They float in slow motion, the young girls, across fields of spring flowers, advertising hair spray and deodorants. Girlhood means white muslin and lace, innocence and purity; jeunes filles en fleur, milkmaids in sprigged cotton from Laura Ashley, dreaming. Here is one of their dreams:
On my way from the convent, I stopped outside the hospital. A woman who had just given birth was being lifted off a stretcher. I was horrified by her swollen and distended stomach. I heard them say that she had been brought to the hospital because her belly was still full of urine.
Virginity (female virginity, a boy cannot really be a virgin) has almost everywhere been revered: an emblem of uncorruptedness, unfleshliness, as mythical as the unicorn who can only be tamed by a virgin, and yet powerfully moving. The myth has been briskly and only recently destroyed. But it survives, in demonically twisted form, in one place: among girls who themselves reject corruption, fleshliness, sexuality, who sacrifice health and sometimes their lives to a terrified passion for purity—the starving girls, trapped somewhere between the convent and the hospital, dreaming nightmares about the horrors of swollen, dirty, female flesh.
Though anorexia is a modern illness (all these books are short on statistics, but Hilde Bruch quotes a recent assessment of one case per 200 girls, in an English middle-class environment), it has a history. Descriptions of something resembling it come from as far back as the seventeenth century, but the most recognizable accounts date from the late nineteenth century. Lasègue, in Paris in 1873, published a paper “On hysterical anorexia.” His description is classic:
After a few months, the patient finally arrives at a state that can rightly be called one of hysterical anorexia. The family is in a turmoil. Persuasion and threats only produce greater obstinacy. The patient’s mental horizon and interests keep shrinking, and hypochondriacal ideas or delusions often intervene. The physician has lost his authority; medicaments have no effects, except for laxatives, which counteract the constipation. The patients claim that they have never felt better; they complain of nothing, do not realize that they are ill and have no wish to be cured. This description would, however, be incomplete without reference to their home life. Both the patient and her family form a tightly knit whole, and we obtain a false picture of the disease if we limit our observations to the patients alone.
A year later William Gull in London described the syndrome in similar terms. This was the great age of the hysterias, and much subsequent discussion centered around the relative role of hysteria, neurasthenia, or insanity; but it was not doubted that anorexia was a mental rather than a physical illness.* Freud’s definition was “melancholia of the sexually immature”; later psychoanalytical work has probed into its origins. Pierre Janet, one of the neglected giants of nineteenth-century psychiatry, gave an acute description of an anorexic patient, “Nadia,” describing her illness in terms of a horror of the body, of the fleshiness of womanhood.
Bruch’s book is subtitled “The Enigma of Anorexia Nervosa”; why do those who discuss or write about anorexia so often find themselves faced by a core of mystery in the illness? Anyone can understand exasperation with the ludicrous, disobedient body that can seem an enemy rather than ally to a self trapped somewhere inside it; revenge on the carnal, especially revenge through fasting, is nothing new. And it is easy to grasp how tightly connected with emotion is our most elementary function, that of taking in the world as nourishment: how sadness makes us choke over “swallowing” things, or gobble insatiably. But the starving girls’ illness, in its typical form, is enigmatic because, while they are sane and quite different from psychotics, their thinking, self-perception, and phobic fear are all characterized by insane rejection of fact. Anorexia—lack of appetite—is the wrong word for the illness: literally the an-orectic is the melancholic who “has no appetite for life.” The girls described in these books, on the contrary, are characterized by fierce ambition to succeed in their project of self-starvation; by a paradoxical, feverish energy; by extreme terror of having any flesh on their bodies; and in particular by flat denial of the truth—that they are thin, ill, and hungry.
We can rely on the accuracy of these writers’ accounts of symptoms, but must take on trust their picture of the “typical” patient and parents. Certainly they come to remarkably similar conclusions (though both Self-Starvation and Bruch’s earlier book Eating Disorders, from which The Golden Cage is derived, make clear that there are also borderline cases where anorexia is only a secondary symptom). Steven Levenkron’s novel (he has specialized in treating anorexics) will do as a fictional summary, stilted though it is, of what the other books spell out in clinical detail. His anorexic heroine is presented as the odd one out in an averagely unhappy family: father growls into his whisky, mother covers exasperation with sweetness and martyrdom; sister gets attention by being the “bad girl,” brother by being the apple of everyone’s eye. Francesca is docile, shy, lonely, and almost invisible in the family hurly-burly. When weight phobia grips her she secretly renames herself: the thin girl is going to be a new, realler self. The obsession escalates and takes over, family panic rises; the girl is hospitalized. No gruesome detail of forced feeding and near-terminal symptoms is spared. Recovery is promised through a sympathetic therapist and some work with the family, which shows up, as we have guessed, that Francesca from now on needs some attention and respect from them.
While this has not half the vividness of the German psychiatrist Binswanger’s classic piece on an early case, “The Case of Ellen West,” or of some of the extracts from patients’ letters and diaries that Bruch and Selvini Palazzoli quote, in capsule fictionalized form it presents the classic syndrome on which they agree. The family background is shown as by no means a “bad home”: it is fenced in, insensitive, unwilling to face problems—in Lasègue’s words, “a tightly knit whole,” too tight for the anorexic’s sense of autonomy. The girl Francesca is hypersensitive and docile; secretly an ambitious perfectionist, yet hopelessly lacking the rudiments of confidence. She hates the crudity of her adolescent growth, and in particular her periods (they always stop during the illness). She is hyperactive, astonishingly in view of her desperate physical condition. And—the enigma again—though she longs for food and may have secret bouts of eating, the rest of the time she will defy and deny to the limit to ensure that no food goes into her. The denial quite simply displaces her reason: while the patient with a phobia about insects or elevators knows intellectually that his terror is not justified and would like to be free of it, the flesh-phobic anorexics apparently claim (to return to Lasègue) that “they have never felt better; they complain of nothing, do not realize they are ill and have no wish to be cured.” It is the encapsulation of a piece of madness within an otherwise sane—though fragile—personality that is the uncanny element in the illness.
The Golden Cage and Self-Starvation, each good in its own way, confirm this picture and each other. The Golden Cage is the shorter and simpler; like Selvini Palazzoli’s book it is written out of extensive experience with anorexics. It gives a concise and readable account of the antecedents, characteristics, and course of the illness (though more or less ignoring psychoanalytical theory about its origins), and uses much case history material.
Each book has special insights of its own. One of Bruch’s points, not generally made, is that some of the symptoms considered typically anorexic may be simply secondary effects of starvation. The suggestion makes the exponential character of the illness seem a little less mysterious: as she sees it, once the phobic obsession has taken root, its dizzy escalation is partly the result of the starved state (though anorexics force-fed often lose no time in restarting the cycle). At the same time, she points out, fasting has also long been known to induce a “high” which can be exhilarating. “Being hungry has the same effect as a drug,” wrote a fifteen-year-old;
You feel outside your body. You are truly beside yourself—and then you are in a different state of consciousness and you can undergo pain without reacting. That’s what I did with hunger. I knew it was there—I can recall and bring it to my consciousness—but at that time I did not feel pain.
Compare Selvini Palazzoli’s quotation from a Catholic theologian on the spiritual delusions of the fasting state:
The spirit becomes more sensitive; more far-seeing and more acute, and the conscience more quick and lively…. The awareness of spiritual power is increased and with it the danger of losing sight of what is assigned to each one of us, the limits of our finite existence, of our dignity and our abilities. Hence the dangers of pride, magic and spiritual intoxication….
The anorexic’s project, in one aspect, is one of pride and magic: ineffectual and afraid in most ways, she has found out almost by accident that she can achieve immense power from the fact that it is difficult to stop anyone starving herself. She eats up the desperation of everyone around her instead of food.
Bruch makes it clear, however, that the anorexic does suffer cruelly, both mentally and physically, beneath the exhilaration, but is unable to stop the machinery of denial and admit it. When she can she is already getting better.
I remember now how it felt at that time, and how I talked about it. It was not really lying because starving was what I wanted to do, but I remember feeling terribly uncomfortable…. I felt weak when I ran home, but I made myself run all the way. I used to be hungry and I couldn’t concentrate on things. I don’t remember any of the books I read when I was starving; I don’t remember the movies I saw at that time…. I never used to think about anything except food.
In her earlier book Bruch quotes an even more revealingly pitiful extract from the diary of an anorexic boy:
I feel now that suicide would be very easy but I am so obsessed with food that I couldn’t even eat a death meal for fear of being over-weight on death….
I look at recipes to find the one that will finally satisfy me….
I think of quick death to end it all, and then slow death to have your love while I am dying. Oh, mom and dad, help me….
So much runs through my mind, I feel like a ticker tape hours behind.
I don’t think I’ll have the power to fast any more. Food is so good. Now I’m worried I’ll surely gain weight. I think that it is terrible; it is just like mental spite work.
I want to save all my gaining for when I come home. Where I can be spoon fed by you and you only.
Soon after writing it, he died.
Mara Selvini Palazzoli’s Self-Starvation presents the same picture of the hopeless and helpless child possessed both by a terror of the flesh and by a runaway urge to gain autonomy by subduing it. Her book is more detailed, discursive, and clinical than Bruch’s, though easy enough for the layman to read. First published in 1974, it is reissued with a new concluding section on family therapy. In spite of the different cultural background of pasta-eating Italy, her account of the anorexic syndrome on the whole confirms Bruch’s. She places rather more stress on the dietary obsessions of anorexics’ mother; possibly what is abnormal in this respect in Italy is less so in the US. She supplements her perceptive account with a historical survey, medical details, and an outline of psychoanalytic theory, which Bruch neglects.
Selvini Palazzoli goes a little way toward answering two especially puzzling questions about anorexia: why the current epidemic? And why girls only? There are no figures given here for the apparent spread of anorexia, but it seems to be a matter of common observation. Bruch writes that when she first saw cases of anorexia they always believed they were the only girls to have had the experience; now they come to her, having read her book and checked their symptoms against it. Fashion in psychological illness is a mysterious thing: where are the grandes hystériques of the nineteenth century? The obvious—almost too obvious—reason for the spread of anorexia is the current Western psychosis about slimness, which provides a good basis for the obsession to take root in.
Selvini Palazzoli also points out that pressure on women, especially middle-class women, has never been greater: that they are expected to have unisex energy, to perform as brilliantly in a career as in running a home, to be good lovers as well as good students—all earlier and earlier. For the type of girl who becomes anorexic, unlimited choice can mean unlimited pressure to achieve. If the Victorian girl became a hysteric because of the stifling of her energies, the contemporary anorexic may retreat into illness because of the demands made on them. And she is found more often in middle-class than in working-class families; that is where social and parental demands are strongest, where food has lost its primary value as something worked hard for and good to eat, and become part of the good behavior game.
Why is it a girl’s illness? In fact, boys do get anorexia: in her earlier book Bruch cites 14 percent boys and 86 percent girls in the group of patients she studied, but only about half the boys showed the classical syndrome. The boys were younger than the girls when they became anorexic; she suggests that puberty in boys is so much more charged with self-assertion and sexuality than it is in girls that boys are less likely to stay attached to childhood and parents. Their adolescent difficulties are more likely to be directed aggressively outward in delinquency. The boy’s worry, typically, is about being able to impose force and control; the girl’s about being open to mysterious impingements that are beyond her control.
Selvini Palazzoli points out that puberty starts earlier in girls than in boys, when they are less ready emotionally, that it is more visible because the whole shape of their bodies changes, that menstruation can be an extra trauma. In particular she emphasizes the pubescent girl’s vulnerability: she “is exposed to lewd looks, subjected to menstruation, about to be penetrated in sexual embraces, to be invaded by the foetus, to be suckled by a child, etc.” (The psychoanalytic association of taking in food with impregnation is dismissed by both writers as relatively unimportant, but it must play some part in this pattern.) Since typically the anorexic suffers so much from helplessness in relation to her parents, from a sense of having no real self, the passivity of the approaching sexual roles is particularly terrifying, she points out. And at the same time her “new” body is itself a rapist, an enemy taking her over that comes to epitomize everything she has to fight in her struggle for autonomy. The anorexic is trying to grow up, to get free from the family, but paradoxically she does it by fighting the threatening image of a swollen, invaded adult body—and so ends up clinging to childhood.
The self then seeks by being unembodied to transcend the world and hence to be safe. But a self is liable to develop which feels it is outside all experience and activity. It becomes a vacuum. Everything is there, outside; nothing is here, inside. Moreover, the constant dread of all that is there, of being over-whelmed, is potentiated rather than mitigated by the need to keep the world at bay. Yet the self may at the same time long more than anything for participation in the world. Thus, its greatest longing is felt as its greatest weakness and giving in to this weakness is its greatest dread, since in participation the individual fears that his vacuum will be obliterated, that he will be engulfed or otherwise lose his identity, which has come to be equated with the maintenance of the transcendence of the self even though this is a transcendence in a void. [My italics]
Not from Bruch or Selvini Palazzoli, but from R.D. Laing’s The Divided Self; and as pertinent to the anorexic syndrome as to Laing’s schizoid patients. Anorexics also dread obliteration by the outside world (represented by food, the first “outsideness,” after touch, that the individual encounters), and at the same time “long more than anything” for it. Indeed anorexia is essentially an unusual and exaggerated somatic dramatization of the dilemma Laing describes—a dilemma of the self whose boundaries feel infinitely vulnerable to invasion from surrounding territory, either because of some constitutional fragility, or insensitive impingement from the environment, or both.
Since Laing’s book appeared, other work—D. W. Winnicott’s psychoanalytical papers, observational studies of very young babies, supported by Piaget’s early books—have enabled us to see that infancy is a crucial and active time, and that it is the first months of life that establish what Gerard Manley Hopkins called “my selfbeing, my consciousness and feeling of myself, that taste of myself, of I and me above and in all things”; and that there are degrees of success in managing to do this. “I feel full of my mother—I feel she is in me—even if she isn’t there,” said one of Bruch’s patients. Another was worried by the fact that she was not sure whether anything she felt had not been suggested to her by someone else. Some anorexics, so biddable until their illness, may never have felt that they had selves of their own; the conforming self that ate what was given was a false one controlled from outside. Selvini Palazzoli describes a boy whose borderline anorexic symptoms took the form of mixing up his mother’s anxiously prepared dishes on the plate before he ate them, pouring beer over his spaghetti and custard over his salad. The only explanation he would offer was, “It’s because of my taste buds.” The capricious taste buds were the microscopic nucleus of his new, real self.
Neither Bruch nor Selvini Palazzoli shows much interest in the infantile antecedents of anorexia, preferring to concentrate on the effect of invasive family pressures on the patient in adolescence. But the adolescent was once a baby in that same family, even more vulnerable to pressure and dependent on feeding. Though Selvini Palazzoli quotes a psychoanalytic account by Anna Freud of the course of early feeding disturbances, she doubts its relevance since the histories of anorexics are often trouble-free. This may not mean very much if denial is, as these writers claim, the characteristic style of anorexic daughter and mother.
It seems unlikely that children with such fragile personalities who develop such a serious eating disorder in adolescence should have had straightforward feelings about food until their illness. An “eating problem” in a child suggests rebellion and naughtiness, but could also mean unnatural conformity. The children who become anorexic may never have actively eaten, merely taken in what was chosen for them. D.W. Winnicott has said that the baby creates his food, which is “lying around waiting to be found”; Piaget has shown how the baby’s gestures indicate his feeling that he summons things up “as if by magic.” When supply and demand happily coincide, the baby learns to feel pleased and powerful, and getting the food into himself is active, successful effort—“all his own work.” In some of the families that these books describe it is possible to imagine that for the child food has always felt “put in” rather than eaten, and that this later combines with other experiences to reinforce the anorexic reaction. (It is a two-way process: studies of mother-child pairs have shown that some babies are exceptionally passive and slow to signal what they want.) Greed, resentment, guilt can also get early tangled into the experience of feeding, so that food always feels dangerous. The early history of anorexia still needs to be pieced together.
The road from the outside to the inside of me has never been built,” said one of Bruch’s patients; the road is via the mouth, so the food that went in was actually “nothing,” eaten by “nobody.” If anorexia is partly an attempt, via orality, at finding a self, the only new diet the new, real person can choose is a reversal of this: she chooses nothingness, and insists that it is food. This is what poses special problems for psychotherapy, which can be a kind of symbolic feeding and nurturing: how does a therapist psychologically nourish a patient whose way of feeling real is to refuse nourishment? Bruch and Selvini Palazzoli are in agreement about the difficulties: anorexics seldom come of their own free will, they are suspicious and defensive, and are especially liable to exasperate the therapist. Both writers agree that “interpretations” of behavior are disastrous, and feel to the patient like just one more attempt to take over her mind and tell her what is in it; she will certainly vomit them out again.
Both agree that therapy consists of letting the anorexic patient discover that she has a right to exist, of waiting patiently for her own authentic feelings to surface. Neither writer is optimistic about genuine cure in long-standing cases. They describe anorexics who are typically polite and conformist, but hang on to a secret and determined resistance, so that much ineffectual pseudo therapy results. The problem in a nutshell is represented by the patient who bitterly resented her mother sending her to boarding school “to learn independence”—taking away the patient’s independence (she felt) by deciding she should become independent. When things have reached this point the parent or therapist is caught in a double bind and can do no right.
Selvini Palazzoli states that it was the meagerness of results, in relation to the effort demanded for individual therapy, that steered her toward family therapy as the sole treatment method rather than as supplementary. (Bruch sees it as important, but only as a backup to the individual relationship.) Even the early writers were surprisingly unanimous about the importance of the “tightly knit whole” of the anorexic’s family, the “preoccupation of those who surround her”: Gull wrote that relatives made “the worst attendants,” Charcot decreed that separation from them was “the sine qua non of my prescription.” Most enlightened therapeutic work with the adolescent anorexic must always have had an eye on the family.
Both Selvini Palazzoli, however, in the new section added to her book, and Salvador Minuchin and his co-authors in Psychosomatic Families make strong claims for the absolute superiority of their “systems” approach—seeing the patient’s symptom as part of a complex family machine with its own checks and balances—over the “linear” approach that connects her back to her life history. The new approach is an off-shoot of the communication theory associated with Gregory Bateson and later with Laing, which itself has distinguished ancestry in existentialism, information theory, and theory of language. Between Wittgenstein, however, and Minuchin’s work with anorexics the gap is wide indeed.
Like behavior therapists, who work on Skinner’s reward-the-rat-for-the-right-response model, family therapists as represented by Minuchin see little point in unraveling how the patient came to be ill, or in providing the intimate personal support of psychotherapy. They bring the family to the clinic together and with the help of a team of therapists, a tape recorder, and a one-way observation screen improvise a variety of dramas and ploys intended to shake the family out of its established ways.
A rather simple example from Selvini Palazzoli helps in understanding the kind of change brought about. She describes an anorexic’s family that turned everything into a joke of the you-don’t-have-to-be-crazy-to-work-here-but-it-helps kind. Laughing and assuming quaint accents, they egged the patient on as she described the huge joke of her ugliness. The therapist made a longer and longer face and commiserated gravely with the patient on what she must have suffered from their view of her. The “system” blew a fuse, ground to a halt, and honest tears and recriminations followed.
Minuchin’s methods as set out here are easy to criticize intellectually. They involve a great deal of pretentious jargon wrapping up some fairly simple concepts (but that is true of most psychological writing). Generalizations are made about anorexics’ families both by him and by Selvini Palazzoli which not only disagree with each other but are drawn from very small samples. Transcripts of interviews at the beginning of therapy are given, and the results—startlingly good, ones—of the treatment on follow-up are tabulated, but it is hard to gather what were the gradual and permanent changes that must have taken place between the two. And while the concept of the schizophrenic family, popularized by Laing and others, has been criticized on the grounds that many families just as twisted as the ones he studied do not produce a schizophrenic member, one is left with even more doubt after reading Minuchin that there is a typical “anorexic” family pattern.
Minuchin’s therapy transcripts are not always enlightening; three, anyway, of the four families involved do not sound any worse than most other families, though they are certainly more bewildered and docile in letting themselves be filmed, taped, slapped on the back, called by their Christian names, shifted around the room, told what sort of people they are, and sent off to do “homework” for a set time each day on changing their family habits. Perhaps it helps that all this is done with good humor on the therapists’ part, not to say hypocrisy: a bird-brained mother is told she is the family peacemaker, an eccentric father congratulated on being such a warm, regular guy. If these are dishonest families they are beaten at their own game, even though it is in the cause of greater truthfulness.
There seems to be a time, with any new therapeutic method, when enthusiasm and charisma make it very successful; later it ossifies into orthodoxy and something is lost. This work with families obviously demands quick wits, keenness, and a flair for improvising the right ploy at the right moment, and one senses that the pioneers are enjoying it; it would be a pity if it turned into something too literal and heavy-handed. If the children really do get well, that is all that matters. Dedicated to refusal, anorexics are peculiarly hard to nourish therapeutically, and their difficulties probably have such deep roots that a little psychotherapy may be a dangerous thing; for them, drink deep or not at all. To stir up their environment instead, give them room to breathe, and set them free to discover their own nourishment is no mean achievement.
February 22, 1979
During the 1920s and 1930s, anorexia nervosa was frequently considered to be an endocrinological disorder. The authors under review, however, are representative of current thinking in treating the syndrome as entirely psychological. ↩