Spectatorship, voyeurism, and exhibitionism have assumed great prominence in our culture. Many of our patients spend a good part of their days and evenings staring at computer screens, televisions, and videos and conduct their economic and social lives on the Internet. Coupled with this emphasis on “looking” is a corresponding emphasis on “looking good.” Having a perfect body and face is no longer the exclusive domain of movie stars and models. Many of both sexes consider it a requisite goal, universally attainable and obligatory; some of them are psychoanalytic patients. Many have grown up in families in which they were judged, and conditionally loved, in binary fashion: thin or fat, tall or short, small-nosed or large-nosed — in short, good or bad.
Some patients undertake psychoanalytic treatment with the manifest or hidden agenda of reaching bodily perfection. They want to analyze why they do not do more to enhance their appearance. Much of their day and thinking is organized around exercise, dieting, relationships with their trainers, and their visits to nutritionists, facialists, dermatologists, and plastic surgeons. Their goal of body perfection is usually supported by spouses, friends, and the mass media.
The psychoanalytic treatment of such patients is challenging, for psychoanalysis fosters inner solution of internal conflict and uses the language of metaphor, whereas many of these patients, in serious need of help for the emptiness they feel, seek external, concrete solutions.
Should the analyst challenge society's irrational and unhealthy values? Is this the analyst's role?
What role should the analyst take, for example, when a quite attractive middle-aged patient undergoes multiple plastic surgeries in order to appear youthful in our youth-oriented society? Sometimes the cost of the surgery precludes paying for further treatment or leads to cutting back the frequency of sessions.
What role should the analyst take when a young woman patient decides to undertake breast reduction in order to appear slimmer? Should she be told that she will not be able to breastfeed a child? Is that too directive?
What intervention should an analyst make (if any) when a married woman patient quite correctly fears that if she becomes pregnant and gains weight, her husband will abandon her? Or when a patient is told by her husband that he will leave her unless she works out with a trainer several hours daily because he wants her to be muscular and toned?
Should one “analyze” the scanty garb of a patient coming to sessions in a full sweat after working out, panting with exhaustion and drinking water from a bottle? Or “analyze” a request for a change of session time so the patient can go to the gym? Should one mention the stomach growls one hears when patients are starving themselves in order to be thin or the facelift one is almost certain has taken place during vacation and has not been mentioned by the patient? There are no simple answers to any of these questions.
I have worked with several women who left their jobs in order to be with their young babies but end up spending their days instead at health clubs. Instead of working, they “work out.” Are these patients' issues really “old wine in new bottles,” or have these problems always been there but not found their way into the literature? Are we dealing with a psyche different from the one upon which Freud developed his technique and theory? How would Freud have understood the case of a cross-dresser who values his male genitalia and his sexual relations with his wife, but obsesses about getting hair implants so that he can look more beautiful when dressed as a woman? He has no interest in surgical alteration of his genitals and wonders why not, since that is the prevalent topic in his Internet chat room.
I have found that many patients presenting with these issues are located developmentally in problems with basic identity that are unresolved, rather than gender identity. Like children fascinated by their images in mirrors, they are attempting to find out who they are. Their thoughts are often fragmented; and they speak in desperation about their bodies, trying to get the analyst quite literally to look at them, as if the looking will help hold them together.
On the other hand, in this appearance-conscious society, there are patients who neglect their appearance and seem oblivious to what is going on around them. It seems obvious to the analyst that this neglect must be affecting their attaining their goals in love and work. Such patients provide little entry for discussion of such issues, and it is often difficult to assess what narcissistic wounds might be opened if one suggests that the patient is avoiding such issues.
It seems that psychoanalysts must develop new understanding and new techniques for working with such patients. Their issues have received too little attention in the literature and in psychoanalytic symposia.
Janice Lieberman, Ph.D., is a training and supervising analyst at the Institute for Psychoanalytic Training and Research and a member of the Psychoanalytic Association of New York. She serves on TAP's editorial board and on CGRI. Her book Body Talk: Looking and Being Looked at in Psychotherapy has just been published by Jason Aronson, Inc.