Psychotherapy educators have long struggled with the problems inherent in finding good examples of psychotherapy to use for teaching and using the actual cases of trainees and faculty. The cornerstone of psychotherapy is confidentiality, and patients who consent to have their psychotherapy videotaped and observed by others give up the fundamental right to privacy. Under the current HIPAA laws, the legal complications of videotaping psychotherapy are even more formidable. Moreover, the presence of observers, through the technology of a camera, may alter how one actually behaves in the privacy of one’s office when conducting psychotherapy. Hence psychotherapy being taught with the aid of DVD or video may be different from psychotherapy that takes place in the unobserved privacy of the consulting room.

Psychotherapy in the media operates on a set of principles that bear little resemblance to real-life psychotherapy (1, 2). Nevertheless, there have been reports of using psychodynamic psychotherapy depictions in film (3) or TV (4) to teach psychiatric residents and medical students about the fundamentals of psychotherapy. Depictions of psychotherapy that have some degree of accuracy, though, often involve much greater activity than in a typical psychotherapy session. The fundamental and irreducible problem is that psychotherapy is not “showbiz” (5). Hence writers of teleplays and screenplays find ways to keep the audience’s attention by having the therapist or patient get up and walk around the office, attempt to seduce each other, or undergo intense emotional catharses that in reality may occur only once or twice in the career of a typical psychotherapist.

It is our contention that those media portrayals of psychotherapy that come reasonably close to what happens in the therapist’s office are probably more useful to teach how not to do psychotherapy. Even in the best depictions, therapists regularly make the kind of predictable mistakes that are common in psychotherapy practice—what are often referred to as countertransference enactments or boundary crossings (6). In the Golden Globe-nominated HBO series In Treatment, which began in 2008, a psychotherapist named Paul (played by Gabriel Byrne) is featured five nights a week in 30-minute sessions with three individual patients, a couple, and some variation of consultation, supervision, or personal psychotherapy (the exact nature of the process is unclear). Paul treats a female patient named Laura (Melissa George), who, after a year of psychotherapy, has developed a highly erotized transference, to the point where she literally wants to have sexual relations with Paul rather than to understand her longings.

Paul mishandles the transference, in part because he is sexually drawn to Laura, and he ends up terminating the therapy and expressing his strong feelings for her. It is to the writers’ credit that the evolution of Paul’s boundary violation with Laura is portrayed in a reasonably believable way that resembles to a remarkable degree how psychotherapists become sexually involved with patients (7).

Psychotherapy educators can use this step-by-step evolution of a therapeutic boundary violation to illustrate where Paul made errors in judgment and provide alternative therapeutic strategies that might have been helpful to the patient.

Laura is a woman in her early 30s who is an anesthesiologist. She has a history of a sexual encounter with an older man when she was 15 years old. She did not view it as abusive—she described it as having occurred with mutual idealization, love, and pleasure. However, the adult consequences of this teenage experience were a prevailing sense of either veiled resentment of abandoning men or self-disgust because she repeatedly reenacts unsatisfying, erotic situations with men. In the first session of the series, she comes from a sexual encounter with a stranger at a bar and tells Paul about it. Near the end of the session, she reveals that for the last year of the therapy she has fallen in love and experienced sexual longings for Paul. When he does not reciprocate by expressing love for Laura, she leaves, saying that she will go “into a deeper darkness” following the perceived rejection she experienced from Paul. At the end of the next session, while standing at the door to leave, she confronts Paul directly: “Do you want me, yes or no?” Paul pauses for a moment and says simply, “No.”

This brief vignette is useful in teaching psychotherapy. First, it illustrates the common phenomenon of the “exit line” or last-minute interaction (8). Often the patient artificially constructs a partition between what happens while sitting in the session with the therapist and what happens after the ending is announced and the patient walks through the doorway. These moments at the door generally involve heightened transference that was not verbalized during the session and some form of verbal risk-taking because the patient knows that she or he can get out of the office after hurling the parting shot. Laura’s question of Paul poses an extraordinary dilemma for him, and his first technical error is to attempt to answer the question at all in the last few seconds of their encounter. Educators can illustrate ways to respond that suggest the question is of value but should be addressed in the next session, when they have more time to explore it. For example, Paul might have said, “This is a question that we need to talk about in more depth, rather than giving you a yes or no answer at the end of the session. Let us agree to take it up together when we start next time.”

The other aspect of the dilemma of disclosing whether one has sexual feelings for a patient is that it is essentially a no-win situation for the therapy, no matter how the therapist answers the question. Presenting this dilemma to the patient at the next session could be a much more useful way of responding than to give a yes or no answer. The therapist might say, “I know that last time you asked me whether I wanted you, but that is the kind of question that I can never answer during therapy. If I say no, you may feel devastated, and if I say yes, you may feel that therapy is no longer a safe place to explore whatever feelings you have with the assurance that the professional boundaries will be maintained.” In this way, the psychiatrist reinforces boundaries, maintains a therapeutic alliance where it is clear that the task is understanding rather than action, and still takes the question seriously.

An additional problem with this disclosure is that Paul chooses to be dishonest. As the series continues, the writers make it eminently clear that Paul has strong sexual feelings for Laura and desires her very much. Nevertheless, he chooses to say that he does not want her, lying to her while making her feel terribly rejected. Once again, if he had presented the dilemma posed by the question and explained why he could not answer it, he could have avoided being dishonest while he was also avoiding self-disclosure. One can be restrained and reserved without having to resort to lying.

Psychotherapists who find themselves experiencing sexual desire for a patient should probably seek consultation with a colleague to obtain some supervision on optimal therapeutic strategies with which to deal with the transference-countertransference situation. In In Treatment, Paul seeks out help from Gina (Dianne Wiest), a former supervisor during his psychoanalytic training, with whom he had an intense conflict. Indeed, at one point she even wrote a negative letter that prevented him from progressing within the psychoanalytic institute. Here again, the series offers a clear example of what not to do in a difficult psychotherapy situation. Not only is Gina a former nemesis toward whom Paul has ongoing residual feelings of resentment, but, like Paul, she struggles with maintaining professional boundaries.

The process depicted between Paul and Gina is not defined at the outset. No fee is exchanged. Gina says she is retired, but she is coming out of retirement to see him. They do not define whether the purpose is for supervision or consultation or if they are simply two former acquaintances getting together for a chat. They frequently discuss their previous relationship and depart from the purpose of the visits. At one point, Paul talks about his marital difficulties, and Gina encourages him to bring his wife next time. They then proceed to have marital therapy sessions with Gina as though her role has transformed from consultant to therapist.

This development offers useful opportunities to teach about the boundaries of supervision/consultation versus psychotherapy. One could also use the interaction to discuss how one selects a supervisor or consultant. One must have sufficient trust in the individual so that one can open up and be vulnerable without fearing consequences such as those which occurred earlier in their relationship. The therapist who is struggling with boundaries must have clear boundaries in the consultation process so that the consultation itself models professional boundaries for the therapist.

In addition to all the foregoing problems, Gina suggests that Paul should terminate the therapy with Laura without trying to help him work through his countertransference difficulties. When he returns to Laura and suggests that they stop the therapy, she rightly responds with a perplexed, even flabbergasted reaction. Paul’s suggestion appears to have come out of nowhere, so Laura correctly deduces that it must be related to Paul’s feelings toward her. The rejection that she experiences in reaction to his suggestion that they stop violates the basic principle of “First, do no harm.”

Psychotherapy educators can take this interaction as a starting point to discuss what a supervisor or consultant does in such situations to try to ascertain if the therapy is viable. If the countertransference is manageable and the therapy can continue productively, the educator can discuss how a supervisor or consultant approaches the optimal management of such countertransference.

Another failure in the therapy is Paul’s approach to the transference as though it is a real, concrete situation that requires a yes or no decision. Laura’s transference is erotized in the sense that there is no “as if” realm to discuss her feelings. In other words, instead of discussing it as if they were in a romantic relationship and therefore something to be explored, she treats it exactly as though they really are lovers and the question is whether or not Paul will go to bed with her. Paul falls into a similarly concrete response mode. He thus misses the opportunity to deal with this as a significant repetition of a longstanding pattern of male relationships that Laura has had that has led to her unhappiness.

Psychotherapy educators can use this situation to illustrate how a therapist might take advantage of the preexisting therapeutic alliance to use the feelings therapeutically and interpret their meaning for the patient. For example, over a period of sessions, ideas such as the following could be communicated to Laura: “I hear you saying that you are feeling angry at me because you wanted to express love to one another and be together in a sexual and physical relationship with mutual expressions of love. Instead, however, you experienced my insistence on adhering to clarifying and interpreting what is going on as a gutless rejection of the genuine feelings you have. I know the feelings are real to you, Laura, and I must tell you that on your behalf and in my role as your therapist, I place the highest value on restraint of any wishes I would have to reciprocate your expressions of love. The highest value is on your behalf, to help you avoid another repetition of a cycle in which one person rejects the other, leading to blame, anger, sadness, and self-disgust. I want to make it clear that I am not rejecting you, although I know you feel like that is truly what is happening.” Such clarification may be segmented into a series of interventions, of course, but also one is maintaining an emphasis on the therapeutic task when pointing out the here-and-now wishes of the patient.

The focus of the further interventions can be interpretive in nature: “One of the things that I think is happening here is a repetition of a particular type of relationship with an older man who is forbidden that has haunted you throughout your life. By not responding, my goal is to help you learn to love with restraint, both here with me and in the future in outside relationships. This capacity can help you form an enduring commitment instead of another disappointing and tragic romance. Hence I am asking you to fully acknowledge your feelings toward me, even the sense of rejection, but also note that my restraint is not a rejection of you but rather a commitment to further your development.”

The psychotherapy educator would, in the ideal situation, stop the video or DVD at various times and show how a fragment of this lengthy discourse would be introduced here or there, making the point that the patient will stop listening after the first or second sentence. In that way, the educator would teach timing and sequencing of interpretation so that only a digestible amount is offered at one time.

The use of media depictions to demonstrate what not to do in psychotherapy lends itself to an evaluative component. One could easily develop questions, perhaps with a Likert scale, that would determine whether or not psychiatric residents have learned the key concepts depicted in the fictional therapeutic relationship. What constitutes a boundary violation? What constitutes a boundary crossing, short of a true violation? What is the difference between erotic and eroticized transference? How does one select a consultant? When does one seek a consultant? How does one phrase a transference interpretation when there are sexualized feelings present? Does the therapist treat the feelings as “real” or “unreal”? These are only a few examples of the kinds of evaluation questions that can help an educator determine if the learning task is being accomplished.

At the time of submission, the authors declared no competing interests.