Alex from HBO's "In Treatment": trauma and intellectualization

Abnormal Cinema: Alex from HBO's "In Treatment"

Blair Underwood's character, Alex, from HBO's program, "In Treatment" is a highly skilled, high-achieving U.S. Navy pilot who served in the war in Iraq and Afghanistan. Alex was raised in a Navy family and was always encouraged and expected to achieve his best and perform a top level. He is impeccably dressed, extremely formal, and in excellent physical condition. Alex has also been highly educated and possesses knowledge and insight on a wide variety of topics.

From the outside, Alex appears well adjusted, but has chosen to enter therapy to discuss an incident that occurred during the war. Alex is no longer in active military service and discloses to Paul, his therapist, that he flew a mission in Iraq that killed a group of Muslim school children. Wracked with guilt, he seems to be questioning whether he should have reviewed military documents that informed the mission to ensure that no civilians were present at the location of the target prior to the bombing mission. Alex seems to control his emotions and questions very carefully, but many of his comments during therapy indicate that he feels he had a part in killing innocent civilian children.

Abnormal Behaviors

Alex's character is interesting because he doesn't display many abnormal behaviors obvious to a layperson. He is charismatic, very attractive, and extremely articulate. His physicality, at times, is very guarded, but this could be interpreted as professionalism or stoicism. Up until the attack in Iraq he lived a very controlled and focused life. The one issue he does self-report is anxiety and panic attacks related to the flying and bombing he did in Iraq. He can be quite argumentative and condescending, which is social situations, and even in therapy, could appear abnormal or dysfunctional to people who may be offended by his very critical and arrogant approach.

Characteristics and Traits

From a therapeutic perspective Alex's behavior seems very controlling and condescending. He questions his therapist, Paul, about the quality of his therapy, and he states that he is the "creme de la creme" -- that he is expected to be prefect and is able to deliver on that expectation. Alex displays what many therapists would consider intellectualization, a psychological defense mechanism that allows him to isolate his affect and not feel the deep pain associated with his traumatic experience (Cramer, 2000). He can discuss difficult issues but does so with a high level of defensiveness that keeps him from having to take any true part in the discussion or express true emotion. For example, in one session, when he explains the attack in Iraq he notes very quickly that he has no guilt, and that he followed his order correctly in his mission. He further states, "I sleep well at night -- very well."

Alex's inability to connect with his emotions and express them openly presents a challenge to his therapist. Since he seems unable to bring down his guard and admit to his very conflicted and painful emotions his therapist can do little to engage in truly effective psychodynamic work.

Missing Treatment Methods

There are a variety of barriers to Alex's treatment, and as a result his therapy is missing several critical methods. Alex is an extremely defended patient with an exaggerated sense of perfectionism and intellectualization. He struggles to truly disclose the severity of his trauma, and he is too defensive to seek additional services from either the military or his own community and family. He appears to be a great deal of pressure on himself to appear normal and strong.

Alex does not appear to have had a full psychological evaluation from a clinician outside of the military, and the significance is that he has never actually sought medical and mental health services from anyone who specializes in this type of trauma. His case requires a full assessment of his health, eating habits, sleeping habits, and mental and emotional process and thoughts. Grinage (2003) suggests that effective diagnosis of PTSD requires a very empathic and non-judgmental approach, and since Alex is so strong defended it seems very unlikely that a military evaluation could offer him the empathy and encouragement needed to disclose the totality of his symptoms.

Alex's therapist, Paul, does his best to develop a strong, empathic connection that gradually allows Alex to disclose more of his experiences and feelings, but without a full assessment of Alex's mental health needs Paul can't really be sure that his is offering the correct services. This is evidenced when Alex suddenly ends his therapy, only to return and discuss his re-entry in the military and return to Iraq for service. In the end, when Alex is killed, Paul has serious questions about the nature of his death and whether he was suicidal.

Preferred Treatment

Although Paul does an excellent job of developing trust and rapport with Alex the case requires far more than a positive psychodynamic bond. Studies by both Fredman et al. (2011) and Grinage (2003) report that the treatment of veterans with depression, anxiety and PTSD is a complex matter. These cases often require a mixture of psychodynamic therapy, cognitive behavioral therapy, medication, and group support. Alex would have been best served if Paul had been consulting with a comprehensive program designed to work with veterans or, at the very least, a program specializing in men who have experienced trauma. It's quite likely that, although he was quite defended, Alex may have responded well to group support services in which men like him discussed their experiences. It was quite clear in his therapy sessions that he felt a great deal of family and professional pressure to be "perfect" or the "creme de la creme," and he may have responded quite well to group counseling services in which someone with his military background and high level of expertise talked about his experiences and trauma. It becomes quite clear that Alex's case is one that requires more intensive services when he takes action to break off therapy.

In the end, the therapeutic work Alex does with Paul illustrates how essential a positive therapeutic relationship can be -- especially with trauma survivors. The audience is left with the distinct understanding that Alex likely needed far more comprehensive services than individual therapy session once a week.