In Treatment 2 -- week 3
In Treatment -- Reflections, week 3
This week we have seen that all of the patients, Paul included, are struggling with fears and feelings about being left. Mia was left by her parents when they sent her away. April was left by her parents when they failed to notice she was gone and by her mother when her attention was so singularly focused on Daniel. Oliver is left by his parents as they continue to fight over the corpse of their marriage. Walter was left by his brother who died and by his parents in their grief and now is left by his daughter and possibly by his company. And Paul was left by his father and mother and has left his son. Five patients scarred by and scared of leaving and being left. Five patients all reluctant to be in therapy, which they fear can only bring them more leaving and more abandonment.
Setting boundaries -- Paul seems to have difficulty setting boundaries on patients who have really strong personalities. This happened last season with Laura and with Alex -- in both cases he allowed them to act out without placing limits on what was acceptable in therapy. And we see again this season with Mia and Walter that he is not setting limits on behavior that can be destructive to the whole therapeutic endeavor.
While it is important to allow patients to express their feelings, this does not extend to allowing them to act out or against the therapy without any consequences. It isn't Mia's anger at Paul for having left and for, as she believes, having persuaded her to have an abortion, it is her acting out of that anger that poses serious problems here. Her willingness to breach her own professional ethics in order to jab at Paul is a cause for concern. Contrast the way she acted out her anger by bringing in the deposition and questioning Paul about it with the way she was able to express her feelings of wanting to be wanted and her fantasy about what happened between Paul and Laura. The former was about trying to hurt, to punish Paul; acting out feelings in this way makes any interpretation or insight about them impossible. But when she puts the feelings into words, as she does in talking about her fantasy of what happened with Laura, something new opens and it becomes possible for Paul to begin to help her. But it remains for Paul to become firm about limits and what he is willing to accept. He needs to make it clear to her that acting out of the kind she has displayed around the lawsuit is unacceptable.
On an unconscious level, Mia no doubt both wants this therapy to fail, as it did before, and to succeed. If she succeeds in destroying it, then her beliefs about herself and about Paul will be confirmed and her world remains the same albeit not happy. But if it succeeds, if she does not end up in the same place, then that changes everything and she will need to see herself not as so powerful that she can make people leave her, but as someone who as a child was not cared for by her parents in the way she needed. And that kind of change, while it seems it would be good, is very difficult to take. On the whole, as Guntrip said, we would rather be bad than weak, rather believe we made the people around us treat us as they did than that we were powerless to make them that way.
We see this preference to be bad rather than weak in Oliver as well, who believes his feelings cause the fights his parents have. If I am bad, I have hope I can change, can somehow become good and then the people I need can be as I need them to be. But if I am weak, then I am powerless and that feels terrible.
Paul also needs to set a limit with Walter. He is able to use the demands of his business and its attendant crises to keep therapy and Paul at bay. Paul needs to address more forcefully the issue of Walter and the phone, if only to request that their session be time when the world outside has to wait.
In Treatment -- Gina, week 3
Paul is at the breakfast table in his apartment. Tammy comes in. The phone rings and it is Rosie. Paul asks if she has to leave because he thought they would take the train down together. Rosie is asking him about his father. She hangs up on him.
He runs into Tammy again at Gina's. She says Mark -- her husband? -- is in the car. She looks anxious and says she has to go.
Paul goes in to see Gina. She asks if he is okay. He says his father is sick, in late stage Parkinson's. Paul snaps at her. Paul says he can't talk with him. He is in a nursing home. Paul is angry he has to take care of him, and says he thinks his father deliberately mishandled his finances so he would have to take care of him. He says he is just waiting for him to die. Paul says it isn't that his absence is different because he was never there.
Paul discloses that he has talked with Tammy. Tammy revealed that Paul's father was with his mother when she tried to kill herself, that he went with her to the hospital. Tammy told him that his father called her mother all the time to check on his mother. and his sons. Patrick was out playing sports. Gina says his father was at work, his brother out playing sports leaving him with his mother. She talks about the unreliablility of memory. She tells him she knows his feelings are warranted but the facts may be different for that night. Paul is angry that his father did not get her into the hospital, instead leaving him to worry every day about what he would find. Gina says maybe he didn't want to take his mother away from him, or him away from his mother.
Gina asks if maybe Paul is trying to keep things together for his family as his father did. But Paul says his father never did anything good for them. He refuses the idea that his father could have cared at all. Paul believes his father's infidelity drove his mothe crazy. But, says Gina, his mother was diagnosed as bipolar. He knows that the infidelity didn't make her bipolar. And then he recognizes that if one's wife were bipolar, it could make one want an affair.
Paul starts to talk about Oliver. He says it takes everything he has not to invite him to come and live with him, same with April. Gina asks if Oliver reminds him of himself. He agrees because neither of them knows how to be around their father. Gina says she knows he will do well by Oliver but maybe the boy he needs to be good to is himself. Paul says maybe he should try being a good son, go see his father. He admts he doesn't want to see him. And he wondes how his kids will be when he is dying? He wonders if he also has left his son home to take care of his mother. He realizes he has to talk with them, really talk with them. And to his father.
Paul goes to the door saying he has his homework to do. Gina says that next week they will talk about Tammy.
Oh dear -- more than talk about Christmas long ago happened with Tammy. She came to Brooklyn to visit and we know that Mark is a complicating factor.
And why oh why are Tammy and Paul scheduled so close together? It is impossible for them not to run into each other. How can Gina not know this? And why is she not attending to it as a problem?
Gina was excellent with Paul this week. Not getting caught in his irritation at the beginning, staying with him as they explored what happened that Christmas, working with his resistance to see anything positive about his father so that by the end of the hour, he had some new possibilities to reflect on about his father and about the parallels between his life as a child and that of his son and of Oliver.
It might seem odd that Paul was unable to see about his parents the things he began to see in this session. It is important to remember that these kinds of insights can't happen until the person is ready for them. The combination of circumstances in Paul's life -- his own divorce, the work with his patients, the complications in his relationships together with his previous therapy come together with his father's impending death and Gina's work with his to make it possible for this window to open in Paul and allow him to begin to see both of his parents slightly differently. Insights cannot be forced or rushed. And what opened in this session is only the beginning of a great dal of work for Paul to do. Gina's use of the car accident as a metaphor was excellent.
In Treatment-- Walter, week 3
We hear Walter yelling on the phone outside the door.
Walter is still on the phone when he comes in. He tells his secretary not to call for 40 minutes. There is a business crisis. Paul offers to reschedule. Water says they have already rescheduled from earlier in the evening. Walter tries to hand him cash for his time. Paul asks if he is paying for the session in cash, but he says no, for the time lost to the rescheduling. Walter's phone rings.
Walter tells Paul about a power struggle in the office. Paul asks him to slow down because it seems like he is in the middle of a breaking crisis. Walter goes on again about what happened. Paul says he seems unable to focus and maybe they should refocus. Walter says no, he needs him now and it could be a month before he could talk again.
Walter tells Paul he spent the last 44 out of 72 hours on a plane. He tells him he flew to Rwanda to get Natalie because he knew she was in trouble. She didn't ask him to come but he knew there was trouble. He and Natalie had talked or emailed every day of her life but a week before she emailed her mother full of worry about him. He couldn't believe the way she was writing was her voice, that there was something wrong. When he got there he found she had cut off all of her hair. He says he didn't know who he was talking to -- no shoes, very thin, a child in her arms. He stood there looking at her and she asked why he was there. He says he is taking her home. She says no, she is busy. She suggests he lie down in one of the shacks there and he is appalled by the conditions. He took all of her stuff from the shack. She gets furious and screams at him for this. He got very angry. She started to cry and he held her. He tells her again they are going home. She told him to go fuck himself. Walter says she broke his heart with that.
Paul asks Walter why he thinks she was so angry with him. He says he got an email from her that he is domineering and controlling and much other similar. Paul connects this to the way he came into the office, 2 phones, handing Paul his bag. He notes that when he is in a situation in which he is not totally in control, he is very uncomfortable - like with Natalie or being a patient. Paul asks if it might not be good to let her go, pull away. Paul asks him to look at how he responded to her. Walter gets up rummages through his coat and gets a bottle of Xanax and takes one. Paul asks if he took a pill after he saw Natalie. Walter says he woke up from a nightmare not knowing where she was, thinking he was in his parents' house in Tommy's room and then he remembered the pills.
Paul asks if he has been thinking about Tommy since Natalie left. Walter denies that he had pain, says it was his parents who had the pain. Paul suggests that maybe Natalie is doing something Walter was never able to do, to separate. But to Walter it feels she is doing what Tommy did, leaving him. When he read her emails he realized she didn't need him at all, that she was done with him. He tried to help Walter see that before dismissing him, Natalie wanted to talk with him but he wouldn't do it. Paul asks how they left it. He said in the morning the business crisis crashed over everything.
Paul's phone rings. It is for Walter. Walter gathers his things and leaves, saying he'll be okay because they can't get rid of him because he is the glue. His daughter can survive without him but the Donaldsons can't.
Listening to Walter is stressful. His speech is pressured, he can't settle down so we feel more of the anxiety he is experiencing than he does. He needs for Paul to know how deep the crisis is that he is battling but also that he is on top of it. But Walter is another boy needing his father -- like Oliver and Paul himself. And the only way he knows how to cope is by taking control because otherwise he is thrown back into his brother's bedroom again, the place where he was essentially left by his parents when Tommy died. He knows who he is so long as he is able to take care of everything and do things for the people in his life. He can hardly express the loss he feels in his daughter's rejection because he keeps covering it up with the details of the business crisis. And now he uses Xanax to further blunt the anxiety that is mounting as the business crisis deepens and as he becomes more distant from his daughter.
Paul is not able to do much with Walter in the state he is in. He is too agitated to be able to hear much if anything that Paul tries to say to him. But we know that Walter is finding some value in coming to see Paul because he is making the effort to reschedule and plans to return next week.
Just getting that far with someone like Walter is an accomplishment because until he can slow down enough in session to consider what he is saying and what Paul is saying, nothing can penetrate the armor he has encased himself in. We know that Paul's speculation about Natalie and her separation from him found its mark because it was then that Walter jumped up to take the Xanax. But we may not hear more about it from Walter for some time. Work with someone like him requires patience and an strong ability to delay gratification.
In Treatment -- Oliver, week 3
Paul is doing a video chat with his son about how he is doing in school. There's a knock on the door and Paul tells his son he has to go because he has a patient. Max thinks it is a girlfriend.
Bess arrives to pick up the turtle. As Paul gets the turtle, Bess says Oliver has been with Luke all week. She tells him she had time to read and had a difficult three hour phone call with her sister. Bess gives Paul cookies for having cared for the turtle. Bess seems to be seeking care from Paul for herself.
Oliver and his parents are all on the couch. Paul asks how the week was. Oliver says great. He and his father went to a basketball game, watched The Godfather, went to museums. Bess asks how he slept and he says fine. Bess is looking for problems. She brings up the turtle that Oliver forgot. Oliver takes out some electronic device and says again that he got his homework done, that Nina came to help him. Bess is not happy that Nina was there. Bess feels that Luke asked Oliver to keep Nina a secret. But Oliver says he already knew her because she was his teacher last year. Bess is angry. Oliver doesn't want to say more because whatever he says makes it worse. Paul suggests that he and Oliver go to the waiting room so Luke and Bess can talk.
Oliver tells Paul he thinks he shouldn't have said anything. He thought that if he stayed at his dad's, they would get along better but they are fighting again. He tells Paul he still had trouble falling asleep. His dad sat at his desk and watched him. Paul asks how that felt. He says it felt like he was guarding him. Oliver says he doesn't feel comfortable anywhere. Paul asks if he felt comfortable with Nina. He says he missed his mom. Paul asks if he feels he has to keep secrets from his mom and dad so they don't get upset. He tells him he can't make them happy or sad. Paul talks about the turtle, that he always carries his house on his back. Oliver says he noticed when his mom brought the turtle, it was in a shoe box but it wasn't his so he asks if Paul has a son. He thinks Paul is a good dad. Oliver says he thinks his son doesn't live there because he comes right after school and doesn't see him. He thinks he must miss Paul, that he lives with his mom. He says he would like to meet him. He wants to know if Max has brothers or sisters. He says he was supposed to get one, that they were going to adopt to Africa but then it didn't happen. He doesn't know what happened because his parents didn't talk to him about it. He doesn't want to go back into the room with his parents.
Bess is angry because she thinks they agreed it was too soon for Oliver to meet anyone Luke is dating. Luke says there wasn't an agreement, she issues a decree. Paul says they need to learn to be straightforward with each other. Paul asks about the adoption. Bess wanted to adopt for a long time. Luke went along with her to make her happy. Bess did all the forms for the adoption. When they got the referral, she showed Oliver the picture and they were excited. When she showed Luke, he looked at the picture and knew he couldn't do it because they were so unhappy and that they couldn't fix it and announced he was leaving. Paul tells them Oliver needs for them to find a way to make decisions as a team and to tell him things. He tells them Oliver still doesn't know there won't be an adoption. Bess asks if they can bring him in to talk about it.
When Paul goes to get Oliver, he finds him asleep on the couch.
Paul is excellent with Oliver. We see later, when Paul is talking with Gina, that Paul knows how Oliver feels because like him, he was unable to talk with his father or know how to be with him. And we saw that Max has the same problem with Paul. Three boys, all left with their mothers and uncomfortable with their fathers. And Oliver wants to meet Paul's son, believing he would find in him someone who has the same situation he has.
Paul's empathy for Oliver enables him to create comfort for Oliver, enough that Oliver falls asleep on the couch while his parents are with Paul. April and Oliver both fall asleep in space provided by Paul which indicates the trust that is developing there.
Oliver is caught between his father who tries to keep him busy and entertained and his mother who wants to protect and cocoon him. Neither seems able to consider what Oliver might want or need. And it falls to Oliver to try to protect them from his fears and feelings.
In Treatment -- April, week 3
Paul is at his table reading the paper when the phone rings. It is April asking if she can come in early.
April comes in and has her big project for school with her. Paul asks to look at it. It is a model of two spiky towers which she says is meant to be a World Trade Center memorial. Paul compliments it.
April says she is really tired -- because of her anxiety and the lymphoma. She lies down on the couch. She says she couldn't sleep the night before. Her heart was racing, like there was something poison running through her veins and she wished she could open and make it run out. Paul tells her when she said that he thought of cancer. She says chemo, he says no, because she can choose not to have chemo.
She says it reminds her of a time when she had a song she could not get out of her head and she thought she was going insane. he asks he what she thinks that would feel like and she said falling. He asks what she kept thinking about. She tells him she kept thinking she wanted to go home but she couldn't because her home is so long ago and so far away. She tells him she is so tired she wants to lie down for a minute. She asks him to wake her at 8 -- it is 7:59. He agrees. He watches her and then a moment later softly calls her name. He gets up and touches her shoulder to try to waken her. She asks what time it is. Good she says -- it is over because the project was due yesterday but she had until 8 to turn it in. She gets up and smashes it. She says it was hideous and critiques it. Paul tells her it is very hard to see her destroy her own work. April says she did fall asleep and she dreamed she was on the model, that it was life-sized and she fell. She says it was like joy. Paul says it is different from falling into nothing. In her dream she is able to fall and release everything that she holds so tightly under control while she is awake. She is angry because now she will have to think about it. She compares what he said to how her brother is. Paul says he notices she is often trying to feel what her brother feels and that maybe she does this instead of feeling her own feelings.
April says she did once fall out of a building. When she was 10 and they were in Miami and her brother was not with them. She remembers hearing a band playing Cuban music below She went to the window to be able to watch her parents and the music at the same time and she fell out of the window and landed on an awning. Paul asks if she was frightened. She says she remembers as soon as her feet hit the sidewalk she started to cry. Then she looked in the mirror and she made herself stop crying. So when she walked back into the room, her parents were still dancing and didn't know what had happened. Paul asks why she couldn't tell her mother what happened. April says her mother was so happy and her eyes were closed which she can never do because she has to keep her eyes on Daniel. She says that is where home was, in Miami in that room with her parents and without Daniel. She asks if he ever read On the Beach. She was reading it when she was down there and she hoped that would happen then -- that everything else would be destroyed and they could stay on the beach. Her mother never forgave herself for that trip. Paul tries to explain to her that she is empathic and that she can be empathic and still feel conflicting feelings. Daniel could feel anger but she had to be perfect so she couldn't depend on her mother. She angrily defends her mother. Paul says he is not attacking her mother but she cannot hear his care and concern for her. April is certain if her mother knew she was sick, she would drop everything to take care of her. Paul says she wants to protect herself from knowing how her mother feels. She needs to start chemo and who is there she can count on to be there with her. She says she cannot tell her mother that she has cancer. Paul says she can call her mother from his office. April asks to use his phone. He gives her the phone and leaves her to make her call. April is crying. He asks how it went. She says her mother was in the car and wants her to call back. He suggests she can stay and call her in 10 minutes. Se says she needs to take a nap. Paul asks that she call him after she has spoken to her. April leaves and Paul returns to the office and looks at the broken model which he puts back into the box.
As with Sophie, Paul is perhaps at his best with April. She touches him with her vulnerability and reminds him of his own daughter, at least in his ability to feel the kind of parental concern that she is actually longing for.
April displays what is termed counter-dependency. Because she believes her mother cannot bear her dependence, because of the neediness of her brother Daniel, April has huge unmet dependency needs of her own. Her response to this has been to become fiercely independent and to be the care-giver not the receiver. The fierceness of her efforts to control and resist needing anyone or leaning on anyone is a measure of the dependency needs she is defending against. It is a positive sign that she has continued to come to see Paul, that she was willing to let herself fall asleep in his presence, that she is allowing herself the very small measure of dependence she feels with him as this is exactly what she needs to do. Paul is willing to see her and feel her, which has not been the case with her parents. And though she responds defensively to any suggestion of criticism of her mother, that he does see her and her need is registering with her.
In Treatment -- Mia, week 3
Mia is outside and Paul is late for their appointment which is very early on Monday morning. Paul arrives and apologizes.
Mia wants to know why Paul is late. Paul asks about her being upset. Mia is angry that they are starting 12 minutes late. Mia asks if he had a girl friend. She says this is more home than an office. He deflects her questions. She persists in making hostile observations rather than talk about her anger. Paul asks if she is afraid he will leave again.
Mia says she doesn't want to be there. She doesn't like brownstones. She says she did not think about last week's session. Paul says he did, about her comment at the door, that he owed her a child. She continues to spar with him. She asks about Laura. Mia has read the deposition from Laura. Mia keeps talking about Laura. She tells Paul that Laura says he broke the rules for her and that he had an affair with her. She continues to goad him. Paul tries to get back to Mia and what she did -- that she crossed a boundary by reading the deposition and then bringing it there. She throws the deposition on the floor and says it is his.
Mia laughs, says she just made an ass of herself and that she thinks Paul is angry. She knows he can't express his anger and so she says she will leave. He tells her that she is goading him so that she can leave and avoid looking at her own pain. Mia gets up and walks to the window. She starts talking about a show she watched about custom made sex dolls that men can have in place of being involved with real women. She compares them to a receptionist in her office who is leaving to get married. She thinks when men look at her they see blonde lawyer -- maybe good for sex but nothing else. She asks what he got from Laura. Paul asks if she thinks he chose Laura over her. Mia says she had feelings for him and she is certain he knew. And he didn't pick her. Mia imagines they had sex on the couch. Paul encourages her to keep talking about it. She thinks Paul was smitten from the first, that Laura acted seductive and girlish and she would stare at him and admire him and make him feel like he was the best. She goes on with her fantasy. She starts to cry. She thinks it was amazing for him but she felt nothing. She imagines that for Laura it was about winning, about winning him because for those minutes he was hers. She thinks maybe he held her until she fell asleep. Paul softly says that would feel good to her, that maybe that is what she wants -- to feel comforted, contained. Mia says that could never happen because she is difficult. She is certain that when she walks out that door he is relieved. Paul tells her he told her he did think about the last session and about what happened 20 years ago.
Paul gets up and goes across the room and turns on the tape she had given him. She smiles. It is a tape of Mia playing and he tells her it is beautiful. She says it is from a recital - her piano teacher told her she was the best but not to tell the others. He notes they had a secret. She says soon after that tape she was sent to live with a relative and when she came back the piano was gone. Paul suggests maybe she gave him the tape because she thought maybe she hoped he would understand from it how she felt when they sent her away. Paul suggests she was testing him to see if he could be pushed away as her parents did. Maybe she is angry and she also wants him to be close to her, but she is also afraid that he will leave her.
His next patient arrives. He says they are early and sits down but she says she has to leave. At the end she reminds him he owes her the 12 minutes and then she asks if he had sex with Laura. He says it is the second week she creates a doorknob moment. She believes he is saying he had sex with Laura. Finally he says no. He picks up the deposition after she leaves.
Given that Paul goes to Maryland on the weekends, it seems problematic that he schedules any patient at 7 on Monday morning. But he has and this means he is late. And his lateness simply fuels Mia's anger and her fantasies about why. This may be a bit of acting out on Paul's part, knowing he may be operating very close to the line given train delays and other problems that can develop. In the play of transference/countertransference these kinds of things can happen, though one hopes he will reflect on it and try to see what it is about for him.
Mia's open anger and hostility is hard to be with. Given how hard she goaded him, Paul actually did very well handling his own responses. This is the second patient who has tried to get under his skin about Laura -- Alex did so last season with a far more explosive outcome. In both instances, it is likely that the unconscious motivation was to test Paul, to see how far he could be pushed before he would retaliate. And for Mia, to see if he would leave her, or make her leave as her parents had.
I have very mixed feelings about whether or not Paul should be willing to work with Mia. That she was willing to read the deposition, despite knowing it was a serious ethical breach, is cause for considerable concern. I understand being willing to take her back in order to deal with issues left from their previous work. I have often had patients return even after many years. But her anger is leading to dangerous acting out. Trust is a two way street in therapy -- the patient needs to be able to trust the therapist and likewise the therapist needs to feel some measure of trust that the patient will not willfully attempt to injure him or her. Mia re-entered Paul's life via an ethical breach and she has now repeated it. Paul has not moved to set a limit on this, to let her know that he cannot allow her to continue to act out in this way. In fact, he probably should have told his insurance company to refer him to another law firm as son as he knew Mia was there -- the conflict is simply too great. Though I think Paul handled Mia's hostility as well as could be expected, I think he is inviting further acting out from her and that it could well harm him. His passivity in the face of this is troubling.
I have said before that I believe that therapists can have an office in the home. Having said that, it is important when we do to be mindful about boundaries and creating some separation between personal space and work space. Paul is not the first nor certainly the only therapist in New York to have his office in his apartment. But, I noticed he left the sliding door between the kitchen and where he sees patients open enough for patients to see into the kitchen. Not the worst thing in the world, but it does seem to be inviting patients to want to see what they can, to fantasize what is there, and to make the container for the therapy, the physical container, less secure. Mia said his space is home more than office, putting her finger on this very problem. And with a patient like Mia, whose acting out already shows a willingness to pry deeply into Paul's life, this seems especially unwise.