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. 

In Treatment: Sophie

Tonight we meet Sophie, a 16 yr old who has come to see Paul for a professional evaluation for her lawsuit. We see that both of her arms are in casts and she tells us a bit about her accident, while claiming amnesia for any details. 

The episode opens with Paul’s son angling to stay home from school and getting caught out in the process. He storms out of the room telling Paul, “You never believe me!” — which we should know will figure in Paul’s work with Sophie.

Sophie declares she is not interested in therapy. She essentially tells Paul she wants as little interaction with him as possible in order to get the evaluation. So she begins as many adolescents do, with great reluctance and mistrust about the process. Paul, and we, can feel that there is more here to Sophie than meets the eye and he skillfully woos her into talking more than she’d planned and into coming back for 3 more sessions. He expertly gains some trust from her and subtly engages her in the process without pushing hard or making her take flight, though at one point near the beginning she does start to bolt. His work with her was a pleasure to watch.

As Sophie talks about how close she is to her father, who moves so often she has to call 411 to get his phone number, and says that he and her coach are the only two people who love, there is the hint that something is very wrong in Sophie’s world. This accident is not her first one where she flies off a moving vehicle and injures herself in what looks enough like suicide attempts to have been named just that. Two accidents like that in a couple of years for one kid set off alarm bells. And then the drawing on her cast of the mermaid made by her male coach. My hunch is that some sexual boundaries have been crossed. 

Paul is wise to take this very slowly. He has to win her over, to let her develop trust in him, to be the good father, reliable an present that she needs in her life — we see that in her questions about Paul’s daughter.

Nice work, Paul!

Tomorrow night — Jake & Amy

In Treatment — the first week

Photo of Paul

So now we have seen Paul with each of the four patients and also seen him with Gina — his therapist/supervisor/sounding board. Themes emerge.

 ~~ Laura with her disappointment in Andrew and her infatuation with Paul

 ~~ Sophie who cannot put into words what she is suffering at the hands of her coach and father

 ~~ Alex who has no room in his sense of himself for the pain and horror of having done great harm in service of his mission

 ~~ Jake & Amy whose unborn child is the container for their discontent and product of their ambivalence about each other

 ~~ And Paul whose patients set him swimming in a sea of painful feelings which underline his own — in his marriage and with Gina.

Love and longing and disappointment and sex  and fear and anger — the stuff of therapy. 

There has been an extended discussion in the comments to my post on the first episode, not surprising given that Laura’s declaration of love for Paul touches on a lot of issues. I liked what Gina suggested last night — that yes, erotic transferences are common, but when the therapist experiences problems handling one or has a strong response, that is an indicator of an issue within the therapist, most often in his own marriage. And this is why Gina repeated several times that Paul needs to get help, i.e. supervision, on this, because his own marital issues make the risks of mishandling or even acting out with his patient higher than usual.

Good therapists understand that we will get our own issued tripped by patients and that sometimes this creates enough confusion in us that we need to be able to talk with another experienced clinician to help us deal with the problem. Supervision of this kind is far less about the patient than it is the therapist, a kind of therapy for the therapy. It is not an easy process and often the line between therapy and supervision is a fine one indeed. It is not a sign of failure or lack of skill for a therapist to see and act on the need for supervision; indeed it is a sign of a therapist who is deeply committed to being as ethical and conscious about the work as is humanly possible. No therapist is without blind spots and personal issues. The key is to remember that and be willing to recognize our need for help.

So, what do you think?