|Anorexia in Adolescence: Between Analysis and Report|
|Congresses - 2004 Barcelona|
|Written by Gianni Nagliero|
The analytic treatment is assumed to be a process based more on unconscious communications than on conscious ones. The patient’s conscious communications have to be used by the analyst as derivatives of unconscious conflicts1 and not as communications on a level of reality. Deviations from this analytic method can be regarded by the therapist as unconscious attacks to analysis.
These attacks can be an expression of what Rosenfeld calls destructive narcissistic aspects2 which are very powerful in anorexic patients. In the same powerful way they push the therapist to behave similarly, thus spoiling the therapeutic relationship, on the bases of countertransferential problems or projective identification mechanisms.
In my opinion this derives from the fact that since therapists are in constant search of real abuse they often miss the opportunity to remain in a relationship with a patient who is trying to understand the symbolic meanings af his messages and interpret their deep psycho- dynamic significance.
I would also like to state how the unconscious tendency to manipulate the analytic relationship shows itself in trying to make the analyst assume any role but the analytical one: the lover, the playmate, the judge, the social worker, the father or mother, and so on.
It is an analyst’s task to recognise these destructive drives and look for their meaning. When the analyst is dealing with particularly serious events such as sexual abuse, the temptation to remain focused on such traumatic external events is very strong, but can result in missing the symbolic meaning. In this way the communicative exchange between patient and analyst is kept only on a level of surface reality.
In therapy with adult patients, these kinds of mechanisms often bring forth an erotic transference and countertransference relationship. When an analytic relationship becomes a sexual one – unfortunately – analysis cannot go on.
In psychotherapy with adolescent patients, mainly with anorectic girls, the patient’s intense seductive entreaties can easily induce the analyst to act a parental role. Because this role is not considered dangerous or unethical, the analyst can be urged to act as a father or a tutor, for instance, concerned more with reporting sexual abuse than analysing the patient’s feelings and unconscious conflicts. (Archetipal aspects, too, 3 active in the relationship between the analyst and a teenage patient, would press the analyst to act this parental role.)
I would like also to stress the importance of sexual fantasies more than actual sexual events.
In the last few years some authors have pointed out the importance of precocious adverse sexual experiences and violence in the aetiology of eating disorders. Doctors began to pay attention to the search of these kind of experiences: analysts too were involved in searching for actual events. In some countries, like the United States, clinicians are forced by law to refer to authorities every suspicion of abuse, or risk losing their licence.
In my opinion the analyst has to concentrate on the unconscious meaning of the patient’s communications, interpreting them as derivatives of unconscious conflicts and understanding them as related to the tranferential relationship.
It is important to say that, in the analytic process, both fantasies and actual events have the same psychic importance. So when a patient, during the analytic session, speaks about an actual episode of sexual abuse, the analyst will try to search for the unconscious meaning and not to answer with concrete acts (such as a report to the law, for instance).
The report would be an acting-out, causing the rupture of the therapeutic alliance and the analytic frame, with the result that the analysis would be impossible. The patient’s request to the analyst, that is to be healed through psychotherapy, would not be fulfilled.
Obviously, it is very important if we are faced with an act of real abuse, but the dramatic event should not divert us from the analytical task, that is to say, looking for the psychological meaning of the concrete experience.
I would like to stress the importance of “perverse” fantasies in the first years of life, associated with non-containement, in the pathogenesis of anorexia nervosa. These traumatic fantasies are reactivated in puberty and adolescence, when the onset of anorexia is much more frequent.
I would like to go now to the first clinical example, in which the intensity and the importance of fantasies in the first two-and-a-half years of life can be shown.
The patient, whom I will call Sandra, is a sixteen-year-old anorectic girl.
In the first meeting severe depression with unworthiness feelings showed up.
The therapist made the hypothesis, and verbalised it to the patient, of the possibility of suicidal acting-out. The patient agreed and confided that she was thinking of suicide.
The therapist offered her, until summer, twice-weekly meetings. After that they would decide toghether what to do.
The patient agreed but showed distrust and pessimism.
Some time afterwards, when a fairly good therapeutic alliance had been established, 4 Sandra told the therapist that she had been sexually abused when she was four years old by her father’s best friend. Later on in the therapy it emerged that when she was six or seven years old a cousin of hers, who was much older, did with her “what husband and wife do,” Lately, during the last two to three years she, had felt obliged to yield to any sexual request her peers proposed to her because she “could not say no.”
She had never told anyone of these events.
The analyst remarked on Sandra’s ego fragility and feared for her personal safety. He felt urged to report these abuses in order to protect such a fragile patient. Nevertheless he reminded himself of his analytic role and tried to think of unconscious meanings in the patient’s communications. He decided then (helped by the fact that the abuse had stopped), to go on being “just” the analyst and doing analysis, maintaining a private thinking space between patient and himself. Isn’t this what the patient had unconsciously asked by specifying that she had never told anybody anything?
It is only within the shared and secure mental space between analyst and patient that a little girl, who has never felt loved and contained by her family, can find sense in the relationship she had with her father’s friend. It is out of her deprived feelings that she can now face her own seductiveness and sadistic and self-destructive sides.
At the same time the continuation of analysis allowed Sandra to recover some self-confidence and reliance on her mother, to whom she can now tell about her sexual abuse. She has now introjected a mother who is “good enough” and on whose protection she can rely.
Being able to recognise, sorrowfully, some intrapsychic and interpersonal meanings even in the abuse experience, allows the patient to feel she is no longer a passive object of external attacks but an active subject who can begin to decide for herself and her life, and, for example, legally proceed against her abusers.
By lessening her own guilt feelings of shame through analysis, Sandra became aware of her own seductive impulses: neurotic, infantile and naive attempts to cope with feelings of rejection and no love.
I will now consider how a very precocious sexual fantasy can become traumatic when the distinction between reality and fantasy is not well maintained and fantasy is felt as a real event.
In fact, in my clinical experience these kinds of fantasies were always present and associated with other psychological features, particularly the experience of passivity with her mother, low self-esteem, insufficient parental care and non-containment, ambivalent relationship with parents (especially mother), self-punishment, etc.
In psychotherapy with anorectic girls, very precocious memories and feelings concerning a particular sexual erotization often emerge. A short example:
Gabriela, an eighteen-year-old anorectic girl, without symptoms of psychosis, depression or other important psychiatric syndromes: A few months after the beginning of the therapy she remembered an event: “I was sitting on the potty, I probably was two-and-a-half years old. My father was in the bathroom too, sitting on the toilette. I was playing with a Barbie doll. I asked my father to kiss the doll and he did.”
The following analytical work made it clearer that the Barbie doll was naked, that Gabriela asked her father to kiss the doll’s breast and bottom, and that she was playing with Barbie and Ken dolls, pretending that they were making love. That event became erotisized and guilty because the little Gabriela had lost the “as-if” play: she imagined she really could substitute her mother during intercourse with her father.
In adolescence other fantasies emerged in which she felt so much better than her mother as a woman, so she would be chosen by her father.
The first trauma, the successful fantasy to seduce her father, and the subsequent guilt, were reactivated in adolescence. In this case the breakdown arrived in coincidence with falling in love with a peer. This relationship was refused, because of the anorectic symptom, and intense guilt feelings related, also in Gabriela’s associations, to the first potty event. In fact, she linked these intense guilt feelings with her pleasure in the first kiss.
This clinical example shows us that sexual trauma could be represented “only” by the strongly erotisized fantasies concerning the primary relationship with parents, that is, in the first years of life; trauma is reactivated at puberty and adolescence, when anorexia onset is much more frequent.
We could wonder what such a precocious erotization stands for and why the only relationship pattern introjected by Gabriela consists of sexual intercourse with a parent. (Some authors, expecially in the United States, point out that the near totality of anorectic patients are sexually abused. In my opinion, this derives from the law that forces all the doctors and analysts to refer to authorities every suspicion of abuse or risk of losing their license).
Searching for characteristics of a real trauma or sexual abuse changes the field of analysis from mental to concrete aspects. Patient’s fantasies and feelings related to sexual trauma, real or imagined, are what the analyst has to look for and concentrate on, not on other external aspects.
By stepping out of an analytic relationship, the analyst is forced to play a parent role, giving concrete responses to the girl’s problems. Playing this parental role, the analyst falls into an unconscious collusion with the patient’s primitive defence mechanisms. This collusion, which takes responsibility away from the patient, keeps her in a passive role, submitted to external forces and not susceptible to further development.
Obviously it is very important when we are faced with real abuse, but that dramatic event should not divert us from the analytical task: looking for the meaning of the concrete experience. A patient comes to analysis asking for help to untie the hard knot which prevents her from growing up – not asking for legal justice.
Dwelling exclusively on the concrete aspects of trauma could be a destructive collusion between analyst and patient, tending to keep the patient in a passive condition in which the symbolic level of experience is out of reach. Therefore it is considered that in situations in which real trauma or abuse is so present as to flood the analytic field, it is very important to stay close to the analytic set in order to put the “fact” in a psychic dimension.
There is a connection between anorexia nervosa and first object relationships. More precisely, the very first sexual fantasies are very important. Fantasies and feelings about traumatic events do matter to the analyst more than the event itself.