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: 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?