Although what follows happened more than forty years ago and although eating disorders such as anorexia nervosa do not receive the same attention as they once did, they still occur in 30 million Americans/year and are still one of the most frequent chronic illnesses in adolescence.

It is also an example of an approach called Surgical Empathy, which my co-author and I first introduced to the world in Why Cope When You Can Heal? whereby going into where a person is attached to a destructive coping behavior and giving them a very specific, targeted, empathic experience where they “feel felt,” they may let go their attachment to their destructive behavior and attach to the experience of “feeling felt” by that empathy.

She looked hauntingly, “concentration camp” emaciated, drawn and gaunt.

I was the psychiatric resident on call in the UCLA emergency room forty-two years ago when a deathly looking twenty two year old young woman, who I will call Jane, came in who was an obvious admission to the famed eating disorders in patient program at our Neuropsychiatric Institute.

Jane looked as if a strong – or even mild – wind could knock her over as I could see her sunken skin between the two bones of her forearms while her long legs were straight out of a concentration camp.

I conducted a usual protocol ER level psychiatric assessment and evaluation. It was clear how much Jane’s identity was tied to perfectionism and high achievement and how whenever she was less than perfect, she instead became obsessed with exercise and food restriction which she felt she could control more than preventing her anxiety over imperfections from becoming panic.

It was also clear that she did need to be admitted to our In Patient Unit that focused on eating disorders particularly anorexia and bulimia. It was not something I felt particularly happy about inasmuch as I knew that the likelihood of tube feeding being among the modalities awaiting her upstairs.

It was a Saturday night and there were no other psychiatric patients lined up behind her. I could have left her with the nursing staff to check on her while her bed was being readied upstairs. I decided instead to keep her company as she was seated on one of the emergency room grayish brown leatherette covered chairs in our small room that was part of the ER.

The sadness in Jane’s eyes that were as sunken as the skin on her body screamed out to me for some kind of emotional comfort in addition to my professional assessment role.

At UCLA we had access to a number of non-medication modalities in our training. One of those was called Guided Imagery which was taught to psychiatric residents by one of the most kindly, warm and loving people you could ever meet at the NPI. Her name was Marielle Fuller. Guided Imagery was a process in which you guided a person with their eyes closed into various scenes and they would tell you what they saw and their telling of that would symbolically reveal a number of the psychological and interpersonal issues they were dealing with. Another modality we had been trained in by Sheldon Kardener, M.D. was hypnotherapy.

For some reason something about Jane’s waiflike state mixed with her sadness spoke to me to try something. Intuitively I combined elements from several of the modalities I learned into the following.

I said to her, “Jane while we’re waiting for the people from the in-patient unit to come down for you, I had something that I’d like to try that might help you relax. It’s a visualization that’s like meditation with a story connected to it. During it, I’ll ask you to close your eyes and then ask you to imagine what I’m describing to you.  If at any time you feel uncomfortable, please tell me, ‘I think I’d like to stop,’ and we’ll stop. Would you be willing to give it a try?”

Sensing some rapport that we had established which was accompanied by her feeling safe, she looked at me with a weak smile and said, “Sure.”

I began, feeling guided by something outside of my awareness and in retrospect by something she needed emotionally.

“Jane, close your eyes and put your legs up on this chair in front of you and lean back into the chair you’re sitting in all the while breathing deeply and slowly through your nose in a 1-2-3-4 count as you inhale, followed by a slight pause followed by a 4-3-2-1 as you exhale. It might help to imagine walking along the beach next to the edge of the ocean and that when you inhale, you’re leaving footprints in the sand below your feet in the moist sand and then as you exhale it’s as if the next wave is coming up and washing it away. But that you’re okay with that because you keep getting to step forward and leave more footprints. Also, imagine that with each breath you’re freeing yourself from the weight of how difficult and impossible your life sometimes feels to you.

I then asked her, “Jane, are you righthanded or lefthanded?”

“Righthanded,” she replied as she appeared to be resting comfortably into the scenario as I described it.

“Good,” I replied. “Next, place your left hand, palm down on top of your stomach and feel the calming weight of it rising and falling with each breath. I would now like you to imagine that your left hand is the hand of a ‘mommy’ that you’ve always wanted. When we spoke earlier, we only spoke briefly about your parents because the doctors and nurses upstairs will go into greater detail about your family history after they have admitted you. But right now, I want you to feel that your left hand is a mommy, who may be in the image of your own or some other mommy, that you and your emotions have always wanted and I want you to imagine that as you’re taking deep breaths in and out that this mommy is saying to you patiently and calmly, ‘I’m here,’ as you breathe in and, ‘I’m not going anywhere,’ as you breathe out. Now slowly get used to combining your breathing with your left hand on your stomach going up and down with each breath and hearing this mommy repeating, ‘I’m here, i-n-h-a-l-e, and I’m not going anywhere, e-x-h-a-l-e.’

“Keep breathing, feeling your left hand as if it’s your mommy and her continuing to say, ‘I’m here and I’m not going anywhere,’ until you begin to feel and believe it all.

“Now I’d like you to place your right hand over your left hand that is on top of your stomach. Feel the strength and confidence of that right hand because it is the hand of a daddy you’ve always wanted and needed, and could be your own daddy or a different daddy, and also a daddy that works in perfect sync with your left hand mommy. As you feel the right hand of this daddy on top of the left hand of your mommy, I want you to imagine he is saying to your mommy and you, ‘Everything is going to be alright and we’re all going to get through this and be fine.’

“Now I would like you to feel a harmony and synchrony building where you’re continuing to breathe slowly, with your right hand on top of your left hand which is on top of your stomach and I want you to hear the right hand of your daddy saying to your mommy, ‘Everything is going to be alright and we’re all going to get through this and be fine.’  And as he says this, feel the warmth of your right hand daddy on top of your left hand mommy, continuing to reassure her and you and then her continuing to say, ‘I’m here and I’m not going anywhere.’”

As we continued this, slowly and gradually tears started to streak out of the corners of her eyes and down her protruding cheek bones.  Rather than feeling alarmed – which neither of us were – it seemed to me that they were tears of relief as she occasionally sought to wipe them with her right wrist and then some tissues that I placed into her right hand.

Interestingly, as I continued with this visualization, I felt a wave or relaxation come over me along with an emotional calmness that told me that what we were doing was emotionally correct.

I kept repeating this sequence and saw a signal from the nurse that people from the in-patient unit were on their way to admit Jane to the in-patient unit.

Sensing that time was running out I said to Jane, “Jane, this has been a mixture of visualization, hypnosis, relaxation training and the people from upstairs are on their way to take you upstairs. What I would like you to do now is continue to take your deep and slow breaths, feel the right hand of your daddy on top of and reassuring the left hand of your mommy and then her telling you that she’s staying with you. Now with each breath I want you to imagine you are absorbing as deeply into your body as you can, all the love and confidence between your daddy and mommy and between both of them and you. Now I would like you to listen to my counting slowly from 1 to 10 with you taking a deep breath and letting it out with each number I name.

“And now here’s a choice for you. You can remember everything we talked about or remember none of what we talked about. Either way is fine. There is no wrong here. But whatever you remember I want you to direct the warmth and love and confidence that came from both hands into your body as deeply as it can go.

“When I get to the number 7, you will begin to flicker your eyes until we get to the number 10 at which time, your eyes will be fully open and you will feel a little disoriented, but not in a bad way. Instead, it will be as if you’re waking from an amazing sleep and then you’ll come back to where we are and the people who will bring you upstairs will be here.

We then proceeded to go through all those steps and as suggested, Jane flickered her eyes at the number 7 and was fully awake at the number 10, at which point she yawned as if awakening from a restful and long overdue nap.

This coincided with the people from the in-patient unit being ready to bring her upstairs.

When she was fully awake, they introduced themselves to her and I told her that everything was going to work out for her and to never forget how special she was.

With that she stood up from the chair she had been in and headed to the door. Just as she got to the door, she looked at the people who were about to take her upstairs then at me and said, “Would it be okay if I went to the cafeteria first, because I’m really hungry.”

I looked at her and then at the people there to take her upstairs and nodded along with them and said, “I think we can arrange that.”

That remarkable, incident has stayed with me over the years and as I have come to see many more patients over the years, I have developed an understanding of what might have happened to explain it.

I believe Jane, in addition to her eating issues, had a case of what I have since named, Individuation Anxiety.

You are probably familiar with Separation Anxiety, which is the anxiety that babies, infants, toddlers and young children have when they are separated from their parents. One of the reasons that younger children scream loudly when that happens is because they are often not merely experiencing anxiety, but terror.  The terror is about feeling they won’t be able to exist without their parents being in sight. That is why the sometimes ear shattering screams sound like they are crying for their life, because to them they are.

Think of it this way. In a mother’s womb, there is never a need to cry because your fetal need (physical and emotional) is your mother’s physiological command. And then… you are borne and born.

After that, there is a gap between your physical and emotional need and your mother being able to come and fulfill it, which is why you signal her with crying.

Over time as you become gradually more self-reliant, the terror subsides as your developing abilities can gradually fill the gap and begin to satisfy your own needs.

There is a range however of how self-reliant infants are from very non-self-reliant, fearful to precociously self-reliant and independent.

The graphic below, How Personality Develops, describes how all through life we are stepping further and further away from what is familiar and what is that safe connection with our parents, much more often our mothers, when we are younger and into the unknown.  All the while we look back to look for a signal – called Rapprochement – from our mother and/or our father (or caregiver) that we’re safe and we can keep proceeding moving away. The more that step away is too big and we fall and get hurt, the more we look back more vehemently for that empathic (telling us they know we have fallen and feel hurt/scared) and then reassuring look that tell us we can continue to proceed.

As we look back, we internalize what we see and feel from that contact with our parents.  By the time we reach high school/college (as indicated below the graph) we no longer have separation anxiety, meaning a terror that without a connection to our parents we won’t survive. But separation anxiety can gradually give way to Individuation Anxiety.

Individuation Anxiety is a term we have originated to describe the fear of not being able to land soundly and confidently in adulthood. 

What Separation Anxiety is to the terror of not being able to survive if separated from our parents, Individuation Anxiety is to the angst of feeling that of falling through the cracks between childhood and adulthood. And what screaming is at the height of Separation Anxiety, obsessions and compulsions are at the height of Individuation Anxiety.

In others words the not in control verging on out-of-control feelings between childhood and adulthood are converted to obsessive thoughts – as about food and thinness in Jane’s case – and compulsive behaviors such as excessive exercise and anorexia.

This image has an empty alt attribute; its file name is How-Personality-Develops-1.01-1024x791.jpg

Now please refer to the graphic below, “What Your Life Becomes.”

This image has an empty alt attribute; its file name is What-Your-Life-Becomes1-1024x791.jpg

To follow from the prior graphic entitled, “How Personality Develops,’ imagine that as you are going through the earlier separation anxiety of infancy and younger childhood, that when you look back to your parents, after you hit an obstacle, that they can respond in one of the four rows in “What Your Life Becomes.”

If you look back and are Coddled, you won’t develop self-reliance because you’ll always be expecting your parents to bail you out as soon as you feel anxiety, because when you do it causes them to feel anxious and they’ll rush in to make it better to ease both your and their anxiety. Then as you grow older, this may then lead to your developing obsessions and compulsions to distract from your anxiety and “bail you out” of it, much as your parents bailed you out when you were younger.

If you look back and are treated Negatively through criticism or shaming, and even your loudest cries don’t change that, you may grow up to be angry at them. This may then lead to your being cynical and angry about life as you grow older and either acting out rebelliously or turning to drugs and alcohol as if to say, “If that’s how you’re going to treat me, then I will do whatever it takes to make myself feel better.”

If you look back and you receive nothing from them as if they are Absent, then you feel all alone and scared, and this may result in you not taking too many chances by stepping too far forward. As a result, you may live much less of a life than was possible.

If you look back however and you receive a combination of Loving/TMC (loving, teaching, mentoring and coaching) every, time you hit an obstacle, as you grow older and hit later obstacles you can reach into yourself and come up with an internalized feeling that you will make it through it. That is because you internalized that from all the involved and engaged and appropriate parenting you received.

As I think of Jane, it is quite possible that when she looked back during her younger years she received – as most of us do – a combination of the first three rows described above. Those three rows however were not enough for her to deal with the Individuation Anxiety she was feeling at age twenty-two, where even though she may have had a job or even some relationships, she had failed to reach a point of confidence in entering adulthood with optimism and confidence.

As a result, she instead dealt with that anxiety by focusing on exercise and food which she then would do everything to control. However, the more she felt further behind and different from her peers who were moving past her, the more her anxiety mounted, the more out of control she felt and the more she obsessed about thinness and compulsively exercised and restricted her eating.

What the visualization exercise I did with her (where I believe my intuition was “fed” by her unmet emotional needs at not received or felt the loving, teacher, mentor, coach parenting as described in the fourth/bottom row), was to give her a “taste” of the unconditionally empathically attuned parenting (meaning filling in the gaps that she could not fill in from whatever limited individuation i.e. self-reliance and self-sufficiency she had achieved) she always wanted and needed. Her loving, “I’m her and I’m not going anywhere” left hand “mommy and “Everything is going to be alright and we’re all going to get through this and be fine” right hand “daddy” gave her a “taste” of psychological safety that she could attach to, which enabled her to not hold on so tightly to her food obsession and anorexic compulsions. Doing so freed her to feel some of her natural hunger come through.

As such, when she became fully awake, I believe that there was a break in her need to distract herself from her Individuation Anxiety with thinness related obsessions and compulsions and her body was able to communicate to her in a long overdue outreach that it was hungry.

Failure to Launch

What might this have to do with you?

Do you have a family that greatly values achievement and accomplishment?

And if so, do you have a twenty something child that is not quite making it compared to his or her peers or siblings.

Even more worrisome, does that child have younger siblings that are moving past him or her with regard to work, relationships and discovering their role and purpose in life?

If so, is it possible that your Failure to Launch child shares some of the underlying anxieties that beset Jane above?

One of the ways to find out is to the ask him or her the following questions:

  1. Have you ever felt that we stressed achievement and accomplishment to a degree that it overly stressed you out and when you couldn’t achieve, made you feel awful about yourself?
  2. At its worst how awful have you felt about your life or yourself and if you did feel awful, how much of that was connected to feeling that you were not achieving or accomplishing enough?
  3. And if you were feeling that awful about such things, how alone have you felt with those feelings?
  4. At its worst how often did those feelings of not achieving enough and feeling all alone cause you to sometimes not care about life or wish you weren’t alive or even wish you were dead and had thoughts about how you might kill yourself?
  5. If you felt any or all of those, tell us about those times and I/we promise that I/we won’t berate or give you any advice unless you ask for it?
  6. PS If they open up to you and share such times, respond as follows:
    1. I’m/we’re sorry that I/we never knew it was so bad
    2. I’m/we’re ashamed because I/we never wanted to know how bad it was, because we we’re too focused on achievement and didn’t want to feel so anxious about you and as a result, we left you alone feeling that way all by yourself… and I’m/we’re so sorry and really am/are ashamed for doing that.
    3. Going forward I/we have a request. Whenever you’re feeling that way again or even heading in that direction, please do whatever it takes to get my/our undivided attention since our minds are always busy, because there is nothing more important than doing our best to help you feel not so awful and not so alone. And if you do this, we promise to not give you advice or superficial reassurances and will instead just listen.


  • Mark Goulston, M.D.

    Author, speaker, podcast host, psychiatrist

    Dr. Mark Goulston is the inventor and developer of Surgical Empathy an approach that helps people to break their attachments to counterproductive modes of functioning and frees them to connect with more productive and healthier alternatives. He is the host of the “My Wakeup Call” podcast where he interviews people on the wakeup calls that changed who they are and made them better human beings and at being human and the host of the LinkedIn Live show, "No Strings Attached." He is a Founding Member of the Newsweek Expert Forum. He is one of the world’s foremost experts on deep listening, radical empathy and real influence with his book, “Just Listen,” becoming the top book on listening in the world, translated into twenty languages and a topic he speaks and teaches globally. He is an advisor, coach, mentor and confidante to CEO’s, founders and entrepreneurs helping them to unlock all their internal blocks to achieving success, fulfillment and happiness. Originally a UCLA professor of psychiatry and crisis psychiatrist for over 25 years, and former FBI and police hostage negotiation trainer, Dr. Goulston's expertise has been forged and proven in the crucible of real-life, high stakes situations including being a boots on the ground suicide prevention specialist and serving as an advisor in the OJ Simpson criminal trial. Including, “Just Listen,” he is the author or co-author of nine books with multiple best sellers. He writes or contributes to Harvard Business Review, Business Insider, Biz Journals, Fast Company, Huffington Post, Psychology Today and has appeared as an psychological expert in the media including: CNN, Headline News, msNBC, Fox News, Wall Street Journal, New York Times, Forbes, Fortune, Psychology Today and was the subject of a PBS special. He lives with his wife in Los Angeles, California.