Homecoming: First Season

Homecoming: Season 1

***SPOILER ALERTS -THE ENTIRE SEASON. DO NOT READ IF YOU DO NOT WANT TO KNOW ABOUT THE PLOT OR HAVE NOT FINISHED ALL EPISODES

Psychiatrically, the Amazon Series Homecoming does a great job of showing some aspects of Posttraumatic Stress Disorder (PTSD) without really clobbering the viewer with overblown symptoms or melodramatic character portrayals.  Julia Roberts plays Heidi, a counselor hired by a contractor working for the Department of Defense (DOD) in a new program pitched to assist soldiers with PTSD, recently returning from deployment in re-integrating into civilian life. Immediately, the venue appears too slick, Heidi, too inexperienced and the head administrator, too pressured to produce suspicious ‘data’. As the story unfolds over ten episodes, the horror of the program’s true intention is revealed to both Heidi and the viewer.

Veterans return from deployment every day but not all who have seen combat develop PTSD.  It’s hard to imagine that every combat-exposed soldier doesn’t develop the disorder, given the horrific situations in which these men and women fight. It turns out (and this may be an underestimation because of low reporting), the estimates are between 4-12% of those returning experience PTSD.  As we learn more about the brain, here again there seems to be genetic and structural vulnerabilities making one more prone to the disorder.  Environmental factors, such as experiencing previous trauma and prior mood disorders also increase this risk. 

The series hits on some key components of PTSD -trouble sleeping, nightmares, trigger avoidance, hypervigilance or what’s also known as a high level of awareness of one’s surroundings, increased startle response, persistently mood and difficulty experiencing joy.  Several shots do an excellent job of showing the viewer what intrusive thoughts or images can look like. Walter Cruz, the protagonist and returning Homecoming veteran, describes to Heidi the day they lost his friend Lesky as his convoy rolled over an IED (improvised explosive device). We see a closeup of cracked, bloody glasses as the session proceeds. Often an intrusive image isn’t a whole scene and instead one image. Even the way Walter describes the death demonstrates another component often present in PTSD —detachment from the horror as the brain attempts to compartmentalize and cope with witnessing death. Veterans can often describe violent scenes with limited to no change in their tone or expression.

Cruz goes on to later explain that he had made a decision that put Lesky in the vehicle that went first and set off the IED.  The routine decisions these soldiers make and survivor’s guilt that can follow when they potentially prove deadly is portrayed brilliantly by actor Stephan James.

Early on, one of the program participants, Shrier, is suspicious of the food, of the center and even doubts that the program is in Florida, where they were told they had landed.  The supervisor called incorrectly call him “manic” (mania is a very different clinical syndrome), but we do sympathetically view Shrier’s behavior escalating as the program’s intentions become more suspicious with each interaction.

“Shrier’s a good guy, it’s just…things that worked well for him over there, they don’t work as well over here.”  --Walter in session with Heidi.

Soldiers frequently have a very difficult time re-integrating back home post-deployment. If you’ve never been in combat, imagine hours of tedious boredom punctuated by life threatening terror. Civilians often wonder why soldiers would ever want to return to combat…why they re-deploy multiple times. The answers are as unique as the soldiers themselves but frequently there are several themes: unparalleled camaraderie within a unit, structured days despite chronic boredom in many locations, meaningful and critical jobs as part of your unit and shared experience of witnessing indescribable violence.  These experiences make re-engaging in a world of grocery shopping, solitary living, diaper changing or dinner parties beyond difficult.  Add this to potential symptoms of PTSD disconnecting them further from their friends and family, and many soldiers want to return to the place where fear may have ruled but their lives had meaning and connection. 

The real intention behind the program, a large-scale experiment using an untested medication, was a government ploy to increase the ‘return on investment ‘in these soldiers, erasing their memories so that they can be re-deployed.  Roberts’ character realizes this too late and attempts to save both herself and Cruz.  Critics have taken issue with how cryptic and slow moving this series was but I found the 26 minute episodes compelling.  

In another post, I’ll talk more about the way this series was made and some of the symbolism I found fascinating. Fair warning, it will be an MD talking about film theory and for those who know the subject, is likely to be a blunt dissection of something much better analyzed by those in the know.

Homeland: Season 1, Episode 11 -A Portrayal of Mania

Showtime’s Homeland has been running since 2011 but it has been rare to see such an enduring portrayal of psychiatric illness in a protagonist. Carrie’s initial presentation is so compelling, I thought it was worth visiting. 

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Carrie’s concussion has landed her overnight in the hospital. Though we know from early in the season that she takes medication for Bipolar Disorder, her symptoms have not yet emerged. It’s not clear if she’s been off of her medications or if the head injury sparked what follows.

 By the time she’s been cleared for discharge and Saul, colleague and C.I.A mentor arrives, she’s clearly manic –pacing, rambling quickly and stringing together comprehensible but bizarre alliterations about their terrorist target.  

“…a part…a piece…a pixel…a pawn”

“we need to code it, collide it, collapse it and contain it“

 She is demanding as Saul follows her, stunned, back to her hospital room. Half of what she says makes some referential sense but is clearly Carrie intensified and loosely in control.  She’s intellectually running the iterations of potential connections she can suddenly link at breakneck pace.  

At home, Saul watches Carrie sort paperwork as her psychiatrist sister arrives asking, “she’s manic?” who proposes to “up her lithium”, remarking that they are “giving her clonazepam, just to level her out”. Carrie’s psychiatrist is her sister for much of the early episodes and seasons.

Doctors don't treat family members –or at least we aren’t supposed to.  There are numerous reasons for this, most importantly our human lack of objectivity when it comes to our loved ones. In this case –in Carrie’s world, going “into the psych ward” would, as Saul concludes, “kill her security clearance and the sister explains that this is why she is treating Carrie.

Saul knew. He saw it years’ back. He knew something was off but admits he didn’t want to believe it. And then he puts the timeline together –the one that looked like embodied disorganization and determined that her brain was riding that fine line of rapidity vs. psychosis.

Carrie’s backstory is that her first episode was in college when she wrote a forty five page manifesto declaring she’d reinvented music.  Repeated manic episodes in one individual are often similar –if previously mania presented as grandiose, euphoric or paranoid, its recurrence will often take the same shape. This is portrayed with accuracy in the series.  Her description of it occurring in college is also consistent with bipolar disorder. Most patients present with mania in their twenties or early thirties, sometimes in adolescence and very rarely in childhood. 

 We talk less about how common it is that prior to a manic episode, severe and debilitating depression often presents first.  In fact, most people who have bipolar disorder suffer longer with the depressive aspect of the disease –harder and more intractable to treat. Carrie is shown as depressed in portions of the show but not as much as one typically sees when going on and off of medication and misusing substances as much as she does. 

I’ll sprinkle in reflections on this show between more current commentary on psychiatric illness as portrayed in the media.

House of Cards: Season 6, Episode 2 --Clozapine? Really?

***NOTE: Spoilers Below on House of Cards, Seasons Five and Six

Doug Stamper, having ‘confessed’ to the murder of Zoe Barnes out of blind loyalty to Francis Underwood, meets with his evaluating forensic psychiatrist.

Doug: “I don’t know if these sessions are helping me anymore. Why are you trying to drug me up, doctor?”

Psychiatrist: “I think you should consider it.”

Doug: “Clozapine. You must know what that does to a person.”

The doctor goes on to explain that Clozapine is among a newer class of antipsychotics that aren’t as ‘sensational’ as the older ones.  This is medically accurate –in terms of clozapine being a part of a group of newer “atypical” agents used for many diagnoses. 

What is not accurate about this scene, that still confuses me in terms of where Doug is being held as it looks nothing like an evaluating forensic medical facility (a jail or prison that houses those who may be found not guilty by reason of insanity or lacking capacity to stand trial), is that clozapine is almost never a first line medication used for paranoia or psychosis.  It does work and works well but is typically third, fourth or fifth line because it requires some very intensive monitoring.  Weekly blood draws, slow increases and possible dangerous side effects make this one of our most effective but respected and thoughtfully applied medications. 

The idea that this might be a first medication offered to anyone suffering from suspected paranoia is completely inaccurate.  It could be that whoever was writing for the show didn’t want to use one of the medications seen advertised on network television, though I’ve seen more stunning product placement on this class of medications than I ever thought possible (I’m looking at you, Homeland). 

Finally, the reporting of the psychiatrist to anyone in a presidential administration about the content of sessions would be flatly illegal, barred by patient rights to their own personal health data and still upheld within the legal and prison systems.  It makes for an interesting storyline but for anyone at home working psychiatric care, mine surely wasn’t the only jaw that dropped. 

Killing Eve: Season 1 Episode 2 --What is that Psychopathy Scale?

Bingeing can commence on the first season BBC drama, Killing Eve –released in its entirety on Hulu December first! Starring Sandra Oh as a prior MI5, now MI6 agent, it is focused on a particularly ruthless female assassin.  Played delightfully by Jodie Comer, the character clearly enjoys her job but is becoming recklessly confident in her kills.  Though I’m early in the season, it’s obvious the character is meant to exhibit Antisocial Personality Disorder (ASPD), and in its extreme form, psychopathy.  During an exchange with character Bill Pargrave, Eve’s former MI5 boss, she says this:

“I’d say she scores high on the psychopathy scale and she probably killed before she was paid to”

What is Eve talking about?  Most likely, she’s referring to the Hare Psychopathy Checklist (PCL).  Created by Dr. Robert Hare in 1970 in his extensive criminal profiling research, it has been revised to a 20-item checklist that can help determine if someone falls in the range of being high risk for having psychopathic traits.

Antisocial Personality Disorder is a wider ranging diagnosis, encompassing most criminals and those who have not legally offended (or been caught) but who are driven to manipulate and harm others for their own gain, often with little empathy for the victim.  They live amongst us and can be found not only in prisons but also on Wall Street, in C-Suite management of large corporations, and in many positions of power gained by their ability to be ruthless. Not all are killers, but all psychopaths have several commonalities.

Psychopaths are a smaller subset of ASPD, estimated at 20%, and are terrifyingly unique in their lack of human empathy. They are callous, unemotional, often take pleasure in harming others and we believe have a combination of genetically inherited brain anatomy and neurochemical patterns that can be seen in families with these traits. Biology however, is not destiny as researchers also believe that in addition to this genetic loading, psychopaths have nearly invariably also suffered horrific abuse or torture from a very young age, pushing that explosive combination into a person whose nervous system no longer reacts to fear and instead seeks a rush by harming animals, humans physically or emotionally.

The show portrays this killer’s reaction fairly realistically and is on target in that we have much less information on women who serially kill as we believe them to be more rare than men.  Reasons for this are unknown.

The fact that Eve would have mention that this suspect would score highly on the psychopathy checklist to her colleague of many years is slightly unreasonable. It would go without saying that this serial killer, contracted or not, would score high on the PCL and I doubt they would take a moment to even discuss it. Given how many shows get psychopathy wrong and especially when it is a woman, the show is still shaping up to be engaging and not too far off of the psychiatric mark.