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.
His face fell, she reported, when he first caught sight of her, but, to his everlasting credit, he acknowledged that he was indeed George and then behaved like a gentleman throughout dinner. Though Betty never again heard from George, she often thought about him. On several other such attempts in the past, she had been stood up by men who probably spotted her from afar and left without speaking to her.
In some desperation, I stretched for ways to be helpful to Betty. Perhaps (in an effort to conceal my negative feelings) I tried too hard, and I made the beginner’s mistake of suggesting other options. Had she considered the Sierra Club? No, she lacked the stamina for hiking. Or Overeaters Anonymous, which might provide some social network? No, she hated groups. Other suggestions met a similar fate. There had to be some other way.
The first step in all therapeutic change is responsibility assumption. If one feels in no way responsible for one’s predicament, then how can one change it? That is precisely the situation with Betty: she completely externalized the problem. It was not her doing: it was the work transfer, or the sterile California culture, or the absence of cultural events, or the jock social scene, or society’s miserable attitude toward obese people. Despite my best efforts, Betty denied any personal contribution to her unhappy life situation.
Oh yes, she could, on an intellectual level, agree that, if she stopped eating and lost weight, the world might treat her differently. But that was too far removed from her, too long term, and her eating seemed too much out of her control. Besides she marshaled other responsibility-absolving arguments: the genetic component (there was considerable obesity on both sides of her family); and the new research demonstrating physiological abnormalities in the obese, ranging from lower basal metabolic rates to the present, programmed, relatively un-influencible body weight. No, that would not work. Ultimately I would have to help her assume responsibility for her appearance—but saw no leverage for achieving that at this time. I had to start with something more immediate. I knew a way.
The psychotherapist’s single most valuable practical tool is the “process” focus. Think of process as opposed to content. In a conversation, the content consists of the actual words uttered, the substantive issues discussed; the process, however, is how the content is expressed and especially what this mode of expression reveals about the relationship between the participating individuals.
What I had to do was to get away from the content—to stop, for example, attempting to provide simplistic solutions to Betty—and to focus on process—on how we were relating to each other. And there was one outstanding characteristic of our relationship—boredom. And that is precisely where countertransference complicates things: I had to be clear about how much of the boredom was my problem, about how bored I would be with any fat woman.
So I proceeded cautiously—too cautiously. My negative feelings slowed me down. I was too afraid of making my aversion visible. I would never have waited so long with a patient I liked more. I spurred myself to get moving. If I were going to be helpful to Betty, I had to sort out, to trust, and to act upon my feelings.
The truth was that this was indeed a boring woman, and I needed to confront her with that in some acceptable way. She could deny responsibility for anything else—the absence of friends in her current life, the tough singles scene, the horrors of suburbia—but I was not going to let her deny responsibility for boring me.
I dared not utter the word boring—far too vague and too hurtful. I needed to be precise and constructive. I asked myself what, exactly, was boring about Betty, and identified two obvious characteristics. First of all, she never revealed anything intimate about herself. Second, there was her damned giggling, her forced gaiety, her reluctance to be appropriately serious.
It would be difficult to make her aware of these characteristics without hurting her. I decided upon a general strategy: my basic position would be that I wanted to get closer to her but that her behavioral traits got in the way. I thought it would be difficult for her to take offense with any criticism of her behavior when framed in that context. She could only be pleased at my wanting to know her better. I decided to start with her lack of self-revelation and, toward the end of a particularly soporific session, took the plunge.
“Betty, I’ll explain later why I’m asking you this, but I’d like you to try something new today. Would you give yourself a score from one to ten on how much revealing about yourself you’ve done during our hour together today? Consider ten to be the most significant revealing you can imagine and one to be the type of revealing you might do, let’s say, with strangers in a line at the movies.”
A mistake. Betty spent several minutes explaining why she wouldn’t go to the movies alone. She imagined people pitied her for having no friends. She sensed their dread that she might crowd them by sitting next to them. She saw the curiosity, the bemusement in their faces as they watched to see whether she could squeeze into a single narrow movie seat. When she began to digress further—extending the discussion to airline seats and how seated passengers’ faces grew white with fear when she started down the aisle searching for her seat—I interrupted her, repeated my request, and defined “one” as “casual conversation at work.”
Betty responded by giving herself a “ten.” I was astonished (I had expected a “two” or “three”) and told her so. She defended her rating on the basis that she had told me things she had never shared before: that, for example, she had once stolen a magazine from a drugstore and was fearful about going alone to a restaurant or to the movies.
We repeated that same scenario several times. Betty insisted she was taking huge risks, yet, as I said to her, “Betty, you rate yourself ‘ten,’ yet it didn’t feel that way to me. It didn’t feel that you were taking a real risk with me.”
“I have never told anybody else these things. Not Dr. Farber, for example.”
“How do you feel telling me these things?”
“I feel fine doing it.”
“Can you use other words than fine? It must be scary or liberating to say these things for the first time!”
“I feel O.K. doing it. I know you’re listening professionally. It’s O.K. I feel O.K. I don’t know what you want.”
“How can you be so sure I’m listening professionally? You have no doubts?”
Careful, careful! I couldn’t promise more honesty than I was willing to give. There was no way that she could deal with my revelation of negative feelings. Betty denied any doubts—and at this point told me about Dr. Farber’s falling asleep on her and added that I seemed much more interested than he.
What did I want from her? From her standpoint she was revealing much. I had to be sure I really knew. What was there about her revealing that left me unmoved? It struck me that she was always revealing something that occurred elsewhere—another time, another place. She was incapable, or unwilling, to reveal herself in the immediate present that we two were sharing. Hence, her evasive response of “O.K.” or “Fine” whenever I asked about her here-and-now feelings.
That was the first important discovery I made about Betty: she was desperately isolated, and she survived this isolation only by virtue of the sustaining myth that her intimate life was being lived elsewhere. Her friends, her circle of acquaintances, were not here, but elsewhere, in New York, in Texas, in the past. In fact, everything of importance was elsewhere. It was at this time that I first began to suspect that for Betty there was no “here” there.
Another thing: if she was revealing m
ore of herself to me than to anyone before, then what was the nature of her close relationships? Betty responded that she had a reputation for being easy to talk to. She and I, she said, were in the same business: she was everyone’s therapist. She added that she had a lot of friends, but no one knew her. Her trademark was that she listened well and was entertaining. She hated the thought, but the stereotype was true: she was the jolly fat woman.
This led naturally into the other primary reason I found Betty so boring: she was acting in bad faith with me—in our face-to-face talks she was never real, she was all pretense and false gaiety.
“I’m really interested in what you said about being, or rather pretending to be, jolly. I think you are determined, absolutely committed, to be jolly with me.”
“Hmmm, interesting theory, Dr. Watson.”
“You’ve done this since our first meeting. You tell me about a life that is full of despair, but you do it in a bouncy ‘aren’t-we-having-a-good-time?’ way.”
“That’s the way I am.”
“When you stay jolly like that, I lose sight of how much pain you’re having.”
“That’s better than wallowing in it.”
“But you come here for help. Why is it so necessary for you to entertain me?”
Betty flushed. She seemed staggered by my confrontation and retreated by sinking into her body. Wiping her brow with a tiny handkerchief, she stalled for time.
“Zee suspect takes zee fifth.”
“Betty, I’m going to be persistent today. What would happen if you stopped trying to entertain me?”
“I don’t see anything wrong with having some fun. Why take everything so . . . so . . . I don’t know——You’re always so serious. Besides, this is me, this is the way I am. I’m not sure I know what you’re talking about. What do you mean by my entertaining you?”
“Betty, this is important, the most important stuff we’ve gotten into so far. But you’re right. First, you’ve got to know exactly what I mean. Would it be O.K. with you if, from now on in our future sessions, I interrupt and point out when you’re entertaining me—the moment it occurs?”
Betty agreed—she could hardly refuse me; and I now had at my disposal an enormously liberating device. I was now permitted to interrupt her instantaneously (reminding her, of course, of our new agreement) whenever she giggled, adopted a silly accent, or attempted to amuse me or to make light of things in any distracting way.
Within three or four sessions, her “entertaining” behavior disappeared as she, for the first time, began to speak of her life with the seriousness it deserved. She reflected that she had to be entertaining to keep others interested in her. I commented that, in this office, the opposite was true: the more she tried to entertain me, the more distant and less interested I felt.
But Betty said she didn’t know how else to be: I was asking her to dump her entire social repertoire. Reveal herself? If she were to reveal herself, what would she show? There was nothing there inside. She was empty. (The word empty was to arise more and more frequently as therapy proceeded. Psychological “emptiness” is a common concept in the treatment of those with eating disorders.)
I supported her as much as possible at this point. Now, I pointed out to Betty, she was taking risks. Now she was up to eight or nine on the revealing scale. Could she feel the difference? She got the point quickly. She said she felt frightened, like jumping out of a plane without a parachute.
I was less bored now. I looked at the clock less frequently and once in a while checked the time during Betty’s hour not, as before, to count the number of minutes I had yet to endure, but to see whether sufficient time remained to open up a new issue.
Nor was it necessary to sweep from my mind derogatory thoughts about her appearance. I no longer noticed her body and, instead, looked into her eyes. In fact, I noted with surprise the first stirrings of empathy within me. When Betty told me about going to a western bar where two rednecks sidled up behind her and mocked her by mooing like a cow, I felt outraged for her and told her so.
My new feelings toward Betty caused me to recall, and to be ashamed of, my initial response to her. I cringed when I reflected on all the other obese women whom I had related to in an intolerant fashion.
These changes all signified that we were making progress: we were successfully addressing Betty’s isolation and her hunger for closeness. I hoped to show her that another person could know her fully and still care for her.
Betty now felt definitely engaged in therapy. She thought about our discussions between sessions, had long imaginary conversations with me during the week, looked forward to our meetings, and felt angry and disappointed when business travel caused her to miss meetings.
But at the same time she became unaccountably more distressed and reported more sadness and more anxiety. I pounced at the opportunity to understand this development. Whenever the patient begins to develop symptoms in respect to the relationship with the therapist, therapy has really begun, and inquiry into these symptoms will open the path to the central issues.
Her anxiety had to do with her fear of getting too dependent or addicted to therapy. Our sessions had become the most important thing in her life. She didn’t know what would happen to her if she didn’t have her weekly “fix.” It seemed to me she was still resisting closeness by referring to a “fix” rather than to me, and I gradually confronted her on that point.
“Betty, what’s the danger in letting me matter to you?”
“I’m not sure. It feels scary, like I’ll need you too much. I’m not sure you’ll be there for me. I’m going to have to leave California in a year, remember.”
“A year’s a long time. So you avoid me now because you won’t always have me?”
“I know it doesn’t make sense. But I do the same thing with California. I like New York and I don’t want to like California. I’m afraid that, if I form friends here and start to like it, I might not want to leave. The other thing is that I start to feel, ‘Why bother?’ I’m here for such a short time. Who wants temporary friendships?”
“The problem with that attitude is you end up with an unpeopled life. Maybe that’s part of the reason you feel empty inside. One way or another, every relationship must end. There’s no such thing as a lifetime guarantee. It’s like refusing to enjoy watching the sun rise because you hate to see it set.”
“It sounds crazy when you put it like that, but that’s what I do. When I meet a new person whom I like, I start right away to imagine what it will be like to say goodbye to them.”
I knew this was an important issue, and that we would return to it. Otto Rank described this life stance with a wonderful phrase: “Refusing the loan of life in order to avoid the debt of death.”
Betty now entered into a depression which was short-lived and had a curious, paradoxical twist. She was enlivened by the closeness and the openness of our interaction; but, rather than allow herself the enjoyment of that feeling, she was saddened by the realization that her life heretofore had been so devoid of intimacy.
I was reminded of another patient I had treated the year before, a forty-four-year-old excessively responsible, conscientious physician. One evening in the midst of a marital dispute, she uncharacteristically drank too much, went out of control, threw plates against the wall, and narrowly missed her husband with a lemon pie. When I saw her two days later, she seemed guilty and depressed. In an effort to console her, I tried to suggest that losing control is not always a catastrophe. But she interrupted and told me I had misunderstood: she felt no guilt but was instead overcome with regret that she had waited until she was forty-four to relinquish her control and let some real feelings out.
Despite her two hundred and fifty pounds, Betty and I had rarely discussed her eating and her weight. She had often talked about epic (and invariably unproductive) struggles she had had with her mother and with other friends who tried to help her control her eating. I was determined to avoid that role; instead, I placed my faith
in the assumption that, if I could help remove the obstacles that lay in her path, Betty would, on her own, take the initiative to care for her body.
So far, by addressing her isolation, I had already cleared away major obstacles: Betty’s depression had lifted; and, having established a social life for herself, she no longer regarded food as her sole source of satisfaction. But it was not until she stumbled upon an extraordinary revelation about the dangers of losing weight that she could make the decision to begin her diet. It came about in this way.
When she had been in therapy for a few months, I decided that her progress would be accelerated if she worked in a therapy group as well as in individual therapy. For one thing, I was certain it would be wise to establish a supportive community to help sustain her in the difficult diet days yet to come. Furthermore, a therapy group would provide Betty an opportunity to explore the interpersonal issues we had opened up in our therapy—the concealment, the need to entertain, the feeling she had nothing to offer. Though Betty was very frightened and initially resisted my suggestion, she gamely agreed and entered a therapy group led by two psychiatric residents.
One of her first group meetings happened to be a highly unusual session in which Carlos, also in individual therapy with me (see “If Rape Were Legal . . . “), informed the group of his incurable cancer. Betty’s father had died of cancer when she was twelve, and since then she had been terrified of the disease. In college she had initially elected a premedical curriculum but gave it up for fear of being in contact with cancer patients.
Over the next few weeks, the contact with Carlos generated so much anxiety in Betty that I had to see her in several emergency sessions and had difficulty persuading her to continue in the group. She developed distressing physical symptoms—including headaches (her father died of brain cancer), backaches, and shortness of breath—and was tormented with the obsessive thought that she, too, had cancer. Since she was phobic about seeing doctors (because of her shame about her body, she rarely permitted a physical exam and had never had a pelvic exam), it was hard to reassure her about her health.