Treating Through “The Sopranos”: A Biopsychosocial Approach

AIMS: Television is a medium through which an audience can gain insight into the nuances of psychiatric practice. Nonetheless, the psychoeducational benefits are dependent on accurate portrayals. “The Sopranos” has received critical acclaim from various professional psychiatric bodies for its artistic depiction of psychoanalysis and the psychotherapeutic relationship. The series follows Tony Soprano, a middle-aged Italian-American male engaged in organized crime. He is referred to his psychiatrist, Dr Melfi, by his family physician after suffering debilitating panic attacks. Melfi accepts the referral despite Tony's chequered past, employing a holistic approach to his care. We aimed to analyse the psychotherapeutic relationship between Tony Soprano and his psychiatrist, using a biopsychosocial approach. METHODS: Season 1 of “The Sopranos” was identified by a facilitator and utilized for discussion. The season was viewed individually and virtual case-based dialogues took place between the author and facilitator examining the psychotherapeutic relationship using the biopsychosocial model. RESULTS: The Sopranos coincided with the popularity of the serotonin theory of depression in the US, promoted by the pharmaceutical industry. Tony Soprano is pharmacologically treated for panic attacks, anxiety and depression. This sparked thematic discussion around symptom control, medication efficacy and adverse effects. Melfi balances the application of medication alongside understanding the psychological roots of symptoms, deprescribing when necessary. Themes pertaining to conflict between Freud's id, ego and superego persisted, manifesting cognitive dissonance most prominently in relation to Tony's line of work. Symbolism of ducks guided understanding of Tony's biggest fear – losing his family. Projective testing was explored, alluding to the Rorschach test. Scenes depicting transference and countertransference were present, the former representing Tony's unmet needs from female figures in his life. Eventually, Tony's distress induces internally generated pseudohallucinations. Tony's tender treatment of his children offsets his volatile relationship with his parents, particularly his mother who habitually antagonizes her son. His personal and professional life are intertwined, with mental health stigma evident in both realms as Tony seeks help surreptitiously to maintain his credibility. CONCLUSION: “The Sopranos” depicts the psychotherapeutic relationship between a man suffering from mental illness and his therapist. This layered and accurate portrayal can provide a case-based reference for psychoeducational discussion, and give rise to further discussions of psychiatric themes within film and television.