Talk Therapy: Sunil - Week 5: Ep 95

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

Hello, again. In working to a deadline last week, I didn't get to say that Randy, Rachel and I are delighted to have been asked to share our impressions with you. Here we are again. Also, I encourage you to join our conversation by logging in and commenting, below.

"Sometimes there's something primal or animalistic that dreams allow us to express." I'll say.

Well, this episode leaves me pretty worried about Sunil. And Julia also. And about Paul's ability to contain and stabilize Sunil before something dire occurs. Paul is obviously worried as well.

Therapists always have to assess issues of safety and danger although, fortunately, most patients demonstrate enough stability and control that we don't have to worry. In this clip, there are several markers that would raise the therapist's heartbeat, however.

Sunil's dream last week was disturbing, both to Sunil and to the viewer. This week's dream, and his associations to it, are more alarming. It's not just the content of the dream, however, even with the troubling images of an unconscious Arun on the street, fearful children, thick black trees, a frightening woman, an arm pulled off to protect the children, or Sunil's in-dream experience that he could "hurt this woman very much."

Therapists listen to dream content, of course. But any of us can dream anything about anyone and it doesn't mean we're dangerous or desirous. We also listen to how people talk about the dream. For example, after Paul asks a few questions, but mentions the possibility that Sunil's first lover, Malini, might have appeared in the dream, Sunil says he no longer wants to discuss the dream because he sees no point. Why this reluctance?

Paul presses just a little, referring to the expression of primal ideas that dreams allow. This pushes Sunil to the brink, and he exclaims something in Bengali, the content of which is important, but the very fact that he had the powerful urge, and that he gave in to this urge, to speak in a language the therapist could not understand, suggests a momentary loss of contact with the social conventions of the moment. (Let alone the possibility that he is actually speaking to a hallucinated figure. Kamala? Malini?)

This is no small thing. In therapy, we want people to feel safe enough to share underlying fears, shameful fantasies, and guilty desires, for example. But we want them to maintain contact with the fact that they're sharing them with us, rather than exclaiming them in the shower to themselves. Sunil loses contact with that reality.

"A man can only be pushed so far," he says, signaling to Paul that great care needs now to be taken. Sensing that the context of the dream is also meaningful here, Paul asks Sunil what he did upon awaking from the dream and Sunil discloses that, after checking on the children, he checked to see if Julia's door was locked! He utters a phrase which is of the same ilk as his breaking into Bengali earlier in this clip: I could not resist. Now we are all worried.

We have a patient who has mentioned his wish that Julia, his daughter-in-law disappear, who has revealed a wish to smother her laughing (laughing at him with her presumed lover, Mr. Pale Fox), and about whom he cannot stop thinking.

Yes, I'm worried. Right about now, Paul needs to be thinking if he needs to take action. If Paul is worried that Sunil is at imminent risk of harming himself or Julia, he has a duty to take action. The risk of taking such action, however, (e.g., calling Julia to warn her, or calling the police, or hospitalizing Sunil) could destroy the therapy forever. (Remember Season 2 when this was an issue with Walter?) Safety comes first, however. What I might have done is insist to Sunil that he return the next day-at no charge if he resists as he does because Sunil doesn't want to cause his son and Julia more financial hardship. I would tell him, too, that I was going to contact Arun and Julia to let them know that Sunil was experiencing great stress currently, and if they noticed anything at all that concerned them, however minor, they should contact me.

Sunil gives Paul somewhat different advice as the session ends. He asks Paul to pray.

Rachel Seidel, MD

There is a New Yorker cartoon I love: A man is opening a door marked "In" and stepping into a small vestibule only to face yet another door, this one marked with the sign, "In Deeper."

In week 5, all the characters are getting "in deeper" in many ways, as are we along with them. How does a psychotherapist or psychoanalyst come to understand and feel the depths of a person's distress? What do we think and feel, say and/or do once the door into a person's hidden thoughts and feelings has opened and we have gone deeper? I will offer a few vignettes about how this works (and how it doesn't) between Sunil and Paul during this episode.

Paul has little time to assess how his patient is faring. He must draw on what he observes, what he hears when he listens to Sunil and, importantly for a therapist, to the information he can glean by observing his own thoughts and feelings, fantasies and fears as they arise in the encounter with Sunil. Some think that this capacity to self-observe and self-analyze-a skill that is especially challenged in the midst of an intense session with a patient who is possibly unraveling-is really at the heart of what makes a superlative psychotherapist or psychoanalyst.

From the opening moments of this episode, we feel Sunil's growing dis-ease. He relates that a monsoon has flooded an entire village; thousands are dead. Sunil can't sleep; he keeps seeing an image of a boy in the floodwater, his eyes pleading. Moreover, there is static on the radio and little news of the disaster. These words serve as a red flag to Paul since he would understand them to represent something about Sunil's self-state: inundated, overwhelmed, feeling as helpless as a child, encountering interference (static) in his ability to think and communicate clearly. Partly out of empathy, partly due to his own concerns about his work, Paul becomes more anxious.

Sunil's agitation and irritability, his sense of futility and hopelessness, alienation and disconnection, rage and distrustfulness are all expressed by his body language as well as by his words. (Isn't Irrfan Khan a wonder at creating this for us?) Sunil moves physically further away from Paul and lights a cigarette, partly emblematic of wishing emotional distance and some smoke to hide behind. We feel that Paul-out of an empathic identification, and due to his concern for Sunil-gets more worried about the state of their therapeutic relationship and we worry about it, too. Having no time to think, Paul is grasping for a way to connect with Sunil so that together they can build a raft that can weather the flood, a solid alliance that would allow them to observe and learn about emotions without feeling inundated by them or compelled toward action.

Increasingly unable to tolerate his own anxiety, Paul makes suggestions to Sunil about getting a job and moving into his own apartment, then reveals more about himself and his own family. Sunil is not buying in; he doesn't want what Paul has to offer. The gap between them widens. 

Sunil has unshakeable suspicions about Julia that seem to have grown to delusional proportions. Sunil wants to "smother" her laughter, wishes that Julia would "simply disappear." Sunil notices Paul's alarm and says that he is only trying to express himself with Paul. Can Paul believe Sunil when his own anxiety signals to him that this may be a smokescreen? Sunil reports that he has had another disturbing dream. More smoke? Paul grimaces, understandably seeming to feel conflicted about whether or not to attempt dream interpretation when members of Sunil's family may be in very real danger.

By this point in this extraordinary episode, I think we all feel the pressure of Paul running out of time. Some therapists might invoke the mandated duty to break the therapeutic golden rule of patient confidentiality by warning Julia and Arun of the threat to their safety, or by calling the police. By so doing, they would likely cause a rupture in the treatment that would be very difficult to repair.

Paul is a stalwart psychoanalytic psychotherapist, for better or worse still trying to understand Sunil. Paul lifts his teacup and asks whether Sunil wants to tell him about the dream. He offers Sunil the chance to increase the frequency of his sessions so they can deepen their understanding.

Did Paul make good choices? Tell us what you think.

Randy Paulsen, MD

There are times when I tell my students, and my patients, that therapy should come with a warning on the label. This exchange between Sunil and Paul has many of the qualities that would be described on that label: it can bring up things you had buried, can invite dreams to appear more vividly, it can cause emotional upheavals and flooding, and it can make you feel less in control of yourself. Therapy can seem to be making a person sicker. But, over and over again, it appears that when patients come in with great suffering, as Sunil did in the first session, they may need to get worse before they can get better. Please excuse the surgical metaphor. His suffering could be likened to an abscess. It needs to be cut into, so the pus can drain out, and healing can occur. It is a distressing scene to witness, and it tests the skill of the therapist to manage the flooding, the descent, the disorganization, so that the patient can survive and the treatment can actually provide a healing outcome.

Just before this clip begins, Sunil has turned away from discussing a disturbing dream in which his son lies apparently dead on the road, a child watching in fear from the window. In the dream Sunil has pulled the son's arm off, "like heavy plaster," and is preparing to defend the children by clubbing a dark woman coming out of the forest. Paul asks, "can I ask why?" and then goes for the psychological incision with the comment, "sometimes there's something primal or animalistic that dreams allow us to express, that our conscious mind is ..." This causes an outburst from Sunil in his mother tongue, Bengali. In psychoanalytic language, we would call this regression, a going back to earlier states, to his roots, his native self. As another part of Paul's effort to help Sunil, he had made a link to the dark woman, who had a flower in her hair, like the El Greco painting which Sunil and his clandestine lover, Malini, had admired on an early date. When Sunil says, "I would never think of harming Malini," he has descended into his own Inferno, his unconscious where cause and effect, wish and fear, impulse and restraint all roil about. His sense of being accused of harming Malini has not come from Paul, but from some dark place within himself. 

When Sunil, says "we don't have to talk about that now," he bursts into more outcries in Bengali and cries, "you have no idea what my life has been." Paul wants to know. He knows Sunil both does and does not want him to know. He then begins to close the wound by asking what Sunil did when he awoke from the dream. "Checked on the children, and went to see if Julia's door was in fact locked." When Paul then asks what would Sunil have done if the door were open, he is, perhaps assessing risk. Putting all this turmoil into words, into consciousness, can in the long run help a person be more in control, more balanced. But in the short run, the good therapist doesn't want a distraught person to act out in disastrous ways. Sunil then says, "I thought of calling you." Paul invites him to do just that next time he is that distressed. They speak of more frequent sessions, not because Sunil is going crazy, but because he could use the support in this most hazardous, warning-labeled phase of his treatment.

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