©Copyright 2011 by Paula J. Caplan All rights reserved
How therapy differs from fiction and theatre
In my previous essay here, I described my return to theatre as an actor after a break of three decades, followed by the start of my work as a playwright. It seemed a nice bridge between my work as a psychologist and my playwriting that my first play, a comedy-drama with music called CALL ME CRAZY (©1996 Paula J. Caplan), was about psychiatric diagnosis. It was heavily based on the book I had been writing about that subject at the time that I returned to theatre. 
Since then, I've written a number of full-length plays, several one-acts, and a ten-minute play about a variety of subjects.
I spoke recently to my friend and colleague Steve Bergman, a psychiatrist who under the pen name Samuel Shem writes novels and plays. You may know him from his best-selling novel, House of God, which many have compared to Catch-22 and M.A.S.H. and is based on his medical internship, and from Mount Misery, which is based on his psychiatric residency and written in a similar spirit.  With Janet Surrey, a psychologist and his wife, he wrote BILL W. AND DR. BOB, a play about the founding of Alcoholics Anonymous and has played to sold-out audiences across the country and will soon have a national tour.
Both Steve and I have drawn heavily in our plays and his novels on our experiences in the fields of therapy and psychological research, and both of us have stopped doing therapy.
In our recent conversation, we talked about the similarities and differences between practicing therapy and our playwriting and his fiction writing. I will describe here some initial thoughts that we had but would love to hear from readers of this blog what your views are about this subject.
Steve noted that AA, therapy, novels, and plays all break down isolation and enhance connections with others. In important ways, for both of us, our work in all arenas is largely about breaking down isolation. But the ways that therapists aim to do this seems to me to contrast in important respects to the ways that playwrights and novelists do. To begin with, whether individual therapists like it or not, psychotherapy operates in a context of pathologizing, focusing on which individuals are "sick" and need to be "fixed." Most therapists can tell you that no matter how much they try to persuade the client that they do not consider them mentally ill, it is extremely hard to succeed in that effort. That, of course, does not arise for the reader of a novel or an audience member at a play. Too often these days, there is a chasm between therapist and patient because of the emphasis on classifying the latter's alleged pathology and focusing on that, on how the therapist presumably differs from the patient rather than on the commonalities between them. Some therapists even today consider a therapist who cares much about a patient or sees their commonalities to be inadequately professional, to have "countertransference" that is inappropriate or dangerous, to have "weak ego boundaries." Related to this, therapy as too often practiced is not much focused on breaking down isolation and enhancing human connections, because in this culture, emotional maturity is likely to be defined as involving independence, autonomy, and separation without an equally important emphasis on connection. And then if, as is increasingly the case, the "therapy" consists primarily of psychiatric drugs, most people who take them will describe them as blunting emotions and making them feel more distant from others than before. Novels and plays are usually aimed to connect with readers/theatergoers; otherwise, it's too easy to put down the book or leave the theatre.
There is a certain economy to writing a novel or a play, a freedom to take the reader or the audience member through a particular sequence of events, dilemmas, conflicts, and feelings, and the writer gets to choose that sequence with particular aims in mind. In contrast, the ongoing interaction between therapist and client may depend at crucial times on monitoring carefully whether and how challenging and causing discomfort in the client is likely to be counterproductive and lead the client to stop trusting the therapist...and simply walk away. Reading a novel or watching a play, in contrast, is paradoxically more impersonal and thus can become more deeply personal. That is, the reader or audience member is not required to identify with a particular character or conflict in the way that everything dealt with in therapy is clearly in some way about the client. From the safety of thinking "This is not necessarily about me or similar to me," one is in some sense freer to become fully caught up in what is happening to the characters and how they react ... with the option of noticing, "This one really is like me."
Also because of the safety of having the option to assume that a play or novel is not about the watcher/reader, authors and playwrights often aim to provoke and disturb in ways that could be considered unethical if a therapist provoked and disturbed a client. Related to this is an interesting observation Steve made in his article, "Fiction as resistance,"  where he wrote:
Tolstoy concluded in his essay "What is Art?": "Art is a human activity consisting in this, that one man consciously by means of certain external signs hands on to others feelings he has lived through, and that others are infected by these feelings and also experience them" . Notice that Tolstoy says, "hands on to others feelings he has lived through. . . ." He is not referring to a transfer of information or knowledge; he is talking about an infection by feeling. 
Again, therapists who "infect" clients "by feeling" could be considered intrusive, controlling, even harmful if the clients are not ready for intense degrees of feeling, or consider themselves too vulnerable because of what the therapists already know about them. The readers/theatergoers read or watch in the safety of knowing that the writer knows nothing about them as individuals and cannot see their reactions.
Therapists are often expected both to help people and to know more about them than they know about themselves. The first standard can be difficult to meet, and the second is often not only impossible but perhaps in some ways undesirable. But suffering people who seek help and have these expectations can be deeply disappointed and feel betrayed if the therapist fails to meet those standards. These are risks the writer does not run in the same, very personal ways. We may well feel disappointed by authors whose work does not illuminate our problems and help us find solutions, but we are less likely to feel betrayed.
Immersion in feeling and experience can be illuminating. That immersion is often safer if introduced in the privacy and anonymity of reading a novel alone in one's room or of watching a play while sitting with strangers in a darkened theatre.
Writers need not do the work of showing readers/watchers in face-to-face meetings that "You can put your trust in me," though we need to show that we will write as honestly or inventively or entertainingly as possible. But again, that very personal, individual element is not a part of writing for the public. Writers have the luxury of creating and offering a whole world into which a member of the audience can enter, knowing it is possible to leave after the curtain falls and never have to speak of the feelings, questions, thoughts that being in that world provoked. Similarly, the reader of a novel can close the book and walk away. These conditions allow for a different kind of safety in experimentation with emotions, conflicts, and ideas than does the one-to-one confrontation with them in therapy.
Steve Bergman says: "Nowadays people don't want plays that stand for something and are redeeming. I believe in the oldest possible good art, which is catharsis or empathic connection, which is to show the suffering and show the way through the suffering. These days too much starts with suffering and goes down from there till everybody is dead. Our culture is the lowest form of art that Aristotle talked about-"spectacle." I don't want to see people destroyed." He then says that whether in literature or in therapy, he wants "to see redemption," noting that he has seen redemption in patients he has treated and that "Where I personally have seen the most redemption is in the people who go to AA." AA is, of course, in great measure about connecting with others and providing mutual support, what he calls "a shift to the ‘we.'"
What Steve loved about therapy was that when it is good, it "gives people time and attention they need. For him, psychiatry was all about people and character, which interest him both as a therapist and a writer. How has his life changed now that he no longer practices psychiatry and spends a great deal of time every day writing? "I no longer have to make the strange shift from fiction in the morning to reality in the afternoon. It is difficult to be intensely with created characters, listening to what they tell you and shaping it into art, and then dealing with real ‘patients.' The creation keeps on humming in your head. The characters seem to be alive in a town maybe an hour or two away, and they want my attention
But he sees writing as healing: "Plays that really affect people are the great works that offer some hope. In a funny way, I'm thinking of MERCHANT OF VENICE, because it drags you through the most painful stuff about bigotry, and then there are little rays of hope ... or OEDIPUS ...or anything of Chekhov. People view Chekhov as portraying reality, but in that thing about ‘Going to Moscow' is about hope. I have the following Chekhov quote above my desk: "The great writers portray life as it is, but in addition, every line is suffused by life as it should be as well as life as it is, and you are captivated by it.  He was showing the way to hope."
After all his years as a therapist, what Steve believes is helpful to people in therapy is not psychological. He says that "What happens is there's a spiritual transformation. The healing comes from a spiritual practice between patient and doctor. ...Spiritual is whatever is beyond self -- connecting with what is greater than yourself. Nothing that works is about what you say or about the patient. It is about the ‘we,' the connection. The connection is primary, because most psychological problems are about isolation. My new novel, The Spirit of the Place, is all about this journey."
 Paula J. Caplan. (1995). They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal. Addison-Wesley.
 S. Shem. (1979). The House of God. New York: Dell.
S. Shem. (1998). Mount Misery. New York: Ivy - Ballantine.
 S. Shem. (2002). Fiction as resistance. Annals of Internal Medicine 137 (11), December 3, 934-7.
 L. Tolstoy. (1930). What is art? In: What is Art? and Essays on Art. A. Maude, trans. New York: Oxford University Press, p.123.
 A. Chekhov. (1986). Letter to Alexei Suvorin. 25 November 1892. In H. Troyat. Chekhov. MH Heim, trans. New York: Dutton, p. 167.
 S. Shem. (2008). The Spirit of the Place. Kent State University Press.