Jung At Heart
Things to worry about...
This year I will have been doing what I do for 38 years. I started out in community mental health, in the heyday of that movement back in the early 70's, and in those days I worked with young children and their families. My first job was to design and direct a therapeutic nursery school program in Lewiston, Maine. In those days we really embraced the idea of a multi-disciplinary team and on my team, all of the professionals had an equal voice. So the classroom teacher was seen as having the same degree of importance as I, the psychologist, or our consulting psychiatrist. We talked about the kids and families we worked with and developed treatment plans *together*. And we were working with some pretty disturbed kids from very chaotic households. In the nearly 3 years I worked there, I could count on the fingers of one hand the number of children who were placed on psychiatric drugs and none were diagnosed as bi-polar because in those days we did not believe, nor do I today, that such a diagnosis can be made in kids that young. Our operative assumption was that by working in the classroom with the kids, and working with the parents, often utilizing paraprofessionals who spent time in the home, we could make a big difference in the lives of these kids and their families and head off serious problems later. And, we were pretty successful.
The key to what we did was that we really worked as a a team. Three years later, after the first couple of rounds of draconian cuts in funding for community mental health, things changed. And in my next job, in a satellite clinic which was part of a large medical center, there was hardly more than lip service given to the notion of a team of professionals, all with important and unique skills. In that setting, I had to present my cases in staffing conferences each week and get the approval of the psychiatrist for my treatment plan. I still worked with young children and I also did school consultation. This psychiatrist had no training in working with children and knew nothing about school consultation, yet he had to approve any plan I made and he could modify them. I was seen as something of an extension of him rather than as a professional in my own right. That was when I left to enter private practice.
I am a big fan of Ars Psychiatrica. He impresses me as someone who is thoughtful and careful in his work. We don't always see things the same way, but he makes a thoughtful case for what he does, as indeed I hope I do as well.
In his most recent post on antidepressants he says:
But if, as the commenter to the previous post suggested, the primary function of the doctor must be the relief of suffering, what happens when the doctor's tools are in fact too weak to accomplish this, or what is more complicated, what happens when the effect of those tools is owing to their wielders' social power rather than to any inherent properties (i.e. the placebo effect)?
Which I believe gets to one of the nubs of the problems we are seeing in the field today. And some of that is about the hierarchical system which still prevails. In private practice, it is very rare, in my experience and that of therapists I know well, for a psychiatrist to really talk with therapists about what we all do and how we can best, together, meet the needs of our patients. That kind of time is certainly not reimbursable, which is one factor that probably operates against it at least unconsciously. But it is also about how we think about each other and how we see our responsibility to relieve suffering. And then of course there is the influence of insurance companies.
There is another horrific story of over-medication of a preschooler in today's New York Times . Sadly these stories no longer surprise me, though it is interesting to me that it is in the business section, not health. We have heard over the last year or so about the awful fact of high numbers of poor children and children in foster care being on psychiatric medications, and often those medications are atypical antipsychotics. So that fact is not new. But look at what one of the doctors quoted in the article says:
Dr. Edgardo R. Concepcion, the first child psychiatrist to treat Kyle, said he believed the drugs could help bipolar disorder in little children. “It’s not easy to do this and prescribe this heavy medication,” he said in an interview. “But when they come to me, I have no choice. I have to help this family, this mother. I have no choice.” (bolding is mine)
and later
“But if you will commit yourself in giving these children these medicines, you have to have a diagnosis that supports your treatment plan. You can’t just give a nondiagnosis and give them the atypical antipsychotic.”
The desire to help is certainly admirable but the first intervention is not behavioral; a behavioral intervention came only a couple of years later when this child was on his way to becoming a psychiatric cripple. The behavioral approach was a last resort rather than a first one.
I am not working with young children any longer. But I worry about them and I worry about us too and what we are doing. And wonder why we can't find a way to talk to each other about how we can help each other in our work.
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"
The Quest for Both/And
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.
Huge and other fat related thoughts
I am not going to post after every episode of Huge but I certainly hope I am interesting you all in watching this show. Every episode I wonder where these people were when I was a fat teenager.
On the Huge website, they are running blogs by the characters which offer further insights into who they are and the issues they struggle with. Take these two, one by Wil and the other by Amber.
From Wil’s, after the first episode:
I hope Rand [the camp director] doesn’t think I’m now going to get all gung-ho about camp and start opening up in sharing circle about how I secretly YEARN to shed my fat-cocoon and emerge from this summer a beautiful butterfly. I’m not gonna forget they’re making money off us and everything that’s screwed up about that (like the fact that they even let in girls like A and C with crazy body image issues). That is My Promise To me. I feel like as long as I don’t lose my mind and start obsessing over my OMG FAT (OHNOES), I’ll be alright. It’s not like the exercise can hurt me (except I am sore as hell). And there are a few good things about this place. Ian for one. I doubt I’d meet anyone as cool as him staying at my uncle’s place. Or anywhere. And the girls in my cabin (well, most of them) are pretty okay.
Wil is allowed to be transgressive, to choose not to buy into the fat phobia all around her, even in this camp. This is a very big deal because the cultural climate today would far more likely want her to be miserable and wanting to do anything to get thin. To see a fat character who is not apologizing about herself is actually revolutionary.
And from Amber’s, after the second episode:
Some of the people here are really big. Bigger than I can ever imagine getting. I feel kind of weird around them. I’m not sure what they think when they look at me. Everyone is really nice (except Will obvs), I just feel guilty I guess. For feeling relieved that I’m not that big, and also for feeling like I’d die if I ever was. I don’t get how Will can be the way she is — I mean so proud and not caring about how fat she is. I used to think it was an act, but I’m not sure anymore. My biggest fear used to be that I’d start believing what my mom says, that I’m not really fat, and that would be worse because then I’d be a fat girl who didn’t know it. But it’s not like Will doesn’t know. She just doesn’t care.
Amber is far more like we expect such girls to be. Notice that she is careful to note that there are girls fatter than she is and her anxiety about what it would be to be fat and not know. She is the one girl in the group who can pass in both the fat and the thin world. And in episode 3, we see her silent struggle not to sell out and betray the group she actually belongs to when several kids from another camp think she is one of them rather than one of the fat kids. Her dialogue with herself in this diary excerpt is no doubt familiar to anyone who has been in her position.
For myself, at least just for me right now, I am working on a long piece, personal reflections on fat and musing about its meaning. Here is one of the thoughts I am working with --
To cast or project blame is to protect ourselves from our own shadow. We stand in the place of righteousness, and fail to acknowledge those aspects of ourselves hidden in our own shadow. The scapegoating of another person or group allows us to feel guiltless, atoned. It inoculates us against blame. Now unburdened, we can turn to our ego ideal and reestablish our place among the chosen. We are then free to place goodness in one corner (ours) and malevolence in another. Only when we catch ourselves stepping into a righteous, one-sided stance are we in a position to begin to observe our own shadow. This is a very painful thing to do. Why would we do this? Because what we keep in the shadows, in a place of forgetfulness, turns to symptom. A symptom is an untended memory. It is the voice of a forgotten or banished part of ourselves… Memory is the medicine of the psyche - even, and especially when the memories are dark. - George Callan
I am working to find the space between fat acceptance, which I believe is important, if only because fat acceptance encourages people to live a life of dignity regardless of body size or weight, and what I believe with all my Jungian heart --that fat is meaningful. It tells me that we develop symptoms when we are stuck in old patterns and fail to integrate creative potentials within our personality. Symptoms are not to be avoided or downplayed, but the meaning, which has often heretofore been missed, needs to be discovered in order for healing to take place. I start with a big question -- just what is fat a symptom of?
Regular posting will now resume
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.