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:

Jung Diagram


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.

More on Dual Relationships

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.


In Treatment: Week 2

Gina is sitting at her computer when the phone rings. She answers and says “He is not here. He died a year ago. Please don’t call back.”

Paul returns to see Gina. He coughs and looks upset. He tells Gina that it’s true, that Kate has been seeing a man and then makes it that Kate told him all the details, omitting that he pushed for them. Paul feels like everything is falling apart — he tells her that Alex is leaving his wife, that Sophie is having an affair with her coach and alluded to something going on with his daughter. He says Kate says it’s his fault, that she is invisible to him as are the children. Gina says she is confused by all the names and suggests they focus on Kate.

“What am I supposed to do? What am I supposed to do now?”, Paul asks. He exaggerates what Kate told him and says he that he always thought sex was connected with intimacy for Kate. Gina asks if he asked for the details and when he admits he did, Gina says Kate wanted to make sure he got it. And confronts him that he knew. 

He takes a cold pill. She offers him tea, he asks for water.

He tells her about Jake and Amy. 

“Ultimatums from two women”, Gina observes, Kate and Laura. 

“Two”, he asks, “how about three?”, looking at Gina.

Gina asks if his relationship with Kate has been a wall that has protected him from attraction to his patients. Gina tells him she is not worried that Laura will breach the wall, but that Paul is hoping she will. Gina points out that Paul is surrounded by women who demand of him that he feel, that he face his feelings.

He tells Gina that Kate hates his work, hates the secrecy. She wants to make changes and he won’t let her, because he agrees with her, it’s not her space. He says he used to talk about patients in general terms with his family but not any more. 

He asks about the issue with Laura and the bathroom, would she let Laura use the bathroom in the house? That she wanted to breach the wall. Gina asks what he did. He said he panicked, he jumped up because he panicked, he thought she was doing it on purpose. Then he asks himself why he panicked and he doesn’t know. Gina asks if that has ever happened with another patient and Paul tells what happened with Sophie and the wet clothes — a lot more intimate than using the bathroom, Gina observes. Why the panic with Laura and not with Sophie? Why is it all right for Sophie and Kate to meet but Laura scared you?

Paul confesses that he sort of wished that Laura would go into the house and see Kate.  He tells Gina he clearly stated the boundary. Gina asks if he ever entertains the thought of having an affair with Laura. He knows how important it is to set the boundary, he knows it has to be clear that it will not happen. Gina asks further and Paul tells her what Laura said, how much she wants him. “That’s a lot to stave off’, Gina says. And then she suggests that Paul should transfer Laura to another therapist — because the situation with Kate has made him angry and injured. 

A female therapist? he asks? You?

Paul is angry with Gina, at her suggestion, at what he thinks she believes. He refuses to consider transferring Laura and tells Gina if it weren’t for Kate’s cheating, he wouldn’t have come back. And his suspicion that because his father cheated on his mother by having an affair with a patient, she thinks he will also. She can’t answer.

And then he brings up a patient he had referred to her, a male patient who fell in love with Gina. And that Gina fled to England in the face of it. He accuses her of abandoning her patient. 

Paul admits he was disillusioned with her. And he keeps hitting er with her failure with her patient.

Gina asks him to be honest — is he attracted to Laura? 

Gina asserts that she is suggesting they *talk* about transferring Laura and look at his reaction — he is attacking and defending.

The session ends with both of them exhausted.

In Treatment: Jake and Amy Week 2

Amy has arrived before Jake and is smoking when he arrives. Jake comes on to her as they are in the garden before going into Paul’s office. They joke about names for the baby and superficially things seem better.

Amy opens saying that she did not keep the appointment with her doctor because Paul was right, she needs to think it over. They are all smiles and happy, talking about getting along better. Amy says she thinks she may want this baby and has imagined the baby, which she thinks is a girl.

Paul asks if they have talked about this decision. Amy asks what he thinks. And he wonders , despite their apparent happiness, whether they shouldn’t talk about it. Jake says this is their last session because they have decided; Amy says not necessarily. Paul reiterates that they still need to talk about it.

While Amy speaks, Jake looks away. Amy gets up and goes into the bathroom. Next we see them leaving.

And Paul finds a spot of blood on the couch — so we may fairly conclude that Amy is miscarrying.

Paul calls for Kate to ask how to get the blood out of the couch. There is tension between Kate and Paul. He frets about whether or not there will be a stain because he says his patients will wonder. Kate says maybe now he will replace the couch — and then says that he could make the room nicer. She says that she is jealous of the room.

Paul tells her he went back to see Gina, which surprises Kate, who says she thought he despised Gina after what she wrote about him. Paul asks Kate why GIna is such a threat to her. Then they begin to fight about the kids, about Kate’s sense that she carries all of the parenting load. Paul resists the idea of sending their son to a school for gifted children, something Kate passionately believes would be best for him as he hates school and has no friends. Kate cries and tells him he does not make her feel she is the most important thing to him, not her, not the kids compared to what happens in his office. She is furious that he is energetic and engaged with his patients and old and tired with his family. Paul looks defeated and acknowledges that he may be out of touch with Max. Kate sits down on the opposite end of the couch, the distance reflecting how little actual contact there is between them. Kate keeps trying to pull the discussion back to their relationship, which Paul clearly does not want to talk about. “Why don’t we talk”, she asks? He checks the clock and says “we have a few minutes, let’s talk”.

Kate says, “I’m seeing someone”. Paul asks what she means and she asks what he thinks she means. He gets angry and asks about this man, who is he, where she sees him, what they do? She throws the details at him. Paul accuses her of deliberately betraying him while accusing him of being neglectful. One of those fights that takes couples over the brink into the territory of fatal wounds.  And then he sits again and says, “Congratulations. You have ruined any chance of saving this marriage.”

Kate tells him that it was past saving because he never noticed, because he never considered she might do something like this.

“Is it over? Are you going to keep on seeing him?”

Kate says it is up to him and he tells her to please leave.

There is a knock on the door. Paul tidies up and goes to answer, pulling himself together to meet with the next patient.

In this episode, we see one of the great, maybe the greatest occupational hazard for therapists. It is so very easy for therapists to get many if not most of their intimacy needs met in their work. The relationship is intimate, making us privy to  the deepest issues of our patients’ lives and though the work is demanding, we need only pay close attention in one hour increments with no requirement that we ourselves reveal our own interior. Patients are usually grateful and make us feel valuable. Compared with the mundane issues of family life — squabbling kids, household chores — life in the consulting room is vivid, alive, rewarding. And what goes on there cannot be brought back into the family, cannot be shared as other work usually can be. So the life of the therapist easily becomes split between the office and outside the office. 

But the intimacy of the consulting room, while real, is bounded and is not sufficient for either party. Therapists need friends and close family who will not make them special, will be honest with them, and both give and receive love. Our friends and loved ones help keep our feet on the ground because they know us and love us, warts and pimples and all. There is nothing like changing a dirty diaper or washing dishes or  the ordinary stuff of life to bring the therapist back from the cloud of adoration to solid ground again. But in order for those relationships to keep us grounded, they need our attention too, because when they become dysfunctional, the flight into the consulting room is an easy escape. If I am fighting with my husband or struggling with my kids or estranged from my friends, a call from a patient who needs me, who believes I can help and who adores me, rescues me from the unpleasant feelings those conflicts bring and makes me feel special and valued. So I become more open to my patients and avoidant of the people in my outside life. 

I suspect this is what has happened to Paul and now all of it is crashing in on him — his wife’s affair, his son’s school problems, his daughter’s possible problems and his patients are not providing the escape they once did because they keep bringing his own issues to the surface. The more Laura declares her love for him, the more Paul is faced with the rejection of him by Kate. Laura moves toward him as Kate moves away from him. Alex’s struggle for control over the sessions, over his life mirror Paul’s own efforts to keep everything together.  He can feel that someone in Sophie’s world has broken the rules just as he tries to push away his own fears that Kate has broken the rules of marriage. Life in the office no longer provides escape from the messes in his own life.

One other thing to file away — Kate mentions something about Gina having written about Paul in the past, in a way that suggests that this was a big factor in the rupture of Paul’s relationship with Gina. I suspect we will hear more about this as it sounds like Paul may have felt betrayed by something Gina published and that will take us into the issues clinicians face when writing about cases.

In Treatment: Paul

Photo of Paul

I wish it were more common that therapists chose to be in therapy themselves, but surprisingly it is less common than most people think. It is not a requirement of licensure or training, except for psychoanalytic training. So I am pleased to know that Paul has his own therapist, Gina, played by Diane Wiest.

The episode opens as he returns to therapy after an absence of some time. Right off the bat Paul sits in the therapist’s chair, which subtly suggests to us that it is not so easy for Paul to return. Gina has retired following the death of her husband. At Gina’s gentle prodding, Paul begins to talk about what has brought him back — he says he is struggling with his weight and is having another mid-life crisis, referring to one when he was 30 and another when he was 40. And finally he gets to the reason for calling Gina again — that he is losing his patience with his patients, feeling burdened by them, annoyed. He refers to Jake and says he really got under his skin — and if we listen between the lines, we can guess that there is something similar between his marriage and Jake & Amy’s. And Laura and the erotic transference. He ruefully says that if patients could see what therapists really think and feel, they would head for the hills. He tells her he is feeling anxious before sessions. 

And then we learn it has been ten years since he left therapy and Gina had assumed he was very angry.

Gina was Paul’s clinical supervisor and he left her, he says, because he felt she was interfering with his practice. And after a bit of banter, Paul confesses that he and his wife fight all the time and that it is interfering with his work. They fight over their son, his involvement with his practice, her emotional upset. Gina responds to him clinically, Paul tries to back out and turn back to his professional concerns, because he is reluctant to deal with his marriage. He makes a tentative commitment to try meeting with her a few times to see how it goes. And then begins to talk about his marriage again. And we learn that he seems to suspect she is involved elsewhere — an affair — and that their sex life has become lackluster. Gina offers her belief that if a therapist has difficulty with an erotic transference, it may well indicate problems in the therapist’s marriage, be a test of the marriage.

Gina confronts Paul on his evasion, that he tells her he is there to talk about Laura but keeps mentioning Kate, his wife. Paul is angry and defensive when he believes that Gina suspects him of acting out in the transference. He is prickly, argumentative, defensive. Paul critiques Gina and tells her how she is not doing well with him. Gina confronts him about his anger and resistance and tells him she does not know why he has come or what role he has placed her in. They allude to a complex and conflicted history, yet he says he could not think of someone else to talk with. Gina shows the impact of his verbal assaults and tells him he should get professional help with Laura.

The session ends in a draw and we are left uncertain whether Paul will return.

Working with another therapist in therapy is challenging. I have been in the position of being a therapists’ therapist and found it both difficult and rewarding. The kind of jockeying to be on top that we see Paul do with Gina is not uncommon. Resistance is part of any therapy and no less so when the patient is also a therapist. Paul shows us this very neatly when he gets prickly with Gina and won’t yield to her probes no matter how she frames them. In fact he accuses her of going too far and criticizes her approach. He is actually quite like Alex was with him in his efforts to control the session and keep her away from any points of vulnerability. Nevertheless, I suspect that her arrows about the situation with Laura and his need to deal with his marriage found their mark and because Paul is a good therapist and wants not to screw up, he will be back.

In Treatment: Jake and Amy

Today we meet Jake and Amy. Jake is restless and agitated because he has arrived for the appointment with Paul and Amy has not. He paces, makes calls trying to find her. Jake does not want to stay and begin without Amy. Amy finally arrives. 

This is their third session and Paul observes that Amy has been late each time. Jake interrogates Amy about where she was, clearly suspecting that she is keeping a secret from him. And then it emerges — they are there trying to decide whether or not to have an abortion and he suspects she has finalized the plans. So among other things, this couple is struggling over whether or not to have another child, Amy’s fears that she cannot do it, and Jake’s desire to proceed. But they are each enacting the other’s ambivalence.

Now, I rarely work with couples; I find it less satisfying than working with individuals. To me, with couples it feels like there are too many people in the room — the couple and all of the shadow couples in their lives that they bring with them. And I simply do not feel as well equipped to deal with them as I do with individuals. So, I confess I had less investment in this episode and found it less engaging.

At the end of the session, when Jake and Amy leave after provoking Paul, he makes a call — to his own therapist. Which is where we go tomorrow.

Tomorrow I pull together thoughts about what we have seen so far.

In Treatment: Alex

Tonight we meet Alex, Tuesday’s patient. Alex is a Navy pilot, arrogant and challenging who has sought out Paul because his friend and others told him Paul is the best and Alex will have nothing but the best. Alex is that patient who comes in and dares the therapist to be of any value, to get past his defenses and surprise him with something he doesn’t know, hasn’t thought of. Paul does a nice job of allowing Alex to feel that he is in charge, waiting for his opening to test out an interpretation. 

It’s easy with a patient like this to become defensive, to feel threatened and angry at being challenged in the way Alex does it. But Paul pretty much manages to avoid getting hooked and manages to surprise Alex just enough to make it likely he will return — though in his time and on his terms. Alex needs to feel in control and cannot yet yield to needing Alex — or probably anyone. At the end of the session he tosses his payment, in cash, onto the table as one might leave money for a hooker, and in that gesture expresses volumes. 

One thing I noticed that did not feel familiar to me was the way Alex entered the office for this, his first visit. He comes in and makes a show of looking around and then asks if there are rules. In my experience, most people come in and hesitate for a moment waiting for me to indicate where they should sit. And I usually ask what brings them to see me or something similar. Some schools of thought suggest that even in the first session, it is up to the patient to begin. At any rate, Alex shows us what he will be like from the moment of his entrance into the office. This is one reason that therapist need to treat every contact with the patient, from the first telephone call, as clinically significant. To do otherwise would be to miss important clinical data.

In Treatment: Laura

I am happy to report, as has Glen Gabbard in Slate, that In Treatment does a good job of portraying psychotherapy reasonably accurately. The session, condensed as it is into 30 minutes, manages convey something close to what actual therapy is like, as close, probably, as television can come without turning to a reality show format, and that would be dreadful.

Our Monday night patient is Laura. Last night and on succeeding Mondays we will see her at her sessions. From the HBO website, we learn that Laura is an anesthesiologist and we learn in the session that she has been seeing Paul Weston, the therapist for about a year. Laura comes to this session in a bit of a crisis and reveals she has been outside waiting for her appointment time(9 am) for several hours. The crisis stems, she tells Paul, from an ultimatum her boyfriend, Andrew, issued that they should get married or break up, an ultimatum that caused a fight and her flight from their apartment to a friend, then a club and sexual acting out with a stranger. A stranger she also characterizes as giving her an ultimatum. In the telling of the events, she reveals that at the crucial moment with the stranger, she thought of Paul,  the therapist, and attempted to extricate herself from the situation. After the revelation of what happened, she runs to the bathroom and we hear her apparently throwing up and then we see her looking at the items on the shelf over the sink. When she picks up what seems to be Paul’s hairbrush and brushes her hair with it, I got a pretty good idea that we would be hearing about an erotic transference. Laura reveals to Paul that she has loved him from their first meeting and that she has felt she has in fact been unfaithful to Andrew all along because Paul is the center of her life. Paul is clearly a bit uncomfortable with Laura’s declaration of love and moves quickly to enforce the boundaries. 

Paul does a good job of opening up what had actually happened between Laura and Andrew, that the ultimatum actually came from her. He is quite believable in the process. Of course he does not know, as we, the audience do, about the hairbrush, which might have been a tipoff for him about her feelings. In a purely clinical sense, I wish he had responded to her declaration of love and desire less defensively, for his need to assert the boundaries at that moment does seem defensive, arising as it likely does from his countertransference. ** Optimally he would have allowed her feelings without reacting in that way and waited to assert the boundaries, because his reaction could lead her to simply refuse to talk about it further and her feelings to fall back into the secrecy in which she had held them for the year she has been seeing him. Confessing to these feelings is already difficult. Her response to his boundary statement, that she will not boil his kid’s rabbit (referring to Fatal Attraction) hints at the complexity of her feelings and a possible anger at his firm, even if appropriate, rejection. 

On the other hand, the portrayal of his discomfort lets us see that therapists are most assuredly human, struggle with feelings and thoughts of their own and sometimes hit the mark while at others missing it, even if only slightly.

The folks who endorse a really tight therapeutic frame would have a field day here. There is plenty to think about for those of us who practice at home and whose offices do not have a separate dedicated bathroom. A home office always means that aspects of the therapist’s private life are visible, though rarely so readily available as that hairbrush. Like Gabbard, I have seldom had patients use the bathroom during a session, but I will be more attentive to what is and isn’t openly viewable just in case.

Tonight we meet Alex.

**For the non-therapists reading, I mean here that her declaration arouses feelings in him, making him uncomfortable, which he acts out by asserting control via stating the boundaries of a therapeutic relationship.