The Anorexic Mind

Marilyn Lawrence

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429920097
• Edition: 1
• Topic: Psicologia
• Subtopic: Salute mentale in psicologia

Eating disorders vary in severity from developmental difficulties in adolescence which may be transitory, to serious and chronic mental illnesses. The Anorexic Mind offers a coherent approach to these difficult and demanding problems, always underlining the point that while many of the manifestations are physical, eating disorders have their origins as well as their solutions, in the mind. While anorexia nervosa may be considered the central syndrome in eating disorders, this book also considers how it links and differs from bulimia nervosa, the more common, related disorder. In the process of the research on anorexia and bulimia, valuable insights have been gained into the very common problem of overeating. The author takes a developmental approach to eating disorders, and is very aware of the continuities between infantile, adolescent and adult experience. Our earliest relationship is a feeding relationship and feeding difficulties early in life are not rare.

CHAPTER ONE
Introduction

This book represents an attempt to understand the states of mind that underlie the serious eating disorders of anorexia and bulimia. Compulsive overeating or binge-eating is also considered, particularly as it relates to anorexia.

The ideas in the book have developed through two distinct areas of professional practice. The first is my own direct clinical work as a psychoanalyst, treating adult patients who suffer from eating disorders. The second is as a learning resource to the staff who run specialist units caring for patients with eating disorders. In recent years I have worked with colleagues on the MA programme at the Tavistock Clinic, Working with People with Eating Disorders, and am greatly indebted to both students and colleagues for what we have managed to learn together.

The perspective of the book is psychoanalytic inasmuch as it assumes that mental functioning is unconscious as well as conscious and that, as human beings, we only very partially understand our own motivation. However, the book is not written exclusively for psychoanalysts—quite the contrary. An approach that helps practitioners to find meaning in the illnesses of their patients is likely to be helpful to mental health workers from a range of different backgrounds. Following many years of working with psychiatrists, nurses, dieticians, and others concerned with the specialist care of eating-disorder patients, it seems clear that the most difficult task for the professionals is to go on thinking about their patients. This is a group of patients with many features in common, but perhaps chief among these is a real difficulty in thinking about themselves and their own psychological predicament. Staff, too, can become caught up in the mechanics of treatment, focusing on target weights, the body mass index (BMI), the rules and regulations that govern the unit, and the setting in which they work, while at the same time failing to understand in psychological terms what it might be that the patients are reacting to. Faced with the constant pressure and challenge from the patients to give up thinking, it should not surprise us that sometimes we do just that. A psychoanalytic framework can provide a structure that can enable thinking to be recovered, even if the work itself seems a long way from psychoanalysis as we normally understand it.

I also want to promote psychoanalysis and psychoanalytic psychotherapy as effective treatments for patients with eating disorders, though I fully acknowledge that this also has its difficulties. The psychoanalytic literature on eating disorders is developing well, and in spite of a current preoccupation with short, focused treatments, we have every reason to be optimistic that psychoanalysis is providing a model for treatment as well as a framework for understanding. The difficulties as well as the advantages of treating patients with a psychoanalytically based form of psychotherapy are fully discussed in chapter 3.

The fact that the book has this dual focus—psychoanalysis on the one hand, and work in inpatient settings on the other—gives it, I suspect, an uneven quality. I am aware that I move from one treatment setting to another and that very different kinds of work are being described. However, I believe and hope that this dual focus will be a strength of my approach. The unconscious processes that we can identify in the consulting room can and need to be recognized and addressed within the very ill patients in hospital.

Eating disorders became much more common in the second half of the twentieth century and continue to be prevalent, especially among young women. This has led some researchers, including myself, to speculate about the social origins of these conditions. While such speculation is interesting and it is potentially important to make links between psychiatry, psychoanalysis, and other branches of the human sciences, the stance taken here is that eating disorders are manifestations of mental illness. This statement, of course, begs the question of what is meant by “mental illness” and to what extent mental illness really parallels physical illness. These are questions I cannot answer, but however one understands it, I do regard young people who develop an eating disorder as being in serious trouble and needing help. Often the patients do not recognize themselves as ill. They sometimes claim to be making “lifestyle choices”, and this kind of claim is supported by the proliferation of the so-called “pro-ana”—meaning pro-anorexia—websites, offering support and encouragement for the lifestyle choice of starvation. Worryingly, one sometimes reads articles by intelligent journalists who regard anorexics as in some way icons of our age. It is also noteworthy that the recent guidelines from the National Institute for Clinical Excellence (NICE) on the treatment of eating disorders do not mention that these are mental illnesses. I think this does imply a degree of collusion with the denial of the patients that they are in need of help. It is also particularly unhelpful and confusing for their parents, who can often react much more helpfully when they realize that their children have serious emotional difficulties underlying their behaviour. It seems to me essential that we keep the suffering of the anorexic and bulimic patients at the forefront of our thinking. I shall therefore examine the links and similarities between eating disorders and other forms of mental illness. Chapter 2 looks at the way eating disorders have manifested themselves and been understood historically, with special reference to psychiatric and psychoanalytic accounts.

The most common age of onset of eating disorders is adolescence, somewhere between 12 and 20. However, there are many reports in the literature of children as young as 8 years becoming anorexic. It is also possible for people to develop an eating disorder at any time later in life. Early in my career, I met a woman suffering from what seemed to be typical anorexia nervosa at age 70. The onset of the illness seemed to have been linked to the retirement of her husband and the huge change in lifestyle that this brought about. Sometimes illnesses that appear to be late-onset eating disorders are, in fact, second or subsequent episodes of illnesses that began much earlier in life. It is sometimes impossible to be certain, but I strongly suspect that the vast majority of eating disorders begin in adolescence, or earlier, and probably have their antecedents in infancy. It is perhaps not surprising that the eating disorder may recur as a seeming “solution” to developmental difficulties that occur later in life.

I therefore spend quite a lot of time in this book thinking about development, from infancy through childhood and adolescence, trying to capture and recreate a sense of what mental life might have been like, in the years before they became ill, for those individuals who end up as adult patients (chapters 3–6). This emphasis on development is not based on a quest for the causes of eating disorders. We do not know the causes of many illnesses, in particular mental illnesses, and I feel under no obligation to offer a theory about what causes eating disorders. I think the search for causes, which has tended to bedevil work in this area, has occurred partly because eating disorders appear to strike out of the blue. We are often told that some of these at least are the most promising young women of their generation, who “suddenly” develop serious mental illness. My interest in the infancy, childhood, and adolescence of the patients is rooted in my belief in the continuity of life and development in human individuals. Storms only appear to come “out of the blue” because when we look back, we don’t know what to look for. We were looking for huge grey clouds when we should have been noting changes in humidity. We look for a hurricane when really it is the very stillness of the air which should have alerted us.

This emphasis on continuity should not be taken to mean that I do not believe in change. This whole book—but especially chapters 3, 7, and 8—is about how people can change in some very profound and fundamental ways. I am not referring here to changes in behaviour, but to changes that can take place in the minds of individuals, altering and enriching our sense of who we are and how we can feel related to other people.

I have tried to convey the balance that I feel between acknowledging the terrible seriousness of the underlying illness in some cases of eating disorders as against the hope of recovery. I particularly address this in chapter 6, where I try to understand more about the life-and-death struggle that I believe is taking place within the patients.

I shall be suggesting that eating disorders, like other forms of illness, vary in severity and also in the emotional availability of the patients for treatment. It is very important, before deciding on the best course of action, to make a careful assessment of each patient and to try to gauge the quality and depth of the problem. The majority of the cases require a degree of teamwork, involving psychotherapists working alongside GPs and local community teams—something to which many psychotherapists are unaccustomed. This is fully elaborated in chapter 7.

These patients, and the way they show us their difficulties, represent a huge challenge to us as mental health professionals, but also as human beings. There certainly are no simple answers, and perhaps in some cases there are no answers. The exploration of these difficulties takes us, I think, to the very heart of the human condition: our vulnerability and our need to depend on others: our parents firstly, and then the relationships that we are subsequently able to make.

CHAPTER TWO
Historical perspectives and contemporary debates

The manipulation of the size of the body by deliberately limiting food intake (or, indeed, by overeating) has probably been practised by certain sections of every civilized society. However, it is the tradition we call asceticism, often associated with religious fervour, that has become particularly associated with the eating disorders of anorexia and bulimia. Asceticism nearly always involves fasting, sometimes in extreme forms. Other forms of what we might now call “self-harm”, such as self-flagellation and self-cutting, have often formed a part of both Eastern and Western religious traditions.

Well-known examples would include the early Christian anchorites and anchoresses who practised extreme forms of self-denial, living in caves as desert hermits. Underlying these practices is a dualistic understanding of mind/soul and body. The body is viewed, like the external world, as essentially sinful. The mind/soul can achieve perfection only if the body can be subdued and overcome. The body is felt to be an enemy of the soul, which it attempts to keep trapped in sinful imperfection (Lawrence, 1979). These beliefs have been explicit and dominant in the Christian tradition at certain points in history, such as the Gnostic heresy in the early church and in the Catharism of the medieval period. However, I believe that this dualistic thinking is actually very prevalent, and all of us to a greater or lesser extent experience our bodies as separate from our minds. Very often the body is regarded as inferior to the mind. The body is essentially uncontrollable. This is especially apparent in adolescence and again in the course of the ageing process. In patients with eating disorders, the uncontrollable nature of the body cannot be accepted. In fact of course, the mind is also uncontrollable. If we are able to think, we have no control over what thoughts come into our minds. These extreme religious practices, although ostensibly aimed at controlling and subduing the body, are in fact also a means of controlling the mind, which becomes utterly dominated by the body and its sufferings and quite unable to think. Paradoxically, although the anorexic and the aesthete both regard their body as the enemy, both are able to think of little else. Another problem with the body is its mortality, whereas the soul is widely believed to live for ever. As we shall see, anorexic patients find the idea of death unacceptable and believe they are indeed immortal.

Rudolph Bell (1985) writes about a series of religious figures, the female Italian saints from the thirteenth century onwards. He provides some fascinating snapshots of their ascetic practices and tries to make links between these medieval religious divas and the anorexic girls of the modern era. He is undoubtedly correct that young women like Catherine of Siena, who starved, cut, and beat herself over many years, would today be regarded as highly disturbed. He is also correct when he indicates that these women eventually lost control of their ascetic practices and became unable to eat, just like the contemporary anorexic does. But is it really helpful or relevant to consider these ancient and medieval religious women as being in some way the same as contemporary anorexics as Bell does, when he labels the whole ascetic movement of the medieval period, “Holy Anorexia”? Where I think the medieval saints differ from the contemporary anorexics is in the consciousness of their motivation. One of the most significant features of modern-day anorexia is that while the patients are clearly highly motivated to pursue their relentless goal of absolute thinness, they do not seem to know what it is that motivates them. They often come up with the idea that they are “too fat”, a statement that seems delusional to the observer but might relate to some very uncomfortable internal states of mind. The medieval saints and the desert mothers, on the other hand, were quite clear and explicit that they were trying to free their souls or their minds from the prison of the body, perceived as sinful. They were aiming for spiritual perfection. Now, it may be that some contemporary anorexics do in fact have a similar motivation, but if they do, it is unspoken and, I imagine, largely unconscious. What strikes us forcefully about the anorexics of today is that while they know they have to lose more and more weight, they don’t actually know why. But I am not quite certain here. One exception would seem to be the celebrated case of Ellen West (Binswanger, 1944), where, as I shall indicate, the patient did seem to have something of the same or parallel motivation as her saintly forebears, although she expressed it in terms more apt for the age in which she lived.

In a medieval world, where views about the dualistic nature of humankind were largely shared, the ascetic practices of the saints certainly seemed extreme, but they did not seem necessarily mad. In fact, the women were often questioned about their motivation by the priests and bishops, who asked whether they were certain they were not being mislead (by the devil), but the discourse stayed firmly within religious parameters.

Self-starvation (and other eating disorders) first became identified and categorized as forms of mental illness in the closing decades of the nineteenth century. In the 1870s Gull in London and Lasegue in France published papers describing the syndrome of Anorexia Nervosa (Gull, 1873) or Anorexie Mentale (Lasegue, 1874). Freud was at medical school at this time, and it is clear from a number of references in his work that he was quite familiar with this disorder.

This was an age when much important psychiatric observation was taking place, and a number of psychiatric illnesses were identified and recorded for the first time.

The descriptions that Gull and Lasegue record are detailed and astute. Lasegue describes eight patients aged between 18 and 32. He interestingly emphasizes the emotional origins of the illness, writing of “A young girl. . . [who] suffers from some emotion which she avows or conceals. Generally it relates to some real or imaginary project, to a violence done to some sympathy, or to some more or less conscient desire.”

Gull was more concerned with a description of the signs and symptoms. His prescription for treatment of the condition was simple: “The treatment required is obviously that which is fitted for persons of unsound mind. The patients should be fed at regular intervals, and surrounded by persons who would have moral control over them; relations and friends being generally the worst attendants.”

It is of interest to note that neither Gull nor Lasegue attempted to incorporate anorexia into any other known illness or syndrome. Although they clearly wondered about its links with hysterical illness, neither tried to describe it as a “special case” of hysteria. Although some attempts have been made to link anorexia to other psychiatric syndromes, and to distinguish between different forms of anorexia on the basis of its resemblance to other conditions (e.g. hysterical and obsessional anorexia, see Dally, Gomez, & Isaacs, 1979, for example), contemporary psychiatry has tended to follow Gull and Lasegue in making eating disorders a distinct syndrome in themselves, not explicitly related to other illnesses. In a contemporary textbook on the history of psychiatry (Berrios & Porter, 1995), eating disorders occupy a special section, with no sense of their link with other psychological states. This would seem to be an accurate reflection of current psychiatric thinking, but, as I shall go on to suggest, this may not have helped us to understand the differences within the category “eating disorder” or to accurately plot the links with psychotic illness, personality disorder, and borderline states. It might also have impeded our progress in thinking about the relationship between anorexia and other developmental disorders, such as autism.

In his account of the infantile neurosis of the Wolf Man, Freud mentions the well-known neurosis that occurs in girls at puberty, in which aversion to sexuality expresses itself in aversion to food, or anorexia (Freud, 1918b [1914], p. 106).

This is a throw-away comment, but nonetheless an intriguing one. Freud’s linking of anorexia with both adolescence and an aversion to sex set out a line of thinking that has dominated the debate ever since. Today in British psychiatry, the most commonly used expositionary model, the “regression hypothesis” (Crisp, 1986), is based upon just such a dual link.

A further very interesting and valuable aspect of Freud’s comment is that it occurs within the context of discussion of the...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• SERIES EDITOR'S PREFACE
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• 1 Introduction
• 2 Historical perspectives and contemporary debates
• 3 Psychotherapy
• 4 Eating disorders and object relations
• 5 The sexual and emotional development of girls
• 6 Anorexia and femininity
• 7 Life and death
• 8 Assessment
• 9 Concluding thoughts and future speculations
• REFERENCES
• INDEX