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 Post subject: The Wedding Cake
PostPosted: Mon May 28, 2012 2:19 am 
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I cannot describe how deeply this article resonated with and moved me. It does mention height and weight, so avoid reading if you are easily triggered by that; otherwise, much more of it is focussed on a genuine therapeutic relationship and experience.

The Therapist’s Voice

JUDITH RUSKAY RABINOR, Editor
JULIA SHEEHY
Barnard College Counseling Center, New York, New York, USA

Quote:
As long as a single spark remains, a great fire can be rekindled.
—Rabbi Nachman


WEDDING CAKE: EATING BEFORE MEANING

From the beginning, I was pessimistic. Considering the referring physician’s description of Katherine, I envisioned a demanding treatment without much progress. Katherine was a 59-year-old woman who had been anorectic for 17 years. For the duration of her illness she had been in treatment with a therapist who, during the course of their work together, admittedly went through several relapses into her own eating disorder. Katherine’s husband, desperate in the face of his wife’s unremitting starvation, insisted she try treatment with someone new. The plan was for her to see me and work with a nutritionist and her internist. Katherine was angry about feeling forced and did not want to begin another therapeutic relationship. I was wary of feeling spit out and defeated, as I have with some other patients with similarly poor prognoses.

Katherine was tall and angular with short silver hair. She was painfully thin, under 100 pounds at 5’7”. She wore simple, efficient outfits of pants and sweaters in solid colors. She presented as smart and curious, and her intense gaze seemed to question my comparable youth and ability to help her. I understood her doubts. I had the same ones.


INITIATING TRUST

From the moment we met, I felt Katherine’s eyes continuously scanning my body, literally sizing me up. Each session she stared at me from the moment I opened the waiting room door until she sat down in my office and was situated to talk. Although many eating disorder patients engage in this behavior, most do so less obviously than Katherine. Although I was clear about what she was doing, I was unclear as to the meaning she made of what she saw. I assumed that questions about my eating and weight history were on her mind, especially in light of her previous therapist’s difficulties with her own eating.

I generally do not tell patients whether or not I have ever had an eating disorder. Some therapists with such histories choose to share parts of their struggles and recoveries with patients, hoping to communicate empathy and hope. I prefer to let the transference unfold both in relation to patients’ reactions to my body and fantasies about me. I have found this material tremendously rich and informative.

With Katherine, I thought it was particularly important for me not to disclose personal information, given her previous treatment experience. I suspected that having a therapist who shared her same pathology had vitiated Katherine’s ability to trust and feel cared for.

After some weeks, I grew accustomed to Katherine’s scrutiny. By allowing her to look at me without questioning her, I hoped she might feel free to gather whatever information she needed about my body. I also hoped that detecting my comfort and seeing the stability of my weight might help her trust me as a therapist who needed to neither conceal nor divulge information about myself.

ALEXITHYMIA

Soon into our treatment Katherine launched into lengthy interpretive descriptions of both her mother and the origins of her eating disorder. Her descriptions made me anxious, not because of their content, but because they felt tangential and pre-formulated. Although she sounded sophisticated and savvy, her depictions lacked emotional depth and fresh insight. They felt to me like distractions from, as opposed to helpful elucidations of, her eating disorder.

Katherine reminded me of the alexithymic patients described by Diane Barth (1998) who have an inability to use language effectively to convey and process feelings, despite being highly verbal and intelligent. Katherine’s manner of speech seemed to be an intellectualization that had failed to pierce her anorexia. She had spent years theorizing and interpreting her eating disorder without significant change.

Although I usually work both psychodynamically and behaviorally, I decided to keep Katherine focused on her symptoms, believing that this was the pathway to helping her tap into her feelings. We put family explorations aside. I focused on what she was willing to eat, what thoughts and feelings stopped her from eating more, and what she experienced while eating.

I have found that many of my eating disorder patients need to spend time developing a relationship with me before they can consider making any behavioral change. They first must develop a sense of knowing me and feeling secure with my acceptance of their illness. For some patients, a too rapid resolution of symptoms can be experienced as an enactment of submission. With Katherine, however, I was worried about the trap of developing an artificial relationship, and of engaging in dialogue that was sealed off from rather than penetrating the disorder that was ruling her life.

By staying focused on Katherine’s eating it became clear that she had a potent fear of obesity. Although this fear permeated her thoughts and experience of eating, she knew rationally that obesity was a highly unlikely possibility, having always been quite thin, even before her anorexia. Rather, obesity was a symbolic state of awfulness to her, one that seemed intolerable. To me, Katherine’s central fear was curiously vague and deviated from her usual tendency to be detailed and intellectual. (In fact, alexithymic patients often have no words or images to describe their most personal and governing fears.) I was inclined to believe that the meaning of obesity for Katherine would only begin to reveal itself and become articulated once she forced herself closer to the intolerable feelings she so feared.

WEDDING CAKE

After almost two decades, Katherine was still debilitated by her disorder. Her nutritionist and I both noted early into our work with her, however, that she was willing to experiment with eating a little less restrictively. I had explained that starving less would be internally disruptive but entirely worthwhile. We agreed on a goal of increasing food intake incrementally. Each new morsel added to her restrictive regime produced waves of anxiety. Katherine constantly battled her strict prohibitions against eating and her fear of obesity.

A turning point in the treatment occurred quite suddenly. After making slight but steady progress with food for several months, Katherine finally agreed to take a big chance: She would eat wedding cake at an upcoming wedding that she and her husband planned to attend. Although she had not even considered eating such a food in many years, now, she was open to the challenge. Although her decision surprised me, I was delighted.

At the wedding, her husband brought Katherine a piece of cake. She was filled with fear to the point of shaking. Recognizing her paralysis, he took her out of the reception room and tried to coax her into eating the cake. At first, she refused. However, slowly, and with soft encouragement, her husband began to feed the cake to her. Bite by bite, she was able to swallow.

Katherine and I later deconstructed this incident. She was stunned by the potency of her fear and wanted to understand her reaction. I was moved by her struggle and especially by her ability to tolerate the trembling and allow herself to be fed. We explored her sense of the meaning of marriages, milestones, celebrations, and rich, commemorative foods. Although we formulated theories, none fully captured or explained the meaning of the surge of terror she had experienced.

In talking about the wedding cake incident, Katherine expressed herself with an openness that was new. Instead of preemptively verbalizing and intellectualizing the experience, she searched for ways to describe and understand it. She was able to sit with the aspects that continued to puzzle her. This marked a shift toward genuine curiosity and inquiry and away from superimposing interpretations on her affective experiences. In focusing on her thoughts, feelings, and experiences around eating wedding cake, it was clear she had changed: She was more able to tolerate and confront confusing and overwhelming emotion. She experienced new feelings of trust, first with her husband as he fed her the cake, and later with me in our session.

Katherine and I will most likely find ourselves returning to this wedding cake in future sessions. As she continues to learn to feed herself, the hold of psychic and nutritional starvation will hopefully slacken. This will allow for fuller experience, and will make the discovery of meaning possible.

NEWNESS IN THE OLD

Months after the wedding cake incident, Katherine’s weight neared 105, a number it had not approached in years. Suddenly, her progress came to a complete halt. My fears about a trying treatment that ultimately fails rushed back. Katherine had no understanding of why that particular weight seemed fraught and insurmountable. I put my fears aside and calmly assured Katherine that she would begin to find out when she achieved and maintained that weight, and most likely not before.

When the scale tipped 105, Katherine was engulfed by feelings of sadness and loneliness, feelings that most characterized her childhood. Memories recounted earlier in our treatment re-surfaced, now with more vivid details and emotion. One story seemed particularly important: she recalled a time when, at five years old, her older brother had enticed her to join him in “play” and later abandoned her far from home. When she finally found her way home, panic-stricken and red-faced from crying, she was greeted by her mother’s mocking laughter.

Katherine was unable to recall how she felt at that time. However, she was aware that as an older child, whenever she described feelings of hurt and anger to her mother, she was responded to with a flippant flick of the wrist, and a contemptuous laugh at her teenage “silliness.” In looking back, Katherine was now able to recognize her mother’s lifelong cruelty and feel her own pain about being treated so un-empathically.

Katherine’s memories of her mother painted a portrait of a woman who lacked maternal feelings or instincts for her daughter and who simultaneously encouraged her son’s aggression. She dismissed Katherine’s preferences and strengths, and ridiculed her vulnerabilities. Katherine denied how staved she was and instead, as a survival mechanism, learned to shut off her feelings and process things mentally.

Recalling her mother’s sadism was deeply painful, and left her in a bind. She did not want to feel those feelings, nor did she want to retreat back into anorexia to feel less. Yet really remembering her interactions with her mother allowed her to realize that that now she could safely have unpleasant feelings without becoming consumed by them. I was relieved to see how resilient she had become.

It was at this point that Katherine and I were able to start to piece together the symbolic meaning of obesity. She had learned as a girl that it was dangerous to hold anything inside of her, as this would only be fodder for derision and mockery. She instead operated from regimes self-imposed on her body, trying to squeeze it of its feeling and need.

In our sessions, Katherine began to recognize that starving herself was an internalization of her mother’s sadism. Negating her instinct for hunger and self-preservation amounted to a denial of herself. She also began to see how intellectualizing in therapy had not served her well but had kept her disconnected from her internal life, allowing her eating disorder to thrive.

CONCLUSION

Diane Barth (1998) has found that persistent questioning and collaborative labeling of her patients’ experiences helps to abate their alexithymia. Inquiry into even the prosaic aspects of their lives promotes capacity for self-examination and elaboration of experience. To this I add the importance of leading with symptom interruption toward the goals of self-attunement and fluency of expression. It is through the temporary cessation of starving, binging, or purging that the grip on patients’ interiors is released, opening up sensations and feelings to be understood and ultimately synthesized into meaningful self-knowledge.

A year into our treatment Katherine commented, with amazement, that she’d gained a little more than ten pounds and was finding it tolerable. She came to recognize the sadism she incorporated from her mother and how she had enslaved herself to a disorder of constant judgment and deprivation. She also saw how her anorexia had kept her connected to her mother, uniting them in discounting Katherine’s internal life. By now, however, Katherine was becoming a person who felt entitled to pay attention to and respond to what was inside of her, including her hunger, and there had not been the retribution she feared. Beginning to embrace her insides led her to conclude one day that her fear of obesity was “absurd.” Although she had rationally known this all along, giving up symptoms had moved her closer to both understanding and disproving her own fears through actual experience.

Working with Katherine has reminded me to stay alert to the cloaked nature of alexithymia, and to attend closely to what is vague as well as what is behind quick explanations. She also has reminded me to be wary of my own ideas about prognosis, and to stay open to each individual’s capacity and desire for growth. I believed Katherine would be one of my most difficult patients, one who would tax my patience for the stubbornness of anorexia. She has, however, made remarkable progress.

Despite my ideas about what helps patients with eating disorders, I am left wondering what occurred that allowed Katherine to take me in and grow. She started our treatment in the awful position of keeping most everything out, not yet trusting her ability to distinguish what nourishes from what threatens to poison. She did not, however, reenact starvation in treatment by refusing, politely or aggressively, our endeavor. She slowly took in our relationship and allowed our work to be mutually feeding and sustaining.

Katherine not only defied my initial pessimism but has become someone who inspires hope in me when I feel most at a loss with other patients. I have shared her wedding cake story with those who are stuck longing for understanding before altering their eating. Her story also reminds me that to be a clinician is often to be in doubt, given that the process of change remains illusive and mysterious and that often we, too, must proceed before fully comprehending. I remain respectful and admiring of Katherine’s bravery and willingness to eat first and know later.

REFERENCE

Barth, D. (1998). Speaking of feelings: Affects, language, and psychoanalysis.
Psychoanalytic Dialogues, 8(5), 685–705.


Eating Disorders, 13:213–218, 2005
Copyright © 2005 Taylor & Francis
ISSN: 1064-0266 print/1532-530X online
DOI: 10.1080/10640260590920123

The author thanks Leah Doyle, Ph.D. and Bill Adler for their comments on this paper.

Contributions to The Therapist’s Voice can be sent to Judith Ruskay Rabinor, 36 Biarritz
Street, Lido Beach NY 11561. E-mail: jrrabinor@aol.com

Address correspondence to Julia Sheehy, Barnard College Counseling Center, 3009
Broadway, Hewitt Hall, 1st floor, New York, NY 10027. E-mail: jsheehy@barnard.edu 213

_________________
Whispered words of wisdom,
Let it be.

~~ John Lennon


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