Month: October 2010

Episode opens with Paul talking on the phone to his son. And we learn thus that his wife has moved in with another man and Max doesn’t like him. He and Kate spar with each other, she hangs up. Wendy, the woman he mentioned to Gina at the end last season, seems to be living with Paul.

Paul has a tremor in his right hand — remember, his father died of Parkinson’s — which we see when he puts down the phone.

First patient and first visit: Sunil’s son and daughter-in-law bring him to the appointment.  Sunil certainly looks depressed — his face and his body reflect his sadness eloquently. Son, Aaron, and daughter-in-law Julia come in to session — Paul comments on this as unusual. 

Sumil has been in New York for 5 months following the death of his wife and is having trouble adjusting. As Julia talks about what the problems they are concerned about are, we see she seems to be in charge, angry and wanting Sunil to be gone, though she doesn’t say that. The son seems rather passive and caught between his father and his controlling wife. At one point, Julia wants to talk with Paul without Sunil in the room, but Paul refuses.

Aaron is a physician, an osteopath, and has prescribed Effexor for his father, because, Julia says, therapy is a shameful thing in India and reserved for the insane. Julia expresses discomfort with Sunil and the way he looks at her. Sunil says in Hindi that it is because she is empty.

Finally Paul asks Aaron and Julia to leave the room.

Paul gets an ashtray for Sunil, who had earlier taken out his tobacco only to be admonished by Julia. 

Sunil confirms with a story about a man from his childhood that psychological treatment is not seen as a positive in India. He makes a cigarette and lights it. Paul says he generally does not allow smoking but if it will make Sunil more comfortable, he is fine with it. Sunil asks if Paul ever smoked and Paul says yes, he did and sometimes misses the smell of it even today. 

With this, Sunil seems to become more willing to talk. He tells Paul that his son changed his name to Aaron from his Indian name. He finds this offensive. He implies Julia makes the decisions and says his son is not the man he used to be. He and Julia pretty clearly  do not like each other.. He tells Paul he puts the Effexor pills in a flower pot in his room. 

Sunil  tells Paul he was married for 30 years. He misses his wife, grieves for her. And when he tells Paul about this, it is clear the depth of his sorrow about her death and his loss. He says Aaron and Julia have decided to have another baby and he will be moved to the basement, thus displacing him yet again.

Session ends and Paul says he would like to help him. Sunil says maybe he could write him a prescription that would allow him to return to India and his wife would be alive and they could be together. Paul says he wishes he could bring her back. Sunil agrees to return to next week at the same time.

He thanks Paul again for letting him smoke. 

Payment is not dealt with though Julia asked about it before they left the room.  After Sunil has left, Paul opens the window.

First sessions are often tough. It can be difficult to get a handle on the patient and a sense if this is someone we can work with, someone willing to engage in the therapy process. In the first half of this session, it did not look promising. Julia was overbearing and angry and Sunil did not speak to Paul or in English. Had the session continued as it began, I don’t see that therapy would be possible. In fact I am surprised that Paul did not ask Julia and Aaron to leave sooner. As long as they remained in the room, Sunil was treated like a child. And as Paul said, it is not usual for family of an adult to be in the session.

The issue of allowing a patient to smoke in a session is an interesting one. Because I really dislike smoking, I have never allowed it. It has been years since a patient even asked if it would be all right to smoke. Some therapists allow it in the belief that some patients need that to allay their anxiety. I’m not persuaded by that argument. And it doesn’t really allow for exploration of what being able to smoke or not smoke means to the patient. No matter how long the window is open, traces of the smell of the smoke will remain in the office, in a way an intrusion of the previous patient into the time of the next one. Clearly I can find a lot of good reasons not to allow smoking in my office. And truthfully even without good clinical reasons, I still wouldn’t because I so dislike the smell. I’m interested to know what any of you have experienced on this issue.

The last thing that caught my attention is the issue of payment. Julia is in charge of the money and doles out an allowance to Sunil, further infantilizing him. My preference would be for that issue to be between Sunil and Paul, without Julia in between. If she is in charge of payment, she becomes a kind of third party to the treatment and in control of how long it can last. 

In the snippet of conversation between Paul and Kate, we know there is still a great deal of tension between them, which I suspect we will learn more about as the season progresses. As we will about Paul’s tremor.

Paul is putting water into a vase with some white peonies. He opens the door and his patient is there — early.

Thus we meet Frances, whose sister, Patricia, was Paul’s patient 18 years ago. She starts by asking if she looks like sister. Followed by talk between them of the ethics of Frances becoming Paul’s patient. He says given that it was so long in the past and that she is no longer seeing him, it is all right if Patricia is okay with it.

Frances says she called because she is opening in “Night of the Iguana” and is having trouble remembering lines. She asks if Paul sees her as a former star and then makes a joke about being the cliched narcissistic actress. Paul asks about her previous history and therapy. She ticks off a variety of alternative kinds of approaches, including seeing a shaman when she was on location. Then again in an attempt at humor suggests it is  cliche that she is coming to therapy, to the therapist her sister saw when her mother was dying. Frances says she was never attracted to traditional therapy because it seems naked, sitting and talking. She is anxious. She refers again to her sister. And then returns to the issue of the forgetting lines. She tells Paul she learns the lines and then in rehearsal, she loses them. Paul asks if the part makes her uncomfortable, if she trips over lines in particular places. She denies this is the case and asks if he saw Ava Gardner in the film version. Then that she has heard that one of the producers didn’t want her because she is too old.

We learn that she was married to a history professor at Columbia who used to help her learn lines, but they are now divorced. They have one child — 15 yr old Izzie. She says the daughter is doing well but when she tried to change custody arrangement now that she is in New York, the father became unhappy saying the daughter didn’t want it. So now she and Izzy are estranged. She says her daughter sees her as having bailed on her responsibilities by taking the play but Frances feels she doesn’t appreciate how much she passed up to do things for and with her.

We see a momentary lapse as if Frances forgets her train of thought and wonders why she started talking about the issue with custody Paul says it’s hard with teens. She talks about how she handled work and making sacrifices to see her mother when she was dying. Paul says she could handle it then but she was younger. Frances gets angry he mentions aging. She tries to turn it on him and his age. When he asks if age is a sensitive issue for her, she says she bets he is with some 25 yr old and again mentions what her sister said about him. He says they seem to talk about him a lot. 

Frances tells Paul her sister married and is now a widow. Then she says her sister is sick — with breast cancer like their mother — stage 4. Paul expresses concern about the sister — is she seeing a therapist? Frances is not happy at the focus leaving her. She says “death runs in the family”, referring to her mother and her sister both having breast cancer. She doesn’t want to be tested for the gene associated with breast cancer but sister wants her to. Then she reveals the sister now also lives in New York. At the time rehearsals started, it became clear that chemo was not helping Patricia and they had stopped treatment. 

Paul wonders if in light of a difficult divorce, estrangement from her daughter, and her sister’s illness, was it a good idea to take the play? Frances says work is the solution but she is failing. Paul suggests she might need to fail, self sabotage. Paul points out that she lost her train of thought when she accused herself of being selfish and maybe that’s what happens in rehearsal — which she is doing for selfish reasons. Paul asks if she thinks there might be some special meaning in coming to see him because of his prior relationship with her sister. Only then does she say Patricia is dying, something she has not allowed herself to say before.

She ends the session and asks if he always buys fresh flowers or did he do it for her. He suggests she pay attention to what she was feeling if she goes up in her lines.

Paul goes to his desk and picks up the phone. He speaks with another doctor and after they exchanges pleasantries about their kids, he asks for a referral to a neurologist about Parkinson’s. He is asked to hold.

There is much more energy in this session. As well as Sunil shows how slow and thick the session can be with someone who is very depressed, this one with Frances gives a good sense of what it is like to be with someone who is anxious. Throughout the session, Frances’ anxieties about aging and death weave in and around her questions, her attempts at humor and her frequent references to her sister. She gives the appearance throughout of doing a bit of a performance, trying to cover the flashes of deeper feeling and her anxiety with humor or deflection. 

When issue of whether or not it is all right for her to see Paul given that her sister was a patient years ago takes us into a piece of interesting territory. Regardless of the fact that patricia saw Paul 18 years ago, in the depth therapy perspective that relationship persists even without additional contact in the intervening years. Once a patient, always a patient in a sense as that form of relationship takes priority. So if Patricia objected to her sister seeing Paul, that would have to be dealt with and Paul likely would not see her. This may seem odd given that so many years have elapsed, but we can see through the many references that Frances makes to conversations she and her sister have had about Paul that that prior therapeutic relationship in a sense is still very much alive. I wonder about competition between Frances and Patricia, who we know is the younger sister, and what it means for Frances to start seeing her sister’s therapist. And why the sister did not call Paul when she learned of her illness and now that she is dying. I suspect Paul wonders this also. 

Paul’s expression of concern, his insistence really that Patricia should be seeing a therapist to help her cope with her illness reminds us of his work last season with Mia.

The first session in therapy is always important. Entire books have been written about the first session. Each therapist has her own way of beginning. I usually start by asking  what brings the person to me today or how I can help and then let the patient tell her story in her own way. There are others who use a more formal intake procedure, following a standard history taking format. Paul does pretty much what I do and follow the patient’s lead allowing that person’s story to unfold in its own way. In this way the first session takes the form of any session with the therapist listening, asking occasional questions, making an interpretation. Both parties are getting to know each other and the pace needs to be slow enough to keep the patient comfortable but also with enough depth to suggest how therapy is done. As a general rule, heavy interpretations do not belong in early sessions as they would likely meet with strong resistance and perhaps flight from therapy. So we see Paul asking Frances if perhaps there is a connection between the major events in her life and her problems remembering lines — a bit of testing the waters with her to see how she responds as a way of helping him to begin to understand how he must calibrate his efforts in order for her to be able to metabolize the work of therapy.

Jungians believe we get the practice that we need, that our patients bring to us the issues that we must tend to in our own lives. In these first two sessions, we see Sunil and Frances bring to Paul in their issues his own — with death, with family relationships, with estrangement from children, depression, work, and his own mortality and concerns about illness.

Paul is on the phone and is holding Gina’s book.  He is in a waiting room of another doctor. He and Wendy are discussing arrangements for the evening. Adele comes out and introduces herself and we meet his new therapist.

Paul is on the phone and is holding Gina’s book.  He is in a waiting room of another doctor. He and Wendy are discussing arrangements for the evening. Adele comes out and introduces herself and we meet his new therapist.

Her office is bright, light and modern. Paul comments on that right away and says his office is dark and burrow-like. Paul looks awkward and uncertain about how to begin. Adele reflects that he doesn’t want to be there. He called, he says, because he needs a refill of his Ambien prescription. His doctor in Baltimore had been refilling it but won’t now. So he called her because she is in the neighborhood and had an opening. He reports he has been Ambien every night for 14 months. Paul becomes irritated by Adele’s questions and tells her he had run out on Wednesday and hadn’t slept since Tuesday night. Paul says he didn’t expect her to be so young. She asks about his sleep — he says he wakes up after a few hours. His college friend referred him, he says, and she remarks that his friend is an excellent doctor. He again attacks her age by saying he thinks she couldn’t know how excellent his friend is because she is so young. His hostility is clear. She remarks about his repeated statements about her age. Paul just wants the prescription. He says he has been in therapy for 20 years and when she asks,  he says  it was with Gina whose name she does not recognize. Paul needs to tell her how important Gina is and says he saw her first for supervision then she became his analyst. And that she had also seen his ex-wife. All of this feels like jousting. She asks if he is an analyst and he says yes.

Adele returns to his sleep. He said the problem started as trouble falling asleep and he would take a pill and sleep. But now he wakes up. She asks what that wake time is like. He says he has always had trouble sleeping. She wants to know more — does he dream, have nightmares. Paul says for a while he has been waking up with a recurring dream but he knows what it is about. She reflects that he does not want to tell her and he says no he doesn’t. She asks what he thinks the dream is trying to tell him. Paul refers to Frances coming at the beginning of the week. He goes on talking about her. And that he reacted to her talk about the breast cancer gene. Paul looks at his hand and Adele sees he is afraid he has Parkinson’s, like his father. Adele asks about the fear which Paul says is not a fear, but a fact. He believes his unconscious has been trying to get him to stop ignoring the symptom. Paul angrily resists talking about any of this, saying he has already been over all of it with the best analyst. Adele says — Gina was your teacher, then your supervisor, then your analyst and saw your ex-wife? Paul asks why she asks and she says she just wanted to know more about how “the best analyst on the east coast practices”. Paul again angrily attacks her age. She observes he looks distressed — he says of course he is — he is divorced, estranged from his children, facing confinement to his chair. She gets more medical info and then Paul defends Gina, that what she did was good. Adele again apologizes.

She asks what it feels like to be reading his analyst’s novel. He waxes rhapsodic about Gina. He says he can imagine what Adele sees — that his bringing in the book was a security blanket. Adele asks how it feels to read the high praise of the blurbs he shares with her. He says he is pleased for Gina. Adele asks what he is jealous of. That she has escaped patients like me, he says. Adele asks why she would feel that and he says Adele likely feels that way already. Paul admits he sometimes feels that way, and that Gina was disgusted to hear that when he told her. Paul says patients become oppressive, the work becomes oppressive. He talks a bit about Jesse. He shares with her that Jesse told him about the message from his mother, that sometimes they make real contact and then Jesse goes into the world and it all implodes. Adele asks if he doesn’t think the listening matters. Then Paul talks about Sunil — saying he has the loneliest face he has ever seen because all he wants is for his wife to come back.

Adele asks if outside his office he has anyone to talk to. She observes that all of his significant attachments have ended. Paul says he does have Wendy. Adele asks if that was who he was talking to on the phone and why he told her he was in the grocery store. Paul says Wendy is 35 and he is 55 and he  doesn’t want to tell her yet about Parkinson’s. Adele says he isn’t seeing her for that and he says it is all related. Parkinson’s, the dream and not being able to sleep.

Adele ends observing that he used the same language of escape and entrapment about Sunil, about Gina and she wonders if the dream does also. He denies this, takes the prescription and goes.

At the very end, Adele reflects that  he had the dream again last night  but said he had figured out what it means  — so why he would have it again. She says if he decides he would like to talk again, the door is always open. He arrives home to find Max sitting on the stoop. He asks what he is doing there and Max says he came to live with him.

Any thought we had that Paul’s prickliness with Gina was just due to their complicated history flies out the window as we see him fence with Adele. He is angry and defensive. It seems that Gina’s importance in the field satisfied his need to be special and now to see a woman who is younger and less experienced appears to be a blow to his narcissism, his need to be important. After all, Adele doesn’t even know who Gina is.

It is curious that Paul chose to find a psychiatrist to get a new prescription for Ambien rather than finding a new primary care doctor, who could easily prescribe it for him without expecting him to discuss his therapy history. In fact, I wonder why he has not found a new physician in New York given that he has been there for two years now, unless he keeps the ties to Baltimore as a way to remain attached to his life there. My guess is that he knows he needs help and so selected someone who would ask questions. And Paul has a need to fence with her, likely to determine if she can withstand his attacks without rejecting or abandoning him. Adele looks to me to have passed that test with flying colors.

Note that Paul mentioned all three of the patients we met this week. He knows Sunil’s loneliness and it may well be that he misses Kate in a way he never expected to. He shares with Frances her fear of aging and death and that he, like she, may meet the same fate as his parent. And Jesse who is 16, very close to the age when Paul’s mother committed suicide, abandoning him.  He has the patients he needs to surface his own complexes and problems.

With Adele, who is skeptical about the way Gina and Paul complicated and re-complicated their relationship and may well already see that though Paul believes that he has worked through all of his issues, they actually have barely been touched, we will see Paul having to contend with an actual therapeutic relationship. This promises to be very interesting. Among other things, Paul must deal with his weariness about his work. I hope this is one of the things Adele helps him to explore.

I am also interested to see what else we learn about what Gina wrote and how Paul feels about it. It is not at all unusual for patients of an analyst who publishes to want to read what they write and I am certain Paul is curious.