Wednesday, February 06, 2008

Why Does Laura Need A New Therapist?

The sub-blog post on the episodes of In Treatment where Laura, the patient, announces her love for her therapist, Paul, have gotten a number of comments. I fueled it with my subsequent post, You Don't Have To Say It All. I ended by saying that Paul needs to document what's going on, seek professional consultation, and end therapy with this patient.

Yup, if this were a real life case, it would be both upsetting and extreme.

I don't want to talk here about transference or counter-transference, they may feed into how things have played out, but psychodynamic terminology is not what the treatment setting is about at this point.

What is it about? I think it's about everyone's safety.

A quick recap. Laura is obsessed with her therapist. She's been seeing him for a year, she has a serious boyfriend who's proposed, she shows up to her first session after sitting outside in the dark for 4 hours, dressed in an outfit she'd worn to go to a bar and nearly have sex with a stranger in. She announces that she's in love with Paul, has been since the beginning. The next session, she arrives in her anesthesiologist uniform and announces her engagement along with her fears of becoming a domesticated animal (I may be reading too much into that). Paul is shocked at the engagement, less than enthused for her, asks why, when the week before she was presenting it as an unpleasant ultimatum, and Laura says, "I said yes because you said no." She talks about how Paul looked like a dead man when he first met her, implies she's brought him to life, pushes every boundary, and says--and please excuse my R-rated bluntness here-- "I want you to fuck me." We know from Paul's therapy session that his marriage is stale, that maybe his wife is unfaithful, that he is resisting looking at his own feelings towards Laura. We, as viewers, are probably meant to believe that Laura is just a bright young woman with a sixth sense and an ability to judge people. We hope and believe that she doesn't have have access to information about Paul's marriage and stale sex life (was she lurking at his session?), and because we know there's some truth there, it comes off a bit differently than if Laura said all these things but Paul was oh-so-happily married.

So here's the deal: there's a young woman who loves (real, transferential, does it really matter?) her psychotherapist and she's pushing for sex, for the bathroom inside the house, for a glimpse of his wife ("is she lying on the couch watching TV and drinking beer?"). She's raw and vulnerable, and she's decided to marry her boyfriend not because she loves him but because her psychotherapist won't have her. Perhaps she's angry, or desperate, or who knows what. But she's making a major life decision unwisely and tossing it onto the therapist (--seems to be a theme with Paul's patients). And she's not exploring her feelings with curiosity or respect for Paul's marriage, their doctor/patient relationship that absolutely forbids a sexual relationship, or as a therapeutic endeavor. She's saying "I want you to fuck me." She's trying, rather successfully, to make him uncomfortable, and right or wrong, she's making it about him and his needs/insecurities/feelings as well. Maybe she's got it right, or maybe she's projecting onto him her desire that he love her back (oops, I did it, I mentioned a defense mechanism, forgive the psychobabble). At any rate, we now know we have two raw, vulnerable, and hurting people and if this isn't a set-up for disaster....well, it is.

How does therapy continue from here? Does Laura even want to get better or is her goal to get laid? At any rate, she's been rejected from a pretty hard push proposition, and I'm guessing she's angry and her feelings are hurt. She's alone in an office with Paul, and so far we have no reason to believe that he's done anything unprofessional, and he's said point blank, "I'm your therapist, I'm not an option."

Laura has assured Paul that she won't boil his kids' rabbit. Oh good, but it's an unnerving reference to Fatal Attraction and violent unstable stalker women. It's not that I think Laura is a violent stalker woman, but I don't know and Paul may not know. At this point what I do know is that no one is safe.

From Paul's perspective, he could end up in bed with his patient--she's gorgeous and we know he's thinking about sex all the time. Such things unfortunately happen. This would not be a good outcome for anyone, it would ultimately injure the patient in unspeakable ways. Paul could also do everything absolutely right, continue to work therapeutically with Laura, refuse her advances, hold tight on reasonable therapeutic boundaries, and hope he can help her and that she has the strength to bear the pain of her unrequited love, to work in therapy, and to uphold the integrity necessary for the process. But these two people are alone together in an intimate setting-- if she decides to complain about her care, or to accuse Paul of any sexual wrong-doing, the issue becomes one of He Said-She Said and Paul's career, professional reputation, and marriage are a step away from ruin. The doctor isn't always in control-- when two people are alone together the issue of trust and safety goes both ways. The reality is that both the patient and therapist are vulnerable-- she is vulnerable to being used in a sexual way, he is vulnerable to the possibility of both his own misbehavior or that she might lie.

I've said that Paul needs to document what's going on, certainly for his own protection. He sought consultation, but he resisted talking about this patient. Now, however, with her new engagement, her statement of distress over his rejection, and her blatant "I want you to..." (oh, I've said it enough)... Paul needs to seek a consultation with more honesty. Do I think he should call Laura and dump her before the next session? Of course not. I do think they need to figure out what might make the sessions safe-- another person in the room would do it. Maybe Paul could borrow an office at a hospital clinic to see Laura in-- a little less intimate, two chairs, no couch. If he can get her to quickly cease her advances, to be willing to look at her feelings and the distraction and disturbance they create, and to address the issues of safety that they both now have, maybe it can be salvaged.

Please don't get me wrong here-- I'm not in any way saying that a psychotherapy needs to end if the patient becomes attracted to the doctor. It happens all the time. I'm not saying that it shouldn't be addressed in the therapy and looked at in whatever way works for both parties (--Hey, Tony professed his love for Dr. Melfi, lavished her with gifts, and moved on when she said "No, it's part of what happens in treatment.")

It's hard to get it to work, though, if it's more than a discussion of feelings. Laura's session was a full-court press for intercourse. In real life, these things end badly.