The Biggest Myth About Therapy That HBO's <em>In Treatment</em> Promotes

HBO'sunfortunately reinforces a view of the therapeutic relationship that is misleading to the public and harmful within our profession.
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Oh, right. Paul Weston isn't a real therapist. He's just a character on the HBO series In Treatment. So, I suppose it's rather silly when my wife and I -- both psychologists -- react to stuff he does with exclamations like "Good interpretation, Paul!" or "Christ! He keeps missing the boat." No sillier, I suppose, than when the American Psychoanalytic Association once held a panel discussion about film and television depictions of psychoanalysis and had the actress who played a psychiatrist on The Sopranos, Lorraine Bracco, on the panel -- the implication being that Bracco would have something especially interesting to say about Tony Soprano's psychology or treatment. Analyzing the vicissitudes of a fictional shrink's clinical technique is sort of like analyzing David Caruso's police work on CSI Miami.

Psychotherapy, however, seems to be an enterprise that most people have some opinion about, how it works or doesn't, whether shrinks are especially screwed up or just ordinarily so, or whether their kids suffer a special burden. And caricatures and scandals abound (not just in the New Yorker) about endless psychoanalyses, "old-fashioned" therapists who won't answer personal questions, therapists who sleep with their patients or who fail to predict their horrendous acts of violence.

The series In Treatment makes dramatic use of all of these beliefs and controversies. Specifically, it creates drama through depicting the therapist as not only emotionally tortured but as repeatedly struggling to keep his personal issues and inclinations out of his work with patients. The climax of the third season has poor Dr. Weston awash in a sea of questionable therapeutic failures and boundary violations. To make matter worse, he is faced with the pregnancy of his own therapist, one of those types that strictly refuse to answer personal questions, and the contradiction between his desire for her and inability to be part of her real life appears to drive him to quit. In Treatment, then, brings to its viewers' attention -- in dramatic form -- the apparent problem therapists and patients have differentiating between therapy and life and, therefore, the danger that violations of this boundary poses to both parties. It makes for good television.

Unfortunately, it reinforces a view of the therapeutic relationship that is misleading to the public and harmful within our profession.

Its not that "boundary violations" don't occur frequently in psychotherapy or can't be harmful. They do and are. The one most like to inflame passions and offend our sensibilities is when a therapist (usually male) has sex with his patient (usually female). Other boundary violations, however, are common and often cause damage as well. For example, a therapist might hire a patient to perform a personal or professional service, or benefit from a stock tip garnered from the therapeutic work. Or a therapist might willingly interact with his or her patients socially, or collaborate on a project outside therapy. These occasions are fraught with complications for both parties and many of them are frankly deemed unethical or even illegal by licensing boards and state laws.

The situation of therapy invites an idealization of the therapist that some therapists are tempted to take as real because it fulfills the latter's unmet needs for admiration and power. Further, in their therapist roles, such therapists can be tempted to express their "therapeutic zeal" and more directly cure and help their patients by doing things with and for them in the world outside the office, not appreciating the costs to their patients' autonomy. And, finally, for many therapists, their caretaker roles mask a deeper sense of entitlement and deprivation that can hide behind seemingly altruistic decisions to give patients various satisfactions, satisfactions that appear to be for the patient but are ultimately for the benefit of the therapist. Thus, the dangers of exploitation are very real in the therapy relationship and boundaries are clearly necessarily for real therapeutic work to proceed.

So, "boundary violations" make good television and are a concern in psychotherapy. But therapists in the field and those consulting on television scripts exaggerate these dangers and substitute a hidden but rigid morality for the flexibility and empiricism necessary to conduct an optimal psychotherapy. The only defensible criteria for judging therapeutic technique is outcome; that is, technique is good if it helps the patient get better and it's bad if it doesn't. Theories can't tell us this. Ethics can't tell us this. The "gut feeling" of the therapist can't tell us this, either. And the "rules," or any other received wisdom, can certainly not tell us how to do this. The only thing that can tell us if what we're doing is good or bad is whether the patient moves forward in his or her therapy and life.

Obviously, "moving forward" or "getting better" aren't always obvious or easy to define. Among other things, we have to distinguish between short and long term progress. But these caveats aren't mysterious. They, too, can be studied. A therapist generally knows, for example, if a patient's response to an intervention indicates progress or is simply compliance with the therapist's authority. In the former, there's usually a lessening of anxiety, a greater sense of affective freedom, some new insight or recollection, or some greater willingness to face some developmental challenge. In the latter, a compliant response is usually relatively empty of affect, seems thin, and lacks any sense of freedom or discovery. A therapist may not be 100% correct, but, on the other hand, does have some reasonable criteria to go on. And these criteria are empirical in the sense that they are observable either through therapists' direct perception or introspection.

If that's the case, then the danger posed by boundary violations aren't universal at all, but completely patient-specific. That is, if therapeutic boundaries are intended to protect the patient and the therapist and ensure the safety of the therapeutic space, then the therapist's task is to figure out over time what constitutes protection and safety for each individual patient and to gauge the appropriate boundaries accordingly. I have had patients for whom social engagements of various kinds communicate safety and facilitate the therapeutic work because they reassure the patient against fears of traumatic rejection and abandonment, reassurances that can't be provided or constructed any other way. And, on the opposite end of the spectrum, I've seen patients for whom any divergence whatsoever from the strictest type of analytic "neutrality" is experienced as a dangerous intrusion. The point isn't whether or not you draw a line. You always draw a line, first, because some types of engagement are illegal and usually harmful, like sex, and, second, because in order to be maximally effective, the therapeutic relationship should always retain a special quality of being both inside and outside a patient's normal social life. Thus, without some boundaries, the special nature of the relationship, a special-ness that gives therapy much of its power, is eliminated and it comes to resemble a simple friendship. The nature of those boundaries, however, can't be derived from our canon.

The problem with many prevailing psychotherapy traditions is that they view boundaries as obvious and universal rather than elastic and patient-specific. They reason from theory, not outcome. They develop and teach axioms that are presented as self-evident. Don't supervise the same person you've treated in psychotherapy. Don't have any social relationship with a patient. Don't divulge too much personal information. Don't fiddle around with time and money. Don't take calls outside the sessions unless the patient has an urgent need. Don't give too much advice.

On In Treatment, our tragic hero, Dr. Weston, is challenged by his own therapist about his problem with "boundaries." She rarely asks me whether his patients are improving. Weston, like many therapists, hardly blinks an eye at this bizarre blind-spot because he was trained the same way. He either echos these rules as if they were, indeed, sacrosanct, or he unwittingly violates them. Either way, the the drama on the show, and the corresponding concerns in our field, revolve around everything but the only question that should really matter -- is the patient getting better?

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