It is a widespread belief among clinicians that people suffering from anorexia nervosa are often academically capable and physically attractive. If this were the case, it would not be difficult to understand the conflict between giving space to the mind, seduced by a variety of intellectual stimuli, and allowing to the body the attention it demands, ultimately subtracting time and energy from the development of the mind. In fact this description does not apply to everybody. In my experience, anorectic girls were more preoccupied with soaps, newspapers, cookery books, fashion and, superficially, boys; they had not one textbook among them. An explanation might be that the drive to break the link with the body, found in the anorectic individual, comes not from the seductive promise of intellectual stimuli, but from the negative expectation that needs cannot be met. It is this disillusionment, that drives one forward to place oneself above/outside of needs, to "not need." The combination of being academically capable and physically attractive might be experienced as terrifying in its potential for success. In such a case it may be safer to sublimate it in becoming a successful anorectic individual, which could explain the furious competitiveness among inpatients.
Food as Basic Means of Communication: Anorexia nervosa is commonly regarded as a culture-bound syndrome, on the grounds that only in a wealthy society one can afford the luxury of self-starvation and turn it into an act of protest. Where starvation is endemic, such an act would have no place. There are however some further issues to consider. Food is a basic means of communication in different societies. It is the first vehicle of communication between mother and child before and after birth and continues to retain its power throughout childhood. It is a common way of greeting a guest. Refusing it, can be a way of rejecting someone's hospitality and, within the family, the physical and psychological ties with the mother: it can be a way of severing the umbilical cord. In this sense it could be argued that anorexia nervosa should occur in any culture in any epoch.
The Fear of Greed: The anorectic individual rejects her own self with its instinctual life and its greed, trying to replace it with a self that is incorporeal and totally controlled. The body is given away, its energy dispersed, used up. There is no longer a flow of food between the parent and the anorectic child. The mother is rejected in her nurturing role as she can only feed the body, not the spirit, leaving the child enslaved to the needs of the body. Such a body will always be too fat, too full, too sexual. In a case reported by Andreoli in Un secolo di follia, the patient revealed her delight in losing her menstruation, which she defined "a nauseating expression of the body." In her diary, she referred to food as "contamination" and "putrid metamorphosis," describing herself as a corrupted being. For her any "amount of body" would subtract space for the mind. The living body, being corruptible, is not valued and, in the case of this patient, is already seen as rotting away before death. To reduce the amount of body is also to reduce the amount of material that finally will rot away after death.
The anorectic person strives to become a mind without a body, to be free from the uncontrollable demands of the instinct. What would happen if such demands were unleashed, if greed took over? "I was frightened of my greed," commented a patient, "I thought that if I let myself go I would turn into a wolf, a greedy beast." She could not have chosen a better image. Lupa, the Latin name for she-wolf, was commonly used as a slang word for whore. In Dante's Inferno a lupa is a symbol of lust and an obstacle on the way to salvation. The new self is free from the servitude of senses and, being incorporeal, will achieve what an embodied self cannot obtain. Paradoxically, the greed that would have enslaved the individual to the needs of the flesh now tries to achieve the annihilation of the body; it is a cupio dissolvi, something more than a desire for dissolution, as the word cupio implies.
Old and the New Self: From an existential point of view, anorexia, as an attempt at replacing a self with a new self devised by the anorectic individual, is doomed to fail. This appears clear when we compare the given self with the new one. The self to be replaced is strongly linked to the parent and dependent; it is greedy and needy; it is out of control and could potentially fall victim to its own appetite; can become lecherous and voracious, allowing the demands of the body to prevail on the needs of the mind. The newly devised self rebels against needing the parent, yet its rebellion causes it to be strongly linked to the parent, else the protest would have no meaning. Starvation cannot occur in isolation, but requires to happen "in relation to" and "in front of" somebody who will witness it, be it a parent, a health curer or, as for Catherine of Siena, God. This need to act "in front of," maintains the continuity with the previous rejected self. The new self is chosen because it is supposedly not greedy. However the element of lustful appetite is still present and while no longer directed to food or sexual pleasure, it aims towards the achievement of physical dissolution. The object of greediness is now weight loss, the pleasure is in the mastery over the body.
The Totally Controlled Self: The new self has achieved freedom from the mother and from the demands of the senses, but free it is not. It is totally controlled, but who is exerting the control over it? We could say that the new self simply controls itself. This controlling activity of the self is, at times, perceived by the patient as a separate entity, an "it" that controls her. One patient commented: "I would like to eat, but it would not let me." Asked to clarify what the "it" was, she replied: "it is a part of myself telling the other part not to eat, it is something there in my mind." The anorectic individual finds herself in a paradoxical situation. She wants to be in control of herself, she devises a new controlling self and then she finds that it is controlled by an "it," against which she is unable to rebel. Sometimes anorectic patients report the experience of seeing a controlling "it" as an entity outside of them and this becomes their way of describing what is going on in their mind.
For the anorectic person not being in control is unacceptable, yet it is also true that the self has little capacity to control her pursuit of starvation Attributing her lack of control to an other agent, which is recognized as part of her self, allows her to say: "Although I am being controlled by "it" and, thus, I am not in control, at least the controlling "it" is part of my mind and my mind ultimately is part of me, so that, in a way, I am in control."
From the point of view of the anorectic individual, the new self, endowed with an it, the powerful controller, is superior not only to the old self, but to the self of other people, who are enchained by the demands of instinctual life: the heaviness of food, the sticky business of sex. Yet this new self, which strives to become a pure mind, like Homunculus, lacks the solidity of a body to contain it and is fragile as though contained in the glass ampoule, vulnerable to external factors that cannot be predicted, avoided or controlled.
An Unachievable Task: The new self is, however, doomed to fail. It is not after all able to escape the dilemmas of the old self and the anorectic individual struggles to achieve what can never be achieved. The new self can only exist while in the process of forming itself, since its actualization would coincide with its annihilation: the death of the anorectic individual and the self's. The self can never succeed in establishing itself and leaves the anorectic person with two potential choices: She can remain in a state of incompleteness and enter an unproductive phase of attempts and renounces to become the new self, which clinically appear like the opposite: relapses and partial recoveries. Alternatively, she can go back to the old self, a situation that is dreaded and arouses despair.
Therapeutic Implications: Establishing a therapeutic alliance is notoriously difficult with patients suffering from anorexia nervosa, first of all because they do not see their condition as an illness, as observed by Sir William Gull. Secondly, they may find it difficult to form an alliance with the therapist because of their "feeling of superiority" discussed above. The anorectic patient tends to prefer to find allies in other anorectic individuals with whom to devise new ways of defying the therapist. The reaction of the therapist, induced by the challenging and provocative attitude of the anorectic patient, can vary between aggressive therapeutic intervention and resignation.
The anorectic person, being preoccupied with herself, does not leave much space for a therapeutic alliance. Collaboration with the therapist is often superficial, only apparent and not deeply felt. Although the anorectic individual may be "smashing herself" against the illusion of getting rid of her body whilst preserving her Self, the therapist might also shatter him/herself against the illusion of successfully treating the patient, only to face the fact of having been deceived, having fallen victim to the patient's seduction. In such cases the narcissistic patient's sense of superiority has triumphed over the narcissistic therapist's omnipotence.
As already discussed in "The Self, Angst and Despair", an existentialistic approach implies that responsibility is not taken away from the patient. The therapist is required not to engage in a battle with the patient, or to fall under her seductive spell or to resign him/herself to failure. These outcomes would follow from a lack of understanding of the patient's inner world, of her existential dilemma, and of her strategies employed to live with the despair of bodily existence. Offering "treatment" to an anorectic individual implies that the condition is an illness. Although it can clearly become so at a later stage due to the biological changes induced by starvation, it is first of all an expression of an impossible existential position. Recognizing this, as well as accepting the patient's sense of her "superior" position, can open the way toward constructive dialogue. This can be viewed in terms of "therapeutic alliance," provided that one is aware that the concept of "therapy" may be alien to the point of view of the anorectic individual.
- Rusca, Roberto; An Existentialist Approach to Anorexia Nervosa; American Journal of Psychotherapy, 2003, Vol. 57 Issue 4, p491
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #10
The preceding section contained information
about an existential perspective on Anorexia Nervosa. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are three reasons why it is difficult to form a therapeutic alliance with an anorexic client? Record the letter of the correct answer