Getting It Right

In HBO's In Treatment, Art Imitates Therapy

Magazine Issue
July/August 2008
Getting It Right

I was into the sixth week, at five shows a week, of watching In Treatment, the HBO fictional series about a psychotherapist in the Washington, D.C., area, when one Monday morning in my own office I found myself—how to say this?—sitting in my chair like the therapist, Paul (played by a craggy, lean-faced Gabriel Byrne, Irish accent and all). Or maybe it was his supervisor, Gina (Dianne Wiest, looking both relaxed and regal). Something had happened to my posture: I’d straightened up, become more organized around the midline of the body. I guessed there was some imitative mirror-neuron thing at work, as if all those hours of watching other therapists, albeit fictional ones, had made me more aware of my own sitting. “Well, we don’t often get to see ourselves quite so clearly,” a friend explained.

I’d been talking with other therapists, following the blogs about the show, taking in the opinionated, antsy reactions: this intervention was wrong, that part was false, a therapist shouldn’t do this or that, as if the show were a training tape from the American Psychological Association. As for myself, I watched it not with an eye to whether the series got the details of psychotherapy right, but whether it got being a therapist right.

In Treatment was originally the wildly popular Israeli series Betipul, and except for a few changes and some significant Americanizations, the HBO series matches it word for word. The idea was to follow the therapist (played in the Israeli series by the rumpled, masculine Assi Dayan, the son of Moshe Dayan) through week after week of therapy sessions. When we tune in on a Monday, we see Monday’s patient; on Tuesday, the regular Tuesday patient; and so on, until the fifth day of the week, when Paul sits at last in his supervisor Gina’s office, talking over the week’s problems.

With 43 shows in all, In Treatment is an unprecedented immersion in the ebb and flow of ongoing therapy. In addition to the cases themselves, we’re privy to how Paul thinks about these patients via his supervision sessions with Gina, where he is often as angry, confused, and self-deluding as he is perceptive and responsible. You know, just like . . . a psychotherapist.

In the first week, Paul has to intervene with a couple when the husband, Jake, verbally attacks his wife, Amy, because she’s been considering an abortion without consulting him. Look, Paul says, it’s not just about this decision you have to make. He points out Jake’s belligerence and Amy’s sneering evasion. Then he asks, Isn’t this all really about your relationship?

Our relationship?! Jake shouts, Are you serious?! How do you sleep at night? We came here for advice about this pregnancy! He yells some more, and then stomps out.

I felt a jolt of recognition. Sure, that’s how a couple sometimes deals with their own disheartening sensations: they turn on the therapist; they accuse the therapist of letting them down. Every couples therapist knows what I’m talking about. Well, I thought, the writers got that right.

Next evening, Paul meets with Gina, now retired and trying to write fiction. These two have been estranged for more than nine years, since the time he left her supervision in a huff at how she’d interfered with his work. Their falling-out hardened when Paul failed to show up at her husband’s funeral. The memory of that act obviously still hurts her. You must have been really angry at me, she observes, not to have attended David’s funeral.

I was watching the program with a group of therapist friends who’d gathered to see a week’s worth of episodes. All of us were old hands at supervising other therapists. Some of us had met long ago behind the one-way mirrors of the Philadelphia Child Guidance Clinic, and now we sat entranced in front of a wide-screen television set. Hmmm, the group was wondering, why has Paul come back to this confusing relationship with Gina? Supervision is meant to be a safe-enough place to take an honest look at your work, to figure out what you’re missing, what you could be doing differently. Gina herself is curious about why Paul is seeking her help.

In Paul’s renewed supervision with Gina, the show shifts away from offering the foxy charms of melodrama into something edgier and more complicated. He admits that he’s lost patience with his patients, that he’s tired, that he often has to restrain himself from having an outburst. He comes across not as the preternaturally Wise Therapist, the comic Boob Therapist, or the autocratic Wicked Therapist, but as someone else: a person struggling with the same issues his clients present to him. As a matter of fact, as he describes the dismaying fights he’s having with his wife, Kate, he uses some of the same language Jake used: My wife, he laments to Gina, makes decisions without consulting me.

Oh, I think, this could be interesting. Paul, we now observe, is at this moment no more open, no more capable of introspection, than his clients.

One problem Paul wants to discuss in supervision, it seems, is Laura, the client who just that Monday confessed her love for him. It’s no big deal, he says; happens to therapists all the time. Against his increasing stubbornness, Gina makes the connection between handling an erotic transference from a patient with the problems in a therapist’s marriage. Like your father, she says, implying that the story of Paul’s unfaithful father has influenced his vulnerability to this seductive patient.

You, you . . . fiction-writer! Paul says angrily. You’re shoving all this into one of your preconceived narratives. Oh, you should see how much you’re enjoying yourself.

So it goes, as they feint and punch.

I made a mistake coming here, Paul says. You’re an old, sleepy spider; you’re waiting to strike. Look how you wake up, how full of life you are now.

You’re angry with me, Gina declares.

Me? Paul says, dialing it down. No, I’m not angry.

Our group of therapists required supper at this point. We had to talk. Over lamb and rice, we agreed that the demands of drama had jacked up the circumstances in which Paul was foundering, despite his years of experience. For example, after more than a year of therapy, how could he be surprised by Laura’s confession of love? And when she gives a detailed account of her sexual subjugation in a cafe restroom, why doesn’t he raise the question of her self-destructiveness? A woman therapist would never fall for the titillation, we agree. How could he be as passive as he is with the macho martinet of a Navy pilot? Why does he let the negativity go on and on with Jake and Amy? It’s supposed to be a third session, and he should have more of an alliance. And how could he be so unconscious about renewing his difficult relationship with Gina? We work harder to be more self-aware, we all agree. Don’t we?

I detail bits of this group assessment over our supper because I think it starts to illustrate something about what it’s like to be a therapist: the layers of questioning, the arguments back and forth, the looking and looking again. “A good story, but bad therapy,” one friend says. “You really think so?” someone else asks; “I could teach from this show.”

Reviewing the episodes, we found ourselves questioning the writers, our own assumptions, the varieties of therapy. We entered and reentered the membrane of the story. That’s what we do, we therapists: we give up our longing for certainty; we keep a liveliness about our own not-knowing, what Keats called “negative capability”—what we might experience as a curious mind, open and aware one moment, closed and groping the next.

An Oral Tradition

Writing this now, I pause for a moment to count all the groups of therapists I meet with regularly, once or twice a month. It adds up to five groups, plus one that convenes on Cape Cod four or five times a year. Evidently that’s how much conversation about the work of therapy I require.

It seems when you take on the enterprise of psychotherapy, you enter what’s fundamentally an oral tradition. It’s Homeric: a handing down of knowledge and stories, a transmission of the culture, some of it meant to stay within the small group in which it’s told. The practice of supervision itself—the tradition of sitting at a teacher’s knee—gives another dimension to this culture. Sure, there’s much written about therapy, there are case studies and theories, there are journals, books, articles, the words I write just now.

But all these words are as often as not a barrier to what psychotherapists need most: exposure to our own palpable experience. We don’t get that from books. We get it from a relationship with a teacher or a supervisor or a therapist, where there’s room enough to suspend hard judgment, to suspend the fixed idea that we should have “known better.” Then we get access to ourselves. The confusion we share in supervision or with a friend isn’t something to be eliminated, a problem to be solved, but a basic, recurring condition, which creates a need for sorting out ourselves, for sanity—which, in itself, is a piece of sanity. If we can tolerate it, confusion spurs a therapist’s most fruitful explorations.

Luckily, In Treatment conjures up a psychotherapist who’s in the thick of a great confusion. He’s struggling with his marriage, struggling with what gets stirred up in him by his patients, struggling with how much he wants and doesn’t want feedback. Indeed, the ambiguity of his marriage haunts all transactions. In one scene, he demonstrates his reliance on Kate, when he summons her for help with the failing office toilet, only to dismiss her later with a wave of his hand. Oh, you’re finished with me, she says with biting sarcasm; I can go now.

Sometimes people are amazed that a therapist has troubles. Or not amazed: “Those therapists, ha-ha, they’re crazy themselves!” But the truth is that trouble is central to a therapist’s education.

The other day, a young woman came to see me for some help with a 15-year-old incident, the shock of discovering her father’s dead body. She couldn’t talk about it or even think about it without quickly going numb and silent. She was a psychotherapist herself, just out of an initial round of training, new to the work. It seemed to her a distinctly shameful situation to be a psychotherapist who had to get help. She’d bought the idea that therapists were people who have not only a special understanding of what makes people tick, but also an unwavering understanding of what makes them tick. “I should know,” she said, abashed and apologetic: “I should be able to handle it all.”

As if “knowing” were some sort of Kantian a priori category, something you figured out from a great theory or from your own smart brain, and didn’t have to come to know through exploration and practice. As if, to be a therapist, you were supposed to be a fully realized person, pure of heart and mind and soul, sitting in your ergonomically correct therapist chair, taking your ethically correct therapist notes, nodding your head with unending compassion at your dear patients, who are struggling and shortsighted and not at all like you.

But there’s no way for any of us to learn how to “handle it all” unless we sink down into it. It’s constant, the way we therapists explore our own lives, our own reactions, our own thorny dilemmas. It’s part of the training, part of the work, part of the job of sitting day after day in the therapist’s chair. The sinking down constitutes one of the primary learning modes for psychotherapy.

Mercifully, we don’t all have to leave a marriage or fight with a child or renounce our parents to be able to work with divorces and temper tantrums and radical alienation. But we have to explore the impact of our own losses and deprivations, the terrible assaults on our own spirits. We’re regularly stuck, sidetracked, narrowed by our own thinking. And that’s the good news, because each of these human impasses becomes . . . the way through. These are our most vivid lessons, when we learn not only how to sit with patients, but how, in fact, to live. We enter into knowledge about ourselves, and about what it is to be human, through our wounds. That’s the way in. Otherwise, we’d just tootle along, under the illusion that we’d figured it all out. So it’s the wound, the injury, the mysterious irresolvable conflict, the recurring depression, the grown child lost in rehab that makes us stop and think again.

Paul comes up against his own hard and unyielding realities in the same way. Gabriel Byrne’s hewn face, its paleness a chiaroscuro against the darkness of the office walls, is the center, the anchor and harbor, of the actions set in motion around his character. All the twists and folds of what moves around Paul are registered in his face and in the movement of his hands, whether they gesture outward or knit together “in steepled comity,” as a friend put it. As we watch his face and gestures, we come to understand how these shoving, pulsing lives push on the Paul character, and quicken or forbear his responding. Well, I thought, the writers got that right.

To this extent In Treatment approaches the heart of what it is to be a psychotherapist. As we register Paul’s empathic nod or smile or gesture, session after session, we develop a gathering sense of what all this responsiveness and/or forbearance costs. The picture builds up, the palimpsest of what this patient or that patient writes and overwrites onto the pulpy layers of Paul’s motives and desires. He’s caught in the thick of it, this business of being human—the insufferable risk of making one’s way in a world perceived imperfectly, with a self perceived imperfectly in a dark mirror.


The Therapist as Oedipus

In one scene, Jake and Amy, the married couple, are fighting again in Paul’s office, when Amy abruptly rises and rushes into the bathroom. After one of the few jumps in the continuous time of each 30-minute show, we next see Paul alone in his office, looking with dismay at his sofa. It seems Amy has had a miscarriage, the couple has rushed off to a hospital, and there’s blood on the sofa.

Paul bellows for Kate to come help, and as she ministers cleaning solution to the besmirched sofa, the two fall into their own argument, until Kate blurts out that she’s having an affair. She’s tough and unyielding; Paul’s retaliatory entreaties don’t engage her. He asks her to leave, but now there’s movement outside the French doors: someone has arrived.

Paul gathers up the cleaning supplies and hurriedly tidies up the office. He collects himself and opens the door to the next patient, a man who rushes in, barely looking at him while removing his jacket and announcing as he settles on the sofa that he’s dreamed of “Becca” again.

We watch Paul pause. Same dream? he asks, and settles into his chair to listen to the patient’s recurring imagery. Yeah, I’m in the boat, but she’s in the water, the patient says.

We understand now that Paul’s face will be attentive, his hands will be knitted. As best he can in the pulsing reality of this patient, he’ll allow Kate’s bitter revelation to rest, to hover. It’s a snapshot of how many reverberating layers the therapist bears within him- or herself.

The psychotherapist could be Oedipus—not the character that Freud created, the child who unconsciously wants to kill his father and marry his mother, but the passionate character out of Sophocles, the person who thinks he knows who he is, but actually doesn’t; who stumbles around in the dark, who doesn’t know who his own family is. It’s what they mean by Sophoclean irony, the particular irony of the character who speaks, but is blind to the fuller, truer meaning of what’s said.

We’re born into this world with the horrible prophecy that we’ll hurt even the people we most want not to hurt. The therapeutic response to this fate isn’t a wished-for flight into arrogant perfection, the dream of a transcendently guilt-free life, but toleration, awareness, the open eye. I thought the writers of In Treatment got that right, too—to show the therapist seeking wisdom even as he fights against it. The daunting project is to tolerate ourselves, to understand our family.

Through these weeks of tracking Paul, the writers captured not only the vulnerability of a psychotherapist, but also his attentiveness. I’d say they caught as well the richness of the therapeutic conversation—the way it starts out with an innocuous sidebar and heads invariably toward the thumping matter at the core. The therapist engages in a moral conversation, not by entering on high with absolutes, but by sinking down into the particular, idiosyncratic life of the people “in treatment”—their tight spot, their suffering, their mess. It’s moral because it’s a questioning search for understanding—including self-understanding, self-observation, self-regulation—that’s fundamental to our good care of ourselves and others, and to repairing the world.

There’s one other touch that should be mentioned about this program. All those sessions spent in Paul’s office make it into a cloistered place, sheltering but narrow, the way focus can be narrow. And then from time to time, usually when Paul has said something especially observant, a dog barks in the distance. Even the bloggers have noticed the barking: what gives?

The directors and editors could let their camera linger on Paul’s face or the patient’s face, and let the silence reverberate—which they do plenty of times. Instead, they deliberately put in a far-off dog’s bark, and, suddenly, the space in the room expands out into the neighborhood, into the world. We become aware that all this talk and understanding in a cloistered room isn’t merely a private matter, a constriction, or a reduction, but an opening, a fanning out.

One of my favorite supervisors used to teach us that you could take any moment in a person’s life, and it would all unfold: the whole life would be contained in any one, particular moment. “You have to see a world in a grain of sand,” he said, paying tribute to William Blake’s great poem. In this way, you might say, the creators and writers of In Treatment have seen eternity in the therapy hour.


Molly Layton

Molly Layton has been writing for the Psychotherapy Networker for over 25 years. Her short stories have been nominated for a Pushcart Prize and included in the Writing Aloud Series at the InterAct Theater in Philadelphia. She has a private practice in Erdenheim, Pennsylvania.