Sunday, October 6, 2013

A Psychiatrist's Favorite Breaking Bad Moments

I came upon Breaking Bad very late in the game. I have only been watching for the past few weeks, and I still have 8 episodes left. But since watching Season 2, I have decided it's my favorite show since The Wire. While I'm obviously not unique in feeling that way, I wanted to share some of the things I've enjoyed most about the show, from my perspective as a psychiatrist and doctor.

What impresses me most about Breaking Bad is how it portrayed the interactions of its characters with the healthcare system. Just as The Wire showed how individuals were entangled with dysfunctional inner-city institutions, Breaking Bad showed the absurd hoops people have to jump through for good health care in America. This has been written about extensively elsewhere, but what I found most fascinating and revealing was how the characters – like most people in real life – had no recourse but to work with the system as is, since the system is too colossal for any individual to fight.

Breaking Bad, Anywhere but America Edition

Moreover, every single "medical drama" I have ever seen has made me cringe because they just felt off. The doctors and patients were overly dramatic, acting too angry, or too serious, or too witty. They always brought out the paddles when they were trying to revive someone, even if the patient was in asystole. There were too many aha moments, too many exciting procedures, too little quiet suffering. I could go on forever. Breaking Bad made few of those mistakes and got lots of little details right. In particular, I think that the way the characters reacted to being poked and prodded, the look in their eyes as they had to accept the indignity of using a bedpan or stripping down for a PET/CT, and how the doctors and patients talked to each other, all seemed true to life. After seeing the episode in which Walt and Skyler met his new oncologist Dr. Delcavoli for the first time, I had the unprecedented urge to google the name of the actor who played Dr. Delcavoli to see if he was a doctor in real life.

Other details that I loved about the show:

Walt's Family Dynamics

It was clear to me early on that Walt's father was not around when he was growing up, though the show did not reveal why until late in Season 4. I have witnessed numerous patients who grew up in abusive or neglectful homes, who vow to be better parents to their own children, but then inadvertently create a dysfunctional situation of their own. In Walt's case, his justification for starting a meth lab was so he could provide for his family after his death. He likely grew up poor, so his ideal image of a father was someone who could make sure his family did not have to scrape by. However, in embarking on his quest for money, he deprived Skyler and his son Walter Jr. of his presence, driving him apart from the rest of this family. Thinking that he only had months to live, he never seemed to consider whether his family would prefer to have $700,000 or some meaningful time with him. He tries to make it up to his son later by buying Junior a muscle car, but that's no substitute for being a good parent.

My favorite moment of the entire series came in Season 4, Episode 10, when Walt, after the stress of a huge fight with his partner Jesse, broke down crying in front of Junior, who comforted him and helped him to bed. The next morning, Walt talked about how when he was a child, he saw his own father die from Hungtingon's disease, growing weaker physically and mentally, and how he did not want his son remembering him that way. Junior forcefully told Walt that he had no need to feel ashamed, and that unlike how he had behaved for the past year, at least last night "you were real!"

Hank's Post-Traumatic Stress

After Hank's shootout with Tuco Salamaca and then nearly being killed by a Mexican cartel's IED-planted-in-a-decapitated-head-on-a-tortoise in Season 2, he was clearly suffering from post-traumatic stress. The show did not try to get fancy by showing what was going on inside his head from his point of view, but the viewer can clearly see all the external signs of fear and hyperarousal, whether triggered by intrusive recollections/flashbacks or misinterpreting popping noises at night for gunfire. Then, Hank suffered even more trauma when he survived an attempt by the Salamaca brothers to kill him in Season 3. He grew angry and terse with his wife and nearly withdrew completely from life. Even though his emotional recovery from those traumatic events seemed to happen a bit too smoothly and quickly, it felt true to me that what helped him most was having a purpose in life again when he put his energy into going after Gustavo Fring's meth operation.

Jesse's Misinterpretation of Acceptance

While Jesse was in rehab at the start of Season 3, the show did a good job of illustrating the concept of acceptance when the therapy group leader talked about accidentally killing his own daughter, and how beating himself up for it only led to more drug use. Acceptance, as I understand it, does not mean thinking that something is ok. It's an acknowledgement of fact, that something unpleasant or terrible has happened and that one is imperfect, but also acknowledging that one cannot change the past, but can only control how one acts in the present moment. However, Jesse seemed to interpret acceptance somewhat differently, because after he left rehab, he told Walt that he had learned to accept the fact that "I'm the bad guy." Later in Season 4, after killing a man, Jesse berated the same group leader at a 12-step meeting, asking if he is supposed to accept himself no matter what he does. Given Jesse's emotional turmoil and the extent of his grief and guilt, it is not surprising that this was a difficult concept for him to, well, accept.

Walt's "Fugue State"

In Season 2, Walt went missing from his family because he was stuck in his mobile meth lab out in the desert. Upon hitchhiking back to civilization, he stripped naked in a convenience store and made up a story about being in a fugue state. What I love about this scenario is that it fits my experience (admittedly based on a very small n) that most of the time, when someone is found far from home claiming to have forgotten everything, it's B.S. made up by a somewhat sociopathic person to get out of trouble of some sort. And just like in real life, first Walt was seen by his medical providers, who ordered various tests and called a neurology consult. Then, when no answers were forthcoming, they brought in the shrink. I got a good laugh when Walt told the consulting psychiatrist the truth about how he made up the fugue state after the psychiatrist explained the rules of confidentiality. This, unfortunately, is not something I've had the fortune of seeing yet in real life.

I'm impressed if you've never seen Breaking Bad but managed to read this far. What are you waiting for? In addition to being thrilling entertainment, Breaking Bad is an incisive examination of the follies of our society, with some of the finest acting and thorniest moral questions that I have seen.