Nov 10

“Ted Lasso” Charges Therapist With Fee-Based Caring

Among the various possible challenges therapists regularly hear from prospective or new clients (or even long-term clients) is that it’s weird to have to pay someone to listen to them. I was reminded of this recently while watching the highly enjoyable series Ted Lasso.

Ted Lasso‘s second season actively deals with both mental health and sports psychology/therapy. To elaborate further (you probably should stop reading here if you haven’t seen the newest season), Coach Ted Lasso (Jason Sudeikis), who’s been experiencing panic attacks on a regular basis, supports his players getting therapy from Dr. Sharon Fieldstone (Sarah Niles) but is loath to accept it for himself.

Eventually desperate to feel better, however, he does make attempts to see “Dr. Sharon.” In his second of two very brief sessions (because he keeps bolting) Lasso accuses her of not actually caring for the people she treats because she charges a fee. (He blasts the profession in other ways too.)

Dr. Sharon’s response when Lasso returns again? Linda Holmes, NPR: “Finally, on his third try, she tells him that she doesn’t appreciate his attitude, particularly given that he is also paid to do a job in which he still legitimately cares about people. This brings Ted around a bit, and he finally sits down across from her to talk.”

The thing is, therapy is neither free nor a friendship—it’s a professional service generally offered by individuals who’ve chosen this as a career because they genuinely care about helping others.

In essence, if a therapist is actually serving solely as a “friend” he or she is doing professional boundaries wrong. Good therapist boundaries, which are established with the welfare of the client in mind, enable clients to develop trust and a feeling of emotional safety. Confiding in a therapist—who follows an actual ethic of keeping things confidential and is trained to be relatively objective and to understand human issues on a deep level—should feel differently helpful than confiding in a friend.

The therapist is not expecting the same in return from a client just as your roofer, to name just one instance, doesn’t expect you to now come over and do his or her roof.

In a friendship, on the other hand, each person might share thoughts and feelings in a back and forth kind of way. If it’s a healthy enough kind of friendship, this helps forge a mutual relationship involving neither payment nor obligation—but also sometimes lacking objectivity, insight, patience, consistency, effective listening skills, and other good stuff worth sometimes paying for.

May 07

“In Treatment” (HBO): Therapy for the Masses

With a new and fourth season of In Treatment coming to HBO Max later this month, starring Uzo Aduba as the therapist, I’m posting today about the first three seasons (2008 to 2010). This series about Paul Weston (Gabriel Byrne) both providing therapy and receiving it was based on Hagai Levi‘s Israeli series Be’Tipul, which ran two seasons.

As reported by Gaby Wood, The Guardian, Be’Tipul‘s Levi was motivated by a desire to reduce mental health stigma in Israel. Levi felt that whereas in the U.S. “people mention their therapist at the drop of a hat,” not so in Israel. The series went on to become popular among clients, therapists, and many more, including those discovering acceptable therapy depiction for the first time.

In the American-made In Treatment Paul Weston’s therapist is Gina (Dianne Wiest). While Paul is a “boundary-challenged, deeply conflicted, terribly appealing psychotherapist” (Michelle Orange, New York Times), Gina “[cuts] through Weston’s self-absorbed obsessions” (Peabody Awards).

Clinicians and critics had varying but mostly positive opinions about In Treatment‘s portrayal of therapy sessions, viewed in 30-minute segments as opposed to the standard therapy “hour.” Psychologist Ryan Howes, self-confessed lover/hater of the series, listed his pros and cons in a Psychology Today article titled  “In Treatment Ambivalence.”

Excerpts from a sampling of Howes’s cons:

    • …Paul often begins sparring with new patients before they take off their coat…
    • 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.

A sampling of pros:

    • The writers may not have Ph.D.’s, but they get a lot right about 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’ve heard unsubstantiated rumors that complaints are made to licensing boards about Paul’s behaviors. If this is true, I love this….

At the start of the second season Jeremy Clyman, Psy.D, wrote in Psychology Today, “At last the field of clinical psychology has a show free of melodrama and full of the detail and depth necessary to realistically represent the therapeutic process. Predictably enough, patients all across the country are discussing the show in therapy and therapists are discussing it with each other.”

Because Be’Tipul only had two seasons, the third In Treatment season was created from scratch. Furthermore, it involved Paul having a different therapist (Amy Ryan). A fitting summary from Nancy Doyle Palmer, HuffPost:

Ryan plays Adele, Paul’s end-of-the week analyst and foil, who at first glance seemed perhaps too young and fresh-faced for the task — but quickly took on him, his patients’ issues of the week and his 30 year plus roster of mommy/mentor/tortured Irish issues. She’s pitch perfect in a completely new way and knows just how to handle him…

While demonstrating the finest qualities of a therapist Monday through Thursday – deeply caring, observant, benevolent and wise – Paul comes to Adele (as he did to Weist’s Gina) often in a rage – harsh, condescending, duplicitous and game-playing – basically giving credence to the fact that doctors are the worst patients ever and shrinks, well…

Aug 28

“I May Destroy You”: The Therapy Scenes

Michaela Coel‘s powerfully told HBO series I May Destroy You is now fully available to stream. Its description on IMDB: “The question of sexual consent in contemporary life and how, in the new landscape of dating and relationships, we make the distinction between liberation and exploitation.”

Several episodes feature snippets of therapy received by lead character Bella (full name Arabella), a writer. Some thoughts on these follow. Thus, spoilers ahead.

Episode Four: “That Was Fun”

Arabella has been drugged and raped. Sometime later she meets with a counselor. Monica Castillo, Vulture, describes what we see:

She wants Arabella to start talking about her sexual assault, but unfortunately, Arabella still struggles to find the words to recount her experience…Eventually, Arabella begins to open up about how she’s coping, mentioning the flashbacks that continue to interrupt her thoughts and how she’s struggling to focus on the next draft of her book. Her therapist suggests taking care of herself even under pressure, listing a number of soothing activities like coloring…

This form of treatment is often labelled crisis intervention, in which the therapist is providing a directive response to a client’s recent trauma. The aim is to support the client’s efforts to stabilize and to feel better in her current life, not to delve deeply into the issues.

Episode Six: “The Alliance”

Meghan O’Keefe, Decider:

This week’s episode opens with Arabella visiting a sexual trauma support group run by an old school mate, Theo (Harriet Webb). She opens each session by saying, ‘I hate abusers. I think that abuse, grooming, assault, domestic violence are the most abhorrent qualities of our species.’

Group support, whether led by a therapist or a peer—in this case, a peer—can be one of the most powerful ways to heal following trauma. It decreases emotional isolation by connecting a participant to others who share common issues.

We learn over the course of the episode, however, that in addition to Theo having a history of victimization she has also been a perpetrator—not that group members are aware of this.

More on this important plot point from O’Keefe:

‘The Alliance’ might offer the clearest articulation of I May Destroy You‘s central thesis: abuse is everywhere and there is no obvious way to fix it…In most television betrayals of assault, we have an obvious idea of whom to condemn. I May Destroy You is unflinching in its refusal to give us an easy out with Theo’s story. That’s why the episode is so haunting and so necessary to watch.

Episode Nine: “Social Media Is a Great Way to Connect”

Bella freaks out late at night and shows up at the Episode Four counselor’s home. The reaction of Micha Frazer-Carroll, Independent, is similar to what I had. She also makes an important clarification about therapist boundaries.

…’Night-time therapy?’ I thought, half-expecting the scene to quickly reveal itself as some sort of metaphor, hallucination or dream sequence. But it wasn’t…

At some point in the scene, there is a faint acknowledgement that this is unusual – Arabella apologises for ‘turning up’, to which her therapist responds that that’s what the ’emergency line’ is for. This struck me as incredibly odd. Yes, in very rare cases it might be possible that therapists would allow this kind of emergency session (distinct from crisis lines). But make no mistake, in the context of the real world, rocking up at your therapist’s house in your Halloween costume after a failed night out would be highly, highly unusual.

And therefore, as Frazer-Carroll adds, this is yet another in a too-long list of annoying and/or unrealistic portrayals of therapist boundaries in TV series and movies. (See previous posts here, here, here, here, and here for some other examples).

Nov 14

Clients Outside the Office: When Therapists Chance Upon Their Clients

How do therapists handle chance encounters with clients outside the office?

Such boundary-related decisions are regularly confronted. How we proceed, though, is likely to be unique to each particular therapist and client, as there’s a lack of hard-and-fast rules about this.

On the other hand, there’s no lack of guidelines. For example,  social work ethics include avoiding dual relationships whenever possible and not becoming friends with or otherwise consorting with a client after a therapy episode. Regarding the latter, “Once a client, always a client” means being prepared for the possibility that a former client who’s not currently seeing you may want to return someday for additional help.

What informs our boundary-making other than the code of ethics? Resources might include reading, consulting with others, and taking courses and workshops–such as one I recently attended titled “OMG…Didn’t We Go to High School Together?” led by social worker Rachel Legend.

As I’m not originally from the state in which I practice, that kind of OMG is less likely to happen to me than to many others. More pertinent to me are those other out-of-the-office unexpected sightings of each other, which Legend got us thinking more about.

Although most of my own instances of running into clients outside the office have felt relatively comfortable, I often can’t know for sure if the same is true for them (unless it’s someone who’s actively seeing me in therapy and we can therefore discuss it in a following session). And some situations have decidedly proven less than comfortable.

Some examples of circumstances in which I’ve seen, by happenstance, clients outside the office:

  • At a social gathering, a store, an event like a concert, or anywhere around town. My View: In this situation, it helps if this kind of potential occurrence has already been addressed in the office so I’ll know how a particular client wants to respond. Some would prefer not interacting, for instance; others will gladly wave or say hi. But if I don’t already know, I try to follow a client’s cues in the moment.
  • The gym. My View: It helps that this isn’t a social place for me—I’m always plugged into my music and focused on my tasks. And, unlike another participant at the workshop, I’ve never been naked in the locker room with anyone—because I go home to shower.
  • Community activities/clubs. Many years ago a client who’d seen me at a gay club noted in her next session that I “must’ve been drinking a lot” to be dancing the way I was. Oops. Caught. Not drinking a lot. Dancing. (Badly?) My View: I do my best to avoid certain places and circumstances. It’s probably just as weird for me to be in the “fishbowl” as it is for a client to feel that way. Which leads me to the next one…
  • I once showed up to a small house party at which there were the two hosts and, besides the three I came with, only a few other guests—unexpectedly, one was a recent but past short-term client. Everyone sat in the same room, and interactions felt laden with tension (at least for me); but the ethic of confidentiality, of course, meant being unable to share with anyone else what only I (and my client) knew. Years later I was invited to another little gathering with totally different hosts. Also totally different guests— except, that is, for that same client. Same dilemma, as I hadn’t seen this person since the previous time. My View: I try to avoid dinner-party kinds of situations if I don’t know the guest list.
  • A short-term client chose to go to the same hairdresser as me; although she told the hairdresser she knew me, she didn’t say how. When my hairdresser then wanted on various occasions to talk to me about my “friend,” I was unable to respond, which I imagine was pretty puzzling for her and felt terrible to me. My View: If a client now asks where I receive certain kinds of services, I might first explain the potential for awkwardness. In a recent example of this, a client opted for trying to get a “second opinion” from my dentist—but without mentioning my name.
  • One particularly memorable and positive experience involved a twentysomething client greeting me at a deli near my office. She then turned and saw my partner—whom, to the surprise of all three of us, she recognized. Turns out my partner, also a therapist, had seen the same client years earlier in a children’s unit. Our client was thrilled to see her—as well as us together!  My View: Although unlikely to ever happen again in my lifetime, I wish it would—it was a hoot!
May 19

Therapists On TV and In Movies: Common Tropes

If you’ve been reading my blog, you already know I believe therapists on TV and in movies are often badly portrayed. Today’s post organizes the types of therapists we’ve all seen into categories designated by TVtropes.org, a useful resource that describes itself as “a catalog of the tricks of the trade for writing fiction.”

According to TVtropes.org, therapists on TV and in movies tend to be shown in three different ways:

  1. The Harmful Shrink: “The worst kind,” of course. Possible traits include cruelty, lack of empathy, non-compliance with confidentiality ethics, pill-pushing, likely to cultivate dependency for financial gain.
  2. The Well-Meaning, But Dopey And Ineffective Shrink: Possible traits: liberal, highly empathic, a good listener, but with an inability to have a helpful perspective or strategies.
  3. The Awesome Shrink: “He can be compassionate and understanding where everyone before has been cruel to the protagonist. Alternatively, he provides the character in question with the kind of Tough Love he’s always needed. Regardless, he’s always smart, almost always cool and never resorts to drugs when they’re not needed.”

As with all typologies, there’s often overlap between categories. Also, many characters may not fit neatly into any one type.

Taken from previous posts, some examples are listed below.

The Harmful Type

  • Therapist Boundaries That (Hopefully) Go Without Saying, 10/21/11: What About Bob?‘s egotistical therapist (Richard Dreyfuss) tries to kill his annoying patient (Bill Murray).
  • Halloween for Therapists, 10/31/11: A now-deleted post had a couple video clips, first from the film Dead Bang and second from TV’s Dexter, featuring bad shrinks.
  • Hannibal Not-Yet-Known-to-Be Cannibal, 4/1/13: “Hannibal the new TV series offers a prequel kind of twist on Lecter. As described by Slash Film, ‘Hannibal follows Will Graham (Hugh Dancy) and Hannibal Lecter (Mads Mikkelsen) in their early days — back before the FBI profiler knew that the famed psychiatrist was actually a cannibalistic killer.’ Lecter is a forensic specialist working for the FBI in some capacity. Graham’s boss is Jack Crawford (Laurence Fishburne), head of Behavioral Sciences at the FBI.”

Well Meaning, But Ineffective

  • Two posts about 50/50 the movie, from October 2011, are here and here. Crossing of boundaries by an earnest inexperienced therapist (Anna Kendrick) places her somewhere between this category and potentially harmful.
  • “Prime” Therapy, 10/19/11: Meryl Streep as a therapist who seems to want to do right but can’t.
  • Silver Linings Therapy Playbook, 11/30/12: Dr. Patel tries to encourage client Pat to make healthier choices but doesn’t model this very well himself.

Awesome

  • A President in Therapy, 9/26/11: Adam Arkin helps President Josiah Bartlet (Martin Sheen) on The West Wing.
  • The Therapist’s Day Off, 10/20/11: In the video clip it’s seen that as a client “Monk” (Tony Shalhoub) is a challenge; his kindly therapist has trouble being firmer, but overall he’s a good shrink.
  • Meet Dr. Sidney Freedman, 1/11/12: The psychiatrist on M*A*S*H played by Allan Arbus. As stated in the post, “Although I’m a fan of Freedman’s wry sense of humor, progressive politics, and ability not to be fazed by things others may consider bizarre, I do need to point out that the schizophrenia joke written for this character has probably helped perpetuate the myth that schizophrenia consists of having multiple personalities.”

Multiple Types

  • Therapist Boundaries That (Hopefully) Go Without Saying, 10/21/11: The “good” therapist (Robin Williams) who achieves a breakthrough with Will previously chokes his client in Good Will Hunting. Is he both awesome and harmful?
  • One TV Therapist’s Scary Dilemma, 11/3/11: Dr. Melfi (Lorraine Bracco) on The Sopranos is generally considered competent, but her limits were also severely tested, leading to highly questionable urges.
  • A Charlie Brown Therapy, 12/23/11: “Peanuts” character Lucy Van Pelt is not a psychiatrist—she just pretends to be for “5 cents please.” But, oddly, her services can be helpful.
  • Grief Counselor: “Scrubs,” 1/26/12: TV Tropes says, “Sacred Heart’s grief counselor is portrayed as a great counselor, but is nonetheless seen as smug and annoying by the main characters, even when it’s them he’s helping.”
  • Psychiatrist Brothers on Drugs, 4/19/12, and Confidentiality Unbreakable, 10/25/12: Both Frasier (Kelsey Grammer) and Niles Crane (David Hyde Pierce), apparently reputable enough shrinks, continually have heaps of trouble in their own personal lives—and sometimes professional, as in considering breaking confidentiality in order to help their dear friend.

Additional examples can be found at the TV Tropes website.