Like all cases, Laura is fascinating in many details. Today, however, I want only to give a vignette from her and my work together that I believe is on point for understanding the basic issues with which a girl struggles to resolve through the mechanisms of an eating disorder.
Laura, a woman of thirty years, whom I have now seen for six months, has been in therapy from the time she was a teenager. This included a brief hospitalization for suicidal tendencies. A constant symptom, however, has been an eating disorder. Three years ago, she began to recover memories of sexual abuse by a neighbor. It probably began when Laura was only three years old and it finally stopped when she started to menstruate at eleven. Laura first told her mother of it only a year and a half ago. Her mother's response was, "Your father would have killed him." Laura has been steadily bulimic from that time. [Her mother's response, I believe, heightened the loyalty pulls she felt between her mother and her father; wanting her mother's love and instead experiencing her mother's coldness and focus on the father's concern for Laura.]
She came to see me upon the recommendation of an older mentor she had in another state, when she moved back to the Chicago area. Her reason for moving here was to be with a new boyfriend. Just previously she broke up with a man who seemed to love her dearly and whom she refers to as an ideal man. She describes the problem as being that she told him she did not want to have sex and he agreed; but somehow that ruined the relationship for her. The present boyfriend persists in wanting to have intercourse with her, although he does not force himself upon her.
In listening to Laura's material, you will perhaps agree that issues of her own worth as an autonomous person, her ability to respect herself, conflict over dependency on her mother, right to be sexual and to have the love of a man are constantly in states of imbalance and that bingeing and throwing up are part of her efforts to put these things into balance. The compulsion to eat is associated with mother's dominance. Throwing up is an attempt to free herself.
Laura started a session by saying that she had informed her present employer that she was looking into possibilities of employment in her own profession. This was a reference to my having encouraged her to tell him the truth rather than a convoluted story that anyone would have regarded with suspicion. His response was apparently positive. She went on with a plan that would permit her to complete the year of service she had promised him initially while she slowly built up a private practice in her field. [Significance to me: she saw me as respecting her right to grow without needing to feel fragmented over it.] The other issue was that of commitment because she felt strongly her loyalty to the employer. [He happened to be also a family friend, as the abuser in her childhood had been to her parents.]
[Having a right to her individuality was conflicted by loyalty pulls that were related to sexual activity.]
Laura next let me know that there was something she wanted to tell me about, but first she let me know that she and Tom had had a tremendous fight and that she was still angry at him. Her job situation required her to arrange for her mother to pick her up. (This statement was simply placed at the beginning of the account to follow.) It was necessary yesterday for her to work very late, preventing her from coming home early enough to walk her dog. She asked Tom whether he could get him from his office in time to do this. He told her it was no problem. She actually was able to return earlier than she expected, only to find that Tom still had not arrived. A friend who shared the apartment had come earlier, however, and spontaneously had walked the dog. Laura had something to eat.
[Laura's initial reaction was to evaluate the situation as under control; the dog had been attended to and she was hungry after a day at work.]
When Tom appeared, Laura asked him why he had not at least tried to let her know or call the boarder in case he was there. Tom became defensive, insisting that it was no big deal since the walked was taken care of. It turned out that he was not at work late, that he had been preoccupied with a report that he needed to make, only that was not immediate. That said, Laura realized what she wanted to talk about. It was her eating disorder. In the middle of the argument, she went to the bathroom and threw up. Then she came back and the battle continued. "It's all relieved, now," said Laura, "but I am still enraged at him."
I asked Laura to reconstitute the argument to see at what point exactly she had the irresistible impulse to throw up. She repeated to me her exasperation with Tom's insisting that what he did was no big deal and her own conflict over whether she should feel so strongly. Finally, Tom did acknowledge that in the future he should remember that it meant a great deal to her. He told her that if he could not get back in time to help the dog, he would try to let her know so that something workable could be arranged. That was when she rushed to the bathroom to throw up. And came back still feeling angry and yet not entitled to the feeling, since the problem appeared to have been resolved in a reasonable way.
I mused about the sequence of her associations. I went back to her having set the scene by mentioning first her dependence on her mother. Then, her justifiable anger with Tom for his not recognizing her distress, indeed acting cavalierly about the matter. But there seemed to me to be a tip-off in her throwing up just after Tom demonstrated that at least he ought to prevent such a thing from happening in the future.
Was it possible, I wondered, that feeling angry with Tom and comfortable with her mother, she could eat--as she did before Tom arrived. Yet when Tom became forthcoming (taking responsibility for not doing what he promised, when it was important to her), her conflict became so deep that the only way in which she could handle it was by ridding herself of food/mother.
Laura immediately responded with thoughts about her mother's fatal illness. Doctors have said that she has at best three years to live, which Laura assumes is an effort to facilitate her reconciliation with imminent dying. Laura found herself surprisingly and suddenly sad. She had not before felt emotional about her mother's serious illness. It occurred to her that perhaps some of her sense of barrier against her mother may have been a reaction to protect herself from feeling the sadness.
She cried a little. She ended with a plan to spend the evening with her mother, since her father was going to be out of own. [Laura was now talking about important feelings she had not permitted herself earlier and the eating metaphor did not intrude.]