Using Breaking Bad to Teach About Defense Mechanisms

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COLUMN: MEDIAUsing Breaking Bad to Teach About Defense MechanismsJustin M. Johnson & Eugene V. Beresin &Theodore A. SternReceived: 29 October 2013 /Accepted: 2 May 2014# Academic Psychiatry 2014Abstract Defense mechanisms represent an important com-ponent of medical education that should be taught to allmedical students, psychiatry residents, and other mental healthtrainees. Teaching about defense mechanisms can becomemore engaging by analyzing popular media. Using BreakingBad, a well-known television show, we recommend specificscenes and episodes that can be used in teaching about defensemechanisms.Keywords . Defense mechanisms . Psychiatry education .Breaking Bad . Television .MediaFor decades, psychiatrists have described the merits of usingfilm to teach psychiatric skills and concepts [16]. Televisionshows have also been used in psychiatric education, thoughnot as commonly as films [7]; Breaking Bad, one of the mostcritically acclaimed television dramas of all time [8, 9], offersexcellent opportunities for character analysis and expositionof defense mechanisms.For those unfamiliar with the show, Breaking Bad tells thestory ofWalterWhite, a humble high school chemistry teacherwho turns to making methamphetamine to support his familyafter he is diagnosed with terminal lung cancer. As the storyunfolds, he becomes more involved in a life of crime,transforming himself from a gracious family man to a ruthlessdrug lord.The characters of Breaking Bad use a variety of psycho-logical defense mechanisms, and they can be used as an idealplatform from which to teachperhaps in a more engagingfashion than reading a textbook, especially since images andarchetypes on the screen might visually, cognitively, andemotionally enhance learning [10, 11]. Whereas othertelevision shows also display psychological defenses, thepopularity of this show, its availability on Netflix, and itsrecent finale make it especially relevant nowmany traineeswill relate to, and be fans of, this popular show. This articlewill describe a few of the potential avenues for exploration ofdefense mechanisms presented inBreaking Bad, with the hopethat it will facilitate the education of medical students andpsychiatric trainees. Although this show portrays a bevy ofinteresting psychiatric conceptsmost notably the develop-ment of a sociopathmost 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 andthe Mechanisms of Defense. They are unconscious psycho-logical processes that quell anxiety caused by internal con-flicts [12]. Conflicts are normal and a natural part of beinghuman. How patients cope with conflicts, through defensemechanisms, is important in their navigation through life.Defense mechanisms represent a core component of psy-chodynamic theorya developmental model that helps psy-chiatrists understand the motivational aspects of mental andemotional life and behavior. In classical psychoanalytic theo-ry, the developmental continuum has been labeled as extend-ing from immature, to neurotic, to mature levels of growth[12]. For clinicians, appreciation of defense mechanisms re-mains invaluable in understanding behavior and explanationsof emotions, cognition, and action [13]. However, more med-ical schools are teaching strictly toward the definitions in theDiagnostic and Statistical Manual for Mental Disorders(DSM) and psychodynamic concepts are being marginalized[14]; this has occurred perhaps because of increased emphasison the neurosciences, a need for evidence-based medicine,J. M. Johnson (*) : E. V. Beresin : T. A. SternHarvard Medical School, Boston, MA, USAe-mail: jjohnson54@partners.orgAcad PsychiatryDOI 10.1007/s40596-014-0161-4the development of manualized treatment approaches, orstrict insurance reimbursement pressures for psychiatrists tobecome psychopharmacologists [15].Nevertheless, we believe that learning about defense mech-anisms should be a part of the educational content in everymedical school. Understanding defensemechanisms improvespatient care by helping to understand human behavior, im-proves medical knowledge by expanding psychiatry beyondthe DSM, and improves communication skills by increasingthe understanding of colleagues and patients motivations.All three of thesepatient care, medical knowledge, andcommunication skillsrepresent vital components of the Ac-creditation Council for Graduate Medical Education(ACGME) core competencies [16, 17] and are therefore im-portant in resident education. One of the core clerkship re-quirements for medical students, as set by the Association ofDirectors of Medical Student Education in Psychiatry(ADMSEP), is to discuss general features of common psy-chotherapies and recommend specific psychotherapy for des-ignated patients [18] . Since defense mechanisms are integralto understanding psychodynamic psychotherapy, even at abasic level, understanding them represents a basic objectiveof all medical student education. In addition, because it hasbeen increasingly recognized that medical students lose em-pathy during their training [19], teaching about defense mech-anisms 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 medicalschools in the USA, as set forth by the Liaison Committee onMedical Education (LCME), is that the curriculum of amedicaleducation program must include behavioral and socioeconomicsubjects in addition to basic sciences [21]. Defense mecha-nisms, and human psychology in general, can represent a corepiece of this behavioral requirement in medical education.The potential benefits of teaching defense mechanisms tomedical students are myriad, including, but not limited to,enhancing patient care, medical knowledge, and communica-tion skills as well as improving understanding of psychody-namic psychotherapy, building empathy, and meeting theaccreditation requirements of the ACGME, ADMSEP, andLCME. Although little has been written about the specificteaching of defense mechanisms, a popular television showlikeBreaking Bad can be used to enhance exposure of medicalstudents to one of the less scientific parts of medicine (i.e.,understanding psychological defenses).Immature Defense MechanismsWalter White (aka, Walt), the anti-hero protagonist ofBreaking Bad, displays many immature defenses [22].Walt, during his transformation from passive, push-oversubjugate chemist for Gustavo Fring (a drug dealer), toempowered, belligerent drug lord (aka, Heisenberg), il-lustrates the concept of identification [23]. Identificationhas been defined as the process whereby the subjectassimilates an aspect, property, or attribute of the otherand is transformed, wholly or partially, after the modelthe other provides [23]. Identification with a feared objectserves to avoid anxiety when the aggressive characteristicsof the object are internalized, by putting the aggressivedrives under ones own control; because of this, identifi-cation has often been referred to as identification with theaggressor [2224]. Walter White, initially fearful ofFrings violent, unpredictable nature, identifies with com-ponents of Frings personality and becomes the monster heonce feared. By incorporating the aggressive aspects ofFrings personality and placing them under his control,Walt becomes less distressed by them, thereby servingthe classic function of this defense mechanism.In Season 5, Episode 4 (i.e., 5.4), the principle of theimmature defense mechanisms of acting out and passiveaggression are dramatically displayed when Walt buys hisson, Walter White Junior, a new car, and later, whenWalts wife, Skylar, attempts to hurt herself. Acting outis commonly used to put uncomfortable affects into actionrather than into words [22]. Passive aggression developswhen one enacts aggression indirectly, through passivity,masochism, or turning against the self [22]. Rather thandiscuss marital disagreements and anger in a mature fash-ion, Walt bought a car that his wife considered to be tooexpensive; he was likely expressing his anger toward herthrough action, rather than words, and was thereforeacting out.Passive-aggressive behavior occurs later in the sameepisode. Frustrated by an inability to directly confront Waltabout his involvement in the drug trade, Skyler walks intotheir backyard pool, attempting to kill herself. Followingher rescue, her children are removed from their home,angering Walt. Skyler directs aggression against herselfto indirectly cause others more than the actual harm toherself would be; she accomplishes her goal of havingthe children removed from what she considered to be anunsafe home with passive aggression.Walt also utilizes projection while manipulating hismeth-cooking assistant, Jesse Pinkman. Projection in-volves the perception of undesirable impulses that areactually in oneself as being outside of oneself and inanother [22]. After Walt attempts to poison Jesses girl-friends son Brock in Season 4 and blames it on Jesse,Jesse becomes overwhelmed by sadness and guilt. Waltlacks guilt or sadness related to the attempted murder,possibly because he projected all of these undesirablefeelings into his impressionable assistant, Jesse. Projectionserves to remove these painful affects from his inner worldand to implant them into another.Acad PsychiatryNarcissistic Defense MechanismsThroughout the narrative, Walt employs narcissistic defensemechanisms, consistent with what appears to be a narcissisticpersonality. Like many narcissists, Walt seeks ways to inflatehis self worth via self-aggrandizing criminal activity.One narcissistic defense mechanism Walt displays is reac-tion formation, or the transformation of an unacceptable feelinginto its opposite [22]. In Episode 5.7, while negotiating with acompetitor in the drug trade and before forcing a business dealon him, Walt demands to be recognized as the criminal master-mind Heisenberg, whereupon he gloats and appears invigo-rated. This scene represents the culmination of his quest for self-recognition, which protects him against vulnerability, insecuri-ty, and low self-esteem. He invokes reaction formation to feelthe opposite of insecurity, as many narcissists do. This behavioralso culminates his identification with Gustavo Fring.Walt also displays the defense mechanisms of distortion,rationalization, and denial. Distortion, the reshaping of exter-nal reality to meet internal needs [22], is often employed tosustain feelings of superiority or entitlement [22]. Rationali-zation provides logical explanations for behaviors or feelingswhich are otherwise unacceptable [22]. Finally, denial facili-tates the avoidance of negative aspects of reality by negatingsensory data that support it [22].As he evolves into a drug kingpin, Walt distorts reality toachieve his goals, rationalizes his ongoing involvement, anddenies his role in the creation of his problems. Perhaps be-cause of his inadequate sense of self, Walt, once consumed byhis quest for power, distorts reality to describe all of his actionsas benefiting his family. His distortion makes the painfulemotions of what he is doing more palatable. His logical,rational explanation for his continued involvement to supporthis family, without acknowledging the emotional high andinflated sense of self he obtains from his narcissistic pursuits,represents rationalization. Last, he denies that his involvementin the drug trade does any more than provide for his familyhe denies its negative impact.These three defense mechanismsdistortion, rationaliza-tion, and denialare best captured in the last scene of Episode4.6, in whichWalt, while talking with Skyler, explains that hisinvolvement persists solely to provide for his wife and chil-dren. Aware of the physical danger that his involvement withdrugs has created for both Walt and their family, Skylerreplies, Someone has to protect this family from the manwho protects this family. This quote powerfully capturesWalts use of these three defenses.Neurotic Defense MechanismsWalt also employs multiple neurotic defense mechanisms, thedominant one being isolation of affect. Isolation of affect, orthe splitting off of an idea from its associated emotion, allowsWalt to carry out heinous acts [22]. Walt murders or orders themurder of multiple people without once shedding a tear orexpressing remorse. Like much of his work, he thinks of murderas a cost of doing business; he isolates himself from the painfulaffects (such as remorse, guilt, or fear) that most people wouldexperience. This is displayed in Episode 1.3whenWalt commitshis first murder, killing Domingo Krazy 8Molino. He chokesKrazy 8 efficiently and without displaying any feelings.In a similar vein, Walt often employs intellectualization,which is the excessive use of intellectual processes to avoidemotional experiences [22]. Walt, a science wizard, oftenturns to the chemistry of methamphetamine production andto scheming (e.g., ingeniously hiding from the police ormanaging logistics of a criminal enterprise) withoutexperiencing the powerful emotions that affect others.Mature Defense MechanismsAlthough immature defense mechanisms are more commonlyportrayed in Breaking Bad, mature defenses are also evident.Walt and others in the show frequently utilize anticipation, orthe realistic planning for upcoming inner discomfort [22]. InEpisode 5.2, Walt hides the ricin poison in a wall outlet athome, clearly anticipating the possibility that it might befound and/or harm others. By anticipation, he is able to planfor, and to minimize, his anxiety around its being discovered.Humor, another mature defense mechanism, is utilizedoften by the morally questionable lawyer, Saul Goodman.Though seemingly obvious, humor, as a defense mechanism,uses comedy to express feelings that could otherwise beuncomfortable [22]. Goodman regularly jokes about moneylaundering, murder, theft, and other criminal activities as ameans of reducing the anxiety that often surrounds thesetopics. Humor is specifically on display with Saul Goodmanin Episode 2.11, when discussing the murder of a drug dealer.Saul replies flatly, Drug dealer getting shot? Im gonna goout on a limb here and say its been known to happen.Humorallows Saul to tolerate difficult emotions.Avenues for TeachingThe authors used Breaking Bad to portray defenses to PGY-3psychiatry residents. The teaching session began by reviewingthe basic theory of defense mechanisms, then discussing plotdetails from the show, before showing each of the scenes listedabove. Following each example, the trainees identified andcommented on the defense mechanisms. Following the ses-sion, residents reported satisfaction in learning about defenses,particularly by using a popular television show. Several re-ported that their ability to characterize specific defenseAcad Psychiatrymechanisms and therefore their ability to understand defenseswithin their own individual cases of psychodynamic psycho-therapy were all improved. This highlighted the ability of thisshow in improving understanding of psychodynamic psycho-therapy. Unfortunately, the authors did not gather objectivedata 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 mecha-nisms, more description and discussion would be necessary.Such sessions might also lend themselves to a discussion ofintellectualization on the part of educators, who teach cogni-tively based theories rather than exploring the feelings arousedby a show. This would further demonstrate for trainees that allof us, including educators and seasoned psychiatrists, usedefense mechanisms routinely.ConclusionThe teaching of defense mechanisms represents an importantcomponent of psychiatry and medical training. The televisionshow Breaking Bad, currently popular with medical studentsand residents alike, portrays a bevy of examples of defensemechanisms that could be used to teach both medical studentsand residents in a popular, engaging format.Disclosure On behalf of all authors, the corresponding author states thatthere is no conflict of interest.References1. Hyler SE, Moore J. Teaching psychiatry? Let Hollywood help!Suicide in the cinema. Acad Psychiatry. 1966;20:2129.2. Fritz GK, Poe RO. The role of a cinema seminar in psychiatriceducation. Am J Psychiatry. 1979;136:20710.3. Hyler SE. DSM-III at the cinema: madness in the movies. ComprPsychiatry. 1988;29:195206.4. 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DoubledayAnchor Books. 1957.Acad Psychiatry Breaking Bad to Teach About Defense MechanismsAbstractWhy is It Important to Teach Defense Mechanisms?Immature Defense MechanismsNarcissistic Defense MechanismsNeurotic Defense MechanismsMature Defense MechanismsAvenues for TeachingConclusionReferences