Month: April 2009

Week 2: Gina

Paul opens the door and sees Kate who has an envelope of financial aid material for Rosie. They start to have a spat. Paul asks her please not to come to his therapist’s again. Tammy comes out again and they greet. She apologizes for interrupting last week.

Paul starts mentioning Tammy and Gina says they can’t talk about that. Paul says he cannot be in therapy with her now. Gina says she is sorry but she respects his decision. She gets up to go and says he can stay there till the kids arrive. Paul looks unhappy. Gina asks if he wanted her to argue with him. He wants an hour of conversation, that he will pay her. She says she doesn’t charge for conversation. Paul wants her to stay and talk. Paul starts to complain about his week. He looks miserable. Gina says okay, just for a few minutes.

He mentions he thought about Tammy Kent when they were 17 and wonders why he did that. Gina says he could work on that in therapy. He tells her that the lawyers are deposing Laura this week. Gina asks if he is worried that she will try to get back at him. Paul says he doesn’t want to talk about his past because it his present that is causing him problems. Gina says it occurs to her that he thinks about Tammy because there is something incomplete from that period in his life when his father left his mother and when she died.

Gina asks Paul if he thinks that Alex decided that instead of fighting his guilt any further he would just let go. Paul nods. Gina says she doesn’t think Paul has no fight left in him, that if he would he could do the work and put it to rest. He says he knows he wouldn’t do the work, he would just start drinking too much. Paul wonders why he does this, why he comes there to fight with her to not be in therapy. Gina says she thought about whether she could treat them both. She says if she treats both of them there must be rules, and asks what rules he would expect. He says they would have to know they cannot expect to be told anything about the other. That they both saw her would have to be an open secret — known but not talked about. Gina asks him if he was able to do that with Laura and Alex. He says that is different because their affair was about him. Paul realizes Alex slept with Laura to show him how self-destructive he could be and Paul didn’t see that at the time. Gina says he can see why she needs to be neutral. Paul says nothing will happen with Tammy until or unless they are no longer patients. Gina says she will not mention what he just told her in the deposition. She asks if he wants to proceed. He says yes.

She starts asking him for more about Tammy. That she moved in down the hall. That his father moved out shortly after. Paul says that Tammy made him excited rather than sad about what was happening in his house. Tammy would reassure him that everything would be okay, that it was okay to let his mother cry. Gina says then Tammy helped him take care of his parents. He says he saw her as his girlfriend and that made him feel better. They didn’t have sex then, that it wasn’t until 3 years later. That it didn’t happen until his father left for one of his patients and his mother went into a deep depression. Tammy’s mother was strong, unlike his. He fell in love with Tammy when her family invited him for Christmas and he went and left his mother. He went home and found his mother unconscious and somehow got her to the hospital. The memory is not there, no memory of his mother’s first suicide attempt and he thinks if he had stayed with her she wouldn’t have done it. Gina tells him she punished him for not staying with her, taking care of her. Gina asks what he could have done. He says he doesn’t know, that all he knows is that he left her for one night and that is when she did it. Gina urges him to stay with it, because maybe he will discover some detail that he is missing. She knows for a fact that he couldn’t save her, as he couldn’t Alex. So he has to do whatever he can to remember that night. They end the session. Paul thanks her.

Paul calls information to get Tammy’s phone number. And calls her and asks that she call him so he can ask her about his mother.

A session nicely done though I have grave reservations about the wisdom of Gina taking Paul on in therapy. She handles his resistance far more deftly than she did last season when they never really arrived at a clean contract. This time instead of arguing with him and feeding his resistance, she does a very nice maneuver by being willing to let him end it but also not gratifying his desire to be in control. This reminds me a lot of the kinds of things Sheldon Kopp, a brilliant therapist who wrote a number of books* about his experience as a therapist. He often used this kind of maneuver to deal with patient resistance and it worked brilliantly here. Had she agreed to sit and just talk with him for more than a few minutes, had she not been matter of fact about letting him know that if he wasn’t there for the session they had agreed to, then she had other things she would like to do, they would have fallen into the pattern we saw last year. Once the contract is established and ground rules laid out — ground rules I have no doubt Paul will try to break, because that is the nature of these things in therapy — they get down to work and we see Paul willing to open a bit about himself. We can see that Paul is depressed, sad, lonely and confused and I believe Gina is correct that the origins lie in the issues he has still about his parents.

The parallels between the acting out between Laura and Alex and the potential for the same between Paul and Tammy will likely play a significant role in Paul’s therapy. It is possible to work with two people who are friends with each other, but it also carries risks. Patients can and should expect confidentiality from the therapist but, and this is little mentioned, for the container of the therapy to be solid, they also need to maintain confidentiality and not discuss the therapist with each other — this one is much harder to get across to patients and far less often honored.

Week 2: Issues

On the HBO forums there has been considerable discussion of the note-taking issue. And we saw this week that after seeing April, Paul sat down to write some notes. Which we know from what he said to Mia when they met to discuss the lawsuit taking session notes is not his usual practice. So why now?

The answer is simple — anxiety.

The whole issue of session notes is related more to risk management and insurance company requirements than it is to good care and the best interests of the patient. In fact. until fairly recently, it was up to the therapist what kind of notes if any notes would be taken. And, depending on licensing requirements and whether or not one accepts third party payment, it is still up to the therapist on this issue. Some therapists document via a short notation the occurrence of a session combined with billing records. Others take notes during the session. There is nothing in these approaches or any other that correlates to skill or outcome.

In a paper presented to the APA, Martin Williams explains how what starts as a way to manage risk morphs into standard of care — and sometimes into mandated requirement:

“Why wouldn’t you want to take notes about your session? …

Some psychologists—many more, I think, back a few decades ago and fewer today—do not think of what we do as medical, or as a treatment, or as something for which written documentation is appropriate. We see our work as forming relationships with patients, relationships that are unlike that of doctor-patient, but more like teacher-student, consultant, clergy-parishioner, or simply peers. Some of us believe that medicalizing that relationship by writing notes about how “the patient is progressing” or even about what happened during the session creates a barrier between the two people who are engaged in a personal journey together. Along those same lines, some of us eschew diagnosis and treatment plans.

It doesn’t really matter whether you agree with this Humanistic approach to psychotherapy. It serves as a good example of how risk management evolves to become the standard of care. Somewhere along the line, psychologists thought it would be a good idea to document what you did in therapy as a way of protecting yourself from certain claims, especially claims that you failed to do something. If someone claims you failed to ask your patient if he or she was still feeling suicidal, and your notes show that you did ask that question, bingo, you’re protected. If the patient later suicided, but after the session you wrote a note documenting the reasons that you believed the patient was not suicidal, and those reasons make sense to a later adjudicator, you have a degree of protection that you wouldn’t have had you just reconstructed that session from memory—subject to the skeptic’s view that your memory had been conveniently altered and rearranged to diminish your liability.

So it makes sense that those of us who want more protection would minimize their risk by taking notes, taking notes to document that we did all those things that someone later might claim we failed to do—a fine risk management idea. Fast forward to 2002 and we find that record keeping is no longer about risk management. It has become the standard of care…

One no longer keeps records to protect oneself. Now, one keeps records because not doing so is considered unethical in and of itself. Risk management evolves to become the standard of care.”

Ultimately each therapist has to decide where he or she stands on this issue. If one does not accept third party payment, it is a little easier because there are not then concerns about insurers demanding to inspect files, which they have the right to do for covered patients. The therapist must weigh duty to protect the patient’s interests and confidentiality vs. risk management. Consider also that patient files can be subpoenaed in other legal actions such as divorce cases and the confidentiality issue can be quite significant.

So Paul, now anxious about the lawsuit filed by Alex’s father, is taking notes after seeing April, not because it makes him a better therapist but because of his fears. It isn’t clear whether he is also taking notes on other patients.

This is a difficult issue. Before therapy was routinely covered or expected to be covered by insurance, risk management and these kinds of records requirements were rare for therapists. And given the low incidence of lawsuits against therapists, the fear generated by risk management folks is disproportionate. Years ago in response to someone asking how he felt about insurance coverage for analysis, a well-known Jungian analyst said that we must remember that he who pays the piper picks the tune. We do well to bear this in mind as third parties become more a part of what we do.

“Psychoanalysis cannot be considered a method of education if by education we mean the topiary art of clipping a tree into a beautiful artificial shape. But those who have a higher conception of education will prize most the method of cultivating a tree so that it fulfils to perfection its own natural conditions of growth.” Jung C W, vol. 4, para. 442

Carl Jung risk management

In Treatment: Walter

Paul is on the phone leaving a message for his kids about a visit scheduled for the next week.

Walter arrives for a first appointment. A well-dressed man who comments on his “nice things” and then fusses with the pillow in the chair and lets Paul know he is a CEO. Paul asks him to tell him about himself but Walter wants to know what he already knows about him. Walter is surprised he knows nothing about him. He is surprised that Paul doesn’t read the business section and tells him that his daughter’s friends at college never read that section either — and he sounds very disapproving. Walter keeps impressing on Paul how important he is.

He tells Paul it was his wife’s idea that he seek therapy because he doesn’t sleep well. Paul notes he has mentioned his wife twice and that she takes good care of him. He says he has tried Xanax and Ambien and says they did not work for him. He says his doctor told him he has underlying anxiety and should talk to someone. Walter is distressed that his whole life he was able to sleep whenever he wanted but now he can’t.

Paul tells him gently that the kind of therapy he does is not a quick fix. Walter is impatient with this because he wants things to be better now, no matter he cost. Paul tells him he needs to know more about Walter and what is going on before he can say what is wrong.

Paul keeps trying to find out when he began to have trouble sleeping and Walter says he doesn’t really know, that it happened gradually. He mentions his daughter and then he smiles as he talks about her — she is the youngest of his children and only daughter. He is delighted in her and now she is in Rwanda. Walter grabs that as the problem but Paul says he thinks there is more to it than this.

Paul tells him he can see he is suffering for some kind of anxiety and the only way he knows to deal with that is to talk. Paul suggests to him that yes, he should say whatever comes into his mind.

Walter is fidgety and uncomfortable being asked to talk. Paul asks if he has anyone he can talk to about the pressures he experiences and he says no one at work and not his sons because they aren’t interested.He reads Paul an email he received from his daughter. He becomes visibly upset reading her account of how difficult it is there and how much she finds being there important. Walter thinks he should run to get her ought because of what she describes because he fears she will be kidnapped. Paul says he thinks Natalie can be trusted to take care of herself.

Walter is angry at this and wants a concrete solution to his insomnia and as he angrily gets up to leave he falls down holding his chest. He seems to recover and still wants to leave. And he does.

Walter, like April, promises to be very challenging patient. Walter wants concrete specific answers. He needs for Paul to know how important and busy he is. It is only when he talks about his daughter that we catch of glimpse of a man who loves deeply. Notice that from the beginning he makes repeated references to his importance and success so that Paul will know he is not dealing with an ordinary man. The intensity of this repetition leads me to suspect he has some deep seated feelings of insecurity, inadequacy and anxiety. His refusal to think about or talk about it means these feelings have no place to go but into his body — in the form of insomnia and the anxiety attack we saw at the end. But somatizing in this way carries its own dangers and can be as deadly as April’s cancer.

Like April, Walter leaves without scheduling another appointment. And like April, Walter foreshadowed his leaving when he talked about the doctor who prescribed medication that didn’t work. Walter is telling us he will not wait long for results.

In Treatment: Gina

Paul is on the train. A large man takes the seat next to him and starts eating and talking. Paul looks uncomfortable. He lies to the man when asked what he does and says he is in sales.

Gina greets him at the door. She has redecorated. Paul has not talked with her in a while. He asks if his lawyer called about the malpractice case. She says he did and she will be deposed though she doesn’t know how much help she can be.

There is a knock and a woman has come back to get her glasses. She and Paul know each other. Gina identifies Paul as a friend not a patient. Gina tells him she is seeing patients, that her book is doing well and she asks if he has read it. He says he hasn’t, that he isn’t ready for it.

Paul tells her this is the first time in his life he has lived alone.

Paul is gloomy about the suit and the outcome of it. He is afraid he will lose his license, his apartment. He says he doesn’t care if he loses his license because he is sick of sitting day after day listening to people’s problems.

He asks Gina why they do this, why they do their work? He says his office is in his living room. He sleeps in the living room.

Paul is still angry — at Kate, at life. He realizes he has come because he needs clarity in his life, he needs help.

Paul tells Gina he wants her to tell him what to do — how to feel about everything. He doesn’t know how he feels. He tells her he needs her help.

Gina offers him a drink. She says it’s fun not having therapy and they toast to friendship.

They move in and out of casual conversation and then they turn again to therapy talk. He tells her about April. He asks what does a good therapist do when a patient needs more than just talk? Gina connects the anger Paul feels to the anger he felt toward Alex and to anger he felt about his mother. And he tells her he does not want to go into therapy. They move back into his anger about his mother’s death and how it connects to his feelings and fears about his patients.

Paul asks what if he said he wanted to come to her for therapy. She asks if he can trust her. Gina agrees. They settle on the time.

And now Paul is back to see Gina, ostensibly to discuss the pending malpractice case. But it soon becomes clear that Paul wants more as he asks Gina what to do and how to feel, very much as Walter asked him.

The unspoken elephant in the room with Paul and Gina is the dual relationship they have. In fact it is even more complicated than that – they have been friends, colleagues, she has been his therapist and supervisor. And the lines between the roles become too easily blurred. As they did repeatedly in this session where she identifies him as a friend, shares a drink with him as a friend, talks about Alex with him as a colleague and supervisor, and responds to his deeper issues as a therapist.

At the very end, Paul finally asks Gina if she will see him in therapy and after perfunctorily questioning whether he can trust her, she agrees. Much as I believe that Paul does indeed need to be in therapy, it should not be with Gina. And Gina should not have agreed *unless* she is willing to make it clear that if they are to work together in therapy, the friendship must close and priority given not just now but in the future to the therapy relationship. But she didn’t. She established no expectations except that they settle on a time. This does not bode well for the therapy.

In Treatment Season 2: Thoughts on Week 1

A long time ago a clinical supervisor told me we get the patients that we need in this process in which both therapist and patient become immersed. With that thought in mind, let’s look at the patients Paul has this year and how their issues and his relate. In Jungian terms, we see what happens in therapy as illustrated in the diagram below:

All four of the patients we will be following are ambivalent at best about being in therapy. And all of them resist Paul’s efforts to encourage them to look more deeply in themselves — this is a guess about Mia but she will be coming back with her own agenda of unfinished business from previous work with Paul; in fact it appears her desire is to deal with Paul more even than with herself. And Paul is reluctant to acknowledge his need for therapy. The ambivalence and defensiveness of his patients mirrors his. Five reluctant patients and a reluctant therapist.

Paul tells Gina he is sick of listening to people yet in his work with the patients we see, none of that shows. He does good work with all of them, reflecting something good therapists do all the time, which is to set aside personal issues in order to be present to patients. However it is essential that he be talking with someone about these feelings of his or they will inevitably leak into his work — in impatience, overly harsh interpretations, empathic failures, and the like.

Each of these patients brings to Paul some of his own issues. With Mia, he has history. She is still angry with him for leaving and feels abandoned by him. He will have to listen to her and deal with the painful experience of having to deal as non-defensively as possible her negative feelings and memories of him. And in the process of helping her deal with her feelings and whatever else brings her back to therapy, he will confront and work his way through some of his own issues and past, work he will do with Gina and within himself.

April presents him with a patient at risk for death and no doubt he wants to rescue her as he could not rescue Alex. It is a terrible experience when a therapy patient commits suicide or dies for any reason, but especially if there is a suspicion of suicide. It is not a common experience for therapists — around 20% of us experience the suicide of a patient. Paul is having to deal with the very real possibility that Alex did kill himself and that tough issue of whether he could have done anything to prevent it while also defending himself against a lawsuit that could cause the death of his professional life. With that as background in his work with April, it is not surprising that he feels pressure to get her to get treatment and for it to be more than usually difficult to let April lead and work through her fears in her time.

Walter brings to Paul his own resistance, his own desire for someone to tell him what to do and his fears that his success could crumble around him. Two men, both at critical points in their lives with issues and anxieties rooted in their pasts. Neither Paul nor Walter can look to family to listen to their fears. Walter experiences his fears in physical symptoms while Paul is angry, but both men are afraid and alone.

Finally, Oliver, as I said earlier, brings Paul face to face with his own estrangement from his children and his history with his parents and his inability to fix them or keep him mother alive. Paul and Oliver are both suffer from the traumas of divorce. Paul is away from his children and judging by the phone message we see him leaving and his wistful comments to Gina, he feels estranged from them. Just as Oliver does not want to go to his father’s house, Paul’s children apparently don’t want to come to his.

In The Difficult Art Carotenuto says that we become therapists as a way to keep ourselves immersed in our own issues. Now I know there are people who think therapists should be free of their own stuff, but that is impossible. The diagram above shows how the therapist as healer reaches the wounded patient and the unconscious healer in the patients reaches the unconscious patient in the therapist In this rich exchange that goes deeper than what can be seen objectively in the room, both parties are changed.

Week 1: Oliver

Oliver and Paul are sitting on the couch. Oliver asks if they have to wait for his mother and father. They decide to play cards while they wait. Oliver suggests blackjack and expertly shuffles the deck. He gives Paul the rules. Oliver says Paul sucks at the game and he wonders why if he sucks at it, why play? Oliver doesn’t really know why he is there. Paul tells him that his parents are getting divorced. Oliver denies the divorce — he says his dad has moved out but it doesn’t mean they are divorcing. He finds it annoying that his dad has moved out. Paul tells him they are meeting to help work out a solution to the problem that Oliver refuses to stay at his father’s apartment.

Oliver doesn’t like the food at his dad’s or his friends or that it takes longer to get to school. Paul says maybe they can help get things to change at his dad’s and make it easier for him to stay there. His mother arrives with Oliver’s snack and complaints about the father and where he lives. She doesn’t want to wait in the waiting room until the father arrives. We can see his mother is reluctant to have Oliver stay with his dad.

The father arrives in a rush. The parents complain about each other to Paul. Paul asks Oliver to wait in the waiting room while he talks with the parents.

Paul tells the parents they need some ground rules and that Oliver doesn’t really know they are getting divorced. Each of them blames this on the other. The dad wants Paul to explain to Oliver but Paul refuses because it is important for them to tell him these uncomfortable things. Luke, the father, believes that by allowing Oliver to choose his own food from take-out menus he is teaching him self-sufficiency. Paul explains that what Oliver may be saying is that he is not getting enough nurturance.

Paul picks up that both parents are using Oliver to get information about the other parent and tells them this is not good for Oliver. Paul proposes separate meetings and both refuse because they want to know what the other says. Oliver creates a distraction and they invite him in. Oliver tells his dad that it’s hard when his friends come on school nights. And dad agrees to change that. They also come up with a solution for after school snacks. Oliver says he doesn’t want to stay with his father and the mother says he doesn’t have to. The father leaves. Then they all leave.

Oliver is around the same age as Paul’s youngest child so we have to wonder if Oliver’s unhappiness makes Paul think about his son and the effect of his divorce on his children.

In this case, Paul has a complex dance to do — helping Oliver and gaining the cooperation of the warring parents. This is never easy. The parents are not interested in being seen as a couple, which is too bad because they could perhaps become better able to work together as parents if they did. So he has to try to get them to make agreements while steering around their long standing conflicts.

Parents are the hardest part of working with children.

I liked the way Paul let Oliver explain the rules of the card game to him. Playing games with a child in therapy is never about the game but what the game allows the child to reveal about himself and the issues he struggles with. So Paul pays attention the way Oliver explains the rules. And we learn something important about him when Oliver asks of Paul what is the point in playing something if you suck at it — we should not be surprised if we learn that Oliver feels he is no good at sports or other games that maybe his father enjoys. And note that Oliver did not seem excited by the football his dad gave him when he arrived. It was when he was playing with the football in the waiting room that he knocked over the plant. It looks like Oliver is struggling with some things in addition to his parents’ divorce.

Children Divorce

Week 1: Mia

Paul has made some major changes since we left him. He is now divorced from Kate and lives in Brooklyn. Each weekend he commutes back to Maryland to see his children and Gina.

Paul is awakened by a knock on the door and opens it to see Alex’s father there. He is angry with Paul for not stopping Alex from flying. And he serves him with a summons in a lawsuit against him. Mr. Prince believes that talking with Paul is what killed his son and he wants Paul to have to pay for that.

We next see Paul as he comes to consult with an attorney for his malpractice case. He is surprised to see Mia, who was a patient some years ago. Paul is apprehensive about consulting her given their previous history. She urges him to proceed because they have little time until the hearing so he agrees. Paul looks stunned when he hears her say the word malpractice. She reviews the basic outlines of his background and then explains that he is being sued for $20 million, though his insurance covers only $3 million. Mia explains that the plaintiff is claiming that Alex committed suicide, which Paul does not believe.

Mia takes a call from her father.

She tells Paul she wants session notes but Paul says he doesn’t take notes. He asserts that many therapists do not take notes. They argue a bit about this and she rather snidely says she is pretty sure he took notes with her. She takes another call and Paul wanders around the office while she is out on the phone. She returns and tells Paul the photos he was looking at are not hers, that she never married.

They move to a more comfortable sitting area and she asks if Paul consulted with anyone on the case. He tells her he consulted with Gina each week. But he is not certain Gina would agree to appear because things were strained between them.

Paul explains that Alex was not in treatment very long. Mia asked if he referred him elsewhere and why did he leave. Paul said he wanted to leave and told Paul not to mess up his, Alex’s, life. Mia says that the opposing lawyers can claim he let a depressed patient go without referral.

Paul picks up on some issues in Mia’s questions that are arising from Mia’s history — did the therapy end too soon. Paul is uncomfortable with Mia dealing with his case. Mia says they have been in this place before when she was seeing him years ago. Mia is angry because she feels Paul abandoned her and that they did not in fact deal with how things had to end when he moved. Paul comes back to the fact that Mia grabbed his case and he wonders why. He tells her he believes that she wanted him to see she is a success. She angrily throws the appearance of her success in his face. Paul reflects that she wanted to show him both how well she has done and how sad she is.

They both rise to end the meeting. He leaves. She sits back down on the couch.

Dual Relationships and Notes --

Paul was correct in the first place that it was not a good idea for him to consult Mia given their prior therapeutic relationship. To follow through would create a dual relationship even though the therapy was years in the past. Because in reality the therapeutic relationship, once established, remains in effect even if dormant. That is the tightest standard, though some would be more relaxed and say that after a few years it can be relaxed. But as we saw tonight, bits and pieces of old issues for Mia came up rather quickly and she was relating to Paul more as her therapist than as a client from very early on. So the kinds of reciprocal relationships that are commonplace between other professions and occupations really don’t work for therapists, at least not for those who work from a psychodynamic or depth perspective. Once undertaken, the therapeutic relationship has primacy over any other relationship the two might have or want to have.

About Paul’s lack of notes. I’m sure every risk management-aware person nearly had a coronary when Paul said he didn’t take notes, that he didn’t feel the need to do so. But I understand where he is coming from and I suspect that he is correct that many do as he does, documenting patient visits through billing records but not through session notes. And in fact, because therapists do not have privileged communication — our records can be subpoenaed — many choose to keep minimal to no session notes to preserve the patient’s privacy. It is an ethical decision a therapist must make for him/herself.

Week 1: April

A young woman, April, is sitting in the waiting area. Paul opens the door and invites her in.

Paul’s office has large bay windows and is comfortably furnished. April walks around looking and admires the office, mentioning she is an architecture student. She asks if he did it himself or used a decorator and when he says he did it, she congratulates him.

April tells him she is 23, a student in architecture and urban planning at Pratt. She is recently single, having just broken up with a long time boyfriend. Paul asks if that is why she has come and she says no, the breakup was fine. She says she found his name online because she wanted to see someone near Pratt who would take her insurance. She tells him no one had commented and she had assumed it was a new practice. He tells her he recently moved there. Paul tells her she needn’t apologize for questions and that she needn’t censor herself to spare his feelings. He asks if she has seen a therapist before and she says she had — through student health. She speaks scornfully of the previous therapist. She felt that that therapist saw her as a complete waste of time. She tells Paul that the therapist had told her the same joke twice. Paul asks about it and she tells him. April stopped going and never spoke to the therapist despite receiving many telephone calls from her. She says she did not return the calls or tell her because she didn’t ant to hurt her feelings. April gets angry and defensive at Paul’s questions about her previous therapist.

Paul reflects to her that he knows now that she doesn’t want him to tell her things twice, not to feed her platitudes, that if he fails to engage her she will leave him without telling him even if he calls her 87 times.

She likes that and asks how many people come to her because of something really big. He tells her she can tell him anything — a rape or death. She tells him she was not raped and she is trying to tell him. Then she asks if she can write it down and he says of course. She writes and she is clearly upset. She hands him the paper. She looks terribly ad and so does Paul. He asks how she feels — she replies she is tired. He asks what type of cancer it is. She says she doesn’t want to talk about it. She just wanted to tell someone and she rushes into telling him all the things she has to do. He asks if she is getting sleep and she says no, she has terrible night sweats which are a symptom of lymphoma. He asks how she found out. She tells him she had a cough that wouldn’t go away. She went to the health center but what they gave her did not help. Her father is a doctor in the Army and she couldn’t reach him. Her symptoms got worse so she returned to the health center. Finally she was sent for further tests and she was diagnosed. She has a big mass behind her spine. She tells him to never get a bone marrow biopsy and describes how bad the experience was. She has met with an oncologist. He asks if she was alone when she did and she says she was. He asks if she has told her parents or friends. And she says she has only told him and a construction worker who harassed her on the street. She says she wanted to talk someone who is objective and won’t care what she does so she can talk about what she wants. She says her mother would become hysterical as would her father. Her brother, who is autistic, she says would become violent. Paul asks if she came to him looking for someone who would tell her it’s okay not to get treatment and she says no. Paul asks her if she really believes she has cancer, does she believe what she knows?

April tells him the oncologist said she was at stage 3 and she should start chemotherapy immediately. Paul challenges her resistance to starting treatment. Paul suggests to April that the other therapist told her the same story twice as a way to tell her it’s okay to need help. Paul says she needs to tell the oncologist what she is contemplating and that she needs to tell her parents as well. April gets angry and wants to leave. Paul offers her another time and presses to schedule another. She says she will call him. Paul is worried. She leaves.

April presents Paul with some interesting issues. He knows she will leave if he does not meet her expectations for his behavior, if she feels he has not listened and really heard her. And she is also in denial about the seriousness of her illness and the necessity to allow people to help her and to engage her in treatment. So he must find the line between listening and confrontation that will allow her to stay. The threat of abrupt termination is hanging over the therapy from the outset and Paul knows this.

Notice how Paul understood from what April told him about the first therapist and her scorn for her that she was telling him what would lead her to similarly reject him. And in fact she is primed to reject him because she is deeply ambivalent about getting help of any kind. It is not uncommon for patients to tell us how we will fail them, and we often do exactly that because it is an unconscious agenda for the therapy. The trick is in getting the patient to be willing to work through what they feel as a failure of empathy in order to see the greater complexity of the issue.

Paul is hoping April will come back. He stepped on the mine when he bluntly told her she needed to allow herself to be helped and to tell her parents. But he also earned some credibility in her eyes when he got what she was saying about the previous therapist. The odds favor her return. But it was a gamble he had to take on the chance that she did not return, a chance which was present from the very first moment of their meeting.

Cancer Terminal Illness