Psychotherapy and the Sopranos

There is no shortage of schools of thought of psychotherapy. We have Freudian or psychodynamic to behavioral, cognitive behavioral and a host of others. What some of the research in the field is showing however is what is important is not the theory or approach but the alliance between therapist an patient. And what is important in establishing an alliance is not what the therapist thinks is important to bring about change but what the patient thinks is important.

To demonstrate this to students and trainees I often use the example of the TV Series the Sopranos. Not only is the Sopranos one of the most watched TV series in history but the therapy scenes are discussed, debated and analyzed by therapists at social gatherings and on many Internet discussion groups. Sometimes these debates get so intense that one would think that some therapists forget that it only a TV show and Tony Soprano and Dr. Melfi are played by actors. It's not real!

However with that caveat, let's examine this therapeutic relationship.

The patient is a middle-aged self-employed man who presented approximately 3-4 years ago with panic attacks that among other things was an impediment to his job performance. The therapist, an experienced psychiatrist, might be described as eclectic but with a strong psychodynamic orientation. The questions are: What is the quality of the therapeutic relationship? Is there a good working alliance? And is the patient better? What does better mean for a head of a crime family?

The various symbols from the ducks, the meat, woman hanging clothes, and the Rottweiler dog are clear not only to anyone with training as a therapist but to just about anyone who has seen a Woody Allen movie. It is quite clear to Dr. Melfi. But is it clear to the patient, Tony Soprano? For the research that Drs. Scott Miller and Barry Duncan produced at http://www.talkingcure.com suggest that that the perception of the patient is the only opinion that really counts.

James Gandolfini, a first rate actor, expressions as the Tony Soprano character reveal a great deal in the therapy sessions. Frequently when Dr. Melfi shares her interpretations he has the look of disbelief. Of course the standard interpretation might be that he is in denial, but while rough around the edges and with little formal education he is no dope. One needs to have some smarts to survive in his line of work. The fact that the therapist has been unable to form a real alliance might suggest why after all this time he seems to be not much better than when therapy started.

However there was at least one breakthrough that I recall. When Dr Melfi she suggested that Tony read Art of War by SunTzu , they connected. He had something he could relate to; it helped him in real life and may have saved his life. The fact that saving his life meant that there might be a few more of the show's characters sleeping with fishes, in unmarked graves or melded into the fender of a Cadillac is the ethical dilemma. But it seemed to me for the first time a real alliance was being formed.

The Soprano's, at least to me, also brings home another important finding of the Scott Miller et al. research findings. Miller and his colleagues in Escape from Babel (Norton, 1997); The Heart & Soul of Change (APA, 1999) state that extra therapeutic forces account for the largest explained variance in change. This includes all factors including the relationship model, placebo effects etc.

A season or two back, Tony Soprano was depressed, clinically depressed. There were even hints that his depression was accompanied by suicidal ideation. Neither the medication prescribed by Dr. Mefli nor the therapy seemed to be working. Then one day as he was driving his SUV, a couple of men from a competing Family came up and tried to take him out. Within seconds, he snapped out of his depression and took necessary steps to stay alive. He took out his automatic and fired away at this would-be killers. The best way to snap out of depression apparently is have someone try to whack you

There are many lessons that can be learned by watching therapist scenes on TV and the movies. Some are good some bad, some comical some serious. While consumers are learning these lessons it is unclear if therapist are looking at the right things. Many still attempt to fit a patient from a working class Italian/Sicilian culture into a model developed for upper middle class northern Europeans. It is not a good fit. Imagine if the patient's culture is even more removed.

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