Anorexia: body, psyche, ritual

Anorexia nervosa is a frightening clinical presentation for any thoughtful analyst working with children and adolescents. In my view, this is due to several reasons.

Anorexia is a deadly disease. It has the highest mortality rate not only among eating disorders but among all mental disorders. Anorexia patients experience fatal outcomes even more frequently than those with depression or schizophrenia, which is why it has received heightened attention for many years.

The situation becomes particularly acute because anorexia often debuts in adolescence, with teenage girls becoming the risk group for this illness.

As a disease, anorexia raises important questions about the nature of self-destruction: "Why do I do what destroys me? Who controls the part of me that harms me?" And the most difficult thing for patients to understand is that, although it concerns food, it is not about food at all.

The second difficulty in treatment, often highlighted, is the divergence of goals between patient and therapist. Treatment must be voluntary. If we come to give birth, we want the delivery to go well and to have a healthy baby: the doctor and patient share the same goal. In the case of anorexia, it is entirely different.

The main symptom of anorexia nervosa is recorded in medical histories as follows: "Fear of even the slightest weight gain; the patient does everything possible to avoid gaining weight." The second symptom is "low body mass index, underweight." Given the high risk of mortality from complications related to underweight, the primary goal of therapy is weight gain, which is precisely the greatest fear of the anorexic patient. That is, the goals of the doctor and the patient are categorically misaligned" (Lapina, 2018, p.102).

If you imagine what every person fears most, you can answer with one word: "loss." Losing a child, family, loved one, job, and ultimately, life. In the book "Body, Food, Sex, and Anxiety," Yulia Lapina writes well about this: "Now imagine that you need to see a specialist to make the great terror of your life a reality: 'Good afternoon, I am very afraid of getting cancer and going blind, please help this to happen quickly.' Gaining even 100 grams of weight is the worst nightmare for someone suffering from anorexia. Even if they agree to therapy, part of their consciousness still hopes to remain thin. Ideally – to even lose a little more weight, even if it defies common sense, their interests, health, and the laws of biology" (ibid).

This paradox immediately, figuratively speaking, knocks you off your feet; my colleague recounted that his patient repeated for a long time like a mantra: "We can handle it, we can handle this, there is hope that together we can handle this." The therapist thought she wanted to overcome her fear of food and gain weight, but all this time the patient was repeating, like an incantation, her desire to cope and lose even more weight, to cope and stop wanting to eat. My young patient, who will be discussed later, said: "I want you to help me, but I don't want a single extra gram on myself. I won't be able to accept that. I am perfect now, I always wanted to look like this. I am beautiful."

When I looked at the painful thinness of this girl, I saw a ghost; she looked like a skeleton, sharp, protruding collarbones covered with overly white and transparent skin. What we see and what they feel are vastly different. With each gram, they feel fat and experience an unbearable feeling of disgust, hatred, and rage towards their own body. The body becomes an object of transference for psychic pain, and rage is unleashed upon it. Therefore, anorexia is often accompanied by bodily harm (cuts, burns, skin piercings) and other forms of self-destructive behavior.

Modern psychiatry views the causes of anorexia nervosa as a mixture of genetics, environment, and personal history.

Let's start with genetics: just as there is no gene for schizophrenia, there is no gene for anorexia. There is interesting research on this subject, for example: "According to the evolutionary theory of anorexia, during the primitive communal system, when the tribe lacked food, most people weakened; they could only lie down and be ill. But there were also those for whom hunger provided a surge of strength and energy sufficient for a dash to obtain prey for all the offspring. This means there are those who expend leftover energy slowly and calmly, which is subjectively experienced as weakness, and those who expend it in one euphoric burst. Why is it so important for us to know this? Because people suffering from anorexia do not possess an iron will, but a genetic predisposition to endure hunger easily. It is not a merit: the person simply drew that ticket in the DNA lottery. According to anorexic patients, they feel a 'strange lightness and purity, all sounds and smells become sharper, even water acquires a taste – and there is not the slightest desire to spoil this bliss with any food'" (ibid., p. 104).

VIGNETTE

Trauma is a defining component in understanding the etiology of anorexia. The readiness to endure the torments of hunger and the level of pain to which people with anorexia subject themselves are unequivocally linked to the presence of hidden trauma. A large body of research has accumulated on the connection between eating disorders and childhood sexual abuse. One research group described 158 patients with eating disorders, 30% of whom had negative sexual experiences before the age of 16 (Oppenheimer, R., 1985). In scientific circles, this correlation was called the "missing link" in the etiology of eating disorders. Other studies conclude that the majority of those suffering from anorexia do not have a history of sexual trauma.

R. Oppenheimer synthesizes these data with the observation that adolescents with anorexia resemble those who have experienced sexual violence in two aspects: "fear of intrusion" and defenses of the "no entry" type (ibid).

Thus, in the etiology of the disease, patients with anorexia became objects of psychic and/or physical intrusion. This formed an intrusive object in their psyche, which may be based on a history of real or fantasized intrusion.

This deserves special attention. The term "no entry" was first used by Gia Williams to describe countertransference feelings when working with anorexia (Williams, 1997). The first thing we encounter in working with such patients is the "fear of intrusion" in front of the object. The intention to "enter" – to establish emotional contact, to see the person's inner world – is met with a strong defensive reaction of "no entry," which reflects the patient's internal situation. Help is experienced as an intrusion! The analyst is immediately invited into an enactment of what is already present in the patient's psyche. The psychotherapist encounters the patient's inner world being played out externally; he must immediately play the role of an internal object from the past with the intention of intruding into the patient's world.

"A property of the human psyche is to project the 'inner invisible' onto the visible and tangible – food, body, and other people – according to the principle of a film projector: we only see the result when the rays it sends fall onto a white screen. No screen – nothing is visible" (Lapina, 2018, p. 87).

The therapist becomes a screen on which inner tragedies are often played out.

In practice, we will encounter pronounced reactions: overt hostility and projection of intrusiveness, as well as a refusal to talk about and acknowledge the problem of critical weight.

My young client, in the meeting before hospitalization, was excitedly agitated and said she saw no problems with her weight and that all this was just her parents' silly worries. She had simply become captivated by "correct calories," the weight had dropped, and it would be easy to regain. She understood her family's concerns, but they were excessive. She had done something foolish, but she would fix everything quickly. Otherwise, everything was fine with her. Because of it, she had finally become what she had long dreamed of, never even imagining she could look like this. She had finally become beautiful with her white hair and blue eyes, thin arms and legs; she was like a model from real runways; there were few such girls, no, there were none at all around her, and everyone admired her. She was a great rarity. She was beautiful! She could breathe the spring air and finally not go to school. She had all the time for herself and her favorite activities. She would finally start living! To my persistent suggestion that her body had little strength for life and that it wouldn't be easy to replenish without help, she indicated that her family's support and her own desire were sufficient.

She poetically, yet very clearly, told me that "entry is forbidden," that I was not allowed to understand and see her, yet at the same time, her body literally forced me to see something terrible. In words, she said that nothing special was happening, "everything is beautiful," but her body was conspicuous because it testified that she was mortally ill. She "forbade" penetrating her narcissistic world, cut off from everyone, where she imagined she needed no food, care, or people.

In my personal history, I had no experience of fasting or prolonged dieting and, consequently, drastic weight loss; I could not empathically attune to my young patient's physicality. This prompted me to search for descriptions of experiences and bodily transformations during starvation. The Minnesota "starvation" experiment of 1944, conducted by Dr. Ancel Keys, provides such a description:

"By the 16th week, physiological changes became visible to the naked eye: facial features thinned, cheekbones protruded, atrophied facial muscles made the face devoid of any expression, apathetic – a 'hunger mask.' Clavicles stuck out like blades, broad shoulders narrowed, ribs showed, shoulder blades stuck out like wings, the spine turned into a line of knots. Knees sagged, and legs resembled sticks. Fat tissue on the buttocks disappeared, and the skin began to hang in folds. The subjects now always carried pillows with them if they had to sit down, because sitting had become uncomfortable. Dr. Keys found that the average heart rate of the young men dropped dramatically: before starvation, it was 55 beats per minute, but afterward, only 35. Due to the calorie deficit, the body switched to 'energy-saving mode.' Their bowel movements occurred once a week, blood volume decreased by 10%, and heart size also shrank. Despite all the physiological changes, the subjects did not consider themselves too thin. On the contrary, they began to think that the other participants in the experiment were fat, while they were normal. Such thoughts are characteristic of anorexic patients." (Wikipedia)

My client had also been on a "starvation diet" for six months, and this description allowed me to feel and understand more deeply the level of changes occurring in her body and psyche. She could not talk about her condition at that time, so I searched for an "entry," relying on my active imagination.

Another reaction is pronounced hostility; there is no chance for dialogue about food or weight. Immediately, there is a strong aggressive attack: "My body is my business."

FEMININITY AND FEMALE NATURE

M. Lawrence writes about another, in my opinion, very important cause of anorexia: it lies in femininity itself, in the biological and psychological characteristics of belonging to the female sex (Lawrence, 2000).

Clear numbers indicate this: the ratio of women to men with anorexia is ten to one. Lawrence hypothesizes that certain aspects of femininity become a catalyst for anxieties about the intrusion of the intrusive object. A girl's sexual development is physiologically oriented towards receptivity, i.e., the desire to fill the inner world with good objects. And this tendency gives rise to specific anxieties. If a boy is afraid of losing something precious, a girl is afraid that something will penetrate and wound her. The main anxiety of a woman is based on this: the fear of intrusion, penetration, damage to the internal part of the genital organ by something dangerous entering it (Lawrence M., 2000).

And here, the mother plays a huge role.

If the mother becomes a non-intrusive but reliable container for her daughter's anxieties, then her fears of intrusion and damage diminish. In the case of anorexic patients, the mother's anxieties are instilled into the daughter herself, or the mother lacks the container capacity to process the daughter's anxieties.

The genetic timer fails: the girl's body becomes female, but the psyche does not change, and therefore cannot accept the changes happening to the body. She is frightened by signs of femininity – hips, belly, any curves that indicate she is no longer a child. The relentlessness of the changes happening to her body throws her into a panic; they are repulsive to her. She feels like a little girl trapped in the body of a "woman," and hunger does not seem too high a price to escape this cage.

This is precisely what happened to my young client when puberty greatly frightened her; she developed ritual fantasies – to cut off excess flesh, to dry it out. I was not working with her during that period, so I can only assume that during this "threshold age," her psyche was searching for its "rite of passage." In primitive rituals, cutting always symbolizes farewell to an old stage on one hand, and a new birth on the other. I cannot delve into this girl's family situation, but I appreciated the description of the ritual and the role of parents in it.

Anthropologist Arnold van Gennep writes: "Each new step of the child also advances the parents one step further on the path towards the end of their own lives. In this connection, I find it very interesting that the step towards adulthood is anticipated on condition of the parents' ritualized consent. For example, among the Maasai in Kenya, a boy or girl can only be circumcised when his/her father performs a ceremony of 'stepping over the fence,' by which he expresses that he accepts the new status of an 'old man,' who from then on will be called 'father of ... (child's name)'" (van Gennep 1999).

This ancient ritual shows the psychological readiness for a new stage and a new identity, ensured step by step across generations. In our time, the fear of old age, and therefore of growing up, leaves parents behind the "fence," making it twice as hard for their children to step over their own "inner fence" and accept adulthood.

"Food is the very first metaphor for love, the very first relationship a newborn builds. A child at the breast receives food, warmth, protection, and love all at once. That is why disturbances in the relationship with food always compel us to look at other relationships in a person's life – with a partner, friends, children, parents, but most importantly, the relationship with oneself. Simply put, the root of eating disorders lies in a disturbed relationship with oneself, in the inability to love and accept oneself. For many of us, food becomes a psychotherapist, a comforter, a universal solution to problems. Food becomes punishment and salvation. Gradually, food, just like drugs and alcohol, takes control of human behavior and subordinates existence to itself. Overcoming this problem does not require violence or constant self-control: one simply needs to learn to trust oneself" (Lapina, 2018, p. 86).

Physically, girls suffering from anorexia are caught in a fantasy of a pre-oedipal fused relationship with the mother, and experience strong, uncontainable anxiety about their sexuality and female body, while their mind is completely occupied by a figure that attempts to intrude and harm. They cannot translate their experiences and thoughts to a symbolic level; they cannot think about it; they lack the words to describe anything. Concrete thinking and difficulties with symbolization are expressed in that aspects of the maternal function are equated with food and rejected.

RITUALS

Throughout human history, food, like sex, has been associated with various rules and taboos. Since ancient times, food has been used in religious rituals and has given people vital energy. "Food penetrates the body and changes it. In fairy tales and legends, food could kill and resurrect or cause metamorphoses of the body. Food is endowed with a huge number of meanings and almost magical properties when it is believed to help gain control over various aspects of life" (ibid).

Initiation rituals have existed since time immemorial for a person to transform their body in order to acquire an identity: who they are, man or woman, warrior or shaman, and which group they belong to. These rituals are also called rites of passage from one life stage to another.

Anthropologist Arnold van Gennep described the three-phase flow of a ritual: separation from the old identity, transition (liminality), and finally, incorporation into the group. Each step is associated with specific actions on the body (van Gennep, 1999).

The deep task of the ritual is to help a person master their belonging to society. The ritual helps transform individual fears and ambivalences into traditional ritualized actions, into collective belonging. The unshakable and strong connection established in collective rituals provides people with identity and confidence in their group belonging.

Among primitive peoples, through body practices passed down from generation to generation – no matter how cruel they may seem to us – the ambivalence about growing up is expressed. Through the body, the process of separation, change, and new acceptance is represented, resulting in respectful treatment and acceptance of new community members, as well as the strengthening of their self-awareness.

Rites of passage help symbolize the child's ambivalence during the transition to adulthood. The rebellious teenager seeks their own rituals that will help their self-awareness grow, rituals in which they can be accepted by their peer group. This is a temporary period based on "identification against," which helps fight against dependence, as the teenager defines themselves in opposition to norms. Peter Blos calls adolescence the second individuation, when the teenager does not use the ego knowledge of the parents but independently forms the ego structure (Blos, 2010). This becomes a weak point in the adolescent's psychological world, where their own structure does not yet exist, and the parents' ego knowledge is no longer used; then a critical, archaic Super-Ego with overvalued ideas can break through. Weight loss, as an overvalued idea, can completely captivate the child's psyche.

In psychotherapeutic practice, we encounter various kinds of bodily enactments, and anorexia is one of the most severe pathological enactments.

In anorexia, we encounter a pathological bodily enactment that involves no identity development whatsoever. One can observe a false attempt to create a rite of passage through diets and the idea of weight loss. The anorexic girl openly and triumphantly rebels against the demand to accept a female identity but finds nothing for herself and remains in a state of resistance to identification with her growing female body. By refusing food, they find a way to suspend the physical development of the body, which temporarily reduces anxiety about the fear of growing up. Anorexic girls take power over their bodies and believe they have gained control over their lives.

M. Hirsch writes: "Pathological bodily enactment also provides no development; it fixes a constant repetition because ambivalence and dependence are not overcome, and identity development stops. The pain associated with bodily enactment symbolizes not the pain of separation (as in the rituals of primitive peoples), but the irresolvable tension between the desire for autonomy and the desire for dependence. Here, self-mutilation is not separation, but a desperate attempt at self-determination" (Hirsch, 2014).

To support the described ideas about pathological bodily reacting in adolescence, which is a failed attempt to create a rite of passage to master a new adult identity, I would like to give a few examples of ritual behavior that is invariably present in the clinical picture of anorexic patients.

And one last, very common ritual – buying food. This is one description you can find on open anonymous forums:

My therapeutic practice shows that young people seek, figuratively speaking, "archetypal paths" during transitional stages of their lives. In ancient times, initiation rituals, which always helped to process and integrate strong emotions and feelings, included pain. Pain is an important meaningful part of rituals. It plays a certain role in all initiations: tooth pulling, circumcision, tattooing – all of this is very painful. Through all these diverse rites, birth is symbolized. Simultaneously, in all such cases, there is the pain of separation; thus, psychic pain is transformed into physical pain. To some extent, self-inflicted bodily harm can be understood as an attempt to "know oneself." The diffuse state of the soul becomes 'visible' as bodily pain; this gives a sense of control and makes it easier to cope with fear.

We see in the three described examples that the psyche remembers its ancient heritage and attempts to create its own rite of passage, to give psychic pain "physicality" in order to see its own suffering soul. But there is a great difference between ancient rituals and today's false enactment rituals: it lies in the role of the adult or society. In ancient rituals, the entire community participated and helped, guiding young souls through the necessary trials. Nowadays, the rituals themselves and the role of adults (society) are lost, diffuse, and undefined.

Pathological bodily enactment in our culture is a lonely attempt to obtain a kind of pseudo-identity in a state threatening disintegration, and therefore threatening psychotic breakdown, especially in youth. Here one might recall certain hairstyles, tattoos, piercings – all of these provide a kind of transitional identity for young people. If the ego boundaries are threatened with collapse, establishing artificial boundaries of the somatic ego becomes a means to finally stabilize oneself.

Weight loss is a substitute war waged against weight; the real front and danger for young people lie in the task of beginning to organize their individual lives, full of independent responsibility, separately from their parents.