Strictly therapy?
Therapy Today, February 2018: Volume 29, Issue 1

A young American couple, both committed Christians, have come to therapy to address their mutual lack of sexual desire. As the session progresses, the woman confesses that she only enjoys sex when her husband pretends to be a roguish, sexually confident Frenchman called Jean-Claude. It is a brave admission from a deeply private couple. But this couple aren’t my clients – I was listening in on their therapy, along with thousands of others who tune in regularly to US psychotherapist Esther Perel’s podcast series Where Should We Begin?¹

Each episode is an edit of a two-hour, real therapy session with the couples and relationship therapist at her private practice in New York. In another episode, we hear a mixed-race couple facing the unspoken challenges that their cultural differences bring to their relationship. In another, a lesbian couple deal with the negative impact on their relationship of finally having their longed-for children.

As a therapist, the chance to be a fly on the wall while a fellow practitioner works, especially one as respected and successful as Perel, is hard to resist. But as I listen, entranced, I also feel unsettled. Confidentiality is at the heart of what we do, so can it ever be ethical to use real-life sessions as a basis for what is, after all, entertainment? And is the argument valid that it benefit our profession and our clients by demystifying what happens in the therapy room? Is it simply a distorted representation of what we do, edited down for entertainment?

Client confidentiality

Addiction counsellor Mandy Saligari, Director of the Charter Harley Street private rehabilitation centre in London, wrestled with this dilemma before agreeing to be involved in the Channel 5 series, Celebrities in Therapy. Each programme is an edit of several therapy sessions conducted by Saligari with celebrities known for their ‘troubled’ pasts, such as Kerry Katona, Daniella Westbrook and Bobby Davro. The sessions are filmed in single takes with a fixed camera at Saligari’s therapy room in central London, then condensed into a 45-minute programme. It often makes for compelling viewing – we see Davro deny and then admit his dependence on alcohol, and Katona talk about encouraging her drug-addicted mother to kill herself.

Saligari admits to having qualms even as she is being filmed. ‘A couple of times, I felt protective of the clients, of how much they would give themselves over, not just to the camera but in general, to the media,’ she says. ‘Kerry Katona was a perfect example of that. I became aware that there was literally a tiny bit of her left that was Kerry, and having spotted that, there was an internal conflict – do I move in to work with it on TV, therefore making it public, or do I shield it? I chose to point it out, but said, “I am not going to go there because you need that.” I made her conscious of how much of herself she gave away, which was part of her primary issue: not enough of Kerry belonged to Kerry.’

The production company chose which celebrity clients were interviewed, but Saligari says she had the right to veto their choices, on clinical grounds. ‘My criterion was, are they robust enough to do the type of therapy I do on TV?’ She also ensured clients had some power over what was included in the final edit: ‘At times they would say, “I don’t want this filmed,” and I would say, “The camera will keep rolling, but you can mark it by saying, ‘Don’t use this’ a few times, as you say it,” then it can’t be used as they can’t edit it out,’ she explains.

The ethics of consent

There are ethical concerns even with consent, says Professor Brett Kahr, psychoanalyst, author and former BBC Radio 2 Psychotherapist in Residence. ‘I have been approached by a number of television companies over the years for exactly that sort of project and I have always turned them down. I just did not feel sufficiently comfortable with the notion, and sometimes I felt that the researchers and producers from television companies had really not thought through the ethical implications carefully enough and the potential long-term impact, both on the clients and the therapist.

‘One has to ask how much preparation, how much informed consent is being provided before people expose those parts of themselves through their own authorisation in a public forum,’ he says. As there is an element of unknown potential with every broadcast – how many people will view it, will it trigger media interest, will the press coverage be positive or negative, how will that influence public opinion? – it could be argued that clients are unable to give full consent, as they are unaware of what they are consenting to. Perhaps the most famous example of this is ‘Gloria’, the client who featured in the famous Three Approaches to Psychotherapy films made by California psychologist and psychotherapist Everett L Shostrom in 1965. Gloria was filmed in session with three leading proponents of three different models of therapy – Franz Perls (Gestalt), Carl Rogers (person-centred) and Albert Ellis (rational emotive therapy). Shostrom originally cast an actress in the role of the client in his first attempt, called Introduction to Psychotherapy, which he made in 1963, but he wasn’t happy with the result, so found a ‘real’ client for the 1965 project.

Gloria was told it would be an educational series on how therapy works, but the film was shown nationwide throughout the US on mainstream cinema screens, and she found herself the subject of widespread and prurient public interest in her  sex life. According to an account written after her death at age 45 by her daughter, Pamela J Burry, taking part in the sessions negatively impacted on Gloria for the rest of her life.²

‘One has to think very carefully about the meaning of informed consent,’ says Kahr. ‘When one invites Ms X from Scunthorpe or Mr Y from Basingstoke to appear on a television programme, one must ask whether anybody has had a thorough conversation with these people beforehand to help them think with consideration about the meaning of such a decision, particularly the meaning of one’s mind and body becoming public property. One must be very vigilant as to whether exposing oneself on camera might become a re-enactment of an early sexual trauma.’

Saligari agrees that consent is a complex issue, but says the production company she works with takes the issue seriously. ‘Prior to filming and through the agents, should there be any concerns regarding mental health issues, the production company offers to pay for an independent mental health assessment with an accredited professional. These individuals are already in the public eye and are talking here about issues that they have mainly discussed in the media before. They are well versed in the pitfalls of those issues being public knowledge.’

Fact versus fiction

Without broadcasts of real therapy sessions, prospective clients only have fictionalised accounts on which to base their knowledge of therapy, and these are notoriously unreliable and misleading, argues Dr Otto Wahl, Professor of Clinical Psychology at the University of Hartford. He conducted a systematic review of the portrayal of therapists and therapy in films released between 2000 and 2013,³ and, while he found some changes for the better in terms of accuracy of portrayal, there was, he says, still ‘a lot of unethical behaviour’.

‘It wasn’t the same as in films of the past, when the therapists were usually shown as evil and manipulative, or sleeping with their patients, but in a more insidious way. Therapists would share personal information about their clients without their permission. If I’m a client considering going to psychotherapy, I might think, if I am going to tell someone something really personal, I want to know that it is between me and the therapist,’ he says. Such fictional portrayals can easily normalise this kind of practice. ‘In the films we looked at, therapy was also seldom helpful. You rarely saw people get better, and for those that did, it tended to be because of a dramatic breakthrough that occurred.’

His biggest concern was over physical touch. ‘Seventy per cent of therapists in the films we studied touched their clients in some way, other than shaking hands. It wasn’t always overtly sexual, but one of the problems with boundary violations is that they begin gradually. If a client is uncertain about what the boundaries are – what kind of touching is OK and what is not OK – those who tend to trust their therapists can be led into relationships in a gradual fashion. If you are communicating that touching is a common and acceptable part of therapy, you are opening the door to expanded physical contact.’

Kahr agrees that fictionalised accounts of our profession largely do us a disservice. ‘I do not recognise the psychotherapists and counsellors I see in films and TV programmes. In Treatment [HBO’s drama series that showed ‘realtime’ client sessions with the fictional psychotherapist Dr Paul Weston] was beyond diabolical in giving so much air time to a mental health practitioner who had an affair with a patient,’ he says.

It is for this reason that, while we should take the issue of consent seriously, says Wahl, we cannot let it stop us from finding ways to bring real therapy sessions into the public domain. ‘We have to show real psychotherapy. To contradict and challenge stereotypes, we need to stimulate discussion about them. We have to say, “What you see in films, it’s not what you see in real life.” We have to help people become more critical viewers, to make them ask if this is accurate. But confidentiality belongs to the client. If the client says it’s OK, then it’s OK for you to show their treatment, as long as there is no coercion or persuasion involved.’

Kahr agrees: ‘We have a huge responsibility to disseminate useful, admirable, responsible knowledge about our profession to members of the general public. We may think of ourselves as kind, compassionate people, but we are an intimidating profession in that people have all kinds of fantasies about what we are going to say to them, what we are going to say about them, what aspects of their secret lives will be unearthed, and whether we can be trusted to keep their secrets. So, I think we do have a responsibility to portray ourselves so that people can learn about our work.’

Therapy as entertainment

There is also the issue that good therapy doesn’t necessarily make good entertainment. Therapy rarely achieves its results in a cinematically dramatic breakthrough; its ‘plot’ is rarely linear – generally, changes unfurl very gradually over time.  How accurate can ‘real-life’ portrayals of therapy be, given the impossibility of sustaining dramatic interest in real time? Did Saligari feel a pressure to change the way she worked, to make it more dramatic, I wondered? ‘I took responsibility for therapy and the producer took responsibility for TV, so we had our clear roles, and when we disagreed with one another, we would argue it out and hold our corners,’ she says. ‘If it wasn’t interesting TV, it wasn’t my problem: they gave me the clients, I worked with them in the same way I work with all clients. That’s how we did it, and it worked.’

Her guide was that fundamental principle of therapy: ‘I would say, we have to trust the process. With [reality TV star] Nikki Grahame, for instance, for 25 minutes she didn’t speak, and in terms of television, that is a long, long time. I pushed her and she went into a shame-based withdrawal, and I knew I had to sit it out. If I went to retrieve her from it, I was rescuing her and reinforcing the victim space. But, in my mind, I wondered how easily the production team were waiting. They were downstairs, and I could almost hear their thoughts through the floor: “This is 25 minutes of television time!” And I’m thinking, “Don’t come in the room.” Afterwards I said, “I am so grateful that you trusted me to roll with that.” They said they had discussed what they should do, but the mutual respect between us meant they held off from coming in.’

This potential for ‘good entertainment versus good therapy’ conflict was an issue for psychotherapist Susie Orbach in the making of her Radio 4 series, In Therapy. ‘Therapy is not a good spectator sport, and there can be longueurs where nothing happens,’ she says. ‘The fact is, you are sitting with somebody and helping them not to feel alone. There isn’t very long; each [broadcast session] is 12 and a half minutes, so the BBC had to struggle with allowing silences in that time.  More time, two 20-minute sessions for instance, would have been much better but it wouldn’t have fit the schedules.’

The series didn’t feature live clients. The sessions took place in Orbach’s own therapy rooms and were unscripted; the clients were actors, who were given a detailed brief about their character and then freed to improvise. ‘I knew I didn’t want to script something; that would not show how therapy actually goes,’ she says. ‘I suggested very little beyond the barest outlines. I said, give me a young couple whose life dilemma may be reflecting their personal histories; give me a 60-year-old trade union person who is facing a difficulty, but I didn’t know what that difficulty was. I would be told a paragraph of background, similar to what you would know about any new client before they walked through the door. But then we had to make it sound like I had been seeing them for six months.’

She had no idea what would emerge – that John, the trade union steward, for instance, would confess that he had fallen in love with her. ‘The director would put a few “bombs” into each session. Although I did say, you can’t put too many  bombs in each situation as then I am being thrown about too much, and it’s implausible.’

Orbach’s motivation was to show how therapy is done. ‘There has always been a strong aesthetic for me in therapy – it’s a craft,’ she says. ‘I wanted to show many different things – how deeply interesting it is, how therapy is a different form of talking, a different form of listening, and a different form of engagement. I also wanted to show how people can think differently when exposed to different ways of talking and feeling.’

Demystifying therapy

Orbach also wanted to ‘bring people closer to the experience of the consulting room’: ‘Attitudes to therapy have changed dramatically since I’ve started working, when it really was a taboo; now, it’s not a taboo in the same way, but it’s still a mystery, and I had the opportunity, through vignettes with imagined people, to show what I do and what my day is like.’

Saligari similarly says her motivation for being involved in the programme was to ‘destigmatise therapy and addiction’: ‘I saw it as an opportunity to make therapy seem accessible, to teach people to interview their therapists rather than just turn up to be fixed, and to push through an unconscious glass ceiling that therapy doesn’t have to come at the end of a long line of changes, like moving house, changing relationships, changing your hair; it could be an earlier option,’ she says.

Orbach has always been in the public eye, so the clients she sees in her private practice three days a week were unaffected by the programme, she says, although it did trigger a rise in enquiries from potential clients. Saligari also carried on seeing regular clients during filming of her TV show. ‘I preserve two days for client work. My pattern is that I do the intake session, then refer the client to my team or onward for inpatient treatment. I also have 12 regular clients a week, and I refused to let the filming schedule intrude on those days, so they had their time with me as normal.’

She believes the show has had a positive effect – she sees a spike in enquiries when the series airs; most want to know how to find a therapist near them, and she refers them to the BACP, UKCP and BABCP websites. ‘Loads of people have written and said, “I’d never thought I’d have therapy but since watching the programme I am going to give it a shot.” One man got in touch and told us he had booked into a hotel to take his own life. He turned the TV on, watched the Bobby Davro programme and was transfixed, and decided to go to AA instead.’

Certainly Channel 5 thinks there is a growing public appetite for real-life therapy. A fourth season of Celebrities in Therapy is planned for this year, and Saligari is currently looking for couples to appear in a new programme on couples counselling. Esther Perel’s podcast frequently appears in the top 10 of iTunes’ ‘most-listened to’ podcasts,⁴ and Orbach is working with director Ian Rickson at the National Theatre to develop a stage version of In Therapy.

These pioneers of the genre are carefully walking the line between education and entertainment. Broadcasts of ‘live’ or simulated therapy are a way to showcase ethically and responsibly to the general public what therapists and therapy do. So long as principled and accountable practitioners are working with responsible and principled broadcasters, we can be hopeful that they are making it easier, safer and more acceptable for people to seek help, without creating another generation of Glorias.

Sally Brown is a counsellor and coach in private practice (therapythatworks.co.uk), a freelance journalist, and Executive Specialist for Communication for BACP Coaching.

References

1. Where Should We Begin? is available on iTunes or at audible.co.uk
2. Burry PJ. Living with the Gloria films: a daughter’s memory. Ross-on-Wye: PCCS Books; 2008.
3. Wahl O, Reiss M, Thompson CA. Film psychotherapy in the 21st century. [Online.] Health Communication 2016; 29 December. doi: 10.1080/10410236.2016.1255842
4. bit.ly/2lFjUkB

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