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.


Dinah said...

I gave you a pic.

Anonymous said...

Oh, give Tony some relief, IN PRISON, far away from all the other pts in the waiting room. You can't know who walks in the door off the bat but eventually you do or you should. I knew one of you would mention white collar crime and I had a hunch it would be Clink, not because she deals with criminals but because she just would. There is evil aplenty out there in that sense, and they "harm" to others is huge, but usually measurable in dollars and cents. They should pay the price too but often get off easy,(I said people go to prison for right and wrong reasons. Some who should don't go at all). Back on track, I don't want my pocket picked big time but hey, the gov't gets to do that too. Main thing, Melfi had lots of time to get who Tony was and to protect her other patients. Didn't say that feeling bad was the natural outcoem of criminal acts. Often, it isn't. Not sure Tony was feeling bad about what he did but that somehow these things can come back and bite you. I have kids, and if you think about it, a reasonable parent would allow a child to feel bad about a bad act and not soothe it away. "Now you go think about what you did and how you made so and so feel when you did it." I wouldn't give the kid ice cream after he walloped a kid or cheated on an exam. Sometimes that is life. None of mine has ever been violent but if they had been, they wouldn't be sharing a bedroom with a sibling.You gotta make sure the others are safe. You don't leave the kid stewing in its own juices forever. Not saying that.

Ladyk73 said...

Thank you Clink....

Your comment on the subject was greatly needed, as your expert observations will hopefully be insightful to many.

KipEsquire said...

Just as gays are finally convincing people that homosexuality is not something to be cured, now comes along the quest to "cure" evil -- the ultimate expression of which is, apparently, a CEO.

I'd rather take my chances with the homophobes.

Now excuse me while I go watch "A Clockwork Orange" for the umpteenth time.

Roy said...

This whole discussion about kicking out "evil" patients from our collective waiting rooms because they may harm or infect non-evil others has me feeling a bit uneasy, as well.

So, I went to Wikipedia, where the current definition of evil is a bit broad: In ethics, evil refers to violations of an empathetic ideal which manifests as morally or ethically objectionable thought, speech, or action; behavior or thought which is hateful, cruel, violent, or devoid of conscience. I can see why Kip includes CEOs.

But the last sentence homes in on the source of my uneasiness: Critics of the term argue that it is inextricably bound to a particular religious worldview and that it allows believers to ignore the specific or complex causes for social problems in favor of one generalized simplistic cause (evil).

Speaking of evil CEOs, what *are* your thoughts on the Federal Reserve System's recent cash infusions to support subprime mortgage lenders?

Anonymous said...

don't give a care about the semantics. going down that route gets everyone off track. okay, don't call it evil if you feel that is the wrong word. what i am talking about is someone who is a danger to others. isn't that what Tony was? i don't know shrinks in private practice who would, upon coming to the realization of the fact that this person was dangerous would put their lives/practice/pts at risk. don't come back with definitions of danger or dangerous or say it can't be defined. if a shrink has a gun toting murderer in her waiting room and the shrink is not working in a prison setting that shrink is --you choose the word. shrinks in private practice are different than those who work in hospital or prison-they get to choose who they will take on and so they should because they do not have mechanisms to deal with gun toting murderers unless they want to hire security guards and post them at the door. so stop focussing on the word evil which was didn't even come from me to begin with and get back to some reality based notion that the shrink could refer to someplace more secure as in : Tony man, I hear ya about the panic attacks. The prsion shrink might be able to help you out if you wanna turn yourself in.
For stuff on the Fed, go ask Dinah to ask her partner.

Midwife with a Knife said...

roy: I think the infusion of cash to bail out the lenders but not the borrowers sort of bespeaks a bias in favor of corporations and against the individuals. After all, they all made essentially the same bargain and lost. The borrowers bet that they would be able to make enough money to cover their mortgage when the mortgage payment went from $1500 to $2000/month with their sub-prime loan. The lenders bet that the borrowers would also be paid. If our government were really interested in helping out, they would offer some sort of relief to the lenders too.

As for evil, I don't always know the answer. I know that child abuse and child rape go so far beyond bad as to be evil. I know that murdering strangers is evil. It's kind of an Aunt Ida... I can't tell you what Aunt Ida looks like, but I know her when I see her.