Issue 4 - October/November/December 2011
Welcome to the fourth issue of TRANSFORMATIONS. In this issue, we conclude a three-part series, METAMORPHOSIS, based on the experiences of one woman in psychotherapy. Dr. Katie Barnes examines the phenomenon of eating disorders in gay men, and guest author Michel Horvat, MFT-I explores the internal struggles for both client and psychotherapist in the process of welcoming change into the therapeutic process.
Katie and I are settling into our new office space at 450 N. Robertson in West Hollywood. Please visit my website (www.drchrisemerson.com) for more information about my practice and for past issues of TRANSFORMATIONS. I look forward to hearing from you with your comments, questions, opinions and insights!
Dr. Chris Emerson
Eating Disorders in Gay Men:
Factors That Increase Vulnerability
By Dr. Katie Barnes
We know there is an overrepresentation of eating disorders in gay men, as gay men are more than twice as likely to suffer from eating disorders as straight men. This article highlights much of Miles Cohen, M.D.'s article on the topic, which examines factors that make this sexual minority vulnerable to taking unhealthy measures to achieve the ideal physical appearance.
The message to gay men in the media is loud and clear: 'you must have a defined chest, washboard abdominals, and practically no body hair in order to be successful, accepted and loved'. The preoccupation with this stereotypic masculine image is no different from the preoccupation with the slender look idealized by most women. Whereas an estimated 1 in 4 women will engage in disordered eating to try and lose mass, the focus of gay men tends to be over exercising and cutting caloric intake to a dangerously low level in order to burn fat and maintain sculpted muscle.
So, why do gay men strive for an exaggerated "masculine" appearance?
Dr. Cohen proposes that low self-esteem, in addition to lacking a sense of control over one's life are the major factors contributing to eating disorders. Although it is 2011 and "times are changing," gay men have always been and still are marginalized, feeling less-than for living in a "straight world." Therefore, low self-acceptance seen in the form of internalized homophobia can be nearly impossible to overcome. In a "straight" world, gays are often viewed as bad, unusual, shameful, or sinful, and these feelings are therefore directed at the self. In order to raise one's feelings of self-worth, especially in the gay community, physical appearance is the first personal quality to be manipulated.
In gay communities, it is quickly learned that "appearance-oriented criteria determine the amount of acceptance, understanding and positive regard one receives." Thus, a better appearance leads to more attention, recognition and sexual feedback, which the gay man with low self-worth so needs or desires.
I thought the notion interesting that perhaps subconsciously, in an effort to distance themselves from a "weak", or classical "sissy-boy" stereotype, gay men strive for a masculine physique to suggest masculinity and hence, competence and ability. This physique might also be strived for in order to distance themselves from illness associated with the HIV era, since muscularity is thought to automatically connote good health.
What can be done to help?
Education is most likely the best strategy for prevention and early detection of eating and body image problems. Because "working out", even to excess, is culturally lauded, most gay men do not seek treatment for their difficulties. Specific education focusing on gay men's struggles would be especially helpful, given a chronic sense of sub-par acceptance from society.
If the gay media were to portray a variety of body types as being culturally acceptable, then perhaps gay men and gay youth would be deterred from developing negative eating and exercise habits. Ultimately, with greater self-acceptance, gay men are more likely to lead healthier, more balanced lives.
Cohen, M. 2011. National Eating Disorder Information Center: http://www.nedic.ca/knowthefacts/documents/EatingDisordersinGayMen.pdf
Naming The Battles Within
by Michel Horvat, M.A., MFT Intern
In my quest to continue my education surrounding the fascinating concepts
that examine the inner workings of the mind, and more specifically in my journey
to become an increasingly effective practitioner in the face of resistant and entrenched clients, I stumbled upon "Working With Resistance" (J. Aronson, 2002). I found the text concise and practical in its approach and directly applicable to my work with clients in psychotherapy.
I was able to see with crystal clarity how concise word usage and mindfully placed
statements within the therapeutic environment can elevate what Bertha Pappenheim, (aka Anna O.) coined in 1893 as "the talking cure", from an aphorism to a precision tool skillfully applied to be of maximum use to clients.
It is paradoxical that a client would spend time, effort and expense to come to therapy and at the same time expend considerable effort blocking his own path to progress, but these are the defenses Stark addresses precisely. The author proposes well-placed and carefully thought out statements that systematically name and help to dismantle the battles within a client.
Whether it be a statement naming the client's resistance to the process in the room or one that divulges their ambivalence toward changing a behavior that might be causing them pain out in the world; the accurate voicing of the conflict in specific order, alternating between challenging and supporting, in what Stark calls containing statements and conflict statements, allows the client to hear truth articulated by an empathic source, dislodges their unconscious resistance into awareness, and allows them to ingest it internally. The result, according to Stark, is a marked reduction in their resistance to change.
As a parental surrogate, we responsibly and gradually "sour the milk" that had been feeding unconscious conflict until the client feels increasingly motivated to reject their defenses and wean themselves from the need to nourish their resistance. As I digested the text I realized that I had been missing an element required to pull this off - courage. Indeed, pushing the client toward independence from their defenses and eventually from us, which, after all, is our ultimate goal, exposes us to the danger of becoming the "bad parent" and risks our losing our child-client in the process, whether by attrition or graduation. Had I been afraid of losing my client's affection or of affecting a therapeutic empty nest? Perhaps.
Being perceived as the "bad parent" is a sacrifice that many endure for the sake of the healthy development of their child; and weaning a child comes in a myriad of forms. In the case of our clients, it may come in the form of gently ushering them into awareness, resulting in growth and an increased ability to turn from unconscious resistance to conscious choice, which after all, is the ultimate freedom of maturity.
So the primary resistance I was able to identify in attempting the therapeutic methods outlined in Stark's text was my own. Only after articulating the battle within me have I been able to loosen the hold of resistance that had kept me from utilizing this valuable intervention.
I have since used some of the methods outlined in the book in my clinical practice and have found some surprising responses from my most entrenched clients, manifesting in an emergent understanding of their defenses by way of their own realizations of their resistance.
The interventions are effective - but first I had to be willing to name the battles within me.
Stark, M. (2002). Working With Resistance. Northvale, N.J: J. Aronson
Michel Horvat is an MFT Intern (IMF 66940) in private practice:
8170 Beverly Boulevard, Suite 200
Los Angeles, California 90048
Supervised by Steven Uribe MFC 17634
METAMORPHOSIS: Part III of a three-part interview with "Laura"
By Christopher Emerson, Ph.D.
Dr. Chris Emerson recently interviewed a 45-year old woman named "Laura" who agreed to speak in detail about her experience in psychotherapy over the last 25 years. In this final installment of Chris's interview with Laura, she talks about ending therapy, moving into new relationships, and starting a family of her own. ("Laura" is a pseudonym of an independent individual who is not and has never been a patient in this practice).
DR. CHRIS EMERSON: Laura, when we left off last time, you mentioned that you followed your therapist into his private practice, and were feeling the positive effects of being on a low dose of an anti-depressant.
LAURA: Yes, it felt like a very good period in my life. Things were going well at work, and socially, new opportunities were presenting themselves... but as I say that, I'm aware that it's really more about new parts of me opening up that allowed for me to be more social. I started enjoying myself, really, for the first time. Including dating...
CE: What was that like for you?
L: Well, I had not been very experienced in that aspect of life (laughs). Remember, the depression and sadness had been a constant part of my life during my late teens and early 20s - and I realize now that it started even well before that - so there was not much experience with boys and men. I needed to discover that part of myself, and I was coming into that awareness later than most young women.
CE: What role do you see your therapy as having played in that awakening?
L: It played a part in everything, in all areas of my life. After two years working with James, I was making a place for myself in the publishing company, slowly moving up and taking more and more responsibility. And it just became clear to me that after working so hard to understand myself and the factors that had influenced my life up to that point, I just needed to make sure I had balance in my life...
CE: Do you mean balance between personal and professional? Work and love?
L: Exactly. I think society rewards - over-rewards, actually - putting all of our energies into our work, and we deny or delay taking care of ourselves in a more intimate, personal way. That sure had been true for me. And at around 25, I finally felt ready to face that part of my life.
CE: What happened?
L: I accepted a transfer to Seattle to help open a new branch office of the firm. At first, it terrified me. I would be leaving family - even though it had been a difficult relationship in many ways, you know, family is family - and it meant leaving my therapist and the work we had done together. By that time I had gotten active in Al-Anon, and had come to understand a lot more about the impact that my dad's alcoholism had had on the family, on me and my way of being - or not being - in close, intimate relationships.
CE: It must have felt like a risk leaving those comfortable relationships behind...
L: Yes, a big risk. But you know, I also needed a break from all the self-examination. I kept up the medication, the anti-depressants, and found a doctor to work with first thing when I got to Seattle. And I stayed connected with Al-Anon - even got a new sponsor my first week in town. I launched myself into work, opened the office, and met Steve. For the next two years we dated, first casually, then it got serious. And I was terrified all over again.
CE: What terrified you?
L: The whole idea, you know, of commitment, of marriage eventually, of whether or not I was equipped for it. So I realized that I wanted to address that chunk of work, and I went back into therapy in Seattle.
CE: What was that like for you?
L: Different. Very different. By this time I was a more "sophisticated" patient, and I knew what to expect and how to best position myself to benefit from the therapy process.
CE: What did that mean for you?
L: Well, this time I didn't expect my therapist to have all the answers or to save me or to function as a surrogate parent or boyfriend or whatever. I felt self-sufficient, but needed to work on the whole relationship thing. I found an analytically-trained woman in Seattle, and saw her for six or seven months a couple of times a week. It seemed to kick me into a good place with intimacy issues, and I even moved to a much more comfortable place with letting the past problems with my parents go.
CE: You've been back in Los Angeles for nearly fifteen years now. What is your life like today?
L: Well, I have two great kids and a good marriage. I feel solid, self-sufficient in so many ways, and I have come to realize that only with that kind of emotional self-sufficiency can one person ever really be present, be intimate, with another person. I'm still active in Al-Anon - I sponsor other women with alcoholic family members and friends. And although regular psychotherapy is not currently a part of my day-to-day life, I'll always be grateful for the changes I was able to make through the therapy process.
CE: Laura, thank you so much for taking the time to share your story with me.
L: It's a pleasure.
This concludes the fourth issue of our quarterly newsletter, TRANSFORMATIONS. It has been a very exciting year for us! We hope you have enjoyed reading, and we'll see you again in January 2012 with a brand new issue. Until then, we wish you peace and prosperity during the remaining months of 2011 and beyond.
Chris, Katie, and Dylan
"The concept of transformation is an interesting one. It raises many questions.
Who or what is it that is being transformed? And who or what is the agent of the transformation? Does transformation take place completely out of time, or in an instant, or only after careful and thorough analysis? Is transformation an evolution or a revolution, more closely related to insight or to thought?
The self is the architect of endless forms of reinvention, of the affirmation and reification of it-self. We must ask, then: can the self perpetuate its own illusion of existence and continue to convince us of its everlasting value and its ongoingness by acceding to and accepting the notion of transformation as process?"
-Satish H. Noe
"I work with my clients to help facilitate lasting change by combining a number of approaches. Deep, empathic listening is always a part of my work -- from there, we identify old patterns of behavior and belief and link them to early failures of attachment, and old injuries and traumas. The work of transformation can be long and painstaking, requiring many weeks and months of collaboration -- on the other hand, sometimes change comes when you least expect it. The body, the psyche, and the nervous system are always working in our own highest and best interest; we actually do move in harmony with the universe as a whole, and with our own inherent inner wisdom."
-Francene Eguren, MFT
Redondo Beach, CA