This week on Better Call Saul, Jimmy, the main character, seemed for a moment to genuinely consider the possibility of seeing a therapist, whose name his girlfriend has given him on a referral slip. Of course, he would mislead any therapist and then scoff at her ineffectiveness, since he justifies his whole, conniving way of life as a reaction to the incompetence of authority figures. He thinks he started stealing because his father, a shopkeeper, would give money from the till to anyone who claimed to be in need, so young Jimmy figured he’d just take some of the money for himself. More likely, he started stealing to compensate for his big brother’s monopoly on their parents’ affection and respect. In therapy, Jimmy would likely think he was proving the therapist’s incompetence by demonstrating her inability to read his mind, but in reality he would be re-enacting his sibling drama by mocking the therapist’s preference (in Jimmy’s mind) for her more earnest patients. Only a very skilled therapist would see through his slick presentation and attune to the angry little boy inside him.
Anyway, Jimmy doesn’t even give the therapist a chance. He runs into Howard, who is suffering from insomnia for reasons that are too complicated for this post, and he asks Howard if he’d like a referral to a therapist (the one Jimmy is thinking of consulting). Howard, who looks like death warmed over, says he is already seeing someone, twice a week. Jimmy asks if that therapist is any good; Howard says yes and leaves; so Jimmy tears up his referral slip, presumably figuring that if a good therapist can’t help Howard with his sleep problems, then therapy doesn’t work.
A good case formulation explains the problem the dyad will work on in psychological terms and makes it clear how the therapy will help. This is easy to say and hard to do. Much of clinical training is organized around teaching students to articulate and implement case formulations. There has to be an emphasis on doing this collaboratively, so the patient buys in. My fantasy was always that my patients’ BFFs would find out they were in therapy and ask my patients why, and then my patients would tell their BFFs our case formulation.
Imagine Jimmy’s response if Howard had said, “We’re not working on my insomnia; we’re working on its cause. My whole life, I have pretended to be better than I am so I could feel as if I merited my position in my father’s law firm. My whole life has been a masquerade, acting perfect and meritorious by stifling myself and by finding people like you, Jimmy, who make mistakes and stifling them. My real self, my imperfect, emotional, connected, embarrassing real self, comes out only when my masquerading self is off duty, when I am lying in bed, and then I spend the whole night trying to stifle it. I won’t be able to sleep until I give my real self someplace else to breathe freely, and my therapist and I are trying to create a space for me to do that in therapy. However, there’s a lot of guilt to get through. I know I’ve stomped on you in the past, Jimmy, because by doing so I could go back to feeling superior and meritorious. For me to embrace my real self, though, I will have to face all the harm I’ve done to you and others in the name of keeping my real self hidden.”
Would Howard ever say such a thing? Probably not, but the odds certainly increase if his therapist had said it to him, to explain the dilemma that was keeping him awake at night and to explain what they would be doing in therapy to face that dilemma. And if therapy patients talked that way to their friends and victims, other people would be more likely to consult therapists. But that requires therapists who know how to conceptualize problems in psychological terms.
THE BASICS