by Edith Eger
Today I have been assigned two new patients, both Vietnam veterans, both paraplegics. They have the same diagnosis (lower T-injury of the spinal cord), the same prognosis (compromised fertility and sexual function, unlikely to walk again, good control of hands and trunk). On my way to see them, I am unaware that one of them will have a life-changing effect on me. I meet Tom first. He is lying on his bed, curled up in a fetal position, cursing God and country. He seems imprisoned—by his injured body, by his misery, by his rage.
When I go to the other vet’s room, I find Chuck out of bed and sitting in his wheelchair. “It’s interesting,” he says. “I’ve been given a second chance in life. Isn’t it amazing?” He is brimming over with a sense of discovery and possibility. “I sit in this wheelchair, and I go out on the lawn, out on the grounds, and the flowers are much closer. I can see my children’s eyes.”
The way I tell this story now, when I’m talking to my current patients, or addressing an audience from the stage, is that every person is part Tom and part Chuck. We are overwhelmed by loss and think we will never recover a sense of self and purpose, that we will never mend. But despite—and, really, because of—the struggles and the tragedies in our lives, each of us has the capacity to gain the perspective that transforms us from victim to thriver. We can choose to take responsibility for our hardships and our healing. We can choose to be free. What I still have trouble admitting, however, is that when I first met Tom, his rage thrilled me.
“Fuck America!” Tom screams as I enter his room that day. “Fuck God!” I think to myself: He is letting all that anger out. And witnessing his fury calls out the huge rage in me, the need to express it, release it. Fuck Hitler! Fuck Mengele! It would be such a relief. But I am the doctor here. I have to assume a role, present myself as in control and having solutions, even though inside I want to punch a wall, kick down a door, scream and cry and fall apart on the floor. I look at my badge, Dr. Eger, Department of Psychiatry, and for a moment it seems to read, Dr. Eger, Impostor. Who is the real me? Do I know who I am? I’m so scared of the feeling, of the mask falling apart, of seeing how broken I am, of all the rage that pushes at me: Why me? How could this happen? My life has been changed irrevocably, and I’m furious.
It was thrilling to watch Tom because he was so overt about expressing what I’d been hiding. I’d been too afraid of others’ disapproval or anger, afraid of anger itself as a destructive force. I hadn’t let myself feel the feelings, afraid that if I started to let them out, I might never stop, I’d become a monster. In a way, Tom was freer than I was, because he was giving himself permission to feel the rage, to say the words, the ones that I could barely allow myself to think, much less speak. I wanted to get down on the floor and rage with him.
In therapy I timidly say I want to try it, I want to express that rage, but with a professional there to help pull me out if I get stuck in it. I get on the floor. I try to yell, but I can’t, I’m too scared, I curl into a smaller and smaller ball. I need to feel a limit around me, a boundary, I need to feel something to push against. I tell my therapist to sit on me. He is heavy, his weight almost suffocates me. I think I’m going to pass out. I am about to tap the floor, to beg him to let me up, to give up this silly experiment. But then a scream comes out of me, so long and full and anguished that it frightens me, what awful wounded thing would make a noise like that? But I can’t stop making the sound. It feels good. More than thirty years of silenced ghosts come roaring out of me now, the full-throated outpouring of my sorrow. It feels good. I scream, I scream, I push against the weight bearing down on me. My therapist doesn’t make it easy, and the effort makes me cry and sweat.
What happens? What happens when the long-denied part of me is let out?
Nothing happens.
I feel the force of the rage, and it doesn’t kill me after all.
I’m okay. I’m okay. I’m alive.
It still isn’t easy for me to talk about the past. It is deeply painful to confront the fear and the loss all over again each time I remember or recount it. But from this moment on, I understood that feelings, no matter how powerful, aren’t fatal. And they are temporary. Suppressing the feelings only makes it harder to let them go. Expression is the opposite of depression.
In 1978, my son, John, graduated from the University of Texas, one of the top ten students, and I earned my PhD in clinical psychology. It was a triumphant year for our family. I decided to pursue my licensure in California because it was the toughest state (there I was, putting on the red shoes again!), and beyond the ego needs of proving my worth (as though a piece of paper could accomplish that), California licensure had the practical advantage of allowing me to practice anywhere in the country. I remembered Béla’s struggle to earn his CPA license, and I girded myself for a difficult journey.
I needed three thousand clinical hours to sit for the exam, but I doubled the requirement. I didn’t even sign up to take the exam until I had six thousand hours—almost all at William Beaumont, where I had developed such a good reputation that I was asked to conduct sessions behind one-way glass, so that my fellow clinicians could observe my way of building rapport, establishing trust, and guiding patients toward new choices. Then it was time to face the written test. I was terrible at multiple-choice tests—I had to study for months even to pass the driving test. Somehow, through gritty persistence or sheer luck, I passed the written exam. But not on my first try.
Finally, I sat for the oral exam, which I thought would be the easiest part of the process. Two men conducted the interview, one who wore blue jeans and had long hair pulled back in a ponytail, and another who wore a suit and had a crew cut. They grilled me for hours. The man with long hair spoke sharply, tersely, asking me all the questions about statistics, ethics, and legal matters. The man with the crew cut asked all the philosophical questions, the ones that got my mind working more creatively, my heart more engaged. Overall, though, it was an unpleasant experience. I felt stiff and numb and vulnerable. The examiners didn’t make it easy—their expressionless faces, cold voices, and emotional distance were alienating. It was hard to put my energy into the next question when each previous one left me churning with self-criticism, with the desire to go back and revise what I had said, to say something, anything, that would elicit a nod of recognition or encouragement. When the exam finally ended, I felt dazed, my hands shook, I was both starving and nauseated, my head hurt. I was sure I had blown it.
Just as I reached the front door, I heard footsteps behind me, someone running to catch up. Had I left my purse behind in my disorientation? Were they telling me already that I had failed? “Dr. Eger,” the man with the crew cut called. I braced myself, as though awaiting a punishment. He reached me, paused to catch his breath. My jaw and shoulders clenched. At last the man extended his hand. “Dr. Eger, it was an honor. You have a wealth of knowledge. Your future patients are very lucky indeed.”
When I got back to my hotel, I jumped on the bed like a little girl.
CHAPTER 16
The Choice
MY JOYOUS OPTIMISM, my sense of professional accomplishment, my feeling that I was reaching a full embodiment and expression of myself all withered when I established my private practice and met my first patient. I visited him in the hospital where he had been living for a month, awaiting diagnosis and undergoing treatment for what turned out to be stomach cancer. He was terrified. He felt betrayed by his body, threatened by his mortality, overwhelmed by the uncertainty and loneliness of illness. And I couldn’t reach him where he was. All of my skill in establishing a climate of warmth and trust, in building a bridge between me and my patient, had disappeared. I felt like a child dressed up in a doctor’s white coat. A fake. My expectations of myself were so high, my fear of failure so toppling, that I couldn’t see past my own self-absorption to reach the man who was asking for my help and my love. “Will I ever be healthy again?” he asked, and my mind flipped like a Rolodex, spinning through theories and techniques, my eyes pointed at
the wall, trying to mask how nervous and scared I was. I was of no help to him. He didn’t invite me back. I realized, as I had when I met Tom, the paraplegic veteran, that my professional success had to come from a deeper place within me—not from the little girl trying to please others and win approval but from my whole and authentic self, the one who was vulnerable and curious, who was accepting of herself and ready to grow.
In other words, I began to formulate a new relationship with my own trauma. It wasn’t something to silence, suppress, avoid, negate. It was a well I could draw on, a deep source of understanding and intuition about my patients, their pain, and the path to healing. My first years of private practice helped me to reframe my wound as something necessary and useful, and to shape and develop my most enduring therapeutic principles. Often the patients I worked with mirrored my own discoveries about the journey to freedom. Equally often they taught me that my search for freedom wasn’t complete—and they pointed me in the direction of further healing.
Although Emma was the identified patient, I met her parents first. They had never spoken to anyone, least of all a stranger, about the secret in their family: Emma, their oldest child, was starving herself to death. They were private, reserved people, a conservative German American family, their faces creased with worry, eyes filled with fear.
“We’re looking for practical solutions,” Emma’s father told me that first visit. “We have to get her to start eating again.”
“We heard that you’re a survivor,” Emma’s mother added. “We thought Emma could learn something from you, that you might inspire her.”
It was heartbreaking to see their panic for Emma’s life, to see their shock. Nothing in life had prepared them for a child with an eating disorder; they had never considered that something like this could happen to their daughter and their family, and none of their existing parenting tools was having a positive effect on Emma’s health. I wanted to reassure them. I wanted to ease their distress. But I also wanted them to begin to see a truth that might be even more painful for them to acknowledge than Emma’s illness—that they had a part in it. When a child is grappling with anorexia, the identified patient is the child, but the real patient is the family.
They wanted to tell me every detail of Emma’s behaviors that concerned them: the food she refused to eat, the food she pretended to eat, the food they would find tucked inside napkins after family meals, the food they discovered stuffed into her dresser drawers, the ways she pulled away from them and retreated behind closed doors, the terrifying changes in her body. But I asked them instead to talk about themselves, which they did with obvious discomfort.
Emma’s father was short and compact—he was a soccer player, I learned. He looked a little like Hitler, I realized with unease—he had a thin mustache and dark, pressed hair, and a way of barking when he talked, as though behind every communication was the insistence on not being ignored. Later I would have individual sessions with each of Emma’s parents, and I would ask her father how he had decided on his career as a police officer. He told me that as a boy he had walked with a limp, and his father had called him Shrimpy-Limpy. He chose to be a police officer because it required risk taking and physical strength; he wanted to prove to his father that he wasn’t a shrimp or a cripple. When you have something to prove, you aren’t free. Even though I didn’t yet know anything about his childhood during our first visit, I could tell that Emma’s father was living in a prison of his own making—he was living within a limited image of who he should be. He behaved more like a drill sergeant than a supportive husband or concerned father. He didn’t ask questions; he ran an interrogation. He didn’t acknowledge his fears or vulnerabilities; he asserted his ego.
His wife, who wore a tailored cotton dress with buttons down the front and a thin belt, a look that was both timeless and no-nonsense, seemed hyperattuned to his tone and speech. He talked for a few minutes about his frustrations at work when he was skipped over for a promotion, and I could see her searching for a careful balance point between affirming his indignation and stoking his anger. She had clearly learned that her husband needed to be right, that he couldn’t handle being confronted or contradicted. In our private session, I would be impressed by her resourcefulness—she mowed the lawn and did many of their home repairs, she made her own clothes—and the seeming contradiction between her skills and the power she gave over to her husband, the price she paid to keep the peace. Her habit of avoiding conflict with her husband at all costs was as damaging to her daughter’s health and their family dynamic as were his domineering behaviors. They were partners in making control—not empathic connection, not unconditional love—the language of the family.
“This is a waste of time,” Emma’s father finally said during our first visit, after answering my questions about his job, their family routines, how they celebrated holidays. “Just tell us what to do.”
“Yes, just tell us how we can get Emma to come to the table at mealtime,” her mother begged. “Tell us how we can make her eat.”
“I can see how worried you are about Emma. I can see how desperate you are for answers and fixes. And I can tell you that if you want Emma to get well, your first job is to understand that with anorexia, the issue isn’t only what Emma eats; it’s also about what’s eating her.” I couldn’t just fix her and send her back, her healthy self, I told them. I invited them to help me, to be my cotherapists, to observe their daughter, but not with the agenda of making her do or be anything different, just paying attention to her emotional states and behaviors. Together we could build a clearer picture of her emotional landscape and get more familiar with the psychological aspects of the disease. By enlisting their help and cooperation, I hoped to lead them toward an understanding of their part in her illness. I was nudging them toward taking responsibility for the way they contributed to what was eating Emma.
The following week, I met Emma for the first time. She was fourteen years old. It was like meeting my own ghost. She looked like I had at Auschwitz—skeletal, pale. She was wasting away. Her long, stringy blond hair made her face look even thinner. She stood in the doorway of my office, her too-long sleeves pulled all the way down over her hands. She looked like a person with a secret.
With any new patient, it’s important to be sensitive to his or her psychological boundaries from the very first moments of our initial encounter. I must intuit immediately if this is a person who wants me to take her hand or keep my physical distance, if this is a person who needs me to give him an order or a gentle suggestion. For a patient with anorexia—a disease that is all about control, about relentless rules for what and when you eat or don’t eat, for what you reveal or conceal—these first moments are critical. For one thing, anorexia has an inescapable physiological dimension. Because of the lack of nutrients entering the body, and because the bulk of the few calories consumed go to autonomic functions (breathing, elimination), the brain is deprived of blood flow, and this leads to distorted thinking and, in severe cases, paranoia. As a psychologist beginning a therapeutic relationship with a person with anorexia, I have to remember that I’m communicating with a person who likely has distorted cognitive functioning. It’s easy for a habitual gesture—putting a hand on someone’s shoulder as I guide her to a comfortable chair, for example—to be misinterpreted as threatening or invasive. As I greeted Emma for the first time, I tried to simultaneously warm and neutralize my body language. Because someone with anorexia is an expert at control, it’s important to disarm her need for control by offering freedom. At the same time, it’s vital to create a structured environment where there is safety in clear rules and rituals.
Having met her parents, I knew that the home language was full of criticisms and blame, so I began our session with a compliment. “Thank you for coming,” I said. “I’m so happy to finally meet you. And thank you for being right on time.”
When she had chosen a seat on the couch, I told her that anything she told me was confidential—unless her life was
in danger. And then I made a soft, open-ended invitation. “You know, your parents are so worried about you. I’m interested to know the real story. Is there anything you’d like to tell me?”
Emma didn’t respond. She stared at the carpet, tugging her sleeves even farther over her hands.
“It’s okay to be silent,” I said.
More silence stretched between us. I waited. I waited some more. “You know,” I said after a while, “it’s fine for you to take as long as you need. I have a little paperwork I need to do. I’m going to go work in the other room. When you’re ready, let me know.”
She eyed me suspiciously. In a home with punitive discipline, children grow accustomed to hearing threats, and these threats can escalate quickly or, at the other extreme, prove empty. Although I was speaking kindly, she was looking to see if my words and tone were going to escalate into an angry criticism or admonition, or if I wasn’t really going to leave the room, if I was just a pushover.
I think she was surprised when I simply stood up, crossed the room, and opened the door. Only then, my hand on the doorknob, did she speak.
“I’m ready,” she said.
“Thank you,” I said, returning to my chair. “I’m happy to hear that. We have forty minutes left. Let’s use them well. Is it okay if I ask you a couple questions?”
She shrugged.
“Tell me about a typical day. What time do you wake up?”
She rolled her eyes, but she answered my question. I continued in this vein. Did she have a clock radio, or an alarm clock, or did her mother or father come to wake her up? Did she like to lie in bed for a while under the covers, or did she jump right out of bed? I asked her mundane questions, getting a sense of her daily life—but none of my questions had anything to do with food. It is so hard for someone with anorexia to see anything in life outside of food. I already knew from her parents that her focus on food was controlling her family, that all of their attention was consumed by her illness. I had a feeling she expected me, too, to be interested only in her illness. With my questions I was trying to shift her attention to other parts of her life, and to dismantle or at least soften her defensive structures.