In Therapy

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In Treatment Ambivalence

Oh great ... In Treatment is on again

imageI have a love/hate relationship with HBO's dramatic series In Treatment. It gets plenty of love from reviewers and therapists (including excellent posts from fellow PT bloggers Ilana and Jeremy), but I have my reservations. Am I the only shrink who feels this way?

Many movies and TV series include therapy as an element of the show, but for In Treatment, psychotherapy is the show. In case you missed it (and with a viewership of only 657,000, most of you have), HBO has an Emmy- and Golden Globe-winning fictional drama about therapy. Each week we eavesdrop on four sessions between Dr. Paul Weston (Gabriel Byrne) and his patients as well as one "supervision" session with Dr. Gina Toll (Diane Wiest). The half-hour episodes are wrought with conflict, awkward moments, boundary testing, statements dripping with layered meaning and the inevitable cliffhanger. Entertaining for all, conflictual for me.

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Honestly, In Treatment depicts therapy better than any other fiction I've seen (sorry Drs. Seaver, Katz and Freedman). It also has enough frustrating elements to leave me truly ambivalent; retaining equal parts admiration and disdain for the show. I've had mixed feelings plenty in my life, but rarely toward a TV program. I thought this was worth a deeper look.

I tried to arrange an interview with a writer or producer from the series to get some clarity and enhance your reading experience. Unfortunately, that idea went down in flames - much like the ill-fated Alex. It appears my interview luck ran dry. Instead, I'll just go with the old pro and con list to sort out my feelings. I'm even ambivalent about this post because I don't like sounding like the guy who complains that "the book was so much better than the movie." Regardless, here are my In Treatment pros and cons:

The Cons:

  • After years of doing therapy, my neurons know 50 minutes. In Treatment presents a 50 minute session, beginning to end, in 30 minutes. It messes with my head.
  • According to this article, the series (about a psychologist and his patients, mind you) employed no mental health consultants during the first season. Instead, each writer "had some experience with therapy." That bugs me. Apparently, a psychiatrist consults on Season 2.
  • TV has to be compelling to attract viewers, and conflict makes better viewing than harmonious collaboration; I understand this. But Paul's "the customer is always wrong" therapeutic approach means he often begins sparring with new patients before they take off their coat. The cringe-worthy antagonism would make Dr. Laura blush.
  • Paul attended a psychoanalytic institute, but his therapeutic approach doesn't always appear psychodynamic. It's more like Rogerian reflection and withholding, which results in the frustrated patient demanding advice, followed by Paul's defensive reaction and howitzer-like interpretation.
  • In each episode you'll hear several variations of an accusatory: "so you're telling me..." or "you think I'm saying..." or "what's that supposed to mean?" followed by an infuriating misinterpretation. Wait a minute, I've got an idea: Introducing The In Treatment Drinking Game: take a shot every time someone makes an assumption, questions the validity of therapy and/or storms out of the session early.
  • Speaking of ambivalence, Paul can't decide if he wants to be Gina's friend, supervisee or patient. Either one is fine, a combination is not.
  • Paul is an analytic therapist who sees his patients in his home. This isn't unheard of, many therapists practice from a home office. But his consultation room is his living room, and patients use his bathroom with a fully stocked medicine cabinet. For a shrink who isn't very good with boundaries, this spells trouble.
  • In the eleven weeks represented in the series, Paul has dined at this nightmare buffet: a suicide attempt and a miscarriage in his office, a child abuse report, a minor patient flashing him, the death (potential suicide) of a patient, an emotional affair with a patient, his divorce, estrangement from his kids, a lawsuit and a disgruntled former patient stalking him. Keep this up and psych grad school applications will plummet.
  • I'm a big fan of leaving work at work, of not letting psychology become both my career and my hobby. I break that rule every night I select it from my TiVo list. It's got flaws, but it's real enough to feel like a continuation of my workday. Which brings me to:

The Pros:

  • The writers may not have Ph.D.'s, but they get a lot right about therapy. Patients struggle with the boundaries, transference and resistance. The therapist is a fallible person who gets some things right and misses the boat at times. Beginning the session can be awkward, patients react to others in the waiting room and cell phones interrupt powerful moments. Some patients improve, others get worse. It really does capture the details and intensity of therapy.
  • It reveals the "layers of the onion" in therapy incredibly well. The patients enter therapy with an immediate and obvious complaint. As the weeks unfold, you see how the problem has roots that extend deeper and deeper.
  • I'm impressed by the realistic movement of the sessions: some conversations have an intense focus, others follow a non-linear stream of consciousness.
  • I've heard unsubstantiated rumors that complaints are made to licensing boards about Paul's behaviors. If this is true, I love this. I can imagine how the boards respond:

"Hello, what's your complaint?....A psychologist having an affair with a patient? Yes, that is a reportable offense. What is the psychologist's name?....W-E-S-T-O-N, thank you. Are you the patient? No?....Okay, her name is Laura, and your relationship to her?....On a television show? Is it a reality TV show?....I'm sorry, In Treatment is a drama on HBO and Dr. Weston is the actor Gabriel Byrne. Ever see "The Usual Suspects"? You know, Keyser Soze?....Perhaps you should call the Screen Actors Guild...(.....dial tone......)"

I'm not sure if board complaints are a compliment to the writing and acting or a slam on the viewers. Either way, it's making an impact on people.

  • With all the boundary problems, the show could work as a PSA. Any therapists considering having an affair with a patient, keeping pills in the patient's bathroom, indulging dual relationships and not taking notes? Watch In Treatment to see what could happen.
  • As a therapist, I can't help but backseat drive through these sessions. I watch the patient talk and imagine what I would say. As a supervisor of student clinicians I'm accustomed to viewing sessions and giving feedback; it's educational for me and helps me grow as a clinician. And sometimes Paul makes a good intervention that I didn't anticipate.
  • It's just good television. There's suspense, action, redemption and development of the characters. Watch the Sophie sessions if you don't believe me.
  • Truth is, In Treatment does resemble therapy, and therefore it does feel similar to my work. Fortunately, I'm one of the lucky few who really enjoy my job. I like the sparring, the growth, even the misinterpretations. Watching this program brings a different perspective to my career, and I welcome growth and change.

So I'm torn. Half of me wants to scrap the series like I did Deadwood and Lost. The other half says this may be a Six Feet Under experience. I think I'll just tolerate this ambivalence each Sunday and Monday night for the next couple months. Winnicott says tolerating ambivalence is a sign of emotional maturity; but I should probably just watch less TV.

Ryan Howes, Ph.D., is a clinical psychologist, writer, musician and professor at Fuller Graduate School of Psychology in Pasadena, California.

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