Talk Therapy: Week 6 - Sunil

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 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

When Sunil gives Paul the cricket bat, it's both an occasion for genuine worry on Paul's part but also a sign that the therapy has had a significant effect on Sunil. Paul says as much when he asserts that Julia and Arun are wrong to discontinue the therapy. How then can Paul see the therapy as helpful when his patient has just handed him a potentially lethal weapon? How can we?

It's precisely because Sunil gave Paul the bat.

What Paul has accomplished in just six weeks (allowing for the acceleration of the therapy process for dramatic purposes) is nothing short of remarkable. His patient, Sunil, is a displaced immigrant who is grieving over the loss of his wife, courting estrangement from his beloved son, and on the doorstep of committing violence against his daughter-in-law. And Sunil began as a very reluctant patient who had only negative associations to the therapy process and refused even to speak English at the beginning of the treatment. Now we have Sunil divulging, with clear anxiety in his voice, "I have no idea why my mind is seized with these terrible ideas." He then exposes his deep fear that there is something terribly wrong with him and seeks reassurance from Paul who at this moment, truly worried himself, cannot offer it.

What we know, however, is that Sunil has been gradually able to share with Paul, through dreams and through revelations, more of the thoughts that plague him and that have plagued him for many years. His willingness to share these potentially shameful and humiliating aspects of himself attest to the profound connection he has developed with Paul, a connection which may yet be called upon to save Julia's life, or so we hope.

Paul has built this connection with each word and gesture of empathic understanding, with each cigarette allowed, and with each cup of tea. In the first session, we may have thought, wait, Paul, don't stretch the boundary that far, we can now see how instrumental this has been in creating a safe space for Sunil to reveal more and more of what has been agitating him.

In our language, we call this connection the therapeutic alliance. Simply put: no alliance, no therapy. In prior seasons, Paul demonstrated his gift for fashioning a powerful, and therapeutically beneficial, alliance with virtually all of his patients, notably Sophie, Oliver, April, Walter, Mia, and this season, with Jesse and Sunil.

Sunil confirms this when he describes Paul earlier in this episode as a kind and wise-hearted man of whom he has come to think fondly. But he confirms it even more significantly by entrusting Paul with his dreams, with the story of Malini (more to come?), with his disclosures about how he views Julia – in this clip revealing his fantasy of striking her with the bat while she stares transfixed in her office, as well as revealing that he sneaks into the office at night uninvited. Sunil's disclosures to Paul are offered even though he knows they might give evidence that he is "crazy," that "something is seriously wrong with me."

This is the power of the alliance. To be willing to share shameful aspects of oneself, often for the first time, to a stranger, with the expectation that one will still be accepted and not judged. To be willing to hand over a cricket bat with the full knowledge that this might readily be seen as proof of potential danger as well as a sign that Sunil is, in his own language earlier in the session, mad.

Sunil trusts Paul and he is inviting Paul to trust him. It has been the very nature of this trust, the relentless belief Paul has in the alliance, that has stopped Paul from taking the kind of protective action I mentioned last week. Paul's conflict, which he brought to Adele last week, has been between taking this action, thereby risking the entire alliance, or continuing the treatment as is, thereby risking imminent harm to Julia.

With the cricket bat in Paul's hands, accompanied by Sunil's admission that he had imagined harming Julia with it, the danger has been diminished. But the risk of no action by Paul is too great. Especially with Sunil now having had the safety of the therapy office yanked from him, Paul needs to do something.

Randy Paulsen, MD

Many years ago, I used to be the director of a psychiatric in-patient unit. We used to have a "gun policy" when considering possible admissions. It may seem unimaginable in today's climate of rapid admissions, diagnoses and discharges, but in the 1980's, we had time to consider how to frame an admission so that safety could be assured while a person worked through impulses that might lead them to harm others or themselves. If there were firearms in the household, we would require the patient and family to check these weapons in with their local police, before we would schedule the admission. In this very moving and tense exchange, Sunil asks Paul to take his found cricket bat for him, and to keep it "safe" in his office. He is doing the same thing. He is removing the potential instrument of destruction from the all-too-easy access in his house. He is asking Paul to become an agent of his containment, to help him weather these "terrible ideas."

A patient in the throes of intense emotion, such as murderous feelings toward his daughter-in-law, needs help at the most basic level. He needs to be restrained from certain actions, while at the same time brought into more conscious awareness of his inner turmoil. Sunil asks, "Do you think there is something terribly wrong with me?" Sunil has moved from the nearly mute, depressed man in the first episode, to a person who is now "disturbing" Paul. This is another level on which he is asking for, needing, help. He needs Paul's mind to help him know his own mind. Sunil is in terra incognita. When he says, "you do?" he is registering that Paul is worried about him. What I love about the way Paul is working with Sunil is that he is not jumping to conclusions. He has accepted the cricket bat into his safe keeping. But this therapy, as any therapy with powerful emotions involved, is a controlled experiment. It has to be assessed whether it is safe to proceed, and how. Julia has jumped to a conclusion: it is the therapy that has made Sunil worse. It is the therapy that must be stopped.

I admire Paul's integrity in this session. When Sunil says, "Perhaps they were right to discontinue my therapy," Paul answers, "No, they weren't." But when Sunil begins to offer a Bengali saying about the impossibility of changing a person, Paul forcefully interrupts to ask if Sunil is listening to himself, understanding what he is saying. And here we have the crux of therapy stated: it is about change. It is about growth, about understanding, grieving, remembering and becoming less of a prisoner in one's own inner life. Sunil still appears to have some secret involving Malini that is hidden within himself, in some way still hidden from himself. And he is in an impossible situation in Julia and Arun's household. Forced to witness what he thinks is an affair that Julia is having with one of her writers, prevented from singing Bengali lullabies to his own grandchildren. Each week he comes in having digested some of what happened the week before. He has said to Paul that he was right about the dark woman in the dream being somehow related to Malini.

So why isn't Paul calling the police? Why is he offering to see Sunil at a lower fee? I think he sees that genuine therapy is happening. Sunil has turned in his cricket bat. He is promising Paul one more chance to help him. When Sunil says, "you told me to change myself. I'm trying to follow your advice," I would not be able to turn my back on him. There is evidence that he is changing, that he might be able to turn this corner.

Rachel Seidel, MD

Doctors are for life.

I mean that in three ways:

1. By our own histories and characters, as well as by our professional training, we doctors/therapists are for life, not death.

2. We are not for merely existing, but for living life more fully through understanding ourselves deeply, through creating meaning of the events that have shaped us.

3. In most cases, we therapists sign on to be available to our patients for as long as we both shall live. This is — as you can tell by my language — an enormous commitment, and an inherently complex responsibility. Having no crystal balls, being only human, we make this commitment at the beginning of therapy, for better or for worse, without knowledge of what will unfold over the course of treatment.

Treatment dilemmas, moreover, belong not solely to the therapist. Sometimes, as a family bears the brunt of a period of worsening symptoms in one of its members (the identified patient), the treatment itself is challenged from outside — as is Sunil's treatment, in this episode, by Julia and Arun. Paul and Sunil's work together — with its small but solid victories, and its potential for much good — has barely begun, Sunil starting to trust Paul to some degree. Embattled with Sunil, frightened for the safety of their children and — perhaps unable to look at their own role in his decline — Sunil's son and daughter-in-law blame Sunil's therapy and therapist for his worsening symptoms: Paul is given two sessions to wind the treatment down; no room for discussion.

Sometimes, it is not only the treatment that is threatened: When a person's life is in danger due to a patient's suicidal or homicidal impulses — as it was during season 1 with Alex, during season 2 with April, and now in season 3 with Sunil — and, taking into account our limited understanding (always the case), we are faced with challenging dilemmas and decisions about what would be in our patient's best interests, while respecting the lives of others, including ourselves.

Sunil, for example, is in a bad way: He is more aware than before that he may be seriously troubled, without understanding where these "terrible ideas" about murdering Julia come from or how to tame his impulses. Depressed, alienated from himself and from his culture, feeling as broken as the cricket bat he has found in the park (which he then fantasizes using against Julia), Sunil brings the potential weapon to Paul for safekeeping. He has come to depend on Paul and on this process of therapy to help him get back in touch with himself and to separate fantasy from reality.

While some of the smoke has begun to clear, enough so that Sunil and Paul both have a sense of the depth of Sunil's rage, Sunil also moves through some of his life in a haze, drawn hypnotically to Julia's study and to the fantasized scene of her murder. Partly he wants the help that Paul offers, partly his murderous impulses — dissociated from his conscious thought to a great degree — seek expression. Sunil is unable or unwilling to clear the smoke further in order to let Paul understand more about his inner life.

This leaves Paul in the unenviable position of having hope but only partial knowledge of his patient. He also has blindspots and countertransference feelings that he may not fully understand.

Is Paul still doing well by his patient, under these circumstances, to try to keep this exploratory therapy going? Should he get more help by speaking to a consultant? Ought he, at this point, warn the family? Hospitalize Sunil?

Does he stand for life?

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