Talk Therapy: Week 6 - Adele

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...

(The content in these discussions does not reflect the opinions of HBO.)

Joseph Shay, PhD

"It's all a crock of shit anyway. It's all designed to give power and thrills to the sphinx-like doctor at the expense of the humiliated patient." Paul is angry. He is angry at Adele, he is angry at the psychoanalytic approach, he is angry at sphinx-like Gina all over again, and he is soon angry with himself: "How absurd and navel-gazing can one get?"

Paul feels seduced. Seduced and abandoned? Indeed, there are a number of patients who express the belief that the therapist has led them down the path to dependency, to attachment, to erotic feelings, even to hatred. The truth of this assertion can range from largely false to entirely true, with a lot of co-constructed territory in between. It is the exploration of this process with an eye toward recognizing one's historical vulnerability to its occurrence that can result in major and liberating insights. The hope is to promote healthy interactions in current relationships by appreciating the befogging filter of past relationships.

The puzzle here is whether Paul has indeed been seduced or whether we are simply observing his proclivity for developing rapid, intense, and sexualized connections with women. We know Paul tips in this direction based on his behavior of all three seasons so it's easy to think he's bringing all of the fixings to the picnic. And we have so welcomed Adele as an antidote to the confused boundaries presented by Gina that we are reluctant to think that she has also lost her moorings -- in a way not dissimilar to Paul having become unhinged by Laura in the first season.

I don't want to believe this of Adele. I really don't.

However, the evidence is there that she has become unsteady in the therapy with Paul, at least to the point of behaving in ways uncharacteristic of her earlier presentation and her training. In week four, when Paul made his "pronouncement" of his feelings for Adele, Adele ended the hour by saying "let's pick this up next week. This'll be an excellent place to start." Yet she doesn't reference it all in week five until Paul brings it up, asking Adele "why the delicate evasion, the muted suggestion?" We were still unsure of where Adele stood, unless we chose to read into her body language that she was feeling uncomfortable or perhaps even excited.

This week, however, she calls Paul on Tuesday, at 7:30 in the morning still in her nightgown, to try to schedule an appointment for the next day, purportedly to discuss Paul's concerns about Sunil. But these concerns were presented by Paul the previous Friday, so how worried about this could Adele really have been? Moreover, Paul notes that by discussing Sunil now, they are playing out Paul's fantasy that they discuss patients together, which Adele had disparaged before.

In that early morning phone call, Adele's voice seems softer, less assured, more personal. It sounds more like a tentative call for a date than a call to schedule an appointment. Then Paul, in a cunning cat and mouse way that we haven't seen this brazenly before, reminds Adele that he wasn't the one who called, that he hadn't mentioned red wine. He's not done. Paul then entraps Adele into revealing that she did indeed call him from her home. Caught, she gulps hard as Paul wonders whether there is something more that she feels, and appeals for honesty. The phone rings, Adele stands up, and Paul is devastated to realize that Adele is pregnant, which neither mentions for several painful minutes as they continue to discuss Sunil.

Adele notices Paul's agitation that she is pregnant but adds the evocative clause, "I have to say you seem upset, as if it's some kind of betrayal." Seduced and abandoned. Paul is humiliated. He calls Adele cruel and narcissistic and accuses her of encouraging his fantasies and his delusions while promising to "understand my miserable fucking life." Thinking that she is in a committed and happy relationship, he feels betrayed. We viewers, having seen Adele alone in her bed, unable to sleep and waiting for the alarm clock to ring, know differently. Ironically, Paul has now dissolved his fantasy that Adele might be interested in a life with him while we wonder if that's precisely what this single mother-to-be has been fantasizing herself.

When the idealizing Laura fell in love with Paul, he realized that he too was in love with her. Is this what has happened to Adele? Has her own yearning for rescue been triggered by Paul? Not to be too cute about it, but is Adele in danger of becoming Paul?

Rachel Seidel, MD

Paul is consulting with a third neurologist. The doctor asks without raising an eyebrow, "Are you taking anti-anxiety medications?" Paul replies, deadpan, "I am not." The consultant is not deterred. "Do you have any interest in trying anti-anxiety medications?" Paul responds pseudo-politely, "No, thank you." Sighing, the neurologist tries one last time, "OK, I'm gonna write down some names for you, in case you change your mind." He adds wryly, "My colleague is an excellent psychiatrist."

With all four therapies heating up just one week before this 'In Treatment' season comes to an end, we could all use a little anti-anxiety medication, some additional sessions (are you listening, HBO?), or maybe a consultation.

I have been following along intently as Paul and Adele have become more deeply engaged in their work. This is no easy collaboration, as we have seen (especially starting in week 5), with Paul so immersed in the creative but painful space created by his erotic transference toward Adele. Until now, I felt reasonably comfortable that Adele's insight, clear sense of the limits of the therapeutic frame, and ability to withstand and contain Paul's burgeoning emotions and fantasies, would keep the anxiety evoked by treatment adequately in check. Week 6 certainly raises doubts about that!

Early in week 6, we speculate that Paul is not the only member of this therapeutic pair who is having fantasies. Adele lies awake in bed, smiling, in unspoken reverie. She wraps a robe over her nightclothes and, after brief reflection (and with some evident conflict), she phones Paul to offer him an extra session. This action is very unlike the boundaried Adele we have been learning to rely on. Is she, as she states, only concerned about how Paul may unconsciously sabotage his career? Is Adele, in parallel to Paul with his ardently proclaimed wishes, imagining "something more" than therapy? Or — as I imagined after the eye-opening scene of Adele placing her hand on her fecund abdomen in the way that only a pregnant woman does — is Adele enthralled by a reverie that D.W. Winnicott called "primary maternal preoccupation"?

Adele is certainly primarily preoccupied with her baby-in-utero, when she asks Paul whether he was trying to alarm her concerning Sunil — "there are small children in the house," she admonishes. I have a sense of her urgency when Adele warns that if Paul doesn't intercede, he will not only have ruined his career, but "you will always know you could have done something to protect a woman and her children." Observing no wedding ring on her finger and no partner in her bed, I imagine that Adele is becoming a single mother, and that she may well be dreaming of Paul as someone to protect her and her child, to be her partner and a father to her baby.

Everyone experiences transference reactions, in life and in treatment. Under the best therapeutic circumstances, this repetition of feelings toward someone in the present which have their origin in experiences with important others in the past, provides what Winnicott called a "transitional space," a space between inner and outer worlds where creativity can occur, a space between people in which intimate relationships can occur.

In the context of a fertile, thriving transference, Paul's not unflawed humanity has been unfolding. Now, through revelations about her internal and external realities, we are beginning to learn something more about Adele's humanity.

At the end of this volatile session, an anxiety-provoking question looms: Is Adele clueless about her own countertransference wishes toward Paul, or will she be able to utilize these fantasies in order to understand herself and Paul more deeply and to further his treatment? If, in the context of the biological and psychological imperatives of her pregnancy, she is unable to do so, then the one who deserves consultation is Adele.

Randy Paulsen, MD

I found much of this episode hard to watch – perhaps particularly hard for a therapist. It's hard to see Paul, who many times this season has done admirable work, been a mensch, so to speak, devolve into this nasty, seemingly irrational, at times even conniving, manipulative pain in the ass. Much of the heated concern in this current session revolves around Paul's identification with Sunil, a lonely man in his mid 50's attracted to a younger woman who is unavailable. I ask myself why is this so hard to watch? Well, I say, perhaps it's because much of the time, when he is doing good work, I have identified with Paul. But now I want to turn away from what he is doing. I wonder what's the matter with the writers here? This show is going downhill. Too bad.
Then I say, wait a minute. Isn't my revulsion for this scene a bit similar to why people "dis" psychotherapy? Isn't it because psychotherapy exposes too much of our unconscious psyche, our messiness, our craziness. It discomforts us. Paul is in the grips of his own transferential craziness. He's regressing in front of our eyes. He's becoming a different Paul. He and Adele agree on one thing: it's Hell.

There was a Paul who, days earlier, was very worried about Sunil and the position he was putting Paul in. He was actively trying to get Sunil to listen to what he, Sunil, was saying. As any therapist would, he was working hard to expand the limits of Sunil's self-awareness, to facilitate his growth, so that Sunil can control his urges, emerge from his depression, shape his life, and so on.

Those concerns have receded to the background in this session with Adele. He dismisses her concerns about Sunil, and instead begins to hone in on demonstrating that she is in the grips of her own emotions. He points out that she has called him in the early morning to offer an extra session. She has called from her home phone, at her breakfast table, and he seeks to make the case that she is living out the fantasy that he described the week before, talking about cases over a glass of red wine. Whoops he didn't say "red" wine; she did. He is seeking a kind of gotcha leverage to prove that she too has feelings, attractions, in short, an unconscious psyche. An unconscious psyche that is affected by close relationships, professional or otherwise.

Then, Adele's phone rings. She has forgotten to turn the ringer off. She puts her hand to her swelling abdomen as she handles the call. She notices him noticing her. There is now another reality in the room to react to, perhaps, to hate. Adele is pregnant. This reality brings Paul's efforts to preserve his fantasy crashing down. He is particularly angry because he had Adele cornered. He had shown her that she had her own version of pre-occupation about him, thinking the wine was red, calling him when she first woke up in the morning. So in the wake of the real news about the pregnancy Paul launches a torrent of derision at Adele, the "Freudian Ice Queen," who seeks to humiliate him. When a fantasy is destroyed, people attempt to destroy the person they fantasized about. In his rage, Paul seeks not only to destroy Adele, but psychotherapy, itself. "It's all a crock of shit, anyway."

Freud said something like the nature of treatment is to create a contained version of the craziness in a person's life – a transference neurosis. And then the trick was to cure the person of that particular, iatrogenic craziness. It sounded crazy at the time, and in some ways it still does, but we are witnessing a pretty good semblance of this strangeness here.

What we see in this clip is not only Paul's rage, but Adele's efforts to get him to acknowledge it. Basically, the belief is that if a person can "own" their feelings, they are less likely to be governed by them. It's the same effort that Paul has been making with Sunil. Adele manages to weather Paul's barrage. She survives and is then able to say she is concerned that he may be unconsciously arranging for the destruction of his career. She is concerned that by not acting more effectively with Sunil, Paul may be arranging his liberation from his "miserable life," by failing to protect a young woman and her children. Her alliance with Paul enables her to speak truth to him amid the rubble of his destroyed fantasies. As he calls Sunil's daughter-in-law, Julia, perhaps he, too, realizes that his alliance with Sunil does not depend on his keeping reality outside his office door.

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