Talk Therapy: Week 7 - 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

Please, Paul, do not give up your practice.

There are many reasons I feel this way, even though you have lost your way moreso this season than in the first two. First, you are actually a good therapist, sometimes even a great one. Second, no Paul, no ‘In Treatment’ – and that would make me very unhappy. Third, to my mind, this has been the best show featuring psychotherapy ever. Not that the competition was that keen. Dramatic or comedic presentations of therapy have ranged from the Bob Newhart show to legions of therapists sleeping with their patients to some therapists even committing murder. We did have Dr. Melfi, though, which was a very refreshing change -- until it wasn’t.

Dr. Melfi in ‘The Sopranos.’ One of the great moments of great psychotherapy happened on this show. Do you remember the episode after Dr. Melfi was raped by a man who was freed by the judicial system on a technicality? Tony Soprano, her patient, sensing that something was gravely amiss with Dr. Melfi and that she was suffering, asked her if there was anything he could do? We viewers anxiously awaited her reply, hoping that she would ask for Tony’s help, and hoping that she wouldn’t. She said, no thank you, fighting against every fiber of her desire for justice and of revenge. This was great psychotherapy.

Adele is placed in a similar position, if you will, in this final session with Paul. He asks Adele, “Do you ever think about us being together? Do you? I’m not in treatment with you any longer. You can answer the question.” Adele remains silent. Is she too fighting against the fibers of desire?

While we don’t know for sure, as we discussed last week there was that early morning phone call from her home when in her nightgown in that softened voice. By the way, speaking of Chekhov’s gun, those books on Adele’s bedside table in week six (whose titles were too tiny to be read on the postage-size file we do our pre-screening on), were Single Parenting That Works and The Complete Single Mother.)

This brings me to a fourth reason that Paul should stay in practice. I want to see more of Adele. That is, more of Adele as a therapist.

While imperfect, which we all are, Adele has been a marvelous therapist for Paul with respect to seeing him clearly, isolating his core dynamics, communicating her understanding to him in ways that get through to him and keep him coming back to her, until he decides no more. At her best, Adele is clearly a match for Paul, even though we can see in her throat and in her emotionally charged reactions that he absolutely gets to her as well. The therapist’s nightmare is the patient who can leave us feeling unknowledgeable, unskilled, or unhinged, Paul has the ability to do all three. Gina wrote a book about it!

Paul knows he needs continued therapy at some point. In this episode, he wonders whether he is even capable of loving another human being. He accepts Adele’s interpretation, which is a profound one, that he seeks out emotionally safe relationships, preferring to connect deeply inside the office where he’s safe, and keep his distance outside the office where he’s not.

Not only does Paul accept that Adele is correct, he tells her that it is the very truth of her analysis that has led him to conclude that he cannot return. If he does prefer the safer intimacy of the office, where the relationship cannot have a future, why torment himself with this faux intimacy with Adele?

Paul laments, “I can’t distinguish it from reality.” Therefore, he has to leave.

This is another reason Paul believes he has to stop being a therapist. After dealing with Sunil, what is real and what is false? He complains, “maybe any serious communication between two people is useless. Even without outright lying, people only hear what they really want to hear or what they’re capable of hearing which has little resemblance to what’s actually said.” Paul has lost faith in the very process of listening to others.

In season two, even though she was infuriated with Paul, Gina says to him, “you’re a good therapist. When you describe your patients, it’s clear to me how carefully you listen. You have a great ear. You have a great sense of empathy.” And Paul does. We have seen that again and again, across all three seasons. His ability to penetrate to the core issues of his patients has at times been literally breath-taking, causing many therapist-viewers, including me, to feel twinges of jealousy of Paul.

One final thought about Adele.

Paul’s confusion about Adele is not crazy. We know that Paul is prone to fuzzy boundaries and we know that he can fall for women fairly quickly. But think about how the session with Adele ends. Paul offers his hand for a final goodbye handshake, trembling either from anxiety or from the Parkinson’s that he doesn't actually have. Adele shakes his hand, puts her other hand atop his and says, “my door will always be open to you,” the symbolic meaning of which – said at this very moment – it doesn't take a Freudian to see. And then she gently if briefly caresses his hand. Why the caress, Adele? Why the caress?

Finally, Adele is right when, in this episode, she criticizes Paul’s overall therapeutic stance, noting that he has “blurred boundaries with your patients, treated them as friends or children, [and] again and again allowed your own feelings to interfere.” Why, then, has Paul been able to help so many of them?

Despite Paul’s personal flaws combined with his many errors (some disastrous, such as with Laura and with Alex), Paul’s patients feel the constancy of his attention, the penetration of his analysis, the depth of his empathy, and the power of his compassion. A great teacher of psychotherapy, Frieda Fromm-Reichmann, once said, patients will always forgive mistakes of the head, but not of the heart.

Rachel Seidel, MD

There is poignancy in the arc of Sigmund Freud’s writing, from his early expansive belief in the universal efficacy of the psychoanalytic method to his late admission of some clinical failures among the numerous patients he treated over decades. It was partly due to his failing health, old age, painful losses and professional disappointments, and the growth of Nazism in Europe (which forced his emigration from Vienna to London), and partly due to these failed clinical treatments that Freud became pessimistic about the ability of psychoanalysis to effect character change.

Somewhat like Freud in this one way, over this last season of ‘In Treatment,’ Paul Weston moves from a previously expansive view of psychotherapy (including Paul’s broad role as a therapist with permeable borders who tries to be everything to his patients) to an acknowledgment of his professional and personal failures and losses (most recently, with Sunil and Jesse) that leaves him feeling despondent about life and relationships, and distressed about what he comes to see as the futility of even trying to communicate. Paul feels as stuck as a mouse in a mousetrap, terribly alone and unable to change. His crisis deepens until he feels he can no longer work as a therapist. Adele’s refusal of extra-therapeutic contact with Paul (even though her body language shows signs of weakening, of responding to Paul’s seductiveness, her words — or the withholding of them — say “no, no, no”) drives Paul over the edge. If he can’t be with Adele in love, then neither will he continue his treatment with her.

Paul as a patient is demonstrating with Adele what Paul’s patients have often experienced with him: the unhappy intersection of the patient’s desire for love (Frances, as one example among many) or friendship (Sunil) or a surrogate parent (Jesse) from the analyst, with the analyst’s conscious goal of understanding her patient and helping to foster a curiosity and desire for understanding also in her patient. Into that already busy intersection, add the therapist’s own unconscious wishes for love, friendship and intimacy, and we have a veritable traffic jam that, unless carefully unsnarled, can result in paralyzing gridlock or perhaps even a blow-out. Under these circumstances, therapeutic change becomes very difficult to achieve.

Yet another aspect of psychotherapy’s limitations relates to the conundrum of what constitutes both truth and lies in psychotherapy (a topic I also touched on in my commentary on Sunil week 7). Is the true/false dichotomy even applicable once we enter deeper into the foggy realm of memory and amnesia, repression, dreams, wishes, imagination and reconstruction? Or rather, is there a spectrum that runs the gamut from a person’s experiential conscious truth on one end to conscious prevarication, deception, malingering on the other, with a very large gray zone of unconscious and pre-conscious wishes and thoughts between the two poles?

After the felt betrayals/abandonments by Sunil and Jesse, Paul says he is leaving his work as a therapist and leaving his therapy with Adele in order to move outward toward life and real relationships. Do we accept at face value what Paul is saying, or is he not also trying to lure Adele into a personal relationship in which she would rescue him from dealing (in treatment) with his own loneliness and despair? Another possibility is that it is not clear whether he is telling himself and Adele the whole truth (that is, whether his nihilism is all there is) or whether he is simply feeling and stating one side of his conflict fully: his disappointment and sense of failure/futility. As Adele reminds him, at one moment he felt as if his future would be foreshortened by Parkinson’s and he could plan on dying soon; now he speaks of a future10-20 years in front of him as if he had never felt without a future at all. Might not Paul appear in Adele’s office on another day feeling certain that he wants to continue his work as a therapist, that he values the clarity and intelligence Adele has to offer him as his therapist, and that he wants to become able to really love someone? Couldn’t all these statements be true but different aspects of Paul’s deeply divided self?

While Freud’s late-life pessimism about the value of psychoanalysis in effecting character change is sobering, I couldn’t agree more with the words of gratitude offered Freud by one of his psychoanalytic patients, Lou Andreas-Salomé, about the value of this special endeavor: "No other relationship can come close in quality to that between analyst and patient. Nothing else provides such deep understanding of humanity, and so convincingly asserts the dignity of the individual."

In that spirit, I imagine that Paul can get his groove back, ultimately returning to his therapy with Adele (maybe increasing the frequency of sessions and making it a thorough-going psychoanalysis) in order to make sense of his ambivalence, understand his human imperfections and illuminate his self-deceptions. Then he would return to a valued clinical practice with the full benefit of all his experience, empathy and insight, only less encumbered by his own neurotic conflicts.

I can hear the very thoughtful and talented ‘In Treatment’ actors, writers, consultants and producers complaining that my scenario won’t make for compelling edge-of-the-seat drama, but then I’m a psychoanalyst/psychotherapist first, a writer second. And anyway, a gal can wish, can’t she?

With thanks to all the dedicated people who bring us this incredible series,
Here’s wishing for more seasons of ‘In Treatment’!

Randy Paulsen, MD

Adele is my new female Odysseus. Having strapped herself to her own mast, she manages to sail past Paul’s Siren calls and not crash on his rocks. Sorry for the metaphor; I’m writing on a deadline. Paul as Siren, pulls out all the stops. He ends therapy. “I’m not coming back. I can’t.” And then he asks her one more time, “do you ever think about us?” He says she can answer now; he’s not in treatment any more - 10 seconds after he quit. All there is then, that we can see, is silence, Paul and Adele directly gazing at each other, in silence. What we can’t see, but only imagine, is that something is settling in Paul’s mind, something that enables him to say, “You are a good therapist.” And then those smiles from both of them. Still, for now, he must stop. She says, “my door is always open to you.” The good-luck-farewell handshake. His hand between her two hands. And he leaves.

The episode doesn’t end there. It shows Paul, perhaps the way he is now in the world, coming out onto the sidewalk, somewhat self contained, walking toward us. Then he comes to a crossing, and with great subtlety it is clear that he doesn’t know which way to go. He makes a half step forward, then turns and walks away from us, politely, ambling in a slight zig zag, slowly walking away. What is going on in your head, Paul? How lost are you? Speaking as a therapist, there is that time after many sessions (we’ve seen Paul looking out his window or putting his head in his hands) where you have to, as I say sometimes, let the patient take himself into his own hands. Speaking as a patient, there is a time after a session, when you re-enter your own life, perhaps taking a walk, or pausing in the car, letting yourself sense what is happening inside, what is the echo, what are the feelings. The way this session ends gives us all a taste of that transitional time, from both perspectives.

So, again, I have a few themes:

1. The value of a good question.

Paul has started his last session with Adele in full blaming battle mode. Sunil has been deported because Adele made Paul call Julia. He is angry, belittling, projecting and unaware of what he is saying. Daniel Goleman would say Paul has been “hijacked” by his emotional reactions. Adele keeps listening, and then asks, “if returning to Calcutta was what he wanted, why are you upset?” This simple question, formed out of close listening, stops Paul, momentarily in his tracks. That’s the point of a good question: to stop the juggernaut of our reactions, to ask why, and to ask it at just the right moment. Suddenly a person actually hears what they have been saying, and may be confronted with the fact that, having been stopped, they may not know why they are saying it. Why, indeed. The answer is not automatic.

2. The stages of idealization.

Adele is younger than Paul, closer to her training, more newly minted as a psychotherapist. She takes his words about “freeing himself” from Wendy, and makes them into a plan for his future. Making an interpretation, she says to him, “you have sought relationships that are safe, where the risk to you emotionally is a small one …. they’re all substitutes of a kind, allowing you to avoid actually engaging in the world experiencing life in any real way.” We can hear Paul describing his job to Frances, “my job is to help you see yourself, and if you don’t like what you see, to help you change it.” It isn’t quite that neat. I’m not saying that Adele isn’t doing Big League work here. She is. But her description of the “work that lies ahead,” sounds idealized. It leads her to focus on the folly of Paul’s work, his boundary issues, and to ignore the bravery of it. Many people have been helped by Paul. He has been an Odysseus too, sitting on the steps with Jesse, accompanying Sunil to his forgotten bad neighborhood.

At one time, Paul, perhaps 20 years her senior, had a similar idealization of his profession. “I used to think you could say something clearly, and the other person would hear and digest that response.” But he’s been coloring outside the lines for a long time. He has worn himself out with his own effort. At his mid-life stage of disillusionment, it seems he needs her youthful reassertion of the ideal, the frame of their shared profession, in order to find himself.

3. The Bridges of Evasion, the Body and Reality.

Just after Adele asks Paul the bombshell question –is he thinking of closing his practice - he says, “you look more pregnant.” This is an evasion of a real question in search of another reality that begins with her body. It leads to a kind of musical bridge in which they talk about her due date, being a single mother, continuing with her practice after the birth, because she “wants to.” Her body, his body, in physical proximity. The desire and yearning are crackling in the air. She says the solution isn’t to “run away from this office.” But Paul is not sure he can keep up. He can’t tell “what is real.” He says, “you said ‘relationship,’ but it isn’t one!” The physical relationship is immediate. The psychological relationship takes time. It may be too simplistic to say that is why Paul needs to quit. But perhaps at base level, it’s true: he needs time.

We’ll see. We will all see, but in the meantime thank you, Gabriel Byrne, Amy Ryan, Anya Epstein, Dan Futterman et al. It has been such a pleasure.

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