A main reason for my selecting the case of Laura for BOL discussion is that I have long been intrigued by the syndromes that eating disorders engender. I see implications for different approaches to her treatment in what Polly and Ginger say--and Don has already pointed out that each therapist might prefer different approaches. In fact, I am delighted with the close reading of Laura's material that Polly and Ginger impart and I agree with most of their observations.
There are points, nonetheless, that I would like for us to consider further. Laura did not begin her narrative with a simple statement that she had to be at work late. She first informed me that her mother came to pick her up (which she knew I understood meant for her mother to make a long journey to get Laura to her apartment and then turn around again and drive back to the place where she and Laura's father lived). I repeated in my account Laura's words about eating because she "was hungry after a day at work" since it struck me that Laura reacted without immediate anger at Tom and without a compulsion to eat that seemed conflicted or out of context.
When Tom appeared and became defensive, Laura had no trouble showing him her fury. She continued to be angry at him after she threw up. That was not the emotion that she needed to relieve by throwing up. She did not give evidence that I could see of having swallowed Tom's view of reality at any point. I would more be able to see her throwing back her food as related to resisting him if she first indicated having been swayed by him.
In any case, I find it hard to conceive of this miserable routine as something an intelligent adult consciously chooses as a way in which to handle conflict. Vomiting is so unpleasant an experience, so concrete an action, so physical, I cannot understand it as a reaction to anything so sophisticated as another person's "view of things." It seems to me she had to be stirred at a level where deep feelings are beyond words.
My speculation with Laura was based on a guess about how the vomiting fit into the whole of the session up to that point of her telling. Have you not found that the opening statement in a session often foreshadows the significance of the whole (just as often enough an initial session with hindsight often can be seen to foreshadow what the person wants to work on)? I think that in little girl terms, Laura let me know that she needed her mother, then that the man in her life was bad, then that he may not be so bad and she had to prove she did not need her mother. The degree to which Tom was bad did not seem to be the crucial matter.
As it happened, I did underscore for Laura my recognition that Tom's rapprochement was feeble. Her relief came only after my interpretation of her conflict over feeling she had to give up her mother in order to maintain a relationship with a man. I do think it was important that the metaphor of food was included as a bridge between her induced bodily reaction and her self-understanding. (It was a long time before Laura again felt compelled to vomit out her food, although until that session, she had been doing so almost daily.)
Polly and Ginger seem to indicate how easily Tom could make a therapist of Laura's very angry. I certainly do not care to repeat her mother's behavior in ignoring what bad things occur to Laura in a relationship. Yet, I have to stay close to what Laura's perspective is in relation to Tom's emotional problems, including ways in which she feels she provokes him and what she values in him. What I have opted to do is acknowledge her reports of his objectionable behavior, support her wish that he be in therapy, and try to use material involving Tom as much as possible to help her see herself. Succeeding segments will bear out Ginger's intuition that both Tom and his "ideal" predecessor are significant in Laura's efforts to master the traumas of her early years.
As to Laura's responding to the idea of losing her mother, her mother's illness was not a new fact that came up for the first time. I believe that Laura freed herself to feel her sadness when I--as a representative of her "good mother" feelings--refrained from scooping her up and away from the man in her life. After all, her mother was good enough that Laura did survive and develop. Exchanging her feelings to vomit with words enabled Laura, in my understanding, to think about her mother in the here-and-now, rather than from the frozen vantage point of her childhood.
Unfortunately, her mother was so caught up on her own feelings that over Laura's entire childhood, she never recognized Laura's plight with the family friend. My experience when grown daughters report childhood sexual abuse to their mothers is that the mothers say something defensive about their own lack of attention at the time. They do often refer to what the father's reaction would have been, but they do not just completely leave it there. Laura's reaction to her mother's single statement that the father would have killed the man was that her mother still could not handle knowing what Laura went through.
I would like to echo Polly's statement that Laura's goal is to be both autonomous and connected in relationships. To me, that is the essence of what all of us strive for in our efforts toward a harmonious life.