Talk Therapy: Frances - Week 5: Ep 96

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

Have you ever marveled, as I have, at how Paul can be so gentle and empathic with some patients and so brutal and even bullying with others? In Season 1, Paul was so careful and attentive and, yes, loving to Sophie, and even to Jake once Paul saw the vulnerability beneath Jake's bullying. Remember Paul's moving treatment of Oliver in Season 2, and also his deeply caring moments with April and with Walter, and let's add Mia to this list in their final session last season. Until this week's encounter with Sunil, we could also mention his name.

But not Frances. What is it about Frances? One commenter on the In Treatment Facebook page (which we three writing here do follow) noted that Frances and Paul seem to have the most in common. In my comments last week, I mentioned that both of them were struggling with issues of identity, namely, is there a there there?

In this clip, Paul makes what many of would see as a rookie error for a therapist. He is certain, absolutely certain, that he knows what the best course of action is for Frances, namely, to go see her sister Trish before Trish dies. He is certain that Francs has no reason left not to see her since the test results for the breast cancer gene were negative. He is certain that Trish will be very glad to see Frances. And he is certain that if Frances doesn't go, she will always regret it.

Quite a lot of certainty for a therapist who has not really examined with the patient what forces might be at play beyond the important ones he has already examined with her. Yes, she has a hard time seeing her family members ill and aging. Yes, she is angry with her sister for judging her for the shallow way she has lived her life. Yes, she is angry at Izzy and at Trish for the bond they have formed, supplanting her bond with Izzy. Yes, she is angry with Paul for seeming more concerned about Trish than about her: she's the one who's dying, not you, inappropriately shouts Paul. And maybe she is angry at Paul for loving Trish and not loving her. Doesn't Frances relish the moment when she tells an uncomfortable Paul she had sex with the 25 year old Eduardo who relished her breasts! Take that, Paul.

We have to hope that Paul's pressuring of Frances is not fueled by his anger at her for acting out her impulses rather than reflecting on them. What is more likely is that Paul is driven by three less conscious forces. First, as I recall, in Season 2 Gina encouraged Paul to visit his dying father so that he wouldn't regret it, and indeed, this was an important moment in Paul's life. Second, Adele has been encouraging Paul to speak with his son, Max, both about Max's anxieties regarding Paul's health and also Max's relationship with almost-stepfather, Steve, toward whom Paul feels the jealousy that Frances feels toward daughter-stealing sister, Trish. Finally, isn't it possible that Paul was actually in love with Trish 20 years ago.? As we can see through the lens of ex-wife Kate, of Laura, of Mia, of Wendy, of Adele, and who knows about Gina twenty years earlier, it doesn't take a lot to have Paul fall in love.

Rachel Seidel,MD

In one of my favorite childhood TV shows, ‘I Love Lucy,' Lucy was forever scheming and then acting as naïve as a puppy who had stepped into buckets of paint. Getting wise to her schemes, Lucy's equally comical Cuban husband, Ricky, used to chide his hapless wife: "Lucy, you got a lot a ‘splainin' to do!"

In theories of psychoanalytic psychotherapy, some think that an important function of the therapist is to keep what is sometimes called analytic "neutrality," a concept that is enlivened by plenty of professional controversy. The essence of that controversy is best posed as a question: Can a therapist stay "neutral" and still be genuinely involved with her patient? It depends, of course, on what we mean by "neutral"-that is, within the clinical situation, neutral to what?

One possible answer is that the "neutral" therapist is not at all indifferent to her patient, but attempts to avoid aligning herself with any one side of a patient's conflict, thereby ignoring others. Under the best of circumstances, when the therapist does inevitably break neutrality, it is with a heightened awareness of her motives for recognizing and addressing only certain aspects of the patient's internal conflict, and with an understanding of the influence of breaking neutrality on the direction of the treatment.

With this concept in mind, we may wish to nettle our very human therapist: Paul Weston, we might remonstrate, you got a lot a ‘splainin' to do! In your treatment of Frances, what's happened to your analytic neutrality?

Let's take a brief look at Paul's difficulties staying neutral with regard to Frances' conflicts during her session, week 5 of season 3.

Even during the prologue, Paul's neutrality is compromised. Experiencing anxiety at the beginning of her session, Frances razzes Paul about how long he would sit there silently if she herself didn't speak. He answers her questions, reassures her and uses humor to diminish her anxiety, while not expressing any curiosity about what the silence is like for her, what Frances feels, what or whom it reminds her of, what it might be difficult for her to say.

This episode continues to be full of further examples. Paul calls Frances on the carpet for not yet reading her BRCA test results. Upon learning that the results are negative, he assumes this news must be a relief to her. While relief might be one expectable feeling, I can think of other psychic realities, such as the survivor guilt Frances ultimately acknowledges: She feels terribly guilty that she will continue to live even as her sister is so near death. Then, without inquiring about the mixed feelings that Paul understands Frances might have, or even attending to Frances' defenses, Paul hounds Frances that she must visit her dying sister. We viewers join Frances in trying to understand what is driving Paul. Is Frances on to something when she asks whether he's still in love with Trisha? We see a fleeting reaction on his face; perhaps it is so. And perhaps Paul's own fears of illness and death also contribute to this glaring blind spot- his conducting Frances' treatment with such inattention to analytic neutrality.

Randy Paulsen, MD

There are many times in psychotherapy when the patient is unwilling, and/or unable, to look at themselves. What is therapy like then? These several minutes between Frances and Paul show us what it is like. It's like a wrestling match between two realities, two agendas. The combatants are using whatever they can get their hands on to fend off the other, to make the other see it his or her way, to throw sand in the face, change the subject, to say things in order to have an effect on the other, rather than to say things that can help them communicate or explore.

Paul has an agenda that Frances should see her sister before the sister dies. Because there is very little reflective capacity in this dialogue, because it sounds like Patricia (the sister) is in a very advanced stage with her cancer, he is not saying, "let's think about this," he is saying, "you need to see your sister before she dies." Paul wants action. He pulls out all the stops. He even says, "knowing what I know about her, she (Patricia) will be pleased." Patricia had been Paul's patient many years ago. He is so invested in this outcome, that he's willing to trample over a boundary by using his own knowledge of Patricia to counter Frances' different conviction. Paul thinks Patricia will be pleased to hear from Frances. Frances does not. Another urgency for Paul remains unstated in this clip. He is remembering that he did not see his Father before he died. He carries that regret in him and is trying his damndest to prevent Frances from repeating his own mistake. What happens in this clip is a fundamental principle taught in all schools of psychotherapy: if you don't explore the patient's resistance to the issue (seeing her sister), you just increase the patient's reluctance. Paul hasn't yet gotten Frances to take the risk to talk about her terror, her aversion, her refusal to see her sister. We don't know what Frances is feeling about that unvisited visit.

Because Paul has gone to the lengths of telling Frances how he thinks Patricia will react, Frances asks, "what the hell happened between the two of you anyway? The way you talk about her, it's like you're still in love with her." Words can invite consciousness, like a window, or they can attempt to destroy consciousness, like a stone. These words between Paul and Frances are stones thrown through windows.

"She thinks you were in love with her."
He says, "No." 
"Well then she's deluded," she says.
"You're so angry with your sister..." 
"....It will kill me." 
"She's the one who is dying. It is not going to kill you."
And finally, "if you don't do it now, you'll always regret it." 
Door slam. Exit stage right.

Hopefully, Paul and Frances will have all this to talk about in their next session. They have acted out, enacted we say, a whole tableau of agony, fear and unconsciousness. Enactments are necessary. This one was necessary. Now they will have this recent scene to talk about next time, like an audience Talk Back after an Albee play.

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