Every so often when he visits her office, Tony Soprano accuses his psychiatrist, Dr. Jennifer Melfi, of being bad at her job. He complains about how much money he spends on his treatment—"fa what!" He gets so infuriated with her that he regularly jumps out of his chair, breaks something, and storms out of the room. He blames her almost every time he has a panic attack; in his eyes, the fact that they keep happening means that whatever she's doing, it isn't working.
You can't help but wonder, sometimes, if Tony might be right—if Melfi's fixation on his mother and his childhood are misplaced, and if he might be better off in the hands of someone more capable.
To find out just how good (or bad) of a therapist Melfi is, I turned to a few real-life experts in the field: Glen O. Gabbard, a practicing psychiatrist and clinical professor of psychiatry at Baylor College of Medicine in Houston, Texas, who literally wrote the book on the subject (it's called The Psychology of The Sopranos); and Eddie Gamarra, who received a PhD in psychoanalysis and film, and taught at Emory University before going on to have a career as a producer in Hollywood. Their take, in a nutshell: Melfi is unbelievably good at treating Tony, and anyone who thinks they could do a better job is full of shit.
Before you begin to evaluate Melfi's work, you first have to understand that Tony would be "just about the most difficult patient you had ever seen," Gabbard said. Melfi diagnoses him with antisocial personality disorder (APD)—making him someone who, according to the Mayo Clinic, "consistently shows no regard for right and wrong," "ignores the rights and feelings of others," and shows "no guilt or remorse" for his behavior. In other words, he's a sociopath, incapable of empathy, prone to lying and manipulation, and devoid of a conscience. Psychology Today describes APD as "one of the most difficult personality disorders to treat"; there are treatment recommendations, but no cure.
On top of all that, Tony's a mob boss—leaving any psychoanalyst who took him on in a state of constant fear that would make it almost impossible to do their job.
"You'd be sitting there trying to treat him and you'd think, God, if I say the wrong thing, he might pull out a gun and blow me away," Gabbard said. "The biggest problem for a therapist would be maintaining some therapeutic goal without ruffling this guy's feathers too much, because you never know what might set him off. The underlying fear would be present in any therapist, and anyone who said they wouldn't be afraid would be lying."
Adding yet another layer of difficulty is the fact that, because you'd be legally bound to report anything Tony told you that might put others in danger, he could never be fully forthcoming with you. He'd have to constantly lie as a condition of your sessions—making legitimate honesty, the bedrock of psychiatry, out of the question.
"You'd have to settle for a very limited kind of psychotherapy," Gabbard said. "Any kind of improvement at all is extraordinary success with a patient like that."
And Melfi does improve Tony. She helps him reduce the frequency of his panic attacks. She helps him unpack his abusive relationship with his mother, and see that his subconscious attraction to women similar to her—like Gloria Trillo, the Mercedes saleswoman he has a deeply flawed affair with—is unhealthy. She helps him manage his anger, and learn to think before he berates, beats, or kills someone on a whim. She helps him understand why he is the way he is, and use that knowledge to break patterns of behavior he doesn't like.
"He had a place in her office where he could actually look at emotions without changing the subject, turning away—he had to focus on the feelings he had about things that had happened in his life," Gabbard said. "She helped him grow in self-understanding. He had a better sense of who he was and what he was trying to accomplish in life, instead of just being a very shallow guy who never had any deep thoughts, but only tried to get by and make money and do what he had to do. So she created a more humanistic version of him."
Just as important as what Melfi does, Gamarra said, is what she doesn't do. One of Tony's "superpowers," Gamarra said, "is to be very seductive"—but Melfi doesn't give into that seduction. He's also physically, verbally, and psychologically intimidating—but Melfi doesn't let that shake her. No matter what Tony throws at her, and no matter how he tries to manipulate her, Melfi manages to remain calm, always treating him with a level of professional distance.
"She handles herself deftly when she asks questions, when she makes statements—but what resonated with me was when she was more restrained," Gamarra said. "She's handling a maelstrom anytime he walks into her office. But does she lose her shit? Does she act up?"
You might say that Melfi's reliance on drinking as a crutch, seemingly caused by her sessions with Tony, betrays her inability to actually handle treating him. You might think that the way she talks about being attracted to him (romantically or otherwise) in her sessions with her own therapist is a red flag. But what's important, Gamarra said, is that she never brings any of that baggage into her office—and if Tony doesn't see those issues, you can't use them as a knock against her.
"When you judge whether or not Dr. Melfi is a good analyst, you're always going to be biased, because the viewer has more access to her than a normal client would," Gamarra said. "The question is, is she a good therapist for and with Tony?"
Melfi isn't blind to the effect treating Tony has on her, and she's forthcoming about her issues with him when she talks to her analyst. That's commendable, Gabbard said. Speaking candidly to her own shrink about Tony makes her better at treating him, and allows her to stop herself from giving into unhealthy impulses—like, say, asking Tony to kill her rapist, a thought she entertains but never acts on.
"I like that Dr. Melfi goes to her own psychotherapist," Gabbard said. "Almost all analysts or therapists go to their own therapist to get help, so that they'll know what their hang-ups are and not foist them on the patient."
More impressive than any specific technique Melfi uses, Gabbard said, is that she agrees to treat Tony at all. Most psychotherapists would write him off as a lost cause and, out of fear for their own safety, refuse to see him. The fact that Melfi is willing to work with him—and somehow actually helps him—is remarkable.
When I asked Gabbard if he'd consider taking Tony on as a client, he cut me off before I could finish the question. His answer, firmly, was "no."
"I didn't even hesitate to think about it," he said. "If he called to get an appointment, I'd say, ‘You know, my practice is full right now. I can't take new patients."
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