In Treatment, Week 5 | Jung At Heart

In Treatment -- a couple of thoughts

Sat, 01 Mar 2008 11:39:02 -0500

A note or two here about what we are seeing with Paul and his patients and Paul in his own therapy.

Each of these patients does exactly what patients are supposed to do when they see

their therapist: they bring their "illness", their self-destructive patterns, in the

only way they know how—by repeating it with the therapist right there in the room. The therapist can either react as others have, or can offer a way to begin recovering from past injuries. At these critical moments, the path taken depends not on the patient but entirely on the therapist.

So, yes, the therapy with Alex can continue, but it falls to Paul to respond to what happened, to the fact the he acted out, probably in a way similar to Alex's father, by creating a new and different path. By apologizing. By being willing to look at it and see what was going on, what Alex was feeling.

As Paul did with Sophie when she returned and he received her without scolding or ignoring what she did and then being willing to make an entirely appropriate demand on her, that she agree not to threaten or try to kill herself again while they are working together. This is a different path for Sophie.

And yes, with Laura too. Paul must reassert the boundaries, not punitively, not reactively but out of knowing that doing so, that holding the boundary is what she needs and only through doing so can she begin to move out of her old patterns.

As Anne Ulanov writes: How does the analyst heal the wound that has been evoked in himself or herself and still serve the patient? Ethics based on doing no harm

demand: not by perverting the analytic relationship. As the fictitious analyst

remarks to himself, “She is no other, she is I. In loving her I love myself, in

rescuing her I redeem a part of myself—weak, frightened, ...

of which otherwise I must be ashamed”. The analyst must turn to other

resources, not the patient, to tend to this part of himself, as shameful or embar-

rassing as that may be.

In Treatment -- Paul, week 5

Fri, 29 Feb 2008 19:02:40 -0500

We open with Gina carefully arranging the chairs in her office as she waits for Paul and Kate. They arrive and Gina and Kate embrace. They haven't seen each other for sometime. Exchange of small talk.

Gina moves to structure how they will proceed. Coming together was Kate's suggestion, Paul says. Gina suggests that they meet three times and then decide where to go from there.

Gina asks how it is that Paul agreed to go along with Kate's desire to come to see her. Paul talks about Kate and her going to Rome and what she told him when she got back. Paul says he wasn't able to talk with Kate, and Gina says then Kate doesn't know how he feels. Paul turns a bit and tells Kate he has felt rage and hurt and doesn't know if he can get past it. Kate asks why he couldn't talk about it and he responds with what he tells patients. Gina catches this and points out how controlled he is.

Paul says he feels like he is falling apart. He tells her about attacking Alex because he knew he was reacting to Kate's return because he heard her. He pulls back and says he can't talk about a patient there. Kate is surprised he won't talk about what Alex did, about spying on them. Gina asks how Alex learned what he did -- Paul says he doesn't know. Kate asks if Alex, whom she calls his creepy patient, is her fault too.

Kate starts to talk, says it is always hard to describe her feelings. She draws an analogy to childbirth and just wanting to know she wasn't alone. But describing the experience is impossible. She makes a joke about what that process is like and she and Gina laugh but Paul feels left out and gets petulant.

Gina says Paul is not a therapist there just as he isn't at home.

Kate tells Paul she thinks that he told her about the attack on Alex for her benefit, to show her what she did by going away with Edward. Paul says she is the best thing in his life and she says she doesn't believe that. Kate says she asks if he loves her and how it feels for her when he answers, "Yes, for now." Paul protests that it is a joke, but Kate can't experience it that way.

Kate talks about how seriously he took her when they were getting together and how wonderful that felt. That he was the first person who tried to understand her and how grateful she felt. Now she feels that it was no about her at all, it was about him. She feels he using his analytic approach against her.

Gina asks if Kate can explain to Paul why she was seeing Edward. She says she doesn't want to and doesn't want to know. Then she yields and talks about the excitement and spontaneity of it, parts of her that died in her life with Paul.

Paul starts to interpret and she gets angry and tells him to stop. Kate says she did it because she felt something, she felt wanted.

Paul says he wants her, that's why he is there. Gina asks if Paul wants a witness to verify that he loves Kate. Kate makes a comparison to Clinton denying what he did with Lewinsky.

Kate says she has to feel something in her gut to believe it and doesn't feel that with him. She asks if he can remember what it is to feel truly wanted. Gina and Paul exchange a look. Kate realizes they know something and she asks what is going on. Paul begins to talk about transference in order to broach the issue of Laura to show he knows what feeling wanted is like. Gina leans her head back. Paul is doing exactly what Kate has accused him of doing. Kate asks if he had sex with her. She asks if he is saying he had sex with a patient. He tried to make it non-specific but Kate knows.

Kate presses to find out what the unnamed patient has aroused. Paul is quiet and Kate says he doesn't have to say anything. She says that this is Paul's wagging finger and that he wouldn't say anything if thee weren't something there for him to cover up.

Kate and Paul trade jabs over who is the more betrayed.

Gina asks Paul to describe what he feels with Laura like Kate did about Edward. He says it isn't the same because he didn't act it out. And he says she left therapy Monday. Kate attacks Paul for not rescheduling Laura for a meeting at school about Max, a meeting Kate cannot have gone to because she was not back from Rome.

Kate says it started a year ago, she knows it did. And demands the patient's name. Paul says her name is Laura. Kate badgers him to say it is nothing.

Each of them feels the aggrieved party. Gina points out they have both been pulling away and now they fight over who has been hurt the most. She asks how did this happen, how did the marriage come to feel this empty. She wraps up the session and says they will meet a few times.

Paul wants to write a check; Gina says no, she needs to think about it and send a bill.

Paul and Kate in marital therapy are like most couples -- wounded, angry, wanting the other to be made responsible for what has gone wrong. Neither Paul nor Kate can see or feel the other or recognize the full impact of their withdrawal from each other. Neither Kate's affair nor Paul's weakness with is the cause of their difficulty; they are symptoms of a deeper problem which began before either wandered away from the other. We don't know yet what that problem is, what happened to set them off on this course away from each other.

I have doubts about the wisdom of Gina working with them a a couple because she has such a tangled prior history with them. Better to refer them to another therapist and continue to see if she and Paul can work together because he still needs supervision -- with Laura, with Alex, and Sophie. There isn't a rule about how to handle this, but y personal belief is that they would be better off with a therapist who does not know either of them.

Paul's use of a kind of therapeutic dodge is an occupational hazard for may of us. It can be hard not to slip into interpreting the behavior of a spouse or friend, but that behavior does not belong in our personal lives and when we do it, it is usually a means to maintain control and distance.

In Treatment -- Jake & Amy, week 5

Thu, 28 Feb 2008 19:03:45 -0500

When Amy arrives in her running clothes, Jake is sitting in the garden outside Paul's office waiting. He says someone is with Paul. They are 5 minutes early. They have apparently not been together. They talk warily.

They are sitting apart on the couch. Paul asks how they are. Then he says that he will not tolerate violence of any kind in the office. Amy says it's all right because they have been separated for a week. Paul does not respond as Amy and Jake expect so they join together for a moment to criticize Paul. Paul tries to make it clear to them that what they have been doing is chaotic and unproductive because they do not respect boundaries.

Then Paul asks what happened. Amy starts to talk about what happened. She had taken their son to her mother's. Jake came by and they argued and then had sex. Paul asked what happened. Amy says that while Jake was still in her, he says if she leaves her, he will kill her which she found disgusting. Jake then counters that what she and her mother do to their son, feeding him junk food, is disgusting. Paul asks if Lenny is overweight. And Amy says he is like she was. Amy is very defensive about their son and about her childhood weight.

Then they argue about their son -- his weight, his fighting, who is at fault. Jab. Counter jab.

Paul observes that they take the most sensitive subjects and then toss them away which makes it difficult to get t the bottom of their actual feelings.

Paul asks if Jake had ever threatened her before physically. And Amy shakes her head. Amy says she was not afraid but was disgusted. Jake makes threats but denies meaning them.

Paul stays with the statement --"If you leave me, then I will kill you." He goes to the first half and the underlying fear in it, that something will happen to Jake if Amy leaves him. They are both quiet.

Paul asks Amy to go back to her feelings as a child being overweight. She resists. She is fine. Lenny will be fine. Paul suggests to her that it works for her to see Jake as pathetic, an underachiever to keep her from her own insecurities and negative feelings about herself.

Amy says no -- and she wants a divorce.

Jake reacts and looks devastated. Then says fine and he will take their son. They spar about Lenny a bit. Then Jake asks what she wants from him. She says nothing and can't they do this nicely. Jake gets up, crying, asking what's nice about it.

Amy looks impassive.

Jake sits down again and there is a long silence which Paul breaks giving an example of a couple who ended up staying together through therapy after deciding to divorce. He offers it as hope -- we know he is talking about himself and they begin to get that. Amy says she can't do this anymore. Paul asks if she sees anything positive and lists a few things.

Jake has fixated on the element of infidelity in what Paul said and pushes Amy about whether she has been unfaithful. Paul points out that neither of them is being open, they just attack and defend. Jake says he has come to save their marriage and Paul tells him to tell that to Amy.

Amy buttresses her argument that they should divorce because all they do is fight. Jake is crying. Paul tells him to say what he feels to Amy. Jake sits forward, turns to her and says he doesn't want her to leave, doesn't want to lose her. He talks about how bad he feels without her. Amy's face remains impassive. Jake puts his head in her lap, sobbing. She awkwardly touches him or seems to in an automatic gesture but seems as removed and untouched as before. The session ends.

I wonder if what we are seeing here is a couple where the hidden agenda is an already made decision by one party to end the marriage. Amy has not seemed much interested in doing anything to work on the relationship since we first saw her 5 weeks ago. It is Jake who seems to want to work it out, to find a way to solve their problems. And Jake who voices a fear that the therapy will lead them to divorce. And he may be right, though it is not the therapy that creates this but a decision made by Amy before they came.

When a marriage ends, one partner has already made the decision, sometimes long before the other can even allow him or herself to suspect it. That partner begins a process of imagining life without husband or wife and a kind of psychological callous begins to form, sealing over what was an open connection between them. Amy's impassivity leads me to wonder if this is in fact the case with her, that she has already left emotionally and all that she sees remaining is the actual ending of the marriage, which she hopes Paul will see and support while helping Jake deal with his feelings.

Amy then might be seen as the leaver, having already left Jake emotionally and psychologically and beginning to imagine herself as single again. For Jake, the left, this process is just beginning and he must go through feelings of betrayal, abandonment and anger.

In order for the therapy to help the marriage, both partners must want it to survive and improve. Without both of them wanting this, no therapist can alter the outcome. Paul may be able to get Amy to pause long enough to look at herself, at how she came to this place and what it means that she is again leaving a marriage, probably because of yet another man. And if Jake and Amy can hold on the mast of their ship, they might be able to ride it out and come out of the storm they are in in a far better place with each other. But I must say I am not optimistic.

In Treatment - Sophie, week 5

Wed, 27 Feb 2008 19:35:40 -0500

Sophie and her mother are outside until time for the appointment. Sophie does not want her to come in with her, even though Paul asked for her to come. Paul opens the door and asks the mother to come in. Sophie pushes past.

They sit as far apart on the couch as possible. Sophie wants Paul to say she can return to training. Sophie is hostile and attacking with her mother, says she is a crazy bitch that no one understands. Sophie says if she has to stay at home, she will slit her wrists. Sophie threatens that is she doesn't try out for he Olympics she will kill herself. Paul calls for a halt to the threats.

Paul supports Sophie's return to the gym. Sophie smiles smugly and Olivia looks worried and upset. Olympia leaves. Sophie smiles triumphantly.

Paul tells Sophie that he thinks he knows why she took the pills in his bathroom, that she was testing him and that he passed the test. But what if she tested someone else and they did not pass. They need to understand what she finds so attractive about death.

She says she would escape her mother. She says death means not feeling anything. Paul says that last week they got to a place of deep feeling and then she went into the bathroom and put herself to sleep. She resists. He points out that on the beam, she is strong and confident but off it, in the rest of her life she is more susceptible, vulnerable. She says she hates that part of her Paul tells her that he will be with her, help he and support her but he will not work under the threat of suicide.

They talk about her parents, her father and Paul suggests it is easier to feel close to her father because he is at a distance. Olivia knocks on the door and comes in.

Olivia sas she is not going to let her go back to the gym because it is killing her. Sophie says she will go to her dad. Sophie hurls at her mother that she was having sex with Sy in her hospital room while her mother banged on the door. They fight -- Olivia reveals that Sophie's father has not called her in a month.

Paul asks if she was with Sy in the hospital. She denies it. Paul says he has thought long and hard about whether or not to report Sy. He asks again if she was truthful when she said they had not had sex again after the first time. Paul defends Olivia to Sophie, that despite the punishment she gives, Olivia doesn't give up on her.

Sophie gets up to leave. Paul asks about the agreement. She says she won't try to kill herself as long as she is in therapy.

How painful this was to watch! As the mother of a daughter now grown up, one who was never as hostile toward me as Sophie is toward her mother, I could feel the arrows of anger as Sophie shot them into her mother. Sophie is not able yet -- and really are we ever ready -- to see her mother as a person, as something other tan the role she has assigned her. She has no awareness nor wish to be aware of her mother's conflicts, wishes, hopes, regrets. And similarly, she cannot see her father as anything other than her idealized parent, the one who can do no wrong. We don't know much about the divorce, but these are issues that have carried over from it for Sophie.

Still, Paul, while no doubt feeling empathy for Olivia, must protect as much as he can the emerging therapeutic alliance with Sophie. So he puts himself on her side without opposing Olivia too strongly, and this does enable him to defend Olivia to Sophie later.

About Paul's insistence that Sophie commit to not trying to kill herself or threaten to in order for their work to proceed -- this should be standard but too often isn't. Therapy cannot proceed when the patient is holding the threat of suicide over the therapist's head. The suicide of a patient is a devastating event for a therapist and one that as I recall only around 20% of therapists experience. As a member of that unhappy group, I can testify to the terrible effect it has. There is, of course, no way to stop a patient intent on suicide from doing it. But laying the cards on the table, saying openly that the work they do cannot proceed under threat, is essential. The message to the patient needs to be that we can talk about your wish to die and where that comes from, but when you threaten to turn that wish into action, our work stops. The therapist is willing to commit to being there, to walking this path with the patient who can call him or her, ask for additional time, but in return she, the patient, must commit to staying alive. I was pleased Paul did this.

Fathers, fathers everywhere -- Laura's father, Alex' father, Sophie's father. And yes, Paul's father. Disappointing fathers. Abandoning fathers. For each of these patients, Paul is the recipient of their father transferences at the same time that he is swimming in the muddy waters of his own father complex as he struggles to find his way through it without becoming his father. With Sophie, he held his position well.

In Treatment -- Alex, week 5

Tue, 26 Feb 2008 20:07:14 -0500

Alex arrives a little early again. It's still raining.

Alex begins by telling Paul that he broke up with Laura. Tells him he took Viagra or one of those drugs and drank and then he and Laura had sex all night. Then he says he realized Laura was using him and it was over.

Paul asks him why he makes the connection between him, Laura and himself. Alex says "Tell me that something didn't happen between you and Laura." And he says that Laura talks about Paul, asks questions about him. Paul says again he will not discuss anything about his other patients with him. Alex is convinced that Paul has had sex with Laura. Alex makes hostile jabs at Paul.

Paul collects himself and Alex backs off of asking about Laura. They start to talk about Alex and his father. Paul asks how he feels and about his relationship with him. Paul reminds him about what he said abut his father the previous week -- that he was unfaithful to his mother and yet is a good man. Alex says his father is like iron, cast iron. Paul says that iron makes him thinking of something powerful yet cold.

Alex replies by asking Paul how he feels about Alex having dropped the bomb on the madrassa. Alex digs and pushes for judgment from Paul, certain he talks about him and what he did negatively. He challenges Paul to be honest with him about how he feels. Then he says that his father said nothing, just registered that he heard him when he told him about it.

Alex again attacks Paul with his assumptions about what he thinks.

Paul tells Alex that he thinks he has never dared to fight back at his father, that he has been too terrified to do so and that he comes to therapy with all his anger.

Alex hears Kate and asks if that is his wife. Paul gets uncomfortable. Alex continues to push Paul to talk abut his feelings. He talks again about Laura -- that she idealizes him yet knows nothing about him. "Who are you?", he asks. He again asks if Paul had something going on with Laura. And starts in with his notions of what Paul thinks and feels. Alex crtiticizes him fr loving a woman so much younger.

Paul asks why Alex had to sleep with her and suggests that it was about getting back at Paul, because she was his patient. That he did it to provoke Paul, to get a reaction, any emotional reaction.

Then Alex asks Paul how he feels about his wife being with someone else in Rome. And says he would be surprised how much he learned. That he had to investigate Paul to see who he was. Alex is walking around during this, looking smug and delighted to have this information. He reveals what he knows about Paul's daughter.

Finally Paul loses it and jumps up to grab Alex. After this outburst, Alex leaves.

Paul picks up the mess, then is clearly upset at what has happened. He calls and cancels with a patient. Kate comes in while he is on the phone. She asks what has happened. She tells him she just got in. Kate tenderly tends to the cut Paul got on his hand when a glass got broken in the skirmish with Alex. She asks about the kids.

Kate tells him that she and the man she was in Rome with moved into separate rooms the first day and that it is completely over. A noise outside draws his attention. Kate sweeps up the glass. Paul gets ready to open the door. The next patient enters.

This is a tough one. Paul's reaction is understandable on one level given how unrelenting and violating Alex is. Anything other than anger would be very difficult to understand. But he needed to say something, to put a stop to it before he got to the boiling point. It is hard as a therapist to know really how to respond when a patient makes a verbal assault. There is a struggle between maintaining a therapeutic posture and wanting to lash out in return. And I suspect that all of us, when confronted with this kind of situation, have ended up not feeling very good about what we did, no matter which way we went.

Alex has violated the boundaries in a serious way. He has violated trust and done so with intent. Paul's interpretation that Alex acts out his anger toward his father on Paul is spot on but right now, in the moment of being under that violation of privacy, that falls by the wayside. So it isn't Paul's anger that is problematic but that he let it go too far.

The therapeutic mantle can only protect us so far when we are attacked by patients. When the criticism is of what we say or how we look or the more usual kind that happens every day in therapy, through practice and by doing our own work in therapy, w become better and better able not to take such attacks personally. But it can happen that a patient makes a particularly well aimed assault and despite all of the training, we get hurt and angry and scared. Which is what happened to Paul. And Alex is surgically precise in his attack, keeping his eye n his instrument, just like he said he does when he flies, and makes his run and drops his bombs right on Paul. In the moment he is doing exactly what he wants to do and doing it very effectively. But just as he must come to terms with the effects of his precision in bombing the madrassa, so he will have to deal with the damage his attack on Paul has done. And Paul will have to do some work himself, in himself, with what he did and what it means and how to proceed, if at all.

And in the background of this fight between the two men is Laura. Perhaps their fight on some level is the one that didn't happen between her father and David? Because she is the match that set off the explosion, even if she is not present and even if, as he says, Alex broke off with her.

In Treatment -- Laura, week 5

Mon, 25 Feb 2008 19:13:51 -0500

Paul is cleaning his teeth; the sofa bed is still open and the bed unmade. It is raining. Is Kate back? Is that the reason Paul is sleeping again in the office?

Laura is sitting on the couch and making a call. Paul tells her that they have to talk about ending therapy, not abruptly but to create a timeline. Laura says no, they are ending today and that it feels good. She says she feel better, relieved now that she has told him. And asks how Paul feels.

Paul tells her this comes as a bit of a shock and that he also feels sad. Laura doubts that he feels sadness, she thinks he is relieved.

He asks Laura how her week has been and she says terrible. Tells him about a patient, a 15 yr old, whose procedure goes wrong and she does not come out of the anesthesia and she stops breathing. The attending jumped in and managed to bring the patient back. She says she was terrified, that she only looks confident.

Paul asks if she expects that nothing will go wrong. He asks more about the girl.

Laura talks of the girl as being pretty and with beautiful hands whereas at her age her own nails were chewed down. Ad he asks her who was watching over her when she was young. Laura asks what good it does today to know how much she suffered then.

She says she hates eggs, because omelets and all sorts of eggs were what she and her father ate the year after her mother died. She talks of how absent her father was and how much she wanted to get away, and then she went to California. And when she returned she thought she could make her father feel better but she couldn't. She says that when David came to visit from California, she seduced him and compares it to Lolita. She again tells him in great detail what happened.

Paul asks if she ever felt that David was taking advantage of her. Laura disagrees. Paul says the comparison to Lolita made him ask, as Lolita was only 12. And she tells him that David was her first lover. Laura is adamant that she was not a victim. Paul tells her that he was 40 years old and he had a responsibility to send her away. Paul asks if she ever feels anger toward David. He asks where her father was when all this was going on. Laura says he was depressed and needed her to take care of him. Paul asks again if she might not be resentful that her father did not protect her.

Laura asks for something other than water to drink. She sees the coffee machine. She keeps herself very close to Paul. She tells him she ended it with Alex. She pushes Paul again to respond. Then confesses that she made an error with the girl because she was thinking about Paul and that it has to stop. She goes to the door to leave. She hugs him and he returns the hug. Laura leaves.

If Paul really believed they were terminating, then I question the wisdom of his pursuing the issue of her father and David with Laura. If he actually believes that they are ending, then this is not the time to go deeper. And in that case, Laura's question about what good it does today to talk about her suffering when her mother died makes sense -- termination is not the time to explore the wound. But if he believes they are not ending or is hoping to turn things around, I can understand what he did.

Paul's statement to her that her father failed her by not protecting her is also a statement to himself, because he must stand firm against her wish to have him in order to keep this from being another enactment of her earlier life.

The hug at the end -- I understand the desire to respond to a patient who is in pain, and Laura is in pain. But this was not the time to relax and be willing to hug her. No, Paul, no. For my commenter who sees Paul as the major problem in this case -- his return of the hug was an error because of his feelings for Laura and because his estrangement from his wife no doubt leaves him starved for touch and care -- a very bad combination. Paul needed to be the man who holds the boundary against the efforts of the girl to seduce him.

Now, touch in therapy is a real can of worms. It is way too easy to fail to pay attention to what a hug means. And if it is not made part of the talk of the session, if the reason for wanting the hug is not explored, then it becomes acting out -- on both sides. Someone might ask what then could Paul have done? He could have said to her that he is sorry to see her go, hopes she will return next week so that they might talk about what happened and how she feels. No doubt that would make Laura angry but on a deeper level it would support the boundaries Paul has attempted to hold, with mixed success. A handshake is far less subject to misunderstanding and far less fraught with potential sexual overtones.