Eating Disorders

This book presents an accessible introduction to the conceptualization

and treatment of eating disorders from a psychoanalytic perspective.
Each of the chapters offers a different perspective on these difficult-
to-treat conditions and, taken together, illustrates the breadth and
depth that psychoanalytic thinking can offer both seasoned clinicians
and those just beginning to explore the field. Different aspects of how
psychoanalytic theory and practice can engage with eating disorders
are addressed, including mobilizing its nuanced developmental
theories to illustrate the difficulties these patients have with putting
feelings into words, the loathing that they feel toward their bodies, the
disharmonies they experience in the link between body and mind, and
even the ways that they engage with online Internet forums.
This is an accessible read for clinicians at the start of their career
and will also be a useful, novel take on the subject for experienced
practitioners.

Tom Wooldridge is an associate professor of psychology, psychoanalyst,

and board-certified, licensed psychologist. He has published numerous
journal articles on a range of topics as well as several books.
Routledge Introductions to
Contemporary   Psychoanalysis
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Eating Disorders

A Contemporary Introduction

Tom Wooldridge
Cover image: © Michal Heiman, Asylum 1855–2020, The
Sleeper (video, psychoanalytic sofa and Plate 34), exhibition
view, Herzliya Museum of Contemporary Art, 2017
First published 2023
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group,
an informa business
© 2023 Tom Wooldridge
The right of Tom Wooldridge to be identified as author of
this work has been asserted in accordance with sections 77
and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted
or reproduced or utilised in any form or by any electronic,
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in writing from the publishers.
Trademark notice: Product or corporate names may be
trademarks or registered trademarks, and are used only for
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British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the
British Library
Library of Congress Cataloging-in-Publication Data
Names: Wooldridge, Tom, author.
Title: Eating disorders : a contemporary introduction /
Tom Wooldridge.
Description: Abingdon, Oxon ; New York, NY : Routledge, 2023. |
Series: Routledge introductions to contemporary psychoanalysis |
Includes bibliographical references and index.
Identifiers: LCCN 2022010347 | ISBN 9780367861209 (hardback) |
ISBN 9780367861216 (paperback) | ISBN 9781003016991 (ebook)
Subjects: LCSH: Eating disorders.
Classification: LCC RC552.E18 W65 2023 |
DDC 616.85/26—dc23/eng/20220330
LC record available at https://lccn.loc.gov/2022010347
ISBN: 978-0-367-86120-9 (hbk)
ISBN: 978-0-367-86121-6 (pbk)
ISBN: 978-1-003-01699-1 (ebk)
DOI: 10.4324/9781003016991
Typeset in Times New Roman
by Apex CoVantage, LLC
Contents

Introduction 1

1 Alexithymia and the Psychic Elaboration

of Emotion 13

2 Early Relationships, Object Relations, and

Traumatic Themes 26

3 Traumatic Themes, Repetition, and Mourning 36

4 Abjection and Bodily Disgust 49

5 Body–Mind Dissociation and False Bodies 64

6 Gender, Culture, and Desire 75

7 Affect Regulation, Dissociation, and

Body Imaginings 87

8 The Role of the Father and the Paternal Function 97

9 Eating Disorders in Cyberspace 111

Index 127
Introduction

This book is intended to introduce students and clinicians as well as

general readers to the psychoanalytic conceptualization and treat-
ment of eating disorders. Each of the nine chapters offers a different
perspective on these difficult-to-treat syndromes and, taken together,
illustrates the breadth and depth that psychoanalytic thinking can
offer both seasoned clinicians and those just beginning to explore the
field. Because this volume does not aim to be comprehensive, each
chapter is chosen to specifically illustrate different aspects of how
psychoanalytic theory and practice can engage with eating disorders,
including mobilizing its nuanced developmental theories to illustrate
the difficulties these patients have with putting feelings into words,
the loathing that they feel toward their bodies, the disharmonies they
experience in the link between body and mind, and even the ways that
they engage with online Internet forums.
But at the outset, it must be acknowledged that the term eating dis-
orders refers to a set of descriptive diagnoses – anorexia nervosa, buli-
mia nervosa, binge-eating disorder, muscle dysmorphia, orthorexia,
to name those most recognized – that describe sets of observable
symptoms and behavioral phenomena. This stands in contrast to psy-
chodynamic or structural diagnoses, which emphasize the patient’s
personality structure, including its underlying psychodynamic mech-
anisms, to understand her as a whole person. Because eating disorders
are descriptive diagnoses, they do not point to homogenous groups of
people but, instead, group together people who have similar observ-
able symptoms and behaviors.

DOI: 10.4324/9781003016991-1
2 Introduction

To illustrate this point, consider an empirical study that uses the

Shedler-Westen Assessment Protocol (SWAP-200) to assess the
personality structure of patients with anorexia nervosa and bulimia
nervosa. Three categories of patients emerge: a high-functioning/
perfectionistic group, a constricted/overcontrolled group, and an emo-
tionally dysregulated/undercontrolled group. As this study suggests,
reliance on descriptive diagnosis groups together anorexic patients
who are high-functioning and self-critical with those who are highly
disturbed, constricted, and avoidant, while also grouping together
bulimic patients who are high functioning and self-critical with those
who are highly disturbed, impulsive, and emotionally dysregulated
(Westen & Harnden-Fischer, 2001). For the purposes of this book,
“eating disorders” refers to a heterogenous group of people who,
despite their underlying differences, all struggle with difficulties in
relation to food, weight, and body shape. Distinctions such as those
in the aforementioned study are profoundly clinically relevant yet lost
with sole reliance upon descriptive diagnosis. Psychoanalytic think-
ing is of immense value to clinicians working with eating disorders
for its ability to clarify such distinctions and to elaborate on their
treatment implications.
With this point in mind, each chapter in this volume is chosen
because it offers a way of thinking that will be applicable to a wide
range – though certainly not all – patients with eating disorders
encountered in clinical practice. Although clinical practice with this
population, especially with patients at medical risk, demands exten-
sive training and supervision, this book is intended to provide an
introduction. It is hoped that it will be useful for psychoanalytically
trained clinicians and students who are working with patients with
eating disorders and for generalist clinicians who are interested in
learning more about what psychoanalytic thinking can offer.
This book is intended to fill an important gap in the literature.
Despite the long history of psychoanalytic work on eating disorders,
contemporary endeavors have lost sight of the insights our field has
provided. Most practitioners who work with eating disorders focus
on so-called “evidence-based treatments” that emphasize rapid symp-
tom reduction and neglect underlying psychodynamic structure. For
example, the “gold standard” treatment for adolescents with anorexia
nervosa is family-based therapy, which promotes an “agnostic”
 Introduction 3

position with regard to etiological factors, particularly the family’s

role in the child’s developing an eating disorder (Lock, Le Grange,
Agras, & Dare, 2001). This position can be effective in mitigating
shame and stigma, which facilitates treatment engagement – a first
step with a population that is often difficult to engage in treatment. In
my own practice, I refer patients to FBT treatments to facilitate weight
restoration and as a steppingstone to engagement with deeper treat-
ment. Yet I am also always aware that an emphasis on rapid symptom
reduction may also lead us to neglect less overt, and less easily mea-
surable, aspects of the patient’s experience. Patients with eating dis-
orders contend with an emotional landscape marked by isolation and
loneliness as well as shame, guilt, and embarrassment, not to mention
a profound hopelessness about the possibilities of emotional connec-
tion. Help with these struggles will never be found in a pill or a set
of therapeutic exercises, in spite of the potential usefulness of both.
It is only through a meaningful emotional connection that we can
help patients begin to “bear the unbearable and to say the unsayable”
(Atwood, 2012, p. 118).
In a field in which manualized, symptom-focused treatments are
increasingly deployed in clinical practice, psychoanalysis provides a
refreshing counterpoint with its emphasis on the depth and complex-
ity of the individual. Especially when combined with other modalities
such as nutritional rehabilitation, psychopharmacology, and devel-
opmental help, as well as an in-depth knowledge of the interaction
between psychodynamics and sociocultural phenomena,1 it provides
a uniquely powerful means of assisting patients struggling with these
complex, even deadly, clinical syndromes. Analysts who work with
eating and body image problems often hear stories about the crushing
impact of multigenerational criticism about weight, body type, and
appearance (Zerbe, 2016). We hear, too, about the multiple meanings
of food, weight, and body shape and how those meanings are embed-
ded in complex familial and cultural systems. Throughout all of this,
we attempt to understand and resonate with the deep anguish con-
veyed by bodily sufferings. Reflecting on this difficult work, I have
often thought that our emphasis on rapid symptom reduction signifies
not only our intent to help as quickly as possible but also our need to
evade confrontation with our patients’ profound emotional pain (and
perhaps, at times, our own).
4 Introduction

From a psychoanalytic point of view, full recovery from an eating

disorder is tantamount to the growth and development of the person-
ality. Ernest Becker (1964) captures the extent of the change required
for full recovery quite eloquently, so I will quote him in full.

The patient is not struggling against himself, against forces deep

within his animal nature. He is struggling rather against the loss
of his world, of the whole range of action and objects that he so
laboriously fashioned during his early training. He is fighting,
in sum, against the subversion of himself in the only world that
he knows. Each object is as much a part of him as is the built-in
behavior pattern for transacting with the object. Each action is as
much within his nature as the feeling he derives from initiating
or contemplating that action. Each rule for behavior is as much
part of him as his metabolism, the forward momentum of his life
processes . . . the rules, objects, and self-feeling are fused – taken
together they constitute one’s “world.” How is one to relinquish
his world unless he first gains a new one? This is the basic prob-
lem of personality change (pp. 170–179).

Overview of the Book

In Chapter 1: Alexithymia and the Psychic Elaboration of Emotion, we
will discuss the difficulty that many patients with eating disorders have
putting feelings into words. Some patients may struggle to describe and
elaborate on their experience, for instance, of need, desire, or hunger.
While they can speak to their feelings, often quite articulately, in other
realms, in these particular areas this capacity is conspicuously absent.
Other patients’ difficulties manifest more globally, as trouble putting
feelings into words that extend across most or all domains. The capacity
to think about, to reflect upon, difficult feelings is what allows us to
forego expressing them in more problematic ways, such as, for patients
with eating disorders, through a binge, or a purge, or food restriction.
With this idea in mind, we will discuss the idea of mentalisation, which
is a way of thinking about different “registers” of emotional expression
and how we can identify these in patients with eating disorders, as well
as the concept of reverie, which speaks to the intersubjective process
that occurs between parent and child as well as between clinician and
 Introduction 5

patient and that is central to facilitating the capacity to identify and

elaborate emotional experience.
In Chapter 2: Early Relationships, Object Relations, and Trau-
matic Themes, we discuss the contributions of object relations theory
to understanding the psychological structure of patients with eating
disorders. Object relations theory is concerned with how early rela-
tional experiences have been internalized as a psychological structure
that continues to organize and give meaning to experiences in the
present. From this point of view, it is the underlying psychological
structure – not just the eating disorder symptoms that manifest because
of it – that is a focus of treatment. We also discuss several traumatic
themes (Shabad, 1993), or chronic patterns of frustrating and depriv-
ing childhood experience at the hands of caretakers that take on the
emotional significance of cumulative trauma (Khan, 1963). These
themes are chosen because they are commonly described by patients
with eating disorders. Although each will only apply to some patients,
these examples will clarify how underlying psychological structure,
shaped by internal representations of early relationships, may mani-
fest, symptomatically, as an eating disorder.
A central task with patients with eating disorders is facilitating the
capacity to postpone action in favor of reflection, yet the pull to binge,
or purge, or restrict is difficult, if not impossible, to resist. In Chap-
ter 3: Traumatic Themes, Repetition, and Mourning, we begin with
a discussion of Freud’s (1914) notion of the compulsion to repeat
and formulate the eating disordered patient’s symptoms as repetitions
against traumatic themes from childhood, never-ending (because
never fully successful) attempts to magically undo the pain of the past
(Shabad, 1993). We discuss Novick and Novick (2001, 2016) dual-
track, two-systems model of development, which provides a way of
thinking about the development of agency, or its curtailment, through-
out life. We conclude with a discussion of mourning, which is seen as
a counterpart to Freud’s (1914) notion of working through. Mourning
is the mechanism through which traumatic themes can be acknowl-
edged, disillusioned wishes for an ideal object relinquished, and
painful early relationships transformed into aspects of the patient’s
character that are carried forward in constructive ways.
Patients with eating disorders commonly describe the loathing that
they experience toward their bodies. They refer to their bodies, or
6 Introduction

parts of their bodies, as disgusting, ugly, gross, and “fat.” In Chap-

ter 4: Abjection and Bodily Disgust, we discuss Kristeva’s (1982)
notion of abjection in an attempt to more fully understand this expe-
rience. We consider two traumatic themes that may contribute to the
experience of abjection in these patients: a form of breakdown in con-
tainment (Williams, 1997) and the formation of a “rotten core” (Lax,
1980). In the first, the parent uses the child as a receptacle for her own
unprocessed emotion, which the child experiences as a “foreign body”
inserted into her vulnerable psyche. In the second, the experience of
the self is split, with the rotten core representing the experience of
the “bad” mother with the “bad” aspects of the self that exists along-
side an experience of the self and mother as good and loveable. This
traumatic theme develops in response to the mother’s unavailability
during separation and individuation. These ideas may facilitate our
ability to empathically grasp the profound extent of the self-loathing
and bodily disgust with which eating disordered patients struggle.
In Chapter 5: Body–Mind Dissociation and False Bodies, we
explore false bodies in patients with eating disorders. The term false
body describes how the body’s state is rigidly controlled so that
spontaneous emotional experiences are avoided. For some patients
with binge eating disorder, the weight gain that results from eating
symptoms may serve as a false body. Patients with orthorexia, who
have an unhealthy focus on eating in a healthy way, may use seem-
ingly healthy exercise regimes, including a rigidly controlled diet and
obsessive self-care rituals, to maintain a false body. We will focus,
however, on a particular form of the false body that is commonly
observed in patients with anorexia nervosa: the entropic body (Wool-
dridge, 2018b). The entropic body is cultivated through self-starvation
to subjugate an underlying emotional experience of need and depen-
dence. It develops to compensate for the failure to internalize the care-
taker’s capacity to comfort and soothe the child during the period of
separation and individuation. Without the capacity to provide comfort
to oneself or to seek it in emotional connection with another person
in hand, these patients are unable to emotionally “digest” traumatic
experiences in infancy and beyond and, as a result, are forced to rely
upon the entropic body to attenuate their distress.
We begin Chapter 6: Gender, Culture, and Desire by examining the
nature of desire. From one point of view, desires are already-formed
 Introduction 7

inner strivings awaiting direction. From another, desire is a function

of its context, shaped in relationship and the larger cultural surround.
From this perspective, the task becomes not only to uncover desires
that have been defended against but also to help the patient begin to
want freely so that, over time, new containers of desire can emerge.
The topic of desire leads to a consideration of gender. Gender differ-
ences are dramatic in the prevalence of some eating disorders, with
far more females than males diagnosed with anorexia and bulimia
(Stice & Bohon, 2012). Although a cultural analysis helps to elucidate
this difference, it fails to explain why females are more susceptible
to certain cultural influences than their male counterparts. With this
in mind, we draw upon contemporary psychoanalytic models of gen-
der development to explore the relationship between gender identity
and agency. We highlight the necessity of the developing of a diverse
gender “repertoire” (Elise, 1998) – sense of oneself as both mascu-
line and feminine in various ways – to counter problematic gender
identifications.
Chapter 7: Affect Regulation, Dissociation, and Body Imaginings
begins with a discussion of a perspective from the relational school
of psychoanalysis that regards the self not as a unified entity but as
decentralized and composed of relatively discrete psychic structures –
“selves” – that, in a good enough developmental situation, attain an
“illusion” of coherence and continuity (Bromberg, 1998). In this par-
adigm, relational trauma is defined as exposure to chronic misattune-
ment and prolonged states of dysregulation in the context of an early
attachment relationship. We use these ideas to formulate the notion of
the “hungry self,” a self-state prominent in patients with binge eating
disorders. We also consider how the experience of body image may
vary according to the shifting landscape of dissociatively structured
self-states. We describe how body image is an expression of past rela-
tional experiences and how, in patients with histories of relational
trauma, an important aspect of treatment is helping patients to “stand
in the spaces” (Bromberg, 1998) to understand the dynamics driving
shifting experiences of body image.
Chapter 8: The Role of the Father and the Paternal Function
focuses on the role of the father and of the paternal function in patients
with eating disorders, specifically on patients with anorexia nervosa
and muscle dysmorphia. One purpose served by the paternal function
8 Introduction

is to assist the child in separation and individuation from his mother. A

father’s establishing a loving bond with his son encourages the child’s
capacity to explore the outside world (Abelin, 1971). In the families
of a child who develops anorexia nervosa, the mother’s use of the
child to maintain her own equilibrium makes separation and individu-
ation more difficult. In such families, a potentially important factor in
whether the child goes on to develop anorexia nervosa is the strength
of the paternal function, which optimally helps the child learn how to
appropriately deploy his aggression in the service of separation and
individuation. In these families, however, the relative absence of the
paternal function may lead the anorexic-to-be to locate his experience
of agency in relation to eating and his body, which he rigidly controls.
In families of children who develop muscle dysmorphia, in contrast,
the father may maintain his own equilibrium by keeping his son small,
vulnerable, and weak. Whereas in optimal development the paternal
function would facilitate the developing boy’s separation and individ-
uation, it instead threatens the child with the possibility of remaining
forever lost in dependency upon his mother. To avoid this, the child
defensively idealizes a particular form of masculinity characterized
by “bigness” (Corbett, 2001) that the paternal function comes to rep-
resent and that is concretely expressed by his drive for muscularity.
In chat rooms, newsgroups, and websites, pro-anorexia has emerged
in recent years as a cultural movement in cyberspace that takes an at
least partially positive attitude toward anorexia nervosa and other eat-
ing disorders. Notably, there are also “pro-mia” online forums that
focus on bulimia nervosa, bodybuilding websites that have many par-
ticipants who struggle with muscle dysmorphia, as well as a range of
other online spaces in which those struggling with food, weight, and
shape interact and express themselves. In Chapter 9: Eating Disor-
ders in Cyberspace, we focus specifically on how participants make
psychological use of pro-anorexia websites. On the one hand, they
may provide participants with a potential space (Winnicott, 1971) – a
state of mind in which play and creativity are possible – that fosters
psychological development, allowing them to play with ideas about
relationship, identity, and even recovery. In contrast to this, they may
also provide an opportunity for a psychic retreat (Steiner, 1993) in
which cyberspace becomes a ‘funhouse mirror’ (Malater, 2007):
an escape from a reality that has become unbearable and a place of
 Introduction 9

“relative peace” (Steiner, 1993, p. 1). Psychic retreats are problematic

because they foreclose the possibility of emotional growth, creativity,
and authentic engagement with relationship.

Acknowledgments
I wish to thank Aner Govrin, PhD, and Tair Caspi, PhD, for inviting
me to contribute this volume to their book series, The Routledge Intro-
ductions to Contemporary Psychoanalysis. When I received their
invitation, I had been thinking about writing a book on what psycho-
analysis has to offer in the treatment of eating disorders for some time,
having recently edited a volume on the topic (Wooldridge, 2018a). I
had hesitated to take on such a project until receiving their encour-
agement, for which I am deeply grateful. They have been responsive
every step of the way.
I also wish to note that Chapter 1: Alexithymia and the Psychic
Elaboration of Emotion, Chapter 4: Abjection and Bodily Disgust,
Chapter 5: Body–Mind Dissociation and False Bodies, Chapter 8:
The Role of the Father and the Paternal, and Chapter 9: Eating Dis-
orders in Cyberspace contain material drawn from articles previously
published in a peer-reviewed journal (Wooldridge, 2021b; Wool-
dridge, 2021b; Wooldridge, 2018b; Wooldridge, 2021a; Wooldridge,
2014). I wish to sincerely thank Gil, Jan, and Aaron at 310 Eatery for
providing me with a space to write. This book is dedicated with love
and gratitude to the friends, family, and colleagues who have offered
much support and affection over the years, with special mention of my
son, Parker, and my parents.

Note
1 An important limitation of this book is that it does not incorporate the lit-
erature on the sociocultural factors that contribute to eating disorders or
discuss interaction of these factors with the psychodynamics of individual
patients. It is, unfortunately, simply not possible for me to do justice to the
many important contributions that have been made in the literature, includ-
ing research on the idealization of the thin body type within Western society
(Bruch, 1962; Garner, Garfinkel, Schwartz, & Thompson, 1980), the role of
the mass media in promoting pathogenic attitudes toward the body and self
(Stice, Schupak-Neuberg, Shaw, & Stein, 1994), the promotion of dieting
10 Introduction

behavior in athletes such as ballerinas, models, jockeys, and wrestlers (Gar-

ner & Garfinkel, 1980; Mickalide, 1990; Wooldridge, 2016; Wooldridge &
Lytle, 2012), and the influence of ethnic group values upon the development
and experience of eating disorders (George & Franko, 2010).

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Wooldridge, T., & Lytle, P. P. (2012). An overview of anorexia nervosa in
males. Eating Disorders, 20(5), 368–378.
Zerbe, K. (2016). Psychodynamic issues in the treatment of binge eating:
Working with shame, secrets, no-entry, and false body defenses. Clinical
Social Work Journal, 44(1), 8–17.
Chapter 1

Alexithymia and the

Psychic Elaboration of
Emotion

If there is one commonality between patients with eating disorders,

perhaps it is that there is disharmony in the link between body and
mind. This can manifest in various ways such as, for example, the
“false bodies” described in a later chapter. In this chapter, we will dis-
cuss another way that it commonly appears: difficulty putting feelings
into words. Some patients may struggle to describe and elaborate on
their experience, for instance, of need, desire, or hunger. While they
can speak to their feelings, often quite articulately in other realms, in
these particular areas this capacity is conspicuously absent. In this
vein, I am reminded of one patient with a binge eating disorder who
was striking for his generosity and willingness to help at home and
at work; over many months, he described his efforts in this direction.
As I listened, I could see that he was often exhausted, even burdened,
by the time and energy he devoted to others, though he never men-
tioned this. His sole symptom was binge eating, late at night, alone.
Over time, we discovered that binge eating was the only way he had
of expressing need. He had not yet developed the capacity to speak
about his need in words, to generate symbols that might express this
set of feelings.
Other patients’ difficulties manifest more globally, as trouble put-
ting feelings into words that extends across most or all domains. The
patient “Lucy,” discussed again later in this chapter, is an example of
this. Entrenched in her anorexia nervosa, she spent several months
almost silent in our sessions, responding only briefly to my inqui-
ries. Her capacity to put feelings into words was compromised in a
more general way, a phenomenon often referred to as alexithymia.
DOI: 10.4324/9781003016991-2
14 Alexithymia & Elaboration of Emotion

Regardless of whether the difficulty putting feelings into words is

circumscribed or more general, these patients may as a result have dif-
ficulty postponing action in favor of reflection. The capacity to think
about, to reflect upon, difficult feelings is what allows us to forego
expressing them in more problematic ways, such as, for patients with
eating disorders, through a binge, or a purge, or food restriction. With
this idea in mind, we will discuss the idea of mentalisation, which is
a way of thinking about different “registers” of emotional expression
and how we can identify these in patients with eating disorders, as
well as the concept of reverie, which speaks to the intersubjective pro-
cess that occurs between parent and child as well as between clinician
and patient and that is central to facilitating the capacity to identify
and elaborate emotional experience.

Alexithymia
Alexithymia, a term originated by Sifneos (1973), comes from the
Greek (a = lack, lexis = word, thymus = emotion) and refers to a
cluster of features including difficulty identifying and describing sub-
jective feelings, a circumscribed fantasy life, and an externally ori-
ented thinking style (Taylor & Bagby, 2013). Even before the 1970s,
Horney (1952) and Kelman (1952) described patients who reached
an impasse in treatment because of limited emotional awareness,
concreteness in thinking, and a dismissing attitude toward their inner
lives. Such patients were prone to developing somatic symptoms,
binge eating, alcohol abuse, and other compulsive behaviors in an
effort to regulate affective states. Upon its introduction as a formal
construct, alexithymia was of interest to psychoanalysts engaged in
the treatment of classic psychosomatic diseases. Soon, however, it
became incorporated into the broader field of research on emotional
processing and affect pathology (Taylor & Bagby, 2013). Since that
time, it has been noted in a wide range of patient populations, includ-
ing post-traumatic states (Krystal, 1968), drug dependence (Krystal &
Raskin, 1970), eating disorders (Bruch, 1971, 1973, 1978), and panic
disorder (Nemiah, 1984). The spectrum of disorders with which it is
associated is consistent with the notion that emotion that cannot be
put into words and images may generate bodily symptoms secondary
to unregulated activation of bodily systems (Taylor & Bagby, 2013).1
 Alexithymia & Elaboration of Emotion 15

Hilde Bruch (1971, 1973, 1978) recognized that patients with

anorexia nervosa have a diminished capacity for “interoceptive aware-
ness,” that is for accurately identifying and articulating their emo-
tional experience. Not only do they exhibit a profound disturbance in
their ability to recognize and discriminate between feelings, but they
also struggle to distinguish between emotional states and bodily sen-
sations. Empirical research has since established that alexithymia co-
occurs with eating disorders of all subtypes (Westwood, Kerr-Gaffney,
Stahl, & Tchanturia, 2017) and with eating disorder symptomatology
that does not rise to the level of an eating disorder diagnosis (e.g.,
Ridout, Thom, & Wallis, 2010; De Berardis et al., 2007). Even in the
empirical literature, it is accepted that eating-disordered patients may
use maladaptive eating behaviors (e.g., bingeing, purging, restricting)
to regulate their emotions (Cooper, 2005). Whereas some studies have
reported no significant differences in alexithymia across eating disor-
der diagnoses, others have suggested individuals with anorexia ner-
vosa experience higher levels (Nowakowski, McFarlane, & Cassin,
2013). Alexithymia appears to decrease significantly post-treatment
with all eating disorders (ibid).2
Let us return to Lucy, a patient with anorexia nervosa. For the
first several months of treatment, she was mostly silent in our twice-
weekly sessions. Although she participated in her family-based ther-
apy that was aimed toward weight recovery, in our meetings she
seemed at a loss about what might be worth speaking about with me,
though I knew, from her psychiatrist’s reports, that her family was in
considerable turmoil. Although her silence might have been viewed
as “resistance” by previous generations of clinicians, with this under-
standing of alexithymia in hand I could entertain the hypothesis that
her silences might instead reflect an internal emptiness stemming
from a difficulty identifying her feelings. Unable to identify her feel-
ings, she tended to enact them through restrictive eating: a behavior
that was, in fact, powerfully expressive. Our work, which was often
slow and painstaking, was to help her develop a capacity to speak
about her emotional life which, in turn, would allow her to begin to
think about her feelings instead of acting them out.
Empirical research suggests that alexithymia has a multifactorial
etiology, with genetic and environmental factors contributing to alex-
ithymia through gene-environment interactions (Taylor & Bagby,
16 Alexithymia & Elaboration of Emotion

2013). As Fonagy (2002) suggests, it is not the actual environment

that regulates gene expression but the way that the child experiences,
processes, and interprets that environment. Increasingly, evidence
suggests correlations between alexithymia and insecure attachment
(Scheidt et al., 1999; De Rick & Vanheule, 2006; Montebarocci,
Codispoti, Baldaro, & Rossi, 2004; Troisi, D’Argenio, Peracchio, &
Petti, 2001) and emotional trauma (Krystal, 1988). Regarding the lat-
ter, several studies have shown that alexithymia is associated with
retrospectively reported experiences of emotional and/or physical
neglect or childhood sexual or physical abuse (Berenbaum, 1996;
Frewen et al., 2008; Paivio & McCulloch, 2004; Zlotnick, Mattia, &
Zimmerman, 2001). Other empirical studies have linked alexithymia
to trauma in adulthood (Frewen et al., 2008; Taylor, 2004).
Historically, it was taken for granted that all psychic life was rep-
resentational, either in words or in different kinds of imagery: visual,
auditory, kinesthetic, etc. Now there is now a vast literature on unrep-
resented states of mind: that is, mental contents not stored in rep-
resentational form as words and images but that nonetheless shape
our experience and behavior (e.g., Bion, 1962; Green, 1975, 1999;
Matte-Blanco, 1988; Lecours & Bouchard, 1997; Botella & Botella,
2005). The concept of alexithymia emerged as psychoanalysis was
beginning to turn its attention toward unrepresented states and groups
together patients for whom the capacity to symbolize and represent
affect is markedly impaired. Freud (1917), with great foresight,
describes affects as composite experiences that include “particular
motor innervations or discharges” and “certain feelings” (p. 395).
Since then, emotion has been defined as the neurophysiological and
motor-expressive component and feelings as the subjective, cogni-
tive-experiential component of affect, a general term encompassing
both. In his writings on alexithymia, Nemiah (1977) pointed to the
capacity missing in alexithymic patients: the psychic elaboration of
emotion, through which emotions are represented mentally and expe-
rienced as feelings. This has been termed the “immune system of the
psyche,” for it absorbs external stresses as well as internal pressures
by mentally processing their effects on the body and elaborating them
further (Lecours & Bouchard, 1997).
The psychic elaboration of emotion relies upon symbolic function-
ing: the creation and manipulation of symbols in the form of images
 Alexithymia & Elaboration of Emotion 17

and language. In an early paper, Segal (1957) distinguished two

modes of symbolic functioning. In the first, an object is concretely
equated with a symbol, resulting in a symbolic equation. She provides
an example of a psychotic patient who reported that he could not play
the violin because he would not masturbate in public. Here, the violin
is equated with the patient’s penis. It does not remind him of his penis
or conjure associations to his penis; it is his penis. In proper symbolic
functioning, a symbol serves as a representation of the object (i.e., a
word or image that points to it) and is not experienced as the object
itself (as with a symbolic equation). It only arises through the loss
of the object – a recognition of separateness from it and the mourn-
ing that entails – which leads to the recreation of the object within
oneself as a symbol. In a later paper, Segal (1998) describes how a
symbol becomes a container for the thoughts and feelings attached to
the object, giving meaning to the external world.

Mentalisation
A process of mentalisation has been proposed to describe a precon-
scious (that is, operating below the threshold of consciousness) linking
function that connects bodily excitations with psychic representations
(Lecours & Bouchard, 1997).3 This theory is particularly useful for
it allows us to understand this process in a more fine-grained way
than the binary of symbol and symbolic equation proposed by Segal
(1957). The theory of mentalisation discussed here (Lecours & Bouch-
ard, 1997) allows us to describe the relative presence or absence of the
ability to put feelings into words as it manifests in the treatment situ-
ation. The notion of mentalisation was originally proposed by French
psychoanalysts to understand psychosomatic patients. At that time,
it implied a binary view – either experience is mentalised or not –
and neglected the fact that psychic contents exist on a continuum of
increasing mental quality (Lecours & Bouchard, ibid.).
Lecours and Bouchard (1997) expanded this theory to account for
the never-ending transformation of psychic contents in increasing
levels of complexity. Their theory draws upon two processes: rep-
resentation and symbolization. The first is a process of elaborating
and using a stable mental image of a thing in place of the thing itself
(Sandler & Rosenblatt, 1962). The latter is a superordinate function
18 Alexithymia & Elaboration of Emotion

that links already-formed mental representations as its basic building

blocks (Perron, 1989). Together, these functions drive our capacity
for the elaboration of bodily states into increasingly organized men-
tal structures. In this model, this elaboration is described along two
dimensions: a “vertical” dimension of four registers of expression and
a “horizontal” dimension of increasing capacity for tolerance, con-
tainment, and abstraction.
The four “vertical” registers of emotional expression are somatic,
motoric, imaginal, and verbal. In the somatic register, affect is
expressed viscerally through internal physiological sensations, func-
tional disturbances, and somatic lesions. In an infant, affect is first
experienced as bodily excitation (e.g., pain, tension, or nausea) in
the internal organs, head, musculature, and skin. Throughout devel-
opment, the body remains our ultimate emotional backdrop, the
place in which experience we cannot know with our minds continues
to make its mark. Motor activity involves the behavior and action of
the muscular body, including positive and negative manifestations
(i.e., twitches and pacing and but also silences, stillness). The infant
squirms, wiggles, cries, and smiles – all are reflexive enactments
of a felt somatic state. Yet adults equally make use of activity as
a proxy for understanding and verbalizing affect. Quatman (2015)
describes a binge-eating patient who found herself eating fast food
as a response to feeling taken advantage of by her husband; only
when the patient was helped to translate that action into words could
it be fully understood.
The imaginal, a pivotal step in the chain that bridges body and
mind, involves mental imagery: mental pictures and scenes as rep-
resentations of underlying bodily states. Its content takes the form
of images as expressed in dreams, fantasies, and metaphors. It is a
pivotal step, for it is the first register that moves from the experience
of a thing in itself to a representation of that thing, which can then be
elaborated further through symbolization. The verbal, finally, entails
the manifestation of affect in language, in words and stories, expla-
nations, and insights. It is the pinnacle of our emotional architecture,
allowing us to link past and present, to hold up an experience and to
examine it from different angles, to put our emotions “on pause,” and
to bridge, even if only partially, the gaps that separate us as individu-
als (Quatman, 2015).
 Alexithymia & Elaboration of Emotion 19

The “horizontal” dimension is composed of five levels of affect

tolerance, containment, and abstraction. Those levels are disruptive
impulsion, modulated impulsion, externalization, appropriation of
affective experience, and abstract-reflexive meaning association. At
the first level, disruptive impulsion, affects are neither tolerated nor
contained but, instead, expressed directly without mediation. In gen-
eral, the subject does not “own” the affect and it will have a strong
impact upon the listener. At the second, modulated impulsion, the dis-
charge process is modulated, yet the affect is still impulsively evac-
uated from the subject’s mind. The third, externalization, entails that
an affect has begun to be tolerated and contained, undergoing some
reflective activity, but not enough for it to be fully appropriated as
an aspect of the subject’s psychic activity. The fourth, appropriation,
demonstrates that the subject fully tolerates the affect, experiencing
it as subjective, private, and available to self-observation. The final,
abstract-reflexive, obtains when the subject is able to make sense
of what is being encountered and to subject it to complex meaning
associations.
At each increasing level, the subject is protected by a “thicker”
mental buffer of layers of representation and symbolization. This buf-
fer not only dampens internal and external impacts, but it also allows
for an increased capacity to subject affects to reflection and elabora-
tion instead of immediate expression. The binge-eating patient who
eats fast food without intentionally choosing to do so is operating at
the level of disruptive or modulated impulsion, for her behavior is
an impulsive expression of her underlying affect without reflection
upon it. As she is able to put her behavior into words and, over time,
to forego the behavior in favor of owning and symbolizing the under-
lying affect (e.g., anger at her husband), she moves toward appropri-
ation, experiencing the anger as her own. When she is able to reflect
and elaborate upon her relational pattern of feeling taken advantage
of and subsequent anger expressed through masochistic behaviors,
she has reached the abstract-reflexive level, the height of symbolic
functioning.
In this model, alexithymia can be understood as a deficit in the
capacity for mentalisation, with affects largely being expressed
through the first two registers – somatic and motoric – and with little
capacity for tolerance, containment, and abstraction.
20 Alexithymia & Elaboration of Emotion

Reverie
How does a child develop the capacity to mentalise? Mentalisation
is fundamentally a process of transformation through which bodily
excitations, whether somatic or motoric, undergo a qualitative trans-
formation into mental contents within the context of human relation-
ships (Dunn, 1995). Winnicott (1949) suggests that for infants, affect
is foremost a bodily experience and that only within a “good enough”
intersubjective environment – a child’s relationship with his caretaker
and a patient’s relationship with his analyst – does the “psyche-soma,”
the psychic elaboration of emotional experience, begin to unfold. In
this section, we now turn to Bion’s (1962) ideas to better understand
how the capacity to mentalise is fostered by caretakers and, by exten-
sion, how it may be promoted by clinicians working with patients with
eating disorders in the consulting room.
Bion (1962) provides us with the tools to understand the inter-
subjective development of the capacity for the psychic elaboration
of emotion or, when that development falters, of alexithymia. In his
model of the mind, the development of thought is related to psycho-
somatic phenomena insofar as thought grows out of a matrix of bodily
processes and is always derived from it. These bodily processes are
a ‘thing in itself’ – they can never be known directly – but, through
thought, they can be approached so that they can be contained by the
mind for communication and thinking (Graham, 1988). Bion refers to
the “thing in itself ” as a beta element, the most primitive element of
thought that lacks meaning and cannot be distinguished from bodily
sensations. With beta elements, there are only two possibilities: they
can be evacuated – expressed through an earlier stage on the “hori-
zontal” dimension of mentalisation discussed earlier such that they
are not appropriated as one’s own and able to be reflected upon – or
transformed into alpha elements. Alpha elements, for Bion, are the
basic building blocks of thought. In the language of mentalisation, we
might think of alpha elements as symbols that can be further linked
and elaborated through the process of symbolization into more com-
plex forms of mental abstraction.
How does the patient, in Bion’s view, develop the capacity to gen-
erate alpha elements? It depends upon her relationship with another
person. For the child, this is typically the mother, though of course
 Alexithymia & Elaboration of Emotion 21

other caretakers, including the father, can provide this function as

well. The mother, through her reverie – her engagement with her
own imaginative capacities – works to “decode” the child’s affective
expressions, whether they are somatic, such as a warmth in the cheeks
or motoric, such as cries or gestures and other nonverbal cues. With
her words and her responsiveness, she, over time, scaffolds the child
into the world of representation. When the child cries, she says, “Oh,
sweetheart, your diaper is wet,” thus conveying that the child’s cry has
meaning. As clinicians, we seek to provide the same to our patients.
We use our own mental capacities to understand and to elaborate on
their distress and hope that in the process, they will internalize this
capacity and increasingly be able to do this with their own creative
engagement.
Again to Lucy. In one particular session, she began by telling me
about a conflict that she’d had with her father the night before. After
the fight, she had skipped dinner, depositing her meal into the trash
while her mother was briefly away from the table. In our session, we
returned to the event in detail. I asked her to recount each moment in
as much specificity as she could, inquiring about the particulars of
her behaviors, sensations, and thoughts. As I listened, I found myself
imagining Lucy screaming in rage at her father; her anger, it seemed
to me, was immense and demanded her attention. “Perhaps,” I sug-
gested, “in throwing away your meal, you were expressing how angry
you were at your father.” After an initial moment of protest, the idea
began to resonate with her and we explored it together at length. In
this brief example, I made use of my own reverie to help Lucy elab-
orate her feeling, previously expressed in the motoric register, into
the verbal register, as a feeling of anger that she could expand in the
conversation between us.
With a sketch of Bion’s model in place, the development of alex-
ithymia can be illuminated further. Krystal (1988) suggests that
alexithymia results from a rupture in an individual’s symbolic pro-
cesses because of traumatic events in which the caretaker was not
able to receive and elaborate on her infant’s emotional experience. In
other words, the caretaker was not, for whatever reason, able to make
use of her own reverie to promote the child’s capacity to make sense
of emotional experience. Repeated over time, the child’s developing
capacity to do this for himself was undermined and, as a result, he
22 Alexithymia & Elaboration of Emotion

comes to rely more upon the somatic and motoric registers for emo-
tional expression and less upon the imaginal and verbal. In Bion’s
terms, alexithymia reflects a relative absence of alpha function; there
is a spectrum from rudimentary toward greater complexity, the latter
allowing for the possibility of more creative and innovative thought.
An individual’s capacity for alpha function may be radically uneven:
available in some domains and absent in others. Notably, Bion sug-
gested that beta elements are indistinguishable from bodily states,
which is consistent with the alexithymic patient’s difficulty making
this distinction.

Notes
1 As Taylor and Bagby (2013) point out, alexithymia is a dimensional con-
struct instead of an all-or-none phenomenon. Krystal (1982) understands
alexithymia as a personality trait that has potential state variation. More
recently, empirical research has provided strong support for conceptual-
izing alexithymia as a dimensional construct (Parker et al., 2008; Matilla
et al., 2010). The implication here is that it is most useful to think of
alexithymia as a continuum instead of as an all-or-nothing phenomenon.
Patients may be more or less alexithymic and, equally important, may have
more capacity to put their feelings into words in certain emotional states
and less in others.
2 It has often been observed that because of the cognitive impairment it
creates, starvation can exacerbate, or even create, an alexithymic presen-
tation in patients with anorexia nervosa. In some cases, the capacity to
describe internal states is dramatically improved by nutritional and medi-
cal rehabilitation.
3 The concept of mentalisation was introduced by French psychoanalysts in
the early 1960s (Fain & Marty, 1964). Over 30 years later, the term was
adopted by Fonagy and Target (1997), who conceptualized mentalization
as the capacity to be aware of and to think about feelings and other mental
states in oneself and others. This conceptualization is distinct from, though
certainly overlapping with, the one proposed by Lecours and Bouchard
(1997), discussed here.

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Chapter 2

Early Relationships,
Object Relations, and
Traumatic Themes

Object relations theory is concerned with how the patient’s early rela-
tional experiences have been internalized as a psychological structure
that continues to organize and give meaning to her experiences in the
present. Are her objects “whole,” reflecting both the good and bad
aspects of important early relationships, or are they “parts,” represen-
tations of “all good” or “all bad” experiences of intense gratification,
longing, or deprivation? The objects that populate her psyche shape
the anxieties with which she struggles, the longings she feels, and
the defenses she erects to manage the intensities of both. From this
point of view, it is the underlying psychological structure – not just
the eating disorder symptoms that manifest because of it – that are
a focus of treatment. The eating disorder, in other words, is a result
of dynamics that are woven through the patient’s personality. These
ideas also provide a way for us to think about how our patients are
interacting with us, moment by moment, in our work. What relational
experiences are shaping her experience of us? How is this, in turn,
shaping our experience of her? They inform, in addition, how we talk
with our patients about both their current relationships and their his-
tories, which is an important way that we promote their capacity to
mentalise, as discussed in the previous chapter.
Gaining wide recognition, Hilde Bruch’s (1962, 1973, 1978) foun-
dational work was the first to describe anorexia nervosa in the lan-
guage of object relations. For her, self-starvation represents a struggle
for autonomy, mastery, and self-esteem. Disturbances in the early
mother–child relationship predispose the child to develop the disor-
der during adolescence, a time that demands an increased capacity
DOI: 10.4324/9781003016991-3
 Early Relationships, Object Relations, and Traumatic Themes 27

for autonomous functioning. In her clinical work, she observed over-

involved caretakers who were domineering, intrusive, and discour-
aging of separation and individuation. This, she argues, creates an
internal confusion in children, expressed through body image distur-
bance (patients with anorexia nervosa tend to overestimate their body
size), interoceptive disturbance (an inability to identify and respond
to internal sensations, including hunger, fullness, and affective states),
and all-pervasive feelings of ineffectiveness and loss of control.
Masterson (1978) suggests that patients with anorexia nervosa have
a maternal object that becomes hostile and rejecting as they move
toward separation and individuation and another that becomes sup-
portive and rewarding in response to dependent, clinging behavior.
Each internal representation of the mother has its corresponding
self-representation – the first as bad, empty, and guilty and the sec-
ond as passive, compliant, and good. Working together, these inter-
nal objects undermine patients’ journeys toward adulthood, which
is incompatible with the symptoms and behaviors of the disorder.
Like Bruch, Masterson highlights the difficulties that patients with
anorexia nervosa are having with separation and individuation. Con-
sider, for example, “Octavia,” a 17-year-old adolescent who speaks
insightfully, after nearly a year of intensive clinical work, of her fear,
even terror, about getting older and developing an adult body with
thighs, breasts, and hips. When she imagines dating, she feels an inex-
plicable anxiety that, over several weeks of patient inquiry, she links
to a fear that her mother will withdraw her support if she “grows up.”
Other theorists have emphasized different aspects of anorexia ner-
vosa. Some have highlighted the difficulty these patients have putting
feelings into words, as discussed in the previous chapter (Birkst-
ed-Breen, 1989; Boris, 1984; Sprince, 1984). With this idea in mind,
Lawrence (2001) expands on failures in symbolization and argues that
mother – who is cast as dangerously intrusive – is concretely equated
with food and, consequently, renounced. For the patient, emotion-
ally, food is the mother, instead of evoking feelings that are similar
to those evoked by the mother. His formulation highlights the ways in
which these patients tend to form transferences shaped by this fear of
intrusion, leading them to avoidantly approach the therapeutic rela-
tionship. In fact, clinicians working with this population often report
feeling relationally deprived by their patients, in the same way that
28 Early Relationships, Object Relations, and Traumatic Themes

these patients deprive themselves. It is not uncommon for clinicians

to feel that they are “pulling teeth” as they attempt to engage with
some patients with anorexia. While this is often due, in part, to their
difficulty putting feelings into words, it often also emerges that these
patients fear that intimacy within the analytic setting will result in an
unwanted intrusion.
With Octavia, for example, I notice after several weeks that she
rarely allows for silence between us, filling each moment with her
words. Sometimes she speaks about matters that feel emotionally
important whereas, at others, it seems to me that her words lack emo-
tional depth. It is not until I hear her speaking about the pain she feels
when her mother “speaks over” her in their conversations, as if eras-
ing her thoughts and feelings and replacing them with her own, that
I begin to wonder whether the urgency in Octavia’s speech with me
might represent both a wish to be heard and a fear that if there were
space for me to speak I might, like her mother, engage with her in an
intrusive way. This theme, elaborated over many months of clinical
work, is eventually also linked to her developing sexuality. “What
could be more intrusive than sex?” she rhetorically asks.
There have been fewer investigations of bulimia nervosa. Master-
son (1995) describes bulimia nervosa as a “closet narcissistic person-
ality disorder.” In his view, pathological grandiosity meets traumatic
disappointment and the resulting psychic pain is hidden behind a
defensive idealization of the other and an accompanying neglect of
the self. Sugarman and Kurash (1982) propose that these patients lack
object constancy: when separated from the symbiotic mother, they
are unable to evoke a mental representation of her for the purposes of
self-soothing. Bingeing is used to evoke a sensorimotor-based expe-
rience of the mother, akin to the patient’s early experiences of child-
hood feeding. This formulation is consistent with the experience that
many patients with bulimia describe of deriving a feeling of relief
from overwhelming emotion during a binge. Sugarman (1991), in
contrast, highlights the failure of these patients to communicate in
symbolic form; the body, instead, is the vehicle for the expression
of unconscious conflict. Other eating disorders, such as binge eating
disorder and muscle dysmorphia, have received far less attention in
the object relations literature, having only more recently gained wider
recognition.
 Early Relationships, Object Relations, and Traumatic Themes 29

In the remainder of this chapter, we will discuss two traumatic

themes (Shabad, 1993), or chronic patterns of frustrating and depriv-
ing childhood experience at the hands of caretakers, which take
on the emotional significance of cumulative trauma (Khan, 1963).
These themes were chosen because they are commonly described by
patients with eating disorders. Although each will only apply to some
patients – remember, eating disorders are descriptive diagnoses –
these examples will clarify how underlying psychological structure,
shaped by internal representations of early relationships, may man-
ifest, symptomatically, as an eating disorder: how the eating dis-
ordered symptoms are only the tip of the iceberg, with the iceberg
referring to the dynamic structure of the patient’s personality as a
whole. In addition, in many cases, these themes hobble the mind’s
ability to symbolize and represent the feelings they evoke. They may,
in other words, compromise the capacity to mentalise, or put feelings
into words, discussed in the last chapter.

Traumatic Theme #1: Object Hunger

One of the most common themes observed in patients with eating
disorders centers on early traumatic disappointment in the child’s
object(s) that derails the development of an internalized represen-
tation of those objects – a key component of healthy psychological
structure. In other words, because the child experience’s recurrent,
disappointed need for connection with an important other, he is
unable to internalize that other and, over time, to provide, at least
to some degree, for himself what that other might have originally
provided for him. This, in turn, fuels intense object hunger which,
absent intervention, persists throughout further development. The
term object hunger has been widely used in the literature (Blos,
1967; Kohut, 1968; Ritvo, 1971; Chessick, 1985; Boris, 1984;
Yarock, 1993, for examples with eating disorders). It is a desperately
felt need for contact with another person who can serve as a substi-
tute for missing segments of one’s own psychic structure. This other
is loved not as separate, whole person but, rather, is fervently needed
to make up for what is missing internally. This yearning often has a
desperate quality that may be conscious or, in contrast, vehemently
defended against.
30 Early Relationships, Object Relations, and Traumatic Themes

Consider, for example, the diagnosis of anorexia nervosa. Many

years of clinical reports, in addition to a number of more recent empir-
ical investigations, indicate a disturbed relationship with the mother,
a distant and uninvolved relationship with the father, and a distorted
sense of self. In one empirical study, anorexic patients were found to
experience disrupted maternal relationships, to have a defensively over-
developed, yet highly self-critical, sense of self, and to struggle with
intense but well-defended feelings of neediness. Behind the repudiation
and rejection of food and nurturance, of which these patients feel deeply
undeserving, lies a powerful longing for the care and attention of the
mother – in other words, object hunger (Bers, Harpaz-Rotem, Besser,
& Blatt, 2013). A central task is to address not only the dangerous,
self-destructive symptom of self-starvation but also the dependency
needs defended against by a refusal to accept nurturance.
Freud (1938) writes, “A child’s first erotic object is the mother’s
breast that nourishes it; love has its origin in attachment to the satisfied
need for nourishment” (p. 118). Alexander (1950) affirms this notion:
the child “experiences the first relief from physical discomfort during
nursing; thus the satisfaction of hunger becomes deeply associated
with the feeling of well-being and security.” Eating is an expression
of the patient’s longing for comfort, which he cannot otherwise pro-
vide to himself. Yet patients with eating disorders are deeply defended
against a direct recognition of their object hunger, repeating their
defensive engagement with this traumatic theme in their relationship
to food. Boris (1984) suggests that the hunger for food is

a ruse, the flames of which are fanned to obscure object hunger,

so food itself is a counterfeit substance to substitute for a longing
for fusion – for being touched by hand and eye and voice, for
being held in body and mind. (p. 319)

“Jim,” for example, spends his days in a work environment that is

fraught with conflict and tension. He has no conscious sense of being
affected by his work environment, but over time we notice that his
binge eating episodes almost always happen on the drive home after
work. Perhaps, we begin to wonder, his decision to stop at a fast-food
restaurant reflects his longing for comfort, for soothing from another,
and, perhaps, an escape from his own anger.
 Early Relationships, Object Relations, and Traumatic Themes 31

Writing about patients with bulimia, Yarock (1993) suggests that

these patients deny their dependency through food restriction but
that this denial breaks down in a “rush of object hunger” (p. 9), lead-
ing to a ravenous appetite and a subsequent binge. Within moments,
however, disgust and guilt lead to an undoing of that object hunger,
manifesting as subsequent vomiting. We can also understand patients
with muscle dysmorphia as seeking to turn their bodies into hard,
impenetrable surfaces in a defense against a longed-for soft embrace
with the maternal object. In these brief formulations, traumatic disap-
pointment in early caretakers leads to compromised psychic structure,
with object hunger signaling an urgent need to compensate for this
deficit. From a young age, patients with eating disorders may begin
to repeat a defensive engagement with this object hunger, shaping
their developing characters and leading to particular kinds of symp-
tom formation.
It has often been observed that eating disorders most commonly,
though not solely, manifest in adolescence. Notably, adolescence is a
period in which object hunger is exacerbated. Blos (1967) conceives
of adolescence as a second individuation process: a phase in which
the processes of the separation-individuation crisis (Mahler, 1963)
are re-worked and expanded upon. Whereas toddlers in separation-
individuation gain emotional supplies from the reunion with mother,
adolescents are more likely to seek supplies from peers, including
through the expression of their emerging sexuality in those relation-
ships. Adolescents are notable for seeking out experiences of height-
ened affect, whether of excitement and elation or pain and anguish
These are manifestations of object hunger, intensified in adolescence
because of the concurrent lessening of parental ties as adolescents
establish a greater sense of autonomy and personal identity.
Ritvo (1971), similarly, emphasizes that adolescents, impelled by
emerging genital sexuality and intense object hunger, are confronted
with dependence upon external objects for the gratification of these
needs, for attempts to meet these needs in fantasy will inevitably
prove disappointing. There is a large body of literature examining
the relationship between sexuality and eating disorders (Wiederman,
1996). Confirming clinical experience, it has been found that anorexic
symptoms are associated with decreased sexual activity and bulimic
symptoms with increased sexual activity (Eddy, Novotny, & Westen,
32 Early Relationships, Object Relations, and Traumatic Themes

2004). The anorexic is strongly defended against her object hunger

whereas the bulimic’s defenses against that hunger break down, lead-
ing her to over-consume and, in an effort to undo the eruption of that
need, to vomit. The relationship of each of these types to their sexual-
ity, which can be understood as a genital manifestation of object hun-
ger, follows the same pattern. The exacerbation of object hunger and
the emergence of new modes of its expression places great demand on
patients with particular emotional vulnerabilities as described earlier
and thus contributes, at least in part, to the emergence of disordered
eating in adolescence.

Traumatic Theme #2: Breakdowns in

Containment
From a psychoanalytic perspective, disruptions in early experiences
with parents, especially with the mother, may constitute an import-
ant traumatic theme for patients with eating disorders. Bion (1962)
describes the vital developmental function of a caregiver who can
receive a child’s communications of emotion that, due to the child’s
relative lack of psychic development, cannot be represented by the
child in images or words and thought about alone. Put differently,
without the caregiver’s assistance, the child cannot “make sense” of
what she is feeling. When all goes well, the caregiver receives these
communications, attempts to make sense of them, and communi-
cates this understanding back to the child, perhaps in words but just
as often through her way of behaving with him. The child cries, for
example, and the mother uses her own mind, both consciously and
unconsciously, to think about the meaning of those cries and, finally,
responds in a way that makes use of that understanding. Bion referred
to this process between mother and child as containment, naming
specifically the capacity to “make sense” of emotional experience as
alpha-function. Over time, the child becomes increasingly able to per-
form alpha-function for himself, rendering the caregiver’s capacity a
persistent part of his psychological structure. Now, the child can link
and organize thoughts and feelings, giving order to his internal world.
Returning to Jim. Upon analytic inquiry, we discover that his binge
eating began early in elementary school, soon after he began to grap-
ple with a persistent and troubling feeling that he was “different.” It
 Early Relationships, Object Relations, and Traumatic Themes 33

was not until his early twenties that he could articulate his feeling
more clearly as conflict about his sexual orientation. The child of a
conservative minister, he knew early on that his parents could not
help him with these struggles. Instead, he recalls, he often lay awake
feeling tormented by this sense of difference, gripped by a feeling of
shame that he can only name in retrospect. His parents, we came to
feel, so invested in their religious beliefs, were unable to intuit their
son’s distress or to comprehend the developing shape of his sexuality.
This scenario constitutes a breakdown in containment, for Jim was
left without the help of his parents’ more developed minds in making
sense of his distressing emotional experience. Instead, he came to rely
upon binge eating, always done in secret, as a way of soothing his
overwhelming distress.
The process of containment can break down in several ways. Bion
(1962) described one scenario in which containment breaks down:
when a child attempts to communicate her emotions to a parent who
is impermeable or otherwise unavailable and receives them back in
unmodified form, leaving the child with an experience of “nameless
dread.” The process of containment may also fail when a parent needs
to divest herself of her own unprocessed emotional pain and so uses
her child as a receptacle for it. This latter form of breakdown is dis-
cussed in Chapter 4: Abjection and Bodily Disgust. When contain-
ment breaks down too often, it interferes with the child’s developing
ability to make sense of his feelings – to mentalise, as discussed in
Chapter 1: Alexithymia and the Psychic Elaboration of Emotion.
Patients with eating disorders who have suffered this traumatic theme
may thus rely upon their symptoms – restriction, bingeing, purging –
to regulate affect that they cannot name, reflect upon, or communicate
to another person.

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mother, and father. Psychoanalytic Psychology, 30(2), 188–209.
Bion, W. (1962). A theory of thinking. In Second thoughts (pp. 110–119).
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Birksted-Breen, D. (1989). Workings with an anorexic patient. International

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Works, 139–208.
Khan, M. M. R. (1963). The concept of cumulative trauma. Psychoanalytic
Study of the Child, 18, 286–306.
Kohut, H. (1968). The psychoanalytic treatment of narcissistic personality
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the Child, 23, 86–113.
Lawrence, M. (2001). Body, mother, mind: Anorexia, femininity and the
intrusive object. International Journal of Psychoanalysis, 83, 837–850.
Mahler, M. S. (1963). Thoughts about development and individuation. The
Psychoanalytic Study of the Child, 8, 307–324.
Masterson, J. F. (1978). The borderline adolescent: An object relations view.
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Chapter 3

Traumatic Themes,
Repetition, and Mourning

One of our central tasks with patients with eating disorders is facili-
tating the capacity to postpone action in favor of reflection. We inev-
itably find, especially early on, that this is challenging: the pull to
binge, or purge, or restrict is difficult, often impossible, to resist. To
understand this fact, in this chapter we begin with a discussion of
Freud’s (1914) notion of the compulsion to repeat and then formu-
late the eating disordered patient’s symptoms as repetitions against
traumatic themes from childhood, never-ending (because never fully
successful) attempts to magically undo the pain of the past (Shabad,
1993). Ultimately, this pull toward repetition undermines the patient’s
capacity to direct herself – her agency. We discuss Novick and
Novick’s (2001a, 2016) dual-track, two-systems model of develop-
ment, which provides a way of thinking about the development of
agency, or its curtailment, throughout life. In this model, the open
system of self-regulation is based on mutually respectful, pleasurable
relationships formed through realistic perceptions of self and others.
It allows for the possibility of generative creativity in love and work.
The closed system of self-regulation, on the other hand, is character-
ized by omnipotence and a sadomasochistic stance that transforms
experiences of overwhelm into hostile defense. The task with eating
disordered patients is both fostering the former and ameliorating the
latter.
We conclude with a discussion of mourning, which is seen as a
counterpart to Freud’s (1914) notion of working through. Mourning is
the mechanism through which traumatic themes can be acknowledged,
disillusioned wishes for an ideal object relinquished, and painful early
DOI: 10.4324/9781003016991-4
 Traumatic Themes, Repetition, Mourning 37

relationships transformed into aspects of the patient’s character that

are carried forward in constructive ways. It is an essential aspect of
the treatment of patients with eating disorders that remains almost
entirely unmentioned in the mainstream literature. It leads, ultimately,
to the amelioration of the repetitions that have driven the patient’s
eating-disordered symptoms and diminished her agency.

Repetition and Traumatic Themes

In 1914, Freud published “Remembering, repeating, and working
through,” from which we get the often-referenced notion that what
cannot be remembered will be repeated in action. Ultimately, this
paper is a deep meditation on the nature of transference, that is, how
the past shapes our experience in the present. Lear (2003) suggests it
is Freud’s most significant contribution, for if all his works were lost
except for this one, it would still be possible to reconstruct what is
most valuable in psychoanalysis (p. 137). A central focus with eating
disordered patients is to promote the capacity to postpone action in
favor of reflection. We discover, especially early in treatment, that
this is challenging: the pull to binge, or purge, or restrict is difficult,
and at times impossible, to resist. This pull can be understood as a
repetition of a defense against a traumatic theme from childhood, a
never-ending (because never fully successful) attempt to magically
undo the pain of one’s past (Shabad, 1993). The idea of traumatic
themes, along with examples commonly encountered in patients with
eating disorders, is discussed in both Chapter 2: Early Relationships,
Object Relations, and Traumatic Themes and in Chapter 4: Abjection
and Bodily Disgust. In this chapter, we will consider specifically how
traumatic themes drive the process of repetition.
A child’s inherent wish for a fruitful exchange with her parents can
be frustrated in innumerable ways. To capture this, I use the term trau-
matic themes, which are chronic patterns of frustrating and depriving
childhood experience at the hands of caretakers day after day, often
for many years, that take on the emotional significance of cumulative
trauma (Khan, 1963). A mother’s persistent intrusiveness, or her over-
whelming desire to be taken care of by her child, or her withdrawal in
the face of her child’s upset feelings, or a father’s ongoing emotional
unavailability in the face of his son’s longing for connection are a few
38 Traumatic Themes, Repetition, Mourning

examples of traumatic themes that emerge with varying degrees of

severity in the histories of these patients. The parent is likely repeating
a traumatic theme from her own history that has not been mourned
and, because so often repeated, has become an aspect of her character.
The child is rendered helpless in his attempts to change the parent into
the wished-for figure and the traumatic theme becomes an “evolving
blueprint of helplessness and disenchantment before the powers of
fate” (Shabad, 1993, p. 66). Faced with such experiences at a young
age and without adequate emotional support through which they can
be digested, the child is unable to mourn the loss of the wished-for
experience with his parent, relying instead on defenses against dis-
illusionment in this all-important relationship. These defenses, in
turn, become the repetitions that, over time, etch themselves into his
character.
“Mark” is a 31-year-old man who struggles with binge eating.
Diagnosed with several learning disabilities at a young age, his early
experiences at school left him profoundly frustrated and desperately
in need of help from his parents to contend with that frustration. Yet
his parents, overwhelmed with their own difficulties, often struggled
to acknowledge their son’s experience of need, instead communi-
cating, at times subtly and at others more overtly, that he should be
grateful for the privileges that he enjoyed. Over time, analytic inquiry
suggested that Mark increasingly gave up on finding assistance in his
parents and, instead, resolved to handle his difficulties on his own. By
early grammar school, his neediness had been so defended against that
he barely experienced it at all. His teachers, and his parents, compli-
mented him for handling his learning difficulties with such stoicism
and self-reliance. It was around this time that he began to binge eat,
always at night and in secret, in the family kitchen, after his parents
were asleep.
The notion of agency may be the most encompassing perspective
we have of eating disorders, addressing many aspects of the struggles
that we encounter clinically (Zerbe, personal communication). Agency
refers to an individual’s observable capacity to direct himself – or
not – in a particular context: his or her local competence as an agent.
This can be assessed using the clinical markers provided by Caston
(2011): reversibility, self-observation, and appropriateness.1 The
compulsion to repeat is an impairment in agency, typically attenuating
 Traumatic Themes, Repetition, Mourning 39

or negating each of these three clinical markers. Patients with eating

disorders typically report little power to stop their eating disordered
behaviors (i.e., reversibility), are often unaware of the thoughts and
feelings they have when engaging in them (i.e., self-observation), and,
by definition, their behaviors are self-defeating and fail to forward
their development in constructive ways (i.e., appropriateness).
Novick and Novick (2001a, 2016) propose two distinct kinds of
solutions to conflicts throughout development, captured in a dual-
track, two-systems model, which offers another language for the
development of agency and its derailments. Because of its emphasis
on sadomasochistic patterns of relationship, this model facilities a
more precise description of the dynamics frequently observed in this
patient population. In a single-track model, pathology is understood
to be rooted in, and used to describe, early development. Adult pathol-
ogy is seen as a regression to what was normal in childhood or as an
arrest in the developmental processes of childhood. In a dual-track
model, an individual’s strengths and impulses toward progressive
development and orientation toward opportunities provided by her
environment are acknowledged. Novick and Novick (ibid.) character-
ize these two systems in terms of self-regulation, which includes the
regulation of self-esteem. We all need to feel safe, that the world is
predicable, that obstacles can be overcome, and conflicts resolved – in
short, to maintain narcissistic equilibrium. When such conditions are
met, infants can pleasurably engage with their environments. When
faced with overwhelming experience, internal or external, they must
find a way to restore their fragile self-esteem. Some infants, especially
when faced with overwhelm that cannot be overcome, turn away from
reality and toward an omnipotent solution. This learned response feels
dependable and, over time, takes on an addictive quality, restricting
her access to other solutions and pathways to further growth.
This closed system of self-regulation is characterized by omnip-
otence and a sadomasochistic stance that transforms experiences
of overwhelm into hostile defense. The organizing belief in this
defense is of magical power to control the other and likely origi-
nates in the efforts to force the mother to be “good enough” in the
face of traumatic disappointment. Such omnipotent beliefs become
the patient’s source of self-regulation and once constructed and
further consolidated in adolescence, are highly resistant to change.
40 Traumatic Themes, Repetition, Mourning

The open system of self-regulation, in contrast, is based on mutually

respectful, pleasurable relationships formed through realistic per-
ceptions of self and others. It is open to internal and reality-based,
external experiences, thus allowing for the possibility of generative
creativity in love and work (Novick & Novick, 2001a, 2016). In
such a system, an individual exhibits a greater degree of agency
thus and her actions will be characterized by the clinical markers
described by Caston (2011).
Kernberg (1995) points out, following Bruch (1962, 1973, 1978),
that female patients with eating disorders often have a history of long-
term, superficial submission to mother – “good girls” – while har-
boring deep resentment against mother’s invasiveness and use of the
child to bolster her own self-esteem. Their self-starvation represents
a masochistic form of rebellion against mother and the assertion of
autonomy under the guise of self-punishment. Many authors, includ-
ing Kernberg (ibid), point out that the patient’s hatred of her body is
a derivative of her hatred for mother, an attempt to destroy her body
as if it belonged to the mother. This closed system of self-regulation
relies upon omnipotent control of the body and is an attempt to aggres-
sively dominate the mother, with whom the patient’s own body is
experientially equated. Patients with anorexia nervosa often describe
the addictive quality of self-starvation, for it offers them a feeling of
control and power in a situation in which they would otherwise feel
helpless.
Mark’s binge eating also took on an addictive quality. Over time,
he relied on binge eating to manage the distress evoked by the expe-
rience of need in a wide range of contexts. He experienced the behav-
ior as entirely outside the scope of his agency, for he was utterly
unable to interrupt the pattern that had plagued him since his child-
hood. Although our work together was extensive and involved the
exploration and elaboration of numerous themes, an important thread
involved slowly introducing the idea that he might have more control
than he acknowledged in relation to his binge eating. Even if he was
not able to stop himself on a given occasion, he did have the power to
seek out various kinds of relational support, including with his ana-
lyst, and to work on developing a less conflict-ridden experience of
his own need. An important aspect of this work involved the two of us
noticing those moments – both inside and outside our sessions – that
 Traumatic Themes, Repetition, Mourning 41

he experienced himself more agentically, as having a greater degree

of authorship in his actions and in his life.
Indeed, viewed from a perspective of this dual-track, two systems
model, technique entails elucidating the functioning of the closed,
omnipotent system and addressing conflicts over using the open sys-
tem, with the analyst maintaining the conviction that there is a pos-
sibility for genuine choice. While analysts will inevitably be drawn
into sadomasochistic interactions, such a conviction helps to maintain
hope and facilitates the noticing of moments, past and present, in the
patient’s life that have the qualities of an open system (Novick &
Novick, 2001a). While a full discussion of technique is beyond the
scope of this book, single-track theory can lead to technique that min-
imizes or ignores the role of the parents in the treatment of children
and adolescents. In addition, work with parents is crucial to restoring
a child or adolescent to a path of progressive development (Novick
& Novick, 2001b). This is especially the case for children and ado-
lescents with eating disorders, where parental resistance can easily
stalemate a child’s treatment.

Mourning as a Process of Transformation

and Growth
In Freud’s (1914) “Remembering, repeating, and working through,”
we are introduced to the notion of working through – the active labor
of the patient, as opposed to an analytic technique – that involves
recognizing (insight) and overcoming (change) resistances. In the
process of working through, the patient becomes conversant with her
resistances and defenses by approaching them, again and again, from
different perspectives. Drawing on her will to recover, she marshals
her strength to overcome these resistances and defenses and to engage
with the work of remembering. In this way, she increasingly comes
to rely upon remembering, as opposed to repetition, as a means of
reproducing the past (Sedler, 1983). Freud describes working through
as that “part of the work which effects the greatest changes in the
patient and which distinguishes analytic treatment from any kind of
treatment by suggestion” (pp. 155–156). In spite of the importance
he assigns to the concept, he only mentions it, briefly, two additional
times in his corpus (ibid).
42 Traumatic Themes, Repetition, Mourning

During our second year of work together, Mark begins the ses-
sion by describing how he walked into the kitchen the night before,
well after midnight, and opened the fridge. While we had covered this
ground many times before, this time his story took a different turn.
“As I opened the fridge, I thought, ‘Why am I doing this?’” Sitting at
the kitchen table, he found himself beginning to cry. For the first time,
he is able to emotionally link his nighttime eating to a felt sense of
deprivation that originated in his early experience. Although this does
not eliminate his difficulties with food, it opens a new space in which
we can increasingly make emotional sense of his behavior. Over time,
he continues to gain an increasing sense of agency with respect to his
eating and to his health.
In this book, we have cast repetition as a repeated defense against
a traumatic theme from childhood. Whether there was, in reality, an
event or series of events in childhood that exceed average and expect-
able levels of emotional strain or whether one interpreted life events
in such a way that they were experienced as traumatic is, in an import-
ant sense, irrelevant: the relevant events were experienced as extreme
psychic pain, fear, and helplessness (Sedler, 1983). We all need to
feel that the world is safe and predictable and that obstacles and con-
flicts can be overcome. Faced with an experience that his ego cannot
sufficiently master, infants adopt a defensive stance characterized by
omnipotence and sadomasochistic object relations. In my view, joined
to the work of remembering is that of mourning, in which the help-
lessness and pain, including the disappointment with early objects,
that the patient faced are directly confronted and grieved. Mourning is
the vehicle of transformation through which traumatic themes can be
acknowledged, disillusioned wishes for an ideal object relinquished,
and painful early relationships transformed into aspects of the sub-
ject’s character that are carried forward in constructive ways.
Ever since Freud’s (1917) Mourning and Melancholia, psycho-
analysis has been concerned with mourning. In that landmark paper,
he attempted to elucidate the pathological mechanisms of melancho-
lia, or depression, through comparison to mourning. This led him to
the study of the superego and of structural conflict within the psyche.
In his view, whereas in successful mourning the subject severs her
emotional attachment to what has been lost and, thus, is free to rein-
vest its emotional energy elsewhere, in melancholia “one part of the
 Traumatic Themes, Repetition, Mourning 43

ego sets itself over and against the other, judges it critically and, as it
were, takes it as its object” (p. 247). This “critical agency” attacks the
ego in an expression of the subject’s grievance against the lost object,
which it would have liked to express to that object had it not been lost.
As a brief aside, this “critical agency” is quite pronounced in
patients with eating disorders. We can conceive of identification with
the aggressor – that is, taking on the attributes of the originally trau-
matizing object – as a superego process that reflects an underlying
traumatic theme. The subject remains fixated on offering herself to
her parents in search of their elusive goodness and, as her bid is never
accepted, it must be offered again in greater degree. When disillusion-
ment becomes unbearable, she bridges the gap between herself and
the lost parent narcissistically, by “becoming” the parental aggres-
sor herself (Shabad, 1993). This patient population is notable for the
intensity of their self-laceration. Frequent self-rebukes about weight
and appearance are common, as are punishing routines of starvation or
overeating. The former, for example, can be understood as a patient’s
identification with a caretaker by whom he felt emotionally starved,
whereas the latter as an identification with a caretaker who was felt to
be aggressively intrusive.
Returning to the issue of mourning, toward the end of his career
Freud (1923) published The Ego and the Id, which is the culmination
of his thinking about grief. Revising his earlier account of melan-
cholia, he re-conceptualizes the ego as “a precipitate of abandoned
object-chathexes” (p. 29), by which he means that it is effectively
an embodied history of lost attachments (Clewell, 2004). Mourning,
rather than coming to a decisive finale as was assumed in his earlier
work, is never-ending: it is a process of transformation through which
lost objects are preserved by taking them into the structure of one’s
own identity. These accretions are what make up the ego itself.
Hans Loewald (1989) builds upon this insight by casting mourn-
ing as an occasion for psychic integration and development. For him,
the human psyche is a psychological achievement, its development
making up a series of losses and reformations. The introjects that
constitute the superego can, through the work of mourning, become
constructive aspects of the subject’s character. Internalization, an
essential aspect of mourning, refers to a process of transformation
through which “relationships and interactions between the individual
44 Traumatic Themes, Repetition, Mourning

psychic apparatus and its environment are changed into inner rela-
tionships and interactions within the psychic apparatus” (p. 262). The
prototype of this is eating, in which food is lost to us (as food) but,
in the process, is transformed into something different inside of us,
whether nourishment, satiation, or indigestion and other pains (Lear,
2014). In this view, internalization is an essential aspect of psychic
growth, yet it is also a vehicle through which the ghosts of the past
may continue to haunt us.
John Bowlby (1980), father of attachment theory, recognized the
centrality of mourning in the recovery from traumatic disappoint-
ment in early objects. All forms of attachment trauma, in his view,
constitute a loss which, if not mourned, lead to “the persistent and
insatiable nature of the yearning for the lost attachment figure” (ibid.,
p. 26) – in other words, to object hunger, which is discussed as a
traumatic theme in Chapter 2: Early Relationships, Object Relations,
and Traumatic Themes. For Bowlby, mourning is cast as a process
through which an individual both confronts the reality of loss and
transforms representations of self as frightened, unprotected, and
helpless (George & West, 2012). He describes three forms of defense
that interact with mourning: deactivation, cognitive disconnection,
and segregated systems. Deactivation includes strategies that shift
attention away from attachment events, memories, or feelings and is
associated with evaluations of self and others as not deserving care. It
fosters “failed mourning” or “prolonged absence of conscious griev-
ing” (ibid.). Cognitive disconnection severs attachment distress from
its source, undermining the ability to hold in mind a unitary view of
events and emotions. It results in confused evaluations of the self and
others and makes it difficult to turn away from attachments. Mal-
adaptive forms of this defense are linked to a chronic mourning state
characterized by disorganized behavior: longing for, anger toward,
and an endless search for attachment figures (ibid.). Segregated sys-
tems refer to painful and threatening attachment experiences that have
been blocked from consciousness. When this defense breaks down,
dysregulated experience and feeling manifest as a form of chronic,
pathological mourning (ibid.).
Attachment insecurity is an established risk factor for eating dis-
orders, with estimated prevalence rates between 70% and 100%
(Ramacciotti et al., 2001; Zachrisson & Kulbotten, 2006). The Adult
 Traumatic Themes, Repetition, Mourning 45

Attachment Interview (AAI; Hesse, 2008) designates five adult

attachment patterns: secure, dismissing, preoccupied, unresolved, and
cannot classify. The majority of empirical studies conducted so far
report a predominance of dismissing, which indicates a prominent use
of the deactivating defense just described, and unresolved attachment,
which suggests a breakdown of defense against emotional distress, in
patients with eating disorders (Cole-Detke & Kobak, 1996; Fonagy
et al., 1996; Ward et al., 2001; Ringer & Crittenden, 2007; Barone &
Guiducci, 2009).
In one empirical study, the role of defensive exclusion (that is, of
the defenses of deactivation and segregated systems) with respect to
past attachment trauma was assessed in patients with anorexia nervosa
using the Adult Attachment Projective Picture System (AAP; George
& West, 2001, 2012). In the study, 37% of the sample was classified
as dismissing, describing patients who tend to maintain an avoidant,
detached, or distanced position in relation to attachment. Using the
framework of traumatic themes discussed earlier in this chapter, we
might formulate the situation with these patients as follows: having
suffered substantial attachment trauma, they defend against object
hunger by using deactivating defenses. In this way, they repeat their
defense against their traumatic themes from childhood. With patients
suffering from eating disorders, this repetition is displaced onto food,
eating, and the body. The majority of patients in this study (51%) were
classified as unresolved, suggesting their inability to use deactivation
and cognitive disconnection strategies or to use their internal working
models of attachment to manage attachment threat. Both the dismiss-
ing and unresolved patients showed evidence of traumatic segregated
systems: responses to testing stimuli often contained severe, eerie,
evil, or surreal material. Especially relevant for the current discus-
sion, dismissing patients (58%) and unresolved patients (69%) were
frequently found to be experiencing chronic pathological mourning
(Bowlby, 1980).
This empirical study, which draws upon attachment theory and its
extensive empirical literature, is brought into this chapter because it
provides a distinct lens on the relationship between traumatic disap-
pointment in early objects, repetition conceived of as a character-
ological defense against traumatic themes, and mourning as a process
of transformation through which traumatic themes are accepted,
46 Traumatic Themes, Repetition, Mourning

disappointed wishes are relinquished, and painful early experiences

are reintegrated as aspects of the self that may be constructively
deployed in future endeavors.
Mourning continues to be an important aspect of Mark’s treatment.
As we build up a narrative of his history, he increasingly speaks to
his grief about his childhood experience of struggling with intense
frustration and need that could not be encompassed by his parents.
He voices feelings of anger at his parents for failing to acknowledge
and help him with his pain. As he increasingly recognizes that their
limitations stem from their own histories, he speaks from a place of
profound sadness, acknowledging his grief over the struggles that
he has endured and the opportunities that have been foreclosed or
delayed as a result. In one session, during our third year, he describes
how the urge to binge eat has significantly attenuated. “I feel sadder
than I used to,” he remarks, “but for the first time, I also feel that I can
inhabit myself. I can actually tolerate being me.”

Note
1 For Caston (2011), reversibility refers to the range and character of power
over actions within a given domain, self-observation refers to the degree of
conscious focus available to and/or attendant to target actions, and appro-
priateness refers to the coherent fit of an intended action to the context
in which it plays out (p. 915). In his view, these three markers serve as
an operational framework for daily work with patients and apply across
psychoanalytic paradigms without supplanting them. As we assess our
patients’ agency (or lack of it), these three markers serve as useful guides.

References
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vosa. Psychosomatic Medicine, 24, 187–194.
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Bruch, H. (1978). The golden cage: The enigma of anorexia nervosa ed.
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Chapter 4

Abjection and Bodily

Disgust

“Lisa” points to her thighs, which seem to me to be excruciatingly thin,

and exclaims, “Can you see how disgusting these are? I can’t stand to
look at myself!” “Max,” a young man of average weight who purges
after almost every meal, laments that his stomach has always been a
source of shame. “I’ve never lost my baby fat,” he says sadly, “and I
think it’s gross. I’m worried that my girlfriend does, too.” Patients with
eating disorders commonly describe the loathing that they experience
toward their bodies. They refer to their bodies, or parts of their bodies,
as disgusting, ugly, gross, and fat. Although psychoanalytic thinking
can contribute to our understanding of this phenomenon in numerous
ways, in this chapter we will focus on Kristeva’s (1982) notion of abjec-
tion. Kristeva’s thinking is notoriously complex and difficult to grasp,
so we will work through these ideas slowly, with examples, so that, with
luck, it comes to life as a creative way of thinking about patients’ strug-
gles with these problems. We will also discuss two traumatic themes –
a concept first introduced in Chapter 2: Early Relationships, Object
Relations, and Traumatic Themes – that may contribute to the promi-
nence of abjection in the experience of these patients.

Kristeva’s Abject
In Powers of Horror: An Essay on Abjection, Kristeva (1982) presents
a theoretical account of the psychological origins of the mechanisms of
revulsion and disgust. The notion of the abject1 is developed to draw our
attention to those moments when we experience a frightening loss of
the distinction between ourselves and objects, including people, in the
DOI: 10.4324/9781003016991-5
50 Abjection and Bodily Disgust

outer world. These moments erupt when we experience transgressions

into the fragile boundaries that protect our sense of self from that which
immediately threatens our sense of life. We may, for example, experi-
ence the abject when the skin that forms on the top of milk unexpect-
edly touches our lips or when we encounter blood, vomit, or a corpse.
The abject exists outside the social world of linguistic communication
and intersubjective relations and, because of this, an encounter with it
disturbs identity, system, and order. Consider, in this vein, how meeting
with a corpse may upend what we have taken for granted about our
lives, reshaping our priorities and projects.
The abject consists of that which is taboo: horrific, monstrous ele-
ments that were once categorized as part of oneself but have now been
rejected. Vomit, perhaps, is an apt example, for it was once inside of us
and now, existing outside, is experienced as repellent. Kristeva (ibid)
seems to understand abjection primarily in terms of bodily affect:
moments of physical “discharge, convulsion, a crying out” (p. 1). In
her writing, she is preoccupied with the ways in which we are both
repulsed by and fascinated by these taboo aspects that have been cast
out of the social order. To continue with the example of a corpse, it is
something that we both want to look away from and are drawn to look
at; it repulses and compels us at the same time.
In Kristeva’s (ibid.) thinking, the abject is associated with the mater-
nal, for we must successfully and violently render the maternal – the
object that created us – abject in order to separate from her and to con-
struct an identity. Yet abjection is not a stage that is passed through;
rather, we are forever “abjecting subjects” (Tyler, 2009, p. 80), and all
subsequent abjections contain the echo of this first, primary abjection:
the infant’s separation from the maternal body. To this point, Butler
(2004) writes,

We cannot represent ourselves as merely bounded beings, for the

primary others who are past for me not only live on in the fiber of
the boundary that contains me, but they also haunt the way I am,
as it were, periodically undone and open to becoming unbounded.
(ibid., p. 28)

Abjection, for Kristeva, is always a reminder of this primary repudi-

ation of the maternal.
 Abjection and Bodily Disgust 51

Beginning with Bruch (1971, 1973, 1978), the self-starvation

characteristic of anorexic patients was seen as a struggle for auton-
omy from a mother that is domineering, intrusive, and discouraging
of separation and individuation. Since that time, empirical evidence
has supported this idea (Bers, Harpaz-Rotem, Besser, & Blatt, 2013)
and difficulties with separation and individuation repeatedly emerge
in psychoanalytic case studies of these patients (Ritvo, 1976; Sours,
1974; Hamburg, 1999; Lawrence, 2001; Wooldridge, 2018, 2021a to
name only a few). Other eating disorders, including bulimia nervosa,
have also been linked to difficulties with attachment and separation
and individuation (Gander, Sevecke, & Buchheim, 2015). Given this,
it is theoretically congruous that abjection, associated with the repu-
diation of the maternal, may be a prominent theme in many patients
with anorexia nervosa and bulimia nervosa.
The image of the anorexic patient is, as Warin (2010) writes, an
object of fascination, a “spectacle” (p. 9) that draws in the viewer with
its lurid and shocking depiction of the female (or male) body. These
images hold immense power not only to engender disgust in the spec-
tator by confronting her with the abject but, further, in their ability to
move vulnerable spectators to imitation. Ellman (1990) argues that
such an image is both seductive and repellent because of its relation-
ality: even though it seems to represent a radical negation of the other,
it still depends upon that other to represent anything at all. Regardless,
the anorexic patient conveys her experience of the abject through the
canvas of her own body. Writing of her struggle with anorexia in ado-
lescence, Probyn (2004) eloquently describes this experience.

Like many, I spent much of my childhood feeling disgusting.

However, any evidence of that time is scant. Of the series of pho-
tographs that document my childhood, there is an absence that
occurs about the time that I was severely anorexic. The reason
for the lack of previous documentation is simple: why or how
could such a sight be documented? Even now my eyes turn in
aversion from memories tinged with a mixture of shame, disgust,
and guilt. At the same time, I do remember the splinters of pride
that accompanied the disgust: pride at the beautifully prominent
set of ribs, the pelvic bones that stood in stark relief, causing
shadows to fall on a perfectly concave stomach. Looking back at
52 Abjection and Bodily Disgust

my experience, I wonder at the forces of pride and shame doing

battle in a body that knows itself to be disgusting.
(p. 127)

As Probyn’s (2004) description shows, many anorexic patients

locate the abject, accompanied by the affect of disgust, at times in
their own bodies and at others in the bodies of, as one patient put it,
“the soft, greedy flesh” of the other, reflected in a brittle sense of pride
about one’s own emaciation. This oscillation, between the feeling that
one’s body is abject and the feeling that one has rendered her body
“clean” through self-starvation and cast out infection, locating it in
the other, characterizes their struggle. These patients are frequently
alexithymic, as discussed in Chapter 1: Alexithymia and the Psychic
Elaboration of Emotion, and, thus, this struggle is enacted primarily
through emotional expression in the somatic and motoric registers
with little capacity to tolerate, contain, and elaborate the emotions
involved (Lecours & Bouchard, 1997). Were her capacity for elab-
orating emotion into images and words more developed, she would
experience her mind as bounded, buffered by representation and sym-
bolization, which would render her less psychically porous (Williams,
1997) and, hence, less susceptible to contagion by the abject, which
has been located outside the self. This struggle, to the degree that it
was present, would be contended with in language, not action.
Kristeva (1982) identifies three forms of abjection: in relation to
food and bodily incorporation, to bodily waste, and to the signs of
sexual difference. Indeed, she identifies the first form of abjection
as “oral disgust,” the most elementary and “archaic form of abjec-
tion” (p. 11), linking this observation to Freud’s (1925) account of
the defense of ejecting what we cannot abide, saying, “I should like
to spit it out” (p. 369). Warin (2003) describes the remarkably uni-
fied, embodied reactions of anorexic patients to certain foods. In her
fieldwork, she observed how certain patients “shuddered at the very
thought of eating,” drawing their bodies inward, closing their lips,
and covering their noses and mouths (p. 83). In Kristeva’s frame-
work, this embodied reaction of closing and protecting is an effort
to defend against abject horror. The fear of fat and calories, rather
than stemming solely from a desire to lose weight, arises from a fear
of contamination. Fats and calories are often described by anorexic
 Abjection and Bodily Disgust 53

patients as having the potential to engulf, contaminate, and merge,

abject insofar as they threaten to “cross a border between two distinct
entities or territories” (ibid., p. 75). Even as these patients desire to
cast out the abject, they are simultaneously drawn toward it, as in the
anorexic patient who spends hours poring over cookbooks that depict
foods he will never deign to consume.
Warin (2003) describes the case of Bronte, a young woman cov-
ered in the Australian media who had a fear of “flying calories.” In
Bronte’s words,

One thing I remember is that when I first came in here [for treat-
ment] I couldn’t walk past anyone who was eating because. . . . I
felt the calories had gone into me somehow. I’d roll up towels and
push them under my door so the calories from outside couldn’t
come through and go into my body.
(New Idea, 1997, p. 15)

Warin (ibid) evokes the miasma theory of disease common through-

out the Middle Ages, in which the body was understood as permeable
and highly susceptible to invasion and attack by disease, leading her
to speak of “miasmatic calories and saturating fats.” In my clinical
practice, I have observed several anorexic patients whose fears of
contagion take a different form: dread of infection with a sexually
transmitted disease. Such fears, which often emerge later in recov-
ery as a patient begins to engage more directly with his sexuality but
may also be observed in some patients earlier in treatment, concern
the possibility that the abject in the other could cross the self-other
boundary, rendering the self infected and, thus, repellent.
The abject is frequently experienced in relation to sexuality in
other ways. Warin (2003) points out that anorexic women frequently
describe their bodies – reproductive, digestive, and sexual – in the
same ways they describe food, as dirty, polluting, and dangerous.
Menstruation and digestion are often recounted with great detail and
disgust. One of my male patients with anorexia was terrified that his
semen would be stolen and used to impregnate an unknown woman
or, even worse, to substantiate allegations of rape against him, both of
which, in his mind, would reveal his abjection to the world, including
his entanglement with the maternal.
54 Abjection and Bodily Disgust

The history of eating disorders begins at least with ascetic medieval

saints who, like the modern anorexic teenager, scrutinized every desire
for its purity or lack thereof (Bell, 2014). The anthropologist Mary
Douglas (2003) argues that purity, far from being based on the fear of
“germs,” is a means of differentiating some phenomena from other phe-
nomena, whether bodies from bodies, castes from castes, or races from
races. These laws of purity are, most often, a ritual repudiation of what
reminds us of the body of our mother – menstrual blood, mucus, etc.
Rituals are designed to exclude any reminders of maternal dependence,
which is abject and threatens to disrupt our sense of identity and order.
In the modern era, many young anorexic women express strong
associations between their own bodies and their mothers’ bodies,
wishing to forestall or prevent entirely further development of sim-
ilarities to them: the growth of hips, thighs, breasts. More generally,
food and sexuality are feared because of the connections they imply to
other people (Warin, 2003). Numerous patients with eating disorders
refuse to eat with their families and friends, even insisting on eating
only in private. Many of the practices that are seen as essential for cre-
ating and sustaining relatedness – the sharing of food, living together,
sexual relationships, and even reproduction – are consistently negated
by anorexic and other eating disordered practices.

Roots of the Abject Self: Foreign Bodies

In Chapter 2: Early Relationships, Object Relations, and Traumatic
Themes, we discussed the prominence of traumatic themes (Shabad,
1993), or chronic patterns of frustrating and depriving childhood
experience at the hands of caretakers, in the histories of patients with
eating disorders. In the remainder of this chapter, we will discuss two
traumatic themes that are commonly observed in patients with eating
disorders for whom the experience of abjection is prominent. These
themes are specific aspects of a larger pattern frequently observed
in the literature: the mother’s use of the developing child to maintain
the stability and coherence of her own sense of self and to regulate
her self-esteem (Bruch, 1971, 1973, 1978; Birksted-Breen, 1989;
Williams, 1997).
In this section, we return to the idea of breakdowns in containment,
first discussed in Chapter 2. As you may recall, Bion’s (1962) theory
 Abjection and Bodily Disgust 55

of containment describes how the mother uses her own mind to make
sense of her child’s emotions, for the child lacks the ability to do so
on his own. Both through her words and how she behaves with him,
she conveys that his emotions have meaning. In healthy development,
over time this fosters the child’s ability to increasingly make sense
of his emotions on his own. In this way, he internalizes his mother’s
containing capacity.
This process can fail in various ways. Bion (1962) describes one
scenario: when a child attempts to communicate his emotions to a
parent who is impermeable or otherwise unavailable, leaving the child
with an experience he evocatively calls “nameless dread.” Williams
(1997) describes another way in which containment may break down:
when parents need to divest themselves of their own emotional pain,
which cannot be adequately managed within their own minds, and
instead use the child as a receptacle for it. In this situation, the child
tends to experience the parental divestment as a type of foreign
body inserted into her mind, which serves as a receptacle. Lawrence
(2001), along these lines, argues that the mother is experienced as
dangerously intrusive and is concretely equated with food. The patient
cannot think about how food is experienced like the mother; rather,
at an emotional level, it feels that food is intrusive because it is the
mother. Lawrence’s formulation highlights the ways that patients with
anorexia tend to form transferences shaped by the fear of intrusion,
leading them to avoidantly approach the analytic relationship. This is
consistent with the experience reported by many clinicians of feeling
relationally deprived by anorexic patients, in the same way that the
patient deprives herself.
In her article, Williams (1997) describes a class of “psychically
porous” patients who suffer from eating disorders, most frequently
bulimia nervosa, and suggests that they had parents who themselves
suffered extensive traumas and as a result were either frightening or
frightened or both in relation to the child. Such parents are more likely
to divest their anxiety than to contain it. Williams’ description of her
patient, Daniel, is as follows:

Describing his bulimia, Daniel conveyed a vivid perception of

being full of inimical foreign bodies. When I started seeing him
he was bingeing and vomiting up to six times a day. He was
56 Abjection and Bodily Disgust

tormented by concrete bodily feelings, of being “all dirty inside”.

Blocked sinuses and nose contributed to his perception. He said
he felt “greasy”, “full of soot”, “disgusting”. Vomiting gave him
very temporary relief.
He binged on anything he could find or buy with his limited
pocket money allowance. He bought mostly loaves of white
bread which, he said, was “like blotting paper”. It soaked up “all
the nasties” that could then be got rid of by vomiting. After being
sick, he felt temporarily “clean inside”. His mind became clear
and for a few hours he could apply himself to his studies. Then
“the buzz”, as he called it, would start again. When “the buzz”
started, Daniel was unable to concentrate. . . . He described “the
buzz” as “thoughts racing through his mind at 150 miles per
hour”. It became clear that they were not thoughts he could think
or talk about, but something more akin to flying debris.
(p. 930)

Daniel’s felt himself to be “all dirty inside,” a concrete experience

of having been the receptacle for his mother’s anxiety. This led him to
expel, through vomiting, those toxic foreign bodies – soaked up by the
“blotting paper” of white bread – which left him, temporarily, feeling
“clean inside.” Before long, however, the cycle starts again. In fact,
Williams (1997) suggests that patients such as Daniel have internal-
ized a parent overflowing with projections, which exerts a disorganiz-
ing impact on their internal worlds (i.e., the “buzz” that he describes).
For Williams (1997), many patients with anorexia nervosa have
been subjected to the same experience of being used as a receptacle
for their parents’ unprocessed anxieties. Unlike psychically porous
patients with bulimia nervosa, however, these anorexic patients have
developed a “no-entry system of defense” that covers over their expe-
rience of having been permeable in this way. This no-entry system
of defense consists of a defensive rejection of input not confined
to food intake but manifesting across the patient’s character. Along
the same lines, Zerbe (1993) observes that the refusal of food is “an
autonomous statement, par excellence: “I don’t need you. I don’t need
anything. I don’t even need food to survive. I am totally indepen-
dent” (p. 95). Chasseguet-Smirgel (1993, 1995), similarly, suggests
that anorexic patients attempt on the level of unconscious fantasy to
 Abjection and Bodily Disgust 57

function in an autarchical manner, completely without the need of

nourishment, literal and figurative, from external sources, especially
the early, primary object.
These ideas are also illustrated with “Sara,” a patient in analytic
treatment with anorexia nervosa who is also discussed in Chapter 5:
Body–Mind Dissociation and False Bodies and Chapter 9: Eating Dis-
orders in Cyberspace. Born profoundly premature, she was subjected
to numerous surgeries early in life and her family lacked the capacity to
contain the intense distress aroused in her by these experiences. Early
in treatment, she described how every thought shared with me held the
potential to be used as a sharp instrument that could pierce her psy-
chological skin. Such statements reflected the contribution of her early
trauma in shaping our experience together, insofar as she felt herself to
be, once again, a young child who was intensely vulnerable before an
adult who repeatedly invaded her delicate internal space. In trying to
help her find relief, I risked hurting her, and in fact during substantial
periods of the treatment I found that despite my efforts to craft sen-
tences that were gentle and curious, my comments often had an unin-
tentionally sharp edge. I came to dread the experience of feeling that
my words hurt this woman whose physical appearance conveyed such
profound fragility, yet for several years I could not find a way of engag-
ing with her, over an extended period, that avoided it.
The experience of being heavily projected into in the countertrans-
ference alerts us to the possibility that the patient might have been at
the receiving end of massive projections in early development (Grin-
berg, 1962). In addition to trauma originating in prematurity, Sara’s
mother frequently made use of her as a receptacle for her own unpro-
cessed anxieties. Around age eight, for example, she was eating a pear
in her family’s kitchen when her mother walked in and noticed pear
juice running down her daughter’s chin. She became distraught and
insisted that Sara explain what, in her mind, was an overt exhibition
of sexuality. Her mother’s need to divest herself of her own psychotic
anxieties about sexuality left her feeling “filled up” with toxic shame
and disgust with her physicality. This intensified at puberty when boys
began to show an interest in her and her body became more curva-
ceous. Throughout treatment, we discussed her visceral disgust with
her sexuality and those aspects of her body that she associated with it:
breasts, thighs, genitals.
58 Abjection and Bodily Disgust

Although this treatment was extensive and aspects of it have been

described at greater length elsewhere – in particular, there was a great
deal of work put into establishing a treatment team (Novack, 2021;
Wooldridge, 2021b) and facilitating medical and nutritional rehabil-
itation – I wish to emphasize the slow, painstaking work that was
required for Sara to develop her capacity to represent and symbolize
(Lecours & Bouchard, 1997) her experience, to put her feelings into
words. At several points, I found that my attempts to put words to her
distress recreated the experience of being “filled up” by ideas that she
could not yet digest, which led to her experiencing me (accurately,
to some degree) as a persecutory figure. Each time, after a difficult
period of repair between us, I sought to attune myself more accurately
to what she could, and could not, tolerate thinking about. At other
times, I struggled to find words for her experience, for the horror of
certain aspects of her childhood was simply too much to encompass.
Yet after several years of work on this, her capacity for the psychic
elaboration of emotion (Nemiah, 1977) significantly more developed,
what she was previously only able to describe in impoverished, con-
crete terms – fat, disgusting, repellent – she was now able to express
in complex, multi-faceted narratives about her experience. Though
treatment is still ongoing at the time of writing, Sara has maintained
her physical health for many years and is now productively engaged
with her inner and outer life.

Roots of the Abject Self: Rotten Core

The second traumatic theme I have observed in anorexic patients for
whom the experience of abjection is prominent is the formation of
a rotten core: a feeling of inner rottenness that lies hidden behind
an adaptively functioning, outer self (Lax, 1980). This theme, once
again, occurs within a larger context in which the mother has marked
vulnerabilities that manifest in relation to her developing child. The
rotten core may develop when mother becomes severely depressed, or
otherwise emotionally unavailable, during the patient’s toddlerhood.
In particular, the rapprochement subphase of development – already
a difficult period in the life of the toddler – is cast as the time when
the toddler is most vulnerable to the development of this form of self
pathology. The rapprochement subphase was first described by Mahler
 Abjection and Bodily Disgust 59

as a developmental phase of the separation-individuation process in

which the toddler develops a new awareness of her separateness from
her caregiver and struggles with the simultaneous need for both auton-
omy and support (Mahler, 1972). In this subphase, “practicing” – the
child’s “love affair with the world” – has come to an end. The child
now contends with a wish for reunion with the mother and a fear of
being engulfed by her. Only mother’s loving acceptance of her child, a
good enough combination of ambivalence and encouragement, leads
to a healthy resolution of this crisis.
For Lax (1980), the rotten core develops in response to the mother’s
emotional unavailability to her child during this period, frequently due
to depression, which the child interprets as anger. Since the toddler is
unable to comprehend the objective origins of the mother’s emotional
unavailability, he regards his own strivings as the cause of it. He may
even regard this unavailability as punishment. This, in turn, interferes
with the normal processes of separation and individuation, especially
if he begins to regard his impulses toward autonomy with the disap-
proval ascribed to mother. At its most primitive level, the rotten core
represents the fusion of the “bad” (angry-rejecting) maternal introject
with the “bad” (rejected) aspects of the self. The rotten core represents
that part of the self that was “hate-able” to the mother. This typically
exists alongside an experience of self and mother as good and lovable.
Most relevant to the formation of a rotten core are situations in
which mother’s intensified needs for closeness lead to an invasion of
the child’s autonomy and the foreclosure of his attempts to explore the
world and when the mother’s capacity for object constancy – that is,
to maintain a sense of both her good feelings and bad feelings toward
her child at the same time – breaks down, leading her to experience
the child as either all good or all bad (Lax, 1980). “Adam” is a patient
seen for nearly eight years in an analytic treatment, beginning nearly
ten years after “recovery” from anorexia nervosa but still plagued by
difficulties.2 He remembered a mother who was at times intensely
engaged with him, implicitly conveying that he was the center of her
universe, whereas at other times she became wounded by his need
and withdrew into her room, leaving him alone for hours. Over time,
we came to suspect that his expressions of need, often provocatively
insistent, as a child may have been attempts to turn incomprehensible
hostility into comprehensible anger.
60 Abjection and Bodily Disgust

In our early work together, Adam frequently voiced complaints

about his body shape and size, reporting that he experienced his
body on some days as “utterly disgusting” and on others as “fine,
even good.” This former experience of his bodily self is an expres-
sion of the fusion of the “bad” (angry-rejecting) maternal introject
with the “bad” (rejected) aspects of the self, though these affects
remained in an unsymbolized, unrepresented form (Lecours &
Bouchard, 1997). The rotten core is established as a permanent psy-
chic structure because of the child’s identification with the maternal
attitude toward him, which fosters an identical attitude toward the
self. Aspects of the self unacceptable to the mother are rejected by
the child and merge with the primitive rotten core toward which the
combined mother-child hatred has been directed (Lax, ibid). This
identification with the aggressor gains further strength from the
wish to obtain mother’s love. Adam’s eating disorder was, among
other things, an alexithymic expression of mother’s rejection of
his need, which he had identified with and enacted upon his needy,
bodily self (Sands, 2003).
Adam described several relationships with women who treated
him poorly, including his current wife. Though deprived of relational
nourishment in numerous ways in his marriage and often quite angry
about these deprivations, he nevertheless remained deeply attached,
in a rather symbiotic way, to his wife and committed to their marriage.
Over time, analytic investigation revealed an unconscious fantasy of
an idealized mother who would gratify him in every conceivable way:
the good symbiotic mother (Mahler, Pine, & Bergman, 1975). This
fantasy had persisted into adulthood because the reality of his moth-
er’s poor treatment of him was explained by the conviction that it was
caused by his inability to evoke her goodness because of his inner
rottenness. “Bad” behavior, in both fantasy and reality, was used to
explain mother’s aggression. In this sense, his wife’s treatment of him
felt “right” and served to spur on his efforts to be a “better husband.”
As Lax (ibid.), points out, this masochistic relational stance is fueled
by a fantasy that sufficient suffering will bring atonement and rescue
by the good mother.
Adam, healthier at the beginning of treatment than the other
patients discussed in this chapter, nevertheless presented with impair-
ments in his capacity to symbolize and represent affects, especially
 Abjection and Bodily Disgust 61

those pertaining to the traumatic theme of the rotten core (Lax,

1980). His impairment was less broad than that of other patients
with anorexia for whom the capacity for the psychic elaboration of
emotion (Nemiah, 1977) is more generally compromised and who
are often described as alexithymic. And in contrast to the ruptures
that occurred in the treatment of Sara previously discussed, Adam
and I were consistently, even enthusiastically, engaged in the work
of being able to “think together,” although much of what we thought
about was painful and evoked a prolonged mourning process. Had we
worked together during the height of his anorexia, I suspect, based on
an extensive reconstruction of his history, that his impairment, too,
would have been more general and that our treatment would have
been more difficult, with more risk of alliance ruptures. Despite his
greater health, however, the traumatic theme of the rotten core created
a traumatic organization that repetitively manifested, in unrepresented
and unsymbolized form, in Adam’s experience of his body and in his
relationships with women.

Notes
1 The term “abjection” also commonly appears both as an adjective (“abject
women”) and as an adjective turned into substantive (“the abject”) (Men-
ninghaus, 2003).
2 Epidemiological data suggests that as much as 25% of the anorexic popu-
lation is male (Hudson, Hiripi, Pope, & Kessler, 2007).

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Chapter 5

Body–Mind Dissociation
and False Bodies

For Ferrari (2004), the body–mind link begins to develop when the
earliest experience of the physical body, the onefold, is taken as the
mind’s first object. Through successive mental elaboration, it man-
ifests in its mental expression, the twofold, whose primary function
is to contain the sensory stimuli that emanate from the body (Lom-
bardi, 2009). This successive mental elaboration is facilitated through
the mother’s reverie, as described in Chapter 1: Alexithymia and the
Psychic Elaboration of Emotion. When this reverie is interrupted or
inadequate – when there is a breakdown in containment, as considered
in previous chapters – one potential consequence is an impairment in
the ability to put feelings into words, as we have discussed. In this
chapter, we turn to another way in which the body–mind link may be
disrupted: the development of a false body. The term false body refers
to the way that the body’s state is rigidly controlled such that spon-
taneous emotional experiences are foreclosed. Because the body’s
experience is kept within tight parameters, emotional experiences,
fundamentally grounded in the body and potentially catastrophic if
experienced outside the context of relational support, are kept out of
awareness.
For some patients with binge eating disorder, the weight gain that
results from eating symptoms may serve as a false body. The experi-
ence of being overweight may, for example, stifle desire, need, and
longing. As one patient put it, “When I’m overweight, my sexuality
shuts down. I know that I’m not desirable and I’m so filled with self-
loathing that I don’t feel desire.” Efforts to lose weight resulted in the
return of desire, which was experienced as emotionally overwhelming
DOI: 10.4324/9781003016991-6
 Body–Mind Dissociation and False Bodies 65

and undermined her weight loss efforts. Goldberg (2004) describes

how patients – who might be described as orthorexic, a term which
though not in the diagnostic manuals is nonetheless increasingly used
to refer to an unhealthy focus on eating in a healthy way – may use
seemingly healthy exercise regimes, including a rigidly controlled
diet and obsessive self-care rituals, to maintain a false body. Another
patient described to me how after her two-hour morning yoga session,
she remained so exhausted throughout the day that she was unable to
feel anything. Her feelings, we came to learn, were disturbing for they
were not under her immediate control.
In the remainder of this chapter, we discuss a particular form of
the false body that is commonly observed in patients with anorexia
nervosa called the entropic body (Wooldridge, 2018). The entropic
body is cultivated through self-starvation and rigidly maintained to
subjugate an underlying emotional experience of need and depen-
dence. It develops as a “best attempt” to compensate for the failure
to internalize the caretaker’s capacity to comfort and soothe the child
during the period of separation and individuation. Without the capac-
ity to provide comfort to oneself or to seek it in emotional connection
with another person in hand, these patients are unable to emotionally
“digest” traumatic experiences in infancy and beyond. The fear of
getting “fat,” commonly expressed by patients with anorexia nervosa,
conveys the emotional agony that results from having to contend with
these undigested traumatic experiences. These ideas will be illustrated
with reference to an extended case presentation of “Sara,” a young
woman with anorexia nervosa.

Breakdowns in Containment:
A Clinical Example
In this section, we will focus on “Sara,” a young woman in her late
teens who has been seen for many years in twice-weekly analysis
for a severe case of anorexia nervosa. In what follows, we will see
the traumatic theme of breakdowns in containment, first discussed
in Chapter 2: Early Relationships, Object Relations, and Traumatic
Themes, as revealed through her recollections and reconstructions of
early experiences after a traumatic birth as well as difficulties in the
relationship between mother and child. In addition, we will explore
66 Body–Mind Dissociation and False Bodies

how this theme was repeated, and ultimately repaired and worked
through, in the relationship between patient and analyst.
Sara was born approximately six weeks premature, and according
to her father, the family was uncertain for several weeks whether she
would live. For a substantial period, her life was maintained in an
incubator, isolated from human contact. Through latency, she suffered
from numerous of physical complaints, including fatigue, stomach
pain, and headaches. She remembers innumerable visits to doctors
and hospitals, and several invasive procedures, including colonosco-
pies and endoscopies, were performed.
In the early months of treatment, Sara would become angry and
withdrawn when I suggested possible meanings to her associations.
These interactions culminated on several occasions with her curling
up tightly in her chair, yelling that I was “cold and cruel” while tears
ran down her face. This situation, in which my interpretations seemed
to evoke her early wounding, led to an impasse that persisted for sev-
eral months. Despite my efforts to craft sentences that were gentle and
curious, my comments often had a subtly sharp edge. I came to dread
the experience of feeling that my words hurt this woman whose phys-
ical appearance conveyed such profound fragility, yet I could not find
a way of engaging with her, over an extended period, that avoided it.
But one Friday afternoon Sara made a comment that brought us
out of a prolonged and deadened silence, and my thinking began to
shift. Looking at me without expression, she said, “It’s like I’m giving
you weapons that you can pierce me with.” Certainly, this statement
reflected the contribution of her early trauma in shaping our expe-
rience together. My interpretations felt “piercing” in the same way
her earliest experiences with medical doctors had been. I continued
to worry about how much she suffered in our sessions. In trying to
help, I seemed to be hurting her. I often imagined her early life in an
incubator, in which light and sound would have been experienced as
overwhelming. And I envisioned myself as a well-intentioned physi-
cian who, in trying to save her life, pierced her skin with needles. At
times, this experience of myself was overwhelming.
The clinician’s experience of receiving overwhelming projections
in the countertransference often reflects the patient’s experience of
having to contend with intrusive projections in early development
(Grinberg, 1962). While Sara’s medical history helped to explain
 Body–Mind Dissociation and False Bodies 67

what was happening between us, we soon learned that her early emo-
tional life had been marked in this way. She remembered one incident
that represents the intensity of her mother’s projective identifications
(that is, of putting her own undigested emotional experiences into her
daughter). Around age eight, she had been eating a pear in her family’s
kitchen. When her mother walked in and saw “the juice running down
[Sara’s] chin,” she became distraught and insisted that her daughter
explain what, in her mind, was an overt exhibition of sexuality. Her
mother’s need to divest herself of her own psychotic anxieties left
Sara feeling “filled up” with toxic shame. This was prototypical of
many of her childhood experiences in her family.
As previously considered, anorexia nervosa can be understood, in
part, as stemming from a breakdown in containment in early life (Bion,
1962). In some forms of breakdown, in which the child is used as a
receptacle for the mother’s own unprocessed emotions, a system of
defenses develops that is characteristic of anorexia nervosa. Williams
(1997) describes this as the “no-entry” system of defenses: an effort
to keep things from “getting inside” that stems from earlier experi-
ences of traumatic intrusion. As we soon learned, Sara was subjected
to intense physical and emotional intrusion throughout her childhood.
As a result, the experience of nourishment, of “taking in” – both phys-
ical and psychical – was terrifying to her in all areas of her life. To
protect her vulnerable and needful self, she was determined to not
let anything get inside. She was terrified of physical manifestations
of penetration and avoided sexual contact. She had never received a
gynecological exam.
This relational pattern dominated the analysis for the first year. In
such situations, it is imperative for the analyst to examine her own
emotional history to understand what she might be contributing to
such an impasse. During this time, I spent innumerable hours won-
dering why I continued to find myself speaking with a sharp edge,
despite my best efforts to remain curious and empathic. I recognized
that I was relying too heavily on my intellect, but why? My impres-
sion of Sara in our first meeting had been a deep sense that something
catastrophic had happened to her. With difficulty, I had pushed that
thought aside for fear that it would make it impossible for me to help
her. In a situation where life and death hung in the balance, how could
I maintain equanimity? I inhabited my intellect because the emotional
68 Body–Mind Dissociation and False Bodies

experience of being with her catastrophic experience was overwhelm-

ing to me. With the help of ongoing self-analysis and consultation, I
was able to encompass the extent of her suffering more fully, includ-
ing the catastrophic pain of her early life and the ongoing repetition
of that catastrophe in our relationship, here and now.
The following Monday, the treatment began to move again. Sara
began the session with a cold stare. I said, “I’m wondering if last
Friday’s session is still on your mind. I could see how you’d still
be upset with me for hurting you.” After a brief look of confusion,
Sara said, “Yes, that’s right.” I responded that it was my hope that
we could find a way to be together that hurt less, and that while I
knew it would take a lot of work, I hoped she would join me in that
endeavor. And though there was no overt acknowledgment from her
beyond a simple nod and restrained smile, I could sense that some-
thing in her had softened. She continued to struggle with taking
in nourishment – both literal and metaphorical – but now we were
joined in struggling together.
It was during this period that Sara began to follow her nutritional
plan more regularly and regained a substantial portion of the weight.
By the second year, she was no longer in immediate medical risk. And
our work began to deepen as more primitive anxieties emerged during
the second year of treatment, to which we will now turn.

Annihilation Anxiety
As Sara and I continued, I was struck by the fact that she filled
every moment of her life with work, deploying a complex array of
manic defenses to avoid the feelings lurking beneath the surface.
In an early conversation, she mentioned the possibility of trying to
slow down, and I remarked that I thought this would be difficult for
her. In response, she began to describe a feeling of “shattering” that
she worried she might encounter if she slowed down. This was an
expression of annihilation anxiety: the fear that the integrity of the
self is threatened. Traumatic themes (Shabad, 1993), chronic pat-
terns of frustrating and depriving childhood experience at the hands
of caretakers, such as those discussed in Chapter 2: Early Relation-
ships, Object Relations, and Traumatic Themes, may undermine the
cohesion and differentiation of the developing self. When there are
 Body–Mind Dissociation and False Bodies 69

extreme deficits in the cohesion and differentiation of the self-struc-

ture, certain threats may even lead to an experience of the dissolution
of the self (Kohut, 1977).
In adult life, anxiety becomes associated with a dread of returning
to this infantile trauma and, in fact, with the expectation that it will
recur. In a brief yet potent paper, Winnicott (1974) discusses the fear
of breakdown. His thesis is startlingly simple: The patient’s fear of
breakdown is, in fact, the fear of a breakdown that has already hap-
pened. It is a fear of the original agony – anxiety, he notes, is not a
strong enough word – that caused the defensive organization of the
patient’s character. Until the patient can gather into the present what
happened in the past so that it can be experienced completely, the
catastrophe will always recede into the future.
Freud (1926) describes a sequence of “danger situations” that he
imagined might feel like threats to the structure and integrity of the
self (Horner, 1980). These include overwhelming excitation, the loss
of the object, the loss of the object’s love, and castration anxiety. In
what is perhaps more poetic language, Winnicott (1974) briefly lists a
number of primitive agonies, along with their characteristic defenses.
These include a return to an unintegrated state, falling forever, loss of
psychosomatic collusion, loss of sense of the real, and loss of capacity
to relate to objects.
Sara struggled to put into words the feelings evoked during and
after conflict with her mother. Gripped with fear that she might be
abandoned forever, she described feeling that her “stomach might
drop out” of her body. These feelings were so overwhelming that she
often could not eat at school. Like Winnicott’s poetic description of
“falling forever,” Sara is speaking to a repeated experience of sudden
and unexpected loss of emotional connection with her mother. We can
make use of our own imaginative capacities to better understand her
experience. If you’ve ever been on a roller coaster, for example, you
have a sense of what falling feels like. The hands tighten into fists, the
back arches, and the stomach drops. In fact, we come into the world
hardwired with something like a fear of falling. The Moro reflex,
an infantile reflex normally present in all newborns, is a response
to a sudden loss of support. Such an imaginative exercise serves to
increase our ability to empathically immerse ourselves within Sara’s
emotional experience.
70 Body–Mind Dissociation and False Bodies

Psychic Skin
As previously described, Sara was subjected to intense physical and
psychological intrusion. In her earliest weeks, during the very time
she was most isolated from human, skin-to-skin contact, she was
exposed to the endless examinations and surveillance of a neonatal
intensive care unit. With family photographs from her time in the hos-
pital, she reconstructed a narrative of endless penetration by syringe
after syringe; when she talked about this aspect of her life, it evoked a
visceral sense of what this period might have felt like for her.
Here, again, the analyst’s imaginative capacities are essential to
facilitating empathic immersion. Imagine, for a moment, that the body
is a soft thing, filled with blood and bone and other life-giving pro-
cesses that are remarkable for their intricacy and vulnerability. And in
these earliest moments, for Sara that softness meant pain – physical
and emotional – as her body was penetrated and damaged inside and
out. The skin could not be relied upon as a barrier to keep her insides
safe from the dangers of the environment, or even to keep her insides
safely tucked inside. Moreover, the skin of a loving caretaker was not
available as reinforcement. In these earliest years, this would have
been both a deeply physical and psychological experience.
Discussing the role of skin in early development, Bick (1968) notes
that the most primitive parts of the personality have no binding force
of their own. They need a way to be held together, and the containing
object, in the sense we have described in early chapters, that in opti-
mal development is taken in as psychological structure over time will
be experienced concretely as the skin that holds together all the parts
of the self that depend upon it for coherence. In her incubator, without
physical and emotional holding, Sara’s skin received little emotional
investment from her caretakers and she could not rely upon their help
in managing the experiences that she was forced to endure. In this
way, she came to experience herself as always having the potential
to fall apart.
In a brief aside, Winnicott (1974) comments that the fear of falling
forever is defended against by “self-holding.” Bick (1968), with her
notion of second-skin formations, was the first to describe one form
that this self-holding might take. For Bick, second-skin formations are
a defensive attempt – pseudo-independent forms of protection such as
 Body–Mind Dissociation and False Bodies 71

muscular tension or reliance upon particular sensory experiences – to

provide self-cohesion. The patient’s attempts at self-holding consti-
tute a second-skin, which is a best attempt at holding the personality
together.
Bick (1968) notes that this phenomenon is most easily studied in
the relationship between analyst and patient in the context of prob-
lems of dependence and separation. In the following example, we can
most clearly see the way that being thin served as a secondary skin
for Sara. During treatment, she had increasingly been able to make
use of the containment our relationship provided; this, in turn, made
it possible for her to bear the intensity of her anxieties about falling
apart without resorting to self-starvation. However, shortly before
a planned vacation, she began to increase her food restriction once
again. My vacation confronted her with her dependence upon me,
which evoked past experiences of being left without emotional con-
tact, as she was both in the incubator and, similarly, in her relationship
with her mother. In this situation, she turned once again to self-star-
vation as an omnipotent means of managing overwhelming anxieties
while also eschewing the pains of separation and loss associated with
dependence upon me.
Here we must make an imaginative leap. How is it that the expe-
rience of being thin, of being intensely thin, might provide a kind
of primitive physical and psychological holding? I imagine the pro-
gression as follows: first, the anxieties began to manifest as the fear
and the feeling of becoming fat – of falling apart, a mess of loose
skin, bulging stomach, flabby arms. Then Sara’s caloric restriction
countered this experience, giving her the feeling of being lean and
compact – in essence, together once more. The experience of starva-
tion – the intensity of its sensations – formed a hard physical shell that
replaced the holding ordinarily provided by our relationship.

The Entropic Body

For Sara, my vacation was disastrous. We had established a support
team for the period of my absence, but she lost almost 12 pounds in
two weeks. When I returned, she greeted me with a cold and vacant
stare that, over several days, transformed into a smoldering rage. I had
anticipated that our time apart would be difficult for her, but I had not
72 Body–Mind Dissociation and False Bodies

imagined that she would return to food restriction with such intensity.
For several months, we discussed her fury at my betrayal and, over
time, the sense of camaraderie that we had previously enjoyed began
to return. And yet I sensed that part of her had not returned: that she,
somehow, was not trusting me again. And in fact, she did not regain
the pounds that she had lost but hovered steadily at her all-too-thin
weight.
When I brought this up directly Sara said, “It’s true. I hate to say
it, but our relationship really can’t compete with this. . . . It’s reliable;
it’s under my control. It works.” The experience of emaciation pro-
vided a kind of psychological holding that she desperately needed,
without the risks of having to rely on another to provide it. In my
view, this holding is provided through a particular defensive deploy-
ment of the body, as elaborated in Goldberg’s (2004) model of the
somatic false self. Goldberg’s model describes how the body may be
colonized and put to use for “false self ” purposes, generating a façade
of social appropriateness and functionality through auto-stimulation,
auto-hypnosis, and alterations of consciousness, leaving the under-
lying vulnerable self in dissociated isolation. Patients with anorexia
nervosa emaciate their bodies to create a physical experience that,
similarly, masks an underlying self marked by profound vulnerability.
This is the body-state that defines anorexia nervosa (Petrucelli, 2014).
Imagine the starving body. The hands and feet are frightfully cold
and numb. The stomach and cheeks are concave, sunken in on them-
selves, and the protrusions of the ribs painful against thin and brittle
skin. Not only is this startling to outside observers, but these physi-
cal changes are also palpable for patients themselves. Many patients
report being able to feel their heartbeat even when they are physically
at rest. A sort of deadening calm descends upon mind and body, flat-
tening out all signs of living vitality. The ring of desire can be heard
only in the faraway distance. Indeed, it has often been pointed out that
significant weight loss elicits physiological adaptations that reduce
arousal. With prolonged starvation, parasympathetic activation is
increased (Miller, Redlich, & Steiner, 2003) and bradycardia often
develops (Mitchell & Crow, 2006). These physiological adaptations
reduce the overall intensity of affect (Craig, 2004) and mute hunger
cues (Wang, Hung, & Randall, 2006).
 Body–Mind Dissociation and False Bodies 73

This is the entropic body, the somatic state of maximal rest sought
by anorexic patients. The search for the entropic body is an attempt
to approximate the soothing functions that should have been inter-
nalized during separation-individuation in healthy development. In
a successful treatment, the relationship between analyst and patient
may provide some of these same comforting functions. It is our hope,
of course, that the analytic relationship can facilitate the development
of healthy pathways toward separation and individuation. And yet
how can it compete with the entropic body, which is always available
and albeit dangerous, so effective? It is a body-state (Petrucelli, 2014)
that obviates the need for dependence upon another.
As our third year of treatment began, Sara said, “I see that there’s
more available to me when I’m connected to you, and to everyone
else. But is it worth the cost? I still don’t know for sure.” We spent
many months talking about this dilemma. It is difficult for a human
relationship to compete with the omnipotently controlled safety and
gratification provided by the entropic body, especially against a back-
ground of profound early trauma. The task is to maintain hope that the
gratifications of relatedness are sufficient for her to increasingly relin-
quish her entropic body, while also remaining open to her profound
disappointment in what relatedness can offer.
Sara has slowly put on some weight, though she has not yet reached
the weight she had obtained before my absence. At present, she is an
engaging and often profoundly insightful young woman who is pre-
paring to enter college nearby so that she can remain in treatment with
me. Her entropic body remains, in an attenuated form, a prominent
body-state in her psychological and relational repertoire. And yet she
also recognizes and values the pull of relatedness and all that it can
offer, and this brings us both hope.

References
Bick, E. (1968). The experience of skin in early object-relations. The Interna-
tional Journal of Psychoanalysis, 49, 484–486.
Bion, W. R. (1962). Learning from experience. London: Heinemann.
Craig, A. D. (2004). Human feelings: Why are some more aware than oth-
ers? Trends in Cognitive Sciences, 8, 239–241. https://doi.org/10.1016/j.
tics.2004.04.004
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Ferrari, A. B. (2004).4 from the eclipse of the body to the dawn of thought.
London: Free Association Books.
Freud, S. (1926). Inhibitions, symptoms, and anxiety. In J. Strachey (Ed. &
trans.), The standard edition of the complete psychological works of Sig-
mund Freud (Vol. 20, pp. 77–175). London: Hogarth Press.
Goldberg, P. (2004). Fabricated bodies: A model for the somatic false self.
International Journal of Psycho-Analysis, 85, 823–840. https://doi.
org/10.1516/KFG7-97TU-EP99-1HR1
Grinberg, L. (1962). On a specific aspect of countertransference due to the
patient’s projective identification. International Journal of Psychoanaly-
sis, 43, 436–440.
Horner, A. J. (1980). The roots of anxiety, character structure, and psycho-
analytic treatment. Journal of American Academy of Psychoanalysis, 8,
565–573. https://doi.org/10.1521/jaap.1.1980.8.4.565
Kohut, H. (1977). The restoration of the self. New York, NY: International
Universities Press.
Lombardi, R. (2009). Body, affect, thought: Reflections on the work of Matte
Blanco and Ferrari. The Psychoanalytic Quarterly, 78(1), 123–160.
Miller, S. P., Redlich, A. D., & Steiner, H. (2003). The stress response in
anorexia nervosa. Child Psychiatry & Human Development, 33, 295–306.
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Mitchell, J. E., & Crow, S. (2006). Medical complications in anorexia ner-
vosa and bulimia nervosa. Current Opinion in Psychiatry, 19, 438–443.
https://doi.org/10.1097/01.yco.0000228768.79097.3e
Petrucelli, J. (Ed.). (2014). Body-states: Interpersonal and relational per-
spectives on the treatment of eating disorders. New York, NY: Routledge.
Shabad, P. (1993). Repetition and incomplete mourning: The intergener-
ational transmission of traumatic themes. Psychoanalytic Psychology,
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Wang, T., Hung, C. C., & Randall, D. J. (2006). The comparative physiology of
food deprivation: From feast to famine. Annual Review of Physiology, 68(1),
223–251. https://doi.org/10.1146/annurev.physiol.68.040104.105739
Williams, G. (1997). Reflections on some dynamics of eating disorders: “No
entry” defenses and foreign bodies. International Journal of Psychoanal-
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189–202.
Chapter 6

Gender, Culture, and

Desire

Patients with eating disorders often struggle to tolerate desire, instead

engaging in repeated and immediate action as a means of foreclosing
the experience of wanting. We begin this chapter by examining the
nature of desire. From one point of view, which begins with Freud,
desires are already-formed inner strivings awaiting direction and
growth, only secondarily shaped by the relational and cultural sur-
round. With a post-modern, constructivist epistemology, on the other
hand, desire is a function of its context and must find a “container of
desire” (Brisman, 2002, p. 331) – a language provided first in import-
ant early relationships and, later, by the larger relational and cultural
surround – for its expression. Desire cannot be understood apart from
the contexts, relational and cultural, that shape it. A patient with buli-
mia, for example, may not desire food as a substitute for mother but,
rather, because that is the only available “vocabulary” through which
her desire can be expressed. The analyst’s task becomes not only
to uncover desires that have been defended against but also to help
the patient begin to want freely so that, over time, new containers of
desire can emerge, both inside and outside the analytic relationship.
The question of desire leads us to a consideration of female gen-
der development. Gender differences are dramatic in the prevalence
of some eating disorders, with, for example, far more females than
males diagnosed with anorexia and bulimia (Stice & Bohon, 2012).
Conversely, it is widely recognized that muscle dysmorphia afflicts
more males than females (Olivardia, 2007). Although a cultural anal-
ysis helps to elucidate this difference, it fails to explain why females
are more susceptible to certain cultural influences than their male
DOI: 10.4324/9781003016991-7
76 Gender, Culture, and Desire

counterparts and vice versa. With this in mind, we draw upon con-
temporary psychoanalytic models of gender development to explore
the relationship between gender identity and agency (that is, a sense
of oneself as a subject who can want and act upon those wants). We
highlight the necessity of developing a diverse gender “repertoire”
(Elise, 1998) – a sense of oneself as both masculine and feminine in
various ways – to counter problematic gender identifications.

The Problem of Desire

From an early age, “Alexa” understood that there were two possibil-
ities in her family: she could be sexy or fat. Her mother and father
conveyed, to a degree that reflected their own obsession with this
dichotomy, that the former was her birthright – a state that would
make her sexually desirable, certainly, but also more likable by
friends, family, and employers – but that the latter would be her fate
were she to lose control of her hunger. When we first met, she was thin
while retaining her feminine curves, well-dressed, and profoundly
dissociated as she struggled with the emotional fallout from an assault
that occurred the previous year. As she walked to my office, she was
terrified of men on the street who, seeing her “beautiful body,” not
only would desire her but might also violate her. As she described a
childhood marked by humiliation, abused at the hands of her school-
mates and her parents, she told me not only about the assault but about
her participation in dangerous sadomasochistic sexual practices with
her boyfriend each night.
When Alexa was thin, she felt like a “sex goddess,” as we came to
describe it. Her all-encompassing desire was precisely to surrender
herself to the hands of an all-powerful other. While this felt like a kind
of power (her desirability lent her a measure of control), it also felt ter-
rifyingly passive, for the experience of submission always carried the
potential for violation, heightened ever more since the assault the pre-
vious year but ultimately stemming from her mother’s dehumanizing
use of aggression and shame throughout her childhood. Over the com-
ing months, she gained weight through frenzied overeating: at first
a little but, as the weeks passed, more quickly. Able to reflect upon
her behavior but unable to control it, she described how the pounds
brought her an excruciating mixture of relief and self-loathing. On the
 Gender, Culture, and Desire 77

one hand, she no longer seemed to elicit as much attention from men
on the street, which felt safer. On the other, she was disgusted by her
body, as her “fat” elicited an attacking internal object that mirrored
her mother’s biting description of the change: lazy, childish, selfish,
and greedy.
Kernberg (1995) observes that patients with anorexia tend toward
sexual inhibition, whereas those with bulimia are more likely to enact
sadomasochistic sexual interactions, especially when eating distur-
bances temporarily recede. While Alexa never intentionally vomited,
to my knowledge, she would engage in extensive binge eating as her
desire overwhelmed her, its aftermath leaving her awash in shame.
The eating-disordered patient’s relationship with food has all the
marks of a clandestine love affair: anticipation, excitement, secrecy,
disappointment, emptiness, and shame. And like many such patients,
the breadth of Alexa’s desire is highly circumscribed. As a thin “sex
goddess,” she is overwhelmed by the desire to masochistically submit
to a tantalizing, abusive, other: a concrete situation mirrored by the
structure of her internal object world. As she gains weight, her desire
manifests as a voracious hunger, providing relief and safety from dan-
gerous men but also leaving her feeling ashamed, her mother’s words
echoing in her mind. Conspicuously absent are other kinds of desires,
such as the desire for comfort and tenderness, emotional connection,
or understanding in the context of a trusted relationship.
In her essay, Wanting, Brisman (2002) eloquently unpacks the
nature of desire. From one point of view, desires are cast as already-
formed inner strivings awaiting direction and growth that are only
secondarily shaped by their contexts. Here, the analyst’s role is seen
as examining and interpreting factors that thwart the unfolding of
these inner strivings. “The goal,” she writes, “is to loosen the road-
blocks and let the traffic flow” (p. 331). Whether desire is seen, as in
Freud’s libido theory, as the manifestation of physiologically derived
sexual drives, only secondarily directed toward objects by the ego’s
efforts to negotiate with cultural demands, or as a prewired potential
for interaction with a particular object, most importantly the mother,
in this paradigm we fundamentally know what we want, even if that
wanting is obscure to our conscious minds.
When she was thin, Alexa told me repeatedly about the intensity of
her desire for sex. In my clinical experience, I have never encountered
78 Gender, Culture, and Desire

a desire so voracious: she detailed spending hours with her boyfriend

each day having sex, each encounter punctuated by a dozen or more
orgasms. Over time, a pattern emerged in which she became erotically
obsessed with powerful, unavailable men. Each man tormented her,
tantalizing her with the possibility of emotional and sexual affirma-
tion, always keeping consummation just out of reach. Psychoanalysts
operating from an objectivist epistemology might understand her sex-
ual desire as a displacement of her need for attachment with an emo-
tionally available, affirming other. Sex, in this view, is secondary to a
relational need that only needs to be uncovered. In our work together,
Alexa and I found this view to be a fruitful and revealing approach to
understanding her object relations.
With the advent of post-modernism and the shift toward construc-
tivist epistemologies, this view has been challenged. Ghent (2001)
writes that need (and, by extension we might argue, desire) is “noth-
ing more than an organized motivational system” (p. 21) that is not
value-laden or essentially object-driven. Rather, there is a state of
needing, a formless and fluid craving, inherent in us all. The expres-
sion of a desire is shaped by its past and present relational and cultural
contexts (Brisman, ibid.). These ideas have real implications for our
patients with eating disorders. The intolerance of desires shuts down
human growth and the analytic process more generally. When patients
indulge in action, immediately and repeatedly, it is likely that their
actions serve to foreclose desire, rather than allow for it to take shape
and emerge from its inchoate ground.
As Brisman (2002) points out, Moulton (1972a, 1972b, 1977, 1985)
observes the ways in which mothers give language to the internal
worlds of their daughters. The words they choose may confine, direct,
and narrow the shape that their daughters’ desires take. Alexa grew up
in a family in which two pathways of desire were outlined: the first,
thinness and sexual submission, were esteemed but dangerous while
the second, food, was comforting and safe yet shameful. These were
the only two “containers of desire” (Brisman, ibid., p. 331) at her dis-
posal. Our effort could not be only to uncover other, different desires
and to clear away defenses so that those desires might find expression,
for those desires may never have formed in the first place.
Our work, rather, was to ask, “What, in fact, would allow [Alexa]
the safety to want freely, without holding an object of desire, any
 Gender, Culture, and Desire 79

object of desire, too close to her chest?” (Brisman, 2002, p. 335).

What would make it possible for her to want without finding imme-
diate satisfaction, whether in food or in submission? Ultimately, my
effort was toward providing a different context, one in which an inter-
action between us facilitated the emergence of a greater breadth of
desire, regardless of whether any particular desire might find satisfac-
tion. This was only possible when she tolerated the anxiety evoked by
objects of desire that were not under her omnipotent control through
the seductive power of her beauty or the out-of-control voraciousness
of a binge. For several years, I tolerated my desire for such a change
without satisfaction as we worked together to shift her sense of what
it meant to be a woman who could have desires and act to fulfill them.

Gender and Agency

A cultural perspective has been invaluable in describing how social
influences contribute to the dramatic gender differences in the prev-
alence of eating disorders. Eating disorders are more prevalent in
industrialized cultures and certain eating disorders – anorexia and
bulimia, for example – are more prevalent in females than in males,
mirroring cross-cultural differences in the emphasis placed on thin-
ness for women (Miller & Pumariega, 2001). These have become
more common during the latter half of the twentieth century, a period
during which women’s magazines published more articles about
weight loss and American icons of beauty became significantly thin-
ner (Owen & Laurel-Seller, 2000). Yet a cultural analysis alone may
not fully explain why women are more susceptible to certain cultural
influences than their male counterparts. To address this question, we
will draw upon contemporary psychoanalytic models of gender devel-
opment. In discussing this, we will focus on the relationship between
gender identity and agency (that is, a sense of oneself as a subject who
can want and act upon those wants).
Alexa and I spent considerable time discussing what it means to be
a woman who is capable of desire and acting to fulfill those desires, as
opposed to a woman who submits to the desires of others or enacts her
hungers in secret, always accompanied by shame. Schoen (2015) con-
ceptualizes eating disorders as disorders of a gendered, agentic self: a
man or a woman who wants and acts to fulfill those wants. For her, the
80 Gender, Culture, and Desire

disturbances in agency in eating disordered patients are inextricable

from disturbances in gendered identifications. Such patients tend to
be deeply conflicted about the meanings with which they have imbued
gendered categories and desires. Their symptoms reflect this insofar
as a certain type of body is seen as symbolizing a specific gendered
identity and particular appetites symbolize specific gendered desires.
Women, in Schoen’s (ibid.) view, tend to have greater developmen-
tal difficulty integrating agency into their gendered identity and are
vulnerable to occupying the “un-agentic” side of gendered splitting.
In this splitting, pleasure in activity is seen as masculine, whereas
pleasure in passivity, feminine (Dimen, 1991). In many cases, wom-
en’s sense of themselves as active may be gender-dystonic, in the
same way that a man’s fantasies of passivity may express a fear of
being homosexual, which is associated with femininity. Similarly, our
society fails to confirm and admire little girls’ exhibitionism except in
relation to their physical experience (Sands, 1989). Eating disordered
patients often grow up in families that place an inordinate amount
of importance upon bodily appearance, including weight, and focus
upon particular parts of the body: protruding tummies, thunder thighs,
and tree-trunk legs. We see these same pathogenic qualities in much
of the advertising that is directed toward women and girls (Groesz,
Levine, & Murnen, 2002).
Although self-starvation as manifest in anorexia nervosa is a
deadly form of self-destruction, it is also a healthy expression of the
desire to be autonomous (Charatan, 2015). It is, in other words, an
attempt to preserve an experience of agency – of having desires and
acting to fulfill those desires – in an environment that otherwise fore-
closes it. This is especially apparent in cases where an eating disorder
develops around puberty as an expression of “maturity fears” in those
patients with histories of sexual abuse. Here, sexuality and the body
have become a stage for the imposition of the other’s needs, desires,
and control, leading to a “poisoning of desire” (Slavin & Pollock,
1997, p. 582). Alexa’s binge eating, similarly, was an attempt to pre-
serve a space in which she could express her desire protected from
highly threatening gender-based identifications, which cast her into
masochistic submission. While this creative adaptation allowed her
to preserve her sanity, it also severely limited her relational repertoire
(Ogden, 2005).
 Gender, Culture, and Desire 81

Alexa was devastated as her career accomplishments, which during

the first years of treatment were considerable, were virtually ignored
by her parents who, instead, quickly redirected their conversations
toward the importance of weight loss – a sign of “true success.” There
was no emotional mirroring of her accomplishments, in contrast to
the fact that her father’s success was lovingly celebrated within the
family. To counter this I often emphasized her accomplishments and
suggested that they were an expression of – not in spite of – her gen-
dered self. Yet her family’s negation of her success – in fact, the shame
they sought to elicit because of contemporaneous weight gain – made
it difficult for her to acknowledge her own agency in this domain.
As Tyson (1982) clarifies, core gender identity, gender role, and
sexual orientation are distinct. In contemporary psychoanalytic think-
ing, gender identity emerges from a complex matrix of same-sex
and cross-sex parental identifications. More than the recognition of
anatomical difference and identification as male or female, gender
development encompasses the ways in which masculinity and fem-
ininity are elaborated with personal meanings through the same-sex
and cross-sex mental representations of self and other (Harris, 1991;
Benjamin, 1995). Centrally important in gender development is the
establishment of a coherent, unified experience of gender identity
without sacrificing a diverse gender “repertoire” (Elise, 1998): a sense
of oneself as both masculine and feminine in a myriad of ways.
It is likely that the idealization process is more fraught for girls
than for boys, especially during the oedipal period when children seek
to idealize the same-sex parent and for that parent to delight in the
child’s gender-linked attributes (Sands, 1989). Girls growing up in
contemporary society may lack, relative to boys, figures that can be
idealized, especially within the family. Mothers struggle to manage
multiple and often contradictory roles. Traumatically disappointed
with the pathways available for idealization in the relational sphere,
girls may look outside the realm of relatedness for solutions. Com-
pulsive eating, for example, can represent an attempt “to replace the
selfobject (and the transmuting internalization it provides) with food
(and the activity of eating)” (Kohut, 2009, p. 20). Eating may, in other
words, become an attempt to shore up an otherwise fragile sense of
self. Similarly, food itself may serve the function of an idealized other,
the object of a passionate love affair: soothing, perfect, and capable
82 Gender, Culture, and Desire

of solving all problems. For Alexa, mother was not a figure in whom
she could idealize female agency. Being a woman meant submitting
to the sexual desire of another, for this was the notion of femininity
that she had found in a mother who had sacrificed her career in service
of her husband’s professional development and who labored to sculpt
her own female body into a shape that was compelling to him.
As discussed in the previous section, Alexa did not grow up in a
context in which her desire might take other shapes. There were only
two “containers of desire” (Brisman, ibid, p. 331) at her disposal and,
as an adult, she both lacked other modes of expression and was unable
to tolerate the anxieties that dystonic desires would stimulate in her.
As a woman, she had only one option: to be a “sex goddess.” Yet
another option was available, one in which she could give her hunger
free reign in the realm of food and live in a body that felt sexless or, as
her mother often said, “childlike.” This was an adaptive, albeit emo-
tionally painful, way of escaping the anxieties aroused by the sexual-
ization forced upon her by her early environment. In her binge-eating
episodes, we found a desperate attempt to altogether disavow a set of
gendered identifications that foreclosed her agency and exposed her
to anxiety-provoking sexualization.
What made it difficult for Alexa to integrate agency with her sense
of herself as a woman? Goldner (2011) writes, “Where little girls
operate from the gender premise, ‘I am female like you, and thus we
are bonded via sameness,’ young boys deploy the opposite axiom, ‘I
am not female like you, and we are separated via difference’” (p. 161).
Also making this point, Sands (1989) observes that girls, who need
not go through such a pronounced dis-identification from their moth-
ers as their male counterparts, are likely to remain more psychologi-
cally connected to their mothers than boys. This, in turn, means that
a mother’s investment in her daughter is more likely to emphasize
narcissistic elements, to be based upon experiencing the daughter as
an extension of herself. In families of eating-disordered patients, the
narcissistic use of the daughter by the mother is often immediately
striking. Throughout the literature the degree of enmeshment or sym-
biosis between mother and daughter is remarked upon. Daughters
are torn between the urgings of their own developmental strivings
and their need to meet their mothers’ narcissistic needs. Symptoms
may provide a facsimile of psychological separation from the mother
 Gender, Culture, and Desire 83

insofar as, for example, the anorexic patient takes control of what
comes into her (Bruch, 1973) and the bulimic actively repudiates her
need for the mother through purging (Selvini-Palazzoli, 1978).
Moreover, for girls, “bonded via sameness” to their mothers, mas-
culinity and agency are easily conflated and agency tends to be under-
mined by the way that girls inhibit their use of aggression in the service
of separation and individuation for fear of damaging that all-import-
ant connection. Eating disorders, from this point of view, arise both
from an exacerbation of normative development challenges in dif-
ferentiation from the mother stemming from the mother’s relating to
her daughter to fulfill her own narcissistic needs and from negative
associations to masculinity, especially its equation with destructive
aggression. When eating disordered symptoms arise in men, Schoen
(ibid.) writes, they may signal difficulty integrating dependency needs
into a masculine identification. Sands (2003) notes that men are more
likely to express disavowed needs and wants through projections onto
others – witness the preponderance of compulsive sexual behaviors
in men – whereas women are more likely to use their own bodies to
contain disavowed desires. Consider, for example, the rigid “perfor-
mance” (Butler, 1995) of masculinity in muscle dysmorphia, which
often reflects the failure to fluidly integrate masculine and feminine
identifications. Schoen (ibid.) makes an additional point that affliction
with a so-called “feminine” disorder may reflect the shame-ridden
disavowal of feminine identifications and desires.
Alexa’s mother needed her daughter to be beautiful insofar as she
felt this would confirm her own beauty. Every flaw in her daugh-
ter’s appearance, conversely, exacerbated her mother’s own insecuri-
ties about her gendered appearance and desirability. This narcissistic
mode of relating made it extremely difficult for Alexa to develop
a sense of herself as an agentic woman. She was terrified of mobi-
lizing her aggression in service of separation and individuation for
this might irreparably damage her tie to a figure with whom she was
deeply identified or elicit her wrathful and shame-inducing retaliation.
On the contrary, when faced with her mother’s criticisms in reality
or in her internal object world, she became childlike and apologetic.
Though she was devastated by these attacks, our discussions of them
often elicited laughter as she desperately attempted to circumvent
the shame they evoked (Lewis, 1992). Yet over time, as she began to
84 Gender, Culture, and Desire

experiment with an expanded sense of herself as an agent, we found

that self-assertion elicited a problematic identification with her father
as a ruthless, dangerous figure who disregarded the desires of others
in favor of his own (largely sexual) self-interests. One of her mother’s
most frequently voiced criticisms of her father, she now recalled for
the first time, had been about this fact and the possibility of being
ruthless like her father filled her with guilt.
It was not only the equation of femininity with masochistic submis-
sion and its accompanying vulnerability that made inhabiting a wom-
anly body terrifying; it was, also, that the claiming of agency, and the
aggression inherent in it, seemed an expression of destructive hatred,
akin to her father’s extramarital affairs. Around the time that the “Me
Too” movement entered public consciousness, she began a session with
an offhand remark. “Men,” she said, “know what they want. And what
they want, they take.” This gender-based splitting – passive versus
active, wanted versus wanting, object versus subject (Schoen, 2015) –
was undoubtedly overdetermined, reflecting the dynamics in her family
of origin, the trauma of her assault, the misogyny and patriarchy of our
cultural surround, and an underlying truth about gendered developmen-
tal processes. At the level of her psychic reality, this splitting served to
isolate contradictory feelings, projecting aggression outward where it
could be located solely in men and, hence, fueled persecutory anxiety.
While the idea of inhabiting a feminine body, which for her entailed
vulnerability to sexual violation, terrified Alexa, the possibility of
claiming her desire as her own was equally abhorrent. With agency
as the sole property of men, to claim it risked casting her as a perpe-
trator who would overlook the subjectivity of the other. To claim her
own desire, sexual or otherwise, was an aggressive act. Up until this
point, we had understood her binge eating as an expression of previ-
ously disavowed hunger, exploding into consciousness and enacted in
a frenzy of consumption only to recede and leave shame in its wake.
Now we could articulate that it was also a means of managing her
disavowed rage, a theme that became an important part of our work.

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Chapter 7

Affect Regulation,
Dissociation, and Body
Imaginings

In this chapter, we begin with a discussion of a perspective from

the relational school of psychoanalysis that regards the self not as a
supraordinate and comprehensive structure, stable and consistent over
time, but as decentralized and composed of relatively discrete psychic
structures – “selves” – that, in a good enough developmental situation,
attain an “illusion” of coherence and continuity (Bromberg, 1998).
In this paradigm, relational trauma is defined as exposure to chronic
misattunement and prolonged states of dysregulation in the context of
an early attachment relationship. This leads to self-states becoming
more or less dissociated. We use these ideas to formulate the notion of
the “hungry self,” a self-state prominent in patients with binge eating
disorder like “Alexa,” who was introduced in the previous chapter.
With these ideas in mind, we consider how the experience of body
image may vary according to the shifting landscape of dissociatively
structured self-states. We focus on the way that body image is an
expression of past relational experiences and how, in those patients
with histories of relational trauma, an important aspect of treatment is
helping patients to “stand in the spaces” (Bromberg, 1998) in order to
understand the dynamics driving shifting experiences of body image.
As these dynamics are increasingly put into words, patients’ body
images will likely gain greater stability.

Self-States, Affect Regulation, and Dissociation

It is fruitful to think of Alexa, discussed in the previous chapter, as
occupying two different self-states: the first metaphorically expressed
DOI: 10.4324/9781003016991-8
88 Affect Regulation, Dissociation, and Body Imaginings

by her thin, attractive body, in which she experiences herself as a “sex

goddess” whose all-encompassing desire is to surrender herself to the
hands of an all-powerful other, and the second expressed by weight
gain that leaves her feeling “sexless.” In each of these self-states,
she experiences herself as a significantly different kind of person,
with different thoughts, feelings, and behaviors. Over the past few
decades, a prominent line of relational theorizing (e.g., Bromberg,
1998; Davies, 1996) has emerged that regards the self not as a unitary,
over-arching structure, mostly stable and consistent over time, but as
decentralized and composed of relatively discrete psychic structures –
“selves” – that, in a good enough developmental situation, attain an
“illusion” of coherence and continuity (Bromberg, 1998). Each self-
state comprises ways of thinking, feeling, and acting – different ways
of being in different contexts. In a sense, each self-state is its own per-
sonality system, an assemblage of affective and cognitive processes
that make up “versions” of us (Hill, 2015).
In optimal development, the self-state system is integrated. Our
various self-states are compatible with one another and we shift flu-
idly between them, retaining a feeling of relative coherence and unity
among different versions of ourselves (Hill, 2015). Some self-states,
however, may be partially or fully dissociated. These self-states are
activated involuntarily and automatically, coming upon us without
warning. We are typically unaware that we are in a partially dissoci-
ated self-state, for in these states we know that we are different but
have only a shallow understanding of what is happening to us (ibid.).
We may remember other ways of being ourselves, but they feel distant
and foreign. While Alexa could remember her behaviors, and many
of her thoughts and feelings, across self-states, there was very little
capacity to “stand in the spaces” (Bromberg, 1998) and reflect upon
the dynamics that ordered their shifting landscape.
Central to the self-state paradigm is affect regulation theory. Affect
may be divided into primary and categorical, or discrete, affect. The
former is the somatic representation of the state of the organism, a
sensorimotor physiological representation that generates a felt sense
(Hill, 2015). It is the nonverbal representation of the body. Cate-
gorical affects, on the other hand, are what we typically call emo-
tions, such as the seven delineated by Darwin (1872/1965): shame,
 Affect Regulation, Dissociation, and Body Imaginings 89

sadness, joy, anger, surprise, fear, and disgust. Both primary and cat-
egorical affect comprise the experiential-cognitive appraisal system
that tells us what things mean to us and what our motives, needs, and
desires are. The capacity to regulate affect emerges from the early
attachment relationship, a time when children are crucially depen-
dent upon their caretakers for self-regulation. Growth-enhancing
experience relies upon the attachment figure’s attunement, estab-
lished via implicit communication between attachment figure and
infant. Siegel (1999) describes how attunement allows the parent
to help the infant to organize its own mind. The regulation of the
infant’s affect by the attachment figure – a process called dyadic
regulation – occurs at first largely through touch and, over time,
through nonverbal, implicit communications of affect: “touch at a
distance” (Hill, ibid., p. 10). In optimal development, we can alter-
nate between auto- and dyadic regulation as necessary, depending
on our needs and capacities at a given developmental stage. Later
in development, a secondary affect regulation system emerges –
mentalization (Fonagy, 1999; Allen & Fonagy, 2006) – that consists
of verbal-reflective, slow, deliberate, conscious cognitive processes
(Hill, ibid.). Mentalization, a different concept than mentalisation
described in Chapter 1: Alexithymia and the Psychic Elaboration of
Emotion, is the capacity to understand ourselves and others as hav-
ing mental states, thus comprehending our own and other’s inten-
tions and affects.
In this paradigm, relational trauma, which can be defined as expo-
sure to chronic misattunement and prolonged states of dysregulation
in the context of the early attachment relationship, is seen as under-
mining the capacity for affect regulation. In contrast to the “complex”
or “developmental” trauma described by Herman (1997) and van der
Kolk (2005), which focuses on sexual, physical, and verbal abuse and
neglect within the attachment relationship, relational trauma points to
the less obvious, and in fact often invisible, trauma that occurs within
the attachment relationship. When seeking affect regulation from the
attachment figure, the child encounters responses that exacerbate,
rather than modulate, her emotional dysregulation. The stressor is the
relationship itself, hence the term relational trauma. In the face of
relational trauma, self-states may become more or less dissociated
90 Affect Regulation, Dissociation, and Body Imaginings

and, given the resulting impaired capacity for affect regulation, disso-
ciation likely becomes a chronic pattern of defense.
Although the meaning of the term dissociation varies among ana-
lytic thinkers, Hill (2015) proposes that dissociated self-states share
three characteristics: automaticity, compartmentalization, and altered
states of consciousness. Dissociated self-states are automated in that
they are activated involuntarily and involve scripted behavioral and
psychological responses. They are compartmentalized because their
content is involuntarily isolated. Commonly, aspects of the traumatic
event cannot be voluntarily remembered, assessed, and integrated
into one’s overall functioning. In extreme cases, an entire personality
system, including memories, sense of self, and representational and
perceptual dispositions, are segregated and kept from consciousness
in other self-states. And finally, trauma-based altered states of con-
sciousness may generate a sense of detachment. We feel out of touch
with our body-based feelings and emotionally distant from others
and, in extreme cases, we may feel ourselves to be out of our bodies
entirely.
There is considerable empirical evidence that dissociation is prom-
inent in patients with eating disorders. There is, for example, substan-
tial empirical literature documenting the association between binge
eating disorder and childhood maltreatment (Amianto et al., 2018;
Imperatori et al., 2016; Allison, Grilo, Masheb, & Stunkard, 2007;
Grilo & Masheb, 2001). In one study, for example, 83% of BED
patients reported some form of childhood maltreatment, with 59%
reporting emotional abuse, 36% physical abuse, 30% sexual abuse,
69% emotional neglect, and 49% physical neglect. Emotional abuse
was significantly associated with greater body dissatisfaction, higher
depression, and lower self-esteem in both men and women (Grilo &
Masheb, 2001). In another study, subliminal threat cues increased
state dissociation (particularly levels of derealization) in bulimic
women but had no effect on the nonclinical group, seeming to sup-
port the idea that bulimic women are more vulnerable to dissociation
in response to specific threats (i.e., state dissociation) (Hallings-Pott,
Waller, Watson, & Scragg, 2005). In a third, difficulties with affect
regulation and dissociation were found to be significant mediators
between childhood traumas and eating psychopathology (Moulton,
Newman, Power, Swanson, & Day, 2015).
 Affect Regulation, Dissociation, and Body Imaginings 91

From a psychoanalytic point of view, Bromberg (2001) suggests

that eating disorders develop as the result of a prolonged necessity
in infancy to control trauma and affect dysregulation, leading to a
mental structure that has been shaped by dissociative dynamics and
an impaired faith in human relatedness. Eating disordered symptoms
represent the “repackaging” of unlinked states of mind into symp-
tomatic thoughts, feelings, and behaviors – dissociated self-states.
These dissociative defenses inevitably manifest in the transference as
well, representing the patient’s attempt to “stay enough in relationship
with the human environment to survive the present while, at the same
time, keeping the needs for more intimate relatedness sequestered but
alive” (Sands, 1994, p. 149).

Binge Eating Disorder: The “Hungry Self ”

To illustrate how these ideas might apply to patients with eating dis-
orders, we will discuss a self-state commonly encountered by patients
with binge eating disorder, which might be referred to as the “hungry
self.” Many of these patients, like Alexa, describe a primary relation-
ship, often with a mother, who they experienced as either emotion-
ally fragile or grandiose. In the history that emerges, the narcissistic
aspects of the mother’s character appear to contribute to a dynamic
in which the child’s emotional needs were largely unacknowledged,
much less appropriately satisfied. In other words, the mother’s narcis-
sistic vulnerabilities made it difficult for her to experience the child
as a separate person with her own needs and desires, which would be
a pre-requisite for responding to them appropriately. Alexa’s mother,
for example, was strongly invested in her daughter’s beauty and sex-
uality, for to have a beautiful daughter bolstered her own self-esteem.
Her need for her daughter to be beautiful was so powerful that she
could not assess the impact of this upon her developing child. Against
this backdrop, Alexa experienced her mother as unreceptive to the
communication of her own emotional longings, needs, and desires,
constituting a breakdown in containment as discussed in Chapter 3:
Early Relationships, Object Relations, and Traumatic Themes. In the
face of this traumatic theme, she developed a profound “hunger” for
emotional nourishment, particularly from her mother, and accompa-
nying frustrated rage at the deprivation that she was forced to endure.
92 Affect Regulation, Dissociation, and Body Imaginings

By the time she became an adult, this “hungry self ” had been cor-
doned off so that it only emerges when the dissociative defensive
structure fails, as a binge eating episode, which concretely expresses
her hunger for nourishment and rage at its frustration.
When the “hungry self ” – a combination of need and rage –
emerges in a binge episode, the patient’s thinking and perception is
dissociatively narrowed. She becomes absorbed in the movements and
sensations – not the meaning – of eating and is unable to evaluate that
eating against norms grounded in reality such as, for example, what
might constitute an appropriately sized meal or a healthy selection of
food to eat (Tibon & Rothschild, 2009). Alexa described experiences
of becoming so immersed in the experience of eating that only when
she “awoke,” hours later, could she recognize the enormous amount
of food that she had consumed. The sole feeling she could recall was
a persistent, though subtle, feeling of shame that accompanied her as
she ate. In my experience, patients with binge eating disorder exist
on a continuum, with some having no awareness, intellectual or emo-
tional, of their profound feelings of need and rage with others hav-
ing a much greater awareness of these feelings but not yet having
found a relational context that would facilitate a fuller integration of
them. Both, to varying degrees, make use of binge eating as a channel
through which to express these feelings, which remain more-or-less
dissociated from their conscious minds in their day-to-day lives

Body Image and Body Imaginings

In the Image and Appearance of the Human Body (1950), psychoan-
alyst Paul Schilder began to think about the bodily experience from a
psychological and sociological point of view. In the past, research had
focused upon distortions in body perception caused by brain damage.
In contrast, Schilder defines body image as the meanings and fanta-
sies about our bodies that we form in our own minds. Hoffer (1950)
suggests that by the second year of life an infant has an oral-tactile
concept of his own body. Over time, this becomes a relatively stable
body image. Although not identical with the actual bodily configura-
tion, in health body image is more-or-less congruent with it. Yet clini-
cians who work with eating disorders can attest to the often-dramatic
fluctuations in body image that afflict these patients. In this section,
 Affect Regulation, Dissociation, and Body Imaginings 93

we will discuss how body image is a relationally constituted phenom-

enon, fluctuating as relational identifications shift for the patient. Put
differently, body image may vary as self-states vary, with each self-
state bringing to the foreground relational identifications that, in turn,
shape the way that the body is experienced.
In normal development, a child acquires a sense of himself as
both lovable and attractive through early, preverbal interactions. The
first exchanges between the mother and baby are intensely physi-
cal. The preverbal interplay between mother and baby – an intri-
cately patterned communication of pain and pleasure, excitement
and relaxation – lays the foundation of the child’s developing sense
of self. As Lemma (2009) points out, visual interactions play a sig-
nificant part in this dance. Psychoanalytic studies of blind children
suggest that sight plays a primary role in the child’s earliest “taking
in” of important relationships, leading to structure building and ego
differentiation (Sandler, 1963; Fraiberg & Freedman, 1964). Indeed,
the mother’s face is the child’s first emotional mirror (Winnicott,
1967), insofar as it reflects back to him aspects of his own emo-
tional experience. In healthy development, the mother’s loving gaze
takes in and receives the child, and this gaze serves as the beginning
of an intact body image, which is further consolidated over time.
Ultimately, the child’s internal representations of his own body are
impacted not only by his (objective) physical differences but also
by the relationally constellated meanings that are ascribed to those
physical differences. Recognizing this fact, Lemma (2009) proposes
the term “body imagining(s)” to highlight the fluid, fantasy-based
nature of our internal representations of the body formed by the self
in interaction with the other.
The idea of body imaginings (Lemma, ibid.) allows us to begin
to think about how patients experience their bodies differently –
sometimes large or small, powerful or weak – in relation to the ana-
lyst at various points in treatment. With this idea, we recognize that
body image is not fixed. For example, an (objectively) small body
can be experienced as powerful and dangerous or weak and shameful,
depending on the internal representations active at any given time.
Importantly, patients with eating disorders often present with body
imaginings that are segregated into different self-states. In Alexa’s
“hungry self ” self-state, she loathed her body, focusing particularly
94 Affect Regulation, Dissociation, and Body Imaginings

on the rolls of fat around her stomach and the excess flesh of her
thighs. To be fat, she said, was to be “lazy, childish, selfish, and
greedy,” a description that mirrored her mother’s complaints about
her throughout her childhood. One of the aspects of relational trauma,
which contributes to the emotional dysregulation that drives dissoci-
ation and, over time, the segregation of different self-states, is shame
experienced at the hands of an attachment figure. Alexa’s shame was
intolerable, for it threatened her fragile self with collapse, and at an
early age, she sought ways to dissociatively numb this feeling. In one
session, she described pinching the skin on her arms to a degree that
required stitches and antibiotics to stave off infection. This self-harm,
we discovered, allowed her to distance herself from the painful feel-
ings of shame that she could not regulate on her own. The shame
reflected an experience of being “seen” as defective and unlovable
which could not be elaborated into words and images and so remained
concretely experienced as a body imagining.
Although Alexa’s body was, in fact, physically larger when she was
engaged in binge eating, more important from a psychoanalytic point
of view is how she experienced her body in the self-state that gave rise
to binge eating. We can see this, for example, in how she recalls her
mother’s complaint that she is “lazy, childish, selfish, and greedy.” This
stands in contrast to her experience at other times, when she experiences
her body as irresistible to those around her, a body imagining (Lemma,
2009) corresponding with her parents’ sexualization of her throughout
her childhood. Although her weight gain made it difficult for her to
see that her feelings about her body were linked to more than the con-
crete reality of her weight, as her weight stabilized later in treatment it
became more apparent that her sense of her body varied dramatically,
often independently of whether she had gained or lost weight. We were
able to understand her shifting body image as a way of “remember-
ing” early relational experiences, revived in a given moment because of
what was transpiring in the transference-countertransference between
us, and, eventually, the instability of her body image ameliorated as her
capacity to articulate her emotional experience strengthened.

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Chapter 8

The Role of the Father

and the Paternal Function

This chapter will discuss the role of the father and of the paternal
function – a term to be defined in the next paragraph – in patients with
eating disorders. To make these ideas concrete, we will focus specif-
ically on male patients with anorexia nervosa and muscle dysmor-
phia. One purpose served by the paternal function is to assist the child
in separation and individuation from his mother. Through a father’s
establishing a loving bond with his son, his “attractive function”
encourages the child’s capacity to explore the outside world (Abelin,
1971). In the families of children who develop anorexia nervosa, the
mother’s use of the child to maintain her own equilibrium makes sepa-
ration and individuation more difficult. In such families, a potentially
important factor in whether the child goes on to develop anorexia
nervosa is the strength of the paternal function, which optimally helps
the child learn how to appropriately deploy his aggression in the ser-
vice of separation and individuation. In these families, however, the
relative absence of the paternal function may lead the anorexic-to-be
to locate his experience of agency in relation to eating and his body,
which he rigidly controls. In families of children who develop muscle
dysmorphia, in contrast, the father may maintain his own equilibrium
by keeping his son small, vulnerable, and weak. Whereas in optimal
development the paternal function would facilitate the developing
boy’s separation and individuation, in these cases it instead threatens
the child with the possibility of remaining forever lost in dependency
upon his mother. To avoid this, the child defensively idealizes a partic-
ular form of masculinity characterized by “bigness” (Corbett, 2001)

DOI: 10.4324/9781003016991-9
98 Role of Father and Paternal Function

that the paternal function comes to represent and that is concretely

expressed by his drive for muscularity.
At the beginning of this chapter, it seems important to say a few
words about the term paternal function. There is a long history of
debate within psychoanalysis about sex and gender roles. As Davies
and Eagle (2013) point out, one approach is to begin with the assump-
tion that there are a set of functions that need to be performed by
parents in the service of their child’s emotional and physical develop-
ment. To theorize these functions, we may assume that they consist
of both maternal functions, those typically performed by the woman/
mother, and paternal functions, those typically performed by the man/
father. Within the literature, they suggest, the terms maternal and
paternal – instead of mother and father – may have arisen to sug-
gest that such functions may be performed by caretakers who are not
necessarily the biological or even adoptive parents of the child. Yet
they still retain strongly gendered associations and, as such, may unin-
tentionally contribute to the marginalization of differently configured
families.
Indeed, the diversity of present-day parenting arrangements makes
clear that the paternal function is not necessarily provided by the
male-sexed father. As Diamond (2017a, 2017b) points out, females,
including the mother, often carry aspects of the paternal function and
given the complexity of the paternal function, it cannot be “reduced
to the empirical presence of the ‘father’” (Perelberg, 2013, p. 581). In
writing this chapter, I have experimented with using a nongendered
term in lieu of paternal function, such as third-party function, as sug-
gested by Fiorini (2013). In the end and with considerable ambiv-
alence, I decided to retain gendered terminology because I wish to
draw our attention to the existence of common gender pathways, mas-
culine and feminine, in the development of both anorexia nervosa and
muscle dysmorphia.

Mothers and Fathers in Anorexia Nervosa

As mentioned in earlier chapters, Hilde Bruch’s (1962, 1973, 1978)
foundational work was the first to describe anorexia nervosa in the
language of object relations. In her view, self-starvation represents a
struggle for autonomy, mastery, and self-esteem. Disturbances in the
 Role of Father and Paternal Function 99

early mother–child relationship predispose the child to develop the

disorder during adolescence, a time that demands an increased capac-
ity for autonomous functioning. In her clinical work, she described
over-involved mothers who appear to be domineering, intrusive, and
discouraging of separation and individuation. This, she argued, creates
an internal confusion in children, expressed through body image dis-
turbance (overestimating their body size), interoceptive disturbance
(an inability to identify and respond to internal sensations, including
hunger, fullness, and affective states), and all-pervasive feelings of
ineffectiveness and loss of control.
Since this seminal contribution, the literature on anorexia nervosa
consistently points to disruptions in the mother–child relationship,
describing intrusive mothers who struggle to facilitate separation and
individuation, (Selvini Palazzoli, 1974), impose their wishes upon
their children, forcing them into passive submission (Sours, 1974),
and confront them with an “all-consuming, insatiable demand” to be
needed (Hamburg, 1999). In the face of these dynamics, the anorexic
child is cast as struggling with intense rage toward her mother, which
is displaced onto her own body (Ritvo, 1976). As Zerbe (1993)
writes, the refusal of food is “an autonomous statement, par excel-
lence: “I don’t need you. I don’t need anything. I don’t even need food
to survive. I am totally independent” (p. 95). Chasseguet-Smirgel
(1993, 1995) suggests that anorexic patients function on the level of
unconscious fantasy in an autarchical manner. Lawrence (2001) casts
anorexia as a manic defense, an effort to control an internal represen-
tation of the mother, and suggests that the bodily damage inflicted by
the patient reflects the violence that is felt to be done to the internal
mother.
In these formulations, the father is usually described as passive,
absent, or otherwise unavailable to disrupt the symbiosis between
mother and child (Hamburg, 1999; Sours, 1974; Zerbe, 1993).
Beresin, Gordon, and Herzog (1989) interviewed 13 former patients
with anorexia nervosa who described their mothers as intrusive, over-
involved, concerned with appearance, and lacking in attunement to
their children’s needs, consistent with the theories just described,
and their fathers as distant, successful, and over-involved with work
to the neglect of their families. Similarly, Elliot (2010) interviewed
11 patients in the recovery process who described their fathers as
100 Role of Father and Paternal Function

unreliable and intermittently available. In both these studies, those

interviewed seemed to feel a strong adherence to parental demands,
disavowing a desire for independence and unprepared for adoles-
cence, and a strong pressure to control their own needs, at times in
an effort to protect their parents’ marriages from the impact of those
needs were they expressed.
Consider, in this vein, “Damien,” a nearly 40-year-old patient who
has struggled with anorexia nervosa since his teenage years. Early
on, he tells me how the “terrible disease” has trapped him in per-
petual dependence upon his parents, both financial and emotional,
and has destroyed his physical health. As the analysis unfolds, I learn
about his relationship to his mother, who he has always experienced
as engulfing and intrusive, and with his father, who he experiences as
distant and uninvolved, absorbed in his obsessional tendencies which
manifest in compulsive hoarding behaviors. As a child, his mother
would recruit him to provide “shoulder massages” in which she would
remove her shirt and, covered only by her undergarments, insist that
he minister to her pain. He describes many rooms of their large family
home filled to the ceiling with receipts, papers, and books. He reveals
how as a child, his father would often disappear from both mother and
son for days as he retreated into his study to pursue these interests.
This fueled his mother’s disparagement of his father and her further
emotional entanglement with her son.

Anorexia Nervosa and Agency

What has been lost to Damien, or at least significantly diminished, is
his agency, in the sense that was described in Chapter 3: Traumatic
Themes, Repetition, and Mourning. He is trapped in a closed sado-
masochistic system with each instance of victimization motivating
sadistic retaliation against his mother, manifesting in displacement
as starvation and injury inflicted upon his own body. This leads to
profound guilt, defended against by further victimization (Novick
& Novick, 2016). His father, compromised in his own right, is
unable to shield his son from his mother’s engulfing attention or
to assist him in developing a sense of autonomous identity. As this
vignette suggests, agency and its derailments in patients with eating
 Role of Father and Paternal Function 101

disorders may be the most encompassing perspective we have of

these complex and multi-faceted illnesses to date, speaking to many
aspects of the struggles that we encounter clinically (Zerbe, personal
communication).
Little has been written about the relationship between anorexia
nervosa and agency. Bruch (1962, 1973, 1978), with her usual fore-
sight, identified a paralyzing sense of ineffectiveness and helpless-
ness as characteristic of this population. In the empirical literature,
Bers and Quinlan (1992) compared inpatients with anorexia nervosa
to both control inpatients and non-patient controls on a measure of
“ineffectiveness”: a lack of appreciation of their own resources and
confidence in their initiative, an inability to recognize their accom-
plishments and capabilities, and a feeling that they are not compe-
tent to lead a life of their own. Patients with anorexia nervosa and
non-patient controls were differentiated in that the former showed a
high interest in various activities and a low perceived ability in these
activities, a “perceived-competence deficit.” In short, the experience
of agency in these patients was highly compromised. Feeling helpless
and ineffective, they do not experience themselves as agents, capable
of mobilizing their aggression to push up against the world. Ironically,
clinicians, family members, and friends regularly experience these
patients as having a profound impact on them.
To elaborate upon these findings, Bers, Blatt, and Dolinsky (2004)
examined the sense of self of patients with anorexia nervosa by
obtaining open-ended self-descriptions of 77 women between the
ages of 14 and 24, with groups of psychiatric patients with anorexia
nervosa (n = 15), control psychiatric patients (n = 15), and control
non-patients (n = 48). Their self-descriptions were rated on 18 scales
and fell into four factors (Agency, Reflectivity, Differentiation, and
Relatedness) and two affective scales (Anxiety and Depression). The
patient groups were distinguished from the non-patient group by a
lower sense of Agency and Relatedness. The anorexia group was
distinguished from the psychiatric patient group by the presence of
heightened and harsh self-reflectivity. Surprisingly, physical descrip-
tors and an external focus did not dominate these patients’ self-
descriptions. On the contrary, evident in their inner lives was intense
self-scrutiny accompanied by endless self-loathing and self-criticism.
102 Role of Father and Paternal Function

Paternal Function in Anorexia Nervosa

The paternal function plays an important role in facilitating the child’s
capacity to make use of his aggression. When aggression can be
constructively harnessed, it contributes to an experience of the self
as active and capable of having an impact upon one’s internal and
external worlds. It animates our efforts to “push up” and “push back”
against the environment and against forces within us, lending our
experience agency and empowerment. Through exerting an impact
upon our environment that, by its nature, resists that impact to some
degree, the child develops a sense of himself as causing or generating
an action (Knox, 2011). Aggression, likewise, energizes the child’s
efforts to separate and individuate from his mother and to explore the
outside world.
Herzog (1982, 1988, 2001, 2004, 2010) argues, based on his clinical
observations, that a father’s careful use of his own aggression, as part
of his paternal function, consolidates a child’s sense of himself and the
management of his aggressive drive. In Herzog’s (2004) paradigm, the
paternal function is especially important in helping young boys – who
likely have a greater aggressive endowment from birth (Archer, 2004) –
learn to modulate their aggressive urges, especially during early devel-
opment. Referencing his clinical work, he describes a painful emotional
state, father hunger, which manifests in the absence of the father, actual
or symbolic, and suggests that young boys’ aggression may be amplified
because the father’s absence is perceived simultaneously as the child’s
own doing and as depriving the child of desperately needed protection.
Boys, then, crucially depend on a father’s guidance in the management
of their aggression. This need to be “shown how” (Herzog, 2001) is a
hallmark of their development.
There are good reasons for thinking that young girls also rely on the
paternal function for assistance in developing the capacity to regulate
their aggression. Girls tend to have greater difficulty integrating the
experience of agency into their gendered identity and are vulnerable to
occupying the “un-agentic” side of gendered splitting (Schoen, 2015).
In this splitting, pleasure in activity is seen as masculine, whereas
pleasure in passivity is seen as feminine (Dimen, 1991). In many
cases, a woman’s sense of herself as active may be gender-dystonic,
in the same way that a man’s fantasies of passivity may express a fear
 Role of Father and Paternal Function 103

of being homosexual, which is associated with femininity. The inte-

gration of identification with the paternal object into a diverse gender
“repertoire” (Elise, 1998) is central in the overcoming of this splitting
so that aggression can be deployed in the service of agentic experi-
ence, and separation and individuation for both sexes. Writing about
the prevalence of father hunger in anorexia, Maine (1991) describes
the painful longing for the father, and his paternal function, frequently
observed in female patients.

Muscle Dysmorphia and Gender Development

The main feature of muscle dysmorphia is body dissatisfaction (Oli-
vardia, Pope, & Hudson, 2000), which often leads to the use of ana-
bolic steroids and other physique-enhancing drugs and supplements,
strictly controlled dietary plans, excessive exercise, and body “check-
ing” behaviors. Many of those afflicted are drawn to bodybuilding to
achieve the lean, hypertrophic, and muscular physique they desire.
Those with muscle dysmorphia experience profound shame and embar-
rassment about their bodies. In addition, they often have a history of
disordered eating (Olivardia, 2001) that involves contradictory strate-
gies such as highly regimented diets to increase weight and muscularity
while simultaneously engaging in purging behaviors or laxative use to
avoid fat increase (Cafri et al., 2005; Choi, Pope, & Olivardia, 2002;
Hildebrandt, Schlundt, Langenbucher, & Chung, 2006).
Although more research is needed to clarify the extent of the gen-
der difference in muscle dysmorphia, it is widely recognized that it
affects significantly more men than women (Olivardia, 2007, p. 131).
Empirical research on body image disorders in women suggests that
women, especially women with eating disorders, judge their bodies to
be too large and aspire to often unrealistic levels of thinness (Cash &
Pruzinsky, 2002; Garner, Garfinkel, Schwartz, & Thompson, 1980).
Although there are fewer studies examining body image issues in men
and boys, a growing body of research shows that males tend to desire
a leaner and more muscular body. This preference for a muscular phy-
sique is already apparent in boys as young as six (Jacobi & Cash,
1994; Ricciardelli, McCabe, & Banfield, 2000).
Given the fact that muscle dysmorphia affects significantly more
males than females, gender development may be implicated in the
104 Role of Father and Paternal Function

disorder. As many theorists have pointed out, the concepts of masculin-

ity and femininity should not be understood as unitary. With this in mind,
muscle dysmorphia may commonly express a particular masculine ideal
in its extreme form. For Corbett (2001), this ideal involves “the wish
and effort to be a big winner, not a small loser” (p. 6). The emotional
experience of smallness and vulnerability is defended against by “an
insistent, illusory display of bigness and agency” (p. 6). For Elise (2001),
this is a “fortress of emotional self-sufficiency” – a citadel – that fore-
closes dependency and vulnerability. As Elise (ibid) remarks, this ideal,
far from describing every man instead elaborates a myth of masculinity
that men have to contend with even if it does not reflect their individual
personalities. The pursuit of this ideal is an attempt to protect a vulner-
able sense of self and disavows feelings of dependence, need, and vul-
nerability. This leads to increasing idealization of masculine attributes
in an effort to avoid emotional experiences of weakness and vulnera-
bility (Brady, 2017). This “burden of unrelenting bigness” (Brady, ibid.,
p. 198) constructs a version of masculinity that is an unachievable ideal.
Consider “John,” an adolescent boy who attends treatment at the
insistence of his mother after she found performance-enhancing sup-
plements in his bedroom. In our first session – a family interview –
his father, who works in the military, speaks with a hard edge and, in
one interaction, seems to intimidate his son. His mother, in contrast,
seems affectionate, ruffling her son’s hair at one point in the session,
making him feel claustrophobic and embarrassed. Several months
into treatment, John witnesses a high-school student taunting another
outside my office before our session. Visibly shaken, he describes
both his identification with the taunted child through recollecting
his own experience of being bullied during grammar school as well
as his envy of the bully who, it seems to him, cannot be demeaned
or humiliated because of his strength. Over many months, we elab-
orate on his wish to maintain an impervious emotional façade and
to strengthen his body so that, in his words, “nobody will ever mess
with me again.”

Paternal Function in Muscle Dysmorphia

Muscle dysmorphia, which was originally termed “reverse anorexia,”
has in common with anorexia nervosa that many of those afflicted have
 Role of Father and Paternal Function 105

also experienced a compromised paternal function. The basic trauma

of infancy might be considered the loss of the ideal state of fusion with
the mother (Manninen, 1992). This “nursing couple” (Elise, 1998;
Winnicott, 1952) is interrupted by a third, someone that competes for
the mother’s attention. Over time, the developing boy identifies with
this third, who is often the father. Through the father’s establishing a
loving bond with his son, his “attractive function,” which also stands
for a “nonmother space” (Diamond, 2017, p. 307), fosters the child’s
capacity to explore the outside world (Abelin, 1971) and facilitates
the establishment of his masculine self through the child’s identifica-
tion with his father. For Manninen (1992), the basic condition for the
establishment of this form of masculinity is the creation of an emo-
tional barrier against the wish to maintain a dependent relationship
with the mother and a corresponding experience of gratification in
exploring the outside world.
For patients with muscle dysmorphia, the father, usually largely
carrying the paternal function, may not have been able to establish
a loving bond with the developing boy and thus foster his separa-
tion and individuation and the consolidation of his masculine identity.
These patients, in fact, may have experienced their fathers as bigger,
stronger, and more expansive and themselves as comparably weak,
vulnerable, and shameful. This experience of the paternal function
instead threatens the child with the possibility of remaining trapped
in symbiosis with the mother, making him feel small, vulnerable, and
weak. In the face of this, the child discovers the possibility of ideal-
izing an aspect of the persecutory paternal function, specifically the
version of masculinity characterized by “bigness” (Corbett, 2001) and
impermeability (Elise, 2001) that it seems to represent. Over time,
this splitting leads to increasing idealization of masculine attributes
to avoid emotional experiences of weakness, vulnerability, and shame
(Brady, 2017). Notably, this conceptualization is consistent with the
“masculinity hypothesis” in eating disorders research, which suggests
that conformity to masculine gender roles increases the risk for mus-
cularity-oriented body dissatisfaction and disordered eating (Grif-
fiths, Murray, & Touyz, 2015).
This idea has gained some support from empirical research. In a life
history examination of 20 males with muscle dysmorphia, a common
narrative of childhood victimization through bullying for perceived
106 Role of Father and Paternal Function

differences such as being small, weak, or non-athletic emerged. In

most cases, the father was identified as the central person involved
though in others, sports coaches and peers were mentioned. The men
interviewed described how these experiences of relational victimiza-
tion left them with a heightened awareness of their failings as men
and how the obsessive pursuit of muscularity seemed to offer the pos-
sibility of consolidating a firmer sense of masculine identity (Tod,
Edwards, & Cranswick, 2016). In a recent empirical study, muscle
dysmorphia was significantly associated with vulnerable narcissism,
which also supports the idea that the self-esteem of these patients has
been undermined (Boulter & Sandgren, 2021).
After our work continues to progress, John is increasingly able to
speak about his experience with his father who, it seems to him, is
invested in maintaining a dominant stance in relation to this son. His
stance, we come to believe, might appropriately be described as “bul-
lying”: “the exposure of an individual . . . to negative interactions on
the part of one or more dominant persons, who gain in some way from
the discomfort of their victims” (Twemlow, Sacco, & Williams, 1996,
p. 297). His father is likely experiencing himself in these interactions
as a good father who is protecting his son, teaching him important les-
sons, while also defensively shoring up a sense of himself as knowl-
edgeable and powerful in relation to his son, who he experiences as
small, vulnerable, and weak. John describes how although he deeply
resents his father, he also envies his apparent strength. Bodybuilding,
he feels, is a concrete way to develop his own strength so that he will
never be bullied and so have an experience of feeling small, vulnera-
ble, and weak again.

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Chapter 9

Eating Disorders in
Cyberspace

Introduction
This chapter offers a psychoanalytic perspective on pro-anorexia
(“pro-ana”) Internet forums. In the form of chat rooms, newsgroups,
and websites, pro-anorexia has emerged in recent years as a cultural
movement in cyberspace that takes an at least partially positive atti-
tude toward anorexia nervosa and other eating disorders. Notably,
there are also “pro-mia” online forums that focus on bulimia ner-
vosa, bodybuilding forums that have many participants who struggle
with muscle dysmorphia, as well as a range of other online spaces
in which those struggling with food, weight, and shape interact and
express themselves. While the online landscape continues to evolve,
in this chapter we will focus specifically on pro-anorexia forums both
because they have been subjected to the most theoretical and empiri-
cal research and because the ideas elaborated here will prove fruitful
when thinking about patients who make use of other kinds of online
platforms.
The empirical literature documents both the harm and poten-
tial benefit pro-anorexia forums offer participants. The deleterious
effects of participation, including decreased self-esteem, self-
efficacy, and perceived attractiveness, as well as increased negative
affect and perception of being overweight, have been clearly demon-
strated (Bardone-Cone & Cass, 2007). Recent empirical research,
however, takes a nuanced point of view, suggesting that participa-
tion has benefits, including social support, a way to cope with a
stigmatized illness, and a means of self-expression (Yeshua-Katz

DOI: 10.4324/9781003016991-10
112 Eating Disorders in Cyberspace

& Martins, 2012). Here we explore how participants make psycho-

logical use of these forums. On the one hand, they may provide
participants with a potential space (Winnicott, 1971) that fosters
psychological development, allowing participants to play with ideas
about relationship, identity, and even recovery. For the purposes of
this chapter, potential space is a state of mind in which play and
creativity are possible. In contrast to this, pro-anorexia forums may
also provide an opportunity for psychic retreat (Steiner, 1993) in
which cyberspace becomes a “funhouse mirror” (Malater, 2007):
an escape from a reality that has become unbearable and a place
of “relative peace” (Steiner, 1993, p. 1). Psychic retreats are prob-
lematic because they foreclose the possibility of emotional growth,
creativity, and authentic engagement with relationship.
At the outset, it must be acknowledged that while this chapter
investigates the constructive psychological use that some participants
make of pro-anorexia forums in addition to the harm they may suffer
by engaging with them, clinical treatment, especially with adoles-
cents, often involves helping parents think critically about how their
children are engaging in cyberspace. At times, this may entail helping
parents to set limits with their children that foreclose their participa-
tion in these forums entirely. At other times, parents may themselves
not yet be psychologically capable of providing or enforcing such lim-
its. Each situation must be evaluated on a case-by-case basis and the
ideas developed in this chapter are meant to enhance the clinician’s
ability to assess the impact that these forums are having on patients.

Pro-Anorexia Forums
Pro-anorexia has emerged in recent years as an Internet-based cul-
tural movement that takes an at least partially positive attitude toward
anorexia nervosa and other eating disorders. Most pro-anorexia (com-
monly referred to as “pro-ana”) forums offer guidelines for beginning
and maintaining anorexia, tips for rapid weight loss, dieting compe-
titions, ways to avoid detection by family and friends, and motiva-
tional images (“thinspiration”) to inspire further weight loss (Strife &
Rickard, 2011). More than 500 forums exist at a given time, though
estimates are unreliable as forums are frequently shut down by their
hosts and reopened at new locations (Atkins, 2005; Bardone-Cone &
 Eating Disorders in Cyberspace 113

Cass, 2007). This number vastly exceeds that of recovery-oriented

forums (Chesley, Alberts, Klein, & Kreipe, 2003).
The pro-ana community does not reflect a single, coherent phi-
losophy. On the contrary, each site has its own unique perspective of
what it means to have an eating disorder – for example, whether eat-
ing disorders are a lifestyle or a medical condition (Strife & Rickard,
2011), a positive or negative experience (or both), an experience to be
cultivated or to be avoided. In some ways, the pro-ana community is
defined in opposition to its adversaries. When an outside user posts an
attack on a pro-ana forum or a site is shut down by its host, the resis-
tance of its users and their shared goals and beliefs are strengthened
(Giles, 2006)
Like anorexia nervosa itself, pro-ana sites confront visitors with
what has been described as “the spectacle of not eating” – words and
images conveying profound degrees of emaciation and embodied
images of suffering (Warin, 2004). Pro-ana sites have raised intense
controversy. Effectively a movement of resistance against conven-
tional conceptualizations and treatments of eating disorders (Giles,
2006), they have raised concern among both health professionals
and parents, who express alarm that these forums harm vulnerable
individuals (Paquette, 2002). What is the impact of pro-ana forums
on participants? The deleterious effects of participation, including
decreased self-esteem, self-efficacy, and perceived attractiveness, as
well as increased negative affect and perception of being overweight,
are documented (Bardone-Cone & Cass, 2007). Recent research,
however, takes a nuanced point of view, suggesting that participation
has benefits, including social support, a way to cope with a stigma-
tized illness, and a means of self-expression (Yeshua-Katz & Martins,
2012). Another suggests that participants who sought emotional sup-
port on pro-ana forums experienced benefit, whereas those who use
the sites for sustaining an eating disorder without seeking emotional
support were harmed (Csipke & Horne, 2007).
The fact that pro-ana forums appear to have benefits for some par-
ticipants is a bracing discovery. Theorists have recently turned their
attention to cyberspace, with a growing body of work on the psycho-
logical implications of the Internet (Marzi, 2016; Turkle, 1997, 1985),
the intersection of psychopathology and cyberspace (Curtis, 2007;
Wood, 2011), and the interplay between the Internet and psychoanalysis
114 Eating Disorders in Cyberspace

(Russell, 2015; Lemma & Caparrotta, 2014; Migone, 2013; Lingiardi,

2008). Without a doubt, cyberspace has introduced a dramatic change
into our cultural understanding of reality (Hartman, 2011) but the nature
of that change is a matter of ongoing debate. Does cyberspace offer a
potential space, an avenue for personal development and growth, or a
venue for psychic retreat (Lingiardi, 2008)? In other words, cyberspace
has been envisioned as offering an opportunity for creative fantasy and
imagination and as a potential “funhouse mirror, trapping the wary and
vulnerable in pseudo-reality” (Malater, 2007).
Consider “Sara,” a young woman with anorexia nervosa who was
first discussed in Chapter 4: Abjection and Bodily Disgust. In our
work together, we learn that pro-ana forums serve several purposes for
her. At times, her participation functions as what Steiner (1993) calls
a psychic retreat, a place to withdraw from overwhelming emotional
pain. Indeed, in cyberspace she is subject to the same ruminations
and fixations and often uses these venues for perseverative thinking
separate from relationship. For example, over periods of weeks she
recounts posting virtually identical material, often focused on the
specifics of calories ingested, calories expended throughout the day,
and current body weight. It seems to me this is done not in hope of
relational response but as a way of containing her anxieties. These
experiences do not contribute to her emotional growth, but rather are
a way to make her overwhelming anxiety more manageable.
Over time, particularly as our work progresses, Sara also finds
herself able to develop a kind of mutuality (though at a sufficient
distance) in her online relationships, which she has not been able to
do in the real world. As we explore this, we discover that pro-ana
forums provide her with a good enough environment for play: the
computer and its connection to cyberspace is sufficiently removed
from the exigencies of reality without becoming pure fantasy, a space
on the “border between self and not-self ” (Turkle, 1997, p. 30). As
Gabbard (2001) writes,

The person sending an e-mail message is alone, but not alone. The
apparent privacy allows for freer expression, but the awareness
of the other receiving the e-mail allows for passionate attachment
and highly emotional expressiveness.
(p. 734)
 Eating Disorders in Cyberspace 115

Pro-ana forums become, at times, a form of potential space for

her because they are a move toward relatedness away from purely
omnipotent fantasy while retaining an element of control. As Lin-
giardi (2008) writes, “Spoken dialogue, more than written exchange,
seems to confer ‘reality’ on a phenomenon” (p. 120). She begins to
find a way to play with her thoughts and feelings in a space between
reality and fantasy, where her fears of traumatic intrusion can be kept
at a distance. With this emergence of the capacity to generate poten-
tial space, she engages in increasingly imaginative dialogue with her
peers. For her, pro-ana forums serve as a space that allows her to
imagine different thoughts, feelings, and ways of being in the world
without the commitment real-life action entails or with the same level
of vulnerability that face-to-face interaction involves. Over time, her
emerging capacity for play makes its way into our clinical work. After
several years, she relinquishes the forums entirely, in favor of more
relational forms of play.

Observations of Pro-Ana Forums

This section draws upon a previously published article (Wooldridge,
Mok, & Chiu, 2014) that conducted a qualitative analysis of pro-
anorexia forums. The data gathered supports the thesis that pro-ana
forums provide participants with the opportunity to make use of
potential space (Winnicott, 1971) for creative play with multiple
dimensions of their experience and, at the same time, offer a venue for
psychic retreat (Steiner, 1993), an escape from truth and relatedness.
In the clinical process, we must assess the ways in which pro-anorexia
forums are utilized with respect to each individual patient’s underly-
ing psychodynamics at each moment in the treatment.
The architecture of pro-ana forums facilitates the generation of both
potential space and psychic retreat. Potential space depends on the
capacity to maintain a dialectical process between oneness and sep-
arateness, fantasy and reality (Ogden, 1985). For patients with eating
disorders, traumatic themes like those discussed in earlier chapters have
compromised the capacity to generate potential space. On pro-anorexia
forums, the high level of control afforded to participants may allow
for certain disturbing aspects of reality to be set aside, making it pos-
sible to maintain the dialectical process between fantasy and reality to
116 Eating Disorders in Cyberspace

a degree and for potential space to become temporarily accessible. At

other times, reality may become too much to bear and this same control
extends into omnipotence, facilitating psychic retreat (Steiner, 1993),
in which participants escape from engagement with painful emotional
experiences entirely. In this section, we will explore several themes that
emerge on these forums with attention to both possibilities.
The experience of alienation is prominent among participants in
pro-ana forums. Here young men and women lament their estrange-
ment from friends and family and their extreme loneliness, which is
the conscious, affective component of alienation (Burton, 1961). As
one participant wrote,

the nature of the beast being mostly secretive and lonely, it’s a
comfort to know that others have gone through the same thing.
When I first found a similar ED [eating disorder] web site at age
16 I nearly wept with relief – I had suffered alone in silence for
almost five years, and didn’t know anyone else who had an ED.

Sartre’s (1984) elucidation of alienation in his analysis of “the

look” assists us in thinking about this aspect of participants’ experi-
ence. When we are engaged in the immediacy of our lives, we expe-
rience the world through a first-person perspective in which others
are experienced as objects related to our current pursuits. When we
become aware of being looked at – in his words, when our subjectiv-
ity is invaded by the subjectivity of another of whose world we are
merely a part – we become aware of another, more objective aspect
of our nature insofar as it exists as an object in the mind of a separate
subjectivity. We become aware that we are alienated from a dimension
of our being that resides outside of our immediate experience.
Many participants describe experiencing the other as forcing upon
them a disruptively different aspect of reality from their own, subjec-
tively apprehended, experience. They frequently speak about parents
and treatment providers who insist that they relinquish their symp-
toms without an empathic understanding of the underlying struggles
that drive their engagement with them. In many cases, this experience
of having one’s subjectivity invaded by the subjectivity of another
reverberates with earlier experiences of traumatic intrusion. In the
words of one participant,
 Eating Disorders in Cyberspace 117

Everybody around me thought they knew more about it than I

did. I felt like the loneliest person on the planet . . . everyone was
telling me what was wrong with me and how I should feel. but
its always been that way for me, even before I had the ED my
parents never thought me my own person.

Pro-ana forums present participants with the possibility of retreat-

ing from the pain inherent in the experience of alienation, for on
pro-anorexia forums almost all participants share a remarkable degree
of understanding of the underlying pain that drives disordered eat-
ing. Of course, psychic retreats can serve as both pathological orga-
nizations or as temporary, self-regulatory private spaces that foster
resilience and reconsolidation (Steiner, 1993). The problem, in other
words, is not the retreat itself but how the retreat is used. When we
emerge from retreat, are we more equipped to deal with the exigencies
of day-to-day living? As one participant wrote,

When I come on here and talk, I can actually cope, can get
through the rest of the day. This place has given me so much
strength. Its given me the support I need to get treatment, to reach
out to friends.

In this excerpt, a participant makes use of a pro-ana forum as a tem-

porary retreat that allows him to refuel, emerging again into the world
of relationship less battered and more resilient than before. Others,
however, use pro-ana forums as extended retreats. In the words of one
participant, “Why bother with people? They’ll fuck you up and disap-
point you. Better to stay on the computer.” Thus, pro-ana forums can
become a way to avoid relational contact that feels too threatening
almost entirely. As Faber (1984) has written,

[The computer] offers itself to its manipulator as a powerful

little world, a powerful little universe, a kind of microcosm, that
can be totally mastered, totally controlled, in such a way as to
offset, at the unconscious level, early narcissistic wounds expe-
rienced in the failure to master, to control, the primary caregiver
or “object.”
(p. 267)
118 Eating Disorders in Cyberspace

At their worst, pro-ana forums serve as a container into which

participants evacuate their emotional lives to dissociate from them,
engaging in repetitive behaviors that do not lead to emotional growth.
The most common of these repetitive behaviors is the declaration of
highest weight, current weight, and goal weight. Similarly, partici-
pants often repeat their calories eaten or calories burned. These con-
versations are notable for their lack of involvement with the other;
they are posted without expectation of response, and any response
that is made is rarely engaged. This is among the most pathological
uses of these forums.
While psychic retreat may be helpful for the ego at times, it
becomes problematic when used at great length. As participants
become increasingly involved with the ethereal world of pro-ana,
they may become increasingly detached from the real world, with
the physicality (and frailty) it entails. Consider the following excerpt
from one participant:

I spend all my free time here. . . . I dunno what I’d do without all
you. Don’t really have any friends, nothing worth spending time
on. This place has saved me.

Although cyberspace may provide retreat from relational anguish, it

also provides the opportunity to make initial steps into a world inhab-
ited by others (Lingiardi, 2008). In some cases, participants make real
connections with their peers. The relative safety of cyberspace makes
the possibility of relational connection feel within reach for those with
fraught histories of emotional intimacy. As one young man wrote,

Part of why this is the best support site is that people on here are
in all stages of [eating] disorders and can come here no matter
what they feel about their EDs. I have made real friends here,
more than in my RL [real life], where it’s so hard.

In this excerpt, we can see a participant who has found “real

friends” on a pro-ana site, both because of common experience he
shares with other participants and, presumably, because of the kinds
of experience an online forum makes possible for him. Indeed, it is
because pro-ana sites protect participants against an experience of a
 Eating Disorders in Cyberspace 119

reality that is too much to bear that potential space and, thus, deeper
relationships become accessible.
Similarly, the atmosphere of tolerance for experimentation and the
relational warmth that accompanies many conversations is remark-
able. Consider the following excerpt:

nice to see you here! i think you’ll find that people are accepting
of what you’re going thru. a lot of us are in different stages of
recovery and a lot of people are still struggling with their sexual
orientation gay? bi? straight? it’s a question that i’m always ask-
ing myself, still no answers.

There is an implicit agreement within the pro-ana community that

the differentiation between “real life” and life in cyberspace will not
be confronted. This makes play, which depends heavily on maintain-
ing an illusion of this kind, possible (Winnicott, 1953). When this
area of illusion is collapsed by outsiders insisting on the differentia-
tion between real life and life in cyberspace – through “flames,” or
comments made by hostile site visitors (O´Dochartaigh, 2002), for
example – strong responses are elicited (Giles, 2006). Consider the
following example of an outsider’s critique.

I know you probably feel you are doing a deed to those who are
afflicted with this illness, but the way in which you go about pro-
moting it is not only wrong, it is contributing to the delinquency
of others (most of whom are more than likely minors). Giving
“diet tips” and encouragement to eat less than the recommended
amount of daily calories could be hindering the health of young
girls (and perhaps boys) everywhere. It is people like you who
continue to put it in these young women’s minds that they aren’t
good enough, when that is simply not true. You think you are the
answer, you think you are doing the right thing; you are not. You
are the problem with this world.

In this excerpt, we see an outsider’s attack on the pro-ana forum,

reflecting a collapse of his own ability to understand what the site
represents to its participants. Instances such as these are often reacted
to with outright aggression; in many cases, moderators remove them
120 Eating Disorders in Cyberspace

from the forum entirely. When the impingement of reality collapses

the illusion necessary for play, participants, both as individuals and
as a community, make a concentrated effort at the restoration of illu-
sion. The consensus of the pro-ana community and the omnipotence
afforded by modern technology are precisely what makes it possible
for this illusion to be maintained with relative consistency.
Questions of identity are inherent in pro-ana forums. Among the
questions pertaining to identity that are explored on pro-ana forums,
perhaps the most common is, “What does it mean to be anorexic?”
Pro-ana websites do not reflect a universally coherent standpoint.
On the contrary, each site has its own perspective on what it means,
and the term ‘ana’ has become the subject of intense identity negotia-
tion. For example, participants appear to frequently consider whether
anorexia is a lifestyle choice or medical condition, a positive experi-
ence or a negative one (Giles, 2006).
Individuals with eating disorders find themselves the object of
public scrutiny and clinical diagnosis. They must reconcile their own
experience of eating disorders as empowering states of distinction
with immense symbolic power with the one-sided representation
of eating disorders by the media and medical professionals (Warin,
2004). Deprived of their agency, these individuals are likely to seek
alternative forums in which they can reclaim their power from out-
side agencies. Indeed, pro-ana forums provide such a venue, a poten-
tial space in which individuals can engage in what has been called
“agency play” (Battaglia, 1997, p. 507), which can be seen in the
following excerpt:

I just wanna put it out there that I’m tired of being told what I am
by my treatment team. They think they know more than me about
what I feel. I’m not a diagnosis; I’m a person who carries around
ana by myself all day, every day. And maybe ana is not what they
think it is, maybe it’s both better and worse.

Here, we can see a participant begin to think about various aspects

of her identity and, furthermore, resist having her identity defined
primarily by others. In this forum, she can develop a more nuanced
perspective about what it means to be “ana” – a perspective that is
ultimately more resonant with her experience.
 Eating Disorders in Cyberspace 121

Pro-ana forums also provide a potential space for participants to

play with various aspects of identity. As Turkle (1997) argues, the
Internet, with its relative anonymity, provides individuals with a lab-
oratory for exploring and experimenting with different versions of
self. With the anonymity these forums provide, participants are free to
express themselves and behave in ways that are frowned upon in their
day-to-day lives (Bargh, McKenna, & Fitzsimmons, 2002). Indeed, in
face-to-face interactions, disclosing or experimenting with one’s sense
of identity can have serious consequences (Derlega, Metts, Petronio,
& Margulis, 1993). In contrast, pro-ana forums provide participants
with the possibility of inhabiting a space between fantasy and reality;
free to fantasize, they are nonetheless in contact with others, but with-
out the same degree of risk found in the real world.
The most striking element of pro-ana forums is visual in nature. In
its most common form, “thinspiration” or “thinspo” consists of moti-
vational images of models, actresses, and actors, or even site partici-
pants, many of which have been modified to make them appear even
more emaciated. Thinspiration image may serve as a concrete repre-
sentation of a yearning for a particular kind of psychological state:
emptied out of toxic projections at the hands of important objects
and the capacity to remain impervious to further projections. In many
cases, participants develop favorite models as sources of thinspira-
tion, and follow and discuss them over time.

Have you seen the Machinist? I want to look like Bale. he’s got
no excess at all, totally ripped. If I could look like that, I think id
be happy with my life for good – ahhhh contentment.

Often, participants post images of themselves, providing a visual

record of their increasing emaciation over time. In these images, we
find a visual representation of the participant’s internalized object
relationship. Lemma (2010) writes that the body can be open and
receptive to the other or it can be shut down, keeping the other out.
Drawing on Frank (1991), Lemma (2010) describes the monadic
body, which serves as a psychic retreat (Steiner, 1993), an idealized
state that can be used to hold the self together and to resist the regres-
sive pull back into a fused relationship with the mother. Consider the
following excerpt:
122 Eating Disorders in Cyberspace

Im still working on it. No breakfast, coffee only, 3 hours of exer-

cise. Im running seven miles every am. Im going to post some
badass thinspo of myself soon! It feels like I barely need food
anymore. Its amazing to see!

We might speculate that this participant’s “barely needing food”

suggests his fight against the allure of dependency. In other cases,
thinspiration seems to serve as a kind of communication by impact
(Casement, 1991). When I first encountered so-called “thinspira-
tion” images, I felt intruded upon by the intensity of their suffering
and frailty. As intrusion and invasion are central to the experience of
anorexia nervosa (Williams, 1997), these images seem to say, “I feel
invaded by your gaze, and I am going to invade you in return.”
Surprisingly, much conversation on pro-ana forums is focused
on the possibility of recovery. The experience of eating disorders is
fraught with ambivalence (Williams & Reid, 2010). In the literature
and in clinical practice, patients report feeling uncertain about whether
anorexia is a “friend” or an “enemy” and whether it is a problem that
needs treatment (Colton & Pistrang, 2004), often spending a great
deal of time weighing its advantages and disadvantages (Cockell,
Geller, & Linden, 2003). On these forums, participants find a space
in which to play with their ideas about the benefits and risks of their
eating disorders. In the following excerpt, a participant gives voice to
a “positive” aspect of the anorexic experience.

Have any of the people against ANA been fat? It’s the worst feel-
ing. When added to physical problems keeping you from ade-
quate exercise, Ana is a godsend. So I feel really grateful to Ana
for that, that she’s taken that pain away.

In this excerpt, the participant is commenting on the perceived psy-

chological benefits of anorexia. She experiences her eating disorder
as the lesser evil when compared to the feelings of distress she expe-
riences when not actively restricting. In contrast, consider the follow-
ing post:

I feel unsure, as well. But I don’t want to go on starving. Like, I

don’t want to have an ED, but I don’t want to have to eat, either.
 Eating Disorders in Cyberspace 123

In this excerpt, we see a participant with more overtly expressed

ambivalence: though eating is a fraught experience, starvation is also
understood as a deeply unsatisfying in significant ways as well. In
some cases, these forums provide the space for sufferers to play with
the idea of recovery in all its dimensions, including weight restoration.

so what’s it like exactly to feel normal weight? I gain a pound

and feel fat as all hell so I cant [sic] imagine what itd be like to be
looking like people I see walking around. but then I look at em
and they look happy sometimes, it makes me wonder if its worth
it . . . [anorexia]

In this excerpt, a participant is beginning to think about what it might

be like to change his relationship to his body and its weight and shape.
He is, furthermore, questioning whether the psychological benefits of
his disorder justify their cost. In the following excerpt, we encounter
a participant who is more motivated toward recovery.

looking to attempt recovery again, and I’m feeling really fuck-

ing passionate about succeeding this time. I’m so done with this
chapter of my life, I don’t want to restrict and b/p [binge and
purge] my brains out all the time. One of the things I’ve failed
to do in the past when attempting recovery is reach out to others
doing the same, so I was hoping to find some others on this site
who are in whatever stage of recovering just as someone to lean
on or even to help encourage. I need all the help I can get!

This participant is strongly motivated to change. He is clearly reach-

ing out for support – an act which may have been made possible
through his relationship to pro-ana forums – and has made a connec-
tion between receiving emotional support and increasing his chances
of recovery.
In each of the themes discussed here – alienation, relational con-
nection and support, questions of identity, and ambivalence about
recovery – we see examples of participants making use of pro-anorexia
forums to facilitate potential space in which to think creatively, as
temporary psychic retreats in which to refuel before further engage-
ment with painful aspects of reality, and as containers into which they
124 Eating Disorders in Cyberspace

evacuate their emotional lives in order to dissociate from them. In

fact, the same participants may use the same forums in each of these
ways, often in remarkably short spans of time. Ultimately, clinicians
are tasked with assessing in each moment how pro-anorexia forums
function for each patient and must position themselves appropriately
within this shifting landscape of the patient’s emotional world as treat-
ment unfolds. In some cases, this may entail working directly with
parents to foreclose patients’ engagement with these forums entirely.
When this is not possible or not immediately warranted, the ideas pre-
sented in this chapter may facilitate our efforts to speak with patients
in ways that forward their emotional development.

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Index

abjection 6, 49–63; definition paternal function and 102–103;

49–50; foreign bodies 54–58; sexuality and 31–32
forms of 52; oral disgust 52; appropriateness 46n1
rotten core 58–61; sexuality appropriation 19
and 53 attachment insecurity 44–45
abstract-reflexive level 19 attachment theory 44–45
adolescence 26, 31, 99 automaticity 90
Adult Attachment Projective Picture
System (AAP) 45 Bagby, R. M. 22n1
affect: as bodily experience 20; Becker, E. 4
categorical 88–89; definition Beresin, E. V. 99
16; in horizontal dimension 19; Bers, S. 101
primary 88; in somatic register beta elements 20
18, 88 Bick, E. 70, 71
affect regulation 88–89 binge eating disorder 91–92
agency 38, 43; anorexia nervosa and Bion, W. 20, 21, 22, 32, 33, 54,
100–101; gender and 79–84 55
Alexander, F. 30 Blatt, S. J. 101
alexithymia 13, 14–17, 19, 21–22, Blos, P. 31
22n1, 22n2 bodily disgust see abjection
alpha elements 20 body image 7, 87, 92–94
alpha-function 32 body image disturbance 27
altered states of consciousness 90 body imaginings 93–94
annihilation anxiety 68–69 body–mind dissociation 64–74;
anorexia nervosa: abjection and annihilation anxiety 68–69;
51–52; agency and 100–101; containment breakdown 65–68;
attachment trauma and 45; entropic body 71–73; introduction
containment breakdown 67; 64; psychic skin 70–71
diagnosis 30; mothers and fathers Boris, H. N. 30
in 98–100; object hunger and Bouchard, M.-A. 17
31; object relations and 26–27; Bowlby, J. 44
128 Index

Brisman, J. 77, 78 Ego and the Id, The (Freud) 43

Bromberg, P. M. 91 Elliott, J. C. 99
Bruch, H. 15, 26–27, 40, 51, 98 Ellman, M. 51
bulimia nervosa: closet narcissistic emotions 16, 88–89
personality disorder 28; object entropic body 6, 65, 71–73
hunger and 31; sexuality and evidence-based treatments 2–3
31–32 externalization 19
Butler, J. 50
Faber, M. D. 117
Caston, J. 38, 46n1 false body 6, 64
categorical affect 88–89 false self 72
Chasseguet-Smirgel, J. 56 family-based therapy (FBT) 2–3
closed system of self-regulation 36, father hunger 102
39, 40 father role see paternal function
closet narcissistic personality FBT see family-based therapy
disorder 28 (FBT)
cognitive disconnection 44 feelings 16; see also emotions
compartmentalization 90 Ferrari, A. B. 64
complex trauma 89 Fiorini, L. G. 98
containment 32–33, 54–55, 65–68 Fonagy, P. 16, 22n3
Corbett, K. 104 foreign bodies 54–58
critical agency 43 Frank, A. 121
cultural analysis 79 Freud, S. 16, 30, 36, 37, 41, 42, 43,
cyberspace 111–126; introduction 52, 69, 75, 77
111–112; pro-ana forums 112–
124; pro-mia forums 112 gender: agency and 79–84; identity
81
Darwin, C. 88 gender-based splitting 84
Davies, N. 98 gender development 76, 79;
deactivation 44 gender identity and 81; muscle
defensive exclusion 45 dysmorphia and 103–104
desire 6–7; nature of 75, 78; gender differences 7, 75–76
poisoning of 80; problem of gender “repertoire” 81
76–79 Ghent, E. 78
developmental trauma 89 Goldberg, P. 65, 72
Diamond, M. 98 Goldner, V. 82
disruptive impulsion 19 Gordon, C. 99
dissociation 87, 88, 90–91 grief see mourning
Dolinsky, A. 101
Douglas, M. 54 Herman, J. 89
dual-track model 39–41 Herzog, D. B. 99, 102
Hill, D. 90
Eagle, G. 98 horizontal dimension 18, 19
early relationships 26–27 Horney, K. 14
eating disorder defined 1 hungry self 87, 91–92
 Index 129

Image and Appearance of the Nemiah, J. 16

Human Body (Schilder) 92 no-entry defense 56, 67
imaginal register 18 Novick, J. 5, 36, 39
individuation process 31 Novick, K. K. 5, 36, 39
internalization 43–44
Internet see cyberspace object constancy 28
interoceptive awareness 15 object hunger 29–32
interoceptive disturbance 27 object relations theory 5, 26–28
onefold 64
Kelman, N. 14 open system of self-regulation 36,
Kernberg, O. F. 40, 77 40
Kristeva, J. 6, 49–50, 52 oral disgust 52
Krystal, H. 21, 22n1 orthorexia 65
Kurash, C. 28
paternal function 7–8, 97–110;
Lawrence, M. 27, 55 anorexia nervosa and 98–100,
Lax, R. 59 102–103; definition 98; in muscle
Lear, J. 37 dysmorphia 104–106
Lecours, S. 17 patient categories 2
Lemma, A. 93, 121 perceived-competence deficit 101
Lingiardi, V. 115 potential space 112, 115–116
Loewald, H. 43 Powers of Horror (Kristeva) 49
primary affect 88
Mahler, M. S. 58 pro-ana forums 8; discussion
Maine, M. 103 of 112–115; effects of 113;
Manninen, V. 105 introduction 111–112;
Masterson, J. F. 27 observations of 115–124
mentalisation 14, 17–19, 20, 22n3, 89 Probyn, E. 51
modulated impulsion 19 pro-mia forums 8, 111
monadic body 121 psyche-soma 20
mother–child relationship: anorexia psychic elaboration of emotion
nervosa and 26–27, 30, 98–100; 16–17, 20
containment and 32, 54–55; psychic retreat 9, 112, 114, 117,
desire and 78; individuation and 121
51; rotten core and 58–59; self- psychic skin 70–71
regulation and 40, 54; symbiosis psychoanalytic approach 3–4
and 82–83; traumatic themes
37–38 Quatman, T. 18
motoric register 18 Quinlan, D. M. 101
Moulton, R. 78
mourning 5, 36–37, 41–46 rapprochement subphase 58–59
Mourning and Melancholia (Freud) relational school of psychoanalysis
42 7
muscle dysmorphia 8, 31, 75, 83, relational trauma 7, 87, 89–90
103–106 repetition 36, 37–41, 42
130 Index

representation 17 symbolic equation 17

reverie 4, 20–22, 64 symbolization 27
reversibility 46n1
Ritvo, S. 31 Target, M. 22n3
rotten core 58–61 Taylor, G. J. 22n1
thinspiration 112, 121–122
Sands, S. 82 transformation 20
Sartre, J. P. 116 traumatic themes 9; breakdowns in
Schilder, P. 92 containment 32–33; definition 37;
Schoen, S. 79–80, 83 object hunger 29–32; repetition
Segal, H. 17 and 37–41
segregated systems 44 Turkle, S. 121
self-holding 70–71 twofold 64
self-observation 46n1 two-systems model 39
self-regulation 36, 39–40 Tyson, P. 81
self-states 87–88, 90
separation-individuation 31, 58–59 van der Kolk, B. H. 89
sexuality 31–32; abjection and 53; verbal register 18
agency and 80; inhibition 77; vertical dimension 18
sadomasochistic 77
Shedler-Westen Assessment Wanting (Brisman) 77
Protocol (SWAP-200) 2 Warin, M. 51, 52, 53
Siegel, D. 89 Williams, G. 55–56, 67
Sifneos, P. E. 14 Winnicott, D. W. 20, 69, 70
single-track model 39 working through 41
skin 70–71
somatic register 18, 88 Yarock, S. R. 31
Steiner, J. 114
Sugarman, A. 28 Zerbe, K. J. 56