Verified by 
No therapist could establish a real psychotherapy with TV character Tony Soprano, a mob captain having panic attacks. I leave aside Jennifer Melfi’s profound incompetence, her prescribing ineffective chemicals for non-medical conditions, converting life problems into chemistry; her social niceties and self-disclosures that make any therapeutic revelation even more disruptive than it needs to be; her taking a phone call about her car during a session. After that call, Tony has her car fixed while she is asleep, and then she acts all huffy about how he has invaded her space, when any patient would assume that the reason for her intrusion on his space was an implicit demand that he do something about her problem—even though most patients would then offer only consolation.
Even the most gifted therapist could not provide real therapy under these circumstances. Because of Tony’s mob involvement, his associates would kill him if they thought he might disclose their business to his therapist, and they would kill her too if they thought she had damaging information. Nobody could provide a sound, reliable relationship knowing that her life was on the line.
Still, because I’m a fan of the show and recently re-watched the first season, I thought I’d use Tony’s imaginary case to explore what I mean by a unique case formulation, how it must capture an explanation for the presenting problem, relate to the patient’s personality, and explain the ways in which therapy can help.
Tony comes for therapy because of panic attacks, one of which occurs while watching a family of ducks fly away that had been living in his pool. A general idea about panic attacks might be that part of the person knows he is in a fight-flight situation even though his executive functions are claiming that there is no immediate danger and requires him to soldier on. A clinician might be inclined to teach square breathing to manage the attacks themselves, or to prescribe medication to prevent them (although most drugs are ineffective after a few weeks). Both of these responses make the mistake that I call disabling the burglar alarm instead of dealing with the burglar. Instead, an understanding of the danger and the insistence on toughing it out can lead to a more suitable adjustment.
Tony reflects on how discrepant the role of therapy patient is from his public persona, a problem for many men in therapy. He tries to reestablish his manliness by sexualizing the relationship with Melfi, by intervening in her life, and by threatening her. At some point, he is reminded of two incidents from childhood. Childhood memories are especially useful for depicting case formulations because they are usually molded by the same forces that mold our personality functioning and because in the post-Freudian world, most people think that their current problems stem from childhood. If you used a TV show or an incident from the person’s workweek to depict their case formulation, they might not see a connection. Dreams used to be ideal for this purpose, but contemporary adults are not as prone to see their dreams as relevant to their own psychology as adults in the last century were.
In one incident, Tony sees his father and uncle beat up a man who presumably owed them money. In the other, Tony is left out of his father’s closeness with his sister although it turns out that what looked like closeness was actually an excuse to go to a park where he ignored her to do mob business.
A case formulation need not be correct. Instead, in Watzlawick’s phrasing, it has to be plausible and imply a course of action. If the course of action is ineffective, then a different case formulation is developed. Most importantly, a case formulation should be shared—tinkered with by both patient and therapist until they both know the focus of their work together. My fantasy about this is that my patient’s best friend finds out he’s in therapy and asks why, and my patient tells his best friend our case formulation. So what follows would be merely my first overture to the patient.
Like many boys in Tony’s culture, his natural needs for nurturance, tenderness, and affection did not have a comfortable place in his life or in his psychology. In his case, the need to be tough is depicted in the memory of his father and uncle beating a man—the only roles available are bully and victim. His yearning for a tenderness that would not lead to victimization is depicted in his watching his sister drive off with his father. It seems as if only girls can be tender, but any hint of girlishness is forbidden in his world. He can accept nurturance only in the form of food; even sex must be a conquest or a dominance. Tony would like to express his tender needs at home in the warm embrace of his family, and this is symbolized by the delight he takes in the family of ducks. When they fly away, it is as if he is losing any chance of tenderness in his life, an immediate danger that he refuses to listen to. In therapy, he could reveal his tenderness guarded by the absolute privacy of the endeavor. He could consolidate and honor his need to be tender and give it a firm voice in the question of how he will live his life. It will be a rough ride, of course, because every breakthrough toward more tenderness will induce fears that he is being emasculated. Ultimately, though, if they can give voice to his masculinity and his tenderness at the same time, he can discover that tenderness is a part of manhood and not its undoing.
Tony loses almost all that is tender in his life partly because it has not been protected and cultivated in treatment. This loss is depicted in the famously ambiguous final scene. In my view, the meaning of the scene is that the simple moments of life have been ruined by the legacy of violence. A.J. gets in his car and starts it and you expect it to explode. Meadow has trouble parallel parking and you expect her to get shot. Tony catches the eye of another diner patron and you expect him to be a hitman. The door opens and you wonder if it’s death or his daughter.
The first season ends with a confirmation of the tender. Caught in a rainstorm with the power out, the family seeks shelter in a friend’s restaurant. He makes them dinner by candlelight—pasta and spinach—and Tony raises a toast to his family. “Someday soon you’re gonna have families of your own, and if you’re lucky you’ll remember the little moments like this that were good.” In the final scene of all, A.J. quotes this moment and Tony accuses him of being sarcastic. Instead of a warm Italian restaurant eating hearty, nutritious fare with red wine, they are in a diner eating onion rings with cokes. A.J. responds, “Isn’t that what you said one time? Try to remember the times that were good?” But Tony by then can’t even remember warmth, much less experience it.
