Last night my family watched Saving Mr. Banks.  We had heard that it was a very good movie and was nominated for several academy awards.  It was not at all what I expected it to be.  As you may recall, the movie centers on the difficulties that Walt Disney and his creative team had in making the movie version of P.L Travers’ Mary Poppins.  I was unprepared for a heart-wrenching depiction of the developmental difficulties encountered by a young girl in the face of her stretched-to-the-breaking-point family.  I do not know how accurate the movie was with the portrayal of P.L. Travers’ life, but the result was a magical, beautiful, heart-breaking, family romance of a movie that gives us a peek into the life of a young girl who tries too hard to be “practically perfect in every way.”

Spoilers ahead.

I often have patients come to my office and say things like “I can’t get out of bed in the morning” or “I can’t take this any more.”  It is clear that what they are saying is that they are having a very difficult time with some aspect of their lives and that they feel incapable of conducting their lives as they wish.  But it also seems that when mental health issues are involved both patients and therapists must wrestle with the difference between “I can” and “I will.”

I must admit that I am frustrated.  A little self examination would likely reveal that my frustration is leading me to overgeneralize and magnify problems.  Still, even in my calmer, more objective moments the problem does not go away, so I think it is real.  I will leave it up to any readers of this post and to my further reflection to judge how severe the problem is.

Capitalism is fine.  Really…I think it is.  But not as a worldview.  Our nation seems to have bought into the Darwinian, “survival of the fittest,” “nature red in tooth and claw” view of capitalism with a vengeance.  The overvalued view of “success” as acquisition of money, possessions, and power has squeezed out of our society values such as community, compassion, beauty, universal rights, and intrinsic human value.  Society idolizes those who are strong enough to overcome those around them, rich enough to indulge their every desire, and powerful enough to command those “under” them to do their will.  They imagine their heroes to be constantly happy and aspire to be like them in their bland euphoria.  They see people around them as merely tools by which they can achieve their happiness.  There are herds of customers to provide them money for their work.  There are shelves full of workers to be inserted into jobs, used up, and be replaced when used beyond their limits.  Customers and workers are a dime a dozen.  They are valuable as groups but not as individuals.  If I can induce (by hook or by crook) a customer to spend more money on my products or a worker to work harder for longer hours, then good for me.  The really valuable people are my fellow entrepreneurs.  They are valuable because they are the only ones really playing the capitalist game.  I sharpen my teeth on their competition.  I see my value reflected in my market share and the number of my opponents I vanquish.

And government has been induced to play the game as well.  “What’s good for GM is good for America.”  “The business of America is business.”  Really?  I thought it was “life, liberty, and the pursuit of happiness.”  Capitalism should be managed to achieve these goals.  It too often seems that these goals have been harnessed to propel capitalism.  We see this as business interests get louder voices in our government while personal interests are ignored.  Not totally, no.  The court system seems to be the last bastion of personal liberty (for now), but even there the question is often asked about how protection of personal liberty is going to affect business, commerce, or personal fortune.  It’s as if personal rights are tolerable as long as they don’t inconvenience the economy.

As a psychiatrist, I treat all kinds of people.  The most frustrating to me, however, are those who suffer from illnesses that are magnified by the conflicting interests of a capitalist worldview —  my disabled patients who are improving and are able to start resuming their jobs are told that they have to start at full time, full duties or they will not be allowed back; my depressed and anxious patients are put on swing shifts, made to work long hours, and are supervised by demanding, inflexible “superiors.”  Our society treats them as disposable or replaceable parts in the engine of industry.  If they can be repaired cheaply enough, they will be used.  If they break, they can easily be replaced.  If they don’t like their lot in life, they should have become entrepreneurs.  Regardless, it the manager’s duty to wring out as much efficiency as he can from them for the good of the business.  It’s only right that workers suffer for their “bad” choices.  The invisible hand of the market has chosen, and they have lost.  The owners’ interests are the ones that matter.  His religion and his values will dictate what opportunities his employees have.  They come to me thinking they are “sick” and can be healed.  I wonder, “Is there any treatment (short of lobotomy) that could make a patient happy or content in such situations?”  My answer is often, “No.”

I often wonder wistfully about what our nation would be like if individual liberty (independent of wealth) had remained our goal.  I am certain that capitalism would have remained our economic model, but what if capitalism served life (not simply survival), liberty (not merely consumer choices), and the pursuit of (real) happiness?  What if the “captains of industry” took the health and welfare of their individual employees as their chief good?  What if the votes of the workers counted more than the interests of the stockholders and boards of directors?  What would happen in our society if people meant more and money meant less?  How would we work?  How would we govern?  How would be take care of the sick, weak, and poor?

As I posted earlier, I am not a big fan of involuntary hospitalization.  I have done it when there were no other moral or ethical options left, but I have consented to it only after intense and prolonged consideration.  In my earlier post, I tried to comment on how to avoid (or achieve — your choice) involuntary hospitalization.  In this post, I want to comment on an important part of the decision that I omitted from my earlier post.  The quality of the institution one is committing a patient (or being committed as a patient) to.

My patients and I will not always agree.  This should not surprise us.  We may have different political beliefs — that’s fine.  We may have different religious beliefs — that, too, is fine.  We will likely have markedly different values and preferences — no problem.  Some people worry about what will happen if they disagree with their psychiatrist.  I suppose that that is not an unreasonable worry for some people.  We might as well get this out in the open for me and my patients.

One problem in seeing life as a conglomeration of games is that sometimes we are not all playing the same game.  We might think we are playing the same game and only later realize that the other involved were using completely different rules and were aiming for different goals.  For example, we may be playing the governing game in which we think that the rules are that the person elected works for the benefit of the people he represents — for which job he receives an appropriate salary.  We are later frustrated to find out that our elected official was playing another game in which he courted the interest of large companies and wealthy power-brokers to obtain personal power and campaign money so that he could get reelected and later have a job as a lobbyist for his benefactors.  He might have represented us when it served his purpose, but his rules and his goals were not those of the governing game.  Not that this only happens in government, it can also happen at work.  A man is hired to play the working game.  As part of this game, the man is expected to make telephone calls and sell some items or some service.  In return, the man will have certain signals sent between the payroll department as his bank, resulting in further signals being sent between his bank and his mortgage company, utilities, magazine subscription office, cable provider, etc. Finally leading to him having a home, lights, water, gas, Scientific American, The Big Bang Theory, and a little money left over for groceries and (hopefully) savings.  Later, the boss finds out that the man was really playing the filling-up-my-timecard game, in which he spends the day surfing the internet, hiding from his boss, and counting this as work.  The list can go on forever.  The question is, “How can we live together, cooperate, pursue our individual goals, and function as a society when we are not sure that we are all playing similar games?”

Of all the games we play, I think that psychotherapy is the most fun, and for many, one of the most valuable.  Many of the games we play are games of discovery though they may be so only on a trivial level.  We might try golf to see if we are any good at it or to see if we can control our frustration tolerance.  We may use the Ouija board to learn some deep, dark, mystical secrets.  We may play Truth or Dare to find out things about our friends.  But the most intense games of discovery are certain types of psychotherapy.  The reason that I like the game of psychotherapy is that both the therapist and the patient can learn important things about themselves.

I know that I addressed this issue in an earlier post on involuntary hospitalization, and this post may be redundant.  Still, I have been reading more posts complaining about the use of coercion in mental health treatment and especially by psychiatrists.  In these posts, and in the comments on my previous post on involuntary hospitalization, it seems that many of the comments by many (though not all) of the writers are addressing particular misuses of coercion rather than a general consideration of whether coercion has a legitimate place in the role of a mental health provider.

To begin with, I acknowledge that there is clear potential for misuse of coercive methods in all forms of health care but particularly in mental health care.  Therefore, an important question is whether it is so dangerous as to be eliminated from use.  Next, if one agrees that there is some role for coercion, we would need to decide what circumstances would permit it.  We would also need to consider what methods would be appropriate if coercion were allowed and if the situation permitted it.

My wife and I were wanting to read a book for Halloween and decided to read Mary Shelly’s Frankenstein.  For those of you who have never read the book, it is NOTHING like you might expect from seeing most of the movies supposedly based on the book.  I highly recommend the book to those of you who have an interest in Gothic horror (though it is not that scary) and especially those who have an interest in the personal and social psychologies of evil.  Please continue below the fold for further discussion (spoilers ahead).

It seems to me that some games are better than others.  Some are trivial.  Some are boring.  Others are fascinating, fun, and profound.  Given that it is possible that all of life is a game (a given that I am not convinced of yet), what makes a game “good”?  Is it merely a matter of taste?  Are there some criteria that we can apply to judge the quality of the games we play?  If indeed it is true that live is a game from top to bottom, then it seems essential to me that we be able to choose what games we play and what role we play within them.  I wonder if this is not a great part of what mental health care is all about.  We help people to find their game and to remain suitable for effective participation in it.  We are part coach and part team physician.  Let’s think some more about this.