“In Treatment”: A Critique of Paul’s First Session with Laura

By Jonathan Lewis

The initial episode of the HBO television series ‘In Treatment’ portrays a therapy session between therapist Paul with his patient Laura, a young woman with conflicts about intimacy and commitment in her romantic relationship. Although this is the first session witnessed by the viewer, we learn later in the program that Laura has been coming to treatment for about a year. This small essay was written a few weeks after I viewed the program, so I am relying upon a sometimes faulty memory of essential details. With this caveat, I begin my critique of Paul’s technique.

Laura recounts, with some amount of distress and tears, a sexual encounter in the toilet of a bar with a man she had just met. The encounter evidently occurs after both participants had been drinking heavily, and is also influenced by Laura’s anxiety about intimacy and commitment following her boyfriend’s proposal of marriage.

There is a box of tissues in front of Laura, on the coffee table that separates patient and therapist. (1) First error; as Laura cries, Paul pushes the box of tissues towards her. This may seem like an innocuous gesture, something we have done from time to time with the intention of expressing sympathy, support or some other aspect of concern. However, in an analytic setting, any gesture, either by the patient or therapist, is subject to investigation. Here, I believe the deep message to the patient by the analyst is, ‘I can not tolerate your distress, dry your tears, buck up, etc’. This represents a subtle refusal on the part of the therapist to be completely open to what Laura is feeling. In addition, if treatment is in large part, an investigation into what makes us most deeply human, our desires, how they are expressed, distorted, perverted, suppressed etc., then Paul’s action negates the opportunity to investigate Laura’s desire. The box of tissues sits in front of her, she could take one, she could ask if she might take one, she could express her desire in many ways. But she does not express any desire for a tissue. She is either tolerating her distress better than Paul does, as he pushes the tissues towards her, or she may be completely inhibited in her ability to express this desire (I doubt this, based on what else we learn about her), in which case it would be more useful to investigate the inhibition which prevents her from taking a tissue for herself.

(2) Laura says something to the effect that ‘this is not going the way I expected’. Paul asks her what she means and she reveals that she has been entertaining two fantasies that she has not previously expressed. These are that Paul would declare his love and desire for her and then they would either make passionate love on the couch or, he would declare his love for her and they would not proceed on to a sexual relation. As I recall, Paul is somewhat startled by this, and discovers that she has had this idea from their first meeting, a year previously (although he apparently had not the slightest clue of this). He tells her that he will not act on her fantasy out of ethical considerations. Laura brings to the treatment what every analytic therapist says he or she wants, a direct emotional communication about the relationship. But what does Paul do? Does he embrace this communication, explore it, welcome it, No – he runs and hides behind rules. This rightly infuriates Laura. He could have done any of a dozen things to advance the treatment (choosing which one of these things constitutes the Art of therapy). I suggest a few possibilities: He could have said (a) “How wonderful that you can imagine wanting to give us great pleasure in our bodies – I get the message, so we don’t have to do this, we can play with it in our minds”; (b) Laura would likely not be satisfied with this response and press Paul for an admission of his love or for some action. Here the therapist might insist on the value and importance of exploring every aspect of this fantasy. But what if Laura continues to persist and demands to have Paul acknowledge his feelings and act on them? – then it might be possible or necessary to say something like ‘Of course I have all kinds of feelings towards you, but as you are the one who brought up the idea of my loving you, tell me more about the nature of my love, what it means to you. And, how do you imagine that my love will help you and our relationship’. If Laura persists in pushing Paul to admit that he wants to have sex with her or that they should have sex, he could respond with more requests to know how this would make things better for her, keeping it in the realm of fantasy rather than action. Finally, if pushed further, Paul might say, ‘As much as I love you, I love being your therapist even more, and I know, even if you don’t believe it, that if we had sex, I could no longer function as your therapist. You can find plenty of men who would be willing to have sex with you, so why insist on this when it is much more valuable for me, and for you, to have this unique relation. Here, we can explore the meaning of our relationship in all its aspects in fantasy, to understand what this means to you without destroying our most valuable therapeutic relationship.” The point is to accept Laura’s feelings as real and valuable. Her sexuality can be celebrated, rather than risk conveying shame and condemnation by trotting out the issue of unethical behavior and implicating her in this destructive wish. The relation remains then in the realm of fantasy, and the therapist rejects the inevitable destructiveness to the patient and therapist of putting things into action.

Further, Laura’s fantasy and desire can be taken as a reliving in the transference: “For you to insist that I breach my professional boundaries in this fashion tells me that sometime in your past, during childhood, someone who stood as a protector and caretaker in relation to you must have broken those boundaries, and this was very destructive to you, I will not repeat that but I certainly welcome everything we can know and feel about that.”

Then, I recall something about Paul getting a blanket for Laura because he thinks she’s cold (same mistake as the tissue, I don’t believe that she said she was cold) and finally after she demands to know if he loves her and he refuses to answer, she is about to storm out. He asks if he can call her a cab, Oh, my God! (pardon me, ‘Oh, my Darwin!’ for us atheists). In effect, he replicates her trauma (albeit in a gentler fashion), molesting her with tissues, blankets, taxi cabs, infantilizing her, closing off and rejecting her feelings, rather than embracing them and emphasizing their great value, inviting her to join him in the intimacy of the fantasy, resisting (but being willing to explore) the sadism of her desire to destroy the therapeutic relationship.

Finally, I must admit that this series evoked a great deal of feeling in me, and is thus potentially valuable both as a tool for introspection and as a tool for teaching therapy students what not to do. But after six episodes, I could no longer tolerate watching Paul fall apart and took up watching ‘The Wire’ instead, a far more gratifying experience. I also recommend a 1955 move called “The Cobweb” with the late Richard Widmark, who does a marvelous job in portraying a progressive psychiatrist, who respects his patients and must deal with conflicts among his clinic staff and in his family, and does so in a much more satisfying way than is portrayed in the series under discussion.