On Not Knowing

In this article, Dr. Ehrlichman explores some of the challenges encountered while treating patients with eating disorders. The article also appeared in the January-February 2022 Spanish edition of Eating Disorders Review.

S. Roy Erlichman, PhD, CAP, CEDS-S, F.IAEDP
Palm Beach Gardens, Florida

To be stuck is not to know. It may be synonymous with not understanding or perhaps a defense against such feelings as helplessness, failure, confusion, or inadequacy. It may be momentary or long lasting. In my experience, feeling stuck is implicit in the process of treating complex emotional issues and is important in helping clinicians better understand our patients and ourselves.

In fact, feeling stuck is but one of many countertransference responses that arise in the practice of psychotherapy, including therapy for eating disorders patients. For me, feeling stuck, much different from being stuck, is inevitable and confirms the realistic limitations on what I can know or accomplish in my work. This may leave me with thoughts and feelings that may differ dramatically from what a patient expects, fantasizes or demands of me or that I expect of myself. In the treatment of eating disorders, there is little that restores health promptly and little that consistently eases or resolves moments of stuck-ness, both for patient and clinician. Healing demands time; and as another aside, do we yet have a clear, universal definition of healing or cure?


And then there is Sarah. In her early 40s, Sarah presented with a fascinating history. Well-educated, she had served in the US government for years, and was married to an accomplished man. She had no siblings and both parents had passed away. When I asked how I could be helpful, Sarah clearly told me she wanted to be rid of her anxiety, her intractable depression, and what she referred to as ‘unusual thoughts’ that intruded in her life. I did not know what they were nor, in the early sessions, did I ask. To do so then felt premature. I could wait.

The sense of interpersonal acceptance may have little to do with the issues at hand, but far more to do with feeling valued or devalued by another.

In the first months of our work, Sarah was cooperative. She came to her sessions on time, spoke openly and paid her bills reliably. One day, for reasons I did not understand, I felt a nagging, uneasy feeling and decided to explore with Sarah how our sessions were going. Actually, I asked her, “How am I doing?” I did not direct my question to her as a command or personal criticism, but instead invited her to speak about me and how I was doing as her therapist. In other words, if she chose to, she could speak critically or positively without recrimination. That was my hope.

Sarah said that our work was going well, but the positive feelings she verbalized did not match the feelings I experienced. Telling me all was going well was simply not the case. Something was wrong, but I did not know what. When feelings and thoughts do not match, I wonder why.

I wonder when patients are too kind, too effusive in praising a therapist’s work — or too critical. Are we hearing what is true or what is self-protective and therefore safe? Does the patient fear retaliation, rejection, or abandonment? Likewise, I question when patients displace rage on me undeservedly for behaviors, thoughts or comments that I neither had nor engaged in, but the patient had attributed them to me anyway. What if I think I am being helpful, but in the mind of the patient I may feel or be of little value? How to respond? Experience and theory have taught me that the prudent thing is to accept and say little or nothing.

From time to time such questions arose when Sarah would ask for exercises or techniques to help ease the stressors she felt. If I were being as helpful as she said, I wondered why the need for more tools and techniques? What was I missing? What was I failing to do? At first these requests felt reasonable. Technically, they were. We discussed breathing exercises, pausing exercises, yoga, meditation, books to read, visualization — but to no avail. Nothing helped.

What did become clear was that Sarah had no interest at all in exercises or techniques—and, in fact, the case was to the contrary. What I realized later was that Sarah was determined that somehow she would compel me to understand and feel the intensity of the emotional pain she experienced every day-and for which she had no words, because there were no words. These were preverbal memories. As time passed, she would use colors to describe early childhood experiences — for example, that the pain of her anxiety was fiery red or that her depression was cold gray. She required that I feel these feelings and somehow save her from them.

She never said this because she had no words. I simply intuited her message.

Through many sessions, I felt I had become an amalgam of the mother and father who are supposed to ‘simply know’ what their child needs. Magically, these parents turn on the light when it is dark, change diapers when they are wet, and feed and love their child naturally and easily. While the infant does not yet have a verbal language, she does know the sounds and feelings of such love and in time, and grows to accept it with trust and confidence. Sarah never knew this experience.

For a long time, I continued not knowing what to say to Sarah. Clearly, my presence was more important than my words and, like Sarah, I had no words. As I was asking Sarah to walk across her own ‘bridge over troubled waters’ and put her thoughts and feelings into language, I had to do the same. What I knew was what I felt — an empty, sad, raw state that often left me frustrated and uncertain and frequently ashamed and embarrassed. I was supposed to be an agent of hope in Sarah’s life, but, in truth, I felt myself a failure. Yet we persisted.

Then, an epiphany

And then came that special moment, the epiphany in which the elements of our work gradually were seamed together. What appeared to have happened is that my inner world had evolved into a narcissistic mirror of Sarah’s. The insecurity that I felt as a therapist mirrored the insecurity she felt as both child and patient. The rage she displaced onto me was the rage that her parents displaced onto her. Feeling like a failure as a therapist was the feeling she felt as a child. Blaming me for failing her in our work was the blame she experienced for not satisfying her parents’ endless demands for achievements, too lofty for the most gifted of us. What was imposed on her was imposed on me. There was no love in their messages, and Sarah felt this. Nor would I get any love or appreciation. I would suffer, too, until I understood.

Feeling stuck is but one of many countertransference responses that arise in psychotherapy, including therapy for eating disorders patients.

More months passed. Sarah persistently railed on about my lack of understanding and what she labeled ‘my lack of proper compassion.’ It was ‘just like my parents,’ she said. Repeatedly, she reminded me that I was a failure as a therapist, and wondered why she ever came to see me. But interestingly—and I grew increasingly curious about this—no matter how fiercely she complained, she continued to come to our sessions and invariably was on time. She paid her bills as we had agreed, and responsibly handled the details of appointment changes. She now periodically requested more sessions, not fewer. This seemed contradictory. If she so loathed and criticized me, why continue treatment? Certainly she could find another therapist more effective than I. In truth, I hoped there was one. I was tired.

As Sarah spoke more openly, we studied together how I had become so disappointing to her, and what I had done to warrant her rage. Had anyone ever listened to her, accepted her dark feelings and her ‘unusual thoughts?’ Was there a safe way to talk about the real relationship she had with her parents and others whose lives had touched hers? Were her parents the good people she described or were they as detached, punitive and toxic as they seemed to me? I continued to ask questions, to study Sarah’s replies with her and, to the best of my ability, rendered neither judgments nor interpretations. It was better, it seemed to me, for her to arrive at her own conclusions independently, without criticism, pressure or editorializing on my part.

Sarah’s voice grew clearer, louder, and braver. In one tender conversation, she confirmed tearfully that she was indeed a brutalized child who had never been allowed to feel or speak. As she felt increasingly safe displacing hateful feelings onto me—as a substitute in the transference for her parents—she talked more freely about her memories, feelings, perceptions, and dreams. At times, this process felt interminable, and yet it grew increasingly informative and relieving to us both. As the rage lessened, her brighter self gradually emerged. Through many agonizing sessions, what became true was that Sarah had grown up with parents who were diametrically different from the parents she had first described. They had nearly destroyed her mind and her soul.

As an infant, Sarah learned that her obligation was to do her parents’ bidding without question. To do otherwise was to manifest disloyalty for which she would be punished. To be silent was to be safe and loyal—the good child. Later in treatment, when speaking no longer terrified her, she needed to confirm with certainty—know—that I would tolerate her rageful feelings and behaviors. If I could do that and remain non-punitive, that would confirm that I could be believed and trusted. Her perceptions, memories and feelings were to be valued, not scorned.

Doing nothing or little, waiting for Sarah to guide me— in her own language and at her own pace—was to do more. Slower was indeed faster.

Sarah and I worked together for several years. Feeling stuck, uncertain and unknowing colored the course of our relationship. Curiously, I do not recall ever feeling hopeless. I have often wondered why. In retrospect it seems to me that Sarah’s determination to have the life she rightfully deserved gave me both hope and courage.

Sarah did prosper in our work, although I frequently wondered if I could. As treatment advanced, she reported significant improvements in her relationships with others. Her career blossomed. She no longer spoke of her depression, anxiety, or unusual thoughts. Her marriage became a source of confident, loving mutuality. After treatment ended, Sarah periodically would call me or send a card to let me know that she was doing well in her new world. She invariably asked how I was, an important step for someone who for years barely acknowledged my existence.

The case of Sarah was one that went well. Not all do. I have had others that have disappointed me, even caused despair. But knowing that feeling stuck can be both meaningful and useful encouraged me to stay the course.

Hearing disguised cries for help

Helping Sarah to restore her ‘wounded self’ required that I hear her ‘disguised cries for help,’ her perceptions and feelings about life and reality, whether real or imagined. When I accepted her perceptions, which frequently defied reason or my own perspective, I believed—actually felt—that this gave her a sense of unqualified acceptance, of feeling understood, and emotion—I believed—which she may have never experienced before.

In other words, the sense of interpersonal acceptance may have little to do with the issues at hand, but far more to do with feeling valued or devalued by another. Whether correct or incorrect, logical or not, I find that a patient’s words are the offspring of their mind, a verbal representation of the self. To have them accepted and valued is to be valued. For me to argue with these perceptions may be experienced as rejection, possibly a replication of her traumatic experiences as a child. Here again, I was one more adult, her doctor now, who may listen but not hear. Clearly relational trust is not legislated in therapy, but cultivated, earned over time, just as the infant internalizes over time that their parents will be reliable, present, loving objects. For me personally, it was a privilege to share Sarah’s journey. Often, I wish I could know more, do more and feel less ignorant and uncertain. However, to borrow from Donald Winnicott (the well-known English pediatrician, psychiatrist, and psychoanalyst who developed the theory of the false self), like parents we can only be ‘good enough.’ It is easier, though, to be good enough when we accept that feeling stuck and not knowing are rightful elements of what we do and who we are.

The Author

Dr. S. Roy Erlichman, PhD, CAP, CEDS-S, F.IAEDP

has had an extensive career in eating disorders treatment. He is a Certified Eating Disorders Specialist and Fellow of the International Association of Eating Disorders Professionals (iaedp) and has served as President of the iaedp Board of Directors. In 2019, he received the Who’s Who in America Lifetime Achievement Award for clinical contributions, and in 2016 was awarded the iaedp Lifetime Achievement Award for service. Dr. Erlichman has written numerous articles, presented at conferences throughout the country, and is an Associate Editor of Perspectives magazine.

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