In Treatment--Laura, week 3

Paul awakens to his alarm clock -- he's sleeping on the couch in his office. Not surprising given the events with Kate last week.

Laura bursts in dramatically. She finds his belt on the couch and asks if he was going to punish her for being late. She tells about seeing a dog hit by cars and that she had to pull over to help the dog. She is certain Paul would have also. He tells her he would not, that he would assume the dog was dead and go on. He points out to her that she would have been late even had it not been for the dog and that he would have appreciated a call. He suggests that being late was not coincidental.

She doesn't want to look at her behavior, that she was already late and that being late and not calling is very unusual for her. She does not want to consider this.

Paul's questions are not off base but he is using them to act out his own discomfort. Clearly Gina's questioning of his continuing to work with her has been on his mind.

Paul suggests that she was already angry before she came in the door and in fact considered not coming.

Paul apologizes to her for hurting her with his response that no, he didn't want her but that he is not sorry for being honest with her.

Laura continues to attack -- refusing to consider his interpretations, his work. She tells him that all of a sudden she misses Andrew, for the first time she misses Andrew. She talks about the wedding and pokes fun a bit at Andrew's delight, that he has told everyone though she has not yet told her father. Paul probes a bit about why she hasn't told him and suggests to her that she hasn't told him because then it will be real.

Anger flares again when Paul tells her that their time is almost up -- she protests that she just got here, and he reminds her that she was a half hour late. Paul says that yes, they do need to talk about whether the therapy is helpful to her. He confronts her with his sense that she doesn't want to be his patient, she wants him entirely differently and that makes him useless to her, makes her feel hurt by his refusal. She tries to get him to give her more time. He goes on in a business like way. She leaves.

As she leaves she sees Alex arriving and asks if he is a patient. They talk for a short time and she asks if this is his regular time. He thinks it's Tuesday. She asks him if he knows of a vet and then she asks where he is headed. He offers her a ride and she accepts. 

We have to assume that Paul has not spoken further with Gina since her suggestion that they look together at his treatment of Laura and whether or not continuing to see her in therapy is appropriate for her or for him. However, I think it is safe to assume that her confrontation caused Paul to look more closely at his work with Laura and to see problems he had ignored previously. 

Basically patients act out with time or money. With time by coming too early, too late, the wrong day, missing the session, trying to run over time, calling the therapist. With money by failing to pay, paying late, writing a bad check, forgetting the check and so on. Whenever a patient deviates from the frame -- the ground rules of their work -- it is important to at least consider what is going on. A patient who is normally punctual who shows up late without calling is saying something with her behavior -- this is what we call acting out because she is acting out what she feels rather than putting it into words. And given how the previous session ended, Paul is within reason to suspect she didn't want to come and/or is angry with him.

But Laura has already shown us in previous sessions that she does not want to hear interpretations or to look too closely at her own behavior, even though that is the point of therapy. Paul then confronts her with his sense that she discarded him as a therapist refusing to be a patient long ago -- she has shown this with her refusal to consider interpretations, complaining when he makes them, and her desire to breach the boundaries with him. 

Paul's assessment is on the mark, no doubt about it. But, it is ill-timed and driven by his anxiety. He knows Gina was right in connecting his problems with Laura with his problems with Kate. And had his marriage not been falling apart, he likely would have picked up on and dealt with Laura's attempts to evade being a patient long before this. It would have been far better for him to have taken time to work on this problem with Gina. But Paul is in the same kind of difficult relationship with Gina as Laura is with him and he is almost as resistant.

Laura is spot on when she confronts Paul by asking him if, as a therapist with 20 years experience, he shouldn't be able to handle a patient who falls in love with him. 

Now about running into Alex -- I hope you have noticed that Paul's patients enter through one door and leave through another. The purpose of this kind of arrangement is to keep patients from running into one another -- to preserve their privacy and to allow each one the fantasy of being the only one. So under normal circumstances, Laura and Alex would not run into each other, even if they were scheduled on the same day. But they do encounter each other. And it is pretty clear from Laura's behavior from the outset that she will act out with Alex if she can -- remember the guy in the bathroom that Laura told Paul about the first week?

 Paul needs to talk with Gina today and commit himself to working with her or someone she recommends to get his own issues under better control. And he probably should tell Laura that he suggests she find another therapist. But this is not an easy move to make -- she would experience it as rejection  for one thing and if she leaves without a solid referral to another therapist, he is open to accusation of patient abandonment. Can this problem be worked through, that is can Laura and Paul hang in there and find their way back to a therapeutic relationship? Yes, but Paul absolutely needs to be consulting with Gina or another therapist all the way. A caveat here -- Laura's move toward Alex will be absolutely destructive of the therapy as this kind of acting out, being willing to behave destructively in this way makes it impossible to maintain a therapeutic relationship because she is so likely to escalate again. Once Paul finds out, and he will, he will have to act and it won't be easy.

© Cheryl Fuller, 2018. All  rights reserved.