The Rashomon effect which I expected to see in our interchanges does not turn out to be the value of the postings on Laura. Nor does the classic metaphor seem to apply of the elephant described by a team of blind people who touch different parts of the elephant. It strikes me that we are all offering interpretations that make sense of the material, only we are separately zeroing in on different layers of the truth. Recent postings seem to emphasize either a layer of intrapersonal conflict, internalization of interpersonal conflict, interpersonal conditioning and interaction, or the effects of social currents from beyond the family that are transmitted within the family. One of us can explain therapeutic results engendered in a particular treatment by emphasis upon a certain layer of the patient's personality. It turns out that others of us therapists can explain the same results in terms, rather, of another layer, which we prefer to emphasize in our own thinking. The intriguing thing to me is that we do focus on the same individual in our discussions; so given respect for the professional ability of each of us, there has to be plausible truth to glean from the various perspectives each of us offers.
Without disputing the likely importance to Laura of her mother's underscoring any fears Laura already had concerning omnipotence over men, I do want to take note of two aspects of Laura's case. Firstly, bulimic vomiting is not to me an act of helplessness. It contrasts neatly with the feelings of shame that accompany bingeing. I hear regularly (including from Laura) that vomiting is accompanied by relief and a sense of triumph.
This act is not the involuntary experience of a victim of the flu or some worse pathology. It is deliberate, though unconsciously driven. Of course, its significance in relation to attitudes toward fat, femininity, sexuality, etc. is very complicated. Nonetheless, the issue of control over all these things seems to come down to archaic bodily metaphors as the only way to deal with feelings about them.
This brings me to the second aspect I want to mention. It seems to me, we do not need to talk in terms of the unconscious in order to foster someone's shifts in manner of integrating layers (and segments) of personality. The hard work of a patient is in the use of whatever framework for self-understanding and self-acceptance we may give them, to stabilize such shifts at the various levels that characterize the person within.
Although old-fashioned debate is fun, I find less interest here in trying to prove the correctness of my approach. What I find I enjoy is increased light on what I do. Other perspectives increase my appreciation of the complexities patients deal with, as must I.
It is fascinating to me how we can respond to the layers of meaning in Laura's case, picking the layer that we feel able to communicate at most sincerely, and offer a framework that satisfies us conceptually. For the patient, it probably matters most that our interpretations and reactions are recognizably in "sync" on some layer with what the patient is experiencing. The task of internal integration remains with the patient.
Research tells us that therapists who have been in the work for twenty years or more are less theory-dependent in what we do than those who are only five years beyond graduate school. Gloria's ingenious selection of techniques from three different schools of theory probably shadows the overall course of many treatments as they actually occur. The course often is the establishment of rapport, exploration of causes of the patient's difficulty, and practical application of the insight. Most often, I suspect, such a course is determined by the natural development of interest on the patient's part. In strict psychoanalytic treatment, the analyst might never say a word about what seems to be practical application of insight, but the patient will be obviously giving this special attention.
Maybe noting in what ways patients determine the course of treatment could help us understand better the worth of our theory-derived techniques and when and why certain things are helpful. We do have some things to learn!