Jung At Heart

I asked in my last post what obesity is a symptom of, because frankly it is not as clear as might be thought. The desire to pinpoint the cause is all but irresistible. As I have struggled with my weight in my adult life, I wanted desperately to find a reason for it, some explanation that I could rest on. At times I told myself it is all about biology and genetics, an inevitable outcome of being my father’s daughter, as the Fullers are a family replete with fat women who lived long lives. And there is comfort in that explanation because if the reason for my fat is biological, then it is not my fault anymore than my eye color or height is my fault; it is just the way I was made.

Other times I would fall to the other side of the coin and believe the cause lay in my psyche. I read Hilda Bruch, Irving Yalom, and Marion Woodman and all those others who led me to believe that if I could just work my way through my issues, then everything would change and I would be normal, I would become thin and stay that way. 

Then I read Fat is a Feminist Issue and it all became muddled again, this time in feminist politics and the tyranny of the patriarchy. I began to consider again that maybe this fat body is  my normal, maybe this is the body I am meant to have and that trying to beat it into submission, trying to make it smaller is to be in a state of war with myself. 

There is a very thin line in the space between “either” and “or”, a razor thin edge where both/and exists. In this narrow space, which is so very hard to hold on to, causation is not a settled matter. It is not a matter of either biological etiology or emotional but the place where biology meets emotion. And where there is no magical solution. In this place, I know I am fat because I came with a body which has instructions for being fat, for being really efficient about storing energy. And in this place, fat also has meaning in my life, exists meaningfully -- that is the Jungian voice in me that knows that there is a meaningful basis alongside the physical. 

It is a very difficult space to hold. It is so very easy to fall into a very concrete and linear thinking and resist looking at meaning because the evidence on the side of biology is so strong for me. And yet, I cannot entirely escape the role fat plays in my life and the meaning it has for me and how it relates to my mother complex and so much else in my psyche. If I am, if we are to hold mind and body together, we cannot privilege body at the expense of mind,  cannot hold to a purely biological cause and reject any emotional one. Surely the shame that is there right under the surface is as much a part of fat as the genes which disposed me to be fat.

When I turn to the literature, I find the Jungian world, and the depth psychological world in general, is oddly silent about fat. Other than the early writings of Marion Woodman, there is nothing to be found in the Jungian literature about it, about what fat symbolizes. There are books and articles about anorexia but not about fat, not about obesity. Much is made of the need to connect with the body, of the body as storehouse of memory. Quadrant’s description says it is a journal of “essays grounded in personal and professional experience, which focus on issues of matter and body, psyche and spirit.” Yet there are no articles that I can find about fat, save for one a year ago, “The Epidemic of Obesity in Contemporary American Culture: A Jungian Reflection” which focuses on compulsive eating. Again an equation of fat with gluttony. There is nothing about fat in the fifty-plus year archives of the Journal of Analytical Psychology. In what used to be the San Francisco Library Journal, there are two interviews with Marion Woodman, in which some of her thoughts about fat are offered, and reviews of her two books which dealt with fat and anorexia. And that is it. No one, other than Marion Woodman to answer my question: what is fat a symptom of?

The current attitude in American culture, in the public health community, is that obesity is the biggest threat to life and health today. There are more dire warnings and predictions about fat than about terrorism. Ideas about what causes obesity abound -- everything from processed food, to sugared soft drinks, to laziness, to fear of sexuality -- yet little to nothing about what it means to be fat, to deal with being fat, or about the psychic toll taken by being in a constant state of war with one's body. This is where my interest lies.

At last I am beginning to feel like myself again. This bug is a fierce thing but I seem to have finally defeated it. Thank you to those of you who missed me and sent your good wishes -- it's really nice to know that the relationship we develop in this medium are real connections.

I am working on a couple of posts relating to Huge.  I watched the second episode and I continue to like it. I want talk a bit about the issues I see and some of my thoughts about fat and the battle with the body.

In the meantime, a reader emailed me about how to know when therapy was finished. For now, I offer this, which I originally posted in Nov. 2009:

Every therapy comes to an end eventually. Under ideal conditions, therapist and patient arrive together at the decision to end and they take the time necessary to fully and respectfully end the relationship. It s a ritual of goodbyes -- taking the time to look back at what has happened, what has changed. It's time to look at what has been accomplished and what has not. It is an exit interview and a farewell all in one and ideally takes up a number of sessions. When this happens there are good feelings all the way around, along side the inevitable sadness at saying goodbye. 

Not all terminations are ideal. Someone asked me recently what it is like when a patient leaves abruptly. Well, it's hard. Sometimes a patient will call and leave a voicemail saying  they won't be back. Or send an email or a note. Or not show up and then not respond to calls. Sometimes this is part of a pattern in the therapy and the patient eventually returns. But more often, they do not and we end up not knowing why. And that is hard because it is in the nature of therapists to wonder and want to know what happened.

It's my job to challenge any changes in our work that patients bring up. It is my job to ask when someone announces they want to leave therapy to ask why now and to raise what I see as possible issues. It is not about wanting to control the patient or protect my income. It is my job. I ask at the beginning of therapy why they are seeking therapy now and we look at that. I ask at the end why they want to leave now and we look at that.  

I think it is hard to remember that the therapist is a person and that therapy is a relationship. It is a RELATIONSHIP. Patients and I spend an hour or so together every week and they live in my thoughts and occupy space in me beyond that hour. It's a relationship. So when a patient says to me, "I want to stop now", I ask why now and I ask that we look at this because it is part of our relationship, because I am a part of this relationship. And if that patient won't talk about it, won't look at why and leaves, maybe in a huff and full of mutterings about me, then she leaves. But she will still occupy space in my thoughts as I try to understand what happened and what might have led to this. And when she wants to return, as often happens, my door is open and we begin again and I do so without carrying resentment.  

It all comes with the territory.  

There are all kinds of reasons for ending -- money, time, dissatisfaction, discomfort with the process, dislike just to name a few. But it is the abrupt ones, with no chance to really say good by or talk through  what has happened and ending that are hard on therapists, and ultimately on patients as well. Ending well is important.  It lets us go forward without lingering feelings and resentments.

Ending is hard. It is hard no matter where in our lives we do it. And we tend to end in therapy in the same style we end other relationships. There are good endings and bad endings and healing endings and wounding endings. And they are all hard. And we can, all of us, learn to do them with more grace when we are willing to look at how we do it and what endings mean to us and have meant in our lives. 

A while back  a reader emailed me this question:

"How do I balance my sense of what's right for me to be looking at right now, and what my therapist seems to focus on? How much autonomy is appropriate?" 

I was puzzled at first by the question. The basic instruction in depth psychotherapy is to say what comes to mind and how could that be if the therapist determines what should be the focus in therapy?

I remember attending a workshop in Boston taught by Raphael Lopez-Pedraza. He noted in passing that being an analyst meant he spent hours listening to patients talk about business or farming or accounting or any number of things he himself knows little or nothing about and gaining understanding of those things and their importance to his patients is part of the process. This is something we do to become the therapist the patient needs. It is not the patient's task to become the patient we need, but the reverse.

So, a patient may come in for session after session and seem to talk only about superficial things -- meals she prepared or what her children are doing or how her garden is growing. One way of looking at this kind of time is that all of what she is saying is a comment about the therapy process itself -- this is the approach Robert Langs advocated. Another way of understanding it is that she is telling me about her life in the way she knows how. I need to be patient, be curious and listen for all of what she is saying, the subtext as well as the actual content. And if I think she might be avoiding something, I might ask about that. But it wouldn't feel right for me to tell her what she should be focussing on.

That said, there are therapists who specialize in one area or issue rather than work as generalists. So they may not be so open to listen to material that seems not to be germane to that issue.

In any case, the therapy belongs to the patient. So talk about it; raise the issue with the  therapist. Let him or her know how you feel.

I am borrowing both title and idea for this post from Blue to Blue. Thinking about what books more or less related to psychotherapy, I realized that novels have been more influential for me than more traditional sources. Probably because I have always been a little lazy intellectually and lack the depth in philosophy that some have. So in no particular order of importance, here are ten books that have stayed with me and in both subtle and not so subtle ways helped to shape my thinking about what I do.

1. Freud's Introductory Lectures on Psychoanalysis -- the basic text for my second course in psychology in college, taken when I was a sophomore. Whether it was the ideas of Freud or the genius of the professor, Irwin Kremen, this book and course grabbed me and really got my interest in psychotherapy and in the workings of the mind going.

2. Man and His Symbols -- Carl Jung. I discovered this book while browsing in the Gothic Bookshop sometime when I was a junior in college. I was fascinated by the ideas, though I didn't understand a lot of them. 

3. I Never Promised You a Rose Garden -- also read while I was in college. I count myself lucky to have encountered these books n my college years when psychoanalysis and depth psychology was still the dominant mode.  This novel set me to browsing the shelves of the library reading all kinds of books about psychotherapy and psychoanalysis.

4. August -- I still recommend this novel by Judith Rossner to friends. The novel focuses on the relationship between a psychoanalyst, Dr. Lulu Shinefield, and a young troubled woman, Dawn Henley, from the beginning of their therapy together through to its termination. And because it gives us perspective from both sides of the couch, I think it is really unusual.

5. The Words to Say It- Claudia Cardinal. Around 20 years ago, a patient gave me this book. It is a fictionalized report of the author's seven years in psychoanalysis and gives a sense of that process. 

6. The Treatment - Daniel Menaker's novel about Jake Singer and his analysis with Dr. Morales, a wild and passionate analyst. Though Dr. Morales behaves as likely no analyst would, his passion and willingness to engage Jake in the way he does captures the excitement that I find at the heart of this work. 

7. Schizoid Phenomena, Object-Relations, and the Self - Harry Guntrip. Through the 70's and 80's I read widely in psychoanalysis, object relations, Jungian psychology. I would look at the bibliography of any book I liked and find as many of those books that sounded interesting to me and read them. This gave me an intensive education that I couldn't have gotten any other way. This book, with its awkward title, was one I went back to a couple of times. 

8. Psychotic Anxieties and Containment: A Personal Record of an Analysis With Winnicott -  Margaret Little. This little book, just 129 pages, was terrific for giving me a deep sense of what it is to be a wounded healer. Not many analysts or therapists write about their own wounds and madness. Margaret Little gives a tremendous gift in this account of hers.

9. Women Who Run With The Wolves - Clarissa Pinkola Estes. I go back to this book again and again, drawn by different fairytales and her analysis of them. To my mind, this is one of  the best books  based on Jungian principles and most accessible to the general public.

10. Of Two Minds: An Anthroplogist Looks at American Psychiatry - T. M. Luhrman. An interesting look at the split in psychiatry between those who lean to brain and those to mind.

Of course in the process of writing this list, another dozen or so books sprang to mind. I'll save them for another day.

Someone asked me how a psychotherapist deals with the situation in which something the patient has come to understand she would really like to do to improve or change her life is likely to cause suffering to someone in that patient's life?   

This questions contains, I believe, a misperception about what therapy is about and what the role of the therapist is.  

A new patient comes to me. I gather a bit of basic data and then ask her to tell me why she is here, to tell the story in whatever way makes sense for her. I listen. Very rarely is what I hear framed as a moral dilemma. I ask and ask many times during the time we work together "What is the life you want?", because this is a pivotal issue. And as she frame possible actions, I ask if that action will take her closer to the life she wants. And we do that process again and again. I don't tell anyone what to do. I am not really a problem solver.  

I deal with what is the life the person wants, what keeps them from having that life, and how/if it can be achieved and what the cost of achieving it might be. In 36 years I have never seen a pedophile or rapist or person who engages in behavior that I think is beyond the pale -- those people don't come in for therapy, at least not to me. Once I saw a person who might have been a murderer. I checked with colleagues and the appropriate state agency to see what my responsibility was to him and to the community. I saw him 3 times and discharged him to more appropriate facility. That was a professional decision not a moral one.  

So how do psychotherapists navigate these waters?  

I don't give answers when asked what people should do. I can help them look at why they want to do it and what the consequences are and whether it will get them what they want. But I do not make the decision.  

In two sets of conditions, I am bound to act on what I hear. If I am told by someone that they abuse someone or are abused, in most states, I am mandated to report the abuse. If someone threatens the life of another, case law says I must inform the authorities, but statute does not -- so I consult and then report or not. Otherwise, my task is to listen.  

I am not Dr. Phil. I am not a priest. It is VERY hard sometimes not to try to tell people what to do. Because the work I do is not short term and because I usually work with people over the course of months, often  years, we have time to sort through issues, to examine them from as many sides as possible. And ultimately what they do is up to them. 

"The principle aim of psychotherapy is not to transport one to an impossible state of happiness, but to help (the client) acquire steadfastness and patience in the face of suffering. " -C.G. Jung