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|The case of Joan : a developmental approach|
|Articles - Clinical Papers|
|Written by Rosemary Gordon|
The Case of Joan
A classical approach : JOHN BEEBE
In the following pages, three experienced and accomplished Jungian analysts comment on where they would focus, what they would do, and what they imagine to be the course of treatment for "Joan." Joan is a pseudonym for a patient whose printed case material each analyst received and read closely before writing a response. Each received the same case report, summarized from the actual records of a forty-four-year-old female patient at the Renfrew Center for Eating Disorders, a private hospital in the Philadelphia area. Renfrew generously made available this material, which had previously been used in the public domain at a national conference on eating disorders.
Each analyst was asked to see things primarily from the perspective of her or his "school," each one being a prominent representative of that approach. Dr. Beebe writes from the classical approach, Dr. McNeely from the archetypal, and Dr. Gordon from the developmental. The analysts did not consult with each other on the case. As you read their responses, you may note how they highlight the model sketched out by Andrew Samuels in the Introduction in which he weighs the importance of the archetype, Self, and the development of personality as well as the clinical issues of the transferential field, symbolic experience of Self, and the phenomenology of imagery for each of the Jungian schools. What he has sketched as an interpretive model for the three schools of analytical psychology (see Introduction, pp. 8-11) works very well in understanding the interpretations of these authors. It must be remembered that none of the three analysts ever met the patient and, consequently, their essays should not be seen as comparing therapeutic practice. Rather, they are designed to illustrate different approaches to a real case. Apart from a few necessary instructions for thinking about the case, the following is all the information the authors received.
Referred to Renfrew by her primary-care physician because he was concerned that she had an eating disorder, Joan weighed 144 pounds at 5' 6" at the time of admission to the hospital. She was bingeing and vomiting at least three times a day.
Six weeks prior to admission, Joan was extremely depressed and anxious. She said "I'd like to jump in a river." She also reported waking in the early morning hours, full of anxiety. She reported hitting herself in the head or stomach or biting her fingers in episodes of emotional pain.
During the admissions interview, Joan expressed a desire to "work with the feelings I've been stuffing down." She described herself as "really fat" and worried that her husband would leave her, wondering why he had even married her. Recently she had become more acutely aware of memories of incest with her father, something she had known continuously, never having successfully addressed it. She wanted to address it in treatment now. She also expressed the desire to eat properly, to stop her bingeing/purging addiction, and to improve her communications with her husband of four months.
Joan lives with her third husband, "Sam" (all names used in this report are pseudonyms), whom she married just four months before entering the hospital. She had become friends with Sam and then lived with him for two years prior to marriage. The couple currently live with Joan's daughter Amy, age twenty-six, and Sam's son David, age fifteen. David's mother died of diabetes when he was three years old. David is a source of conflict in their marriage because he gets into trouble at school and threatens to leave home.
Joan is employed full-time as a cashier and food service attendant in a local convenience store where she has multiple duties and responsibilities. In addition to her work, she has recently organized a women's self-help group for eating disorders and is very enthusiastic about it. Her long-term goal is to become an addictions counselor. She has plans to begin studies when she finishes treatment.
While Joan was at Renfrew, her mother, age eighty-one, became seriously ill with kidney failure. Even so, Joan found it difficult to discuss her anger at her mother's failure to protect her from an abusive father in the past. Joan's mother lived with her briefly, but Joan found it so stressful that she advised her mother to return to her home, which, being in a different state, was distant from her.
At the time of admission, Joan complained of heavy menstrual bleeding, usually every three weeks. Although she has a gynecologist, she had not scheduled an examination with him, claiming that she didn't consider her condition to be "serious enough" to warrant a doctor's help. Often when she was ill or injured, Joan would hesitate to take time off work and/or to seek the medical help she needed.
At the age of eighteen, Joan left home to marry her first husband. She had one daughter, Amy, in this marriage. Joan described the marriage as "painful and abusive." Amy has a history of chronic depression and has been diagnosed as having bipolar disorder. Joan left the marriage after two years. In her second marriage she had two more children, a son, Jack (now seventeen), and a daughter, Lynn (now twenty-one). Both Amy and Lynn were sexually abused by Joan's second husband, for which Joan feels very guilty. "I wish I could have protected my daughters, but I just didn't see the signs."
When Joan was five months pregnant with Jack, she took in a foster child named Johnnie, sixteen months old and afflicted with cerebral palsy. Eventually she adopted him.
Her second husband was unfaithful and abusive, one day abandoning the family without explanation. Because Joan was unemployed and unprepared for this sudden loss, she lost everything at the time: her home and all of her children except Lynn. Joan and Lynn lived in and out of a shelter for a year. During this time, Joan acquired a position as a waitress and prepared to reunite her family.
When she met Sam, her current husband, she found it extremely difficult to trust him, but things have ultimately worked out well.
Joan grew up in a four-room wooden house in rural Arkansas (USA). Her parents and only sibling, a sister eleven years older, lived at home. Her father was a "sanitary engineer" and was strict and emotionally distant. Most of the time, food was scarce and comfort was unavailable. Joan recalls her father being absorbed in repairing his automobile when he was at home and commented "it was more important to him than we were." Her mother was "always depressed" and very obese. Joan recalls feeling ashamed of her mother, who weighed over 300 pounds.
Joan reported that she had been sexually abused by her father, beginning in early childhood. She usually slept in the same bedroom with her mother and father, while her older sister slept in another. Her father would fondle her genitals in the morning before he left for work and when Joan complained to her mother, her mother did nothing. She also had some memories of being urged to fondle her mother's breasts during this time when they shared a bedroom. In general, Joan describes her childhood as "unsafe and full of fear."
When I first read Joan's history, as described by the Renfrew Center, I felt shocked by the bleakness of her story. Her whole life seemed to have been devoid of any experience of love, support, concern, or of somebody or anybody who might have been able to hold her, contain her, or encourage her to value herself, to care for herself and to protect herself. Such a case history can provoke despair, pessimism, pity, and discouragement.
Yet there were just one or two features in her history that were like points of light blinking like small stars in a very dark space. Their very presence provokes a question. To what extent is Joan really only the victim of fate; or is she, or has she been, also, the maker of her fate?
Before I attempt to deal with such questions I want to digress briefly in order to survey both theory and clinical practice that characterize the developmental school. I will also try to describe the use I make of it, though restricting myself to only a few points.
Andrew Samuels (1985) in his book Jung and the Post-Jungians described how the various analytical psychologists became differentiated into three schools, the "classical," the "archetypal," and the "developmental." Until then we used to think of a London versus a Zurich school, which gave it a tribal, chauvinistic, or even jingoistic air. Samuels introduced a more meaningful classification, based primarily on the predominance or the neglect of one or other of Jung's theoretical concepts or clinical practices. When I found myself placed by him into the developmental school I had really no difficulty in recognizing and accepting this attribution.
Now, ten years later, I want to examine whether I am still thinking and working as a "developmental" Jungian analyst, and whether I still value this approach. In other words whether I still believe:
Now to return to the case of Joan. There have been many adverse conditions in her history, much early damage, and clearly her images and symptoms belonged to a pre-Oedipal stage. But signs of a nascent capacity to experience and to communicate through metaphors and symbols, and a potential identification with the wounded healer - all this triggered in me interest and some optimism. It led me to sense that the outcome of her development and therapy may show that men and women are not inevitably passive bystanders of their fate. They are not necessarily just an arena in which biological, instinctual, or even archetypal forces disport themselves.
I believe I feel comfortable in the developmental school because due value is given there to both analysis and synthesis and to the psychological processes of both differentiation and integration.
Taking a cool clinical look at Joan, I believe that she is a depressive person with quite marked masochistic tendencies which are often enacted in a compulsive way. Again and again she has managed to get herself into situations in which she is exposed to conditions that are revealingly similar to some of her earlier painful childhood experiences. This creates the suspicion that there is in her an unconscious need to repeat what has been; that she can't let go of the past. Is it that she dare not risk meeting the new? Her unconscious repetition compulsion is neatly disguised and over-compensated by her behavior and her conscious thoughts: she appears to move swiftly and frequently from one sexual partner to another and from one childbirth to the next one and from one job or occupation to another.
There seems to be in Joan, as a result of a nature-nurture combination, a predisposition to depression and to eating disorders. She has described her mother as being "always depressed" and weighing a quite unbelievable 300 pounds; and her own eldest daughter, Amy, has been diagnosed as having a "bipolar disorder."
Apparently both parents, father and mother, have abused her. Her father, although strict and emotionally distant, abused her sexually from when she was about five years old onwards, while her mother wanted Joan to "fondle her breasts." In other words all the potentially pleasant, nourishing, and enriching stuffs, experiences, and feelings were forced on her, rather than offered as gifts; they were not allowed to develop naturally and organically out of meaningful, relevant, and emotionally matching relationships. It is easy to empathize and to believe that she remembers her childhood as unsafe and full of fears."
When Joan was admitted to Renfrew she was bulimic, "bingeing and vomiting (purging) at least three times a day." Her bulimia, I think, is undoubtedly linked to a powerful body image distortion. She weighed a normal 144 pounds, being 5' 6" high, but she thinks of herself as fat; this suggests to me that there is an unconscious identification with her obese, her grossly overweight, mother. This must be quite particularly painful, given that she is likely to experience a near-explosive cocktail of ambivalence in relation to her mother. She probably longed for this mother to transform herself into a loving, caring one, but primarily and more realistically, she feels an intense hatred and distrust for her who, instead of protecting her against her father's abuse, had actually organized their living arrangements for it to happen, once her older sister had left and escaped from their parents' manipulation and collusive betrayal.
Just knowing about her history and before I have actually seen her or worked with her tempts me to suspect that her bingeing and vomiting is a caricaturing dramatization, an enactment of what her parents have done to her. After all, mother forced her to attend to her breast, the breast that is associated with food, that is, with milk and the oral pleasures that are linked to sucking. And father forced on her a premature experience of the excitement and pleasures linked to and derived from the genitals.
Thus what could and should be potentially satisfying and fulfilling is lost, is perverted, if the stimulations of the body organs are forced upon one, and are out of one's own control. Has Joan's compulsive bingeing not just this very effect of making her feet humiliated if not de-personalized, turning pleasure into intense displeasure?
The bulimic person's body experience, it seems to me, is thrust from states of feeling that his or her inside is uncomfortably over-full to states of feeling the insides as a gaping emptiness. In Joan's case what she vomits and expels represents, symbolically, I suspect, mother's unwanted milk and father's unwanted semen.
The powerlessness and the victim role that Joan had experienced as a child, particularly in relation to her parents, could perhaps be understood as having been transmuted in the adult Joan into compulsions and addictions which then continued to make her feel helpless and impotent.
The fact that Joan had failed to "see the signs" when her second husband sexually abused her two small daughters shows how very deeply she had repressed and split off her own experience of abuse from her father. Indeed very complex and ambivalent feelings must have got associated with the theme of father-daughter incest, which then left her insensitive, blind, and deaf and cut off from her children; and possibly here too is some sort of identification with her own mother.
Joan's masochistic tendencies seem to have taken her into two marriages in and through which she repeated and relived all the hurts and dramas of her childhood. Her first two husbands were cruel, abusive, unfaithful, and ruthless; the second one abandoned her and the three children suddenly without preparation, warning, or explanation. When she came to Renfrew she was in her third marriage, but there was yet no information and no way of knowing how that one might develop.
She also reported to Renfrew that she would, at times, when particularly anxious and in emotional pain, hit herself either on the head or in the stomach. I wonder if this might not show that there is something of a split in her ego consciousness, because by hitting herself she gives vent not only to her masochism, that is her addiction to pain, but also to her sadism, for this activity involves not only a victim, but also a perpetrator.
Adopting another baby, a damaged baby, a baby with cerebral palsy while she was in her third pregnancy strikes me as another acting out of masochism, although I just wonder whether this could perhaps also be understood as expressing an unconscious striving toward an almost heroic caring and healing.
This brings me back to my initial impression that in spite of the general adverse features of her relationships in childhood and also later, there were some glimmers of light. I am thinking of the fact that she had "recently organized a women's self-help group for eating disorders," or that after having "lost everything" when her second husband had deserted her, she managed in the end to find a job as a "cashier and food service attendant" and succeeded in keeping it. But even more encouraging for any possible psychotherapeutic venture are some signs that Joan may be capable of using and thinking and expressing herself in and through metaphors and symbols, as when she asked at Renfrew that she wanted to be helped to "work with the feelings I've been stuffing down." Her long-term goal to become an addiction counselor also supports my hunch, my vague suspicion, that there is in her, linked to her experience of pain, distrust, and impotence, an opposite force, a drive to heal herself and others.
Thus, as I studied and immersed myself longer and more deeply into the descriptions of Joan's history and her presenting problems, my original gloomy forebodings were shot through by some shafts of light; that is, I could see one or two possibly hopeful signs that encouraged me to think that some analytic work might be possible and prove to be helpful.
Let me now suppose or guess how I might proceed, given my theoretical and clinical experience and point of view, and given what I have by now learned about Joan.
Having seen Joan for an initial interview and assessment I might decide to offer to take her on for analytic psychotherapy. I might have liked her; I might have seen her as a woman who had been badly damaged, and who had a very poor sense of her own value and who was very unsure of who she is and what she is; yet I would have sensed an unexpected but deeply buried core of toughness and tenacity. This impression would have led me to feel that she and I might be able to establish enough rapport between us to weather the storms as well as the periods of becalmment, of hatred and love, of feelings of persecution and feelings of trust, of longing for and of angry rejection of dependence, closeness, intimacy.
I would also have realized that we would have to begin very slowly the analytic work, that is, the exploration of her conscious and unconscious experiences, of her history, her memories, her phantasies, and her dreams, and also of the present-day frustrations, satisfactions, events, conflicts, hopes, and fears. Above all it would be most important to respect her privacy and her boundaries and avoid anything that could rouse the suspicion that I might try to intrude with my own thoughts and speculations by making and giving interpretations. Joan having been so much abused, both sexually and as a person, my function as her therapist would be to guide her, slowly, toward her own possible insights. Consequently whatever I said to her would have to be said in the form of a question, except, of course, when I might want to express and tell her something about my own feelings and reactions.
Expressing myself in the form of questions rather than in statements, which I consider to be particularly important in working with Joan, is actually something I tend to use with most of my patients, because questioning involves the patient in taking an active part in the analytic work rather than remain a passive recipient of whatever the therapist produces. In other words the patient must examine whether or not what has been offered seems to fit and make some sense; and if distortions have crept in, they can give a clue and reveal what is happening in the patient-therapist relationship and/or what kind of intrapsychic complex dominates the functioning of perception, thinking, feeling, and intuition.
On taking Joan into therapy I would certainly suggest a face-to-face encounter. The couch would be quite inappropriate for someone so fettered and abused by both parents. Should she, at a much later date, having worked through the traumas of her childhood - and her two marriages -and become herself interested and absorbed in the deeply unconscious inner world inside her, the world of phantasies and symbols, then a move to the couch might be entertained and tried. But the idea of such a change would then need to come from her, by being verbalized, or by the occasional, apparently inadvertent, glance at the couch.
As regards the frequency of her analytic sessions, I would, to start with, see her twice a week. One has to strike a fine balance, in making decisions: a fine balance between on the one hand containing her and making the depression bearable, and on the other hand precipitating the collapse of her defenses and the external structures she has managed to make and keep. I am thinking of work, family, children, and the third marriage. But I would also keep in mind that she is liable to addictions: admittedly addiction to therapy or her therapist may be less harmful than her bulimic addictions, but in the long run such addiction may sap the transformative potential of the therapy.
As in all analytic therapy, the most important function is the transference and countertransference, that is, everything felt, believed, projected, and introjected that happens between patient and therapist. As I have said elsewhere, "Transference is a 'lived bridge' between the I and the other, between past, present and future, between the unconscious that is the split off parts of the psyche on the one hand, and between the conscious and the rational on the other hand" (Gordon, 1993, P. 235). In other words the transference creates "a present past." Through the process of projection the persons and personages, real, historical, phantasized, or archetypal, that had furnished the patient's inner world in the past, are put onto or into the therapist. Thus, through the transference the fears, hopes, longings, moods and feelings that had been experienced but were then lost - repressed, denied - are re-evoked, rediscovered and re-experienced.
Were I to read Joan's case notes, I would, in real life, now want to see the patient myself and so explore my own reactions, intuitive understanding, and expectations. I would try to suspend my memories of the assessor's report, in order to make myself empty enough to receive my own impressions of her. For we know there are no unbiased, pure, and neutral observations; every assessor's interest and personal characteristics inevitably affect his or her view of a patient, quite apart from the fact that a person will react and bring along different parts of him- or herself to different interviewers. If I were to be Joan's psychotherapist then I would have to get to know and to experience her as early and as uninfluencedly as possible.
I would now start to wonder what sort of Joan I would meet in our first interview. She is forty-four years old. Amy, her first child from her first marriage, is twenty-six years old. So Joan was eighteen years old when she first got married. I imagine her to be slightly plump and of low average height.
I expect that her approach and attitude to me in this our first contact would show conflict and ambivalence. She wants to be helped and cared for, but she wouldn't easily be able to trust me: to trust that I wouldn't abuse her need for help. She resents it if and when she recognizes that she depends on someone else - on me, the therapist in this situation. She is actually ashamed of her neediness and fears that she might be considered a nuisance, a nuisance who does not really merit professional attention. (I am thinking here of her hesitation to consult her gynecologist when she suffered from heavy menstrual bleeding, and that she hesitated to take time off from work. Of course, fear of losing her job or the cost of medical attention may be other reasons, other considerations to take into account.)
If I suspected that these internal contradictions prevented her from using this first encounter and making some sort of contact with me, leaving her excessively tense and anxious and unable to speak or look, then I would try to convey to her that I understood something of this inner turmoil. I would also suspect that Joan probably knew that I might be her therapist, which meant that she would see me regularly for quite a long time. Knowing this might be reassuring; but it might also make her more reluctant to speak to me because she might fear that whatever she told me I would remember, I would hold on to it; and if that happened then she would not be able to re-bury it, to forget it, to repress it once more, or to deny it; for I would then be able to push it back into consciousness and confront her with those memories and feelings that she had - and still has - experienced as being too painful, too shameful or too guilt-laden.
Before ending this first meeting I would discuss with Joan some of the practical arrangements - number of sessions per week, the times and dates I would offer her, fees, length of sessions, holidays, etc. But finally I would ask her if she did want to embark on this therapeutic venture, and embark on it with me.
Her masochistic tendencies and her compulsion to repeat the early abuse from both her parents could also hinder, or even sabotage, the analytic work. Masochism can indeed obstruct therapy because it carries with it a denial of one's own responsibilities and the experience of guilt. Nor can discomfort and/or pain act as incentive to change, to develop, to grow, since pain and discomfort are in fact sought out and desired. And if masochism is actually the object of a repetition compulsion - as it is in Joan - then the therapy's effectiveness is likely to be obstructed. As I have already mentioned at the beginning of this chapter, the presence of a repetition compulsion points to a person's need to hold on to the past, the familiar -however bad or painful this past has been - rather than step into the new, the relatively unknown. "The devil you know is better than the devil you don't know" is a folksy word of advice or wisdom one hears occasionally.
I can imagine that on meeting Joan I might come to feel that, in spite of the rather pessimistic case notes, in spite of the severe damage she has suffered in early childhood and later, and in spite of the various psychopathological features in her make-up - in spite of all this, I might feel inclined to offer her psychotherapy. In fact, I might find myself actually liking her. I might see in her something touching, perhaps because she gives the impression of a vulnerability against which she has not erected impenetrable defenses. It is true she seems to took at one with a watchful suspiciousness, yet I sense that there is inside her a stubborn tenacity which I would find encouraging.
Obviously she would not be easy to work with; I would expect crises and rages and also periods of clinging to me and anger and despair when the inevitable occasions of separation loom, for instance, at weekends and holidays. But I might be persuaded - or seduced? - to trust that her tenacity could and would in the end rescue her and our work together in her therapy.
But what might prove to be even more important and encouraging are the various signs that there is in her a quite active archetypal image of the wounded healer; she might be drawn to identify herself with this intrapsychic personage and let herself be guided or inspired by it. The adoption of a brain-damaged infant, her ambition to become an addiction counselor, and having already succeeded in setting up a women's self-help group for eating disorders - all this suggests to me that a wounded healer archetype is present and functions; this bodes well, I think, for a psychotherapeutic venture.
I expect that Joan's feelings for me, that is, her transference, would swing wildly and frequently between hate and love, between a demand for total availability, total provisioning, and total rejection of anything I offer her, or between almost blind trust and deep distrust. Particularly at the beginning of our work together she would not be able to trust me, would not be able to believe that I would willingly give her something good and nourishing, such as my caring for her, or my being there for her, or my interpretations to help her find meaning - all this without demanding in return her submission to me or the surrender of her selfhood, of her own sensuous pleasures, of her instinctive needs.
In view of her experiences of abuse - abuse of her body, her feelings, or her identity - I realize that I would have to be particularly careful in doing or saying anything that could trigger further the projection onto me of the abusing parents.
But having to restrain myself and thwart my wish to make her a gift of some of my insights, my understanding, my discoveries of some of her unconscious forces or personalities - all this would at times leave me angry, frustrated, and impatient. Even in retrospect I would not always know whether these almost hostile reactions to Joan issued from a countertransference illusion or from a countertransference syntony (in which case they would inform me via projective identification of what was experienced unconsciously by Joan). But at other times I might feel myself as if infected by sadness and despair and a fear that I was useless and that nothing could get better. When that particular mood invaded me I would experience a sort of impotent compassion for Joan that would make me imagine myself stroking her cheeks and reassuring her that there was value in her, that she had already achieved much, and that she could become more attractive and lovable. Like many bulimic patients, Joan has very little self-respect and fears that she might rouse in people disgust and repulsion. The fact that her self-attacks are so intense and pervasive might tempt one to counter them occasionally with some simple and straightforward reassurance. Such improved self-valuation might help her when she had to confront and deal with some of the impulses and experiences which, I suspect, exist and are active inside Joan, but had been relegated to the shadow - impulses and experiences such as, for instance, anger, hatred and resentment, or phantasies of violence, of murder, of revenge, or even of furtive sexual pleasure.
One would obviously have to work hard with Joan on the bulimia and on the theme of the conversion of and interdependence and interaction of body and psyche, and on the displacement of genital experience to oral experience and on the whole symbolism that is involved here. Joan herself seemed to be ready to tackle this, to judge by the comment she made in her Renfrew interview when she expressed a desire to "work with the feelings I've been stuffing down." This remark would be particularly significant when I had to decide on whether to take Joan into analytic psychotherapy.
There seems to be an inverse correlation between the tendency to develop psychosomatic symptoms or even actual illness and the capacity to symbolize. Awareness of this fact would determine one's therapeutic strategy and would be particularly important for work with Joan.
So far there is little known of Joan's early infancy, of her pre-Oedipal impulses and phantasies. Her experiences from age five onwards when she felt - and was - abused by her parents were obviously so painful, so intense, so frightening and conflictual that their darkness, their shadow obscured earlier as well as later events in her life. I suspect that some of these events would be revealed in and through the transference and countertransference. And in and through the transference-countertransference we might haul up not only memories of what happened to her, but we might also facilitate the re-experiencing, here and now, of the affects that accompanied those events. It is in this re-experiencing in the new, the present-day context, and the present-day relationships that change and healing may happen. And the present-day relationship to her analyst might help increase trust, trust in the "other" and trust in herself, in her own resources and capacities. And it might help release her from the dark and sinister parts of her own psycho history in which she had felt trapped and condemned to repeat it again and again.
Gordon, R. (1993). Bridges: Metaphor for Psychic Processes. London: Karnac Books.
Samuels, A. (1985). Jung and the Post-Jungians. London: Routledge and Kegan Paul.
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