Ernest Becker

March 26, 2017

What No One Mentions about Health Insurance

I am always amused by questionnaires designed to reveal whether we have enough money to last a lifetime. They are intended to help us plan for retirement. Yes, many of you are too young to worry about this, but humor me. One of the questions is some version of “How long are you going to live.” Another asks, “How much money do you expect to spend each year (for the rest of your life)?” Those questions are often enough to make us stop trying to fill out the form. Why?

Because we don’t know and it’s too scary to think about.

Which brings up the problem of choosing a medical or health insurance policy. I will use the words “medical” and “health” interchangeably to describe this insurance. I intend to target only two aspects of making a choice of health coverage, each of which follows from the questions above.

Simply put:

  1. We can’t predict how much health insurance we will need because we lack a crystal ball about our future health.
  2. Both psychological and intellectual roadblocks make it difficult to choose a policy. Thinking about illness and death, hospitals and doctors, is scary.

Despite all the words spoken about health insurance in the USA, no one discusses these two points and how they complicate the debate over what should be the federal government’s role, if any, in providing medical insurance for citizens.

I am therefore taking on the job. Again, humor me. This is important.

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Lots of adults in the USA still get medical insurance from an employer, who might also insure the spouse and children. Most of you in the rest of the Western World receive government sponsored evaluation and treatment. But, historically speaking (if you are not disabled or “low-income”), in my country there are three choices other than a plan for which the employer pays a big chunk:

  1. Decide you don’t need or can’t afford medical insurance.
  2. Buy a policy on your own, one sold by an association (for example, by your college’s alumni program), or one offered in your state-run online marketplace.
  3. If you are a senior, sign up for Medicare, which is the coverage you get if your employer deducted a portion of your salary to make you eligible once you were old enough.

Our politics is dominated by the question of who makes the choice. Are you free not to buy medical insurance? Are you free to choose the kind of policy you want? One that pays for nearly all medical/psychological conditions or only some? Are you free to assume you won’t need certain medical/psychological services?

Some of the voices in this argument imply this is a rational choice, much like deciding whether you want to buy a car or prefer public transportation; and, if you do want a car, what model might you enjoy and how much are you willing to pay.

In fact, however, the decision is more complicated and not fully rational. Philosophers such as Martin Heidegger, a sociologist named Ernest Becker, and psychologists Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski have raised the issue of our discomfort with even the idea of mortality, let alone facing the reality of serious disease. Moreover, those social scientists created a body of research demonstrating our unconscious flight from the terror of our own personal end. No wonder Ernest Becker called his Pulitzer Prize winning book, The Denial of Death. No wonder the three psychologists do research on Terror Management Theory: not about terrorism, but the terror of knowing you will someday die.

Are you still reading or have you thrown a sheet over your computer screen?

If we cannot frankly face death without a secret shiver and a turning away, how then can we make rational choices about what health care we need or will need?

Will you or your child get depressed, need psychotherapy, or psychotropic medication? Become addicted? Have an accident? Face an unplanned pregnancy and need maternity and pediatric care? Be taken to the ER? Require a vaccination? Encounter a chronic, expensive illness?

No crystal ball, eh?

Few people seek out these unwelcome thoughts. We put them out of our minds when our health is good. Indeed, we must surely have inherited the ability to distract ourselves from life’s dystopian downside. Had our ancestors, broadly speaking, not had such an attitude, they wouldn’t have survived and we wouldn’t be here. They needed to attend to all the immediate tasks of living. “What if I get sick?” was not the most helpful question when the crops needed planting and harvesting.

A certain bravery is to be found in this optimism toward life. The attitude must come from half of our species, the fair sex bearing our children; those who (to quote W.E.B. DuBois) risked their lives and bodies “to win a life, and won.”

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Illness and mortality are prospects most of us compartmentalize unless we are battling them. We will acknowledge the concerns, but in an abstract, impersonal way. They are “out there,” or “might happen someday,” but not today. We give these inevitabilities their own separate room within our psychic space, building the structure with bricks and mortar, double thick, the more to keep our emotions and thoughts untroubled. We wall-off potential weaknesses of our psyche and flesh, put them in isolation where we cannot be turned to stone by the prospect of serious illness, as if we faced Medusa.

My office manager routinely checked insurance benefits for new patients when I was in practice. Why? Because they usually did not know about their coverage. Some, in fact, were saddened and surprised to discover they had no therapy benefits and their insurance paid only for physical issues; that is, until the law required attention to mental illness.

Understand, please, my patients were almost all of average or greater intelligence. Still, most lacked knowledge of potential holes in what they considered to be their healthcare safety net. They trusted they were “well-covered.” Perhaps an insurance salesman told them so or their employer did the same. Or, maybe, after the Affordable Care Act (Obamacare) became law, someone assured them therapy was among the “essential health benefits” in their insurance contract. In the latter case, they did, indeed, have counseling benefits. Again, however, they tended not to know the details.

We live, as humanity always has, in a world requiring a significant amount of faith in other people. What I’m getting at, however, is more than trusting whoever designed your insurance or whoever is offering the product. In order to make thoughtful decisions about medical insurance we must face the issue of illness and mortality squarely, without evasion or distraction; and with a level of experience, intellect, and even specialized knowledge to do the job. We must do this despite our tendency toward mental and emotional evasion of illness and death.

To quote the title of a Tom Stoppard play, what we have here is The Hard Problem.

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The top image is a Saddlebred Stallion in Harness by Jean. Balloons in a Car Lot in Normal, Illinois, by ParentingPatch, is followed by Caravaggio’s The Head of Medusa. All are sourced from Wikimedia Commons.

October 12, 2010

Darkon: What Role-Playing Games Tell Us About Real Life

It is easy to dismiss people who play role-playing games.

Geeks, losers, nerds, they’ve probably been called all these things and more. As William Shatner said on Saturday Night Live to the costumed attendees at a Star Trek Convention, “Get a Life.”

But if you watch the 2006 award-winning feature-length documentary Darkon, you just might get a different idea.

Darkon is “live-action role-playing game” or LARP. That is, real people create and dress-up as characters in a quasi-medieval world. They also fashion back-stories of the origins of these alter-egos that don’t sound much different from religious and biblical legends. Perhaps Moses was found in the bulrushes by an Egyptian princess, but you can be sure that Darkon players have backgrounds no less imaginative.

The Darkon gamers affiliate with other like-minded souls within the game, inventing national groups who strategize about how to enlarge their country’s domain. In order to achieve this, some combination of negotiation and combat between armies is required. The movie Darkon shows just such activities as they are played out by the “Darkon Gaming Club” in Baltimore.

Both men and women, usually in their 20s and 30s, enact a stylized form of combat involving “weapons.” Those instruments of war must be made according to guidelines designed to insure the safety of the soldiers, but the rules permit imaginary “injury” to be inflicted and one side or the other to triumph.

Enormous amounts of energy and time go into the realization of this fantasy world. Public parks, forest preserves, and school grounds are claimed as the battle-ground upon which occur many of the negotiations and all of the wars.

One player, a stay-at-home dad named Skip, doubtless speaks for a good many of the Darkon enthusiasts, when he talks about feeling “…born out of time… I feel like I have some great destiny and I have just to find it.” Clearly, Skip looks for that destiny, in part, within the game. You may think that such people are troubled as you read this on the computer screen, but Skip comes across as an earnest, intelligent, thoughtful, and principled man within the film itself.

The central figures of the documentary include a business executive in the real world who leads the most successful and largest group of Darkonians, a former stripper who is a single working mother, a college student who works part-time as a barista, a buyer in a fabric store, an assembly line worker, and many individuals who find their real lives boring and anonymous. They make no mark and live lives outside of the game that recall Thoreau’s comment on “quiet desperation.”

For some, including the most successful player within and outside the game, this role-playing world appears to serve a therapeutic function: “Playing (my character) helped me become the man I wanted to be in real life.” Opportunities for leadership, negotiation, and political as well as combat strategy transferred to the streets, offices, and board rooms of everyday existence, building his self-confidence and changing him even when the costume came off.

Meanwhile, others struggle with marginalization both within and without the game, but live in the hope of, quite literally, “reinventing” their characters and taking a more commanding and successful role. Some recognize the need to develop social skills in order to have real-life success. But, one suspects, that others not featured in the movie get caught up in the escapism that any such exercise might provide. They never grow out of the game.

As I watched this documentary I couldn’t help but think of the changes that industrialization and urbanization brought to workers during the period known as “The Industrial Revolution.” People went from being independent solo-practitioners working for themselves as tailors, blacksmiths, farmers, and weavers, to employees of others in larger and larger enterprises. The phrase used to describe what they became was “wages slaves,” clearly no longer free and independent.

Perhaps then, the Darkonians are only looking for what most of humanity has lost in a world of big machines, buildings, computers, and cities: some sense of individuality and uniqueness.

Or, like the ancient Greeks of Homer’s day, maybe they seek honor and glory. Honor in that pre-literate day tended to come in the form of goods, precious metal, slaves, concubines, and the like; in other words, mostly material things or things that could be counted or displayed or used. Sort of like today, perhaps you are saying to yourself. In our world, honor is conferred by status and very similar material things – the size of your house, the amount of money in your bank account, a trophy spouse, the car or cars you drive, a gorgeous vacation home, etc.

Glory (the Greek word kleos) was another matter. What might glory have consisted of in a world in which the idea of heaven had not yet been invented? It took the form of a reputation or fame that continued beyond death. And, since there was no written word, you and your accomplishments had to be sufficiently great to generate discussion, song, and story once you were gone. This was usually achieved by being a great hero or warrior. In war, then, one could hope to grasp both of these things: the honor that came with sacking cities and accumulating wealth, slaves, and sexual partners; and the glory of a reputation for fearlessness, strength, and tenacity that would transcend your death.

In other words, a lot like what the Darkon players hope for inside and outside the universe of the game.

Earnest Becker, the sociologist and Pulitzer Prize winning author of The Denial of Death (a book esteemed by Bill Clinton, by the way) talked about each man’s hero-project: the attempt to distinguish himself from other men. It is an effort that Becker thought was motivated by our fear of death and a desire for a kind of symbolic immortality via achievement. Or, perhaps, a self-delusion made possible through accomplishing important feats, thus allowing oneself to deny the inevitable demise of all living things, including one’s own end.

One Darkonian states that the game is “…like watching TV, but you are the hero. If you could watch Brad Pitt or be Brad Pitt, which would you rather do?”

But, there is also darkness here, as another perceives it, “There is a certain desperation to life. It’s all terminal — we are going to die. Maybe fantasy and religion and all those things are (like Darkon), if not crutches, vehicles to get you from birth to death.”

Sometimes a game is more than a game.

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The above image is a scene from Darkon.

July 4, 2010

Denial, BP, and You

Denial isn’t a river in Egypt. It apparently is, however, related to a river of oil in the deep water of the Gulf of Mexico

But there is more to denial than British Petroleum’s failure to consider the possibility that a disaster might happen.

No. Denial is something we all do, at least some of the time.

Still, let us start with BP. Major environmental accidents involving oil have not caused this company and others like it to spend significant money on safety considerations and the prevention of ecological calamity. Clean-up technology remains much the same as it was 40 years ago.

What were the oil executives thinking? Perhaps, that such things wouldn’t happen to them or on their watch. And if it wasn’t going to happen, why reduce profits to take “unnecessary” safety measures. This, despite repeated oil spills over the years.

An example, might illustrate how “denial” such as this is possible, starting at a tender age.

Back when I was a very little boy, I did something similar. I remember walking to Jamieson School on a very foggy day. Indeed, the fog was so thick that one couldn’t see more than perhaps a half-block ahead. Somehow I got it into my head that if I couldn’t see my school, perhaps it no longer existed!

Jamieson School, an enormous building, occupied most of a square city block on Chicago’s North Side.

But maybe, just maybe, it had disappeared!

I didn’t think about the details of how such a thing might have happened overnight. I didn’t imagine what effort it would have taken to disassemble the structure brick-by-brick or consider that I would have heard any explosion that razed it. No, for me, the disappearance of the building would have been a result of magic. Here one minute, gone the next.

Unfortunately, or so I thought, it finally came into view. And with it, another day of school; not the day of fun I had fantasized about on my journey from home. I couldn’t have been more than six or seven at the time.

The point being, that if grown men act like seven-year-olds, we have a problem. And problem is called denial — a failure to reckon with reality — at least at the extreme.

I’m sure you can think of lots of examples. The cigarette-smoker who never thinks about heart disease, emphysema, or lung cancer happening to him; the person texting and driving, who can’t imagine the possibility of an auto accident; the 350 pound man who has two-quarter pounders with cheese, fries, and a diet-cola, and somehow persuades himself that he is being careful about what he is eating because his meal includes a low-calorie soft drink.

More examples: the man who fancies a partner with a history of infidelity, but doesn’t grasp that he could be victim to the same fate as his predecessors in dating her; the morally upright and self-righteous citizen who cheats on his taxes; the parent who persuades himself that his lack of time for his children will be no problem for them; or the family that normalizes and minimizes the drinking of the household’s head, rather than facing his alcoholism.

Not to mention the biggest denial of all — that we are all mortal, all going to die, and that it could happen at any time — not just to the other guy, but to me! Instead, we treat it as unusual and remarkable when someone expires before, say, 70, when it is actually a fairly commonplace event (however, sad it might be). Indeed, I’ve known more than one therapist who avoided thinking about the topic. See Ernest Becker’s Pulitzer Prize winning book The Denial of Death for more on this subject.

In fact, it is our mortality, the very jeopardy of living and the tenuousness of life, that makes denial necessary and healthy for us to do some of the time, even if a number of folks use it altogether too often. Without some amount of denial (coupled with a little courage) it would be hard to get up in the morning and walk out of the house, fearful as we would be of accident or injury on the streets or highways. How could my parents have permitted me to walk to Jamieson School as a little boy unless they put aside the possibility that I might be abducted or harmed? Would you be able to fly to New York City unless you “strapped-on” intellectual blinders to the danger of your plane crashing or another terrorist attack?

At another level, denial simplifies our lives, removing potentially uncomfortable inconsistencies between who we are and who we think we are. It allows us to engage in life and take action without the burden of too much troublesome data that might interfere with pursuing often necessary self-interest.

As I hope you can see, we need some amount of denial just to get through the day. So, while you rage against BP (and they certainly have earned your enmity), do realize that they were simply doing something we all do frequently, but they were using that psychological defense on a much more grand and dangerous scale than most anyone else.

The truth is, no one can look life squarely in the face all the time, lest he be perpetually distressed by his vulnerability to misfortune on the one hand, and an overbearing conscience on the other. Denial is almost as necessary as the air we breathe and the water we drink. Of course, if we deny the dangers of pollution as did BP, we just might foul up that needed air and water, quite literally.

Life is complicated, isn’t it?

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The image above is of the author, at a time before he had any thoughts about disappearing schools.