Lisa hefts herself heavily up the stairs to my office. She must come up two feet to a stair, like a small child. She is breathless by the time she gets to my office and has to take a few moments to collect herself. As she settles in, I realize she has gained even more weight in the few weeks since I last saw her.

She is huge, solemn, powerful, inert. Once she is seated, nothing moves but her head and hands and her big, expressive eyes. Her pace in therapy has been glacial. I wheedle, nudge, poke, prod, shove, usually with very little effect. My anxiety stimulated by her apparent weight gain, today I shove, for all the good it does me. A boulder slammed into the earth by the gravity of her rage, she is immovable.

During the session, she makes some small, wry, self-aware and self-deprecating joke about her resistance to change. I can’t even remember what she said, but flooded with affection for her—impulse and action melded together, racing along the same neurons in tandem—I burst out with, “Oh Lisa, I love you.” I am a little shocked to hear my own voice saying the words. It is true enough, but I did not expect to say it. Had those synapses fired at any distance from each other, I would not have.
She does not look shocked. She has, in fact, a small smile. I would guess that in her half century of living she has heard these words spoken to her fewer times than I could count on one hand. I can practically hear the tectonic rumble of pack ice shifting.

I have so flustered myself that I just carry on with our conversation, ignoring my own exclamation. As we talk, I ask her a question that I have asked her many, many times. “What do you imagine would happen if you stopped bingeing?”

This time she responds differently. Her eyes widen. She looks so frightened I want to turn and look behind myself. “I can’t,” she says. “You don’t understand.”

“What don’t I understand?”

“I am just like them. I am just the same.” I know exactly what she means. She means she is like her brothers, her mother.

Looking at her, I feel as though I am both seeing and imagining a child in her bed, piled high with blankets of flesh, her big, wide eyes peering out at me from beneath her coverings. She is not fully present—her eyes are shifting rapidly back and forth. She has the terrified look on her face of someone who has received a blow and is expecting another. I have been sitting with one leg crossed under me, but I shift both my feet squarely to the floor in an unconscious effort to ground her.
“No,” I say, “you are not like them. You are afraid of being like them.”

“If I wasn’t bingeing,” she says, her eyes still flicking, one shoulder slightly hunched as if to protect herself, “I could really hurt someone. I could kill someone.” Usually, she talks about how her fatness protects her from others, but she has never before talked about how she believes it protects others from her.

I speak to her in the low, soothing voice that you would use with an injured person or a frightened child. In a few moments, I can see her breaths start to even out. Her eyes stop moving and focus back on me. She smiles shyly, almost in greeting. She has been gone, but not gone. The session moves on and before the end, she commits to what is for her a big step.

I have never said “I love you” to a client before. I do not understand what unconscious imperative drew those words out of me. It felt as if I had no choice at all. I am as easily blinded to myself as the next person, but I can think of nothing in my life or day, no need of my own, that drove me to share those words with her in that moment. If my assessment of myself is correct, what then in her impelled those words from me, and what did they mean to her? Did I frighten her into a dissociated state, given that her experience of love is so deeply intertwined with violence? Did my expression of love for her provide her with some increased security so she could reveal more about her experience of herself? Did she want to warn me what a dangerous person she is to love? I am inclined to believe all of the above are true. Clinical error or simple human caring, countertransference enactment or empathy, I believe that in the session our separate continents shifted just a little, perhaps even measurably, toward each other.

File under: The Art of Psychotherapy