Reflections on “In Treatment”

In Therapy, Is the Customer Ever Right?

Season 1, Episode 2

There’s a joke among therapists that the customer (client, patient, consumer) is never right. Sorry, it’s not a very good joke. Actually, only therapists of psychodynamic schools of therapy tell that joke, the Freudians, Jungians, Adlerians, Kleinians, Bernians, and Lacanians among us. Cognitive Behavioral Therapists might chuckle, too; as would any garden variety addiction counselor. But no other kind of psychotherapist would ever think the joke was funny.

The point of the joke is that people kid themselves, they practice denial, and throw up their defenses against knowing the truth. It’s the therapist’s job to get past those defenses and show the client what he should have been seeing all along. The goal of therapy, to a psychodynamic counselor, is insight. They want you to be able to see clearly, and they assume, when you come to their office, that you are not.

The variety of therapist least likely to enjoy the joke would be the person-centered kind. They believe the client is always right when they are fully themselves. That is to say, they are not right all the time, but given enough empathy, sincerity, and acceptance, they will eventually come around to declare the truth. Maybe a person-centered therapist would chuckle a little in private because he knows how seldom people exist in a world where there is empathy, sincerity, and acceptance.

I got to thinking about this joke when I heard it repeated in episode two of the first season of In Treatment, the acclaimed HBO series. They say a new season is coming out soon, so I wanted to catch up. It’s set in a therapist’s office and I can’t watch another therapist in action without doing a lot of kibbitzing in writing.

[Spoiler alert]

The therapist in the series, Dr Paul Weston, imprudently tells that joke to a new client, Alex, the moment he meets him. Alex is a bit taken aback, but he’s not easily deterred, so he charges ahead to show how wrong he can be.

Alex is a Navy pilot, home on leave. He became notorious in the Moslem world after bombing a school in Iraq and killing sixteen children. He claims to feel no guilt. He was just doing a job, carrying out orders. He did not pick out the target, others did. Yet, he gave himself a heart attack himself by running a marathon he was in no shape to complete. Now, he plans to go back to visit the site of the bombing, even though the Moslem world has put a price on his head.

If all this sounds non-sensical and far-fetched; well, it’s television. The presence of absurdity is also a good sign a person is lying to himself. Most would agree the man is acting out of unconscious guilt. Alex is unable to acknowledge his guilt, but goes around acting as a guilty person would, punishing himself, and throwing himself open to retribution.

Guilt is a notoriously difficult feeling for a therapist to maneuver around. All schools of therapy agree that therapists should not go around laying guilt trips on people, even when they need to go on one. Therefore, it’s not Weston’s place to tell Alex he should feel guilty. Indeed, we more often try to talk people out of feeling guilty than talk them into it. People are always feeling inappropriate guilt for things over which they have no control. In Alex’s case, since he did not choose the target, most would agree he should not bear the entire burden of culpability, On the other hand, it is proper when people feel bad after they obliterate the lives of sixteen children, even if they didn’t know they were doing it.

As it is, Alex claims to be both not guilty and not feeling guilty, yet he behaves just as a guilty man would. He’s going to get himself killed for no good reason, and that won’t change anything. It would be better to bring the guilt out into the open and deal with it for what it is. Perhaps then he can make some meaningful amends to the degree he deserves to make them.

The other remarkable thing about this patient is how he takes charge of the session in an attempt to get Weston to do what he wants him to do. Another absurdity. He wants the therapist’s approval for his plan to go to the scene of the bombing. In fact, he has plans to get on a plane that very day. Alex seems to approach psychotherapy as he does a bombing run. Swift, decisive, and precise, Alex is not above flattery, humiliation, and intimidation to accomplish his mission.

In the middle of all this, Weston asks a single question that cuts to the core of the issue. Why does Alex need a therapist’s approval? Can it be that the Navy pilot is unable to take responsibility for himself? Alex has no good answer, but he leaves the session without the approval he came for, forced to take responsibility if he still decides to go.

This little episode is a good illustration of how wrong psychotherapy customers can be. You may be wondering; are they always this wrong? The answer, I believe, is a qualified yes. I believe psychotherapy customers are always wrong because people in general are always wrong. Why should psychotherapy customers be any different? Life is big. It’s impossible to grasp all of it at once. Ethical dilemmas are complicated. It’s impossible to choose one thing without neglecting something else. Whenever we are certain, we are missing something. But, when we are uncertain, we hesitate and miss the moment we should have acted.

But I could be wrong.

Keith R Wilson is a mental health counselor in private practice and the author of three self-help books, three novels, and innumerable articles.