Acad Psychiatry DOI 10.1007/s40596-014-0161-4
COLUMN: MEDIA
Using Breaking Bad to Teach About Defense Mechanisms Justin M. Johnson & Eugene V. Beresin & Theodore A. Stern
Received: 29 October 2013 / Accepted: 2 May 2014 # Academic Psychiatry 2014
Abstract Defense mechanisms represent an important component of medical education that should be taught to all medical students, psychiatry residents, and other mental health trainees. Teaching about defense mechanisms can become more engaging by analyzing popular media. Using Breaking Bad, a well-known television show, we recommend specific scenes and episodes that can be used in teaching about defense mechanisms. Keywords . Defense mechanisms . Psychiatry education . Breaking Bad . Television . Media For decades, psychiatrists have described the merits of using film to teach psychiatric skills and concepts [1–6]. Television shows have also been used in psychiatric education, though not as commonly as films [7]; Breaking Bad, one of the most critically acclaimed television dramas of all time [8, 9], offers excellent opportunities for character analysis and exposition of defense mechanisms. For those unfamiliar with the show, Breaking Bad tells the story of Walter White, a humble high school chemistry teacher who turns to making methamphetamine to support his family after he is diagnosed with terminal lung cancer. As the story unfolds, he becomes more involved in a life of crime, transforming himself from a gracious family man to a ruthless drug lord. The characters of Breaking Bad use a variety of psychological defense mechanisms, and they can be used as an ideal platform from which to teach—perhaps in a more engaging fashion than reading a textbook, especially since images and archetypes on the screen might visually, cognitively, and emotionally enhance learning [10, 11]. Whereas other J. M. Johnson (*) : E. V. Beresin : T. A. Stern Harvard Medical School, Boston, MA, USA e-mail: [email protected]
television shows also display psychological defenses, the popularity of this show, its availability on Netflix, and its recent finale make it especially relevant now—many trainees will relate to, and be fans of, this popular show. This article will describe a few of the potential avenues for exploration of defense mechanisms presented in Breaking Bad, with the hope that it will facilitate the education of medical students and psychiatric trainees. Although this show portrays a bevy of interesting psychiatric concepts—most notably the development of a sociopath—most are beyond the scope of this paper, which focuses on defense mechanisms.
Why is It Important to Teach Defense Mechanisms? Defense mechanisms were first defined by Sigmund Freud, then revised by Anna Freud, in her seminal work The Ego and the Mechanisms of Defense. They are unconscious psychological processes that quell anxiety caused by internal conflicts [12]. Conflicts are normal and a natural part of being human. How patients cope with conflicts, through defense mechanisms, is important in their navigation through life. Defense mechanisms represent a core component of psychodynamic theory—a developmental model that helps psychiatrists understand the motivational aspects of mental and emotional life and behavior. In classical psychoanalytic theory, the developmental continuum has been labeled as extending from immature, to neurotic, to mature levels of growth [12]. For clinicians, appreciation of defense mechanisms remains invaluable in understanding behavior and explanations of emotions, cognition, and action [13]. However, more medical schools are teaching strictly toward the definitions in the Diagnostic and Statistical Manual for Mental Disorders (DSM) and psychodynamic concepts are being marginalized [14]; this has occurred perhaps because of increased emphasis on the neurosciences, a need for “evidence-based medicine,”
Acad Psychiatry
the development of “manualized” treatment approaches, or strict insurance reimbursement pressures for psychiatrists to become “psychopharmacologists” [15]. Nevertheless, we believe that learning about defense mechanisms should be a part of the educational content in every medical school. Understanding defense mechanisms improves patient care by helping to understand human behavior, improves medical knowledge by expanding psychiatry beyond the DSM, and improves communication skills by increasing the understanding of colleagues’ and patients’ motivations. All three of these—patient care, medical knowledge, and communication skills—represent vital components of the Accreditation Council for Graduate Medical Education (ACGME) core competencies [16, 17] and are therefore important in resident education. One of the core clerkship requirements for medical students, as set by the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), is to “discuss general features of common psychotherapies and recommend specific psychotherapy for designated patients” [18] . Since defense mechanisms are integral to understanding psychodynamic psychotherapy, even at a basic level, understanding them represents a basic objective of all medical student education. In addition, because it has been increasingly recognized that medical students lose empathy during their training [19], teaching about defense mechanisms early in medical training may also improve empathy, by providing keener access to the experience of others [20]. Finally, one of the requirements of all accredited medical schools in the USA, as set forth by the Liaison Committee on Medical Education (LCME), is that “the curriculum of a medical education program must include behavioral and socioeconomic subjects in addition to basic sciences” [21]. Defense mechanisms, and human psychology in general, can represent a core piece of this “behavioral” requirement in medical education. The potential benefits of teaching defense mechanisms to medical students are myriad, including, but not limited to, enhancing patient care, medical knowledge, and communication skills as well as improving understanding of psychodynamic psychotherapy, building empathy, and meeting the accreditation requirements of the ACGME, ADMSEP, and LCME. Although little has been written about the specific teaching of defense mechanisms, a popular television show like Breaking Bad can be used to enhance exposure of medical students to one of the “less scientific” parts of medicine (i.e., understanding psychological defenses).
“Immature” Defense Mechanisms Walter White (aka, Walt), the anti-hero protagonist of Breaking Bad, displays many “immature defenses” [22]. Walt, during his transformation from passive, push-over subjugate chemist for Gustavo Fring (a drug dealer), to
empowered, belligerent drug lord (aka, “Heisenberg”), illustrates the concept of identification [23]. Identification has been defined as the “process whereby the subject assimilates an aspect, property, or attribute of the other and is transformed, wholly or partially, after the model the other provides” [23]. Identification with a feared object serves to avoid anxiety when the aggressive characteristics of the object are internalized, by putting the aggressive drives under one’s own control; because of this, identification has often been referred to as “identification with the aggressor” [22–24]. Walter White, initially fearful of Fring’s violent, unpredictable nature, identifies with components of Fring’s personality and becomes the monster he once feared. By incorporating the aggressive aspects of Fring’s personality and placing them under his control, Walt becomes less distressed by them, thereby serving the classic function of this defense mechanism. In Season 5, Episode 4 (i.e., 5.4), the principle of the immature defense mechanisms of acting out and passive aggression are dramatically displayed when Walt buys his son, Walter White Junior, a new car, and later, when Walt’s wife, Skylar, attempts to hurt herself. Acting out is commonly used to put uncomfortable affects into action rather than into words [22]. Passive aggression develops when one enacts aggression indirectly, through passivity, masochism, or turning against the self [22]. Rather than discuss marital disagreements and anger in a mature fashion, Walt bought a car that his wife considered to be too expensive; he was likely expressing his anger toward her through action, rather than words, and was therefore acting out. Passive-aggressive behavior occurs later in the same episode. Frustrated by an inability to directly confront Walt about his involvement in the drug trade, Skyler walks into their backyard pool, attempting to kill herself. Following her rescue, her children are removed from their home, angering Walt. Skyler directs aggression against herself to indirectly cause others more than the actual harm to herself would be; she accomplishes her goal of having the children removed from what she considered to be an unsafe home with passive aggression. Walt also utilizes projection while manipulating his meth-cooking assistant, Jesse Pinkman. Projection involves the perception of undesirable impulses that are actually in oneself as being outside of oneself and in another [22]. After Walt attempts to poison Jesse’s girlfriend’s son Brock in Season 4 and blames it on Jesse, Jesse becomes overwhelmed by sadness and guilt. Walt lacks guilt or sadness related to the attempted murder, possibly because he projected all of these undesirable feelings into his impressionable assistant, Jesse. Projection serves to remove these painful affects from his inner world and to implant them into another.
Acad Psychiatry
“Narcissistic” Defense Mechanisms Throughout the narrative, Walt employs narcissistic defense mechanisms, consistent with what appears to be a narcissistic personality. Like many narcissists, Walt seeks ways to inflate his self worth via self-aggrandizing criminal activity. One narcissistic defense mechanism Walt displays is reaction formation, or the transformation of an unacceptable feeling into its opposite [22]. In Episode 5.7, while negotiating with a competitor in the drug trade and before forcing a business deal on him, Walt demands to be recognized as the criminal mastermind “Heisenberg,” whereupon he gloats and appears invigorated. This scene represents the culmination of his quest for selfrecognition, which protects him against vulnerability, insecurity, and low self-esteem. He invokes reaction formation to feel the opposite of insecurity, as many narcissists do. This behavior also culminates his identification with Gustavo Fring. Walt also displays the defense mechanisms of distortion, rationalization, and denial. Distortion, the reshaping of external reality to meet internal needs [22], is often employed to sustain feelings of superiority or entitlement [22]. Rationalization provides logical explanations for behaviors or feelings which are otherwise unacceptable [22]. Finally, denial facilitates the avoidance of negative aspects of reality by negating sensory data that support it [22]. As he evolves into a drug kingpin, Walt distorts reality to achieve his goals, rationalizes his ongoing involvement, and denies his role in the creation of his problems. Perhaps because of his inadequate sense of self, Walt, once consumed by his quest for power, distorts reality to describe all of his actions as benefiting his family. His distortion makes the painful emotions of what he is doing more palatable. His logical, rational explanation for his continued involvement to support his family, without acknowledging the emotional high and inflated sense of self he obtains from his narcissistic pursuits, represents rationalization. Last, he denies that his involvement in the drug trade does any more than provide for his family— he denies its negative impact. These three defense mechanisms—distortion, rationalization, and denial—are best captured in the last scene of Episode 4.6, in which Walt, while talking with Skyler, explains that his involvement persists solely to provide for his wife and children. Aware of the physical danger that his involvement with drugs has created for both Walt and their family, Skyler replies, “Someone has to protect this family from the man who protects this family.” This quote powerfully captures Walt’s use of these three defenses.
“Neurotic” Defense Mechanisms Walt also employs multiple neurotic defense mechanisms, the dominant one being isolation of affect. Isolation of affect, or
the splitting off of an idea from its associated emotion, allows Walt to carry out heinous acts [22]. Walt murders or orders the murder of multiple people without once shedding a tear or expressing remorse. Like much of his work, he thinks of murder as a cost of doing business; he isolates himself from the painful affects (such as remorse, guilt, or fear) that most people would experience. This is displayed in Episode 1.3 when Walt commits his first murder, killing Domingo “Krazy 8” Molino. He chokes Krazy 8 efficiently and without displaying any feelings. In a similar vein, Walt often employs intellectualization, which is the excessive use of intellectual processes to avoid emotional experiences [22]. Walt, a science wizard, often turns to the chemistry of methamphetamine production and to scheming (e.g., ingeniously hiding from the police or managing logistics of a criminal enterprise) without experiencing the powerful emotions that affect others.
“Mature” Defense Mechanisms Although immature defense mechanisms are more commonly portrayed in Breaking Bad, mature defenses are also evident. Walt and others in the show frequently utilize anticipation, or the “realistic planning for upcoming inner discomfort” [22]. In Episode 5.2, Walt hides the ricin poison in a wall outlet at home, clearly anticipating the possibility that it might be found and/or harm others. By anticipation, he is able to plan for, and to minimize, his anxiety around its being discovered. Humor, another mature defense mechanism, is utilized often by the morally questionable lawyer, Saul Goodman. Though seemingly obvious, humor, as a defense mechanism, uses comedy to express feelings that could otherwise be uncomfortable [22]. Goodman regularly jokes about money laundering, murder, theft, and other criminal activities as a means of reducing the anxiety that often surrounds these topics. Humor is specifically on display with Saul Goodman in Episode 2.11, when discussing the murder of a drug dealer. Saul replies flatly, “Drug dealer getting shot? I’m gonna go out on a limb here and say it’s been known to happen.” Humor allows Saul to tolerate difficult emotions.
Avenues for Teaching The authors used Breaking Bad to portray defenses to PGY-3 psychiatry residents. The teaching session began by reviewing the basic theory of defense mechanisms, then discussing plot details from the show, before showing each of the scenes listed above. Following each example, the trainees identified and commented on the defense mechanisms. Following the session, residents reported satisfaction in learning about defenses, particularly by using a popular television show. Several reported that their ability to characterize specific defense
Acad Psychiatry
mechanisms and therefore their ability to understand defenses within their own individual cases of psychodynamic psychotherapy were all improved. This highlighted the ability of this show in improving understanding of psychodynamic psychotherapy. Unfortunately, the authors did not gather objective data to document the effectiveness of this teaching format. Future efforts shall incorporate pre- and post-course surveys. This format could be used with medical students as well, although given their limited knowledge of defense mechanisms, more description and discussion would be necessary. Such sessions might also lend themselves to a discussion of intellectualization on the part of educators, who teach cognitively based theories rather than exploring the feelings aroused by a show. This would further demonstrate for trainees that all of us, including educators and seasoned psychiatrists, use defense mechanisms routinely.
Conclusion The teaching of defense mechanisms represents an important component of psychiatry and medical training. The television show Breaking Bad, currently popular with medical students and residents alike, portrays a bevy of examples of defense mechanisms that could be used to teach both medical students and residents in a popular, engaging format. Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Hyler SE, Moore J. Teaching psychiatry? Let Hollywood help! Suicide in the cinema. Acad Psychiatry. 1966;20:212–9. 2. Fritz GK, Poe RO. The role of a cinema seminar in psychiatric education. Am J Psychiatry. 1979;136:207–10. 3. Hyler SE. DSM-III at the cinema: madness in the movies. Compr Psychiatry. 1988;29:195–206. 4. Hyler SE, Schanzer B. Using commercially available films to teach about borderline personality disorder. Bull Menn Clin. 1997;61:458–68. 5. Wedding D, Boyd MA. Movies and mental illness. In: Using films to understand psychopathology. New York: McGraw-Hill College; 1999.
6. Welsh CJ. OD’s and DT’s: using movies to teach intoxication and withdrawal syndromes to medical students. Acad Psychiatry. 2003;27(3):182–6. 7. McNeilly DP, Wengel SP. The “ER” seminar: teaching psychotherapeutic techniques to medical students. Acad Psychiatry. 2001;25(4):193–200. 8. Lewis MA. From victim to victor: “Breaking Bad” and the dark potential of the terminally empowered. Cult Med Psychiatry. 2013;37(4):656–69. 9. Brownfield, P. The Writers Guild of America, West. http://wga.org/ content/default.aspx?id = 4857; Retrieved August 16, 2013. 10. Datta V. Madness and the movies: an undergraduate module for medical students. Int Rev Psychiatry. 2009;21:261–6. 11. Gramaglia C, Jona A, Imperatori F, Torre E, Zeppegno P. Cinema in the training of psychiatry residents: focus on helping relationships. BMC Med Educ. 2013;13:90. 12. Freud A. The ego and mechanisms of defense. London: Hogarth; 1937 (Original work published 1936). 13. Gabbard GO. Psychodynamic psychiatry in clinical practice. 4th Edition. American Psychiatric Publishing. 2005. 14. Reiser MF. Are psychiatric educators “losing the mind”? Am J Psychiatry. 1988;2:148–53. 15. Harper G, Becker DF, Copans SA, Flaherty LT, Gharib K, Krasner AJ, et al. Committee on adolescence, group for the advancement of psychiatry. Being with the patient: the use of “clinical evidence”, reconsidered. J Nerv Ment Dis. 2013;20(9):813–7. 16. Dingle AD, Beresin E. Competencies. Child Adolesc Psychiatr Clin N Am. 2007;16(1):225–47. 17. Beresin E, Mellman L. Competencies in psychiatry: the new outcomes-based approach to medical training and education. Harv Rev Psychiatry. 2002;10:185–91. 18. Burke MJ, Campbell C, Dunstone D, Lamdan R, Levine R, Roman B, Rosenthal R, Waterman S, Sierles F, Brodkey A. Clinical learning objectives guide for psychiatry education of medical students. Association of Directors of Medical Student Education in Psychiatry (ADMSEP). http://www.admsep.org/ Clinical_LO_Guide_Outline_Format_Nov_07.pdf. Retrieved March 13, 2014. 19. Benbassat J, Baumal R. What is empathy, and how can it be promoted during clinical clerkships? Acad Med. 2004;79(9):832–9. 20. Neumann M, Elizur A. Group experience as a means of training medical students. J Med Educ. 1979;54(9):714–9. 21. Functions and structure of a medical school. Liaison Committee on Medical Education. June 2013. rhttps://www.lcme.org/publications. htm. Retrieved March 13, 2014. 22. Gabbard GO. Theories of personality and psychopathology, from Sadock BJ and Sadock VA. Comprehensive textbook of psychiatry. Seventh Edition, Volume One. 2000; pages 584–585. 23. Laplanche J, Pontalis JB. The language of psychoanalysis. The Hogarth Press. 1973 24. Brenner C. An elementary textbook of psychoanalysis. Doubleday Anchor Books. 1957.
COLUMN: MEDIA
Using Breaking Bad to Teach About Defense Mechanisms Justin M. Johnson & Eugene V. Beresin & Theodore A. Stern
Received: 29 October 2013 / Accepted: 2 May 2014 # Academic Psychiatry 2014
Abstract Defense mechanisms represent an important component of medical education that should be taught to all medical students, psychiatry residents, and other mental health trainees. Teaching about defense mechanisms can become more engaging by analyzing popular media. Using Breaking Bad, a well-known television show, we recommend specific scenes and episodes that can be used in teaching about defense mechanisms. Keywords . Defense mechanisms . Psychiatry education . Breaking Bad . Television . Media For decades, psychiatrists have described the merits of using film to teach psychiatric skills and concepts [1–6]. Television shows have also been used in psychiatric education, though not as commonly as films [7]; Breaking Bad, one of the most critically acclaimed television dramas of all time [8, 9], offers excellent opportunities for character analysis and exposition of defense mechanisms. For those unfamiliar with the show, Breaking Bad tells the story of Walter White, a humble high school chemistry teacher who turns to making methamphetamine to support his family after he is diagnosed with terminal lung cancer. As the story unfolds, he becomes more involved in a life of crime, transforming himself from a gracious family man to a ruthless drug lord. The characters of Breaking Bad use a variety of psychological defense mechanisms, and they can be used as an ideal platform from which to teach—perhaps in a more engaging fashion than reading a textbook, especially since images and archetypes on the screen might visually, cognitively, and emotionally enhance learning [10, 11]. Whereas other J. M. Johnson (*) : E. V. Beresin : T. A. Stern Harvard Medical School, Boston, MA, USA e-mail: [email protected]
television shows also display psychological defenses, the popularity of this show, its availability on Netflix, and its recent finale make it especially relevant now—many trainees will relate to, and be fans of, this popular show. This article will describe a few of the potential avenues for exploration of defense mechanisms presented in Breaking Bad, with the hope that it will facilitate the education of medical students and psychiatric trainees. Although this show portrays a bevy of interesting psychiatric concepts—most notably the development of a sociopath—most are beyond the scope of this paper, which focuses on defense mechanisms.
Why is It Important to Teach Defense Mechanisms? Defense mechanisms were first defined by Sigmund Freud, then revised by Anna Freud, in her seminal work The Ego and the Mechanisms of Defense. They are unconscious psychological processes that quell anxiety caused by internal conflicts [12]. Conflicts are normal and a natural part of being human. How patients cope with conflicts, through defense mechanisms, is important in their navigation through life. Defense mechanisms represent a core component of psychodynamic theory—a developmental model that helps psychiatrists understand the motivational aspects of mental and emotional life and behavior. In classical psychoanalytic theory, the developmental continuum has been labeled as extending from immature, to neurotic, to mature levels of growth [12]. For clinicians, appreciation of defense mechanisms remains invaluable in understanding behavior and explanations of emotions, cognition, and action [13]. However, more medical schools are teaching strictly toward the definitions in the Diagnostic and Statistical Manual for Mental Disorders (DSM) and psychodynamic concepts are being marginalized [14]; this has occurred perhaps because of increased emphasis on the neurosciences, a need for “evidence-based medicine,”
Acad Psychiatry
the development of “manualized” treatment approaches, or strict insurance reimbursement pressures for psychiatrists to become “psychopharmacologists” [15]. Nevertheless, we believe that learning about defense mechanisms should be a part of the educational content in every medical school. Understanding defense mechanisms improves patient care by helping to understand human behavior, improves medical knowledge by expanding psychiatry beyond the DSM, and improves communication skills by increasing the understanding of colleagues’ and patients’ motivations. All three of these—patient care, medical knowledge, and communication skills—represent vital components of the Accreditation Council for Graduate Medical Education (ACGME) core competencies [16, 17] and are therefore important in resident education. One of the core clerkship requirements for medical students, as set by the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), is to “discuss general features of common psychotherapies and recommend specific psychotherapy for designated patients” [18] . Since defense mechanisms are integral to understanding psychodynamic psychotherapy, even at a basic level, understanding them represents a basic objective of all medical student education. In addition, because it has been increasingly recognized that medical students lose empathy during their training [19], teaching about defense mechanisms early in medical training may also improve empathy, by providing keener access to the experience of others [20]. Finally, one of the requirements of all accredited medical schools in the USA, as set forth by the Liaison Committee on Medical Education (LCME), is that “the curriculum of a medical education program must include behavioral and socioeconomic subjects in addition to basic sciences” [21]. Defense mechanisms, and human psychology in general, can represent a core piece of this “behavioral” requirement in medical education. The potential benefits of teaching defense mechanisms to medical students are myriad, including, but not limited to, enhancing patient care, medical knowledge, and communication skills as well as improving understanding of psychodynamic psychotherapy, building empathy, and meeting the accreditation requirements of the ACGME, ADMSEP, and LCME. Although little has been written about the specific teaching of defense mechanisms, a popular television show like Breaking Bad can be used to enhance exposure of medical students to one of the “less scientific” parts of medicine (i.e., understanding psychological defenses).
“Immature” Defense Mechanisms Walter White (aka, Walt), the anti-hero protagonist of Breaking Bad, displays many “immature defenses” [22]. Walt, during his transformation from passive, push-over subjugate chemist for Gustavo Fring (a drug dealer), to
empowered, belligerent drug lord (aka, “Heisenberg”), illustrates the concept of identification [23]. Identification has been defined as the “process whereby the subject assimilates an aspect, property, or attribute of the other and is transformed, wholly or partially, after the model the other provides” [23]. Identification with a feared object serves to avoid anxiety when the aggressive characteristics of the object are internalized, by putting the aggressive drives under one’s own control; because of this, identification has often been referred to as “identification with the aggressor” [22–24]. Walter White, initially fearful of Fring’s violent, unpredictable nature, identifies with components of Fring’s personality and becomes the monster he once feared. By incorporating the aggressive aspects of Fring’s personality and placing them under his control, Walt becomes less distressed by them, thereby serving the classic function of this defense mechanism. In Season 5, Episode 4 (i.e., 5.4), the principle of the immature defense mechanisms of acting out and passive aggression are dramatically displayed when Walt buys his son, Walter White Junior, a new car, and later, when Walt’s wife, Skylar, attempts to hurt herself. Acting out is commonly used to put uncomfortable affects into action rather than into words [22]. Passive aggression develops when one enacts aggression indirectly, through passivity, masochism, or turning against the self [22]. Rather than discuss marital disagreements and anger in a mature fashion, Walt bought a car that his wife considered to be too expensive; he was likely expressing his anger toward her through action, rather than words, and was therefore acting out. Passive-aggressive behavior occurs later in the same episode. Frustrated by an inability to directly confront Walt about his involvement in the drug trade, Skyler walks into their backyard pool, attempting to kill herself. Following her rescue, her children are removed from their home, angering Walt. Skyler directs aggression against herself to indirectly cause others more than the actual harm to herself would be; she accomplishes her goal of having the children removed from what she considered to be an unsafe home with passive aggression. Walt also utilizes projection while manipulating his meth-cooking assistant, Jesse Pinkman. Projection involves the perception of undesirable impulses that are actually in oneself as being outside of oneself and in another [22]. After Walt attempts to poison Jesse’s girlfriend’s son Brock in Season 4 and blames it on Jesse, Jesse becomes overwhelmed by sadness and guilt. Walt lacks guilt or sadness related to the attempted murder, possibly because he projected all of these undesirable feelings into his impressionable assistant, Jesse. Projection serves to remove these painful affects from his inner world and to implant them into another.
Acad Psychiatry
“Narcissistic” Defense Mechanisms Throughout the narrative, Walt employs narcissistic defense mechanisms, consistent with what appears to be a narcissistic personality. Like many narcissists, Walt seeks ways to inflate his self worth via self-aggrandizing criminal activity. One narcissistic defense mechanism Walt displays is reaction formation, or the transformation of an unacceptable feeling into its opposite [22]. In Episode 5.7, while negotiating with a competitor in the drug trade and before forcing a business deal on him, Walt demands to be recognized as the criminal mastermind “Heisenberg,” whereupon he gloats and appears invigorated. This scene represents the culmination of his quest for selfrecognition, which protects him against vulnerability, insecurity, and low self-esteem. He invokes reaction formation to feel the opposite of insecurity, as many narcissists do. This behavior also culminates his identification with Gustavo Fring. Walt also displays the defense mechanisms of distortion, rationalization, and denial. Distortion, the reshaping of external reality to meet internal needs [22], is often employed to sustain feelings of superiority or entitlement [22]. Rationalization provides logical explanations for behaviors or feelings which are otherwise unacceptable [22]. Finally, denial facilitates the avoidance of negative aspects of reality by negating sensory data that support it [22]. As he evolves into a drug kingpin, Walt distorts reality to achieve his goals, rationalizes his ongoing involvement, and denies his role in the creation of his problems. Perhaps because of his inadequate sense of self, Walt, once consumed by his quest for power, distorts reality to describe all of his actions as benefiting his family. His distortion makes the painful emotions of what he is doing more palatable. His logical, rational explanation for his continued involvement to support his family, without acknowledging the emotional high and inflated sense of self he obtains from his narcissistic pursuits, represents rationalization. Last, he denies that his involvement in the drug trade does any more than provide for his family— he denies its negative impact. These three defense mechanisms—distortion, rationalization, and denial—are best captured in the last scene of Episode 4.6, in which Walt, while talking with Skyler, explains that his involvement persists solely to provide for his wife and children. Aware of the physical danger that his involvement with drugs has created for both Walt and their family, Skyler replies, “Someone has to protect this family from the man who protects this family.” This quote powerfully captures Walt’s use of these three defenses.
“Neurotic” Defense Mechanisms Walt also employs multiple neurotic defense mechanisms, the dominant one being isolation of affect. Isolation of affect, or
the splitting off of an idea from its associated emotion, allows Walt to carry out heinous acts [22]. Walt murders or orders the murder of multiple people without once shedding a tear or expressing remorse. Like much of his work, he thinks of murder as a cost of doing business; he isolates himself from the painful affects (such as remorse, guilt, or fear) that most people would experience. This is displayed in Episode 1.3 when Walt commits his first murder, killing Domingo “Krazy 8” Molino. He chokes Krazy 8 efficiently and without displaying any feelings. In a similar vein, Walt often employs intellectualization, which is the excessive use of intellectual processes to avoid emotional experiences [22]. Walt, a science wizard, often turns to the chemistry of methamphetamine production and to scheming (e.g., ingeniously hiding from the police or managing logistics of a criminal enterprise) without experiencing the powerful emotions that affect others.
“Mature” Defense Mechanisms Although immature defense mechanisms are more commonly portrayed in Breaking Bad, mature defenses are also evident. Walt and others in the show frequently utilize anticipation, or the “realistic planning for upcoming inner discomfort” [22]. In Episode 5.2, Walt hides the ricin poison in a wall outlet at home, clearly anticipating the possibility that it might be found and/or harm others. By anticipation, he is able to plan for, and to minimize, his anxiety around its being discovered. Humor, another mature defense mechanism, is utilized often by the morally questionable lawyer, Saul Goodman. Though seemingly obvious, humor, as a defense mechanism, uses comedy to express feelings that could otherwise be uncomfortable [22]. Goodman regularly jokes about money laundering, murder, theft, and other criminal activities as a means of reducing the anxiety that often surrounds these topics. Humor is specifically on display with Saul Goodman in Episode 2.11, when discussing the murder of a drug dealer. Saul replies flatly, “Drug dealer getting shot? I’m gonna go out on a limb here and say it’s been known to happen.” Humor allows Saul to tolerate difficult emotions.
Avenues for Teaching The authors used Breaking Bad to portray defenses to PGY-3 psychiatry residents. The teaching session began by reviewing the basic theory of defense mechanisms, then discussing plot details from the show, before showing each of the scenes listed above. Following each example, the trainees identified and commented on the defense mechanisms. Following the session, residents reported satisfaction in learning about defenses, particularly by using a popular television show. Several reported that their ability to characterize specific defense
Acad Psychiatry
mechanisms and therefore their ability to understand defenses within their own individual cases of psychodynamic psychotherapy were all improved. This highlighted the ability of this show in improving understanding of psychodynamic psychotherapy. Unfortunately, the authors did not gather objective data to document the effectiveness of this teaching format. Future efforts shall incorporate pre- and post-course surveys. This format could be used with medical students as well, although given their limited knowledge of defense mechanisms, more description and discussion would be necessary. Such sessions might also lend themselves to a discussion of intellectualization on the part of educators, who teach cognitively based theories rather than exploring the feelings aroused by a show. This would further demonstrate for trainees that all of us, including educators and seasoned psychiatrists, use defense mechanisms routinely.
Conclusion The teaching of defense mechanisms represents an important component of psychiatry and medical training. The television show Breaking Bad, currently popular with medical students and residents alike, portrays a bevy of examples of defense mechanisms that could be used to teach both medical students and residents in a popular, engaging format. Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Hyler SE, Moore J. Teaching psychiatry? Let Hollywood help! Suicide in the cinema. Acad Psychiatry. 1966;20:212–9. 2. Fritz GK, Poe RO. The role of a cinema seminar in psychiatric education. Am J Psychiatry. 1979;136:207–10. 3. Hyler SE. DSM-III at the cinema: madness in the movies. Compr Psychiatry. 1988;29:195–206. 4. Hyler SE, Schanzer B. Using commercially available films to teach about borderline personality disorder. Bull Menn Clin. 1997;61:458–68. 5. Wedding D, Boyd MA. Movies and mental illness. In: Using films to understand psychopathology. New York: McGraw-Hill College; 1999.
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