Talk Therapy: Adele - Week 5: Ep 98

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

This is a great episode. Hats off to Executive Producers/Writers Anya Epstein and Dan Futterman and to the psychiatric consultant, Justin Richardson, for a brilliant portrayal of the bristling tension that can exist in therapy and that can result in a therapist (almost) losing it. To my ear, not a false note in this session. (Indeed, the only false note this season that caused me to sit up occurred last week in the session with Jesse when Paul asked Jesse if Jesse had told Roberto that Nate was "fellating you." Not a chance that Paul would stumble over this. If you can't say "blow job," let alone even more graphic language, then working with adolescents may not be for you.)

Boundaries, boundaries, boundaries. They are meant to protect the patient, and they are also meant to protect us. This is a long lecture, not a blog commentary, but boundaries are critical to psychotherapy. This clip begins with Paul stating cavalierly "I actually have a practice where I routinely go five or ten minutes over if it's necessary." He's contrasting himself with Adele who has ended the session at precisely 5:50pm, or at least, has tried to end it, which Paul finds intolerable. Indeed, he sees this as "so f**king rigid." This is the Paul we know so well. The same Paul who has tea with Sunil (which actually might be a good thing); the Paul who discloses to Frances that he has had similar problems with his daughter; the Paul who sees a distraught Jesse at 10:23pm earlier this week (another good thing given the situation). But Paul seems to have a rationale for everything. For (almost) sleeping with Laura, for accepting the coffee maker from Alex, for taking April to the hospital for her cancer treatment, for making Oliver a sandwich or following him to the playground. He's got the good, the bad, and the ugly covered, doesn't he?

In this session, though, he meets a therapist who says: No more. Gina tried, but she was so deeply involved in acting out her own issues that her ability to help him was compromised from the jump.

Adele makes, to my mind, a breathtaking, and also "correct," if you will, interpretation of Paul's behavior in this clip. She says that Paul engages in emotional cartwheels while throwing sand in her face to avoid actually sitting still to be a patient. She tells Paul that he is deeply afraid and that he does anything he can "to push our relationship beyond its prescribed time and purpose. You ask me to be your colleague, your supervisor, your life partner, anything except for what you came to me for, to be your therapist, to get me to challenge you, to look at yourself."

I think Adele is right. And she holds her ground beautifully, even after Paul mocks her by repeating, "5:53! 5:53!" -- an ending boundary, it will not have escaped your notice, she actually does not uphold because of precisely the kind of pressuring interactional process that can occur in such emotionally charged situations. It is then that we therapists behave other than we would like to. Fortunately, we can then examine ourselves, offline, and bring what we understand back to the treatment in the service of the patient.

But I have a different interpretation, not more right than Adele's but one which might explain Paul as well.

I have been commenting in my remarks of the past two weeks on the parallels between Paul's life and experiences and those of his patients. Some of these parallels allow Paul to see deeply into the other and make interventions that are nothing short of "wow! Who is this guy?" We know that Paul can readily tap into these parts of his experience as a therapist yet simultaneously be unaware of himself in his own therapy with Gina and with Adele. Remember when Gina said to him last season, after telling him he was acting like an asshole, "you're a therapist who has remarkably little insight into your own behavior. You are so self-absorbed. You are so entitled." What I think that Gina might have missed and also what Adele doesn't yet see, is that Paul actually does not have a clear sense of identity. Paul lacks (jargon alert...) a cohesive sense of self so that he can so readily merge with the experience of many of his patients because of the overlap between an aspect of the patient and an aspect of himself which is called forth in the treatment. This explains why Paul can so readily feel the experience of the other and yet not be aware that he is feeling it with his own personal tendrils. It explains why he can fall for Laura without realizing the almost-clichéd process occurring, and that he can fall for Adele in like fashion. Paul has a profound yearning but does not realize that it is not really a self-defining yearning. He wants so desperately to feel defined, he gives in to the yearning in the moment. Remember just last week when Paul said, "I seek out people who have themselves a passion for life and I feed off them instead. I allow them to feel for both of us." Paul's therapy needs to be about his identity.

Rachel Seidel, MD

One reason that ‘In Treatment' makes for such compelling drama is its disciplined narrative structure. Now I admit that the words "discipline" and "structure" sound neither compelling nor very dramatic, but I hope you'll stay with me while I explain: Each episode of ‘In Treatment' adheres to the Three Unities of classical Greek drama described in Aristotle's ‘Poetics': Unity of place (most everything takes place in either Paul's or Adele's offices), Unity of time (the length of one compressed therapy session) and Unity of action (the patient's therapy).

Now, this is where the compelling drama part comes in: Within the confines of this strict scaffolding, almost anything can happen-and usually does, either through actions or through word-actions. You might even say that the disciplined structure is exactly what permits anything within it to be said or to happen. That is, we-the audience-know that whatever happens, after the play has engaged our hearts and minds and perhaps resulted in a catharsis or insight, the drama always resolves and ends one way or another at the appropriate time. Our heart rates can return to normal, and we are able to resume our lives.

As you most likely have already understood, I am talking about psychoanalytic psychotherapy, too, where a strong, clear frame (or "boundaries," as it's sometimes called) can and-in my experience, under good circumstances-does create the safety that permits the greatest imaginable freedom of expression of feelings and thoughts of all kinds. This paradoxical tension and all that can be learned and understood by maintaining it is one of the reasons I so love my work.

It seems that the frame is also a high priority to Adele. I will use a very small part of this complicated and rich episode to illustrate why maintaining the frame is of such importance to Adele, to me, and to most psychoanalytic psychotherapists.

We see that Paul has quickly surrendered to transference wishes and fantasies of an unboundaried relationship with Adele-a relationship in which she is his therapist, supervisor, lover, partner, and even caretaking mother.

As a therapist, Paul is familiar with the phenomenon of transference, but the power of his wish is so compelling, surely this time, he imagines, somehow, someplace else, it really could be something more. In Paul's fantasy, Adele will be the queen enthroned where Gina once reigned. In my reverie, I imagine that Paul's mother is the original queen of his childhood daydreams, the mother who was unattainable in so many ways, primarily because she belonged to his father, partly because of her depression, and finally through her death by suicide when Paul was about 17 years old.

During this superbly written episode with stellar performances by Gabrielle Byrne and Amy Ryan, able Adele struggles mightily, against persistent opposition, to maintain the analytic frame that allows Paul to give expression to his wishes, even to reveal his unconscious conflicts, by his use of a double negative: "It's impossible that we could never be together," Paul confesses. Adele is attuned, hears the conflict and reflects it back to Paul, "impossible that we could never...." Paul feels exposed, he has been understood all too well and he stops himself: "There's no way it could happen."

Adele uses this special moment as an opportunity for clarification: She wonders if it is just this impossibility-Paul's certainty that it wouldn't happen-that allows him to contemplate his wish. "Does it feel safer," she adds, "within the confines of a therapist's allow yourself to engage in, to imagine, a personal relationship?"

I think Adele is right on target, and on one level, Paul may even be able to hear her, while on another level, Paul is still driven by the power of his unconscious wishes to continue to penetrate or even to trample the very boundaries that offer him the opportunity to explore and create a different and more durable kind of freedom.

Randy Paulsen, MD

After the harrowing week he had with Sunil, Frances and Jesse, I imagined that Paul would really be looking forward to this session with Adele. I suppose he was, but it confuses me when he tells her, "You haven't really been on my radar." Paul further confounds me when he says that Adele is the only person he is looking forward to seeing in Brooklyn. Prior to this clip, Paul has virtually proposed to Adele. He says he knows they both know about transference, but maybe this is more. "We could make each other happy." I found him to be very faux, very unreal at that moment. It is clear from watching these beautifully written and acted scenes, that Paul does have feelings about Adele. But he jumps to a conclusion as to what those feelings are; a conclusion without really inquiring into his feelings. He decides this is love. They should drink a glass of wine and talk cases in the sunset. This is what we would call transference as a resistance to psychoanalytic psychotherapy. 

It may not even be entirely accurate to call his proposal, or his "pronouncement" from the week before, transference. She has had an effect on him, gotten him to focus less on his practice life, and more on his relationship with his son, to focus less on the oppressive effects of his childhood and more on the way he holds himself back in his adult life. If we think of these projections as a cloud around him, she is dispelling some of that cloud - she is "shrinking" him. He has all kinds of feelings about Dr. Adele Saskia Brouse - angry, frightened, competitive and loving. In this pseudo-transferential ploy he is attempting to "consolidate his loans" as it were, to condense all his complex feelings into one proposed romantic fantasy.

Why do we make such a big deal about ending a session on time, about the whole framing boundary of a psychotherapy session? The stuff that the patient is most trying to avoid often emerges right at the boundary. The boundary in this case is time. "Why are you so f**king rigid?" Now that there is real feeling in the room, Adele has an opportunity to try to get through this amazingly thick wall (or wrought-iron fence) Paul surrounds himself with. He had not told his son Max about the negative work-up for Parkinson's until Max burned the pancakes in the frying pan. Adele now hits Paul over the head with a proverbial frying pan, "I don't think you realize just how paralyzed you have become." 

She lists all the ways he is thwarting himself, and her efforts to help him. She says, "I would really like to help you see your way through, but I cannot do it alone, and I will not do it past 5:50." The time may seem arbitrary but it is a crucial boundary to maintain at this point. Paul had wanted only romance to be between them. Now there is a whole gamut of feelings in the field between them. 

And time is not the only boundary that Adele has maintained. She aims to be his therapist, not his colleague or his lover. But she is right - she "cannot do it alone." Paul really has to join her in the effort to see himself more clearly, to get a little more out of his own way. She says again that they have to stop. He remains in his chair, stubbornly, forcing her to ask, "are you so paralyzed that you're unable to stand up?" Then he stands, "I'm standing, and I'm leaving." There is less than a foot of highly charged space between them. He leaves. She looks after him. Will he join her or not? He, Paul, will have to decide.

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