HOW IS PSYCHOTHERAPY PORTRAYED IN FILMS AND SERIES?

Particularly during the pandemic, many films and series were consumed in which psychotherapies were also portrayed. This is where quite a few patients get their information about the presumed content and course of treatment. Unfortunately, however, the portrayal is often distorted, which is examined in this article on the basis of three practical examples.

Text: Ion-George Anghelescu, Franziska Liedtke, Georgia Wendling-Platz.

Social understanding of psychotherapy may be reflected in the way it is portrayed in entertainment media. Therefore, it is important to consider the realism and impact factors of fictional psychotherapy in films and series. For the viewers, this also results in a lesson of “Dos and Don’ts”.

The portrayal of psychotherapy or psychotherapists in the media can influence the motivation of patients to seek therapy [1]. Movies and series about psychotherapy strongly shape public perception. Especially people who have no contact with the treatment of mental illness in everyday life are influenced in their opinion formation by the portrayals [2, 3]. In this context, the way psychotherapists are represented often reflects the social understanding of psychotherapy [4].

Especially during the coronavirus pandemic and the associated socio-political restrictive measures that resulted in significantly more time spent by people at home, the use of streaming services, media libraries, and also traditional linear television increased sharply. For example, according to a 2021 survey [5], 27% of respondents reported an increase in their television viewing time. It therefore seems all the more important to subject psychotherapy in current films and series to critical scrutiny and to assess them in terms of their realism and impact factors.

The aim of this training article is to use examples of two series and one film to assess whether the factors of psychotherapy are taken into account. In psychotherapy, specific techniques refer solely to concrete aspects of therapeutic action (“technical aspect: therapeutic operations” [6]). General effect factors, on the other hand, refer to different levels of the therapeutic process.They are therefore better suited to assess fictional cinematic works than would be the case, for example, with documentaries. Therefore, we have decided here to use Grawe’s [7] impact factors, which are frequently cited and used as standard.

Impact factors according to Grawe

According to this, the following basic, non-specific effect factors of psychotherapy can be demonstrated – across therapy schools and diagnoses:

– Therapeutic relationship: the quality of the relationship between psychotherapist and patient contributes significantly to a better or worse therapy outcome. In this context, “reparenting” also plays an important role, the patient’s newly gained experience in a supportive and accepting “parent-like” connection to the therapist.

– Resource activation: specifically addressing and utilizing the individual strengths, abilities, interests, and opportunities brought by patients.

– Problem actualization: the difficulties to be addressed in therapy are made directly experiential. This can be done by having the therapist and patient visit real situations in which the problems occur, or by using special therapeutic techniques, such as intensive storytelling, imagination exercises, role-playing, etc., to experientially re-actualize the challenges. -Motivational clarification: therapy uses appropriate interventions to promote the patient’s gaining a clearer understanding of the determinants of his or her problematic experience, thinking, and behavior, i.e., the origins, background, and maintaining factors.

– Problem management: Using proven problem-specific interventions, treatment directly or indirectly supports the patient in gaining positive coping experiences in dealing with his or her problems, thereby increasing self-efficacy expectations and coping skills.

The three prototypical films or series we selected are discussed below.

Television series: BeTipul – In Treatment

The Israeli television series “BeTipul” with two seasons in 2004 and 2008 was a great success with 20 adaptations in other countries: “In Treatment” in the USA, “En Thérapie” in France as well as adaptations in Spain, Serbia, the Netherlands, the Czech Republic, Hungary, etc.

BeTipul describes psychotherapeutic sessions over several weeks around psychologist Reuven Dagan, played by Assi Dayan, with his recurring patients. Viewers follow four individual therapies and one couples therapy in his office, as well as supervisions with his former supervisor and girlfriend Gila Abulafia (Gila Almagor).

The “one-room atmosphere”, which – as in real psychotherapies – creates condensation, leads to a strong tension and demands the highest concentration from both the actors and the viewers.

The viewer enters immediately with the first patient Na’ama, an almost 35-year-old surgeon, into a therapy that has been going on for over a year. The patient comes to the practice crying, alcoholic and hypothermic. She immediately stages several relationship tests with Reuven, recounting her four-hour wait outside his office, hypothermia, a possible dying outside his home, and wondering aloud if she could ask for a sweater.

Reuven shows compassion, provides her with a blanket, asks her to tell the full version, but also asks about alcohol consumption. The therapeutic relationship colors positively, however, suspicions quickly arise that Na’ama might be in love with him. Na’ama provokes him, describing in detail a sexual assault and watching him closely. Reuven seems to be getting more and more uncomfortable, which is clearly reflected in his body language. We learn that she is in a relationship and provoked a breakup the night before.

Finally, the patient confesses to Reuven that she fell in love with him at the very beginning of the therapy. Reuven is astonished, although one does not believe it, and appears visibly touched, almost caught.

The therapeutic relationship is put to the test throughout these sessions – how can Reuven maintain professional distance, how entangled is he? In this distress, he seeks out his old supervisor Gila. The assignment to Gila, however, is unclear – should it be supervision, a friendship visit, therapy, or settling old scores? Gila tries to clarify this with Reuven, but he vehemently refuses.

Therapist’s own intrapsychic conflicts

We experience a therapist who appears weakened by personal problems – his wife has distanced herself from him and is leading another relationship, as parents they no longer pull together, the children have become strangers to him – with simultaneous care fatigue and depressive development.

Very intensively the supervision sessions describe the dilemmas of his own intrapsychic conflicts and those of his patients. As a silent spectator, one would like to jump up and shout at him to take time out, rest, and clean up transference and countertransference as well as his “snake pits” – and find a new supervisor.

Modified form of psychoanalysis

Although it is not explicitly stated, we can assume that Reuven is a psychoanalyst. In the course, big names of psychoanalysis are mentioned, such as Freud, Winnicott, Messer, Davies and Bolas. “Stephen A. Mitchell and his New York gang” is also mentioned in the supervision as a reference to the problem of transference love. Mitchell is a representative of relational psychoanalysis and wrote the book “Can Love Last?” [8], which was published posthumously.

Reuven works with a modified form of psychoanalysis, talking to his patients in a sitting position, engaging more, often suggesting, addressing unconscious conflicts, and relating to their early relational experiences. However, he varies in his interview techniques. For example, he uses systemic questioning techniques, such as circular questioning, reframing, coping and resource questions, and again we see him rather little in the psychoanalytic stance of equal attention. He seems to leave that frequently due to his own lack of equilibrium.

Border crossings of the therapist

It is also problematic that Reuven arbitrarily transforms an expert opinion assignment on a young gymnast Ayala, played by Maya Maron, who has had an accident, into a therapy and thus mixes up the assignments. On closer inspection and listening, his patients always clearly and cleverly object to his crossing of boundaries and his abandonment of the therapeutic or expert position, accusing him of entrapment and helplessness. He tries to cope with his burnout by undermining his patients’ efforts at autonomy and by accepting new patients, thereby falling even more into the trap of over-commitment, and then further into the aggression and cynical rejection of his patients.

The Israeli psychotherapy reality is different from that in Germany, with health insurance-based financing and guideline psychotherapy. There, psychotherapy must be financed by the patients themselves. It can be assumed that a stringent diagnosis, the creation of a treatment plan or the definition of therapy goals hardly occur in the series.

Concern of the therapist weakens effect factors

If we look at the psychotherapeutic effect factors according to Grawe in this series, they can be found in principle, but they are always weakened by the therapist’s concern. Strictly speaking, we experience a therapist who is unfit for work, who only drags himself from session to session, transfers his problems to his patients and urgently needs time off.

For us as viewers, who are psychiatrists, psychotherapists or supervisors ourselves, we see a lesson in “Dos and Don’ts” – instructive examples for the training of young colleagues, reflective examples for experienced therapists and, of course, one or two well-known precarious situations from our own therapy history.

For laypersons, these series are challenging fare. The series differ little among themselves, only in terms of country-specific themes, history, and collective trauma. They offer a good insight into psychotherapeutic work, which is sometimes draining for us therapists, and can also lead to our own illnesses. The demystification of the omniscient and clairvoyant therapist Reuven impressively shows that in psychotherapy two or more people meet, each with their own life story, their own suffering and their personal coping strategies, and explore solutions together.

Netflix series: Gypsy

This thriller series Gypsy (one season, 2017) has a cognitive behavioral therapist as its main character, Jean Holloway, played by Naomi Watts. Jean’s unprofessional behavior gets her into emotionally critical, as well as actually threatening, situations. As a culmination of this, she gets involved in intimate relationships with her patients’ relatives and significant others, for example.

At the beginning of the series, it is presented that Jean is a psychological employee of a well-run practice, married to a professionally successful, loving husband Michael (Billy Crudup), has an eight-year-old daughter and good friends. The marriage is (mis)complicated by the protagonist’s opaque and contradictory behavior.

Despite the very positive life circumstances seen from the outside, she begins to visit a café, at first for no apparent reason. Working there is Sidney (Sophie Cookson), the ex-girlfriend of a patient who has been unable to get over the breakup for months due to an adjustment disorder, perhaps even a depressive episode, that is not labeled as such. Jean does not introduce herself as her ex-boyfriend’s therapist, nor does she discuss her plan with him in advance, but meets Sidney with an impromptu invented identity.

Jean’s behavior also changes in private: She aggressively demands sexual contact from Michael, drinks whiskey and messes with conformist mothers of her daughter’s schoolmates.

As a viewer with a professional psychotherapeutic background, several possible psychiatric diagnoses come to mind for Jean, who finds it increasingly difficult to maintain the facade of the perfectly functioning woman who is always at peace with herself. An acute destabilizing stress factor is added by her distrust of Michael, that he might have started an extramarital romantic relationship. In addition, her problematic role as her mother’s daughter becomes clear, as she shows herself to be emotionally cold and deprecating towards her.

In this regard, Jean remains a supposed mystery for many episodes, but the title of the series already tries to indicate the colorful, multi-faceted intentionality and emotional instability of the protagonist. Naomi Watts lets the viewer experience these shifts from controlled to spontaneous, from calm to angry, without justifying them. This is not always believable. The risk Jean takes professionally and privately with her double life seems far too high.

Personal entanglement of the psychotherapist

Dramaturgically clever, but highly unrealistic is the portrayal of the personal crisis Jean is heading towards. Little lies to have an evening off soon become a habit. The daily need for alcohol increases steadily. Finally, Jean, who is otherwise controlled and level-headed in most situations, has an impulse-control breakdown at her daughter’s birthday party and gets into a heated argument with the mother of another child.

The relationship with Sidney, characterized by erotic tension and mutual fascination, is marked by strong emotional shifts. It becomes clear how much Jean becomes entangled, but also enjoys the vitality. The series is strongly carried by this ambivalence, but this should not be possible in a real active psychotherapist, whose daily work would require a great deal of her own psychological stability.

Sideshows illustrating the psychotherapist’s own disorder are the stories of Jean’s other patients. To Allison, who possibly suffers from a polytoxicomania in addition to a borderline personality disorder, Jean builds up a mothering-distancing relationship in which one wonders what own biographically based deficiencies are to be compensated for. Secondly, there is the widow Claire, who continues to have a pronounced need for control over her daughter and does not understand her dysfunctional ways of acting.

Again, Jean invades the privacy of her patients and influences the course of treatment in a completely detached manner. This would all be justiciable and hardly imaginable in reality. The attempts of the head of the group practice to supervise Jean and to correct individual treatment errors that come to light repeatedly come to nothing through clever concealment.

With regard to the effective factors, only a strong therapeutic relationship is found. However, this is abused by the therapist to act out her own pathology.

Netflix movie: The Woman in the Window

The Woman in the Window is a 2021 mystery thriller directed by Joe Wright, based on the novel of the same name by A.J. Finn, available on Netflix. Depicted is the dramatic evolution of child and adolescent psychotherapist Anna Fox, played by Amy Adams, who has not practiced since a car accident that killed her daughter and husband. She herself suffers from depression and agoraphobia since the accident, which do not allow her to leave the house where she lives in seclusion. She is under the treatment of a psychiatrist (Tracy Letts) who prescribes her medication and visits her at home. The diagnosis of agoraphobia is made by the patient herself, and she reports to a neighbor that she can no longer go outside due to anxiety and panic attacks.

The therapist mentions depression since the accident and a suicide attempt in the past. His treatment consists of prescribing medications such as the β-receptor blocker propranolol, which is not approved for anxiety disorders and is probably only effective for “performance anxiety,” and graduated habituation in vivo, which he recommends to Fox. Following his advice, the patient should go outside (initially with an umbrella) and gradually confront her anxiety; he himself does not accompany these exposure attempts.

No clearly defined treatment plan

Anna Fox, who continues to not leave the house, becomes entangled in observations of her neighbors throughout the film, witnesses a crime in the house across the street, and makes phone calls to her deceased husband. She takes her medication along with alcohol. For her and the audience, reality and delusional experience eventually become inseparable. Anna decompensates and falls into a psychological crisis. For the therapist, who behaves professionally distant, although he visits his patient at home, this is reason to give her his “other number” in order to always be reachable. There does not seem to be a treatment plan or operationalizable therapy goals as well as an evaluation of these goals after the breakdown. Hardly any therapy progress With regard to the therapeutic effect factors according to Grawe [9, 10], the account of Anna Fox’s treatment is one-dimensional; therapeutic interventions with the goal of problem coping or resource activation are not shown. For example, the patient does not have the coping experience of being able to leave the house until the time when she is forced to do so – in order not to become a victim herself of the perpetrator who committed the murder of her neighbor. As treatment progress as a result of therapy, this increase in agency is not apparent to the viewer. A resource orientation in treatment with the goal of reactivating existing competencies as well as strengthening the motivational readiness of the young woman to confront her fears in exposures is also not a component of medial therapy. Only the therapeutic relationship, which seems to be based on a longer existing relationship of trust, can thus explain the patient’s motivation for change. Clarification experiences, such as an increasing understanding of one’s own symptomatology or insight into the disturbance pattern, promoted by the therapist, are also not presented. There is a problem actualization, in the sense of a reactivation of the problem-solving ability in the course of the film, which is expressed in an active change in the patient’s behavior, but which is apparently not due to the psychotherapy, but solely to the trusting relationship with the therapist. Awareness-raising interventions aimed at a precise understanding of the patient’s own psychological problems, underlying needs, or overarching schemas are not part of the treatment depicted, which is thus not very representative and shows little psychotherapeutic reality.

Conclusion for practice

In summary, we can state that there are individual elements in all of the cinematic representations of psychotherapy discussed here that are realistic. However, for dramaturgical reasons, depending on the significance of psychotherapy for the film, these are accompanied by an entanglement of the therapist that would not be so acceptable in real life. Professional distance with simultaneous empathy is found at most occasionally in the portrayals.

Diagnoses are only rarely made, there is usually no therapy in the narrower sense, but coaching to cope with life, the procedures used remain unclear and the goals are very short-term. Tab. 1 and Tab. 2 show semi-quantitatively how much the films/series discussed differ in their fulfillment of important quality criteria with regard to psychotherapy.

It can therefore be assumed that – as with other professions – media portrayal is not a basis for one’s own professional decisions or, as a person affected, for the implementation of therapy. The portrayal in films and series can be very unrealistic and not have much to do with professional treatment. This is characterized more by problem analysis and goal definition than by verbal repartee and by unproductive to destructive interpersonal power struggles.

However, we as professional counterparts for our patients should be aware of this possible expectation, especially when we diagnose and treat patients for the first time. It would be helpful if research projects could address this issue in prospective studies to assess the potential influence also in terms of magnitude.

Finally, a recommendation from our side: A humorous approach to the topic “representation of psychotherapy” can currently be found in the series “Kranitz – Bei Trennung Geld zurück” (Norddeutscher Rundfunk), where much is improvised and intentionally exaggerated.