Another possible scenario, which fortunately did not happen with Penny, is for the parents to bear immediately another, replacement, child. Often circumstances favor such a course, but sometimes more problems are generated than solved. For one thing, it can damage relationships with surviving children. In addition, the replacement child suffers, too, especially if the parents’ grief remains unresolved. Growing up bearing the parents’ hopes that one will fulfill the unrealized goals of their life is hard enough, but the additional burden of housing a dead sibling’s spirit may overwhelm the delicate process of identity formation.
Still another common scenario is for parents to overprotect the surviving children. I learned, at follow-up, that Penny was falling prey to this dynamic: she had grown fearful about her sons’ driving, was reluctant to lend them her pickup, and adamantly refused to allow either of them to buy a motorcycle. Furthermore, she insisted that they have unnecessarily frequent medical checkups to screen for cancer.
In our discussion of her sons, I felt I had to tread carefully and to content myself with helping her to appreciate from their perspective the consequences of Chrissie’s death. I did not want Penny’s guilt, so recently pried loose, to “discover” her great neglect of her boys and attach itself to this new object. Eventually, months later, she did develop guilt about her relationship with her sons, but by that time she was better able to tolerate it and to ameliorate it by changing her behavior.
The fate of Penny’s marriage is, unfortunately, all too common in families that have lost a child. Research has shown that contrary to the expectation that the tragedy of a child’s death might bind a family together, many bereaved parents report increased marital discord. The sequence of events in Penny’s marriage is prototypical: husband and wife grieve in different—in fact, diametrically opposed—fashions; husband and wife are often unable to understand and to support each other; and the mourning of each spouse actively interferes with the mourning of the other, causing friction, alienation, and eventual separation.
Therapy has much to offer grieving parents. Couples treatment may illuminate the sources of marital tension and help each partner to recognize and to respect the other’s mode of grief. Individual therapy may help to alter dysfunctional mourning. Wary though I am always of generalizations, in this instance male-female stereotypes often hold true. Many women, like Penny, need to move past the repetitive expression of their loss and to plunge back into engagement with the living, with projects, with all the things that may supply meaning for their own lives. Men usually must be taught to experience and share (rather than to suppress and evade) their sadness.
In her next stage of grief work, Penny allowed her two dreams—the soaring train and evolution, and the wedding and the search for a changing room—to guide her to the exceptionally important discovery that her grief for Chrissie was mingled with grief for herself and for her own unrealized desires and potential.
The ending of our relationship led Penny to discover one final layer of grief. She dreaded the end of therapy for several reasons: naturally she would miss my professional guidance, and she would miss me personally—after all, she had never before been willing to trust and to accept help from a man. But beyond that, the sheer act of ending evoked vivid memories of all the other painful losses she had endured but never allowed herself to feel and to mourn.
The fact that much of Penny’s therapeutic change was self-generated and self-directed contains an important lesson for therapists, a consoling thought a teacher shared with me early in my training: “Remember, you can’t do all the work. Be content to help a patient realize what must be done and then trust his or her own desire for growth and change.”
4
Fat Lady
The world’s finest tennis players train five hours a day to eliminate weaknesses in their game. Zen masters endlessly aspire to quiescence of the mind, the ballerina to consummate balance; and the priest forever examines his conscience. Every profession has within it a realm of possibility wherein the practitioner may seek perfection. For the psychotherapist that realm, that inexhaustible curriculum of self-improvement from which one never graduates, is referred to in the trade as countertransference. Where transference refers to feelings that the patient erroneously attaches (“transfers”) to the therapist but that in fact originated out of earlier relationships, countertransference is the reverse—similar irrational feelings the therapist has toward the patient. Sometimes countertransference is dramatic and makes deep therapy impossible: imagine a Jew treating a Nazi, or a woman who has once been sexually assaulted treating a rapist. But, in milder form, countertransference insinuates itself into every course of psychotherapy.
The day Betty entered my office, the instant I saw her steering her ponderous two-hundred-fifty-pound, five-foot-two-inch frame toward my trim, high-tech office chair, I knew that a great trial of countertransference was in store for me.
I have always been repelled by fat women. I find them repulsive: their absurd sidewise waddle, their absence of body contour—breasts, laps, buttocks, shoulders, jawlines, cheekbones, everything, everything I like to see in a woman, obscured in an avalanche of flesh. And I hate their clothes—the shapeless, baggy dresses or, worse, the stiff elephantine blue jeans. How dare they impose that body on the rest of us?
The origins of these sorry feelings? I had never thought to inquire. So deep do they run that I never considered them prejudice. But were an explanation demanded of me, I suppose I could point to the family of fat, controlling women, including—featuring—my mother, who peopled my early life. Obesity, endemic in my family, was a part of what I had to leave behind when I, a driven, ambitious, first-generation American-born, decided to shake forever from my feet the dust of the Russian shtetl.
I can take other guesses. I have always admired, perhaps more than many men, the woman’s body. No, not just admired: I have elevated, idealized, ecstacized it to a level and a goal that exceeds all reason. Do I resent the fat woman for her desecration of my desire, for bloating and profaning each lovely feature that I cherish? For stripping away my sweet illusion and revealing its base of flesh—flesh on the rampage?
I grew up in racially segregated Washington, D.C., the only son of the only white family in the midst of a black neighborhood. In the streets, the black attacked me for my whiteness, and in school, the white attacked me for my Jewishness. But there was always fatness, the fat kids, the big asses, the butts of jokes, those last chosen for athletic teams, those unable to run the circle of the athletic track. I needed someone to hate, too. Maybe this is where it began.
Of course, I am not alone in my bias. Cultural reinforcement is everywhere. Who ever has a kind word for the fat lady? But my contempt surpasses all cultural norms. Early in my career, I worked in a maximum security prison where the least heinous offense committed by any of my patients was a simple, single murder. Yet I had little difficulty accepting those patients, attempting to understand them, and finding ways to be supportive.
But when I see a fat lady eat, I move down a couple of rungs on the ladder of human understanding. I want to tear the food away. “Stop stuffing yourself! Haven’t you had enough, for Chrissakes?” I’d like to wire her jaws shut!
Poor Betty—thank God, thank God—knew none of this as she innocently continued her course toward my chair, slowly lowered her body, arranged her folds and, with her feet not quite reaching the floor, looked up at me expectantly.
Now why, thought I, do her feet not reach the ground? She’s not that short. She sat high in the chair, as though she were sitting in her own lap. Could it be that her thighs and buttocks are so inflated that her feet have to go farther to reach the floor? I quickly swept this conundrum from my mind—after all, this person had come to seek help from me. A moment later, I found myself thinking of the little fat woman cartoon figure in the movie Mary Poppins—the one who sings “Supercalifragilisticexpialidocious”—for that was who Betty reminded me of. With an effort I swept that away as w
ell. And so it went: the entire hour with her was an exercise of my sweeping from my mind one derogatory thought after another in order to offer her my full attention. I fantasized Mickey Mouse, the sorcerer’s apprentice in Fantasia, sweeping away my distracting thoughts until I had to sweep away that image, too, in order to attend to Betty.
As usual, I began to orient myself with demographic questions. Betty informed me that she was twenty-seven and single, that she worked in public relations for a large New York–based retail chain which, three months ago, had transferred her to California for eighteen months to assist in the opening of a new franchise.
She had grown up, an only child, on a small, poor ranch in Texas where her mother has lived alone since her father’s death fifteen years ago. Betty was a good student, attended the state university, went to work for a department store in Texas, and after two years was transferred to the central office in New York. Always overweight, she became markedly obese in late adolescence. Aside from two or three brief periods when she lost forty or fifty pounds on crash diets, she had hovered between two hundred and two hundred fifty since she was twenty-one.
I got down to business and asked my standard opening question: “What ails?”
“Everything,” Betty replied. Nothing was going right in her life. In fact, she said, she had no life. She worked sixty hours a week, had no friends, no social life, no activities in California. Her life, such as it was, she said, was in New York, but to request a transfer now would doom her career, which was already in jeopardy because of her unpopularity with co-workers. Her company had originally trained her, along with eight other novices, in a three-month intensive course. Betty was preoccupied that she was neither performing nor progressing through promotions as well as her eight classmates. She lived in a furnished suburban apartment doing nothing, she said, but working and eating and chalking off the days till her eighteen months were up.
A psychiatrist in New York, Dr. Farber, whom she saw for approximately four months, had treated her with antidepressant medication. Though she continued to take it, it had not helped her: she was deeply depressed, cried every evening, wished she were dead, slept fitfully, and always awoke by four or five a.m. She moped around the house and on Sundays, her day off, never dressed and spent the day eating sweets in front of the television set. The week before, she had phoned Dr. Farber, who gave her my name and suggested she call for a consultation.
“Tell me more about what you’re struggling with in your life,” I asked.
“My eating is out of control,” Betty said, chuckling, and added, “You could say my eating is always out of control, but now it is really out of control. I’ve gained around twenty pounds in the past three months, and I can’t get into most of my clothes.”
That surprised me, her clothes seemed so formless, so infinitely expandable, that I couldn’t imagine them being outdistanced.
“Other reasons why you decided to come in just now?”
“I saw a medical doctor last week for headaches, and he told me that my blood pressure is dangerously high, around 220 over 110, and that I’ve got to begin to lose weight. He seemed upset. I don’t know how seriously to take him—everyone in California is such a health nut. He wears jeans and running shoes in his office.”
She uttered all these things in a gay chatty tone, as though she were talking about someone else, or as though she and I were college sophomores swapping stories in a dorm some rainy Sunday afternoon. She tried to poke me into joining the fun. She told jokes. She had a gift for imitating accents and mimicked her laid-back Marin County physician, her Chinese customers, and her Midwestern boss. She must have laughed twenty times during the session, her high spirits apparently in no way dampened by my stern refusal to be coerced into laughing with her.
I always take very seriously the business of entering into a treatment contract with a patient. Once I accept someone for treatment, I commit myself to stand by that person: to spend all the time and all the energy that proves necessary for the patient’s improvement; and most of all, to relate to the patient in an intimate, authentic manner.
But could I relate to Betty? It was an effort for me to locate her face, so layered and swathed in flesh as it was. Her silly commentary was equally offputting. By the end of our first hour, I felt irritated and bored. Could I be intimate with her? I could scarcely think of a single person with whom I less wished to be intimate. But this was my problem, not Betty’s. It was time, after twenty-five years of practice, for me to change. Betty represented the ultimate countertransference challenge—and, for that very reason, I offered then and there to be her therapist.
Surely no one can be critical of a therapist striving to improve his technique. But what, I wondered uneasily, about the rights of the patient? Is there not a difference between a therapist scrubbing away unseemly countertransference stains and a dancer or a Zen master striving for perfection in each of those disciplines? It is one thing to improve one’s backhand service return but quite another to sharpen one’s skills at the expense of some fragile, troubled person.
These thoughts all occurred to me but I found them dismissible. It was true that Betty offered an opportunity to improve my personal skills as a therapist. It was, however, also true that my future patients would benefit from whatever growth I could attain. Besides, human service professionals have always practiced on the living patient. There is no alternative. How could medical education, to take one example, survive without student clinical clerkships? Furthermore, I have always found that responsible neophyte therapists who convey their sense of curiosity and enthusiasm often form excellent therapeutic relationships and can be as effective as a seasoned professional.
It’s the relationship that heals, the relationship that heals, the relationship that heals—my professional rosary. I say that often to students. And say other things as well, about the way to relate to a patient—positive unconditional regard, nonjudgmental acceptance, authentic engagement, empathic understanding. How was I going to be able to heal Betty through our relationship? How authentic, empathic, or accepting could I be? How honest? How would I respond when she asked about my feelings toward her? It was my hope that I would change as Betty and I progressed in her (our) therapy. For the time being, it seemed to me that Betty’s social interactions were so primitive and superficial that no penetrating therapist-patient relationship analysis would be necessary.
I had secretly hoped that her appearance would be offset in some way by her interpersonal characteristics—that is, by the sheer vivacity or mental agility I have found in a few fat women—but that, alas, was not to be. The better I knew her, the less interesting she seemed.
During the first few sessions, Betty described, in endless detail, problems she encountered at work with customers, co-workers, and bosses. She often, despite my inner groans, described some particularly banal conversation by playing several of the roles—I’ve always hated that. She described, again in tedious detail, all the attractive men at work and the minute, pathetic machinations she’d go through to exchange a few sentences with them. She resisted every effort on my part to dip beneath the surface.
Not only was our initial, tentative “cocktail chatter” indefinitely prolonged, but I had a strong sense that, even when we got past this stage, we would remain fused to the surface of things—that as long as Betty and I met, we were doomed to talk about pounds, diets, petty work grievances, and the reasons she did not join an aerobics class. Good Lord, what had I gotten myself into?
Every one of my notes of these early sessions contains phrases such as: “Another boring session”; “Looked at the clock about every three minutes today”; “The most boring patient I have ever seen”; “Almost fell asleep today—had to sit up in my chair to stay awake”; “Almost fell off my chair today.”
While I was considering shifting to a hard, uncomfortable chair, it suddenly occurred to me that when I was in therapy with Rollo May, he used to sit in a straight-backed wooden chair. He said he had a
bad back, but I knew him well for many years afterward and never heard him mention back trouble. Could it be that he found me——?
Betty mentioned that she hadn’t liked Dr. Farber because he often fell asleep during their hour. Now I knew why! When I spoke to Dr. Farber on the phone, he did not mention his naps, of course, but he did volunteer that Betty had not been able to learn how to use therapy. It was not hard to understand why he had started her on medication; we psychiatrists so often resort to that when we cannot get anything going in therapy.
Where to start? How to start? I struggled to find some handhold. It was pointless to begin by addressing her weight. Betty made it clear immediately that she hoped therapy would help her get to the point where she could seriously consider weight reduction, but she was a long way from that at this time. “When I’m this depressed, eating is the only thing that keeps me going.”
But when I focused on her depression, she presented a persuasive case that depression was an appropriate response to her life situation. Who wouldn’t feel depressed holed up in a small furnished apartment in an impersonal California suburb for eighteen months, torn away from one’s real life—one’s home, social activities, friends?
So I then attempted to help her work on her life situation, but I could make little headway. She had plenty of daunting explanations. She didn’t make friends easily, she pointed out: no obese woman does. (On that point I needed no persuasion.) People in California had their own tight cliques and did not welcome strangers. Her only social contacts were at work, where most of her co-workers resented her supervisory role. Besides, like all Californians, they were jocks—into surfing and skydiving. Could I see her doing that? I swept away a fantasy of her slowly sinking on a surfboard and acknowledged she had a point—those did not seem to be her sports.
What other options were there? she asked. The singles world is impossible for obese people. To prove that point, she described a desperation date she had had the month before—her only date in years. She answered an ad in the personal section of The Bay Guardian, a local newspaper. Although most of the ads placed by men explicitly specified a “slim” woman, one did not. She called and arranged to go out to dinner with a man named George, who asked her to wear a rose in her hair and to meet him in the bar of a local restaurant.
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