Episode 29: The Anorexic Dynamic. Or: Why eating disorders are not about the food

Lives of the unconscious, a podcast and psychoanalysis and psychotherapy. Episode 29 The anorexic dynamic, or why eating disorders are not about the food. You are what you eat. We are continuously negotiating our identity through food, setting the boundaries of the ego. Inscribed into the symptoms of anorexia is an unconscious conflict of identity, which has something to do with one's own longings and cravings, with a hunger for the other. In psychodynamic therapies, these longings become part of the therapeutic exchange, while also leading to a characteristic dilemma. Eating too much or too little, purging in secret, refusing, binging, all the way to a pathological regime over one's own eating. It would appear that nothing is more prone to malfunction than our relationship to food. Our therapeutic practice has demonstrated that mental illness, almost always, has some effect on eating habits for women, as well as for men. Food has a profound cultural and symbolic significance. It regulates our daily routines, builds the focal point of communities, the family in particular, from gathering every evening around the table, to Sunday roasts or Christmas dinners, even funeral feasts. Apart from breathing, eating is the most fundamental means of metabolic exchange with the world, of intercourse between inside and outside, something that is also always quite sensitive and intimate. It is also usually the first thing an infant gets from its mother, that which is good, life-giving, what the mother gives, and on which we are existentially dependent, in other words, milk. Food is something we get from the outside world, but which we then incorporate, turning it into a part of the self, of the body. You are what you eat. Herein lies what is so psychologically tricky about eating. For what if your relationship to the outside is full of conflict? If you do not want to be or become what you are given? At the same time, there is probably no other disorder that seems to provoke so much misunderstanding, even aversion and anger. Quite often, the reaction to extremely restrictive eating is annoyance, even condemnation or harassment, such as how can anyone not want to eat? Why are you being so difficult? While, in contrast, lack of control over one's own eating is often taken as a sign of personal weakness. Because when ravenous hunger is seen as weakness of character, along the lines of, has she completely lost control? Why does she eat so much? Indeed, our relationship to eating is frequently the focal point of a lot of shame and shaming. In this episode, however, we want to mainly address the psychodynamics of anorexia, focusing in particular on women and anorexia. Anorexia comes from the Greek word anorexian, which means a lack of desire or craving. It consists of a set of disorders, also listed in the standard diagnostic manuals, and is described in terms of weight loss that falls below a critical threshold, which the patient has brought about themselves by vomiting, purging or exercising strict control of their intake. Depending on the severity, the loss of weight can trigger a series of physical symptoms that can become life-threatening as they progress, sometimes resulting in a high mortality rate. In addition, a so-called body schema disorder is often described in other words a distortion in the perception of one's own body, for instance, the feeling of being too fat, despite obvious malnutrition. The common understanding of the word anorexia, however, often involves several implications that can be misleading. The first is that it is a single uniform disease, but in fact, even here there is a wide spectrum. Media images of women, mostly young, as emaciated skeletons are certainly only one extreme. What is certainly far more common and often equally stubborn are daily struggles around food, starvation and over-regulation, behaviors that are not so easy to attach to external body image alone. Such struggles often play out in secret, much as anorexic disorders frequently revolve around the psychology of secrets and secrecy in general. For this reason, there is a debate among specialists about expanding the range of diagnoses, in order to better differentiate between so-called orthorexia or the compulsive preoccupation with and control of food and anorexia. A second misconception is that anorexia is predominantly about physical appearance, such as in exaggerated ideals of slimness and beauty, which starvation is thought to help achieve. A third misconception stems from the idea that anorexia is a disease that afflicts a single person, something that a single person has, a sick child, for example, in contrast to a perfectly healthy family. In many cases, however, anorexia is not a disorder of an individual person alone. But a disorder of an entire system, as in the case of adolescent anorexia, which is often a disorder of the whole family. A treatment that fixates on the symptom alone, without understanding the relationship dimensions, may easily get trapped in characteristic entanglements. All kinds of tricks and suggestions are used, training and reinforcement plans, rewards and punishments, even coercion and violence, to try to deal with the apparently crazy, disturbing, irrational obsession of the anorexic woman, anything to cast out the demon. In this respect, it seems that anorexia has come to succeed hysteria, as the apparent women's disease of our age. And still, the core question remains, why doesn't the anorexic person want to eat? Is something wrong with her genes? Does she not understand how important food is for her health? Does it be explained to her? Does she need to be given a more realistic beauty standard? Doesn't she know how unhealthy it is to be so thin? Doesn't she have any perception of her own body? Does she need to learn how to look in the mirror? Should she be taught the joys of cooking? All of these questions are asked as if the most prominent symptom of anorexia, the refusal to eat. Does the result of some kind of irrational attitude, misguided perception or ignorance, which only needs to be corrected in order to bring the person back to normality? But this is precisely what she seems to be resisting, with all her might. By the way, it should be pointed out that many anorexic women know quite a lot about food, perhaps even better than their doctors and psychiatrists, and are often good cooks, and very competent in the matters of health. In many cases, the refusal and stubbornness around the anorexic person's eating habits, that is so resistant to all offers of help, often leads those close to them to becoming increasingly vehement, even overbearing, until, as we will soon hear, serious concerns about their health begin to take on new dimensions, namely, in that the supposed attempts to help in fact become disguised efforts to gain control over the anorexic person's will. Within the unconscious relationship dynamics of anorexia, there can also emerge certain predicaments that place a great sense of urgency on everyone involved to act, including physicians. We will see that a very similar dynamic can unfold in therapies, not only in relation to food, but also in relation to what in therapy might be understood figuratively as nourishment. No matter how many good ideas, recommendations, helpful steps, balanced servings, and plans, packs and agreements one presents to an anorexic person, it is all met with determination and iron will, sometimes even a very cunning elusiveness, as if any attempts to help serve at best only to force the starvation into hiding. It is not infrequent for this to result in a kind of dancing around the symptoms, in which the affected person and those around her become more and more embittered with one another. So what is this all about? The secret to anorexia may not lie in false beliefs or a lack of knowledge, but instead in that enigmatic will that alone appears to determine what is ultimately allowed in, whether that be something to eat or a word of advice. A will that also tends to assert itself in other areas of life, for example in conjunction with perfectionism or a strong sense of dedication or ambition. So how can anorexic dynamics be understood? Viewed from a psychoanalytical perspective, it is in fact only superficially about eating. More importantly, eating behaviour is a battle over psychological boundaries that actually strikes at the essence of personal identity. It is no coincidence that this conflict over boundaries specifically comes down to the question of eating. Perhaps a good place to start is the connection between eating and autonomy. Eating always involves negotiating one's own limits and exploring one's own will. This can often be observed quite clearly in young children and is also part of normal development. Closing the mouth while being fed, turning the head away from the breast, playfully regurgitating baby food and spitting it out. These are all part of the child's earliest means of saying no. While saying no may not always be socially acceptable, it is of crucial importance for the constitution of the self, of identity. No means a certain control over one's own boundaries, deciding what is allowed in and what isn't, thereby making an initial demarcation between an inside and an outside. To say no is also to say aye. It is something that comes from outside, something that becomes part of the self, that is absorbed into the body, and thus only those who exercise control over food can decide who they are. Whereas from the perspective of the parents, often beginning with the mother, crucial questions arise about nutrition, such as, "Can I give my child something good? One that will help it develop well. Does the child want to have something of me inside? Does it accept me?" Which is why it can also be so extraordinarily upsetting and torturous when a child rejects food. Children playfully explore their own limits through acts of refusing and accepting, swallowing and spitting out. To begin with, in a still very concrete physical sense, I decide what goes into me. For children, it is important to feel that they are allowed to reject their parents, and what they want to give. At the same time, it remains a basic fact of life that we need others, that something from outside must be let in if we are to live. On the other hand, children are not only protecting their autonomy, they are hungry for others at the same time, for the love of their parents, and for what they have to give. It may be that love and nourishment can scarcely be separated at the beginning of life. But nurturing and nursing an infant is both an act of feeding and of love, which, as is well known, is transmitted through the stomach. In this sense, eating is a metaphor for the physical and spiritual metabolism, with the world that we are existentially dependent on. Herein lies the paradox of all living things. In order to maintain oneself, one must take something else in. There is no limit without an opening. In anorexic development, however, the metabolism regulating the traffic that crosses the borders of the self can become disturbed or at least highly conflictual. Anorexia is an attempt at a solution in a border conflict, aiming to gain command over that which most exposes one to the outside, makes one dependent, in other words, hunger. The reasons for the border conflict can vary considerably. In our analysis, we will examine the functioning of the family and the unconscious relationship dynamics associated with it. However, as with any mental illness, there is not one cause here, but a complex interplay of many factors, including society, family, peers, individual characteristics and biology. Every anorexic disorder has its own history, and therefore its own truth. Some, but by no means all, anorexic people report having experienced traumatic events in their history. Those affected describe sexualized violence, neglect, but often also narcissistic abuse. For example, when children are made to serve their parents narcissistic fantasies of greatness, as is familiar from the biographies of celebrities. Frequently, however, anorexic disorders also arise from complex family dynamics, in which explicit traumatic events are not always to be found. Not infrequently, the family atmosphere is in fact described as very harmonious. The relationship with the parents, perhaps, conflictual, but also very close. For example, when the daughter continues to live at home long after her school days are over. However, over the course of therapy, there often emerges a picture of the family structure, in which something tragic is embedded, although there can be no universally valid classification here. It is worth remembering the principle of systemic thinking, that says conflict in families cannot be understood according to the principle of guilt and causation. They instead involve vicious circles made up of expectations, behaviour patterns, and unconscious assumptions about one another, involving members of the family. Here, cause and effect are often the same, while researchers have worked out what kinds of family structures can contribute to the development of anorexia. Once someone in the family has developed it, it takes on a power of its own, creating momentum that can engulf the whole family, and can even spread far beyond it. For example, into therapeutic or clinical settings, as we will hear in a moment. The difference between a functioning and a non-functioning family structure may, in many cases, not be so significant. It may instead be a matter of certain specific circumstances, or the inability to offset those experiences, bullying at school, for instance. The parents separating, or perhaps a tragedy, thereby setting in motion a vicious cycle from which the family can no longer escape. Some patients describe a family atmosphere, which, psychoanalytically speaking, is governed by repression. For example, when there are serious conflicts with the parents that remain unresolved, or are perhaps even unresolvable. Conflicts that are so threatening that they risk breaking up the family entirely if spoken about. For example, when the parents fear the question of whether they are actually still happy together. The repression sets up a mode of communication, in which points of conflict are avoided, increasingly hollowing out the structure of the family and leaving it empty, possibly creating a form of pseudo-communication, with a cheerful appearance, in which everyone must continuously reaffirm how happy they are, but without contact to real feelings, or to use a metaphor, without emotional nutritional value. Others describe an atmosphere in which the child's attempts to demarcate itself by saying no, for example, are perceived by the family as so threatening and hurtful that as a result any such demarcation is subtly forbidden. Or the parents are so afraid that they are not able to instill anything good in their children, or that they are not good enough for their children, that it is the children who repeatedly find themselves having to unburden their parents, taking in whatever the parents offer, so to speak, just so that they don't feel sad. Even if it is really hard to swallow, or there is something else one actually longs for, which is nothing other than giving priority to the parents' needs, while at the same time acting as if they were one's own, possibly never even discovering what one's own desires are, or how to satisfy them. Instead, these desires are left in an infantile state, where from an early age they are raw and unnourished, something that is also a threat to the parents' love, that can cause them so much pain, a dangerous demon raging somewhere within, without being recognized as one's own longing. Parents in narcissistic relationships can have similar consequences, not only in the form of open narcissistic abuse, but even when children feel that the last thing they are allowed to do, is upset the parental ideal of their perfect family. Even when they are actually angry, and are by no means interested in always being their parents' best friend. Anorexia often discloses a family conflict, that because it cannot be made conscious, has become a symptom, thereby restaging the conflict over something concrete. Food, precisely because the distinction is impossible to think of in any other way. The anger at one's own parents, the desire for separation, for example, is often unconscious to the affected person themselves, or is disguised by massive feelings of guilt. A vicious circle is often inscribed into the family, with a tragic dynamic that is truly sad. Out of a fear of hurting the other, once true feelings are hidden, making real emotional contact impossible, or replacing it with pseudo-contact. And as a consequence they fail one another entirely, profoundly hurting each other in the end. For after all, emotional contact is the nourishment that sustains, satisfies, and brings joy to relationships. And when this contact lacks, it brings emotional pain. There is existential disenchantment at the core of every anorexic development, traumatically marking one's own desire, longing, and hunger, a hunger for the other, a desire to be loved, to be seen, to be recognised for one's own self. But the parents' eyes cannot see, perhaps because they are absent, or perhaps because they are aimed not at the child, but at a narcissistic progression, or perhaps because they are trying to feel some void themselves. Being dependent, hungry for the other's love, is so painful overpowering, makes the child feel so hopelessly lonely, powerless at the mercy of others, and still the child may have to convey to others the feeling that they are doing everything right, that they are completely satisfied. An existential shame begins to take shape around one's own neediness and dependence. That which I am, what I actually feel and need. It appears to be of such little value that my parents don't even notice it. And even take it seriously, passing over it as if it were an embarrassment. The child's psyche, always a survival artist, adapts to the circumstances, doing whatever is expected of it, perhaps mimicking the ideal of the perfect child, just to get a few drops of love. But behind this assimilation and continuous disappointment, a concept of identity is forming that is based on an unsolvable dilemma. Dependency means being reliant on something that cannot be created from within. It inevitably means opening oneself up. And nowhere is a person more vulnerable, more reliant on the delicacy and sensitivity of others, than when some part of one's boundaries is given up. Nothing is as fulfilling as when opening up is met with love and affirmation. And nothing is so hurtful, as when this does not happen, better to want nothing than to be left alone wanting. It is precisely this existential dependence on something or someone else that poses such a threat in the anorexic model of identity, not because the person is not hungry, but on the contrary, because in fact, her hunger is so overpoweringly strong, so insatiable. In order to live, the anorexic person rejects the very thing in life she needs. Anorexia is not primarily about losing weight or being thin. At its core, it represents a fight against hunger, hunger as that which makes one dependent, as that which forces one to surrender, that which compels one's mouth to open. Gaining control over hunger is thus meant to finally gain control over the self, to be completely autonomous, to no longer feel shame and emptiness in one's exposure to others. In this sense, being thin is secondary, not the goal of some beauty ideal, but instead a visible sign of victory, a trophy and an affirmation of one's own separateness and strength, a fixation that can lead to delusion. Psychoanalytically speaking, anorexia is the formation of a complex defence against one's own urges, that has become associated with food amongst other things. As a reaction to an existential lack, a tyrannical super ego forms, establishing a dictatorship over one's own needs. It is a reaction of the other and what they have to give, a declaration of independence, in the truest sense of the word, in which, to draw out the political metaphor, even anger over the disappointing motherland or fatherland resonates. You can't give me anything I need, you don't have what's right for me. The coming hunger, through a tremendous act of will, is initially a narcissistic triumph that triggers a feeling of elation, a feeling of elation that is thus addictive. In most cases, this dynamic spreads to other areas of life. For example, there is in perfectionism and obsessive-compulsive symptoms, a concealed attempt to bring something under control. Being perfect means being completely closed, marked off, while making a mistake means having an open spot, a wound, an inadequacy that others could possibly latch onto. Making mistakes also means having a deficiency, and having a deficiency means, in some way being dependent on something else, a feeling that is nearly unbearable, that activates a crushing shame, and which must be kept down with tremendous effort, indeed often with an impressive degree of dedication. What is one in the victory over hunger is the ability to have and command a will, an almost all-powerful will, that appears able to defy the fundamental principles of life. Herein lies a grave narcissistic temptation that conspire all into a deadly escalation. The feeling of total subjection is converted into the triumph over one's own desire. But therein also lies the tragedy of anorexia. With the refusal to eat, hunger grows, becomes torturous, requiring ever greater means of violence against one's own urges. Thereby, the anorexic person ultimately brings upon herself again and again, what someone else had already done to her. For this reason, anorexia is also a mostly unsuccessful attempt at a solution, trapped in a traumatic repetition compulsion. It frequently leads back into a real dependency on the family. The anorexic dynamic can also take over a therapy and lead to a serious dilemma. Beginning therapy means wanting, needing something from the other. But this is exactly what is not possible for the anorexic. The she risks losing her sense of self or falling into unbearable states. This relationship dynamic is also frequently set in motion during therapy, in which the roles and feelings of dependency are in danger of being reversed. This does not only apply to the question of eating, but increasingly becomes part of the therapeutic relationship dynamic, especially in longer therapies. Consistent with the psychoanalytic principle by which a psychological symptom transforms itself over the course of treatment, back into the relational disorder from which it arose. Anorexic dynamic can obstruct the therapeutic process through a basic disturbance in intake. In other words, no matter how good the analyst's interpretations are, how attentive they are, how much they attempt to understanding, that is no matter the quality of the therapeutic nourishment, it appears that nothing really gets in, nothing is absorbed or assimilated psychically. Be that because any attempt at understanding runs into an iron wall is discarded, rejected, or because it is actively not understood in some way, overheard, ignored, or be that because the relationship between analyst and analyst is less about mutual understanding, and instead increasingly becomes a matter of tug of war and negotiations. Something even over the terms of the therapy, renegotiating arrangements and appointments, again and again, according to the principle, mouth open, mouth closed, or according to the motto, I need something that I don't want. Sometimes it only appears that the therapeutic nourishment is being ingested, instead of being swallowed, it is kept secretly in the mouth, only to be spit out later after the session. And then, in the following session, it is gone, once again, as if everything that had apparently been worked through just disappeared. Nothing changes, therapeutic experiences are not integrated into the psychological structure, which can make the therapist feel increasingly helpless and can also make them angry. It is all the more important in the treatment of anorexic patients for therapists not to act these feelings out, for example, by compelling the patient to understand by force feeding them interpretations, or even exerting direct pressure on them, or instead by withdrawing frustration or resignation. Some anorexic dynamics, however, lead straight into predicaments, such as in the most dramatic of cases, having to act in order to save a life. In some cases, however, there is also an opportunity to name these dynamics, to understand them before they escalate. It is important that therapists also understand these feelings as an unconscious message. They must understand what is going on in the other person. How powerless she feels, the dilemma she is in, how desperately angry she is, or how disappointed. As much as anorexic dynamics can trigger feelings of anger in the counter-transference, they should nevertheless be understood within the context of existential distress, a distress that therapy can intensify, that is something to do with an intense feeling of longing for the other, and at the same time, with the existential threat of having to feel this longing. The therapeutic approach to treating anorexia should perhaps be thought of less in terms of a kind of feeding, according to the principle A, put something into B, but instead like a buffet in which something is put out, offered, and can be taken, but can also be rejected. Some form of "I won't have any soup today", is something that therapists may have to endure for a long time, as the only way to maintain a sense of self, to stabilize self-worth. While at the same time, therapists should not identify with the hopelessness of this dilemma, should not lose hope that something else may be possible after all. What is ultimately decisive in the therapeutic encounter, is the experience that longing, desire, hunger, and an autonomous self are not contradictions, perhaps with a growing sense of one's own self and limits, can the specter of hunger lose its terror, and there can begin to emerge a way out of the anorexic dilemma. This podcast was written and produced by Sicile Lutz and Jacob Miller. It has been translated by Solomon Lawrence and is read by Rebecca Dyson Smith.