Is Dr. Melfi an Ethical Therapist?

June 7, 2007 — -- Tony Soprano -- mobster, gambler, adulterer, murderer -- isn't exactly what you might call a moral authority. But when Tony accused his longtime psychiatrist of being "immoral" for unexpectedly dropping him as a patient in the most recent episode of HBO's hit drama "The Sopranos," viewers couldn't help but nod in agreement with the big galoot.

Therapists, who have praised the show in the past for its accurate portrayal of the doctor-patient relationship, were outraged not only by the actions of Dr. Jennifer Melfi (Lorraine Bracco), but also by those of her own therapist and confidant, Dr. Elliot Kupferberg (Peter Bogdanovich). Kupferberg outed Melfi's most notorious patient to a roomful of her colleagues, ultimately leading her to -- and this is the clinical term -- "abandon" Tony (James Gandolfini).

As the series slouches its way towards its final episode next Sunday, things in Tony's life are falling apart. In the show's seven-year run, the one relationship in Tony's life that was consistently stable -- amid tensions with his family, problems with his crew, and a string of similarly beautiful but troubled mistresses -- was the one he had with Melfi.

And then as much to his shock as to ours, she terminated his treatment.

"We're making progress," Tony yelled at her. "It's been seven years!"

"There were two issues in the last episode: the breach of confidentiality and the abandonment," said Dr. Dorothy Cantor, a former president of the American Psychological Association and a practicing psychologist in Tony's home state of New Jersey. "They were both wrong."

"Confidentiality," Cantor said, "is the backbone of what therapists do."

When therapists talk to colleagues about patients they make a point "not to breach confidentiality. When talking or publishing, therapists make an effort not use names and to disguise the identities of their clients," Cantor said.

It is unclear, experts said, whether Kupferberg was acting as a colleague offering standard supervisory advice or as Melfi's therapist. Either way, said Bruce Hillowe, a psychologist and lawyer, the breach was totally unethical.

In an effort to pressure Melfi to stop seeing Tony, Kupferberg cites a clinical study that argues that sociopaths -- which Tony may or may not be -- use psychotherapy as a tool to hone their skills of lying and manipulation. To further his ends, Kupferberg hosts a dinner party of other therapists who, once learning about Tony, also try to convince Melfi to stop treating him.

That sort of breach of confidentiality "was absolutely atrocious," said Dr. Scott McAfee, director of psychiatric resident training at St. Vincent's Hospital in New York City. "It was a blatant breach of confidentiality and confidentiality must always come first."

But more stinging than the discussion over dinner was what it ultimately meant for Melfi and Soprano's relationship. Convinced she was not helping Tony and was instead helping to make him more dangerous, Melfi abruptly ends his treatment.

"There are clearly written America Psychiatric Association guidelines for avoiding abandonment. It is interesting that the writers made sure Melfi tried to meet the basic requirements for termination by attempting to recommend another therapist, but she missed the mark," McAfee said.

Before terminating therapy, doctors must give their patients ample time to understand why the therapist can longer see them, as well as enough time to find a new analyst.

"There is an old canard that an analyst should give a client one month for every year of therapy. Analysts consider that a very important part of the process," Hillowe said.

McAfee said that even as residents psychiatrists learn to give their patients ample time to understand that treatment will be ending.

"Tony Soprano felt abandoned. It should be a process rather than a shock," he said.

Abandoned? Shocked? If viewers could never relate to Tony Soprano before, we'll certainly feel those emotions come next week.