What is an eating disorder? For many people in the Western world eating is not necessarily a pleasurable or even a nutritional activity. Yet Bulimia and Anorexia are frequently perceived as illnesses, disorders, something out of the norm. What is normal, when so many people are locked in conflict with food, their appetites, their bodies?
Rather than perceiving Anorexia and Bulimia as disorders, from a practical point of view it may be more helpful to see it within a greater social context, where food and eating patterns become the medium of expression for personal difficulty and distress. Anorexia and Bulimia become a response or a coping mechanism, a way to survive, to stay sane, a method of containing a lot of pain and suffering. As a therapist, I think it is Important to acknowledge and explore the purpose the food difficulty serves rather than just seeing it as the problem.
The medical model of perceiving Anorexia and Bulimia as illnesses is frequently unhelpful as it takes away responsibility and control from the person in an attempt to make them ‘better’. There is seldom an understanding that the ‘symptoms’ serve a purpose. The symptoms for the purpose of this discussion being:
Anorexia – starvation in the presence of an abundance of food;
Bulimia – compulsive bingeing followed by a purging of all that has been ingested.
Although Anorexia and Bulimia are considered to be women’s problems, men can also have the same difficulties with food. But for convenience I refer to the client as ‘she’ in this article.
I think it is important not to deny the behaviour or ‘symptoms’, but to understand and work with them, as initially they are the only way the client has of expressing how she feels about herself. Because sometimes the nature of the client’s actions seems so violent and destructive, it can be difficult for the therapist to hold the client and allow her to continue in the existing pattern. Often the client is unable to give up these prac tices until there is an adequate substitute method of expressing the distress she feels . After the client has been in therapy for a while she may wish to start nourishing herself or cutting down the number of times she vomits. This is usually a very gradual process with the client moving at her own pace, discovering slowly what lies underneath the difficulty with food.
With Anorexia and Bulimia the body becomes the arena in which conflicts are expressed – feelings of inadequacy, unworthiness, self-doubt, contempt, emptiness and isolation are but a few and these may be starved out of conscious awareness or suppressed with a lot of food and then purged from the system. The relationship with food becomes the method of dealing with feelings that the client sees as intolerable or too painful to express in any other way. Wanting to be seen as a nice, pleasing almost perfect person, there is no other safe forum to discharge the pain, confusion, anger or chaos that may be felt.
Frequently with eating problems, physical hunger or appetite equates with any need or longing the person may have. In Anorexia self-denial is seen as a good thing, the ability to control and suppress hunger is an outward sign of strength “I don’t need this”. Yielding to the neediness, physically or emotionally is seen as being weak or as a sign of failure. In the therapeutic relationship this may translate as the client rejecting therapy if and when she touches neediness. There may be a fear that by giving in to the need or the hunger there will be no end to the appetite. As regards the relationship with the therapist, she may feel kept out, rejected at times or sometimes gobbled up or drained.
The Issue of Control
The ability to endure physical discomfort and starvation can be exhilarating. The sense of power and control in overcoming a physical need may mirror a feeling of powerlessness or lack of control in other areas of the client’s life. There may be a sense that “If I change how I look my life will be different”. The whole issue of control is central to the therapy. This struggle may surface in areas such as missed sessions, late attendance or leaving altogether. This often seems to happen when you seem to be making progress. It may be another way for the client to reject what is perceived as beneficial or nourishing.
In Anorexia one of the most difficult control issues is around the clients weight. The client’s non-verbal statement “I am in control of my body is coupled with the reality that that control can lead to illness and death. From the therapist’s point of view, that can be worrying and frightening. It is a difficult issue to resolve as while you are trying to convey to the client that you accept them and the way they have chosen to express their conflict, there may be a covert message that “I won’t accept you if you go below a certain weight”. In my experience, talking honestly with the client about this matter is helpful and usually it is possible to come to an agreement or contract in which both client and therapist feel comfortable.
Ambivalence is another big issue, particularly with Bulimia. ‘There is simultaneous longing for and terror of nourishment, caring, intimacy. The client may yield to the need or hunger and allow in some nourishment. This may be taken in in a violent or destructive manner, then overcome with guilt and horror, relief can only be gained by getting rid of the whole lot. This purging also facilitates release of a lot of feelings that may have been bubbling under the surface for a while. Clients describe the relief gained from vomiting as tremendous. It is obviously an effective way of discharging feelings the client finds too much to stomach.
In therapy as the client finds other ways in which to express and discharge her feel ings, the vomiting may gradually decrease and stop, leaving the client free to work on other issues. However as therapy may be perceived as another form of nourishment, it too may be rejected or the woman may have difficulty in letting in or allowing what they learn in a session.
A Secret Activity
Anorexia makes an obvious outward statement. With Bulimia the client looks ‘normal’, it is frequently a secret activity no one knows about. The client is disgusted and revolted by her behaviour, yet cannot stop it. She fears that she will be judged as disgusting and revolting if she tells anyone. This fear is well founded as people frequently are appalled when they hear the woman’s story. This secret behaviour has a purpose of expression of the deemed unacceptable, unpleasant, messy part of the self, as well as being something which is totally private. Nobody else can interfere or get at this part of the woman’s life. In therapy working with the client’s boundaries can be helpful: what can be allowed in, what must be kept out?
To briefly summarise this discussion which is merely touching the tip of the iceberg - what a client does with her food and her body is an expression of the inner world. Even though she may hate what she is doing to herself, she feels powerless to resist. People with Anorexia and Bulimia may not understood themselves but they certainly are seldom understood or accepted by others. They are frequently held in a mixture of awe, admiration, contempt and disgust. Yet to help unravel the woman’s often complex and very painful world, she needs to be held in a loving, caring and very accepting relationship.
For the woman, being in a relationship such as this will be the testing ground in which most of the fundamental issues around liking, accepting and nourishing herself will be explored. The unfolding and blossoming than can occur, while difficult and painful, is often very beautiful.
1. “Women’s Secret Disorder” a new understanding of bulimia. Mira Darva and Marilyn Lawrence. Grafton Books 1988.
2. “Hunger Strike”. Susie Orbach. Faber 1986.
3. “The Anorexic Experience”. Marilyn Lawrence. Women’s Press 1984.
4. “The Art of Starvation”. Sheila MacLeod. Virago 1981.
Deborah O’Neill is in private practice in Dublin and Galway.