The Patient (Hulu)
Spoiler alert - I’ve tried to approach this post while avoiding spoilers, but there is are some in terms of simply setting up the story. If you want to view this fresh, than I encourage you to do so if you can before reading!
I’d been thinking about watching “the Patient” starring Steve Carrell as the therapist, “Alan Strauss” and his patient, “Sam Fortner”, played by Joe Weisberg for a few weeks. The premise sounded interesting…to say the least. Sam initially sees Alan for therapy, but the therapeutic progress stalls, something that Alan points out himself in a session. Alan senses that Sam isn’t being fully honest. The scene closes and the next scene opens as Alan wakes up to find that he’s chained in Sam’s basement. He soon learns that Sam had been hiding the fact that he is a serial killer with a compulsion to kill. Sam sought out Alan for help in dealing with this desire to kill, but was reticent to open up because he feared Alan would simply report him to the police. Sam’s plan is for Alan to provide therapy to help free him from this desire, but from the confines of Sam’s basement.
Alan correctly explains that confidentiality could be maintained even if he’s seeing Sam while free, as long as Sam doesn’t indicate to Alan that he’s going to commit a crime. Now, it’s a bit more specific than that, as therapists are legally required to report or warn a potential victim if their patient poses an imminent threat to a reasonably identifiable victim. Sam could disclose his past murders in the course of therapy and Alan would be obligated to maintain confidentiality, but if Sam were to disclose to Alan an identifiable victim and an intent to kill that victim, then Alan would be required to report. Sam isn’t willing to test that process and the reasoning becomes clear as Sam does have an intent to kill an identifiable victim, though he does want to resist. So, treatment (under protest) commences.
Fascinating right? Many people are surprised to learn that if someone disclosed a past murder that a therapist would be required to maintain confidentiality. However, the process and success of therapy is so heavily conditioned on trust, that this high bar of confidentiality is necessary for treatment to be successful.
This topic though isn’t the one I want to stay with, as the actual treatment goals of this therapeutic relationship are of interest to me and also bring us into a key treatment decision that therapists often have to make. Sam describes, in great detail, his obsession with killing a particular victim who he felt offended by in his day-to-day life. Sam described thinking about killing this person every day, and a multiple month period of trying to avoid it that ultimately culminated in him attempting to see Alan for help.
Alan’s attempt to treat this terrible struggle bring into focus this question for a therapist. Do we focus in the present on thought and behavior strategies to help the client manage their anxiety or obsessive thinking? Or, do we wonder what the deep emotional origins of this particular struggle are and try to treat those? At times Alan is probing at Sam’s past, which at this point in the story revolve around a terribly abusive father and a complicated relationship with his mother. Alan might help Sam develop some insight into the emotional loop he finds himself in that drives him to rage at the mistreatment he experiences in his present day life. How might it connect, for example, with the rage he feels at his father for abusing him and perhaps at his mother for not protecting him? Therapy might be the vehicle through which Sam could identify and work though these emotions and thus lessen their grip on his current life.
The dilemma though, that we haven’t touched on yet, is that Sam may kill again. Do we have time to focus on the past? Or put another way, does Sam need more immediate, present day help, and what might that look like? We actually get to see some of this play out in the story. Sam is grappling with an intensifying desire to act on his obsession, and Alan is working hard to continue to help Sam delay the act. This is similar to how obsessions and compulsions are often treated through a behavioral strategy called exposure and response prevention or ERP, (although Sam’s obsession with killing someone who has offended him is a bit more complex, to say the least). In this approach, a patient is encouraged to find ways to lengthen or increase the amount of time they tolerate the anxiety or pressure they feel to perform a compulsion, while delaying acting out that compulsion. Through therapy, the patient is supported in progressively working at this process, often starting small and building from there. The patient is also given strategies to learn how to cope with the intense pressure they experience. Normally, this process also brings up the patients fears of what might happen if they don’t perform the compulsion. The theory and research shows as the person avoids the compulsive act, the brain, never wanting to be wasteful, begins to send less neurological signals over time, thus lessening the obsessive thoughts.
In these last two paragraphs, I’ve described this tension between past and present. For some therapists, who might prefer a present focused or cognitive and behavioral approach, the ERP technique is where they’d mostly stay. Other therapists might see this as only helping the patient with symptoms, and that this technique might not help the patient address their underlying, sometimes unconscious emotional difficulties. Some might even go as far as to say that attempts to modify a patients thoughts or behavior may actually do some harm as these approaches may convey that the patients emotions are invalid, which may drive the person to repress the emotions, only for them to surface later in a relapse or some other difficulty.
I think a more a more honest approach would be to not oversimplify or to be rigid about ones approach. And, so far, I think this tv series does a good job of unfolding that kind of an approach, though under great pressure! At times, a patient may need some present focused help with their difficulties. There can be an urgency. Someone with social anxiety, for example, might need the support through therapy to adopt behaviors that increase their ability to engage in social situations. But, I also do believe we need to help a person “surface” or bring into awareness emotional patterns that might have set up the anxiety in a person’s life. Now, to be honest, I wouldn’t want to do so under the enormous pressure that Alan is under in this story! I’ve yet to finish the series, so I’m waiting for the next episode with great interest, as we’ve yet to see if or how Alan might be successful.
