Most portrayals of psychotherapy in movies are rich with examples of bad psychotherapy. Prime examples are the boundary confusion and ethical breaches in Prince of Tides, resulting when the psychiatrist (portrayed by Barbra Streisand) has an affair with the brother of one of her patients. Other bad psychotherapeutic techniques that are illustrated in movies include premature confrontations; intellectualizations by patients and therapists alike; overuse of jargon; preoccupation with simplistic single-trauma etiologies, for example, The Three Faces of Eve; and overly dramatic cathartic resolutions. Many other examples are chronicled in Psychiatry and the Cinema (R1VMEDIA1).
There are a few movies in which reasonable examples of competent psychotherapy are presented. These serve as graphic demonstrations of the value of good psychotherapy, and can help counter the usually distorted presentation of psychotherapy in movies. Another educational advantage of movie psychotherapy is that confidentiality is not a problem since the "patient" is an actor portraying a role. A few movie psychotherapies are so accurate and well done that they can be used, like process notes, to illustrate and teach the major principles and techniques of psychodynamic psychotherapy. Ordinary People is one such movie, in which Timothy Hutton portrays the patient Conrad and Judd Hirsch portrays the therapist. The following is a summary of Conrad's background, the transcript of a session vignette, and an extensive discussion of its educational usefulness in teaching psychodynamic psychotherapy, as applied to the treatment of adolescents.
In the film, Conrad is a 16-year-old high school junior when he was referred by his therapist from the inpatient unit in another city, where he had been hospitalized for 4 months by his affluent parents after a serious suicide attempt. After discharge, Conrad continued to experience nightmares, frightening flashbacks to the boating accident that occurred 1 year before in which he saw his older brother die drowning. Conrad experienced chronic agitation, appetite loss, poor concentration, and avoidance of his former friends. The initial diagnostic impression was that Conrad was experiencing a major depression with agitation, without active suicidal ideation, and despite his initial guardedness he agreed to psychotherapy twice weekly. Medication could have been included in the treatment to directly address Conrad's biological symptoms (e.g., loss of appetite and sleep disturbance) as a complement to his psychotherapy, but this addition was not used in the movie therapy.
In early sessions, Conrad avoided talking about his daytime activities and feelings by focusing on his dreams. When the purpose of avoiding his current feelings by doing so was pointed out, Conrad then pushed himself to experience emotional catharses of anger in the sessions. But he reported that he did not feel better afterward. He repeatedly retreated to a guarded attitude about any feelings, which reflected both his longstanding intellectual style of functioning, and his particular inability to grieve for his brother's death. Considerable therapeutic effort was needed to help Conrad acknowledge and address his anxiety about his anger and sadness and the inhibitions in his functioning created by the resulting conflicts.
Conrad then began to address his feelings about his parents. He described his father as passive and inhibited, but concerned and giving. In contrast, Conrad "didn't connect" with his mother, due in part to her obvious emotional aloofness, but which also probably reflected, from a deeper psychoanalytic perspective, his defensive struggles against age-appropriate sexual fantasies involving his attractive mother, part of a normal resurgence of Oedipal conflicts during adolescence. After Conrad's realization in therapy that he had competed unsuccessfully for his mother's attention with his older brother, who seemed to have been her favorite, he quit the swim team on which his brother had been a star, and for the first time asked a girl out on a date. His mother confronted him about quitting the swim team, but she had appeared angrier at the embarrassment she experienced than worried about Conrad.
He had, in turn, angrily confronted his mother with never having visited him during his psychiatric hospitalization. The following is the transcript of a vignette from the psychotherapy session (R1VMEDIA2) that immediately followed. Please notice how the therapist addresses Conrad's numerous resistances and how Conrad's slip of the tongue reveals his conflicts about his mother's love, and suggests his core adolescent identity struggle.
Therapist: So you felt great. You brought a Christmas tree and everything was hunky dory. OK?
Conrad: You're the doctor.
Therapist: Don't take refuge in one liners like "you're the doctor!", OK, because that pisses me off.
Therapist: So everything was fine until you had a fight with your mother, and then everything was lousy.
Conrad: Yeah, but I don't blame her. She's got her reasons. It's impossible, after all the shit I pulled.
Therapist: What shit have you pulled?
Therapist: Hey remember, I'm talking proportion here…Now what shit? Come on, you must be able to come up with one example. And don't give me "I tried to kill myself." That's old turkey! What have you done lately?
Conrad: Hey, come on. Listen, I'm never going to be forgiven for that. You know you can't get it out—all the blood in her towels and rugs. Everything had to be pitched. Even the tile in the bathroom had to be regrouted. Christ, she fired the goddamned maid because she couldn't dust the living room right. If you think I'm going to forgive…she's going to forgive me… (long pause).
Conrad: I think I just figured something out.
Conrad: Who is it who can't forgive who.
Therapist: Well, a real problem, and a real problem has a real solution.
Conrad: I've heard this all before.
Therapist: It doesn't make it any less true.
Therapist: That's a hell-of-a-secret you've been keeping on yourself.
Conrad: So what do I do now?
Therapist: Recognize her limitations.
Conrad: You mean, why she can't love me?
Therapist: Oh kiddo, no; like she can't love you enough. Don't blame her for not loving you more than she's able.
Conrad: She loves my father and I know she loved my brother; it's me.
Therapist: Oh, now we are back to the "rotten kid" routine. She can't love you cause you're unlovable. Where does that leave your dad? How come he loves you? You are a rotten kid. Doesn't he know that?
Conrad: That's different. He feels responsible. Besides, he loves everyone.
Therapist: Oh, I get it, he has no taste. He loves you but he's wrong. Look, maybe she can't express it the way you'd like her to. Maybe she's just afraid to show you the way she feels.
Conrad: What do you mean?
Therapist: I mean there's someone besides your mother you've gotta forgive.
Conrad: You mean me? For trying to off myself?…Don't just sit there and stare at me! What for?!
Therapist: Why don't you give yourself a break. Let yourself off the hook.
Conrad: What did I do?! What did I do?!
Therapist: We'll talk about it on Thursday…Come on, time's up.
Conrad: What do you mean? You're going to pull the plug? What did I do?
Therapist: Come on Connie, you know the rules.
Conrad: Rules…what rules? Can't I have a few minutes?
Therapist: You think about it…just think about it.
Since the session vignette is brief, the dynamics of Conrad's psychotherapy are highly condensed. The movie therapist's interventions are exaggerated, and although I do not advocate that they be literally emulated, they can be used to illustrate, explain, and teach the following aspects of psychodynamic psychotherapy with adolescents.
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1. Transference and Resistance
The session vignette started with a transference resistance, Conrad's sarcastic comment "You're the doctor," with which he recreated two conflicting aspects of his identification with his father. With his words, Conrad conveyed his manifest experience of his father and therapist as infallible. But his sarcasm betrayed the latent meaning that his father and therapist didn't know everything and were viewed also as ineffectual and degraded. He reenacted this frustrating struggle to identify with his loving but passive father in his new relationship with the therapist, by seemingly submitting in agreement to the therapist's intervention, while simultaneously rejecting it.
The therapist effectively confronted this initial passive—aggressive resistance with "Don't take refuge in one liners like ‘you're the doctor,’" and he consistently confronted other resistances throughout this session vignette. For example, when Conrad blamed himself for "all the shit I've pulled," the therapist questioned "What shit have you pulled?" And when Conrad resisted again with silence, his therapist anticipated him and said "And don't give me ‘I tried to kill myself.’ That's old turkey! What have you done lately?" Despite this strategy, Conrad talked about his attempted suicide anyway. Later, when Conrad said about his mother "She loves my father and I know she loved my brother; it's me" (that is bad), the therapist challenged "now we are back to the ‘rotten kid’ routine." This is another therapeutic attempt to challenge the cognitive distortions that undermine Conrad's self-esteem and to reduce his excessive guilt and self-hatred, since such a harsh and punitive conscience contributed to his depression and suicidal attempt. Conrad even attempted to discredit the therapist's comment on his father's love ("Where does that leave your dad? How come he loves you"?) with "That's different. He feels responsible. Besides, he loves everyone." The therapist responded to this resistance with a sarcastic comment: "Oh, I get it, he has no taste. He loves you but he's wrong." Resistances are relentless and require equally relentless therapeutic work to remove them as roadblocks to the unfolding of essential conflicts.
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2. Neutrality and the Real Object
Neutrality of the therapist was evident in his balanced comments about Conrad's mother. When the therapist challenged "What shit have you pulled?" (to warrant his mother's antagonism), the therapist was taking the position that it was reasonable for Conrad to blame his selfish mother. Later, he began to shift the focus to Conrad's internal conflicts about his mother when he encouraged Conrad's objectivity and tolerance of her problems with "recognize her limitations…like she can't love you enough. Don't blame her for not loving you more than she's able." By including both a focus on the mother's problems with Conrad (e.g., her selfishness), as well as Conrad's problems with his mother (e.g., he competes for her love), the therapist's neutrality encourages Conrad to further explore his deeper conflicts about missing, wanting, and fearing his mother's love.
As the therapist put it so succinctly, "Hey, remember, I'm talking proportion here." This is the essence of neutrality, which is not passivity. "Proportion" is the meaning of therapeutic neutrality, originally described by Anna Freud (R1VMEDIA3) as "remaining equal distance from superego, ego, and id." This jargon of psychoanalytic structural theory can be used to describe the great flexibility necessary in applying the concept of neutrality to work with adolescents, because of two important developmental considerations. Conrad's adolescent id, inflamed by hormones, and superego, stimulated by guilt, are so overactive that they easily overwhelm his ego, resulting in anxiety and related symptoms.
His therapist needed to reestablish a "proportion" by using many ego-supported interventions, for example, helping to rechannel desires (id) into obtainable directions, challenging Conrad's excessive self-blame (superego), and expanding his recognition and understanding (ego) of his conflicts.
Conrad's therapist also needed to serve as a real object, and yet still maintain neutrality, since both are essential to effective psychotherapy with an adolescent. Conrad is too hungry for connections with other people to conform to the constraints appropriate for adults. He experiences his adolescent establishment of independence from his parents as, in part, an abandonment of them, leaving a vacuum. (As one early adolescent girl told me poignantly, "I'm too old for toys and too young for boys.") This is not to suggest that the therapist allows a conventional friendship with a patient, but he does allow a more down-to-earth rapport, portrayed in the movie by the therapist's eccentric techniques (e.g., sitting on the floor in some sessions); presenting some personal feelings (e.g., hiding behind one liners: "pisses me off"); and drinking coffee during the session, etc. My adolescent patients use the "analytic" couch in remarkably imaginative ways (e.g., sitting on it and playing catch with me while we talked during a session).
As illustrated in Conrad's therapy, such relaxation of classic technique regarding neutrality, including needed ego-supportive interventions, as well as the therapist serving as a "real object," contribute to an effective therapeutic relationship. While remaining neutral about Conrad's complicated, conflicted relationship with his mother, his therapist conveys warmth, honesty, willingness to understand complex problems, and a courage to confront painful feelings, all which foster the development of a strong emotional engagement, allowing Conrad to be able to hear painful confrontations and interpretations.
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3. Slips of the Tongue and the Observing Ego
Conrad's slip of the tongue was pivotal in his session to an understanding of his deeper problem. After he had said, "Christ, she fired the goddamned maid because she couldn't dust the living room right," he intended to say, " if you think she's going to forgive me," but instead he said, "If you think I'm going to/she's going to forgive…." Consciously, he worried that she blamed him, but unconsciously he blamed her. Crucial to effective participation in therapy, Conrad had listened to his slip: he paused and looked puzzled and then said, "I think I just figured something out…who it is who can't forgive who." Conrad's spontaneous self-observation of his slip of the tongue about his mother allowed him to uncover conflicts about which he had not been aware. These conflicts had been fueling his major symptoms of excessive self-blaming and are crucial to his therapy.
Also, by allowing Conrad to proceed at his own pace, the therapist not only allows him to address issues he can tolerate, but Conrad is more impressed with the significance of his own discoveries. Conrad's more abstract conceptual ability to observe himself, a function of his observing ego, illustrates perhaps one of the most significant requirements for a patient to effectively use psychoanalytic psychotherapy.
Some adolescents may not demonstrate their observing ego so spontaneously or overtly as Conrad did, requiring the therapist to elicit or foster it, for example, by encouraging a patient's curiosity about his/her experiences, by pointing out inconsistencies, or by asking repeatedly, "what did you think of what you just reported?"
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4. Unconscious Conflict Expressed Somatically and Making it Conscious
Conrad reported how tired he felt at unearthing his conflicted blaming of his mother, illustrating the somatic manifestations, which masked his depression. "That's a hell of a secret you've been keeping on yourself," was his therapist's reference to his defensively keeping his conflict unconscious, with the resulting tiredness, distraction, and nightmares. The rationale for making conscious Conrad's unconscious conflict was stated succinctly by his therapist: "Well, a real problem, and a real problem has a real solution." Only after Conrad's problem had been made "real" or conscious could he begin to address and resolve it with his conscious adolescent ego strength and maturing reality testing.
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5. The Role of Education
Specific educational comments about Conrad's parents, their strengths and limitations, his adolescent struggles with independence from and attachment to his mother, and about identical expected developments in the therapeutic process, can be found in this session. Although educational comments per se are not a primary technique in classic psychoanalytic psychotherapy, they helped Conrad free himself from his attachments to his mother, which would then allow for age-appropriate relationships. For example, Conrad asked his therapist "So what do I do now?" The therapist responded with information and advice: "Recognize her limitations"…etc. These were educational comments about the mother's probable narcissistic character disorder, which were intended as a framework against which Conrad might begin to understand his own conflicts about her love. Conrad's focus was initially external when he then questioned, "you mean, why she can't love me?" The therapist shifted to Conrad's internal preoccupation with her love when he clarified, "Oh, kiddo, no, like she can't love you enough" (to satisfy his unspoken expectations). Conrad then responded, "she loves father and I know she loves my brother; it's me," which could be a reference to his disappointment in the Oedipal rivalry with father and brother for her love.
In this session vignette, the shift from external situational to internal psychological explanation is aided by educational comments about the mother's personality limitations.
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6. Open- and Closed-Ended Interpretations/Gratifying or Frustrating Patients
The therapist sometimes used closed-ended, sometimes open-ended, interpretations and was very aware of the importance of the timing of interventions in the context of the psychotherapy. For some of the clarifying, confronting, and educational interventions, the therapist used closed-ended comments (e.g., when he questioned "What shit have you pulled?" or when he told Conrad to "recognize [his mother's] limitations"). These closed-ended comments and questions serve as a useful technique to focus on a specific issue or fact, but may at times limit the patient's exploration of conflicts by prematurely gratifying the patient with information or direction. Helping an adolescent search for his own answers engenders both taking personal responsibility for self-understanding and, if timed well, enable the patient to have the satisfaction of solving deeply seated conflicts when he is ready to do so. An example of an open-ended interpretation with attention to timing is the following: At the end of the session, the therapist suggested "there's someone besides your mother you've gotta forgive." Conrad then twice demanded "What did I do?" Instead of gratifying his questions and his requests for extra time, the therapist frustrated them with "We'll talk about it on Thursday…", etc. This tactic illustrated the importance of timing of interpretations, since by letting Conrad assume responsibility for further exploration of his self-blame, the therapist left him motivated for further therapeutic work, both in sessions and between them.
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7. Multiple Determination of Symptoms and the Working-Through Process
Further sessions would be needed to address the multiple determinates of Conrad's depression, excessive self-blaming, and suicidal attempt, including the effects of his mother's emotional unavailability on his psychological development, his resentment that his mother loved his father and brother more, his rivalry with his brother and father, his guilt for having survived the accident in which his older died (revealed in later sessions in the movie), and this rivalry with his older brother for his mother's love. From a "classic" psychoanalytic perspective, many of the determinants of Conrad's symptoms suggest Oedipal rivalries that he cannot resolve due to a combination of factors, predominantly his continuing to seek (pre-Oedipal) love from his mother who was not capable of supplying it; the disequilibriums in his psychic structures common to the adolescent period; and the intense (Oedipal) guilt he must feel for surviving his brother, a prime rival for his mother's love. Of course, Conrad's difficulties could be explained by other equally cogent constructs and analytic theories, for example, object relations (Winnicott; Kernberg), self-psychology (Kohut), separation-individuation (Mahler), and family systems (Ackerman). These are not inconsistent with the analytic constructs already described, but a detailed discussion is beyond the scope of this article.
"I've heard this all before," said Conrad. "That doesn't make it any less true," said his therapist, confronting Conrad's resistance to the working-through process. Conrad may have "heard" his conflict intellectually, but he probably resisted and avoided the emotional pain that was associated. Each of the multiple determinants of Conrad's depression would need to be identified, clarified, confronted, and understood in all their many manifestations in his thoughts, feelings, symptoms, day- and nighttime dreams, personality traits, and relationship manifestations, for him to make permanent improvement.
This "working-through process" is complicated and requires tact and skill, as shown in many ways by Conrad's therapist. The therapist fosters Conrad's self-observation skills (e.g., the slip of the tongue), his curiosity, and his desire for relief from suffering, while negotiating Conrad's objections to therapy (e.g., the painful reminders of his brother's death), and the anxiety stimulated by exploring conflicts about his mother's love. These complexities of the working-through process help explain why therapy may require relatively frequent sessions (e.g., two to three times a week) and sometimes a longer duration (e.g., 1 to 3 years).
By the end of the movie, Conrad has weathered the suicide of a friend, reconciled with his mother, established a relationship with a girlfriend, and partially resolved his agitated depression. The implication by the end of the movie Ordinary People, which beautifully and accurately depicts the working through and termination stage of therapy, is that the time, effort, and money were well spent for Conrad's considerable improvement of symptoms and in his behavior.