Talk therapy and Tony Soprano

The Sopranos: The patient and the therapist (www.today.com)
The Sopranos: The patient and the therapist (www.today.com)

“I love you.”

“I dream about you…I think about you all the time.

“I’m in love with you…That’s just the way it is.”

This was Tony Soprano’s little speech to his psychiatrist, Dr. Melfi. This was in Season 1 of “The Sopranos” where he had started going for psychotherapy after having panic attacks “out of the blue”.  She, Dr. Jennifer Melfi, had started him on Prozac, and was his listening ear during his regularly-scheduled Tuesday appointments.

After his declaration, she had to let him down easy, and explain to him that the probable reason why he was “in love” with her  was so was because she, like his Mother/Wife/Daughter, was an Italian woman, but the difference was that she had been understanding, compassionate and listened to all that he had to say. She accepted him unconditionally, which made the big difference there.  (Although she is not what you would call “the ideal” therapist. She obviously had problems being objective sometimes, and was too empathetic sometimes.)

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I’ve been watching The Sopranos episode by episode these past few days, upon the recommendation of a good friend. He had told me years before of the series, and I had never taken him up on the suggestion until now (I’ve had these files in my hard drive for years.).

So, why now? Well, after I started on one, I could not help but move on to the next…I was hooked. 🙂 I was told that it would really help me with my “psychotherapy skills”, but actually, I think he was just a big Mafia fan, and loved the character.

Ah, Tony Soprano…he was larger-than-life, an anti-hero with a ball-busting mother issue,  who was doomed to be a gangster because it was the only way of life he knew. Despite his shortcomings, he had a big heart and was undeniably loyal to those he loved (and “honor and family, and loyalty”).

The “internal turmoil” and the conflicts that he could not freely talk about (until he had a psychiatrist to help him sort them out) and presented as physical and psychiatric symptoms, and they were very interesting to watch. Also the interactions between patient and therapist were very riveting…she wasn’t afraid to confront him, and he reacted accordingly, as the textbooks said.

Confrontation. (denofgeek.com)
Confrontation. (denofgeek.com)

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Now, I have gotten many “I love you’s” in the course of my training in Psychiatry, and I was very careful about things going “violent” during confrontations, but I have never had any “fights” with patients and their families. I’ve never had any death threats…(not that I would want to). That is to be expected in practice, especially when you’re doing psychotherapy, but I haven’t seen it yet during the psychotherapy sessions that I’ve done so far.

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An interesting bit I’ve read in the Jeffrey Kottler book, ” On Being A Therapist”,

“Conquering a therapist is the ultimate victory, proof that anyone can be corrupted. It is a way in which the client can regain control of the relationship and win power and approval. It satisfies the desire to flirt with the forbidden, and it gives the client a means to frustrate the therapist just as she has been frustrated by the therapeutic experience.”

The therapist’s efforts to confront the client regarding the seductive behavior often lead to frustration. If the feelings are discussed directly and the therapist gently yet firmly rejects the overtures,the client might feel humiliated and rejected.

If the transference feelings are interpreted, the client may fall back in denial. Yet, if the therapist attempts to back off and let things ride for a while, the seductive efforts may escalate.

There is no easy solution.

It’s pretty much like…dancing with a partner, but you’re doing it objectively. It’s not always asking ‘How do you feel?”, but actually, it’s a mix of different techniques and guided questions (something that can’t be talked about in one blog entry…because it is so vast a topic, and so interesting too).

🙂

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Love,

S.

P.S. The Psychiatry part is not the only interesting part…the quips about psychiatry, the scenes, and the dialogue between the quirky mafia men makes it so much fun.

Couch Sessions

“I think couches are necessary.”

(They’re optional, and because of that, I would definitely want one in my clinic.)

This was my thought when one of the consultants at the round-table discussion asked if we psychiatrists still had hour-long consults and couches in our clinics…

The senior psychiatrist said that it wasn’t necessary anymore, and that real consults did not take as long. I, being the junior, merely nodded, as the question was addressed to him, but being the idealistic young graduate that I was, I knew in my heart that I definitely wanted to have one. 🙂

Granted I do not know much yet about the nitty gritty of private practice yet, I do know that I wanted a place or a space where someone wanted to stay to talk about their troubles, and express themselves and correspondingly, in the same way, I wanted to have a conducive environment where I was comfortable enough in assessing someone’s case.

The Psychoanalyst's Couch. (not mine).
The Psychoanalyst’s Couch. (not mine).

The image of the couch connoted hours and hours of free association as in the times of Freud, where one could spew forth thoughts and musings while a therapist would listen and take notes. More often than not, this is what people think of when they hear the word “Psychiatry” (or the other thing).

I suppose it’s a matter of choice…if I were to empathize with a troubled individual, and ask myself, “If I were a patient, what would I like?”

Well, for starters, I’d want to be able to talk in a calming atmosphere, somewhere without a lot of fuss and noise, or where I could just sit and talk and not be pressured to talk or behave as “psych patients” would do. I’d like to be able to talk freely, without worrying about whether what I would say to my psychiatrist would be tomorrow’s gossip fodder. Confidentiality was a big thing.

Also, comfort. 🙂

I do recall before, with my table and chairs set-up, talking to someone with a family problem. As he/she was talking more and more about the problem, I noticed that he/she had begun to lean back and then almost lost himself/herself in her narrative. I had to suppress a smile when I noticed that he/she had already started to put her feet up on the chair opposite his/hers. Or, if it was particularly nerve-wracking, or distressing, people would need to feel comfortable enough to hold onto something.

🙂

But that’s just me, though. I’ve never been a patient myself, but when I was a sophomore in training, I had a supervisor who had such a comfortable clinic. When we discussed our cases, he’d have me pick my seat on any of the couches, and he would take a different one somewhere else in the room, and we’d talk about the case that way. And, because I could see the books nearby, I felt free to ask him about the titles and to browse about Psychiatry textbooks, handbooks, novels, etc. It was more conducive to learning.

However, I also found learning better when I sat on the table perpendicular to my teacher, so I could see her face to face and talk about the case at close range.

I think I’m going to apply that in my clinic and future practice. There’s the option to use the couch, and there’s also the option to sit comfortably on the chair near the table. Either way, it can be an empowering thing for the patient to be able to decide how the problem will be tackled the problem. I think that having the person choose how he wants to start is one of the steps to achieving an impact with rapport and psychotherapy. Also, I want therapy session to be something they will look forward to because they know that the work they put in of coming to the clinic will help them recover.

I was provided with a nice black corner couch for starters, with throw pillows in black and while and silver accents. I’m getting a full couch soon, but for now, at least these two options (i.e. couch or table) will be available for the patient.

These were my picks for clinic couch when the next time I can get them, though. 🙂

(Photos aren’t mine…got them from random sites online, and Pinterest.)

birmingham-maple-clinic-office-1 black and grey  circle pillows couch  photo8  white