In our book A Womb of Her Own (Routledge 2017) author Meredith Darcy writes about the treatment of a difficult patient during her first pregnancy.
Abbot was one of my first patients in private practice, referred to me as part of a post-graduate training program specializing in eating disorders. I was 34 when I started working with Abbot. For three years prior, I had been working exclusively with children and adolescents, doing play therapy with foster kids. While being both eager and excited to begin working with adults and to build my private practice, I was also attempting to build my family; my husband and I had been trying for several years to conceive a child. Working with these children had begun to take its toll on me—I had wanted them all, and my anger at the parents and the foster care system had become too intense for me to bear. My private practice was the much-needed respite (or so I thought) from the toils and torments of working with the unlucky, and sometimes uncared for, foster children I had been devoting my time and energy to.
A Difficult Patient
Abbot, called Abby, was a prickly middle-aged woman. Upon our first meeting she questioned my age and youthful appearance (“you look like a baby”), my training, and whether I could in fact help her. She was reluctantly seeking individual psychotherapy—an overeating support group at a local treatment center required conjunctive individual therapy. Abby immediately remarked on my unfortunate choice of office décor. When she commented that my expensive, modern, leather therapist chair, a coveted piece I was quite happy with, was “the ugliest piece of furniture that she had ever laid eyes on,” I found myself unexpectedly laughing aloud, being both caught off guard and entertained by her “honesty” and lack of decorum. Usually upon entering my office, she would adjust the venetian blinds to her liking. This would never bother me.
I found her brashness disarming, and , although well aware she was working quite hard to keep me at a safe distance, she intrigued me. Abby tried to be cold and would intellectualize her feelings, but she had a charm, spirit and boldness (often called chutzpah) that I truly enjoyed and even admired. I found her challenging, off-putting manner to be very familiar.
My Own Background
I come from a very loud, intrusive, competitive, hypercritical Eastern European-Jewish family. Having been in psychoanalytic psychotherapy for over a decade at this point, I had learned a certain way to emotionally manage these loved, yet off-putting cast of characters, and it was a relief to finally not take their insults and criticisms personally. It was liberating to understand that the pain a person may be consciously or unconsciously attempting to inflict, was coming from his or her own discomforts and not (only) from me. Eventually, I could spend time with a difficult great-aunt, who could never understand the “rats nest of hair” upon my head and my aversion to a hairbrush. I understood this was her (unfortunate as it may be) way of connecting, with the world and me. And I accepted it, and her, and would “enjoy” (in retrospect, tolerate) her company nonetheless.
Somatizing Overwhelming Affect
Abby had difficulties relating to others and would use food to self-soothe and regulate affect. As with many people with eating disorders, Abby would concretize her emotional experience; she was not able to think symbolically. She experienced her feelings as literally being in her body. Therefore if her problem was experienced in body, she would do something to the body to relieve this discomfort (e.g. compulsive overeating). She felt “badly” and therefore she was bad—ashamed of her self and needs. Concretizing neediness in the body makes it more possible to actually manage and control such needs (Sands 2003), because the body can be used in a way that purely affective experience cannot: eating disorders provide a concrete, doable solution to the experience of intolerable, overwhelming affect and need.
Sands,S. 2003. The Subjugation of the Body in Eating Disorders. Psychoanalytic Psychology. 20: 103-116