Listening With Empathy

Your psychotherapy session is now a major HBO Miniseries, In Treatment. Mine too. Two obvious questions occur. One for prospective clients, one for therapists. If I go to see a therapist about some personal issues and problems, is this what I can expect from treatment? If I am a therapist and someone walks into the room, is something like this HBO series what the individual is expecting? In either case, I decided literally to check out a dozen weeks of the series from Blockbuster and watch it all at once in order to perform a reality check and manage the expectation. Full disclosure: I watched about a dozen of the episodes from seasons one and two.  I did not see how the narrative ends. If you require an update or synopsis on the drama (“melodramatic content”) of the series, that is not provided here.

This is what I learned. The writing is top notch. The screen plays are well written, developed, and engaging – from a dramatic point of view. The acting is top notch. The performances are well crafted. In Treatment is different than real world psychotherapy in at least three respects.

First, the amount of work required getting to a psychodynamic insight, transformation, and result is minimized in the screen play. Thus, the show condenses into a twenty minute segment what might reasonably be expected to require ten or more actual psychotherapy sessions. Unfortunately, by its very nature television turns real human suffering into melodrama. That is not necessarily bad – no finger wagging here – since sometimes we all do the same thing – and that includes psychotherapy patients. We tend to turn suffering into melodrama. Now add psychodrama. However, the challenge is to distinguish real human suffering from the melodrama, each of which is a fundamental part of life. Psychotherapists understand that life can be – is -  a veil of tears. Life is also  inherently dramatic – and melodramatic. Some people are very attached to the melodrama. Without in any way dishonoring or minimizing the challenges of being a victim, the melodrama of victimization or specialness or rescue fantasy provides significant secondary gains (“pay off”). Some flaunt the melodrama; others are ashamed of their melodrama. In some cases, the melodrama is out-and-out human tragedy including shocking trauma, deep suffering, and all the negative side effects that go with it. In other cases, there is a noticeable absence of trauma and yet significance emotional upset, possibly related to pathogenic fantasies and ideas. Significant work over a number of session – not necessarily years, but definitely more than twenty minutes – is required to disentangle these distinctions.

Second, from a clinical point of view, the psychotherapist, Paul, displays excellent intuition. However, he does not have enough time to deploy the long term immersion in listening to the other person required for sustained empathy. What is the difference? Intuition uses subtle clues in the other’s speaking and behavior to provide inferences to the other in a kind of educated guess as to what is going on that can even rise to the level of an “Aha!” moment. Empathy is a form of vicarious experience of the other individual in which I know what the other is experiencing because I experience it too, albeit as a trace affect, experience, or sensation. I repeat: just a trace affect, not total immersion and merging. Empathy includes the additional condition and qualification that the self-other distinction is maintained, even if momentarily suspended via a transient, temporary identification. In a psychotherapy context, empathy requires a sustained immersion – listening – to the other individual and the other’s story, experiences, narrative. There is not a lot of time to do that on camera in a half hour show. Intuition is more dramatic and engaging. For example, in the case of the college student in season two who has a life threatening disease that she does not want to acknowledge (or get chemotherapy for), the young lady presents to Paul with a critical account of a former therapist who kept repeating herself and who was dropped. Paul immediately infers – what is likely accurate – that the client will do the same to him as soon as he stumbles into her blind spot. He shares this with her without apparent impact on the client but with significant impact on the listening audience, who are suitably impressed. Empathy would have required Paul to provide additional context and interpretation based on the real fear (at having a dread disease) and defensive “flight (and fight)” reaction by way of background – you are (perhaps) feeling not listened to, appreciated, or understood; and who do you usually respond when that happens? This is not to say that intuition is useless. It is a powerful tool, and given the urgency of the client’s predicament, it has its uses. The point is just that, as a show, In Treatment is limited in its ability to exploit the distinction between intuition and empathy due to the inherent constraints of the media. The really important content – the empathic resonance – is not visible on the DVD. It never is. To “see” it, one would have to be able to introspect the experiences, sensations, and feelings of the listener and speaker. One more thing. The celebrated psychoanalyst, Heinz Kohut, engaged this distinction between intuition and empathy in detail towards the backend of The Analysis of the Self (1971) where he pointed out that the beginner psychotherapist often has a keen appreciation and use of intuition. As the therapist becomes more experienced in the analysis of the self, this intuition is transformed into the capacity for empathy – as well as human creativity, and wisdom. In this respect, Paul is more of a beginner than is acknowledged in the screen play.

Finally, while psychotherapy can indeed call up the ghosts of the past – trauma and unhappiness – the process can be empowering in the areas of self-expression, creating possibilities, and even fun. In Treatment is a dark and difficult melodrama. Granted that individuals are often impelled into therapy by dark, traumatic, and difficult life experiences, once engaged underway therapy can be a source of satisfaction and even joy. Fun is conspicuously absent (granted, it is rarely apparent at the start). Naturally, all the usual disclaimers apply – your mileage may differ. However, one might reasonably expect to see significantly more favorable outcomes than what occurs in the (otherwise excellent) screen writing. According to the screen writers, the amount of advice, guidance, and confrontation that Paul provides is quite simply “over the top” in relation to real world psychotherapy. Once again this is not to say that advice, and so on, is bad. Far from it. It is useful. However, it is not what psychotherapy is about in its fundamental commitment. In its fundamental commitment, psychotherapy is a commitment to provide a gracious and generous listening (empathy) in the interest of client (patient) possibility, transformation, and self-expression. Often one of the more immediate results of empathy is symptom relief. Significant work is required for the transformation of symptoms into creativity, wisdom, and pragmatic results. Amidst interpretations, pattern detection, transference, and explanations, the work of therapy requires a dogged ability to engage and put what is not working (including the past) back in its place in order to open the future to new possibilities. I know of one client who, in a more cynical moment, said to his therapist, “This process is like being the friend of Tom Sawyer. You have to both paint the fence and pay to do it.” Well, after the age of Listening to Prozac, it can seem like a lot of work; and surely talk therapy takes something extra over and above the band-aide of popping a pill (or a long series of them, the side effects of which you do not want even to think about). Nevertheless, it does not have to be a years long process – though that is possible too – and significant results can be gained in ten or twelve sessions of psychotherapy; and the collateral damage is significantly less than ten or twelve sessions of ECT [electro convulsive therapy] and I have seen ECT used up to 40 sessions. Imagine what can be accomplished in 40 sessions of talk therapy. Okay, ECT is not funny; the delivery of the shocks has been improved to provide micro-bursts; and if you are suicidal, all options are on the table against suffering. Extra caution: Both parties have to be clear and explicit about the therapeutic contract up front in to get results such as those envisioned here. However, the point is that In Treatment just might give talk therapy the boost in requires in this post Prozac, pragmatic, results-oriented age, even amidst its melodrama, virtual experience of treatment, and intuitions.