| Contents | Preface | Acknowledgements | Chapter: | 1 | 2 | 3 | 4 | Conclusion | References |
Sub-clinical eating disorder, (SED), is a new and nasty fact of life (Hsu, 1990, p. 119; Lerner, 1993, pp. 110-113). It is estimated that up to 80% of women suffer from it (Coward, 1993, p.157) approximately the number who are concerned about their weight or dieting in the United Kingdom at any one time. SED does not threaten life, but it is a low-key, persistent form of eating disorder which limits womens lives and their potential. One strand of SED is yo-yo dieting, a term to describe people who go on and off diets over a period of years. The negative effect of yo-yo dieting is that an individuals metabolism slows down to such an extent that in order to remain at a normal weight she has to eat less. If she eats her normal diet, she would put on weight. It should have been the death knell of dieting as a way of life and caught the popular imagination in such books as Geoffrey and Hetty Einsegs Stop Dieting Because Dieting Makes You Fat (1983) and Shelley Boveys Being Fat is Not a Sin (1989). It was not, despite the increasing evidence that diets made you fat, that 98% of diets fail, with 90% of individuals ending up weighing more when they stopped dieting altogether than they did before they began. These figures are commonly cited, for example in Susie Orbachs Fat is a Feminist Issue, (1978) and Kim Chernins Womansize (1983). In (1987) Marlene Boskind-White and William C. White say, Thus, dieting actually leads to an increase in the number of fat cells stored (p. 160).
The figure of 80% is an estimate, but it means that only twenty percent of women are not obsessed with food in some way. SED is a disorder, because it has been found that the effects of persistent and intermittent dieting produce similar symptoms in individuals as starvation itself does (Duker and Slade, 1988). This is a frightening thought. It means that an overwhelming majority of women are unwell, as a direct result of their relationship to food. This is in addition to the emotional or psychological effects of being preoccupied with food, weight and body size. Women express shock, horror and outrage at severe anorexic and bulimic conditions. From my clinical experience of working with women, I think the shock is feigned, a defence erected in order to protect themselves from the realisation of the blurred boundaries between dieting, SED and full blown eating disorders. Women can identify all too easily with starving and bingeing. What it is harder to identify with is when having an eating disorder becomes a way of life, when the psychological and emotional preoccupation with food becomes all encompassing at the expense of relationships, work and play.
The distinction is between the degree and the nature of the preoccupation, with eating, food, weight and body image. Many women may feel terrorised by a pair of scales or the thought of a chocolate eclair, but few will weigh themselves up to 500 times a day, or eat 20 eclairs, before then making themselves sick. These figures and the following descriptions are based on my clinical experience with patients. Some anorexics spend years of their lives counting calories; that is all they do, running totals of yesterday, the day before, last week, the binge that broke the lowest total of the week. Anorexics become skeletal in mind as well as body, nothing is to remain, just what is not to be eaten and how to survive the day, convincing those around you that everything is fine. Some bulimics spend all their day bingeing and vomiting; they do nothing else. They may walk the streets furtively, hoping their frequent visits to the same sweet shops and bakeries are not being noticed, and, if they imagine they are, going further afield in order to feed their habit.
These are extremes, but up to eighteen percent of anorexics die from their illness, and bulimics occasionally do (DSM-III-R, 1988, p. 66). Anorexics die from starvation either directly or indirectly. A bulimic can die from a burst oesophagus or as the result of a stomach rupture. Laxative abuse and vomiting can severely disturb the electrolyte balance, which in turn, can cause brain damage. It is frightening working with these women. An anorexic may collapse at any time, either on her way to a session, during one, or in between. Anorexic bulimics often have the additional problem of self damaging behaviour in the form of overdoses of laxatives, alcohol, drugs, or other pills. Normal weight bulimics are the least frightening group with which to work. They rarely die as a result of their eating disorder, although they often suffer from severe depression, and may be suicidal, but their eating disorder itself is less likely to kill them. All bulimics may suffer from the non-reversible erosion of the enamel on the teeth due to the action of the stomach acid in vomit and all groups risk the increased likelihood of developing osteoporosis.
One in five women are likely to suffer from an eating disorder, anorexia or bulimia, not SED, during their lifetime (Dally, 1989). Official figures suggest that there are nine female anorexics to each male anorexic (Crisp and Toms, 1972). Figures for the proportion of male to female bulimics are much more apocryphal, with its prevalence being cited amongst ballet dancers, models and jockeys. Eating disorders are not bound by age, length of time, intensity or specificity. Here are a few examples of women I have worked with or known. A woman of 35 who was bulimic for three weeks during a difficult time in her life, a woman of 60 who was anorexic for 30 years, a women of 45 who was anorexic at 17, bulimic at 25 and a compulsive eater from 35 onwards. Eating disorders do not have a set course, a set outcome or a set meaning. People who have eating disorders are, however, united by a common feeling of alienation and deep internal distress. They try to assuage, modify, or bury this distress, either by eating or by not eating.
I have worked, first in a humanistic and then in an increasingly psychodynamic way with over 170 women with eating problems, mainly bulimics, both normal weight and anorexic. My interest has been held by the tremendous struggles these women go through, in order to find a way of relating to themselves, to others and to the world at large. I am going to focus upon this problem of how these women relate in the chapters which follow.
I decided upon the title, Lost For Words for a number of reasons. All of which are connected to the recognition that words are as, if not more problematic, for women with eating disorders than their relationship to food. They are either seen as a useless form of communciation, or as being tremendously powerful, so powerful that they may drown in them, or be torn to pieces by them. The pre-verbal, concrete way these women often think and relate make words both a dangerous and unwanted commodity. Finding words, in contrast to being lost, frustrated, or attacked by them, suggests a capacity for communication, which recognises the presence of another and the possiblity of sucessful projection and introjection. As one of my patients said 'words are useless, I want to make you feel what I feel, words are no good'. For her, the only satisfactory state of communication was two people feeling intensely and identically, in phantasy a state of fusion, of non-differentiation. Difference has implicitly to be acknowledged when words are used to attempt communication. This point is well made by Dana Birksted-Breen in her paper 'Working With an Anorexic where her patient was so reluctant to talk that she says 'I sometimes had the fantasy that she and I were buried in a tomb of silence for eternity' (1989, p. 32). The problem for both anorexics and bulimics is how to make a gainful and durable link; an internal link to an object that can in someway be allowed to be good. This is an essential precursor and integral part of the working through of the Oedipal situation.
What I hope to do by looking at the pre-Freudian, Freudian, and post-Freudian approaches is to demonstrate why many eating disordered patients live in almost permanently endangered internal territory. One of the frequent questions that occurs when working with these patients is whether their internal experience can be ameliorated by therapy. There is an implicit tendency in the psychoanalytic literature and in clinical practice, towards hopelessness and helplessness when working with anorexics and bulimics. One of my aims is to focus on this despair and by exploring the different individual psychoanalytic understandings of eating disorders to try to understand it. To do this I shall use Winnicott's ideas of transitional objects and transitional space to explore the mother-daugher relationship, the bulimic symptom and the transference and countertransference. The first two topics are considered in the chapter The Body And Body Products As Transitional Objects And Phenomena (pp. 10-61) and the last in the chapter Implications For Technique (pp. 62-89). By so doing I hope to indicate ways of understanding which can perhaps provide the opportunity of a different and more benign and nourishing link being very gradually established within the therapy and the internal worlds of these patients.
My usual theoretical and clinical approach is more clearly Kleinian This means that I have not had the space to do sufficient justice to here - pathological narcissism, pathological organisations, envy, two-and-three dimensionality and problems of thinking . I shall also leave the field of cultural, social and feminist theory and understanding to others and concentrate on what I have learnt from my direct experience of working individually with these patients. When in the course of this book I offer generalisations about patients with eating disorders without citing references, these conclusions are offered as inductions from my own clinical experience.
When I had completed the first draft, a friend directed me to Joyce McDougalls Theatres of the Body (1989) where I found similar, although not identical ideas to my own. This coincidence provided a welcome confirmation of the validity of my ideas, although I wished I had read her books before I had started on my own. She covers similar ground in linking a mothers narcissistic preoccupation with her child, and her difficulties in allowing her to separate to a later disturbance in the function and development of transitional objects. It is in the area of what constitutes a transitional object, even nascently that I think my views differ from hers. She would, I think, view bingeing (both the eating and the food) as being pathological transitional objects. My own understanding would be that this behaviour represents an attempt to find, mimic, recreate an experience of an internal mother, a stage before the use of an kind of a transitional object is possible. What happens next is where I would look for a transitional object of some kind, an area where rest or play may be experienced.
The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM