Treatment
Long-Term Talking Therapy
What is more likely for Tony Soprano? A successful resolution to his therapy or a federal indictment?
Mobster Tony Soprano is grilling meat on the barbecue. Suddenly, as he observes the ducks that frequent his swimming pool head south for the winter, he experiences a panic attack and collapses.
When the doctors can find nothing physically wrong, he goes to psychiatrist Jennifer Melfi and confides that he is feeling depressed. Dr Melfi assures him: "With today's pharmacology, no one needs to suffer with feelings of exhaustion and depression."
And our overwrought gangster replies: "Here we go. Here comes the Prozac."
But Tony is bleeding on the inside and the Prozac amounts to nothing more than a band-aid. This is a guy, after all, who has a mother who will eventually consent to having him whacked. Thus, Tony agrees to open-ended weekly therapy.
The type of therapy is derivative of psychoanalysis. According to the American Psychoanalysis Association:
"Psychoanalysis is based on the observation that individuals are often unaware of many of the factors that determine their emotions and behavior. These unconscious factors may create unhappiness, sometimes in the form of recognizable symptoms and at other times as troubling personality traits, difficulties in work or in love relationships, or disturbances in mood and self-esteem."
Under psychoanalysis, the patient is encouraged to make associations between present behavior and buried memories on the principle that the patient's life will change for the better. The process is time-consuming, four or five sessions a week over several years or more.
Psychoanalysis is most identified with Freud, who in 1900 began treating a young woman he called "Dora." Under psychoanalysis, Dora told Freud of her family's closeness to that of Herr K, how her own father had been having an affair with Frau K and how Herr K was turning his attentions on her.
Freud wondered why his patient felt disgust rather than desire, and suddenly one of history's great Archimedes moments occurred - an aha! a Eureka!, an apple falling from the tree. Freud speculated that Dora UNCONSCIOUSLY desired Herr K. For good measure, he also claimed she lusted for Frau K.
A few days later, he confidently wrote to a friend: "The case has smoothly opened to the existing collection of picklocks." Freud was about to make himself famous.
Dora, however, was decidedly less impressed and broke off the treatment. Undoubtedly a lot of lusting was going on, but it was almost certainly on the part of the doctor fantasizing about his patient.
Nevertheless, in one fell swoop Freud put an end to the notion that we are rational beings governed by rational thinking. At the same time, he also held out hope that the worst inside us could be stripped of its strange dominion simply by bringing it out into the open.
Sexual desire is a strong part of unconscious motivation, but Freud's peculiar take on the topic (think penis envy) would pollute the waters of psychoanalysis for years to come. These days, Freud is as fashionable as polyester, and psychoanalysis occupies a backwater of psychiatry.
Much more practical and accessible than psychoanalysis is psychodynamics, which can be considered a short form of psychoanalysis. Gone is the couch. Sessions are more focused, typically one a week, and may be time-limited, tailored to the patient's needs, such as encouraging meds compliance. Various studies, however, indicate that short-term psychodynamics is less effective than cognitive, behavioral, and interpersonal therapy.
As long-term treatment, the American Psychiatric Association in its depression Practice Guideline advises that psychodynamics is usually associated with goals beyond that of immediate symptom relief. The therapy is addressed at modifying the underlying psychological conflicts that make patients vulnerable to depression. For bipolar disorder, The APA recommends long term treatment in the context of illness management.
In the Sopranos, Dr Melfi gamely tries engaging her patient in a therapeutic dialogue: "What's the one thing every woman - your mother, your wife, your daughter have in common?" she asks.
Tony replies: "They all break my balls."
Eventually, Dr Melfi notices that meat features in all of Tony's panic attacks, and with her prompting her patient recalls a buried childhood memory of watching his mafioso father chopping off a butcher's pinkie.
"My God!" exclaims Dr Melfi.
"What," Tony responds, "your dad never cut off anybody's pinkie?"
But an important breakthrough has occurred. By this time, however, Tony is into his third year of therapy when it happens. Better late than never.
But Tony is by no means out of the woods. There is the small matter of Big Pussy, his former close associate turned informant, who, thanks to him, is now sleeping with the fishes. Now every time Tony goes near the ocean he experiences painful flashbacks. Finally, after four years, Tony is ready to throw in the towel. "Truth and happiness?" Tony says in reply to Dr Melfi. "Come on, I'm a fat fucking crook from New Jersey. What truth and happiness?"
But you know Tony will be back. The only thing that is going to stop his therapy from going on forever is a federal indictment.
Tony Soprano is obviously a caricature of a therapist's worst nightmare, but when all is said and done there is little to distinguish a Jersey mob boss struggling with being a good son to a mother who tries to have him whacked from a woman in a bad marriage who is trying to put behind her an abusive relationship with her father.
They have yet to invent a pill that solves these problems and heaven help us if they ever do. These are the tough issues that our brain keeps under lock and key inside a strongbox inside a safe in a vault under the bottom of the sea. "X" does not mark the spot. You are in for a long journey.
Many psychiatrists who specialize in medications treatment insist that their patients see a talking therapist on a regular basis. There are no guarantees, but the pay-off can be life-changing. The one caveat is that you should not enter any therapy likely to uncover past trauma and abuse until your mood is stabilized, usually with medications or a less invasive short-term talking therapy such as cognitive therapy.
Unfortunately, insurance tends to cover only a limited number of sessions, so you may have to hit up your friends at the Bada Bing! for a loan.
For free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body.
Jan 25, 2005, reviewed Feb 10, 2008
Articles on Talking Therapy
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Meds plus talking therapy may be more powerful than either alone.
Talking Therapy - The Evidence
We know talking therapy works. Now we are starting to learn when and why and how.
What is more likely for Tony Soprano? A successful resolution to his therapy or a federal indictment?
Knowledge is Necessity
Copyright 2010 John McManamy Contact
