Jung At Heart Archive August 2010

Pity the Kids of Shrinks?

My children have the blessing, or curse, depending on your point of view, of being the offspring of two psychotherapists, both of whom tilt Jungian. My daughter has said she didn't realize until she was in high school that not all families share and discuss dreams over breakfast. I'm guessing that they were not too badly scarred by their upbringing, though, as my son has recently begun his own journey as a psychotherapist, being a newly minted MSW.

Still, people seem to assume that the children of therapists must have more than usual kinds of problems, which exposes a kind of negative idea about therapy and the kinds of people who become therapists. Michael Toub, whose new memoir is about growing up the child of two Jungian analysts, reports he encounters surprise when people meet him that, given his parents, he is so normal.

Take a look at Jessica Grose's piece in Slate to read more about her take on this topic -- she too is the child of a therapist. Now I have to see if Toub's book is available as an eBook. Oh, and BTW, so far as I am aware, what research on children of therapists that there is shows them to be pretty much like other kids of educated parents.

Just as...

Just as it is reported that treatment by meds alone is rising, we have this report today:

Broad Review of FDA Trials Suggests Antidepressants Only Marginally Better than Placebo

A new review of 4 meta-analyses of efficacy trials submitted to the US Food and Drug Administration (FDA) suggests that antidepressants are only "marginally efficacious" compared with placebo and "document profound publication bias that inflates their apparent efficacy."

In addition, when the researchers also analyzed the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, "the largest antidepressant effectiveness trial ever conducted," they found that "the effectiveness of antidepressant therapies was probably even lower than the modest one reported...with an apparent progressively increasing dropout rate across each study phase.

Now this should not come as a shock as there have been reanalyses and meta-analyses of data showing this for at least 12 years. But the weight of them seems to be beginning to register. 

The question in my mind is, given that these drugs have side effects that are not inconsequential, how ethical is it to continue to even tacitly support advertising touting an effectiveness they do not have? And is there a duty to inform patients? If it is questionably ethical to prescribe a placebo ... well, you can see the swamp that develops here.

I am not arguing that these drugs have no value -- unquestionably they do for some people, but we have no way to identify those people nor do we know why they are helpful to them and not to others nor do we have a good handle on the whole placebo issue. To my mind, this growing body of research evidence points more strongly to the advisability of at least combining medication treatment with psychotherapy. 

It doesn't look like this issue is going to go away or become simpler any time soon. 

Treatment by drugs alone rises

We've a wedding in the family this weekend so not much time for a detailed post. I did see this in Reuters this morning:

"More Americans with psychiatric conditions are being treated with drugs alone compared with a decade ago, while "talk therapy" -- either by itself or in combination with medication -- is on the decline, a new study finds.

The implications of the trend, as well as its underlying causes, are not fully clear, according to researchers. But they say the findings indicate that outpatient mental health care in the U.S. is being redefined.

The results, reported in the American Journal of Psychiatry, are based on data from two government health surveys conducted in 1998 and 2007.

Over that period, the percentage of Americans who said they'd had at least one psychotherapy session in the past year remained steady -- at just over 3 percent in both 1998 and 2007.

However, among Americans receiving any outpatient mental health care, the proportion being treated with drugs alone rose from 44 percent in 1998 to 57 percent in 2007.

Meanwhile, combined treatment with drugs and psychotherapy declined from 40 percent to 32 percent, and the use of psychotherapy alone slipped from 16 percent in 1998 to about 10 percent in 2007."


This can't be surprising to anyone who has been watching trends over the last decade.Insurance companies prefer patients receive medication, which they can control, over psychotherapy, which is harder to control. Every day anyone who watches television or reads a mass market magazine encounters at least one and usually several ads for one or another of the heavily advertised antidepressants or atypical antipsychotics. And nowhere in any of those ads is it even suggested that the combination of psychotherapy and medication has been shown again and again to be superior to medications alone. In fact there is no suggestion that depression or bi-polar disorder is anything other than a medical illness. 

I have heard physicians say that they recommend therapy but patients do not want to take the time for it, that they prefer to take meds instead. Well, of course they do -- because that is what they are being taught to do.

There are no ads for psychotherapy. No public service announcements about the value of talking to another human being as a way to deal with depression or other emotional ills. The only advocates for the value of psychotherapy are psychotherapists and our voice is way too muted to be heard over the din of the psychopharmacological  messages. 

I have no idea what the answer to this is. Do you?


Thinking More About Merkin

In the last week or so I have read a fair number of comments about Daphne Merkin's NY Times piece on her 40 years of psychotherapy and most of them, including my own first impression, have been at least somewhat critical of the process she has been engaged in. But in the past few days I have been thinking more about it and wondering why, given that she says she has benefitted from her treatment though she is not "cured", so many view a long experience in analysis as a failure.

What made me begin to rethink this is a conversation I had not long ao with an acquaintance who has been taking one or another antidepressant for at least 25 years. She was told by a psychiatrist at some point that she should think of her medication the way a diabetic thinks of insulin, something she will have to take for the rest of her life and she has never questioned that. There is no sense that her medication as "cured" her but she feels she benefits from it.

I know of many people like my acquaintance, people who have been and expect to remain  on antidepressants for years on end. Yet no one says of them that their treatment is a failure for having gone on so many years.

So why is a period in analysis that lasts 20 years or more criticized for lasting so long while remaining on medications with questionable effectiveness is seen as good treatment?

My question on a rainy Monday morning.

Fat Space and Thin Space

Fat is one of those things I can't talk about as if these issues do not effect me. In fact I must say I don't really trust someone who has never been fat yet claims expertise about what being fat is like and what the struggles are. So that lays one of my biases right out there. 

Why write about this? Well, every day I and all of us are bombarded with pretty simple theories about why people get fat and what we should do to get thin. But almost never does anyone ask a fat person about her experience or feelings or thoughts. In my small way, I am trying to add that voice and to explore some of the meaning of fat and expose the prejudice that fat people encounter, especially in health and mental health settings, and to think about meaning in all of this.


"... the fat body is ... always visible: the only people they are trying to persuade to accept fatness are themselves. While constructing a visible “body of acceptance” does prove that it is possible for fat bodies to be beautiful, it does not directly address the audience who needs to be persuaded: the public who construct and consume norms of beauty.”1

I had a dream once about being interviewed by a small group of people. The interviewer asks me about my weight. I tell her a good part of the problem for me is what they assume they know about me because I am fat.

Embracing fat acceptance gives a measure of dignity and a refuge from self-loathing but every day we confront the assumption that fat people have lost their self-control. And frighten others because there is such a premium placed on being thin, to the point of being a public obsession. Ask and most people want to be slender, but this physical perfection is difficult to hold on to and they fear losing control of it. Women and men can be on diets their whole lives. A fat person, particularly a fat person who seems at home with herself and her body is threatening.  Fear and unhappiness get projected onto people who are bigger and that too often translates into abuse and attacks. In attacking fat people, the person terrified of the security of her grip on her own body disassociates herself from what she fears the most - getting fat. Fat people wear, obvious for all to see, the very thing that many, especially in this time of war on obesity, fear will befall them if rigid control is not maintained. The fat person becomes the example of what no one should be. 

On the internet, where anyone can hide behind a pseudonym, many feel free to express the usually unspoken, free to vent their fat hatred as in the following left in comments on various news sites:

But fat really is gross and ugly. It's a sign of indulgence, lack of exercise, poor life choices. Yuck. I wouldn't date a fat person if we were the last two people on earth.

The last thing we need is another whining class of victims. Most of the time, fat people are victims of only one thing: their own appetites.

Fat people are ugly and they stink. I don't like looking at them. I like looking at athletic bodies, both male and female. They are works of art (and whoever defiles the body, defiles the soul). I like the beauty of a such a bio-machine in motion. It is ART. I like the shadows cast by the muscles; I like when I see the tendons push out the skin. When I see this, I want to go up to that person and strum the tendons like a violin. I don't see any of that with fat people. But I smell fat people when they spill over into my seat. 


There seems to be no barrier to expressing such bigotry. And though it is usually unspoken, nearly every fat person has seen or heard enough similar judgement to be aware that any time she walks down the street, someone is thinking or saying things like that. Fat people swim in a sea of toxic prejudice.


Fat is not only hated, but also seen as doing physical damage to the individual. Frantz Fanon talked of the internalised racist where the ideology of whites was internalised by Blacks. So that Blacks too associated being Black with failing, being lazy, being less, being stupid, and being white meant having power, being successful and being pure! The black man or woman idealised the system of white hierarchy and held it in their own mind as a model. The same is true for people who believe themselves to be fat. They believe the propaganda that thin is better, not only in terms of health, but that it will make them a better and happier person with a higher status and so they hate who they are.2

Lester Spence, a black political scientist at Johns Hopkins recently wrote:

“Predominantly white spaces can be exhausting to navigate. I have to consciously be aware of what I am saying, of who is around me, of what I am wearing, of what I am doing, of what others are saying and doing. In critical ways, I cannot let my guard down for a moment. Because—and even as I write this I recognize how paranoid this may sound to people unfamiliar with the experiences I refer to—at any point I may be forced to defend myself, defend my presence.

In stark contrast, when I am at home, or at my wife’s church, or with my fraternity brothers, or at the club listening to house music, I am at home. I am not a statistic. Not a threat. Not an outsider. Not an anomaly. I am safe to “be.” I can be the “representative for the race.” I can be the one black person in the room. But I don’t have to be. I can take the story I just told you and explain in detail why I think I was being racially profiled, why I think other possible explanations don’t stand up to empirical scrutiny, why I think I was saved by the two black officers who knew what was going on without me having to tell them. But when talking to other black men and women or even to young children (to my children), I don’t have to.

I can, in those spaces, breathe.”3


There is no fat space for most of us, except perhaps at gatherings of fat acceptance activists. There is no place where I can go where I can just breathe, not have to explain myself or watch myself or work to ignore the looks of disapproval. Where I  fit in. Where I can be and do and move without being subject to scrutiny and silent (usually silent anyway) judgment. I have been trying since reading that piece to imagine what that would be like. It is only when I am at home, with the people who love me, or with my friend, who is also fat, that I can approximate that kind of space. Every place else is like Spence’s “white space”. Space where my fat reveals what must be my shame, my laziness, my self-indulgence, my gluttony, my too-muchness.

When I am in thin space and I enter a room where there are other people, without thinking, I scan the room to see if there are other fat people there. To be the only fat person is to stand out in an uncomfortable way. Relief is when there is someone as fat or  fatter than I am.

If I am in thin space and I go out to eat with others -- say for lunch during a workshop, I am aware of what everyone eats. Women apologize to each other for eating -- “I didn’t eat breakfast so I need a big lunch.” “I should just have a salad.” -- it is an unwritten rule that it is gauche to enjoy eating, to eat whatever and as much as one wants. So I am careful to eat sparingly and never have dessert.  

In thin space I am always on guard. I am hyper-aware of my behavior -- my voice, how I move. I made myself learn to walk lightly. I am vigilant. Always aware of the others. In thin space, I am thin-skinned.

How to be in thin space without being thin-skinned, without being angry?

Like most fat people, I know how to be the Good Fat Person. All I have to do is talk about trying to lose weight, about my desire to be thin. I can say I have lost 10 or 15 or 30 pounds and I will be praised for my efforts, even if it is a lie. Because the Good Fat Person is apologetic for being fat and is in a perpetual state of trying to become thin. The Good Fat Person doesn’t threaten thin people because she tells them she is engaged in the same struggle to subdue her body that they are. The Good Fat Person is apologetic for her fat, as if she must ask forgiveness for committing an aesthetic crime with her too-muchness. She doesn’t complain about the relative lack of variety in clothing available to her and accepts that she should wear shapeless coverups, preferably in dark colors. She accepts as just that she pays more for her clothing, health care, seats on airplanes. Because she knows she deserves it.

“You can't hide your fat...

According to the thin or the formerly or even presently fat, the fat person lacks willpower, pride, this wretched attitude called "self esteem," and does not care about his friends or family because if she did care about friends or family, she would not wander the earth looking like a repulsive sow, rhinoceros, hippo, elephant, or, general nine-headed monster. The fat person doesn't even love herself because if she did, she would be slender and lithe and getting exercise by being busy with her bicycle rides and weight-lifting with her three-pound pink weights. The most shameful fat facts, and those facts most avoided when the fat or formerly fat write about fatness, are facts about the fat body. ...

What people do want to write about is weight loss and how to lose it. They want to write about self-esteem and how to gain it".4  

Very rarely has any therapist I have seen asked me about my experience as a fat woman. In Yalom's essay"Fat Lady", he doesn't mention anything he learned about her experience. In fact at the end, it seems he hasn't leaned much at all as she calls him on never having touched her nor hardly looked at her. I suspect most therapists and physicians are caught in their own fantasies about fat people and their prejudices as well. And unfortunately very few fat patients challenge them on that, so opportunities to learn are lost. I have been asked more than once by physicians if I have "given any thought to losing weight?" as if I am somehow unlike every other American woman and as if I have never heard of much less tried any of the myriads of diets out there. It's hard not to get angry at times like that. What I have almost never been asked is how I feel about my body and my weight. As in my dream that I mentioned above, too often the problem is what people believe they know about me because I am fat. 


1. Mack, Ashley Noel Closely Closeted: The Fat Acceptance Movement and Embodied Closets of Power p.16 http://www.allacademic.com//meta/p_mla_apa_research_citation/1/9/3/9/5/pages193951/p193951-1.php

2. Farrell, Em. http://www.psychoanalysis-and-therapy.com/human_nature/free-associations/farrellob.dwt

3. Spence, Lester  http://www.urbanitebaltimore.com/sub.cfmArticleID=1426&IssueID=81&SectionID=4

4. Miller, Judith , “Why I Wrote Fat Girl” -- www.vachss.com/media/righteous/why_fat_girl_moore.html


Indictment of psychoanalysis?

Just a quick post to note that a long piece by Daphne Merkin, which will be in the NY Times Sunday magazine, is available to read now. In it she describes some 40+ years in analysis. In my quick read of it, it seems to be a bit of an indictment of psychoanalysis, or at least of analysis of a certain kind. I am curious how others see it and wonder what a good response to her would be? Take a look and let me know what you think. Merkin's "My Life in Therapy"



© Cheryl Fuller, 2007. All  rights reserved.