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In Treatment: Understanding how patients ‘lie’ to themselves and others is at the heart of dynamic psychotherapy

Mark Dombeck, Ph.D. was Director of Mental Help Net from 1999 to 2011. Dr. Dombeck received his Ph.D. in Clinical Psychology in 1995 ...Read More

New York Times blogger Virginia Heffernan made a brilliant observation the other day in "The Medium" concerning the psychotherapy HBO television show "In Treatment" (You can watch it online if you don’t have HBO). Specifically, she observes that there is a whole lot of lying going on in the show and that sensitively noticing that lying and how it unfolds seems to be central to the movement of the plot. Watching reality television, where there is also a whole lot of lying going on, has taught her this much, apparently. I’ll move the observation further along by making a follow-on point, namely that helping patients become aware of when they are "lying" is in many ways psychodynamic psychotherapy’s central goal. As patients gain insight and clarity into the "lies" they tell to themselves and to others they become more capable of facing and solving their underlying problems.

Heffernan’s comment, published on February 8th, comes in response to two events that have taken place ‘In Treatment’ during week two of the show. The first event involves a tense conversation between Paul, the show’s therapist, and his wife Kate. Kate reveals that she has been having an affair with another man, and Paul goes out of his way to ask her for explicit details of her contacts with this man which she then provides. The second event takes place after the first event. Paul relates his conversation with Kate to Gina, his therapist. In the process of describing the conversation, Paul distorts what actually occurred. He says that Kate made sure to tell him all the details of the affair and suggests that this was done to hurt him. In actuality, we (the viewing audience) know that she would not have given him those details if he had not dragged them out of her.

The act that Heffernan calls lying is not really lying so much, but it is lying’s cousin. Actual lying involves a conscious desire to misinform another person so as to gain an advantage over them. The distortion that Paul conveys to Gina while remembering his conversation with Kate is not really lying. Instead, it reflects what cognitive therapists would call a cognitive bias and what dynamic therapists would call a defense mechanism. Paul remembers the event not as it occurred, but as he perceived it, and in a manner calculated (in an unconscious way) to downplay his own role in causing the event. He does not take responsibility for his role in requesting information from Kate. He only recognizes that the information was hurtful. In so doing, he makes himself more of a victim than he actually is. This is a self-serving bias because he gets to feel righteous. It isn’t enough that he is legitimately hurt by Kate’s actual transgression. He is also (and illegitimately) hurt by his perception of Kate as someone who wanted to "twist the knife" and torture him with details (something she was not trying to do).

This defense mechanism of Paul’s is common and many people use it. It involves the transmutation of hurt into anger, accompanied by the movement of attention from a self-focus on one’s own pain to a righteous other-focus on how other people have transgressed against the angry person. It is a way of avoiding having to feel hurt. It is a way of being defensive by going on the offensive.

Unlike the viewing audience, Gina does not know the actual facts of the conversation between Paul and Kate. She may suspect that Paul has told her a biased account of what happened between them, but she has no way of verifying it. It is her job to know about the various ways that people can distort the facts in a self-serving manner; to identify which particular ways this particular patient (Paul) goes about distorting his facts; and ultimately, to communicate to Paul, in a manner that he can hear without getting defensive and avoidant, what he is doing so that he can become conscious of it, recognize it while it is starting to happen and decide to stop doing it. That is psychodynamic therapy in a nutshell.

I’m generally not much for reality television, but now, armed with Heffernan’s observation of just how much psychodynamic gymnastics can be on display within that category, I may take the plunge. Suggestions for good shows to watch anyone?

Thanks to Daron Larson for pointing this piece out to me. Daron’s blog Learning To Stay is quite wonderful.

Keep Reading By Author Mark Dombeck, Ph.D.
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