Psychosomatics and Eating Disorders

The Psychoanalytic Approach

The Newsletter of the Psychosomatic Discussion Group

of the American Psychoanalytic Association.

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Lost for Words: Psychoanalysis for Anorexia and Bulimia

by Em Farrell.

Reviewed by Melvin Singer, M.D.

Solving the riddle and then treating eating disorder patients, a most intriguing but agonizingly complex group, is the ambitious aim of this highly condensed little book. Only ninety-six pages, but Em Farrell, of the Kleinian and Winnecottian persuasion has given us a delightful gem. The book is highly compressed and therefore somewhat dense, in both meanings of the term. The density does, however, lift as one eagerly journeys through the introductory section of historical highlights as well as the sections on differing theoretical orientations. Finally, she settles firmly on her most secure and fascinating landscape, the primitive conflicts organized around issues of separation and fusion with mother. Conceptualized best, as she sees it, by Winnicott's theory of the transitional object and space, but especially its elaboration by Kestenberg and Weinstein in their concept of the "intermediate object." The book is essentially unbalanced giving major space to the clinical problems experienced at this preverbal level which is also its major strength.

This "intermediate object" is a step before the transitional one can be reached. Here, bodily products and food are temporarily used to represent mother or security. But since these are not only created but also located from without, not from within and lsed to represent mother or security. But since these are not only created but also located from without, not from within and likewise not permanent, but easily destroyed and decayed, they cannot be used as a true transitional object or a successful bridge to one. The theory continues that since there is as yet neither a secure internal maternal image nor body image formed, these bodily products do not provide the internalized security that would permit the movement from the body self to the "blanket" as in a normal process. Thus, food, vomit, feces, etc., are all used without the possibility for growth, but endless repetition as "intermediary objects." This construct is the basis for her treatment of these pregenital, oral, separation/fusion problems expressed in eating disorders. Apparently, Farrell's work is essentially applied from other's theories, especially of the "intermediate object." Since the mother, in a role reversal, used the patient herself as a puppet, an "intermediate object," that was unfortunately a "leaky container" unable to provide the mother's needs, this left the patient sadistically invaded, unheard and unrushed, unable to move to the transitional object phase. Therefore, she was forced to use her body products and food to represent needed maternal supplies and to avoid both the dreaded separation as well as closeness. This closeness, tantalizingly desired, as well as equated with sadomasochistic invasion and destructiveness, is to be avoided at all costs. Thus, the only true self-experience available, is to be secret and hidden in the relentless binging states. Words could not express the pain that is preverbal and must be represented concretely in food, feces, and vomit, which is material that is both "not not me, but not me either." this protects the self from being known and destroyed by the other, thus the title of the book. This thesis becomes the basis for treating these patients who are inaccessibly lost for words, secretive, and mistrustful, requiring the analyst to become an "intermediate object" for the patient just like the vomit. The psychoanalyst must develop a metaphorical form of eating disorder in the countertransference since the "food" offered is neither accepted nor satisfying, inducing by projective identification, feelings similar to the patient. The patient thereby uses the analyst as an intermediary object like the "vomit" so a transitional space can eventually begin to exist. The last section of the book goes into methods to bring this about. It is quite interesting. Treatment must not be viewed as penetrating the skin, but as creating a transitional space between self and object for safety. Interpretations must create a space to be heard, not entered or abandoned, and this will enable the patient to produce a product that is unintegrated, rambling, but at least her own, i.e. "friendly vomit." This can then be accepted and contained, not reprojected by the analyst. This "vomit" now tolerated and protected as in a transitional space will begin to exist and the patient eventually move forward toward separation and a true self. Farrell mentions humor and the tone of voice as useful adjuncts to avoid being experienced as the destructive, internalized mother. Silence also is mentioned to establish autonomy and help the patient emerge from her secret, silent shell. The one drawback of this delightful tidbit, as mentioned, is the author's style of skimming the surface of this very complex topic that can only be understood if one was already deeply immersed in the concepts used. This, Enid Balint's "virulent projective identification" was mentioned without clarification as she breezily moves forward in her exposition. Likewise, her case material is fascinating but limited by the size and range of the book. Finally, the reader as well as the author metaphorically develops a form of eating disorder by being offered a tasty morsel that only wets the appetite leaving one still hungry without the longed for space and nourishment.

Melvin Singer, M.D.


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