by Harriet Parsons
Throughout this article the eating disorder sufferer shall be referred to as feminine, as the majority of sufferers tend to be female. It must, however, also be recognized that this is not a disorder which is female specific and men do also suffer form anorexia and bulimia.
Addiction and Eating Disorders
Eating disorders are so ubiquitous in the twentieth century and in western culture that Orbach (1986) is moved to describe anorexia nervosa as a “metaphor for our age” (Orbach,1986:4). However these eating disorders also touch on our most intimate selves. What appears as an illness brought about by the social climate and external pressure to conform to the ideal of beauty, which is “thin”, is also an extremely private and inherent feeling the sufferer has that she is worthless and bad at her very core.
Addictions in their various forms (to drugs, alcohol or gambling for example), are a poignant “metaphor” for, and counterpoint to, our consumerist affluence. Addiction, like eating disorders, cannot be explained in a uniform way. There seems to be no simple cause-effect relationship between drugs/alcohol and how they effect people (cf. Loose, 2002; Doweiko, 2002). Viewing the toxicity of drugs and the effects of this toxicity as being inherent in the drug, thus excluding the subject of addiction (the individual), fails to explain how drugs affect people differently. Drugs do have an effect, but this effect is not universal, rather it is specific to the individual who takes the drug (cf. Loose, op.cit.). The proposal being made here is that the subjects of addiction – the addicts – come to depend on the subject-specific effect of the drug, based on the subjective experience that has brought them to be the individuals they are. In this way, it is not accurate to say that the drug causes addiction, because it is the subject-specific way the drug effects that particular subject that induces dependency on the drug. It is therefore accurate to locate the cause of addiction within the subject, and, furthermore the toxicity of the drugs may also be located within the subject (Loose, 2002). This way of thinking about addiction is extremely useful when trying to understand why individuals experience eating disorders; and more so when approaching the question of recovery. Locating the cause of addiction within the individual, as well as locating the specific effects of the drug within the individual, results in treatment and recovery strategies focusing on the individual and on his or her subjective experience. Eating disorders, similarly, cannot be studied simply from the perspective of food and diet.
The term “recovery”, like “addiction”, is also difficult to define. For the present purpose, recovery may be thought of as a subjective experience, which needs to be examined in detail in order to gain any meaningful understanding of what it means and entails for the individual. Every factor that contributes to who we are, from our genetic make-up through our development as human subjects in the social and cultural climate surrounding us, is intricately woven into the fabric of an eating disorder.
Psychoanalysis views human beings from a structural perspective. The way we relate to our environment is due to an underlying psychical structure. The way we suffer is therefore also due to our underlying psychical structure. In his delineation of childhood development into oral, anal and phallic phases culminating in what he terms the Oedipus complex, Freud proposed that human development, both at its origins and turning points, is encountered by the individual as traumatic. Thus, symptom formation and the way we suffer are based on an underlying structure that is constructed as the infant grows into a child.
Freud classified an individual’s pathology on the basis of the division between actual pathology and psychopathology. An essential difference between these two forms of pathology is the type of anxiety that characterizes each. Actual pathology is characterized by a traumatic/separation anxiety (“panic”) that is unmediated by language and thus has a direct effect on the body of the subject. Psychopathology is characterized by a signal anxiety that is mediated by language and thus is not as overwhelming as traumatic/separation anxiety. This means that psychopathology has been mediated through language and results in symptom formation which does not have a direct effect on the body. Lacan, following Freud, delineated this categorisation further into three different categories, each differing in terms of the subject’s relation to the object of lack (the traumatic nucleus at the basis of human development) and the mechanism of negation the individual uses to deal with this traumatic lack, that results in his or her psychical structure being set up. Essential to this also is the subject’s relation to pleasure and satisfaction. These three diagnostic categories are neurosis, perversion and psychosis. As general categories, these were the orthodox classifications of the German and Austrian psychiatry of Freud’s day, which were then conceptually recast within psychoanalytic theory. As such they are distinguished from each other by the subject’s orientation towards the object of lack and their mechanism for dealing with this lack, i.e. by repression, disavowal, or foreclosure respectively.
It is important to use a differential diagnosis for addiction because addiction concerns the subject’s relation to lack, pleasure and a beyond of ordinary pleasure resulting from this lack (Loose, 2002), which differs depending on their underlying structure. Therefore, treatment cannot be effective unless one understands the differences in the different diagnostic categories because an addiction will function differently depending on the addict’s underlying psychical structure (Loose, 2002).
“Jouissance” is a word used by Lacan to describe that form of satisfaction that is experienced by the human subject as overwhelming (to the extent that something satisfies itself through the individual, rather than the individual finding satisfaction through something). This jouissance is reduced through the process of becoming a human subject, i.e. as the infant moves from a position of being at the mercy of their sensations, to one in which she can use language and symbolism to cope with and distance herself from her immediate experiences. The concept of “jouissance” is central to understanding addiction from a psychoanalytic perspective. The proposal is that every human subject in one way or another is involved in a relentless pursuit of pleasure and thus an avoidance of pain. As Freud listened to his patients he heard the repetition of the human pursuit of pleasure within the bounds of what he termed the “pleasure-principle” (Freud, 1920g). However in addition to this he came across the seemingly contradictory pursuit of every person to reach beyond this pleasure principle, i.e. to experience the failure of the pleasure principle (which is an experience of too much “pleasure”). In this way the pleasure experienced by human subjects is always characterised by a “not enough”, i.e. it is always limited in some way. Freud saw this limit as being exercised by culture and civilisation (Freud, 1930a). Developing Freud’s work further, Lacan, using his concept of the symbolic order (culture and language) theorised that the limit to pleasure is instated by “the automaton of signifiers” (Loose,2002:214). This means that the acquisition of language by the subject functions to curtail and control a pleasure that is unregulated and beyond ordinary pleasure, i.e. jouissance.
Addiction thus concerns the addict’s relation with this unregulated pleasure. Something about the way the addict has come to be in the world has resulted in him or her suffering in such a way that he or she chooses to refuse the ordinary regulated pleasure of human subjectivity and instead seeks to go beyond ordinary pleasure into the realm of jouissance thereby responding to his or her experiences at the level of the body (without using language as a mediator). Loose (2002) thus proposes that addiction may be defined as an administration of jouissance independently of the Other. Addiction seeks to regulate the tension between ordinary pleasure and uncurtailed lethal jouissance (which is the problematic dynamic at the core of human existence), via a direct route to the body such as experienced when taking chemicals or alcohol.
Thus far I have been referring to chemical addiction; however eating disorders may be examined within this. The administration of jouissance via the control of hunger creates a “solution” to the suffering of the individual via a direct route to the body. Her whole existence becomes increasingly focused on achieving this “solution” to her suffering. G. Ripa di Meana, is a clinical psychologist, psychotherapist and psychoanalyst based in Rome who discusses the psychoanalytic diagnosis of eating disorders (Ripa di Meana, 1999). She proposes that whether the subject is anorexic or bulimic the underlying structure to both the ritual of fasting and that of bingeing and vomiting is anorexic. While both may attempt to find a solution to their suffering in different ways, the underlying aim or motivation is the same, i.e. to find a way of solving the problem of their desire (their relationship with pleasure) that does not involve the Other (that does not require language and keeping within the boundaries of society and culture).
Control and Self Esteem
The anorectic’s relentless pursuit of slimness, may be described as a pathological form of denial. To deny oneself food requires control, and the extent to which an anorectic denies can be seen as a pathological form of control. One aspect of the aetiology of an eating disorder thus clusters around the issue of control, with the patient demonstrating a perceived need to maintain a pathological form of control in order to be safe in the environment. The role of control and self-esteem in the development and maintenance of an eating disorder emerged as incredibly important to understand, especially in regard to recovery. Herein lies the crux of the problem: Eating disorders are progressive and, like other addictions are not satisfied by reduced eating. Rather it is the progressive reduction of food that the sufferer, like the addict, continually craves. The more a sufferer controls the more she needs to control in order to feel safe. By blocking emotions and dealing with every experience through controlling her food, nothing is emotionally or psychologically processed by her. Whatever chaos she was escaping initially builds up and the threat of being overwhelmed by this increases. We can, therefore, further understand why an individual might continue to control to the point of death. Control is central because it brings certainty and from this we can see how the control a person gains through their eating disorder provides a sense of security in an individual’s life. In her control of her food and body, the eating disorder sufferer sets herself apart from the rest of society. She sets herself apart by managing to achieve what she perceives everyone else struggling to achieve. She has found both a solution to her question of identity in her pursuit of food and body control as well as a sense of achieving that which she sees everyone else around her wanting to achieve, which resolves her feelings of low self-esteem.
Duker & Slade (1988) remind us of the fragility of the control the sufferer holds. The control which the sufferer requires to sustain her sense of attractiveness, self-confidence, and new found self-esteem is precarious. This control is gained not from a secure sense of self, but rather from a vulnerable fear of not being able to survive her experiences. The control at the centre of food restriction is the locus of the “self” of the sufferer. The sufferer exists in one of two polarized categories of being in the world – she is either absolutely good or absolutely bad, in total control, or out of total control. This control is based, on a rule system that is punishing, unrelenting and ever restrictive. The sufferer becomes progressively caught up in the cycle of control, her world becomes narrowed and her thinking polarised. She feels herself to either be in total control or out of total control. The underlying sense of low self-esteem, present long before the development of the eating disorder, which is resolved for the sufferer through her food practices becomes evident during recovery (Serpell et al., 1999).
We can now begin to get a sense of the complexities that arise in eating disorders, both from the sufferer’s and the helper’s perspective. The nature of the disorder means that in the majority of cases there are medical issues that need to be addressed as well as the psychological struggle that is on-going. While an eating disorder does not incur the same medical risks e.g. HIV or Hepatitis C (as chemical addictions), the life threatening physical reality of the eating disorder is ever-present. If the sufferer ultimately succeeds in establishing total control the result is death. However, while this may conjure up images of skeletal bodies wasting away, even more at risk are the bulimic sufferers who may appear relatively healthy in terms of their weight, but whose electrolyte balance is haywire due to vomiting. It is the life-threatening physical reality of these eating disorders that causes so much confusion, and power struggles that often result from the different opinions about how sufferers need to be treated.
Addiction treatment models promote abstinence from the drug, seek to establish self-control, and try to understand why individuals need to turn to chemicals as a way of dealing with their lives. Despite the similarities between addiction and eating disorders, the role of control and the way in which the eating disorder functions in an individual’s life differs to that of a chemical addiction. This has consequences for the treatment of eating disorders. Polivy & Federoff (1997) do not advocate addiction models of treatment for eating disorders principally because these models promote abstinence, which in turn promotes dieting and exacerbates binge-eating. Abstinence concerns self-denial and self-control which the eating disorder sufferer does not lack but rather strives to achieve an ever increasing amount.
Duker & Slade (1988) suggest that the helper be able to communicate an understanding of the sufferer’s sense of self, thereby not trying to change how she thinks but allowing her to feel safe in this communication and as such laying the foundations for the work of recovery to begin. A recognition of the positive values eating disorder patients place on their behaviour assists therapists who cannot understand why patients refuse to adjust their eating patterns. For treatment to be effective it is necessary to understand that the patient may experience a chaos emerging whilst and after gaining weight. The eating disorder did not develop for the simple desire to be thin and to look good. It was created to deal with something that the individual could not cope with and as such, in order for the individual to recover from the eating difficulty, she must perceive herself to be in a situation where she will be able to cope with what overwhelmed her. The therapist must be aware of this and be prepared for this, in order to create a space for the patient to make a different response to the emotional conflict. Letting go of their control triggers a re-connection with the emotions they have blocked through controlling their food and body either via hunger or a binge-vomiting cycle. Thus if treatment focuses primarily on weight gain it risks reinforcing the battlements around food (Duker & Slade, 1988). This form of treatment takes the sufferer’s control away without replacing it with an alternative form of safety, i.e. without building up an insight and awareness of how to cope with the underlying emotions. The result is that the sufferer feels unsafe and at the mercy of the emotions she has suddenly come into contact with. Her only recourse in this situation is to try to re-establish her control and this is done through the reinforcement of the battlements around food. In order for recovery to take place, it is therefore essential that the patient feel secure for long enough to find an alternative way of coping. If they do not experience any alternative sense of safety, they will maintain their strict regimes and not eat adequately.
If we take a psychoanalytic perspective we may say that the development of transference within the therapeutic space, between the patient and therapist is the primary tool by which change is brought about (Freud, 1912; 1914). As Freud wrote, “the transference thus creates an intermediate region between illness and real life through which a transition from one to the other is made” (Freud,1914:154). In forming a therapeutic relationship, the therapist is inviting the individual’s pathology (or we may say problems) into the therapeutic space that has been created between the therapist and the individual. In this way, this relationship and the issues that arise within this relationship are problematic. Addiction as a pathology is extremely problematic because by nature the addict avoids using language and speech to deal with his or her anxiety. Rather he or she deals with anxiety through direct acts for example injecting chemicals into his or her arm. In therapy therefore, the addict has enormous difficulty expressing his or her experiences and emotions through speech and it takes much work and management on the part of the therapist to try to curb the addict’s desire to act out his/her anxiety rather than mediate it through speech. In a similar way, the eating disorder sufferer uses control of her food and body as a way of coping with her anxiety and experiences, which is also a substitute for the mediating function of speech. Therefore, as with addiction treatment, using the transference relationship to bring about change for eating disorder patients is vital because this entails the sufferer using speech to mediate her experience.
Referring to treatments that focus on weight restoration as a measure of success, Orbach’s view is that “In trying to get her to eat and to become the ‘right size’ they [the clinicians] negate her protest. They unwittingly deny the meaning of her symptom and in so doing contribute to its perpetuation. They become part of the problem rather than part of the solution.” (Orbach,1986.:9), which shows how an authoritarian response to the sufferer runs the risk of aggravating her food and body control. Ideally, recovery entails facilitating and supporting the sufferer in her task to understand why her eating disorder developed, learning new ways of coping with her life, and thereby creating a situation where the sufferer will begin to let go of her control of food. When this happens her weight will slowly and naturally return to a healthy state. In this way, there has been a thorough reconnection and processing of the sufferer’s emotions so that food does not become an issue when living her life.
It is apparent from examining the issue of “target weights” that the person with an eating disorder evokes an authoritarian response from those around her (Duker & Slade 1988). It is this authoritarian response that is reflected in many hospital treatments which focus on weight gain as a measure of recovery. In addition to the pressure to conform to the target weight, weighing (which is also a weekly feature of the hospital programme), has been found to have negative effects on self-esteem (Ogden & Whyman 1997).
Recovery is not an easy process – it is hard work. The extent to which a sufferer is challenged in recovery gives us an indication of the extent to which she has compromised herself for the safety of maintaining control everyday. Again, the growing awareness that recovery brings, enables sufferers to see in what ways they have sacrificed their needs in order to fulfill the demands they were making upon themselves to stay in control. As they begin to counter this, and carry out different challenges (which may seem as insignificant as having an extra piece of fruit a day, or getting a bus when they would normally have walked), their trust in themselves starts to build up. This growing sense of trust brings an increasing freedom.
Freedom can be highlighted as a crucial aspect of recovery, and it has arisen in connection with the gradual and practical nature of learning during the recovery process which highlights how factors involved in recovery are interrelated and multi-layered. On one level a sense of freedom develops as the sufferer’s self-awareness grows, and on another level freedom is brought about through learning by taking active steps during the recovery process. Awareness also increases with action and in this way we can see that factors change at different paces and that they have different levels of significance during the recovery process. Taking awareness as an example, this develops at a deep psychological level as underlying issues are dealt with in therapy, and at a more superficial level when practical steps are taken during recovery. The freedom brought about by a growing sense of trust in themselves brings with it a new sense of personal autonomy for sufferers. This sense of personal autonomy is characterised by feeling independent of the need to control their food and body.
The disparity in how different factors change during recovery, coupled with their interrelated and multi-layered nature, means that there is no simple answer to the question; what needs to change in order for a sufferer to consider herself recovered? Treatment thus involves the difficult task of delicately juggling all these factors in such a way as to keep enough of them functioning positively at any one time, so that the sufferer does not feel she is about to lose her sense of personal control completely. In this way, recovery involves the slow and steady shift of a sufferer’s sense of personal control, from being of a pathological form to being an appropriate and healthy life control, that ensures she remains connected to her self on a physical, psychological and emotional level. This can only be done when sufferers feel secure enough in the therapeutic space provided. The sufferer’s self-esteem must become adequately built up, so that she gains a new sense of trust in herself and her ability to cope with her life, through means other than controlling food and body. Ultimately, recovery involves developing a self-awareness, both for the therapist and for the sufferer. The patient also has to create a sense of personal freedom and trust in oneself. In turn, this encourages the sufferer to become an independent individual, who is able to take responsibility for herself and her actions.
To conclude it would seem that the crucial aspects of the recovery process include awareness, freedom, independence, learning step by step, and calmness. However, it appears that although all aspects are present in each sufferer’s recovery process, there is a disparity in the way these factors change in recovery. Some factors take longer to address than others and both sufferers and therapists need to be wary of concluding treatment once the manifest behaviour appears balanced. Recovery also involves developing a self-awareness and a sense of personal freedom. In turn this enables the sufferer to become an independent individual who is able to take responsibility for herself and her actions. Ultimately recovery allows the sufferer to live her life in a way that is not driven by a need to control, but rather as an individual who is secure enough in herself to live her life welcoming the ebbs and flows of circumstances and emotions, safe in the knowledge that she can trust herself to be okay and able to cope.
Harriet Parsons has a BA (Psychology), and MA (Addiction Studies) from DBS College, Dublin. She is currently studying for an MA in Psychotherapy at St. Vincent’s University Hospital, Dublin. She may be contacted at firstname.lastname@example.org.
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