In Treatment, Week 4
In Treatment -- Paul, week 4
Paul arrives saying he is sorry to be late but he was at the market. And then asks her if she would put his bags in the refrigerator, that they contain fish heads because he is making chowder.
He begins by complimenting Gina on her dress and hair, says that she looks beautiful, softer. She replies she is going out with friends. Paul speculates they are a bunch of shrinks, which she agrees.
Paul talks about having been thinking about a woman he knew from training. Gina reminds him of the previous session, and Paul says it is not the first time he left angry. He says he is angry a lot these days.
Tells her about Sophie. Paul admits that the pills were his and in the medicine cabinet. Paul says he intervened and asked the admitting psychiatrist to release her, because he thinks she was testing him. He tells her how angry he got when Sophie told him about the guy who said she was like an abuse victim. Gina observes that he thinks he is more effective when he is involved, has an emotional response to his patients. Paul deflects saying he is just trying to tell her about his week.
He tells Gina that when Sophie collapsed he called for Kate, who had gone to Rome. He muses that one of the reasons he married Kate is that she is not a victim, unlike his mother.
He says he hasn't been alone in the house for 18 years -- both kids are away too.He says he makes a mean chowder, maybe he will get lucky. Maybe he will invite the woman he mentioned earlier. Her husband too? No, not the husband but Gina and this woman. He makes light of it, is a bit flirtatious.
Gina tells him h is showing her how it feels to be with Laura, how it feels to be a therapist with Laura, a patient who flirts with him. That Laura draws him into her life as he has been drawing Gina in. Paul tells her about the detail Laura gave about the sex with Alex and that he would have to be made of rock not to react, not to feel a little jealous. Paul thinks that's what Laura wanted. Gina wonders about that.
Gina suggests that Paul wants her to make rules so he has something to push against. Paul says this issue, attraction to patients, always gets them on rocky ground. Paul tries to make a case that if he transfers Laura to another therapist, then in 6 months or a year he could see her socially. Gina says no, that no matter how long, he will always be her therapist. Paul tries to argue. But of course, Paul knew this was Gina's stance which is why he came to her. Gina makes him look at all the things Laura has done to get an Oedipal response from him, and that he knows this. But he wants to overlook that because he wants to be desired.
Paul again turns away from Laura to attack Gina and a critical evaluation she wrote about him. Her letter led to him not becoming the head of the institute. Gina brings him back again to his issues with his father and that her one letter drove him out of the institute. Paul says that letter made him a better therapist, maybe better than Gina.
Gina asks again why he came. He acknowledges that he wanted to test himself, knew she would say what she has about Laura. Paul tries to make the case that he is better because he has more feelings for his patients. He asks if she misses having patients because he always wondered if she actually liked doing this work. Paul says he can't help but connect with the patient but he doesn't see her doing that.
Then he talks again about Laura, about a session when she cried. And he says it was a victory of a kind, that she would do that. But that it was different with her, moving somehow. And that was when he decided to come to Gina, because if Gina couldn't convince him to stay away, how could he do it himself. He admits it is tough being alone with her. He says he wants to look at this, to deal with it, to make sure that what he wants is not immoral or unethical, that it is not an abuse of his power with a patient.
Gina says she will not push him out, won't reject him. But that doesn't mean she will let him do something harmful. But that she will hang in with him no matter what.
Paul says he loves her, he loves Laura. He knows it is a cliche. And that part of him does not care what it mean or what it costs.
So now we know why Paul came to Gina. He fights her because if he defeats her, if he can meet every one of her objections, then he can do what he wants, he can have a relationship with Laura. But he came to Gina because he knows she will fight and he wants her to win. Because he knows she is right, that there is no ethical way he can ever have a romantic relationship with Laura. He needs for GIna to win or he will indeed recapitulate what his father did. And the only way out of this is through it. So he has rightly committed to working it through with Gina.
Paul thought he could avoid being like his father by taking pride in how he was different, by being better than him. But these efforts usually fail, because the shadow lurks there and brings him to having to see how he is just like his father, his father who ran off with a patient, and that he must see this and find his way to make a different choice. Making this different choice, not acting out with Laura is the only way to move through this, for him and for Laura.
Ethics for a psychotherapist demand that we recognize that no matter how long the time since the therapy ended, we remain in a therapeutic relationship with our patients. That relationship takes primacy over any other possibility. The law varies about how long an interval must pass before sexual contact with a former patient is acceptable, but the ethical stance is that no interval is long enough.
In Treatment -- Jake & Amy, week 4
Ah, the patients who least interest me again.
Paul is shelving a book, when he takes down a book of photographs of nudes. Then it is 5 o'clock and Amy arrives, without Jake. Amy says she doesn't know if he is coming and then he arrives.
Jake sits down at the opposite end of the couch from Amy. Amy sits there smiling enigmatically. Then Paul says he has to take the phone call - he says on the phone that as far as he is concerned, she can go home -- indicating Sophie, probably.
He apologizes again for taking the call. Amy asks if he usually takes calls during sessions. Paul again apologizes and says it was important. Jake at first defends Paul then agrees with Amy that at his rates, even a minute is expensive.
Paul notes that both of them keep coming, even when it is difficult. Amy sees it as indicative of their predictability. They argue a bit. Then Amy asks what happened with them. Jake says what happened is that they started therapy, that it has made things worse. Paul observes that maybe their arguments there have become more frequent, but that doesn't mean they are headed to divorce, that maybe they fight there because it is safe.
Amy disparages Jake and his friends as unsuccessful. Jake jabs at Amy about her drinking. Amy says it used to turn him on that she could drink like a guy when they were out with his friends. Jake points out they are the friends that she just characterized as failures. They trade jabs about how the other embarrasses them. Tit for tat arguing.
Jake angrily tells Paul to stop saying "it's interesting" or he will deck him. Jake's anger alternates between Paul and Amy as targets.
Paul observes that characteristics that each used to see as interesting or sexy they now denigrate. Jake become possessive when he is threatened and then Amy becomes secretive. And that they are both afraid to stop doing this.
Paul asks how it was that they began an affair while Amy was married to her previous husband. Amy tells a story that they both know but which never happened. Then they tell what really happened, something they then argue about.
Paul reflects to them they started with distance between them, then joined to attack him after the phone call and if perhaps this is a recurrent dynamic between them, that perhaps the conflict is what keeps them interested in each other.
Another fight ensues -- Jake calls her a liar and she becomes enraged, moves to hit Jake. Then Jake takes out his phone because he recorded what she said. Amy leaves and says she is not coming back to Jake. Jake sits back and rather smugly says she is out of control and he is afraid she might hurt someone. He says she is like a getaway driver without seat belts. Paul asks about the image and he says it is from a dream he had, where they are in a car, Amy is driving and they are going to rob a store.
Jake asks if Paul thinks she loves him. Paul asks him what he thinks and then says he thinks she does love him and that Jake loves her too, that love is not the problem. Paul asks if Jake has ever recorded the fights they have before. And then asks him why. Jake says he just wants to know what's happening.
Jake gets up to go and says he thinks they won't arrive together next week.
Paul does some nice work with this couple today. He succeeds in making a connection with Jake, by the end, a very big deal given Jake's expressed opinion of the value of the therapy. But they are so volatile, it may be that Jake is right and they will likely end in divorce.
There is a foundational problem in their marriage because it began when Amy was still married to another man. The potential for a repetition of this hangs over the relationship from the start, whether or not it is spoken or even conscious. If she got tired of one husband and had an affair, why wouldn't she again, after all. And it takes a strong commitment to the process to dig down into that kind of issue and hang in there. It is not at all clear that Jake or Amy has that kind of commitment to looking at themselves and what they have built their relationship upon.
Marriage is among other things a psychological relationship, as Jung wrote (full text of the essay at the link) --
"The peculiar harmony that characterizes marriage during the first half of life -- provided the adjustment is successful -- is largely based on the projection of certain archetypal images, as the critical phase makes clear.
Every man carries within him the eternal image of woman, not the image of this or that particular woman, but a definite feminine image. This image is fundamentally unconscious, an hereditary factor of primordial origin engraved in the living organic system of the man, an imprint or 'archetype" of all the ancestral experiences of the female, a deposit, as it were, of all the impressions ever made by woman-in short, an inherited system of psychic adaptation. Even if no women existed, it would still be possible, at any given time, to deduce from this unconscious image exactly how a woman would have to be constituted psychically. The same is true of the woman: she too has her inborn image of man. Actually, we know from experience that it would be more accurate to describe it as an image of men, whereas in the case of the man it is rather the image of woman. Since this image is unconscious, it is always unconsciously projected upon the person of the beloved, and is one of the chief reasons for passionate attraction or aversion. I have called this image the "anima," ... Woman has no anima...but she has an animus. The anima has an erotic, emotional character, the animus a rationalizing one. Hence most of what men say about feminine eroticism, and particularly about the emotional life of women, is derived from their own anima projections and distorted accordingly. On the other hand, the astonishing assumptions and fantasies that women make about men come from the activity of the animus, who produces an inexhaustible supply of illogical arguments and false explanations."
In Treatment -- Sophie, week 4
If this is Wednesday, it must be Sophie. And remember, at the end of the hour last week, Paul called Sophie's mother.
Sophie comes in looking quite different saying she was at a party the night before and stayed all night and then walked to her session. She tells Paul she had never drunk so much. And alludes to something with a boy there. Her casts are gone as is the neck brace.
She lies on the couch and looks almost as if she were going to go to sleep. She has taken off her red platform shoes, which she says she bought because of him, because he had called her mother who took her shopping. She talks about her mother, how she hates that she is a gymnast, which Sophie says is because she thinks it will stunt her physical development, especially her breasts. She talks about running away to the gym, but that she cannot get rid of her mother no matter where she goes. Paul suggests that she runs away in order to get and hold her mother's attention.
Paul asks about the shoes, says they remind him of Dorothy's shoes. That Dorothy found she could go home any time she wanted, with or without the shoes.
In an angry outburst, Sophie shows how angry she is that he called her mother. That Sy is also acting protectively and making her practice with the 10 yr olds. She talks about dissociating from her body when she would not eat when she was younger and that she had found how to do it now on the beam. She stands on the back of the couch to demonstrate to Paul, who is quite concerned about safety. She explains what she did and her delight that she had in succeeding in landing just right.
She quickly changes -- puts her head down and says she doesn't feel well. Paul expresses concern. She says softly, "Stop, Sophie." Paul urges her to tell him what is happening.
She starts to tell about one of the gymnasts taking her to his room, and that she felt nothing. And that he had told her she acts like someone who has been sexually abused. Then she couldn't stop thinking about it, seeing terrible images of everything disintegrating. She was afraid to sleep because the terrible images would come again. And images of the accident. She left for the bus stop and sat on the bench, thinking about Sy's child Dana. And she remembered she couldn't breathe, that just before the accident she couldn't breathe. But she does not want to go further into the memory. It was Sy's bike and the seat hurt her, she said. She came to the wide curve and a car almost hit her and it seemed to her that the road was attacking her and she wanted it, she wanted to hear a huge boom and then nothing. And she cries and says she tried to kill herself.
Paul sits next to her and reassures her that she is not , as she thinks, a freak.
As soon as the white car passed she knew she would have an accident and she made it happen. She was hit and she felt free and strong. She said she thought she had finally killed him, but when he asks who, she cries that she doesn't know. She goes into the bathroom and leans over the toilet as if to vomit but doesn't. Then she looks into the mirror. And opens the medicine cabinet and takes one of the bottles of pills. Pal asks if she is okay. She opens the bottle and pours out the pills. We don't know when she comes out if she has taken them or not. She says she is going home. Paul says they have more time but she says know. She tells him that he is like the Wizard of Oz except he doesn't know anything and he is always behind the curtain. She is slurring words -- she took them. She falls onto the floor.
Why oh why does Paul keep prescription meds in a bathroom accessible to his patients? In the words of Dr. Phil, what was he thinking??! Yes, we know that he has some of his personal things there because he has been sleeping in his office, but still, it is irresponsible for him to leave prescription meds in a place accessible to patients. I wanted to yell at him for that. And now he must deal with the consequences.
I spoke with a another therapist who doesn't find it so odd that patients get up during sessions to use the bathroom -- this person also has a home office with a bathroom off it just for patient use. So maybe it's just me. My husband rather wryly noted that he wouldn't use time he was paying for to go to the bathroom and would wait instead -- he is so practical!
Back to Sophie -- she is heartbreaking and I suspect we all ache for her as her story slowly rolls out and she finally says she tried to kill herself. And she is so very fragile. Paul did not respond very well, I thought, to he anger about his contact with her mother. Perhaps because of his concern about her fragile state But he does not pursue it wit her and does not get much closer to understanding how she learned of it, what her mother told her, or what she wishes he had done instead. Working with a minor is tricky this way because the teenager needs to feel she can trust the therapist to hold her confidence while the therapist has to be mindful of his responsibility to keep the parents apprised of potentially harmful situations. There is almost no way to negotiate this kind of problem without running into difficulty.
There s also much to explore about the shoes with the high platform heels, and what they are about for a gymnast who uses her feet to maintain a secure position. She calls them Barbie shoes -- what does that mean to her? How does she see Barbie and what it means to her to wear Barbie shoes. So much in this session.
In Treatment -- Alex, week 4
Alex arrives early, running into another patient as he does. He brings a check from Laura. He offer to pay for the additional time, and puts the cash, in bills and change on the table. Paul asks if he feels better now that he has paid, because he sees it as a way of expressing contempt. Alex pushes that aside and asks how many patients Paul has, because he wants to know how much money he makes. Paul asks if he wants to buy him out, become the only patient.
Paul confronts Alex's effort to control, to keep him in his place. Alex asks if he wants to know why he is early and tells him he went to the base today but forgot his ID. The guard tells him he is not on the approved list. Alex's effort to get the guard to tell them he is there fails and he does not get in. So Alex's sense of importance and ability to control were thwarted and he acts out his frustration with Paul.
He then says that his bad week started on the weekend when he slept with Laura. And he asks if she had already talked with him about it. Paul reminds him he cannot discuss other patients with him. Alex says he saw when he got to her apartment he could see that the meal was all about having sex. He criticizes the food, says it wasn't very good. He characterizes it all as a mating ritual implying he was not very interested or engaged. Alex tells Paul he knows Paul already know what happened, but Paul says what's important is what Alex felt, how he experienced it.
Alex then says he will talk about it after he asks a question -- does Paul ever masturbate about things patients have told him. Alex tells him he won't masturbate to what he is going to tell him about what he and Laura did.
Alex critiques his own performance. He says he started at dinner thinking about his first date with his wife. He remembers her telling him that wine arouses men sexually and depresses men sexually. He told that to Laura and she just looks at him. , Paul asks why did he tell her that. He suggests that it might have sounded like an apology in advance for not being really interested. Alex says he got angry with her and began mentioning his wife every time he could. "We had sex but it was more like two animals", Alex says.
Paul asks if he was thinking about his wife or feeling guilty, which Alex denies. Alex just wants to know if his story and Laura's match. Paul tells Alex that because he felt insecure and that he hadn't performed well, he felt the need to belittle Laura by mentioning his wife. And he draws a parallel to how Alex behaved when he arrived at the session.
Alex gets up to make himself some coffee.
He finishes and then asks Paul if he really thinks he can help him. Paul tells him he can't answer that. He relates a parable and tells him that Alex is looking for a magic trick to work for him, but that the real question is whether or not Alex wants them, himself and Paul, to work on finding their way across the abyss. Alex gets it -- that he would need to be willing to trust Paul, to let go and trust and that is what got him into his situation in Iraq. Paul corrects him and says he has to rely on himself, on his own feelings.
What is the first step, Alex asks? And he says he thinks he will go and have sex with Laura again. Alex says he knows that she is completely and totally hung up on someone else. He asks Paul if he thinks he and Laura have a chance together. Again Paul says he cannot answer. The hour ends.
It is just possible that Alex may engage in the therapy as he seems to have been more willing to hear Paul today, after the skirmishing at the beginning. And his question at the end, about whether or not he and Laura can make it if they try really hard, is also a question about the therapy with Paul.
A note about when patients arrive early -- Paul handles this by allowing Alex to pay for the additional time. Other therapists might gently remind the patient that they must wait for their own session time, still others not add time but stop after the customary 50 minutes. Most of us need the brief interval in between patients to clear our heads, return calls, go to the bathroom, things like that. For me it is a necessary time to make ready for the next person and be ready, as fully ready as I can be, to be with that person without carrying forward thoughts of the previous patient. So there are good reasons for making certain that there is enough time between patients -- in order for them not to run into each other and in order to have that buffer in between.
In my own practice, I always schedule on the quarter hour so that I actually have between 15 and 25 minutes between patients, given a 5o minute hour. And I have never scheduled more than 6 patients in a day, because for me, it is too much to try to see more than that. It is very unlikely that Paul sees 40 patients a week as Alex speculates -- for most therapists I know, that kind of load is just too much.
In Treatment -- Laura, week 4
This week we first see Laura with Alex as he kisses her -- but then we see that the scene is in Paul's imagination, as Laura speaks his name twice.
Laura is describing her encounter with Alex -- she says he was tentative and did everything she did. She seems to be mocking him a bit -- Alex is weak because he isn't aggressive? Her demeanor is seductive, teasing Paul with the information.
Laura asserts that Alex doesn't like sex, that it was as if it were an assignment for him. (And I think about Alex talking about spending the weekend with his gay friend and wonder.) Laura says she brought herself to orgasm when Alex returned from the bathroom using him by riding his thigh. And then she says she felt terribly sad for him. She expected a sad orgasm but said she was surprised by its intensity and she thought Paul would be proud of her, for connecting with herself.
Paul confronts her with the fact that she began a relationship with his patient and his suspicion that she was getting back at him. She tries to deflect that but he points out that she told him she was thinking about Paul when she was with the man in the bathroom, and that was the session in which she told him she loved him. Paul suggests her sadness was because she was not with the man she wanted to be with. And we see a sadistic element in her telling him about it.
Laura says she is tired. That when Alex left, she couldn't sleep and she had a craving for cheesecake, like the kind her mother used to make. She says when her mother started chemo, she stopped baking. She tells of wandering the halls of her apartment building looking for that smell of cheesecake. She cries.
Paul asks her why that memory the other night. She says she looked for a recipe but couldn't find one. Then Alex called and told her he had a fantastic time, that in fact Alex will be picking her up after her session. Paul asks about Andrew -- she says they have broken up. Andrew thanked her for telling him, that she had saved him from a long and terrible relationship. Laura is upset but makes an attack on Paul. She claims she and Paul have been together for a year, that their relationship is more intimate than most couples have. Laura argues for the reality of her love for him and that it is not because of the therapy.
Paul asks how she sees him -- you are a perfectionist, You are not at ease with your body, your profession, restless, she says. And that she loves him the way he is.
"And you can fix me," he says, "so then I can fix you."
She says she will be 30 soon and she has hated herself for 30 years. Paul is surprised by this because she has never said so.
She asks if he ever hated himself -- and he tells her that he did when he was a kid and had to care for his mother, because he couldn't make her better.
When she leaves, Alex greets her at the street and they embrace. She looks back and see Paul is watching from the window.
I'm sure that some therapists when watching this episode will jump on the self-disclosure Paul makes at the end, about his mother and his feelings of failure. But I actually think that part's not so bad because it could be a way to link to her feelings about not being able to make her father better, or her mother either for that matter. But, Laura is not interested in anything Paul says that might be of therapeutic value to her because she pulls everything into her love for him.
The question in my mind is how long Paul should attempt to continue with her, given her behavior and his own difficult situation and resultant countertransference. I want him to call Gina and start talking with her -- and listening to her -- about how best to handle this very volatile situation. And if not Gina, then someone whose skill he trusts. It is not beyond the realm of possibility that if Paul can hold the boundary tight, this could be worked through without transferring her to someone else. But I don't see how he can do this without having regular supervision and he has not yet established that with Gina. For now, it is fraught with danger for both Laura and Pal.