| Contents | Preface | Acknowledgements | Chapter: | 1 | 2 | 3 | 4 | Conclusion | References |
The physical appearance of anorexic and anorexic bulimic patients is shocking. The outward appearance of normal weight bulimics is not shocking. This vital piece of information is usually ignored in the literature, where anorexics and bulimics are thrown together as though the experience of working with one is the same as working with the other, which, of course, it is not. Before looking in detail at some of the transference and countertransference issues presented by anorexics, anorexic bulimics and normal weight bulimics, I wish to look at why psychoanalytic work with these patients has often been opposed. Some have opposed it outright, and others have suggested that particular techniques are necessary to work with these patients. When I look more closely at working with eating disordered patients I hope some of the technical issues will emerge from the theoretical understandings already referred to, and perhaps point to ways of thinking about material and making interpretations that allow these resistant patients to begin to appreciate that they have a digestive tract in their internal world which can be used to good effect.
As mentioned in the Preface, working with eating disordered patients can be frightening. On the surface and in reality, this is truer for anorexics and anorexic bulimics. They frequently put their lives at risk, and yet are often consciously unaware of it. To see a skeletal-like figure walking and talking is deeply disturbing. Skull's heads, death, torture, concentration camps and starvation are some of the thoughts that come instantly to mind. Lasègue's frustration and feeling of impotence is apparent when he describes an anorexic's state of mind as being:
I might almost say a condition of contentment truly pathological. Not only does she not sigh for recovery, but she is not ill-pleased with her condition, notwithstanding all the unpleasantness it is attended with. In comparing this satisfied assurance to the obstinacy of the insane, I do not think I am going too far... "I do not suffer, and must then be well," is the monotonous formula which has replaced the preceding, "I cannot eat because I suffer" (Lasègue, 1873, p. 151).
Extremely primitive feelings are stirred up by anorexics and anorexic bulimics, feelings of resentment, anger, hate and rage. That a fellow human being should so damage herself and not want to be fed or recover is almost unbearable. Many people wish to feed them up before they will work with them. They do not believe it is possible for individuals to make sense, or perhaps be made sense of, at such a low weight. I think this is the reason why Bruch (1970, 1973, 1978), Palazzoli (1978), Gardner and Garfinkel (1982) and Hsu (1986) suggest that analytic work should not be undertaken until a certain amount of weight has been regained. Their rationale is that thought is not possible below a certain weight. Thought is a problem for many anorexics and bulimics, but it is not one that is affected by weight. Concrete thinking and difficulties in symbolising are amongst the basic features of eating problems, regardless of the particular theoretical stance that is adopted (Boris, 1984a, 1984b, 1988; Sohn, 1985; Shulman, 1991). Eating and digestion can be thought of as being metaphors for the taking in experiences in the world and effectively processing them - or not. Unconscious phantasies are rife regardless of weight and are open to interpretation. In The Psychodynamic Technique of the Eating Disorders (1992), Wilson et al. give examples of working analytically with patients who weigh half their average weight.
Bruch (1962, 1965, 1970, 1978), Crisp (1965, 1967, 1968, 1980), Dally (1969) and Palazzoli (1978) went even further and argued that working psychoanalytically with these patients should be avoided. Professor Arthur Crisp and Dr Peter Dally are psychiatrists, not psychotherapists, and their bias may come from personal and professional beliefs about psychotherapy in general, rather than the specific phenomena of eating disorders. Bruch is a special case and changed her mind over the years, as psychoanalytic technique itself became more flexible. She was opposed to strictly classical technique because of its failure to contain these patients adequately, for whom silence is often not tolerable. Palazzoli seconded Bruch's approach to working in an educational rather than analytic way with anorexics. She found the difficulties of working psychoanalytically on an individual basis with eating disordered patients was so great, and the rate of improvement was so slow, that she moved rather suddenly from individual to family therapy.
The main problem in working with these patients is that the very process of taking things in has gone wrong, as has the process of mental digestion. These are others words to describe very early confusion in the mother-daughter relationship. There is very little room for manoeuvre. Using such basic and primitive terms tends to steer me towards a Kleinian understanding of projective identification - not normal projective identification but virulent projective identification - the type which Enid Balint felt had taken place within some of her patients, whom she describes in her paper 'On Being Empty of Oneself' (1993, pp. 37-55). Bion's (1962) paradigm of container and contained also comes to mind.
The absence of both a container and the function of containing can be thought to have been present in both the patient and the mother. This leads to a very difficult place, one I have tried to think about and elucidate by using Winnicott's (1953) idea of transitional objects and Weinstein and Kestenberg's (1988) idea of intermediate objects to exaggerate the absence of an experience of the self, apart from being simultaneously a leaky and chaotic container for, and an extension of, mother. The patient's needs or wants may only be met by accident or in secret in order to preserve the fantasy of not having a separate life in either mother's or her own eyes. I want to use the idea of the baby as an intermediate object as a metaphorical way to understand some of the pressures which the therapist experiences in the transference. In so doing, I hope to allow the therapist the freedom, not to behave in a neglectful or sadistic fashion in the therapeutic encouter.
It seems to be necessary to introduce real objects, not just internal ones, into the picture. A Kleinian understanding does much for narcissism and understanding the confusions of the divide between self and other but does little for the necessary impact of separateness in reality. Anorexic and bulimic symptoms can be thought about as being ways to separate, to attempt to distinguish 'me' from 'not-me', both internally and externally. But a Kleinian approach only deals with one half of the problem. It addresses the concrete nature of the symptoms, the part-object relations and the thoughts and underlying phantasies. The differences between Klein and Winnicott revolve around their respective understanding of the internal and external worlds and the role of internal versus external objects. Kleinians believe that there is a very definite distinction between inner and outer worlds with the action taking place in the internal world. In my opinion the line between external and internal is almost non-existent, rather than definite, as the sense is that it is only the internal world and internal objects that matter. Winnicottians not only recognise the external world but believe it does impact on an individual's internal object relationships. This is why Winnicott could conceive of an in-between 'space', and even in-between 'objects': his ideas of transitional space and transitional objects. For Kleinians this is not a possibility, as the internal objects are so primitive and so embedded in the unconscious that for an external object to represent both an internal and external object would suggest ill-health, rather than a developmental stage, as Winnicott believes.
Winnicott's viewpoint suggests that the interplay between inner and outer, between external and internal worlds, happens somewhere, in a zone, a space, in the external world, which is experienced as being neither internal nor external. For Kleinians there is no zone between the internal and external worlds. For bulimic patients it is this very zone between inner and outer which they are trying to clarify and define in a very conrete way, with the assistance of the bulimic symptom. The confusion for both the anorexic and the bulimic is the tremendous impact that the external world, in the form of food (representing input, stimulation of any kind), has on their bodies. The internal and external world do impact upon each other, and there is arguably a third area between them, and it is here that Winnicott's ideas are useful, for they provide a space, an in-between, that is so clearly lacking for anorexics and bulimics.
This is the problem for the therapist. The patient, whether anorexic or bulimic or a mixture of the two, will have spent her life ensuring that she is not known, at the same time as longing to be known and given the room to grow. Ana-Maria Rizzuto describes it thus:
The patient's most persistent defence is an ever-present attempt to control the analyst. The motive for the defence seems to be to prevent the analyst from making emotional contact with the patient. In fact, if such contact is not introduced very gradually it evokes massive anxiety (Rizzuto, 1988, pp. 371-372).
She goes on to explain how the mismatch may have come about:
It stands to reason that the wish to speak in order to communicate affect and inner experience requires, as an indispensable condition, repeated experiences of achieved bodily communication during the first year and of verbal communication during the second and third years. External safety, however, is not enough. Self and object representations - the internal world - must also offer a modicum of safety for affects to be put into words. Without this safety the attempt at describing feelings may bring about massive anxiety or a discharge in action (Green, 1977, p. 150), as happened with Wilson's patient who had to vomit his words (1988, p. 383).
Being cumulatively misunderstood is traumatic, and the difficulty with working with these patients can be thought as trying to provide a safe space in which understanding can be sought and found. Within the transference the likelihood is of being expected to be a brutalising and misunderstanding mother, who is only there to use her 'child' or 'patient' for her own needs and who cannot understand, contain or process any of the patient's material. In the transference this is what they wish to elicit from their therapist, and they often succeed. Methods vary, from silence to rushing streams of material to material so confused or encoded that comprehension often feels impossible. The patient has adapted to not being understood or known, by withdrawing and becoming apparently un-understandable. Other people are there to be provoked so that the patient may be moved into action, reaction, or puppet-like activity - all in order to protect a self, which is often nascent in form and substance and which is hidden. To be good is to be safe, to do as the therapist wants, for to act as a near-perfect intermediate object ensures the absence of attack, and may even hold out the possibility of good feedback. This often makes psychoanalytic psychotherapy very hard for these patients. All experiences which set off an awareness of difference in mother or self must be avoided. Experiences may be good, bad or indifferent, but they are to remain hidden. For some patients, sustenance of some kind, seems to be drawn by retreating temporarily to a near autistic state during bingeing (Shulman, 1991).
Ways of Trying to Get Around the Problem
This is how the eating disordered patient has managed to survive, and it this very dilemma which Bruch (1973, 1978), Palazzoli (1978) and others have tried to circumvent by avoiding working in a classical psychoanalytic way with these patients. The difficulties may seem insurmountable: Tedesco and Reisen (1985) commented on Mark J. Gehrie's work with patients.
None of his cases of eating disorders were in analysis in the strict sense because none could psychologically survive in the atmosphere of abstinence characterized by a classical analytic procedure (1) emergence of intense anxiety followed by active flight from the process, or temporarily, from the treatment itself; (2) a non comprehending blankness and sense of isolation. In no sense was there an introspective capacity to allow for the development of a therapeutic alliance (Tedesco and Reisen, 1985, p. 156).
This is very similar to the experience of working with these patients which Hilde Bruch describes in her book The Golden Cage: The Enigma of Anorexia Nervosa (1978). What is implied (and is voiced by Lasègue) is how difficult it is for the therapist to tolerate the anxiety, frustration, and the wish to cure these patients - to react - to become the 'user' of the patient, to calm oneself, rather than trying to understand, tolerate and interpret their distress. These countertransference dilemmas are well expressed by K. J. Zerbe in an article entitled, 'Eating Disorders in the 1990s: Clinical Challenges and Treatment Implications'.
Countertransference dilemmas can be tempered by recognizing the principal relationship struggles in the treatment process: (1) the patient's deep masochistic trends, which contend with omnipotent wishes to control the therapist or to render the therapist the "bad object" (Lerner, 1991; Novick and Novick, 1991); (2) the patient's tendency to identify with the aggressor (A. Freud, 1936; Ganzarain & Buchele, 1988); and (3) the therapist's excessive need to change the patient, particularly vis-a-vis the eating behaviour (Boris, 1984a; Gabbard, 1990) (Zerbe, 1992, p. 180).
My own uncertainty about Bruch's educational approach is that it fulfils the conditions noted above, and places the therapist in the position of being a source of all knowledge and perhaps unconsciously recreates an experience of a mother who wishes, in the child's experience, to control her child like an object, as an extension of herself. This is not to disregard the fact that the patient may be simultaneously being understood for the first time. Fact feeding does not allow the patient to find her own solutions and by-passes the muddle, which is an essential component on the search for some recognisable and nameable internal experience. Bruch entirely ignores the unconscious elements of the conflict between mother and child. Palazzoli supports Bruch's approach, particularly its existential aspects in relation to an exploration of the here and now and being-in-the-world. She suggests intensive psychotherapy with the involvement of the parents is necessary. From a technical point of view, she thinks the couch is too frightening to be used initially with these patients, that they must be told that food is the symptom not the problem and that 'References to the transference situation are best avoided, not least because the patient finds them too painful' ( Palazzoli, 1978, p. 128). She says later 'In my view the sexual fears of anorexic subjects are, in fact, almost invariably the expression of their fear of psychological "invasion"' (ibid., p. 157). She says of bulimic anorexics,
In particular I found that patients suffering from severe bulimic crises displayed thought and communication disorders not present in patients who keep strictly to their reduced diets. Family observations also seem to suggest that major bouts of bulimia go hand in hand with psychotic confusion, violence and a complete breakdown of family communication (ibid., p. 205).
There is a tone of despair, defeat and violence in her descriptions, yet the problem she describes is the same one throughout: how to make contact with these individuals without triggering off massive anxiety, flight or fight mechanisms and/or annihilatory terrors. As I have said, Palazzoli finally abandoned individual work in favour of family work. The strands of Bruch's ideas concerning compliancy and deficit in the child were taken up and elaborated by the self psychologists who saw the analyst as acting as a necessary self-object who performed a missing function for the patient, which she would eventually manage to take up for herself. This variation on the theme of narcissism is an important one, but what self-psychologists avoid are the complicated interactions which take place in the inner world, particularly the depth and complexity of the patients negative feelings. For instance, they only recognise anger as a realistic response to a narcissistic wound, (Kohut, 1971) which means their self-object representations will tend to focus on what is lacking, somewhat at the cost of working with very primitive and destructive phantasies.
Envy has no place at all. The primitive oral, anal and urethral sadism of Klein is nowhere to be found. It is this very sadism which has to be thought about and experienced and not acted out in the countertransference, which is the crucial element in working successfully with these patients. The intensity of the feelings of violence obviously varies from patient to patient, but what matters is the awareness from the start of treatment that the therapist is unconsciously going to be persuaded to be or feel sadistic or to use an attacking tone of voice. The aim of the patient is to be invaded, to feel controlling and so controlled, so that no separation is known or experienced. There is in effect no space to play or think. This is a point made indirectly by Cross puts it in her article on eating disorders and delicate self mutilation:
Internal and external sadomasochism are linked through the common element of the body; other people are manipulated as if they were extensions of the body, and functions or parts of the body are tyrannised as if they were unruly persons (Cross, 1993, p. 62).
The emphasis on primitive sadistic unconscious phantasy of Klein sheds light on much of the material which anorexics and bulimics bring to the consulting room. So too do Winnicott's ideas on transitional space and objects. Theoretically, as described above, the two are not compatible. It may be that both positions are needed and that the effect of the lens of the internal world is variable, dependent not only on its own ever fluctuating construction but on the intensity and nature of the light of the external world.
The ego psychologists' scientistic approach makes things appear more cut and dried and less bewildering and confused than I have found it to be in practice. Their 'by the numbers' approach is troubling and their language somewhat alien. Their belief that a conflict free sphere of the ego can be facilitated in themselves and their patients makes working sound easy, with the consequence that the question of who is who from moment to moment in the session is just not explored. Philip Wilson (1992) suggests that whilst dyadic material is being worked with the patient should be seen face to face, and when Oedipal material appears a move to the couch should be made. He says,
Whilst some cases can be analysed with classical technique, in most patients the initial technique involves focusing on dyadic material. Patients are seen face to face with early interpretation of manifestations of their impulse disorder. Only when there has been a modification of the archaic superego with ego maturation and a shift from part-object relationships can triadic oedipal material be interpreted. Recently developed techniques that enable therapists to interpret and resolve severe regressions (primitive mental states) were presented. These include new research on oral-phase dream symbols, such as sand and stone, xerostomia, and projective identification (Wilson, 1992, p. 71).
Having stated that the methods put forward by the ego psychologists are often alienating, I do agree with Philip Wilson's appreciation of how early and powerful the transference can be with these patients. He says, 'The process that many analysts seem not to have understood is that a most intense pregenital transference has already developed at the start of the analysis' (Wilson, 1992, p. 39). Wilson is very aware of the transference and the countertransference, but he uses the latter as a guide for what not to do, rather than as a powerful instrument of communication between patient and therapist:
The analyst has to distinguish carefully between counteractions and contertransferences in the analysis of these patients. The analyst experiences all the conscious reactions to the patient's provocative behaviour and acting in and acting out that one experiences with a rebellious child, except that the eating disordered patient is not a child and is far more provocative, deceptive and manipulative (Wilson 1986, 1987; Wilson et al, 1985)' (Wilson, 1992, p. 55).
I would go further and say that it is only by being closely attuned to the transference and countertransference dynamic - and by containing and interpreting the latter - that effective work with these patients can take place. This shift from being wary of countertransference to making use of it, can be seen as one of the most striking developments in modern Kleinian thought (Brenman Pick, 1985; Young, 1994).
The somewhat denigratory nature of the words used by Wilson to describe the provocative behaviour of these patients is the norm. It was not only Palazzoli (1978) who gave up working in an individual way with these patients. They do stir up powerful and primitive feelings in their therapists, as can be seen in some of the literature. Leslie Sohn (1985) suggests bulimic patients evoke anorexic feelings in their therapists, and that anorexic patients evoke bulimic feelings in their therapists. In my experience the split between the groups is not so clear cut, with both groups illiciting anorexic and bulimic feelings in the therapist. What is of even greater interest is his frustration at the inaccessibility of these patients that can be glimpsed in his writing:
This was borne out in the analytic work, where not only was there neglect in general of the analytic food, but a repetitive nagging demand that each, or parts at least, or each interpretation should be differently couched. This was usually accompanied by interruption into most interpretations. If she started to enjoy an interpretation she would make herself unaware of her enjoyment and therefore unaware of an analyst; if however the interpretation was not enjoyed she was obsessed by the interpretations that were to come (Sohn, 1985, p. 51).
A little later, he offered the opinion that:
The anorexic continues her appetiteless behaviour while greedily demanding an impossible series of satisfactions; the bulimic patient stays greedily searching for unenjoyable satisfactions from an object, while remaining without appetite, understanding and awareness of her state (p. 55).
According to Sohn what happens is that the therapist ends up with a metaphorical eating disorder; he or she feels her therapeutic food cannot be eaten or cannot be tasted, or will never be enough. This then leaves the therapist feeling frustrated and short of options. In this situation it seems to me that the patient is not being helped to become her own therapist. Philip Wilson (1992, p. 370) also talks despairingly of working with bulimic anorexics 'The analyst is derided and rejected, as are his/her efforts to know the patient's private thoughts and feeling'. Earlier, Wilson suggested that:
The bulimarexic seems to be making every attempt to render the analyst impotent as a person and as her helper. Every avenue the analyst tries seems to find the patient ready to block access. No matter what the analyst does, the patient appears ready to pick a fight (1983, p. 190).
Furthermore, he opined: 'In the countertransference the analyst experiences exhaustion, discouragement, anger, humiliation, and a wish to get rid of the patient' (Wilson, 1992, p. 372).
Before working out how to get through to these patients and how to connect to them it is important to know from what they are protecting themselves and their therapists. These experiences of despair, frustration and fury have to somehow be thought about and used to help patients within the therapeutic relationship. By thinking once more about mother's unconscious feelings towards her child and her possible use of her as an intermediate object I think some of the intensity of the experience can begin to be thought about. For these patients, being known is dangerous. Before addressing this I wish to explore how patients receive interpretations from their therapists.
From the Patient's Point of View
They dread the power of the analyst's words to invade them as a destructive weapon, to manipulate them or harm them internally. One of my patients used to warn me not to name her emotions, or to make any statement about her because she would feel invaded by me (Rizzuto, 1988, p. 370).
She also makes the point that the patients feels herself to be an object in her own eyes and in her mothers. This is experienced by Marie Maguire in an extremely concrete way in the transference and countertransference:
However, because in childhood, there was, in reality, no other involved adult who could help her to separate psychologically, in the early stages of her therapy Mrs K. remained preoccupied with an unusually intense physical identification with her mother's body. She experienced herself and her mother as identical, both simultaneously beautiful and repulsively fleshy. In her therapy sessions, over a period of time, it was as if, in fantasy, she wrapped herself around me and became me. When this first happened, I had the sudden alarming feeling that, without understanding how or why, the ground had been cut from under my feet and I had lost all sense of who I was. When I expressed this feeling of intense disorientation, Mrs K. then began to voice her fantasy of having stepped into my skin, sat in my chair and become the therapist rather than the patient. At this point, I began to regain my capacity to think and understand. During these sessions Mrs K. arrived wearing clothes as similar to mine as possible. For, the first time in her therapy, she became visibly enraged. Her anger focused around the fact that I wore an unpredictable colour, one she disliked too much to copy. If she could actually experience herself as being me or her mother, rather than a separate individual in her own right, then in fantasy she could control us. Imagining that she possessed all our attributes, she need not feel her usual sense of inequality and envy in relation to us (1989, p. 119).
Marie Maguire was able to use her experience in the countertransference to enable her to understand the process that was taking place. So, the problem at least becomes a little clearer. It is how to make a link, a link which is thinkable about in words, rather than simply being experienced as a takeover bid or an attack from either therapist or patient or both. This can be thought of as being part of a very early scenario where mother saw child as an extension, a part of her self, and the only way to grow was to become mother, separation and separateness were untenable. The route to finding the self was unknown. What is needed with these patients is compassion; injections of frustration are their bread and butter. They do not expect or hope to be understood
This difficulty regarding making and reflecting on links is well illustrated by a normal-weight bulimic patient of mine. She was very concerned with trying to think about her sexuality, her body and about reproduction. She felt handicapped by the very concrete nature of her thought. She was unable to imagine a link being formed, from which she was excluded and found the end of sessions particularly painful, when she felt forced to leave when she wanted to stay. Links were not allowed or acknowledged if they were outside of herself. Here are two examples from her material which help to illustrate this point.
The first example is of her telling me with some difficulty about drinking three pints of water before the session and at the end of session going to the bathroom and peeing it away. Although it was hard for her to tell me (that she did so was unexpected), she saw it as paralleling what went on in our sessions. During the sessions a whole lot of 'bad stuff' (her words to describe strong emotions) was stirred up. By peeing at the end of the session she felt she had got rid of the feelings. She felt cleansed and very good at the end of the session. This was so. It was also true that it was a way of her controlling the content of the session. She could have it inside and get rid of it at the end of the session. I was, metaphorically, peed away until the next time, when she could magically recreate me inside herself before the session and then do with me as she wished. The action took place inside her, and she felt responsible for it.
What was different was her practising the experience of having a space inside, one that she could use in a non-destructive way and that she was letting me know about it, and witness it. She was practising in the only way she knew, a concrete way of being full and empty, but one which was not actually or potentially physically damaging. The idea of having any kind of a feminine internal space was a very new experience for her, and babies were in her mind still products of eating, drinking or defecating. There was apparently no phantasy of a copulating couple, the phantasy was rather of self-fertilization. In phantasy the wish was to be able to fertilise herself and give birth, without having to know of her own birth, the fact of her parent's intercourse and her dependent relationship to them.
A dream from a couple of weeks later again shows the hope that magical thinking can by-pass the painful, step-by-step process of growth. In the dream she spoke of a four year old girl who was listening to her father giving a speech from a podium. The child then went up to the podium and continued the speech. People commented on how precocious she was. In one move she went from being a four year old girl to being a father, with a father's abilities and accomplishments. In the dream she takes his place; he is no more. Not only has a change of sexual identification occurred, but all of the in-between stages are missing. In real life her father had left abruptly, and she did indeed feel as though she had taken his place in relation to her mother. She has spent her life behaving like a grown man whilst feeling like a four-year-old girl. The deal she struck with her mother, her internal mother, was that mother would give her some love if she played the role of a man. If she competed with mother, not only would she have to forfeit her love, and risk being attacked by her, she would have to come to terms with the agonising loss of her father and thus have to face her unresolved pre-Oedipal relationship with her mother.
Redefining The Problem
Ana-Maria Rizzuto, in her article, 'Transference, Language and Affect in the Treatment of Bulimarexia' (1988), provides a way of thinking about anorexic bulimics and by inference normal weight bulimics and anorexics, in terms of what is to be known and what is not. Hidden meanings and secrets are waiting to be found out, and often seem to be just out of the reach of eye or hand. For the purposes of this chapter I shall in general refer to eating disorder patients and where it is possible I shall attempt to distinguish between them. Rizzuto, suggests that the defence against the transference is the transference itself. Mother and child have colluded to avoid understanding the subjective experience of the child. In the transference there is no wish to talk, as there is no belief in being understood or heard. There is a wish to avoid the repetition of the trauma of not being understood, or of actively feeling attacked. Words, as a form of self soothing, are not available to them. They are felt to be overwhelming stimuli, the affects of which cannot be experienced, for there is no safety in which to experience them. To repeat what I said earlier, the patient feels herself to be an object in her own eyes and in the eyes of her mother.
I think the use of the word 'collusion' gives an unfair intentionality to the child's behaviour. Certainly as adults, eating disordered patients often present through a series of smoke screens, misunderstanding mirrors, which have to be seen through and thought about in detail before sense can be made of them. It is not so much that as children they colluded with their mother, rather that their signals were misunderstood, in different ways, and this misunderstanding was taken in, along with mother's feelings and wishes, until the only safe way of trying to get things from mother was to steal. Mary Magdalen stretched out a hand to touch Jesus without being seen - hoping to gain strength by doing so. Anorexics and bulimics often feel the only way to have something from mother which does not diminish her or attack themselves is by theft. They pray they can feed without it being known or experienced by mother. At the same time stolen food is tainted, and although it can be eaten, it is difficult for it to be nourishing, as in phantasy it has to be self-created and not part of an object relationship. For if it is recongised as having been stolen from mother, retribution is awaited. So it cannot be allowed to lead to growth.
The Location of Interpretations
The area of action or interaction which is possible with these patients is very hard to find. The ground needs to be prepared before interpretations can be used or thought about. In his classic paper on 'The Observation of Infants in a Set Situation' (1941) Winnicott has described a scenario that I think offers an analogy as to how interpretations could be offered to eating disordered patients. The situation in his paper is a contrived one, where a mother and her baby (who is within a specific age range) come together into Winnicott's consulting room. He has placed on his desk a spatula, and the observation involves watching how the child responds to the spatula on the desk. The differing approaches, the types of play, or the lack of them, all provided extremely useful information about the nature of the child's relationships and inner world.
I think this is how interpretations need to be given to anorexic and bulimic patients. They have to be offered. They must not be thrust down the throat of a patient. The timing and the tone has to be considered and close attention has to be paid to how the interpretation/spatula is handled, chewed and possibly discarded. Patient M, to whom I have already referred, used to swallow my interpretations whole. It took some time before I became aware of what had happened. She would talk about herself in a way which was strikingly familiar, and I realised that my words and phrases had been directly and unconsciously purloined by her. They would appear months after I had said them, just as I had said them, whole and undigested, as though they were her own. If I had failed to notice this process, which it would have been easy to do, I could not have appreciated the relevance of the appearance of what I had said in some sort of a digested form.
A space has to be found where some reflection is possible for both patient and therapist. In practice this is extremely hard, particularly with long term anorexic and bulimic anorexic patients and can only come about once very powerful feelings have been experienced and survived in the transference. This is not to state that things then become easier but there are at least moments of possibility. Deidre Barret and Harold Fine suggest that patients cannot tolerate penetrating interpretations:
Interpretation, when initiated by the therapist, never really worked because it was construed as being commanding and could set up resistant behaviour. Liz remained essentially sombre, but began to be able to tolerate gentle humour (1990, p. 266).
Harold Boris makes the point with which I agree - that interpretations have to be presented in the transitional space:
The anorectic problem is the boundlessness of her desire on the one side and the envy on the other and the dizzying simultaneity of the two... Both combine to hate and mentally obliterate the separateness and distinctness of the object. There is no transitional space - the not-me, but yet not-other space - that transitional objects require. The anorectic lives, as it were, without a skin. Others, in their incandescent desirability, impact on her with detonating force. And this is the problem... The analyst, then, needs to work in a transitional space. He cannot work on or in his patient (1984b, p. 437).
The paradox is that this is what these patients lack and what I think Fine and Barret are recognising when they say direct interpretations were not tolerable to their patient. However humour can be, and I think the tone of voice can also be, a powerful tool against the anticipated destructiveness of the internal mother, whom they have tried to provoke in the transference. Alan Sugarman, analysing a bulimic, has noted:
Her wishes to be regarded so highly made it difficult to find ways of phrasing interventions that would not feel critical. To focus on a "problem" felt to her like an attack on not being perfect (1991, p.17).
Silent Interpretations: Toleration of Countertransference Feelings
Interpretations can only be made effectively once some kind of safe arena has been created. The analytic frame itself provides some safety, as does the non-attacking position of the therapist, which is often very difficult to maintain, for there is much pressure from the patient to react in a hostile way, to ensure a repetition of a violent and intrusive object relationship, where there is no space between. The space has to be filled or awareness of separation is unavoidable. I think the first step is, the toleration of powerful countertransference feelings which come from an extremely primitive layer of the child-mother relationship. According to Zerbe,
As Gabbard (1989) has suggested in a different context, such silent processing is often quite helpful in diagnosing the patient's internal object relations and in modifying projections for reintrojection. Such "silent respect for the patient's central self may be the only viable technical approach to fostering the therapeutic alliance" (Gabbard, 1989, p. 533) because it provides the patient with the time and empathic understanding to establish autonomy. Only then can the eating disorder be controlled, because the patient desires change for the self and not for the therapist (1992, pp. 179-180).
This point of silent and compassionate toleration of what is nearer to chaos rather than muddle is also stressed by Boris (1984b) as being instrumental in providing the patient with an opportunity to emerge from her silent, secret shell. It is what I think of as the toleration of vomit within the sessions, undigested material, which patients need to bring up again and again, before they can begin to use it as an intermediate object and then as a transitional object with the help of the therapist in the transference:
But in the end, it is the analyst's own quiet tolerance of the muddle and uncertainty, of the gradualness of approximations, of error and apology that makes it possible for his patient to simply come to be. In being resides the experience that when genuinely experienced leads to the insights with which development is facilitated. The capacity for both parties to the analysis to manage the presence of the absence of certainty is what, more I think than anything, to be or not be the conducive factor (Boris, 1984b, p. 441).
The therapist has to become what the child felt the mother could never be, a container and processor of her feelings, thoughts and terrifying anxieties. The expectation is to receive them back in an amplified and frightening form, and this is what the therapist has to try to avoid. The patient expects to be force fed or starved and to do the same to the therapist. The vomit has to be accepted as worthwhile material, however incoherent, disconnected and fractured it may seem. At some stage the time comes when it is possible to use countertransference feelings to make sense of the material and to allow an interpretation to be given some form of a hearing, however briefly. I want to give a fairly long clinical example to illustrate this point. It is a session with patient M which took place some four weeks before the Christmas break and which I want to use to illustrate the complex nature of the interaction between patient and therapist. I will try to decode the session to illustrate the point about transitional space, the pressures in the transference and the very sparse connections that could be made.
An Extract From a Session
Patient M was on time and pressed the buzzer very lightly.
She was silent for about five minutes. Then she said it was only when she was leaving at the end of the last session that she was able to start crying - when she got to the lift. In the session itself she had felt that nothing had happened. She said she did not want to be here today. What she wanted to say before she came here she did not want to say now. She said there was nothing happening.
She then told me about a watching a programme on television the night before, on men and women who are frightened of putting on weight. Most of them were anorexics, but there was one bulimic. She said that when she binged she imagined that she would put on stones and stones of weight overnight. She added that she was beginning to feel that way again, that she was becoming obsessed about food and that she worried about putting on weight and that she wanted to start making herself sick again. She said she didn't know how she ever lived with herself when she was making herself sick all the time, every day and taking laxatives. She had stopped vomiting when she went to India but she had eaten all the time there, whenever she could, anyway. She did not know whether she would have stopped being sick if she had not gone to India. She said it was just the same as when she started coming here - thinking about food all the time, feeling this way, she does not know what else is wrong with her. A short pause then followed. She said, 'When I think of my mother and sister, they don't worry any more, because I'm not being sick and vomiting. I'm thinking about going home at Christmas'.
She said because she was eating like this she thought there was something that she really did not want to face up to, rather than worrying about changing jobs and going to interviews, that there must be more. She said,
You're making me feel like this. I'm wondering why whenever I see an upset child in the cinema I feel like crying, I feel so bad about myself. I saw this article about a guy who was an alcoholic. I was admiring his ability to change himself so much. I can't even make a small change. I'm dreading Christmas. I'm just going to eat, feel so alone.
I said, 'I think you feel alone when you're here at the moment and even more alone when you leave here. The Christmas break is coming up, I think you feel I've abandoned you already'.
She started to sob quite hard and then said that she had been thinking about whether she had changed or not, that all the changes are negative ones, that she is more outspoken at work, that she nags them, gives out to them all of the time, that she involves herself with bitchiness, that she is more social with people at work - but that it is in a bad way.
I said, 'You're disappointed and want "to give out" to me for not having helped you more'.
She said she thought that I knew what it was, that I knew what the problem was, and that she wanted to know why nothing changes. It is just the same month after month and that I wanted her to figure it out and she never will.
I said 'You feel I'm keeping secrets from you, that I have the answers and that I'm not letting you in on them'.
She said that I was some kind of a trained counsellor and that I was meant to know the stages of getting better. She wants to move house. She does not really get on that well with her flatmate, R, that they were never really that close. It was just like it had been in the last place, when she stayed with people in Boston, that she never kept in touch with anyone from then.
She then gave a big sigh.
She was thinking about going to the second interview and how she had to change the time of her session and leave early. This was followed quickly by her saying that she did not understand why she thinks about so many things when she is here. She said she thought she was just thinking about all of these things to avoid what is really upsetting her. She cannot think of anything, that she is numbed out from eating, that all she thinks about are stupid things, that she does not even know what it is that is upsetting her so much.
I said, 'Are you going to give it a guess?'
She went straight off at a trot, eagerly:
I must have been really unhappy when I was younger. I don't understand how come my sisters aren't like me. I don't know what I picked up to make me feel like this. I suppose when I think about something being wrong with me, I think of something that must have happened a long time ago - that its very deep. I want desperately to remember more, but I feel like I'm choosing to forget more. I never seem to think about my father. I forget about being bulimic, what it was really like, forget what it was like when I came back from Boston and spent five weeks in Maidenhead - that it was a job I hated. I lived with an elderly couple. I can't even remember their names or the names of the people who shared the house with them. I'll never be able to figure it out, because I remember nothing.
She continued by saying she supposed it was that she was thinking about how unsociable she feels, that she does not want to go out with R her flatmate. R had gone out the night before and M had decided not to go out with her. She had gone out the previous week with T, but had not really wanted to. It is not okay when she's binge eating. She does not want to ask anyone to supper; she is 'too depressed, wrapped up in myself to bother about other people'. She then said she wanted to be left alone but that she also did not want to be, and that she felt her life would never improve 'if I keep shutting myself off from people'. She spoke about a woman at the agency, who was confident and enthusiastic - that she must think that M was a pathetic person, that she was so childish. The same kind of thing happens in her French class, where she also feels childish and useless.
I said, 'So you're managing not to shut yourself off from people, although its hard. You're going to your French class, going to the agency, beginning to wonder about the past, your father, your bulimia, your childhood and you're feeling very aware of how you feel.'
She asked me repeat what I had said and I did.
She then said that a friend at work had asked her what colour hair her parents had and she didn't know what colour hair her father had. She just remembered that it was grey, that she hadn't any idea what colour it was before that. It was the anniversary of his death on November 10th.
M was in the middle of a binge when she came to her session and the words flowed towards me in a violent and attacking stream. If my first interpretation had addressed her way of relating, or the rage she was feeling, she would have denied it and would probably have withdrawn. It would have been experienced as a reprojection of her own feelings, regardless of how it was said. Underneath her rage with me was an awareness of a holiday break coming up and the hopeless feelings she had inside. By addressing her feelings of being alone in the session, when she was with me, feelings which became even worse when she was away from me, and linking this to her feeling that I had already left her for the break, I was able to make a connection with her. She started to sob and a point of contact was made. This was immediately followed by a more concentrated attack on the work we did together and how I had just made her into a 'nasty' person.
The initial tirade had been intense and provoked a conscious wish in me to retaliate. I did not do so, but by the tone and language of my next interpretation I very much played into her wish that I should attack her. Her own ferocity was reduced, and although her words may appear somewhat attacking in the transcript of the session itself, I was aware of feeling increasingly angry as she became less so. The pitfalls of remaining silent in this instance are that with this particular patient withdrawal is taken to be an aggressive act, and it would have simply confirmed her feeling of being abandoned. I struggled internally with how to transform my wish to get inside her, to effect her, to stop her being angry, to stop my anger by hurting her. Thinking about space and where and how to place an interpretation, I decided I needed to create a space between us so that we did not get into a downward spiral of attack and withdrawal (see Wilson and Sohn above, pp. 70-71). I said, 'Are you going to give it a guess?' in a light and non persecutory or sharp tone of voice, which meant that she could find her own voice. The session shifted from that point on. It shifted into rich, but confusing material, mixes of old and new, coming out in a higgledly-piggledly way. It felt like friendly and bewildering vomit which I had to hold and not interpret. I understood some of it, the familiar strands, but my role was not to ask questions about it. It had to be accepted and contained, not interpreted or reprojected. I think her wish for me to repeat what I said near the end of the session, was because my words were so at variance with the expected internal attack, which seemed clearly represented in the story of the woman at the agency who was confident and able and who therefore would believe M to be stupid, useless and childish. The not-hearing could be seen as both a defence against an expected attack and also a defence against helpul or understanding words which might need to be attaked to prevent her then feeling diminished. I think her asking for them a second time suggested a wish to hear, to not be knocked out by them, or to knock me out by not hearing them, for them to be allowed to exist as something good.
It was a major shift that she was beginning to bring her rage and distress to the session, after some years of severe depression and suicidal feelings. She was a very powerful woman who often made thought impossible during sessions. She would often, as Marie Maguire's patient did, project so powerfully that I experienced an inability to think and make sense during sessions, so that sometimes a large portion of a session would disappear into a vague dreamscape. The concrete nature and strength of her projective identifications becomes easier to think about and understand using ideas of intermediate and transitional objects.
M, like so many bulimics, does not have an in-between: she takes over, or she is taken over. There is in many senses only one area of experiencing, that of her own internal world. There seem to be only two choices in her world, either being engulfed or engulfing, or abandoned and abandoning. I have to exist in the sessions in a transitional space to help my patients find it within themselves and to avoid the enticements of narcissistic collusion.
By this I mean that many bulimics and anorexics can talk away happily and give the appearance of making progress, whereas they are often unconsciously being the intermediate object for the therapist, who feels very good about the work, and perhaps the closeness of the fit between herself and the patient. By this I mean they are unconsciously picking up the imagined signals of the therapist and giving her or him just what they want. This is how the patient behaved with her mother and continues to behave with her internal mother. This is repeated in the transference where she perceives herself as being purely an extension of the therapist. Anorexics and bulimics protect themselves from the perceived horrors of being known, and it is essential to be aware of this if they are going to be helped and to recognise and address their terror of experiencing a repetition of being uncontained and their material being indigestible.
Hilde Bruch (1978) was very aware of the tremendous fragility of her anorexic patients, and her active approach was designed to contain and to help them. I think it can be replaced by a less directive, but equally active approach. That is, by actively using the dynamic of the transference and countertransference to make interpretations, which do 'contain' annihilatory and separation anxieties. What I have not spoken of directly is the technical difference between working with anorexics, anorexic bulimics and normal weight bulimics. This involves an inappropriate amount of generalization - but moves along a by now familiar trajectory. One of the main differences is the unconscious death wishes of the anorexic versus the more conscious ones of the bulimic. This in practice, makes the anorexic harder to reach with interpretations, as they have invested so much in their wish not to exist. Bulimics are more likely to throw interpretations up, unless presented in a non threatening and digestible way, their ambivalence and wish for relationships parallels their relationship to food. This leads to the next distinction, between those who binge and those who do not. The dynamic is similar but with the anorexic bulimics the presence of much stronger self-destructive tendencies and the wish to use food to abuse, not to nourish, makes them the hardest group to work with. Normal weight bulimics are the group most able to use the therapist and the therapeutic space as a play room, a place where intermediate and eventually transitional objects, in the form of interpretations, may be found and put to good use. They are found in the interaction between therapist and patient. For all eating disordered patients interpretations will often feel invasive or penetrative. When this is the case, an anorexic often responds with an enraged 'no' and a bulimic with a greedy 'yes' with the subsequent wish to get rid of the interpretation. This is the norm and needs to be appreciated, so that the lack of movement can be tolerated and interpretations can then, for many become 'edible'.
The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM