| Contents | Preface | Acknowledgements | Chapter: | 1 | 2 | 3 | 4 | Conclusion | References |
I have tried to elucidate the emergence of eating disorders, since the eleventh century, paying particular attention to the psychoanalytic meaning of the symptom, whether it be anorexic or bulimic. I have attempted to differentiate anorexics from anorexic bulimics and normal weight bulimics, and have done so mainly on the premise of weight, but also on the presence or absence of the bulimic symptom. The symptoms were originally understood as a complex defence against positive and then negative Oedipal wishes. The ego psychologists in the United States became more interested in the early separation-individuation struggles of these patients, and the Kleinians, entering the same developmental period from their particular perspective, saw the problems as being narcissistic, and focused particularly on the role of envy in these patients.
In the chapter on transitional objects I raised the issue of the mothers own pathology and her desire not to know her child, as well as her wish to use her for her own purposes to the childs detriment. This can be seen with anorexics whose way of life is designed to preserve the idea that there own life, their very existence, should not be a matter for concern. It is also paralleled in the bulimic ritual itself by taking in of too much food which cannot be nourishing and has to be expelled. It may also be a childs only experience of connecting with mother, however briefly, and I have argued that it is this moment of re-enacted connection which enables bulimic individuals to use the post-binge period as a transitional time, when vomit or the rituals around clearing up are used as transitional phenomena. Bulimics attempt to use the vomit as a transitional, rather than intermediate object, and this is possible after a binge, when the echo of a good experience of mother is still internally available.
In the chapter on technique I wanted to use these ideas to try to understand the extreme difficulties of working with this group of patients - difficulties that mean that many psychotherapists were opposed to psychoanalytic work with these patients altogether, or at least not until they had put on weight. Bruch (1978), Palazzoli (1978) and the self psychologists put forward a variety of more active styles. The neutrality and abstinence of the therapeutic space was felt to be intolerable by these patients and - I would also like to add - by their therapists. By looking at the unconscious power of mothers impact on the child I hope to move the focus from patient to therapist so that working in the countertransference becomes the way to work with these patients. A way to understand the power of the feelings evoked in the countertransference is to think about the very early separation difficulties and particularly about the possibility of mother having attempted to use her child as an intermediate object.
What is then necessary in the therapeutic relationship is to allow the patient to use the therapist as an intermediate object and for the therapist to provide an effective experience of a transitional space in which patient and therapist can work together. Perhaps the storms in the therapy, the attacks made by bulimics on the therapist, can be understood as an attempt to revive a link and, once this has been survived, work can take place in the transitional space; in the aftermath of the bingeing in the acceptance of the vomit, sometimes projectile, that occurs within the therapeutic relationship. The vomit has to be accepted as a gift and like a transitional object must be not questioned, or taken away, until its use has faded into insignificance. Metaphorical vomiting is being used in the therapeutic relationship as a way of creating a space in which to work, which has to be understood and protected if these patients are to move towards whole object relationships. This move in turn, facilitates the existence of an effective digestive tract in their internal world and internal objects who at last can tolerate the digestive process.
The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM