April arrives early. She tells him she has to leave her cell phone on in case her brother calls.
She couldn't tell her mother about the cancer. She did visit Sloan-Kettering. She told her mother she is a little sick but not what was wrong. Her brother tried to kill himself. All of this tumbles out in the early part of the session. Her mother can't cope with Daniel when he wants to die. April says he can't handle feeling strange. And so April takes over with him then.
Paul tells her he worries that she is feeling strange and has no one, that her mother shares her anxieties with April but April doesn't tell her mother anything.. So she starts telling him how she feels -- depressed, out of control. Paul firmly tells her when she feels like that to call him, any time.
She tells him she saw her mother and they talked about Daniel. She always tries to look her best for her mother because of Daniel. Her mother talked about wanting to leave her father. Paul asks if maybe it is Daniel she wants to leave.
Paul asks about her father. She says he was never around much. She liked talking with her father at the end of his day. Paul points out that neither parent was available to her for her to lean on. Paul talks about the burden for Daniel's care eventually falling on her. April feels horrible that she doesn't want to take care of him. Paul tells her she can make other choices.
Paul says they have to talk about chemo. The phone rings and it is Daniel but he did not talk to the person he was supposed to see. She starts to get up to go get Daniel when she faints. Paul tells her she fainted and she needs to eat. Paul tells her she is treating him the way she treats her mother, not letting him help her. She thinks he means he can't handle what is happening to her, that she scared him. Paul said he can help her even though she is sick and it is scary. She is terrified, angry and believes she will die. She is afraid he will not be able to handle what is going to happen to her, that he will leave her and that he will hate her for letting her help him.
Her mother calls. She tells her mother that Daniel is in Central Park and she asks if she would go get him because she can't leave. Her mother hangs up. Paul tells her to sit down. He tries to impress on her that they don't have time to delay treatment. He asks her what it is about being there with him that makes things seem different, so that they make sense to her. She says he does. He proposes going with her to the hospital. She asks if he will come with her now. He agrees.
Paul has succeeded in winning April's trust, at least as much as she is willing to trust anyone. She arrives early. She responds pretty openly. And then admits it is Paul that makes the space there safe for her. Which allows him to get her to allow him to accompany her to the hospital to start chemo.
This is another tough situation. April is functionally alone. Under ordinary circumstances, Paul -- any good therapist -- would take the time to explore more of what keeps April from being able to get through to her parents, to find care for herself. But there isn't time for that kind of patient exploration. Making Paul's willingness to step in to accompany April understandable. Understandable and risky too. Because April is very hungry for a caring parent and once he has stepped into that role, it will not be easy to step out of it and help her to get what she needs from people already in her life.
A long time ago, when I was first in analysis, I asked my analyst many times what the rules were. And he told me there were no rules, which I found maddening. I wanted to know the rules so that I could follow them and be good. I did not at all understand what he was talking about. Which was that his job was to be the analyst I needed and that would almost certainly be different in a variety of ways from what another patient would need.
Paul is trying to be the therapist April needs. And right now April needs a therapist who will be with her in the way that Daniel's teacher was with him. April needs a therapist who will hear how needy she is and be willing to be with her. Paul is willing to receive her needs and be there. And he must also be willing to weather the storm that will inevitably follow when he is unable to be a new parent for her. That storm holds the potential for April confronting her fears and rage at her parents and becoming better able to allow others to help her at the same time that it poses a lot of danger for her and for the therapy. While technically what Paul does is an enactment, I think I would likely do the same thing under the circumstances. The risk managers out there are no doubt gasping in horror at the whole thing but sometimes we have to be willing to take a chance.
Added April 27 --
When the therapist feels such an intense need to help a patient, to get a patient to do something, it is a clear indicator that there is a counter-transference reaction going on. It is natural to want the people we see to become happier and to have better lives but the intensity of the desire in Paul is what tips us off. Paul was unable to make his mother want to stay alive or make her get well. April's vulnerability taps into this and creates in Paul pressure to help her. So he becomes less able to stand back a little and avoid being directive with her.
Now, her situation is indeed perilous which would tend to induce this sense of urgency in most of us. And as I said above, many of us would feel moved to do as he does. But what is important for Paul to come to understand is how his own issues are involved in the intensity of his reactions.