Reviews

Psychiatrists get an offer they cannot refuse

The Sopranos, Channel 4, Thursdays 10 30 pm (times may vary)

There is no doubt that the United States is way ahead of the United Kingdom in so many ways. This is especially evident when you attend scientific conferences there. While the former colonies were immersed in the third series, we back home were barely getting to grips with the first. Yes, The Sopranos is the talking point in transatlantic psychiatry. There would be enough to enjoy and discuss in this tale of postmodern Mafia hitmen and their families in present day New Jersey. But it is the extra dimension added by the inclusion of a psychiatrist as a central character, Dr Jennifer Melfi, which is the hook.

Tony Soprano, the local godfather, is an effective manager, capable of merciless brutality as well as touching sentiment. He deals with protection rackets, extortion, and, especially, liquidating rivals, while in parallel trying to deal with a sullen underachieving son, a wayward daughter, loopy sister, and demanding wife and mistress. In his sessions with Dr Melfi, Tony Soprano brings his frustrations and disappointments, his panic attacks and insomnia.

So, what are the talking points among psychiatrist viewers? First, we ask each other whether we would take on someone like Mr Soprano. "Only if he made us an offer we couldn't refuse" is the usual response. But most of our discussions centre on peer review of Dr Melfi and her clinical ability. She offers Tony eclectic psychotherapy, which is thoughtful, understated, and believable. The majority verdict is that she does a good job and is an excellent role model. Only the chic designer interior of the consulting rooma counterpoint to the Soprano family's opulent bad tasteedges towards fantasy. Here, Dr Melfi interprets dreams, which is what one would expect of any fictional psychiatrist. However, she also uses cognitive behaviour techniques, pointing out her client's negative cognitions, his tendency to catastrophise, as well as his behavioural avoidances. What will come as a surprise to many lay viewers is the sensible way in which she combines recommendations of psychotropic medication and appropriate discussion of their pros and cons with psychological techniques. This is the way the modern psychiatrist should approach therapy. It is a welcome touch of realism.

A recent episode (22 November) elevated this superior soap opera into deeply affecting drama. It featured the brutal rape of Jennifer Melfi by a stranger on her return to her car following a session with Soprano. This unleashed a raft of plot lines which have been unfolding in subsequent weeks: the bungled police arrest of the prime suspect; the strain on Melfi's relationship with her psychiatrist partner; and, of course, the effect of all this on the counter-transference.

One of the ironies of Tony Soprano's therapy and a comment on the limits of psychoanalysis in general is its banality in relation to the extraordinary violence and degeneracy outside the room. Even understanding the roots of certain forbidden actions does not guarantee that they will be avoided. Dr Melfi acknowledges this in her sessions with Soprano. This also arises in her supervision with her own therapist, Dr Kupferberg. Again, the regular discussions she has with him about her difficulties with Tony Soprano provide an example of good practice. They allow her to reflect on what lies behind his macho, bluff exterior and why she reacts to it in the way that she does, in a supportive, non judgmental setting. "I've let myself be charmed by a psychopath," she muses.

(Credit: CHANNEL 4) View larger version (65K): [in this window] [in a new window]   Charmed by a psychopath: Dr Melfi

Despite her insights, she really has no idea what her patient's life is really like. This begins to change as the ramifications of the rape spread. Melfi's cool self control starts to falter. She struggles to suppress her understandable desire for revenge on the attacker, drawn, significantly, from the same Italian American culture that she and her patient have grown out of. Into her impotent rage, expressed to Kupferberg, begin to seep the kind of compound four-syllable expletives that are the natural argot of Tony and his cronies and that Channel 4 euphemistically refers to as "strong language" in its pre-transmission health warning.

This intrusion is perhaps an ominous portent of future disorder, as is the fearsome black dog of Melfi's nightmarea symbol of her fear of Tony's violence and her own yearning for retribution. The superego of Melfi's civilised values and the intellect begins to collide with the murky id that is Soprano's stock in trade. Such a convergence is not so incongruous. After all, the one thing Mafia hitmen have in common with psychiatrists is that both are, in a sense, part of the waste disposal business.

Tony David, professor of cognitive neuropsychiatry. 

Institute of Psychiatry, London