Gaynor, F., “The Psychoanalytic Understanding of Anorexia Nervosa and The Therapeutic Response.”
kk gaynor The Psychoanalytic Understanding of Anorexia Nervosa and The Therapeutic Response
AN EMPIRICAL EXPLORATION OF THE DYNAMICS OF ANOREXIA NERVOSA: Representations of Self, Mother, and Father
gg bers and blatt anorexia nervosa
Synthesis of Issues Relating to Attachment Style, Introjective Pathology, Defenses against Object Need, Twinship Fantasy, and Scapegoating with Special Reference to Kleinian Theory
In early childhood I struggled with food. I ate little and was seriously underweight. My parents continually fretted about my food refusal. My pediatrician told my parents when I was about three years old, “I’ve seen chickens fatter than him.” The doctor prescribed a tonic to stimulate my appetite; I recall that it was green in color and mint-flavored. My mother gave me a tablespoon of the tonic about an hour before dinner. I remember hating the tonic. I resisted being coerced into eating. My mother eventually realized that the tonic was ineffective, which gave me immense satisfaction. In my mind, I could now resume my food refusal. I had control.
A research study on anorexia nervosa states, applying a Kleinian analysis: “It appears that the anorexic is unconsciously motivated, at least partly, by her desire to repudiate any experience of dependency, separateness, loss, frustration, envy, fear, guilt and helplessness.” Gilhar, L., “A Comparative Exploration of the Internal Object Relations World of Anorexic and Bulemic Patients.”These observations seem significantly related to my own fears of maternal engulfment as well as my dismissive avoidant attachment style. It has been found that anorexics have anxieties of being devoured; they fear loss of love, engulfment or of being consumed by the “evil” part. Further,anorexics have a need for separation, independence, control and protection from their “evil”, self-destructive parts and a need for containment. They also have a need for their own sense of control and escape from the controlling mother-figure. See Gilhar.
For the anorexic food is the symbolic equivalent of mother. The anorexic sees mother not as the provider of food but, symbolically, food itself. The anorexic attempts to separate from her mother and untangle her body from her mother’s by not taking her in. Thus, what she plays out by not eating is an attempt to create the concept of a boundary between her body and her mother’s. The reason why she can never express her separateness is because she fears the annihilation. The anorexic has intense fear of loss, thus, she is unable to ask for what she needs and accepts love in any form that it comes – food. The anorexic has an ambivalent relationship with food because there were such conflictual messages projected into it. See Gilhar.
Research confirms an association between dismissive avoidant attachment and anorexia. “[Dismissing avoidant] patients tend to maintain an avoidant, detached, or distanced position in relation to attachment. Such attitude implies the use of deactivation strategies in order to keep distressing emotions under control after attachment activation. This dismissing attitude represents a defensive turning away from potentially painful emotional material, similar to the anorexic’s denial of hunger. . . . The predominance of dismissing and unresolved adult attachment and analogous personality style groups (avoidant, fearful) in eating disorder samples is striking, especially for anorexia.” Delvecchio, E., “Anorexia and Attachment: Dysregulated Defense and Pathological Mourning.” I note that Westen identified a high-functioning, perfectionistic subpopulation of anorexics who resemble introjective depressives. These individuals tend to be conscientious and responsible; self-critical; set unrealistically high standards for themselves and are intolerant of own human defects; are competitive with others (whether consciously or unconsciously); expect themselves to be perfect;take pleasure in accomplishing things; and tend to feel guilty. Westen, D. and Harnden-Fischer, J., “Personality Profiles in Eating Disorders: Rethinking the Distinction Between Axis I and Axis II.” Like persons in this anorexia subpopulation, patients with introjective disorders are plagued by feelings of guilt, self-criticism, inferiority, and worthlessness. They tend to be more perfectionistic, duty-bound, and competitive individuals, who often feel like they have to compensate for failing to live up to the perceived expectations of others or their own exacting standards. Blatt, S. J., & Shichman, S., “Two Primary Configurations of Psychopathology.”
Like the individual with a dismissive avoidant attachment style the anorexic is able to survive her worst unacknowledged fear, namely, the loss of love and the object. In her anorexic world she feels powerful and self-sufficient, she feels omnipotent and in control of what goes in and out of her body. She attempts to negate her dependence on the object. Furthermore, she feels omnipotent in the face of death. See Gilhar. People with a dismissive style of avoidant attachment tend to agree with these statements: “I am comfortable without close emotional relationships”, “It is important to me to feel independent and self-sufficient”, and “I prefer not to depend on others or have others depend on me.” People with this attachment style desire a high level of independence. The desire for independence often appears as an attempt to avoid attachment altogether. They view themselves as self-sufficient and invulnerable to feelings associated with being closely attached to others. They often deny needing close relationships. Some may even view close relationships as relatively unimportant. Not surprisingly, they seek less intimacy with attachments, whom they often view less positively than they view themselves. Investigators commonly note the defensive character of this attachment style. People with a dismissive-avoidant attachment style tend to suppress and hide their feelings, and they tend to deal with rejection by distancing themselves from the sources of rejection (e.g. their attachments or relationships).
The anorexic’s struggle with autonomy and control over the self parallels the drive for self-sufficiency found in persons with dismissive-avoidant attachment. “As the anorexic deprives herself of food and objects, she feels omnipotent, in control and unthreatened by death. She triumphantly projects into her external world of objects that they have nothing she desires nor needs in order to exist, and that internally she has all she needs to survive. Hence, she maintains the delusion that she does not need, that she is self-sufficient and that she is independent of her object. ‘In phantasy, ‘no needs’ means no separation, for being entirely self-sufficient prevents any awareness of dependency needs in relation to the self. If desire does not exist, mother unconsciously need not exist. The connection of both birth and early nurturing and dependence can be denied. By starving it need never be known.’ Furthermore, it seems that she desperately attempts to barricade any object from entering her ‘ideal’ internal world. With this said, it appears that, unconsciously, she is punishing the external objects for being unable to meet her needs as they watch her fade away.” See Gilhar.
I wonder if the following observations found in another paper on anorexia offer hints about my obsession with my former primary care doctor, Dr. P. as an idealized “mirror image” object. Gaynor writes: “The anorexic refuses the symbolic dependency which ties her to the signifiers of the Other. She wishes to have her own independence and become separate from every object. She is unwilling to be regulated by the jouissance of the drive. The subject no longer wishes to be swallowed up by the desire of the Other. Through anorexia she can introduce a separating element between herself and the abusive jouissance of the Other. ‘The only Other that matters to her is the Other of the reflected mirror image, the Imaginary Other, the idealized similar one, the Other as an ideal projection of her own body elevated to the dignity of an icon, the Other as a reflected embodiment of the Ideal Ego, as a narcissistic double of the subject, the idealized Other of the reflected image of the thin body.’ The anorexic protests against being subjected to the signifiers of the Other. She does not wish to be subject to the desire of the Other. Dependency [as in dismissive avoidant attachment] is to be avoided at all costs as the anorexic strives for mastery and to be separated from the demand of the mother (emphasis added).” “If I have an idealized similar one (twin), I will not need the object, food.”
Are these observations related to Stanley Coen’s ideas about twin transference? Coen writes that twin transference, together with all twin fantasies, subserves multiple functions, particularly gratification and defense against the dangers of intense object need. In this formulation, the twinlike representation of the object provides the illusion of influence or control over the object by the pretense of being able to impersonate or transform oneself into the object and the object into the self. Intense object need persists together with a partial narcissistic defense against full acknowledgment of the object by representing the sought-after object as combining aspects of self and other. Coen, S.J. and Bradlow, P., “Twin Transference as a Compromise Formation.” “If I had a twin, it would extinguish my need for a true other.”
Then too, are these observations related to Kohut’s case of Mr. U who defended against fear of engulfment by mother (who has a breast) by his idealization of a distant but desired and disappointing father? Kohut’s patient Mr. U who, turning away from the unreliable empathy of his mother, tried to gain confirmation of his self through an idealizing relationship with his father. The self-absorbed father, however, unable to respond appropriately, rebuffed his son’s attempt to be close to him, depriving him of the needed merger with the idealized self-object and, hence, of the opportunity for gradually recognizing the self-object’s shortcomings. Cowan, “Self and Sexuality.” “If I had father, I wouldn’t need mother (who has a breast).” Notably, Mr. U’s dilemma parallels the recognized dynamics found to prevail in the anorexic’s relationship with both parents: “Several clinical investigators consider that the father is experienced by his anorexic daughter as minimally involved, inadequately responsive to her, and unable to foster her autonomy by providing ‘a benevolent disruption of the mother–child symbiosis.’ He is unable to facilitate the daughter’s sense of being special and lovable.” Bers, S.A., et al., “An Empirical Exploration of the Dynamics of Anorexia Nervosa:Representations of Self, Mother, and Father.”
Might my defenses against object need help explain the problem of scapegoating I experience in groups? Kernberg writes: “The psychology of the group, then, reflects three sets of shared illusions: (1) that the group is composed of individuals who are all equal, thus denying sexual differences and castration anxiety; (2) that the group is self-engendered — that is, as a powerful mother of itself; and (3) that the group itself can repair all narcissistic lesions because it becomes an “idealized breast mother.” Kernberg, O.F. “Ideology, Conflict, and Leadership in Groups and Organizations (emphasis added).”
In group situations I seem to want symbolically to avoid being fed by the “idealized breast mother” at any cost. I do not participate in group process; that is to say, I do not share unconscious feelings and fantasies with the group. I will thereby be an outsider in groups, and, as an outsider, I set myself up for attack by group members, who view me as an alien threat to group cohesion. “If I remain independent, I won’t need the group (breast mother).”
And because of depressive anxiety I get a psychological gratification from being attacked by the hated group. Elliott Jaques describes the psychodynamics of the complex interplay that can prevail between a persecuting (paranoid) majority group and a minority group struggling with depressive anxiety.
Jaques writes: “Let us consider now certain aspects of the problem of the scapegoating of a minority group. As seen from the viewpoint of the community at large, the community is split into a good majority group and a bad minority—a split consistent with the splitting of internal objects into good and bad, and the creation of a good and bad internal world. The persecuting group’s belief in its own good is preserved by heaping contempt upon and attacking the scapegoated group. The internal splitting mechanisms and preservation of the internal good objects of individuals, and the attack upon and contempt for internal bad persecutory objects, are reinforced by introjective identification of individuals with other members taking part in the group-sanctioned attack upon the scapegoat. If we now turn to the minority groups, we may ask why only some minorities are selected for persecution while others are not. Here a feature often overlooked in consideration of minority problems may be of help. The members of the persecuted minority commonly entertain a precise and defined hatred and contempt for their persecutors which matches in intensity the contempt and aggression to which they themselves are subjected. That this should be so is perhaps not surprising. But in view of the selective factor in choice of persecuted minorities, must we not consider the possibility that one of the operative factors in this selection is the consensus in the minority group, at the phantasy level, to seek contempt and suffering. That is to say, there is an unconscious co-operation (or collusion) at the phantasy level between persecutor and persecuted. For the members of the minority group [struggling with depressive anxiety], such a collusion carries its own gains—such as social justification for feelings of contempt and hatred for an external persecutor, with consequent alleviation of guilt and reinforcement of denial in the protection of internal good objects (emphasis added).” Jaques, E. “On the Dynamics of Social Structure — A Contribution to the Psychoanalytical Study of Social Phenomena Deriving from the Views of Melanie Klein.
This explorative qualitative research investigates whether there is a difference in the symbolic meanings between the bulimic’s behaviour of purposefully expelling food versus the anorexic’s deprivation of food by administering the Thematic Apperceptive Test, as well as, conducting in-depth, semi-structured individual interviews with two bulimic women, two anorexic women of the restrictive sub-type and one anorexic woman of the binge-eating/ purging sub-type, whose ages ranged from twenty-one to thirty-five years of age. Both the conscious and unconscious themes that emerge from their stated relationship with food and their TAT responses are explored, with particular interest being focused on whether the symbolic meaning of food is in essence a “symbolic equation” for an object, specifically the mother and parental couple. The concept of “symbolic equation” is explored analytically from a Kleinian perspective to ascertain whether it is not food, per se that the anorexic is depriving herself of or that the bulimic suddenly and uncontrollably ingests, but then rapidly and violently expels. On the contrary, it appears that the refusal to introject or the ambivalent battle between introjection and expulsion of food is used as a disguise for the underlying conflictual object relation/s. The modified version of the Bellak Scoring System (1986) was used to analyse their TAT responses in order to elicit the themes that represent their internal worlds and object relations. Individual thematic content analysis was conducted on each interview transcript separately, and then a comparative analysis performed to explore commonalities and differences across the transcripts and TAT responses amongst the three anorexic women as a group and the bulimic women as a separate group. After which, the two different eating disorder groups were compared to explore both their differences and similarities. The findings suggest that a variety of conscious and unconscious motives might best be understood within the historical context of each participant’s early development and family dynamics. It appears that the anorexic is unconsciously motivated, at least partly, by her desire to repudiate any experience of dependency, separateness, loss, frustration, envy, fear, guilt and helplessness. Conversely, the bulimic appears to be motivated, at least partly, by the repetitive magical quest to restore a ‘good’ self-object bond and to stifle her destructiveness. Nonetheless, underlying both the anorexic’s and the bulimic’s illness is an ambivalent struggle with internalising a gainful and durable link to an object, which can in some way be permitted to be ‘good’. This appears to have its origin in the mother-daughter relationship, father-daughter relationship, parental couple, as well as, the triangular space between the mother-daughter-father link.
Complete text of paper:
KK-A COMPARATIVE EXPLORATION OF THE INTERNAL OBJECT