Thursday, August 16, 2007

Tony Soprano, My Patient, My Prisoner

I've been following the discussion between Roy, Dinah and Anonymous Commenter regarding Dr. Melfi's treatment of Tony Soprano. Yeah, it's just a TV show. No, I'm not obsessed or preoccupied with any of the characters. It's brought up an interesting question and a few ethical issues though. I will apologize in advance if I've misquoted or misattributed any opinions; I'm writing this off the top of my head and I'm not going to claim to be able to remember exactly who said what.

Anyway, Anonymous Commenter wondered why Dr. Melfi was treating Tony Soprano at all given his antisocial involvements and the potential risk he might present to Dr. Melfi's other patients. There was a suggestion that 'evil' could not be cured, and that a certain amount of psychological symptomatology is the natural result of involvement in criminal activity. There was some discussion about whether or not it was fair or appropriate to allow criminals to live with their symptoms, medical or otherwise.

As a forensic and correctional psychiatrist I find it interesting that these questions are being asked.

When people have brain diseases, they deserve treatment. People deserve to be healthy. When I had pneumonia last January I didn't have to give a justification for wanting to be well, and I wouldn't expect that from my offender patients either. The treatment of offenders does get a bit complicated since some of them do present significant safety risks to those around them; some can only be treated in a secure environment. The tricky part, as I believe Dinah or Roy mentioned, is that you don't always know who you have in your office when they first walk in the door. The true level pathology is not always evident until after you've already engaged the person in treatment.

The next question is whether or not 'evil' can be cured. If not, why attempt treatment? As Anonymous Commenter correctly pointed out, 'evil' is a tricky term. It falls outside the realm of medicine and carries quite a boatload of value-laden judgement. There are behaviors that all would agree are so far outside the realm of compassion that most people would consider them evil. On the other hand, one could make the argument that non-violent criminal activity which harms large numbers of people (eg. Enron and the financial devestation of shareholders) is evil.

Regardless, the real question is whether or not psychotherapy can prevent criminal recidivism the answer to that would be no. I blogged about Maryland's experiment with therapeutic prisons a long time ago in Couch Time. The followup from that experience showed that, at best, therapy did not make offenders worse.

Psychotherapy does help offenders for other issues, though, in the same way that it helps non-criminals. Prisoners are people who need help adjusting to incarceration, people who have family losses or crises, people who are dealing with serious medical illnesses. Crisis intervention and supportive counselling is invaluable for this. And yes, even Tony Soprano deserves it.