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The Shrink RapAt last, a realistic TV portrayal of psychotherapy: In Treatment.

By Glen Gabbard
Posted Monday, Jan. 28, 2008, at 12:00 PM ET

(Continued from page 1)

Then, in 1999, something extraordinary happened: HBO aired The Sopranos, and its centerpiece was an improbable psychotherapeutic relationship. Dr. Melfi (Lorraine Bracco) took on an impossible antisocial patient, Tony Soprano (James Gandolfini). She struggled with his code of silence, her fascination with his celebrity, and his professions of love for her. She sought out help from her own therapist (Peter Bogdanovich) and occasionally took a nip of vodka before her sessions with Tony, but she did a creditable job of psychotherapy. To be sure, it was a treatment made entertaining with the use of flashbacks, crosscutting, and extraordinary threats on her physical safety. But since complete accuracy is next to impossible, the central issue is how writers can approximate true therapy while still holding audiences' attention, and The Sopranos pulled it off, for the most part.

The success of The Sopranos naturally led to some copycats. Last year, Lifetime brought us State of Mind, in which Lili Taylor's talents were wasted as a therapist who works in a house with a veritable personality zoo of other therapists. The show was so concerned with illustrating that therapists' lives are as unruly as their patients' that viewers never got to know any patients in depth. Showtime's short-lived series Huff made the same mistake. HBO attempted to deal with the dullness of psychotherapy by pushing the envelope this year with Tell Me You Love Me, in which private couples' sessions conducted by an aging therapist (Jane Alexander) alternate with soft-core pornographic scenes starring characters from the show. The sex is meant to keep the audience involved, but it turns out to be remarkably boring. Guess you had to be there.

In Treatment has admirably learned from its predecessors' mistakes. The writers wisely play to viewers' attention spans, compressing the usual 50-minute therapy session into 30. It has the courage to keep the camera in the office to let the audience hear what a therapist hears. (And, as a result, the audience starts to care about the patients.) Like most therapists, Dr. Weston is occasionally off the mark when attempting to offer interpretations of his patients' experiences. When his marital problems flare up, he finds himself thinking about the parallels between his own struggles and those of the couple he sees. He begins to unravel a bit, and he wisely seeks help from Dr. Toll.

To be sure, the psychotherapy is not (thank God) an exact replica of what happens in real therapy. Each patient draws us in by gradually revealing a secret to Dr. Weston as the therapy unfolds—a narrative more common in Agatha Christie novels than psychotherapy, where things are more prosaic. One patient overdoses in Dr. Weston's office. Another brings him an espresso machine. Yet another propositions him. And everyone gets up to use the bathroom. (In fact, more patients relieve themselves midsession in one week of therapy with Dr. Weston than in 30 years of my own practice.)

But In Treatment stops short of outrageousness—what happens is unusual, yet plausible. Moreover, one of the most accurate features of the treatment portrayed is that the patients resist the therapist's help. As Freud noted nearly 100 years ago, most patients seek help but then end up fighting off the therapist's efforts. Dr. Weston deftly manages their resistance, and engages them in a therapeutic alliance, the most powerful predictor of a good outcome. But don't jump to conclusions: This is not real life—it's HBO.

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Glen O. Gabbard, M.D., is Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry at Baylor College of Medicine. He is the author of The Psychology of The Sopranos.
Photograph of Blair Underwood and Gabriel Byrne in In Treatment by John P. Johnson, © HBO 2008.
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