Talk Therapy: Week 6 - Frances

Though therapists have supervision (recall Paul's sessions with Gina), one thing they don't traditionally get to do is watch the "game tape" of a session. We've enlisted experts (read their bios and find their comments from prior weeks) to weigh in on select moments with Paul and his patients. What's said, implied, or deeply buried? Let's go to the videotape...

(Please note: The clips under discussion for this week have not yet been posted. They will appear here shortly. The content in these discussions does not reflect the opinions of HBO. )

Joseph Shay, PhD

What if Izzy hadn't walked in just at the moment that Frances asks Paul, is it true that narcissists can never change? I'm hoping he would have said, no, it's not true. Change is definitely possible for people who carry that diagnosis. I hope that he would have added, Frances, a person is not synonymous with a diagnosis.

Yes, Frances could clearly be said to carry the diagnosis of narcissistic personality. The writers have given us ample evidence for that in the past five weeks. We have seen, for example, that she is often self-absorbed and entitled, shifts between idealizing Paul and devaluing him, and is focused on superficial aspects of herself and others to the point where she can't even contemplate a mastectomy, cancer or not. Just as her mother couldn't contemplate it.

In this clip, Frances says that Izzy called her a narcissist and that Paul did as well in the last session. Paul denies this, but I'd say Frances is on to something. While Paul never used the word, it's hardly a stretch to say that he was accusing Frances of being so self-focused that she had lost complete track of the needs of her sister, Trish. Moreover, Frances has just asked Paul if he has something for her to eat, momentarily demonstrating an entitlement to which Paul responds with a boundary. This is the same Paul who drank coffee with Alex, made Oliver a sandwich, met with Mia in his kitchen, offers Sunil tea each week, and almost slept with Laura. It may be that Paul is tightening up his boundaries or more likely that Frances' request strikes him as too much in keeping with the "it's all about Frances" presentation.

Still, Paul is trying to regain an empathic stance toward Frances, one which he lost last week when he told her she wasn't the one who was dying, her sister was. And it's easier to find an empathic connection when the therapist understands why someone is behaving the way they do. This is what we call the "no wonder" stance.

Given the information Paul has, he can see that it's no wonder Frances developed in the way she has. To oversimplify, Frances was raised by a mother who was focused prominently on capturing the attention of those around her which meant concentrating on appearance over substance. One daughter fought against this training and the other succumbed.

That's where the book comes in. The Drama of the Gifted Child centers on the developmental path that ends in narcissism. While the book can properly be faulted for being part of a tradition in our field of mother-blaming (which has been significantly diminished over the years), still it details the ways in which children are subtly yet forcefully trained to serve the needs of their parents, especially the mother, rather than to develop a separate self. Randy Paulsen will give a description, below, of the context in which this book was written, so I won't repeat that here.

Two points are worth noting, however. First, as I recall, the original title of this book was Prisoners of Childhood which perhaps was replaced because it was less sexy than the Gifted Child title. That original title does speak, however, to the invidious process involved of the child trapped in a relationship with a parent in which the power dynamic calls for submission by the child. We have learned from Frances how she was in the thrall of her mother, even being named for a famous movie actress which spoke to the mother's desire for how she hoped Frances would develop, and how, indeed, Frances did. Mother was so enamored with the acting ability of Frances Farmer she was willing to overlook the fact that that Farmer was psychotic.

The second point is that, again if memory serves, the book also highlighted how common it is for therapists to develop narcissistic personalities because they are frequently raised in family environments in which they are asked not only to serve the needs of their parents, but indeed to rescue them. To serve and to rescue. What a recipe for creating a psychotherapist! Was this what Paul experienced with a depressed mother for whom he was presumably the confidant, and a father who may have wanted to be emulated by Paul while not being present for him?

A future therapist raised in this way may develop a false self, a false identity, the price of which is the sacrifice of a more personal identity. Since this process occurs out of the child's awareness, the therapist may not even be aware of this false self. The adult raised in such an environment may later ask himself or herself, is there a there there? Frances is clearly coming face to face with this question. For Paul's sake as well, we hope that he believes that narcissists are capable of change.

Randy Paulsen, MD

The "Freudian slip" has become an almost universally known concept in current society – something escapes our lips that we didn't intend, but it contains an element of unconscious (unknown) truth in it. Frances' referring to Izzy's book as The Gift of the Dramatic Child, instead of The Drama of the Gifted Child, is a good example of the Freudian slip. Frances' daughter is reading and loving this book. The third book by Polish-born psychoanalyst, Alice Miller, it is about the trauma of childhood, the intolerable pain of remembering the helpless victimhood, the way a child has two choices according to Miller, to either become depressed or grandiose. Miller was an analyst of Virginia Woolf among others. So, in a sense, Frances is unconsciously attempting to assuage her childhood pain by remembering the title as if it is about a dramatic child (Frances) being a gift to her self-preoccupied mother.

One of the reasons that I, as a psychoanalyst and therapist, love this show is that it provides life-like interactions, beautifully written, directed and acted, that allow us to simply point to a vignette and say, "that is the problem of narcissism, the tragedy and the hope of treating it." Seeing actors portray it can often convey more than words. Alice Miller's writings paralleled those of another European-born psychoanalyst who immigrated to the West, Heinz Kohut, who settled in Chicago and founded Self Psychology. Kohut, I think, would appreciate what Paul is trying to do with Frances, and I think, like us, he would see that it isn't easy. Narcissists are paradoxes; their self-preoccupation covers an inner sense of inadequacy; their prickliness covers an inner sense of encapsulation, loneliness and emptiness.

Frances has told us that when she goes home from the theater it is to an empty house, a can of soup, nothing. She begins this clip with "Go ahead, say it, I look tired." She is focused on how she looks to Paul, not how she is feeling or how he might be able to sense that. When Paul notes, "that's something you say quite a lot, 'I'll be fine.' Is there a message you want to communicate to me in there?" he is trying to bring awareness to her self-contained quality, her fending off of a felt connection between them. She asks if he heard her stomach grumble. Then she further distances him, and Izzy, by recounting that Izzy's response to her BRCA1 test results was to call Frances a narcissist. It is unavoidable, but often painful, territory in a psychotherapeutic journey, that a person's response to an observation about a fundamental personality trait is to feel criticized, judged. Frances' protective shell is under attack. Her defensive reactions are distorting how she hears Paul's or Izzy's comments. It is the relationship between that is the engine of treatment, so Paul needs to keep repeating, "I don't recall saying anything of the kind." He won't be heard, or make a difference, if he stops after saying it once or twice.

Then we see a hopeful light at the end of a tunnel for Frances. Both she and Paul are moved by her emergency visit to her sister, lying on the tile floor, snuggling in the warm bed, terrified in the face of dying, saying, "I love you." Frances has to see that her story has moved Paul. This is her sore spot. She needs this connection so much, but can only tolerate small doses. Like the drama of the frozen mountain climber, you can't thaw him out too fast or he'll die. She then backs off to a diatribe about the "big nurse" who implied she was getting some "sick pleasure" from delaying Patricia's getting to the Emergency Room. But Frances has acted on behalf of her sister, and herself, in leaving the theater for her sister's bedside. Does change mean she has to throw her old self out and quit the theater? Or can she keep the self she has, an actress, a mother, a sister, and still grow into a more related, emotion-tolerating, less narcissistic woman?

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