Transference and Countertransference in Working with Eating Problems – Part II

Transference and Countertransference in Working with Eating Problems – Part II

By Susan Gutwill, LCSW

(This is the second of a 2-part series on the issues of transference and countertransference.  To read part 1 click here)

Cultural Transference and Countertransference and Body Co-Motion

Treating eating problems and body insecurity requires us to think about transference and countertransference not only from the perspective of the individual client and therapist in their therapy relationship. It also asks us to explore the impact on clients and therapists alike as they are both affected by the society in which these problems are created.

In our culture, eating and body image suffering derives from the intersection of late consumer capitalism and its form of patriarchy. Women, and their bodies, though falsely idealized, are simultaneously controlled and denigrated in our culture. No matter how many millions of pictures of “the ideal woman” we see in our lives, we can never be hard, strong, thin, or young enough, to feel safe within ourselves. The images we see 300-400 times a day are false, airbrushed, starved, stripped, sexualized, and forever, “on offer” for “the other,” men, the male gaze, and to women who will compete with us. False images of the acceptable female body are literally impossible to achieve.  These images are on the one hand, the carrot, or as the mafia might say the “offer we cannot refuse.”  However, on the other hand, their implicit message is the stick: “Though you are not good enough, you cannot stop trying to become good enough, beyond reproach.”  “Watch what you eat and exercise,” is its rallying cry.

This cultural environment is passed along through parents and important relationships, but also directly through our own senses as we see, hear, and feel the cultural messages.  Women become so afraid to trust our own internal environment’s signals about when to eat, how much to eat, and what to eat. In fact, many women do not know what those signals feel like; they forget biological inheritance.   Instead, we are taught that we are forever in danger of getting it wrong. It is tragic, because attunement to physiological hunger and satiation are not only about food, they represent more far reaching psycho-somatic achievements.  Hunger is also a metaphor for safe desire, ambition, and being entitled to care for ourselves as well as others. Satiation teaches us about mourning the real limits of life. “I cannot digest anymore now,” is a metaphor for grieving the small deaths in the reality of life, e.g. I can have this much but not everything.  This is a lesson that the system of capitalism cannot contain, even if it means destroying our mother, the earth, and its ability to nurture. Choosing what to eat is a metaphor for how to be safe in choosing whom to love, to trust.

Eating with hunger, satiation, and food choice, therefore, are certainly cognitive and behavioral goals.  But, they allow the development of a full “potential” self, as well.

We at The Women’s Therapy Centre use the term eating problems because the term eating disorders implies that this suffering is predominantly an individual illness, a medical problem, a form of personal pathology, rather than the norm for women.

Of course severe anorexia and bulimia actually threaten lives; they do often need medical attention.  But all eating problems/disorders derive from the social norm that tells women, a) what to feed to others and b) even more, what we must not feed to ourselves. The social norm for women requires us to discipline our many other appetites so that we can more closely achieve the ideal image of the female body and female responsibility to nurture others before all else.  Lynne Layton calls these lessons part of “the normative unconscious,” an unconscious sense of what is “right,” based in the institutions, the practices, and the ideology of our social system.  (^[i]Layton)

When we include compulsive eating and the diet mentality (“I shouldn’t be eating this.”) to anorexia, bulimia, and orthorexia, eating and body image problems affect about 90% of all women. Therapists and clients alike, share the everyday fear of food and body insecurity.  As members of our particular society, we are all participant/observers and cruelly engaged in “the war” on one of life’s most dreaded dangers, “obesity.”

The preoccupation with fat crosses lines of social class, race, ethnicity, and sexualities.  Women in all of these groups share the fear of food and body insecurity.  There are differences within each group’s history and placement in society, black and white women, each ethnicity, all along the gender/sexual preference continuum of gay, straight, bisexual, trans, and queer persons.  But they all share the social control, the incitement of a terror of being fat, denigrated, and devalued.

Cultural countertransference is the name I give to this inevitable experience which requires comparing our bodies and eating habits to each other.   Sexist culture sets women up against each other, as we face the challenges of how we “measure up to the idealized image of women.” We make conscious and unconscious relationships to cultural symbols and to the society for which they stand.(^[ii]Gutwill).   These relationships, like those to our parents, are also psychologically internalized as unconscious and embodied experiences.  Carol Gilligan calls this the “wall of culture.”  When we hit the wall, we are actually regressed in our previously achieved general psychosomatic development.  The images of consumer culture can actually regress us.  Our society symbolically scolds each one of us for not being ideal. Instead, we are endlessly encouraged to become our own jailers. (^[iii]Gutwill and Foucoult)  We experience our bodies as malleable and do not have a stable sense of body safety so the social message is ever more powerful. (^[iv]Orbach)

Therefore, it is inevitable that in almost all treatments, female patients and their therapists share many feelings which are instantaneously and consciously transformed from feeling language into eating and body language. The results create underlying transference/countertransference   “co-motions.”

A therapist or patient might feel: “I wish I could be that disciplined.” “I wish I had that body.” “I suddenly can’t stand this woman.” “I think she is judging my body.” “I am suddenly checking the size of my thighs and they are huge and don’t even talk about the rolls around my middle.”  Patients are sometimes unable to look at their therapists’ bodies.  It feels dangerous, as if it could overturn the patient’s “idealization” of the therapist.  At certain early times in trust, in fact, that might not be useful.  But at some point it is necessary.

One day a colleague who was seeing a man afraid of intimacy with his girlfriend, called the therapist “round. “The therapist asked what does “round” mean to you?  He replied saying round was fine but he preferred his girlfriends to be slender.  Upon exploration they came to realize that the female therapist had asked, when he spoke about leaving this girlfriend, if he was afraid of being close to her and, if so, why.  After that discussion, he realized he saw the therapist as fat because he was angry with her about being challenged to look at his own fears being known.   Until they realized this, my colleague, who is generally comfortable in her body, felt fat.

Often therapists will find they feel heavy or too small or weak in the middle of a session. They might sit taller in the chair to hide fat and rolls or appear bigger then they might, shift this way or that to make their hips look smaller, feel their skin suddenly aging and lift their chin to hide the age.  That is time to wonder about what is being induced in the “body co-motion” of countertransference.

Strategies for Working with Countertransference in Cognitive Behavioral Work

In treatment, we need to teach the facts about a) the dangers of yo-yo dieting, b) how diets create binges, c) how 95% of dieters gain back more than they lose over a short or somewhat longer time, and d) The diet industry profits from our failure and our addiction to dieting. These facts are a necessary piece of cognitive learning. However, we need to remember that this information can take years to register.  This is due to the fact that our facts cannot compete with or eliminate the primitive anxiety and sadness patients have. Diets and the constant diet mentality are what psychodynamic therapists call a manic defense: let me hop into action and my anxiety will be transformed. We must respect and help patients understand that symptoms are a lifejacket in a raging sea.  So, cognitive work has to be put forward gently and repeatedly, over many months if not years, before clients can integrate it and give up their action symptoms.

In addition, these pieces of necessary cognitive behavioral work have to be timed so that they match not only the rhythm of the therapy relationship, but also that the therapy couple are not in the middle of other profound and sensitive material that is a major priority.  This occurs, for example, if the therapeutic couple is working on a major transference/countertransference issue or deep trauma.

Finally, we need to track the relational transference and countertransference conundrums that arise from our educational efforts.

Tracking means, for example, asking how a client felt about the therapist’s interventions. For example, one day my client Sarit screamed at me that she was furious that now she knew diets didn’t work. But because of me and “my ideas,” she couldn’t diet anymore and she was gaining weight. Although we had been working on eating with physiological hunger and stopping with the body’s satiation for a few years, she couldn’t put them to use in a regular way. At certain points in treatment, she saw me as the new “diet general! ” who victimized her.  I instantly felt I was being too pushy, on the one hand, and, on the other hand, angry at her blame and demand for me to see her as a victim. In reality, I had probably expressed impatience.  I held onto my countertransference blame, anger, and guilt and opened myself to curiosity about her transference and we looked at it more deeply.

Upon further reflection, Sarit felt I was like her actual, demanding mother whom she could never satisfy. Her mother had lived in a family in Poland where there had been many family suicides even before the Holocaust.    Mom was taken prisoner at Auschwitz where she was only saved from death because of Mom’s sexual attractiveness, which enabled her to be used sexually by the SS.  Understandably, Sarit’s mother was very restrictive with food, somewhat anorexic, deeply invasive, and hysterical a great deal of the time Sarit was growing up. Her mother controlled her portions at every meal.  Sarit could not heal her mother, nor her own screaming body. And, she felt guilty that she hated her relationship to her mother.  All of this came clear by following the transference and countertransference.

In concluding, I want to reiterate that in private practice and long term agency practice, working in the transference, countertransference, and cultural countertransference are central to the longer term psychotherapy.  I believe we need an integration of many elements of psychotherapy, cognitive behavioral psycho-education, body work — all unified by a psychodynamic approach to understanding the unconscious and creating a secure and deep psychotherapy relationship.

About the author:

Susan Gutwill, MSW, LCSW is on the faculty of the Center for the Study of Psychoanalysis and Psychotherapy of NJ, and is both a faculty member and supervisor at The Women’s Therapy Centre Institute of NYC. Susan is a co-author of Eating Problems: A Feminist Psychoanalytic Treatment Model and a co-editor and contributor to Psychoanalysis Class and Politics: Encounters in the Clinical Setting. She has written various journal articles and has been providing supervision for psychotherapists for 30 years. Susan maintains a private practice in Highland Park, NJ.

References:

^[i] LAYTON, L.  (2006).  Chapter 7, Attacks on linking.  The unconscious pull to dissociate individuals from their social context.  Psychoanalysis, Class and Politics, Encounters in the Clinical Setting.  London and New York: Routledge.

^[ii] GUTWILL, S. (1994).  Chapter 1, Women’s Eating Problems:  Social Context and the Internalization of Culture;

Chapter 2, The Diet: Personal Experience, Social Condition, and Industrial Empire;

Chapter 8, Transference and Countertransference Issues:  The Impact of Social Pressures on Body Image and Consciousness;

Chapter 9, Transference and Countertransference Issues:  The Diet Mentality versus Attuned Eating.

All in: Eating Problems, A Feminist Psychoanalytic Treatment Model.  New York: Basic Books.

^[iii] GUTWILL, S. (1994).  Chapter 1, Women’s Eating Problems:  Social Context and the Internalization of Culture;

Chapter 2, The Diet: Personal Experience, Social Condition, and Industrial Empire;

Chapter 8, Transference and Countertransference Issues:  The Impact of Social Pressures on Body Image and Consciousness;

Chapter 9, Transference and Countertransference Issues:  The Diet Mentality versus Attuned Eating.

All in: Eating Problems, A Feminist Psychoanalytic Treatment Model.  New York: Basic Books.

FOUCAULT, M. (1979).  Discipline and punish.  Trans. Alan Sheridan. New York: Vintage Books.

^[iv] ORBACH, S. (1986). Hunger strike.  New York: Norton.

ORBACH, S. Countertransference and the false body.  Squiggle, in press.

ORBACH, S. (1985a).  Accepting they symptom:  A feminist psychoanalytic treatment of anorexia nervosa.  In D.M. Garner, & P.E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia.  New York: Guilford Press.