Talk Therapy: Jesse - Week 4: Ep 93

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 three experts (read their bios) 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

To be candid, my first reaction to this episode was to be underwhelmed. It looked a lot like excellent but everyday psychotherapy, rather than featuring the more dramatic interventions Paul has made in the past with his younger patients including Sophie, April, and Oliver.  When I looked at it again, however, my attention was drawn to Jesse's statement near the end of the episode, the last 5 minutes of which we are looking at here.  Jesse says, "I kinda feel like it's all gonna be okay for some reason. I don't know why"  What is that reason? 

Just moments before, Jesse challenges Paul's theory that Jesse's mother has rejected Catholicism because of its objectionable stance toward gay people, and he calls the theory "horseshit."  How did he get from "horseshit" to "it's all gonna be okay"?  What is Paul's magic, if you will, with adolescents?

In this brief clip, what we can see is how Paul creates a safe space for Jesse with his demeanor and just a few comments. When Paul names the "incredible amount of pressure" Jesse is facing, he does so in a deeply empathic way, clearly felt by Jesse. Jesse is soon frustrated with Paul's acknowledgement -- of what Jesse first noticed -- that Jesse's handwriting is like that of his biological father. Paul doesn't waver, however, and tells Jesse, yes, I want to know how you feel about this.  Paul then makes a series of marvelous interventions that articulate Jesse's profound ambivalence about contacting his birth parents: to contact them risks losing the love of his adoptive father, Roberto, who is now clearly expressing that caring; to not contact them risks losing the connection with his biological parents which is now so tantalizingly close.  Perhaps to protect himself against the painful truth of Paul's theory, Jesse rejects Paul's last theory that Marisa, Paul's adoptive mother, rejected Catholicism. Paul is unswerving. He suggests, again empathically, that Marisa's connection to Jesse is real and that she may be fearful of having it slip away. 

Finally, Paul says that both he and Jesse should think, between sessions, about how Jesse might respond to his birth parents "if that's what you want to do," underlining Jesse's right to a choice. It is at this point that Jesse says he feels like things are going to turn out okay. And Jesse's experience of safety with Paul is so complete that he asks Paul to hold the letters that spell out Jesse's  ambivalence -- Jesse's letter rejecting his biological parents, and their letter yearning for connection.  Paul has created, and the writers have symbolized, what we call a "holding environment" for Jesse.  For all of his many issues, this is Paul's gift.

Rachel Seidel, MD  

The closing minutes of this episode are bookended by two statements, beginning with Paul's empathy for Jesse and closing with Jesse's wishful remark, "I kinda feel like it's all gonna be okay."

One way I understand this segment is as a dramatization of a turning point, a triumph, in Jesse's adolescent development, in his capacity to contain his own anxiety and affects, and in the growing closeness between Jesse and Paul.

Prior to this episode, we have been seeing Jesse in his most peppery, acting-out adolescent best form: surprising Paul with a camera flash at the door, using expletives and graphic language meant to shock Paul, taunting and frightening Paul with his sexual activity and risky behaviors, and sinisterly forecasting a dire future for Paul's son. We see how deeply Jesse's actions and words disturb Paul and leave him feeling (empathically) some of Jesse's feelings of worthlessness, helplessness and fury. Nevertheless, Paul stays with him, keeps trying to be of use and doesn't throw him out (as Jesse, feeling unlovable, expects).

In the 3rd episode, Paul underscores how stalwart, self-sacrificing and loving Jesse's adoptive mother has been. Even after Jesse heaps so much scorn and provocation upon her that she flees the room, we see at the end that she has not abandoned Jesse, but that she has withstood his attack on her and sits waiting for him, in her depressive but persistent way.

In parallel, there has been a huge leap in the development of another pair: Max and Paul. Paul has been worrying that he will lose his son. We learn (at the beginning of Frances week 4) from Max's sister, Rosie, that Max has been developing a relationship with his mother's new man, Steve, with whom he shares an interest in art. Through the mediation of Rosie, Paul seems to entertain the thought that Max can truly love him and want to live with him, and still wish to get close to Steve; that it is not either/or, that Paul won't lose Max as a consequence, that everything might be OK.

It is Jesse's realization that his adoptive mother will stick by him, and the closeness he has re-found with his adoptive father, as well as Jesse's growing trust of and containment by Paul, that permit Jesse to express the thought that everything will be OK. I hear this wish as a representation of one aspect of his expanding sense of self -- a relaxed, secure and optimistic self-state, because he is able to imagine feeling that he, within the "holding environment" created by two sets of parents and Paul in his life, will be OK after all; on another level, I believe he is saying that his therapy is going OK, too.

I suspect that Jesse's stormy adolescence and the vicissitudes of working through the complexity of having two sets of parents and parental identifications is not over. Perhaps this episode is the lull before another storm. It affords us a brief but welcome resting place from which to appreciate Jesse's developmental accomplishment and the significant developmental help Paul has given him, as is symbolized by the two letters (two sets of parents, ambivalent feelings for both) Jesse gives Paul to "hold" for him.

Randy Paulsen, MD

Paul's statement to Jesse, "you must be feeling an incredible amount of pressure right now," comes at the end of an engaged, working therapy session.  In front of our eyes they are both working on behalf of Jesse's growth and understanding.  They are now beginning to share a common language.  Jesse's head is in his hands and Paul asks, "how's the static?"  He has remembered, and Jesse knows he has, that word "static" from the last week's session.  It was Jesse's word for what's in his head when he's overwhelmed.  Now it's a word in their conjoined therapeutic dictionary.

Just before this, Jesse asks Paul, "would you have wanted a son like me?"  Paul says "yes."  There is a pause.  "Give your son another couple of years," says Jesse, but it is clear that Paul cares about Jesse, as it has become clear that Roberto cares about his adopted son.  "Awesome," was how Jesse said it felt when Roberto got enraged at the birth-mother's, Karen's, phone call.  Even at the very beginning of this episode, when Paul sneezes, Jesse asks, "are you alright, man?"  There's a ground of acceptance and caring that now underlies all that happens in this scene.  Whether it was threatening to throw Paul's son's bronzed shoes through the window, or talking trash to his mother, the limits have been tested, Jesse feels safe to explore his own riotous feelings now, as feelings.  This is why providing limits in therapy, perhaps particularly with teens, is so important.  They don't know all their molten innards, and somehow, unconsciously, implicitly they need a demonstration that the Other (father, mother, therapist) can survive and contain them, and what comes out of them.  "My math exam went through the machine, like zip."

Jesse discovers that his left-handed writing is like his biological father's.  Perhaps, in the recesses of Paul's mind, he clicks into his own fears of the biological inheritance from his father.   He doesn't disclose this to confuse Jesse's exploration -- "you tell me, because it's a unique experience, and I want to understand."  But this "overlap" lends real energy to the empathy with which Paul can listen.  And from this place, Paul is able to say things that appear very clarifying to the listening Jesse:  part of you is interested in a relationship with your birth parent; this reaction from Roberto, that he cares, is something you've been looking for all your life; you're afraid you'll lose Roberto and Marisa's love if you accept some contact with Karen and Kevin; and you feel you'll gain/keep their love if you reject Kevin and Karen.

After listening to that, Jesse asserts that Paul's theory about Marisa's religion was "horseshit."  There's a kind of back and forth in therapy between a self that takes in new information from the therapist, and the self that asserts itself as the captain of its own experience.  It could be seen as resistance in the service of self growth -- kind of a healthy, "you don't know everything."  It happens again after Paul mentions that Marisa might be praying in the closet because she's afraid of losing Jesse.  Jesse takes that in, but then changes the focus to, "I wonder what their house looks like." 

So, if you accept that building a working therapeutic alliance is like creating a good enough ship, that can hold the passengers safely, can sail into the worst storms, then it is clear that when Jesse says, "I think it's going to turn out all right," he's talking about the ship of their therapy.

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