The Anorexic Stance. Jeammet, P. (1981). J. of Adolescence, 4: 113-129. Abstracted by Kenneth D. Cohen, M.D.
The author presents a comprehensive but very concise picture of anorexia. After tracing its delineation from the latter part of the 19th century to the date of this paper, he presents a very clear description of the cardinal diagnostic triad, i.e. (1) "anorexic conduct" (2) Amenorrhea, (3) Emaciation. This is further augmented by seven "more subtle signs"; distortion of body image, constant fear of putting on weight, food rituals, absence of fatigue, and finally lies and manipulation of the family.
The major point of this paper is that anorexia is a behavior pattern based on conflict, ..."anorexia can be traced back, above all to difficulties relating to personality development for which anorexia is but one form of defense..." (p. 120) The author maintains that this conflict arises out of an identity crisis in adolescence with oral regression as a response. The maternal object of identity is totally absorbed and then destroyed in fantasy. In short, the anorexic cannot achieve a partial identification or separation and the anxiety is handled by total incorporation. Father, seen as weak, is often viewed as an auxiliary mother. Thus, there is a "...contra-oedipal attitude toward the daughter." Because internalization and identification is so conflictual, a "false self" develops impairing the capacity for deeper sustained relationships. The oral regression does not stabilize around a definite position and there is an upsurge of fantasies colored by oral and anal sadism. The body becomes the major autoerotic libidinal investment compensating for the lack of external objects, creating what the author describes as a "fetish body, erect and immutable of which the anorexic wishes to be the sole creator." Nevertheless, suffering takes place, evoking a desire to feel on the part of those around the patient. The author sees this process as an example of Laufer's (1978) adolescent split between the sexual body or persecutor and a sexually denied body which now needs maternal care.
Central to the therapeutic approach is recognition of the "anorexic stance." This is essentially a combative attitude which shows itself by challenging everyone and anyone with contrasting attitudes of solicitous care for others and abject denial of the self. A paradoxical message according to the author which states,"I expect nothing from you, but I want you to know I could die!" The denial of basic body pleasure leads to a "masochistic pleasure." This stance is a compromise between dependence and autonomy, provoking reaction and contact but passing responsibility on to others. Narcissism is protected with a self suffering image and leaving it to others to express disowned desires. In doing this the patient creates an illusion of independence but maintains this circle of other people so that separation is not possible. The author has two caveats for the therapist based on an understanding of this stance.
1. There is danger in taking the stance at face value by attempting to confront and challenge directly and thus involving ones self in a power struggle which could lead to an erotized sadomasochistic relationship.
2. The other is a failure to recognize the cry for help which underlies the provocative behavior.
These two concerns might lead the therapist to ignore the defensive nature of the anorexia which would awaken the hidden drive and create reactive guilt.
Neutrality is not seen as a helpful therapeutic position because it may be viewed as abandonment by the patient. The aim of the treatment is to help the patient gradually realize her wishes and needs for relationship allowing her to experience this without being able to admit it. This is a slow process requiring support by framing expectations in terms of the underlying wish. Practically this means contracts involving weight goals, protection from danger and demands that show interest. This helps with a sense of "firmness" which the author states is a basic requirement of treatment. Flexibility is only seen as a weakness. In effect this represents a form of limit setting.
This is a very elegant paper which manages to combine diagnosis and dynamic understanding into a rational therapeutic approach. Although the paper is sixteen years old, it is worthy of consideration at a time when there is great movement to emphasize biological ideology and deny the impact of developmental psychology as a determinant in the cause of this very perplexing and disturbing entity.
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