In Treatment Season 3 Week 1: Sunil

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.

In Treatment Season 3 Week 1 Jesse

Paul is reading the NY review of books. He sees an ad for Gina’s book. Then a knock on the door. He opens the door to a flash going off as his patient enters.

Jesse, a teenager, sits slumped a bit on the couch, his knees jiggling. Tension is his body is evident. He tells Paul he took a lot of good photos that week and put some on Facebook. He tried to friend Paul but discovered he isn’t on FB for which he admonishes him. 

Jesse says he likes the word bifurcated and then they spar a little about the way Merriam (of Merriam-Webster) is pronounced and Paul reveals a bit of dictionary trivia he knows. 

Jesse is gay. He talks in a dramatic and slightly pressured way.Swinging quickly from anger to a quieter state. He says he loves his camera and when Paul asks who gave it to him, he says he doesn’t remember, which is odd. Then he shows Paul pictures in the camera. Among them are photos in a bar. Paul asks when that was,  to which Jesse vaguely says Friday though Paul says the date stamp says Tuesday. Paul asks if it was at Josh and Rafe’s bar and was it last night? Jesse reluctantly confesses. Paul asks if he went to school that day. He says no. Paul reminds Jesse that he had said he wouldn’t go back to see them because he felt used by them, because they think he is a student at NYU. Paul says he is a minor and it is illegal for them to be with him. And Jesse says he will soon be 17, that they are safe and they always use condoms. His movements become more agitated. Paul asks if Jesse is taking his Adderall. Jesse says he means is he selling it. Jesse then says he found an app that allows him to see who is looking for a hookup. Paul told him to put the phone away.

His mother, whom he refers to as Marissa, sent him a text early in the morning because he didn’t go home. Paul asks if he thinks his mother finds him a burden and then he says he hates talking about his parents as he lies down. His father is grooming another young man to take over the business, D’amato and Sons. Paul asks if that feels like a rejection. Jesse says it is a metaphor which means D’amato and people he wish were his sons. 

After another angry retort, Jesse says this sucks and that he feels like a fuck up today. Paul observes that whenever he talks about his birth parents, he assigns different professions to his father but his mother he always refers to as a crack whore. Jesse tries to slough that off. He takes out his iPhone again and when Paul asks him to put it away he refuses, and angrily says he like holding it. Then he takes it out again and plays a message on the phone — and we hear a woman saying she thinks she is his birth mother.

Paul asks when he got the message. He says yesterday after school. He gets angry and defensive again and mocks Paul. Then he says he felt nothing when she called and how did she get his number anyway. Paul tries to support him and asks what he wants to do. How he feels. Jesse says there is nothing going on inside, all he hears is static and really faint voices he can’t make out. Jesse says he’s sorry and he pulls his legs up. Paul asks what he did after he got the message. He says he went for a walk, to the bridge. Paul asks if he was heading anyplace in particular. Jesse says Josh and Rafe’s. Paul asks if he has noticed when he is emotionally upset he seeks out sex. They didn’t have sex, Jesse angrily says, that Rafe went with him back to their apartment. He attacks Paul for asking about his sex life. Paul firmly tells him not to talk to him that way — Jesse apologizes. Paul also apologizes for not realizing how emotionally important Josh and Rafe are to him. Jesse says they are really good guys.

Jesse says the call came from Westchester. And the exchange tells him she is wealthy. The hour is over. Paul asks where he is going. Jesse doesn’t want to go home because what can he say — that he got a message from his birth mother? Paul asks again where he is going and he says maybe for another walk. Jesse leaves.

Paul is at his best dealing with adolescents, giving them room for their conflicting emotions and mood changes while setting limits as needed. We this again with Jesse who is angry, confused, struggling with issues of abandonment and acting out sexually. Paul handles him deftly, confronting Jesse then making space for him to take it in and respond. Notice that each time, Jesse first responds defensively and then comes round and responds. It’s a dance and one that Paul has to be able to see and understand in order to do it. And Jesse responds to Paul’s care, even though he pokes fun at him, by being willing to play for him the message that he got from his mother. And when he does, the cause of Jesse’s agitation becomes clear to us and to Paul, even as Jesse tries to push it away. At the end, he unwittingly reveals the big wound when he says he knows from where she called that she has money — though not said, we can hear in that the question “Why didn’t she keep me?” So long as he imagined her to be a crack whore, he could keep that at a distance, as he also keeps his adoptive parents at a distance with contempt — a typical ploy by adolescents. But now there is a voice and a telephone number and fantasy threatens to move into reality. 

Recall that with Sophie in season 1, Paul was also dealing with a teenager in a sexual relationship with an adult. It takes a deft hand to both communicate support for the teen while also voicing concern for issues of being a minor and possibly being exploited. If Paul were to press too hard on this, Jesse would likely bolt. Paul’s recognition that Jesse gains emotional support from Josh and Rafe even as he has said he feels “fucked by them when they fuck” him is important. It is important that Paul not become the protective parent here but that he carefully thread his way through Jesse’s need for support from adult males and the real threat of sexual exploitation.

We see also in this session the difference between a first session, which we saw with Sunil and Frances, and therapy which is more established. Paul has a better sense of when he can push Jesse and when to back off. In other words, he knows the dance that works with Jesse whereas with Sunil and Frances it is still to be discovered.

In Treatment Season 3 Week 1: Frances

hBO Intreatment cast Frances

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.

Season 3 Week 1: Paul and Adele

HBO Intreatment character Adele

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.

Week 2: Gina

gina picture

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

Photo of Paul

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

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

gina picture

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

Jung Diagram

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: Oliver

Oliver picture

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.