those who gave the company their contact information.  One booth offered a pocket digest of the new DSM-5, MSRP about $60, to everyone who watched a 12 minute presentation and coughed up a mailing address.  I was tempted... but no.  (It's interesting to ponder how much a single psychiatrist contact is worth to a drug company.  Much more than $60, I'd venture.)

The DSM-5 itself is $200 in hardcover, $150 in paperback — an unabashed moneymaker for the APA.  Despite the incredible controversy it stirred up, my impression is that the changes from DSM-IV-TR are relatively minor.  In particular, the personality disorder section hasn't changed much, although the new edition is no longer multi-axial, i.e., there is no "Axis 2".  Some language has been made more precise, as well as more "biological" in some passages, and some disorders have been expanded to include more that would previously have been considered normal.  Whether this is good or bad depends on one's perspective in several respects; mostly I find it unfortunate.  DSM classifications often matter more to insurers and disability officers than to practicing psychiatrists, who in David Brooks' words are "heroes of uncertainty" (echoing an earlier post of mine, but I'll forgive him for not quoting me).  We deal with individuals, not disease categories.

I will end with a slide from the talk on antidepressant efficacy that summarizes this tension in my field.  As I've discussed previously, randomized controlled trials (RCTs) are the gold standard for scientific rigor in psychiatry; however, a lot of psychiatry is not scientific in this sense.  DSM categories help define the "average" patient with a particular disorder, leaving a lot of wiggle room since the categories are not based on etiology.  RCTs say which treatments best help this "average" patient, represented by the computer composite in the center of this slide.  However, I don't see "average" patients,  I see one of the 12 individuals who contributed to the composite.  Thus, for me, the new DSM was a sideshow at the conference.  The most insightful presentations, whether on PTSD, suicide, or capacity assessment, combined science and the nuanced human communication of meaning.  They recognized that our work is informed by science but goes well beyond it.  Anti-psychiatrists don't like this, insurers don't like this, neuroscientists don't like this, even many psychiatrists don't like this.  But it's true and inevitable for the foreseeable future.  I like it.  As for the APA annual meeting, I'm glad I went, and equally glad I won't feel the need to go back for several years at least.

Narcissists, psychopaths, and other bad guys

A patient of mine recently observed that the increasing use of the the term "psychopath" in popular media is really a disguised way of criticizing selfishness.  Dressing up selfishness as an odd and frightening clinical disorder — slapping a diagnostic label on it — makes for catchy news copy, and grants pundits emotional distance between themselves and those monsters who look just like us, but who lack the empathy and remorse that make us human. I immediately thought of how narcissism had its heyday in popular culture very recently as well, and to similar ends.  Narcissists and psychopaths care only about themselves, and have no qualms about hurting and sacrificing others when it suits their purposes.  These are dangerous people lurking among us; all the more reason to publish lightweight magazine and newspaper pieces on how to spot them in the wild.

Both labels sound like psychiatric diagnoses, but actually they're not.  According to Heinz Kohut and other theorists, narcissism is a quality everyone has to a greater or lesser degree.  It normally develops in infancy: the sense all babies have that the world revolves around them.  However, we gradually learn that we are not the center of the world, and that other people, including our primary caregivers, have their own goals and perspectives separate from our own.  Infantile narcissism is thus tempered by the reality of healthy relationships, although its vestiges are present in our self-pride, and perhaps in our proven tendency to overestimate our own efficacy and performance.  Pathological narcissism in this view is infantile normality carried abnormally into adulthood.  It only becomes a psychiatric diagnosis when the condition fulfills certain observable criteria and impairs social and/or occupational functioning.  Likewise, psychopathy is a personality trait, not a diagnosis.  Renowned psychopathy researcher Robert Hare notes that "psychopathy is dimensional (i.e., more or less), not categorical (i.e., either or)."  DSM-IV doesn't include a diagnosis called "psychopathy" or "sociopathy."  Instead, there is antisocial personality disorder, which overlaps with psychopathy but is not the same thing.

These terms, psychopath and narcissist, are loosely applied personality labels when popularized in the media.  What do they add over simply calling someone callous or selfish?  First, they offer an explanation — a pseudo-explanation really — of frightening and/or mystifying behavior.  Our feeling of powerlessness is eased by the label, as though now that the threat is identified, we may be able to do something about it.  Second, such labels imply that misbehavior is a function of one's character, a categorical determination.  Yet categorical psychiatric diagnosis, especially of personality, is controversial in general.  Moreover, we often overestimate personality factors and underestimate situational ones (the "fundamental attribution error") in explaining the behavior of others.  Using a label like psychopath or narcissist to describe another person (whom we've only heard about in the news, and haven't formally evaluated) reaches for a premature conclusion about the cause of that person's behavior.  In a way, we are falsely reassured.

Third, the label adds power to our verbal disapproval.    We have a long history of abusing psychiatric labels in the service of putting others down.  Consider "idiot," "moron," and "imbecile," all originally coined as official categories describing low IQ.  Or "cretin," which originally referred to physical and mental disability due to congenital thyroid deficiency.  Or the casual use of "crazy" and its synonyms.  Some patient advocates argue further that any diagnostic label used as a noun is demeaning, i.e., calling someone a schizophrenic, a neurotic, a borderline, etc.  Instead, it is more respectful to refer to a person (or patient) who has schizophrenia, or a narcissistic personality.  But that's exactly the point of the popular use of terms like psychopath and narcissist: To show disrespect and disdain, to disapprove.  And to underscore the difference between ourselves and the person with the label.

Our earliest social categories are "good guys" and "bad guys," defining one against the other.  From "cops and robbers," to team sports, to bipartisan politics, to our allies and foes on the world stage, we divide self and other at every level, calling the former good and the latter bad.  Callousness and selfishness are in all of us to some degree, and it hurts to admit it; it damages our self-image.  Instead, we psychologically defend against this realization in ourselves by projecting these traits onto others using a broad brush and pejorative terms.  While some people truly are unusually callous or selfish, the popular use of scientific-sounding labels serves our own psychological needs by identifying "bad guys" and making us feel better about ourselves.

Movie review: "Escape Fire: The Fight to Rescue American Healthcare"

The independent documentary Escape Fire: The Fight to Rescue American Healthcare by Matthew Heineman and Susan Froemke is a thoughtful indictment of the status quo.  Instead of focusing on political polarization, the pros and cons of Obamacare for instance, the film mainly documents the absurdity and waste of what we have now.  Instead of a system to promote health, Americans have a "disease management system" that spends almost twice as much as any other country — and nearly as much on prescription medicines as the rest of the world combined — yet we are 50th in life expectancy, and almost 75% of healthcare costs are spent on preventable diseases that are the major causes of disability and death in our society.  Economic incentives maintain this status quo.  High-tech interventions are reimbursed generously, yet reimbursement for face-to-face primary care often does not even cover the cost to deliver it.  As a result, fewer new physicians enter primary care, and doctor visits become shorter and shorter.  Meanwhile, unnecessary medical and surgical procedures are prevalent despite their risks, and cost thousands of lives each year. Escape Fire uses a firefighting metaphor to make its main point.  In forest fires, sometimes a smaller fire is set in order to deprive the main fire of fuel, creating a firebreak.  Such firebreaks can allow firefighters to escape the area — thus an "escape fire."  The filmmakers use this metaphor to say that the status quo in health care isn't working, and that we may need counter-intuitive and non-traditional solutions to save the system.  I confess that I find this metaphor somewhat ill-chosen: The remedies suggested in the film do not "fight fire with fire."  And there is no escaping our need to address health care.

The film spends much time on the military, in part as a microcosm of the problems facing our larger society.  Soldiers' use of prescription drugs has tripled in the past five years.  A large section of Escape Fire, including fascinating footage inside a C-17 Medevac plane as it crosses the Atlantic, follows Sergeant Robert Yates returning from Afghanistan.  Severely injured in a battle that killed most of his platoon, he suffers chronic pain and PTSD.  Sgt. Yates was given a shopping bag full of pills, but later replaces them with stress- and pain-management techniques he learns as part of an innovative Army program.

Although the film never mentions psychiatry as a medical specialty, mental health issues loom large in both military and civilian health care.  Again and again, patients are depicted in primary care offices reviewing their antidepressant medications, or breaking down in tears.  The current system, devoted to disease management, offers poor care to such patients.  They need time, not reimbursed procedures.  As medical journalist Shannon Brownlee notes on camera: "Health care should have a lot more care in it."

The film proposes several escape fires, i.e., solutions, to rescue American health care.  In 2005 Safeway began to provide financial incentives for employees who engage in healthier behavior, and thereby lowered its health care costs by more than 40%.  (That's how the film puts it.  Actually, from 2005 to 2009 Safeway's health care costs remained flat for the 30,000 employees enrolled in the program, while most companies' costs rose by 40% over the same period.)  This was the one example of a monied interest realigning financial incentives to promote health.  The film would have been stronger with more such examples — I hope there are some.

The military provides a solution of a different type.  Often innovation gains a foothold there before achieving acceptance in civilian society.  Just as America's armed forces were on the vanguard of racial integration and later gender equality, perhaps they can lead the way on health care too.  The Army Surgeon General established a Pain Management Task Force to look at alternatives to narcotics, and now the Army is using acupuncture and meditation to decrease narcotic use in the wounded.  Sgt. Yates, the self-proclaimed "redneck hillbilly" who didn't believe in Eastern Medicine, "decided to give it a shot," and it worked.

I found the profile of Dr. Erin Martin the least hopeful in the near term.  Initially shown as a primary care doctor in a low-fee clinic, Dr. Martin had high ideals, but was demoralized by too many patients and too little time.  She was dissatisfied and frustrated by a system that made her job nearly impossible.  Her escape fire was literally to escape: She quit the clinic, became a fellow in Dr. Andrew Weil’s Integrative Medicine program, and found a practice that supported her patient, humane approach.  The film endorses this as the escape fire for primary care — but of course those clinic patients still need a doctor.

Dr. Martin's path is similar to the one I took myself.  Early in my career I worked for two years in a public mental health clinic.  The patients were in great need, but the system was frustrating and the work demoralizing.  Providing comprehensive, humane mental health care in such a system is an uphill battle at best, and in some respects nearly impossible.  I have much admiration for those who work in such settings.  However, like Dr. Martin, I chose to leave and practice in a way that makes more sense to me.  While the makers of Escape Fire would likely endorse my choice, public mental health clinics still need doctors too.  Moreover, it will be a long time before the American health care system rewards Dr. Martin and others who aim to avoid commodity care.  Indeed, the system is accelerating in the opposite direction.  Those of us who build this particular escape fire in essence work outside the larger system.

As I wrote at the outset, Escape Fire is a thoughtful indictment of the status quo.  The film has been reviewed positively, and it strikes a nice balance between worrisome facts and emotional interest, ending on a hopeful note.  We should have no illusions about easy solutions though.  Healthier lifestyle choices are hard to pursue when fast food is cheap and tasty; a shift to preventative care from disease management would represent a fundamental sea change and a realignment of billions of health care dollars.  For a start, at least, we can agree that American health care is burning, and that new solutions are desperately needed.

On responsibility

I'll leave the "sloppy thinking" series for now, although I expect to return to it in the future.  In this post I'll share some thoughts about personal responsibility, especially as it pertains to the insanity defense.  It's a topic much in the news lately, due to tragic actions by now-household names such as James Eagan Holmes and Jared Loughner.  The matter goes much further though.  We normally assume that adults are responsible for their actions, and that these actions are freely chosen.  The extent to which we treat this as absolute versus a matter of degree determines our fundamental political views, and how we view our neighbors and ourselves. Many facets of everyday life are premised on personal responsibility.  The criminal justice system is the most obvious example.  In a wider sense our willingness to live in community with others depends on each person taking responsibility for his or her behavior.  Nonetheless, we've recognized exceptions to this default assumption for centuries.  Adults who are severely sick or injured may temporarily be unable to assume responsibility for themselves.  Likewise, infants and young children lack the ability to make informed choices and to exercise personal responsibility.  Non-human animals are exempt from personal responsibility and are never considered guilty of a crime — well, not anymore.

English common law recognized that the same lack of responsibility extended to insane adults:

By the 18th century, the British courts had ... developed what became known as the "wild beast" test: If a defendant was so bereft of sanity that he understood the ramifications of his behavior "no more than in an infant, a brute, or a wild beast," he would not be held responsible for his crimes.

The history of the insanity defense then records the trial of Daniel M'Naughten in 1843, where inability to distinguish right from wrong was established as the crucial legal test. This became the standard, both in Britain and the US, for more than 100 years; the "M'Naughten rule" is still the legal standard in many states.  Later modifications tended to liberalize its application, as with the "irresistible impulse" and "diminished capacity" doctrines, until the pendulum swung the other way in the wake of John Hinkley's attempted assassination of President Reagan in 1981.

As a society, we seem to be losing our inclination to forgive the mentally ill, and children, when they commit horrific acts of violence.  Even young teens are now tried as adults when an alleged crime is bad enough.  And although insanity defenses are rare in U.S. courts, and their successful use often results in involuntary hospitalization longer than the prison sentence would otherwise have been, there is nonetheless a popular view that the insane "get away with it."  Jared Loughner recently plea-bargained for life imprisonment despite clear evidence of mental illness and the possibility of an insanity defense.  The court will decide whether James Holmes has severe psychosis, an antisocial personality, or just a very bad attitude.  As in Loughner's case, this determination is unlikely to make a difference in terms of public safety — Holmes won't be freed for decades, if ever.  But the way we handle the question of legal insanity bears on how our society views itself.

Now that we are in a presidential campaign season, we hear rhetoric that cleaves the major parties around the question of personal responsibility.  "You didn't build that," a slightly misspoken point by President Obama about the government's role in promoting business, became a rallying cry for Republicans in defense of the entrepreneur.  Yet both sides have a point:  The government makes and maintains highways (and founded the internet); individuals create trucking companies (and online businesses).  It's really a matter of emphasis, and yet this emphasis is what most of the fighting is about.

Decades ago, social psychologists coined the term "fundamental attribution error" to highlight our tendency to over-apply dispositional or personality explanations to others, in the same circumstances we apply situational explanations to ourselves.  E.g., if others are unemployed we often imagine they are lazy or unqualified (personal factors), whereas if we are unemployed, we often blame a tough economy and a lack of jobs (situational factors).  Of course, some of the unemployed really are lazy or unqualified, just as some killers really have the criminal intent (mens rea) to be convicted of murder.  The question is whether and to what extent we allow for exceptions in cases other than our own.  Denying such exceptions flies in the face of our own legal tradition, our recognition of the fundamental attribution error, and our human kinship — the idea that we humans are more alike than we are different.  We are wise enough not to punish infants or "wild beasts" even if they hurt us; the severity of their behavior and its consequences has no bearing on whether they are personally responsible.  A person who cannot tell right from wrong due to severe psychosis is operating at the same level, and should be treated, not punished.  Personal responsibility is a strong enough concept that it can withstand some nuance and flexibility — especially when that happens to reflect reality.