Talk Therapy: Week 7 - Jesse

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

"Will you drive me home tonight?"

This is what was written on Jesse's green T-shirt in the week six episode on Jesse's birthday. This is an instance of Chekhov's gun which, simply put, means, if you load a gun in act one, it better go off by act three.

The gun went off.

Paul didn't drive Jesse home, or for ice cream, or to RISD. Nor should he have. Here we see the repercussions. Striving to maintain the appropriate distance with Jesse, Paul had encouraged Jesse to be with his adoptive parents, knowing that Jesse might experience this as a rejection. Paul suggests that Jesse's desire to quit therapy abruptly, with his father Roberto's full support if not psychological coercion, is a punishment for that experience of rejection.

"You don't have to choose between me and your father. You can have us both" says Paul. This is, of course, precisely the issue that Paul has been living through with his own son, Max: Max shouldn't need to choose between Paul and Max's new stepfather, Steve. Paul has tried hard to suppress or work through the threat he feels from Steve, the All-American with the strong handshake, so he well knows that a father doesn't like another father or father-figure horning in,

Herein lies a dilemma for Paul and for therapists of adolescents in general. Do we want to be the "better mother than mother"? Even if we want to be, should we try to be?

Last week I spoke about the danger of trying to rescue the patient. This episode illuminates that danger.

Paul says "we've just started to talk about who you really are, where you come from, where you're headed. There is so much good work just beginning." Just keep talking to me, implores Paul. Jesse asks why this is so important to Paul to which Paul plaintively responds, "because you are important to me." Jesse has yearned for this, has wanted desperately to be important to someone, has almost killed himself because he felt he was unwanted and alone in the world. Still, at this moment in time, he shrieks, speaking to the heart of the matter, "that is so f**ked up!" because "you are not my f**king father!"

The therapist is not the parent. We cannot be the parent no matter how deep the wish to step in to save the child. To speak with an adolescent in distress, however, calls up in many of us this wish to intercede, a wish which, if managed carefully, if kept within the boundaries of our role, can provide fertile soil for growth and at times even provide oxygen to one who might die without it.

For many adolescents, however, as with Jesse, the earlier wound is so profound or the familial context so inimical to continued treatment, that a particular episode of treatment will fail. This does not bespeak the permanent failure of therapy for the adolescent. Many adolescents come to treatment just like Jesse, and blow out of treatment just like Jesse.

Sometimes we simply cannot make a good enough alliance with the adolescent, who is characteristically wary of authority in the first place and inclined to see the therapist as a representative of the parents. Sometimes a family member is threatened that another adult is being called upon to communicate with the person he or she has been unable to communicate with. In such cases, some parents seem pleased when the therapist fails. Roberto, who may, for all we know, be a decent guy much of the time, takes pleasure in telling Paul, "you shoulda been a plumber." Sometimes the adolescent cannot tolerate the choice that seems to be called for, as is the case for Jesse. Given his current reconnection with Roberto – a connection we have no reason to think will last the night, let alone the next several years – of course Jesse cannot choose continued therapy with Paul. Even though he loves Paul and believes that Paul loves him. But Jesse also knows that Paul has Max to love, so why not have his own Paul at home?

Moreover, Paul has committed one of those errors in therapy that is best to be avoided, namely, never alienate the parent (especially if the parent holds the keys to continued treatment).

As with many adolescents, however, this may well not be Jesse's last foray into psychotherapy. It is common for adolescents to be at different states of readiness for treatment, and to need to move through different therapists until they are, so to speak, at the right place at the right time.

For Jesse, this may have been the right place. But it was not the right time.

Jesse will drive home with his father tonight. Sadly, his anguish is not over and his journey, as Paul said, is just beginning.

Rachel Seidel, MD

The camera opens on Paul, Jesse and Roberto, each seated on his own chair or couch in Paul's office, forming a visual triangle: In this image, psychological triangulation and tense separateness are made manifest, physical, as in a dream. Scanning their hair styles and clothing, listening to their speech, I see Paul and Jesse as cut from the same cloth, while Roberto — sporting workman's clothes and a razor haircut, his speech clipped and matter-of-fact — seems the outlier in this threesome.

But things are not as they appear. Paul and Jesse, the therapy pair, are not united in facing Roberto, the therapy doubter. In Jesse's mind, Paul has let him down, while his adoptive father, Roberto, has made a heroic 8-hour drive to rescue him from the police station in Providence. Father and son have re-found each other, declarations of love have been made. "We figured it out," says Roberto to a befuddled Paul who has been working hard to figure it out for weeks. "My problem," clarifies Jesse. Paul is advised that the electrical job is done, illumination accomplished, and it is time for the D'Amato and Son team to head out together. But not before Paul and Jesse have their exit interview.

Jesse tells Paul about his exciting experience of riding the express train to Providence with only a regional ticket in his pocket: "The trick is, you never sit — if you sit, you're sunk — you have to stay one car ahead of him at all times, and when you get to the last car, you just hide in the bathroom, but I f**d up. I sat right before we got to Providence." His description is full of self-revelation and worth a closer look.

Jesse, who feels unloved and dead inside, needs to enliven himself with impulsive and risky adventures; we have seen this before, for example, in Jesse's sexual promiscuity. Though he has only enough money for a regional train ticket, feeling entitled to more, he takes the express. We have seen this before, too. Jesse believes that the traumas of his adoption and deprivation entitle him to the expensive program at RISD that is perfectly suited to his needs — surely someone (his working-class adoptive parents, his wealthy birth parents, or the Rhode Island School of Design itself) will pay his way.

Jesse thinks of others mostly as extensions or projections of himself, the way that very young children do. These others are present merely to satisfy his needs and grandiose fantasies, rather than as separate people with thoughts and wishes of their own. What's more, Jesse is filled with rage and destructive wishes that cause him overwhelming anxiety. His only way of dealing with these bad feelings is by splitting them off (to preserve a sense of goodness in himself) and projecting them outside himself. As a result, he fears others as malevolent and potentially harmful. This explains why he must be vigilant, stay one step ahead, never relax, and hide. It is a perfect storm of feelings that often leads Jesse to self-destructive as well as destructive behaviors.
Paul has experienced this aspect of Jesse as often as he has experienced the aspect of Jesse that is hungry for a father. Hurt and angry that he has been replaced by Roberto and is being rejected by Jesse, Paul presses Jesse hard during this last meeting, piling interpretation upon interpretation and urging Jesse to remain in therapy. Jesse — having not yet been able to mourn the ideal mother and father that he never had, having not yet internalized a benign, gratifying, loved and loving object — becomes unbearably anxious (remember the way Jesse cracks his knuckles and punches one fist against another?) and experiences Paul as a persecutor, an object to stay one step ahead of, to hide from or to flee, at least for the moment, until the object hunger is greater than the fear.

Choosing to retreat from invading soldiers, Shakespeare's Falstaff ('Henry IV, Part 1') says as he flees the battlefield, "The better part of valor is discretion." Paul might have taken a lesson from Falstaff. With an adolescent as developmentally challenged as Jesse, discretion and patience could go a long way.

Randy Paulsen, MD

Jesse's father Roberto's brief appearance in this episode put me in mind of a construction site – where a house is being built, a house that Jesse might someday be able to live in. The project will need an electrician, a plumber. Paul is neither one of those. When he works, the lights don't just suddenly go on.

Jesse, though, has learned something about building walls this week. The walls can have good guys on one side and bad buys on the other. For a growing young man the discovery of walls is the beginning of shelter. Walls are better than being homeless, exposed to drive-by relationships and sink-holes of despair. Sometimes you have to divide in order to conquer. Even if the divisions are ad hoc and half-true, they are better than nothing. In psychological terms, Jesse has learned how to split. This is progress for a teenager. Jesse proclaims its usefulness when he says, "it's not my fault." One thing about splitting, whether you're a toddler, or a teenager, or a polarizing politician, it allows you to trade in helplessness for an immediate sense of power.

The new mantra is: The world is now full of Good Guys and Bad Guys. I'm tired of all this pain, and complexity stuff. Jesse gets arrested, jailed in Providence and calls his adoptive father Roberto who drives 8 hours to get him. He and Roberto bond around an us-against-them theme. Roberto and Jesse against Marisa and Paul. In the world according to Roberto and Jesse: 1. Marisa, Jesse's mom, didn't know how to soothe him as a baby; 2. Paul has been letting him leave the office on the verge of suicide, and 3. It was Roberto alone who wanted to adopt a baby because Marisa couldn't have children. He and Roberto are "cool again for the first time in 4 years. He wants me to go work for his business. Do you know what a big deal that is?" Paul does see what a big deal this is. He just wants Jesse to know that he can have both a father and a therapist. For now, at this point, Jesse doesn't think so. Jesse may not be entirely conscious of what he is doing, but he is the central player at this point, making things happen, not just letting them happen to him.

Roberto is Jesse's father. He embraces him in the jail instead of yelling at him. Roberto lost his parents when he was Jesse's age. That early loss left a hole in his heart. He tells Jesse about the moment they picked him up from the adoption agency. "When he held me, the hole in his heart closed immediately. Like magic." As this hole in Roberto's heart closes, the door between him and Jesse opens. What Jesse is saying and the reluctant Paul is, finally, hearing is that the door to his office is closing. I think Paul makes a very good effort to educate Jesse on the difference between these two doors. Paul, as a therapist, cannot come after Jesse, as his father has just done. It will have to be Jesse's decision when and if to come back.

Paul sells himself and the therapy short, by worrying that their work is "gonna all get buried." Jesse, indeed, is "not enlisting in the Marines." He's curious about why Paul is suddenly answering all his questions. "Is this our last session?" Perhaps Paul is trying to became as real as Roberto to keep Jesse coming back. Then he blows Jesse's developing brain circuits by asking if the new security he feels is "coming from inside you?" That's when Jesse tells him to "just shut up." For the house project to go on, we're going to have to ask the owner (Jesse) and the architects (Paul and Jesse) to leave the site and let the carpenters, electricians (re: adolescent brain chemistry) and plumbers do their work in relative peace for a while. Maybe Jesse will take that part-time job in Roberto's company. Maybe he'll focus on schoolwork during the day. That's what I mean by doing work in relative peace for a while.

Two things make me think they could resume treatment in the future. One is that Jesse does apologize to Paul when Roberto asks him to. Actually they both say they're sorry. The second is that Jesse refuses to take back his letters from his birth parents. Those need to stay with Paul. Jesse may be done with that part of his work - at least he will know where they are. I feel the hole in my heart is still open as Roberto's truck, with Jesse in it, drives away.

Bravo, Gabriel Byrne, Dane DeHaan, Sarah Treem and all. Working with adolescents is tough. Whew. Working with the young is a true stitch in time. Thank you for the chance to wrestle at a distance with these wonderful people and this wonderful story.

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