9 Slices
Medium 9781855753839

CHAPTER THREE

Marilyn Lawrence Karnac Books ePub

Once they become established, eating disorders are notoriously difficult to treat. There is no single form of treatment that we can say categorically is effective in all or even most cases. The kind of treatment I discuss here is a form of psychotherapy, based on psychoanalytic principles, that I have found to be helpful to very many patients. The reasons I think that it is often helpful are twofold. The first is that this form of treatment seeks to understand the uniqueness of the individual. While I try to outline in succeeding chapters where the developmental difficulties may lie, each patient is different, and someone needs to take the time and effort to understand precisely what has gone wrong for this individual. This is what psychoanalytic psychotherapy aims to do. The second reason for the usefulness of this treatment lies in the fact that it is based on a relationship. In eating disorders, many relationships will have broken down and the patient will be more or less terrified of getting close to anyone. And yet this is precisely what she needs to do if she is to understand what has happened to her and begin to find a way forward in her development.

See All Chapters
Medium 9781855753839

CHAPTER NINE

Marilyn Lawrence Karnac Books ePub

An observation of mine—and one that is shared by colleagues—is that, over the past thirty years, the eating disorders population has slowly but dramatically changed. In general, the young people we see treated in specialist eating disorder units seem to be more disturbed, more seriously ill, and more difficult to treat than they were in the past.

Practically speaking, we see more dual-diagnosis patients, with self-harming behaviour such as cutting or drug abuse frequently going with a serious eating disorder. The nurses who work in inpatient units report more incidents of violent acting out and more cases of absconding. The cases are often ones that I would think of as forensic, with high levels of delinquent behaviour such as stealing, but also fire-setting and other forms of law breaking that involve police intervention. In terms of the severity of the eating disorder itself, my impression is that more patients today require nasogastric tube feeding. I certainly do not think that staff groups fall back on this course of action easily. I think it is an extreme measure, one that raises issues about the rights of the patient, and in my experience the staff also regard it in this way. The staff who work in specialist units are better educated and better trained than in the past, and some of them are very talented, so I do think that the patients are more difficult. It is not easy to account for this change, but it suggests to me that young people who are encountering serious difficulties are more likely today to show symptoms of an eating disorder as at least a part of the clinical picture than they might previously have done. This is a worrying development. It leads me to doubt the effectiveness of the educational initiatives that have been put in place.

See All Chapters
Medium 9781855753839

CHAPTER TWO

Marilyn Lawrence Karnac Books ePub

The manipulation of the size of the body by deliberately limiting food intake (or, indeed, by overeating) has probably been practised by certain sections of every civilized society. However, it is the tradition we call asceticism, often associated with religious fervour, that has become particularly associated with the eating disorders of anorexia and bulimia. Asceticism nearly always involves fasting, sometimes in extreme forms. Other forms of what we might now call “self-harm”, such as self-flagellation and self-cutting, have often formed a part of both Eastern and Western religious traditions.

Well-known examples would include the early Christian anchorites and anchoresses who practised extreme forms of self-denial, living in caves as desert hermits. Underlying these practices is a dualistic understanding of mind/soul and body. The body is viewed, like the external world, as essentially sinful. The mind/soul can achieve perfection only if the body can be subdued and overcome. The body is felt to be an enemy of the soul, which it attempts to keep trapped in sinful imperfection (Lawrence, 1979). These beliefs have been explicit and dominant in the Christian tradition at certain points in history, such as the Gnostic heresy in the early church and in the Catharism of the medieval period. However, I believe that this dualistic thinking is actually very prevalent, and all of us to a greater or lesser extent experience our bodies as separate from our minds. Very often the body is regarded as inferior to the mind. The body is essentially uncontrollable. This is especially apparent in adolescence and again in the course of the ageing process. In patients with eating disorders, the uncontrollable nature of the body cannot be accepted. In fact of course, the mind is also uncontrollable. If we are able to think, we have no control over what thoughts come into our minds. These extreme religious practices, although ostensibly aimed at controlling and subduing the body, are in fact also a means of controlling the mind, which becomes utterly dominated by the body and its sufferings and quite unable to think. Paradoxically, although the anorexic and the aesthete both regard their body as the enemy, both are able to think of little else. Another problem with the body is its mortality, whereas the soul is widely believed to live for ever. As we shall see, anorexic patients find the idea of death unacceptable and believe they are indeed immortal.

See All Chapters
Medium 9781855753839

CHAPTER ONE

Marilyn Lawrence Karnac Books ePub

This book represents an attempt to understand the states of mind that underlie the serious eating disorders of anorexia and bulimia. Compulsive overeating or binge-eating is also considered, particularly as it relates to anorexia.

The ideas in the book have developed through two distinct areas of professional practice. The first is my own direct clinical work as a psychoanalyst, treating adult patients who suffer from eating disorders. The second is as a learning resource to the staff who run specialist units caring for patients with eating disorders. In recent years I have worked with colleagues on the MA programme at the Tavistock Clinic, Working with People with Eating Disorders, and am greatly indebted to both students and colleagues for what we have managed to learn together.

The perspective of the book is psychoanalytic inasmuch as it assumes that mental functioning is unconscious as well as conscious and that, as human beings, we only very partially understand our own motivation. However, the book is not written exclusively for psychoanalysts—quite the contrary. An approach that helps practitioners to find meaning in the illnesses of their patients is likely to be helpful to mental health workers from a range of different backgrounds. Following many years of working with psychiatrists, nurses, dieticians, and others concerned with the specialist care of eating-disorder patients, it seems clear that the most difficult task for the professionals is to go on thinking about their patients. This is a group of patients with many features in common, but perhaps chief among these is a real difficulty in thinking about themselves and their own psychological predicament. Staff, too, can become caught up in the mechanics of treatment, focusing on target weights, the body mass index (BMI), the rules and regulations that govern the unit, and the setting in which they work, while at the same time failing to understand in psychological terms what it might be that the patients are reacting to. Faced with the constant pressure and challenge from the patients to give up thinking, it should not surprise us that sometimes we do just that. A psychoanalytic framework can provide a structure that can enable thinking to be recovered, even if the work itself seems a long way from psychoanalysis as we normally understand it.

See All Chapters
Medium 9781855753839

CHAPTER FIVE

Marilyn Lawrence Karnac Books ePub

There seems little doubt that the advent of an eating disorder in an adolescent girl signals, among other things, that there is a serious complication in her sexual development. In this chapter, I begin my exploration of aspects of sexual and emotional development that seem to be specific to girls. I suggest that a developmental failure in infancy has far-reaching consequences for the whole personality, and I link this with the familiar difficulties in symbolic thinking, which I go on to describe in chapter 6.

In anorexia, there is usually a marked aversion to all things sexual, which I have described in chapter 4. As well an expression of sexual anxiety, I have linked this with an intolerance of the existence of the sexuality of the parents. In bulimia, sexuality, in line with the eating symptoms, may be more varied, with periods of sexual acting out, often including risks of pregnancy. Such occurrences are invariably followed by guilt and shame, and one feels that although there may be sexual activity, it is not at all integrated into the emotional and social life of the young woman. In fact, like food, sexuality always seems something of a torment to the bulimic patient.

See All Chapters

See All Slices