Mad, Bad, and Sad: A History of Women and the Mind Doctors

by Lisa Appignanesi

  The coincidence of the rise in the eating disorders and dysmorphia with the women’s movement also suggests that in the very process of elaborating and focusing in on the difficulties of being woman at the end of the twentieth century, the movement unwittingly combined with the attendant beauty, fashion and diet industries to forge and consequently swell the numbers of individuals who expressed their conflicts and unhappiness, their identity, in ills related to body size and shape. Was it this very focus on the body, the venom of the backlash, the conflicting values of thinness in the twin mirrors of freedom from femininity and designer-chic that turned women so violently against their own bodies? Marya Hornbacher in her memoir Wasted wonders if she might not have channelled her ‘drive, perfectionism, ambition and excess of general intensity’ into quite so self-destructive an illness as anorexia, if she had lived in a culture where ‘thinness was not regarded as a strange state of grace’. The damage to her body, the radical distortion of her sense of who she was, might have been less if the eating disorder hadn’t taken hold with its bulimic beginnings at the age of nine.

  Devastating in its detail of the growing insanity of a condition that can begin simply enough, Hornbacher notes how the early prevalence of talk of food, fatness and thinness in her parents’ communication with each other and with her played an important part in the progress of her condition. These were the sites over which her parents stated their pronounced difference from each other, and their discord. Each wooed her, the pawn in their battles, with their preferred foods, which also stood in for their modes of being–her father’s excessive, her mother’s restrained. ‘Watching the two of them eat played out like this: My father voracious, tried to gobble up my mother. My mother, haughty and stiff-backed, left my father untouched on the plate. They might as well have screamed aloud: I need you/I do not need you.’ The child distracts them from their tension and becomes their common ground, their symptom bearer. They both urge her to eat. By the time she is five, as her mother tells her to behave herself, restrain herself, stop acting like a child, she feels that if only she can stop herself from spilling out into space, she can contain herself.

  As the progress of the eating disorders was mapped, psychologists and doctors largely agreed that the characteristic profile of an anorectic was of a highly achieving, hardworking, often attractive and amiable teenager, good at sports, with top grades and a competitive desire to do as well as possible and to please those around her. Internally, like so many adolescents–except that the gap here is wider–this budding academic or sports star feels worthless, insecure and unable somehow to fulfil what she perceives as both her parents’ and her school’s expectations. Perhaps she doesn’t feel ready to grow up and away, doesn’t want to grow into her mother or cease being her father’s favourite. A university entrance exam, a falling out with a friend, a grandparent’s death, a new step-parent–any distressing situation can shatter the brittle carapace of confidence she wears. She tumbles into a confused low, feels empty, not herself, out of control. The sense of being out of control demands controlling. The culture tells her she will feel better if only she sheds a few pounds, that lingering puppy fat. Diet and exercise are the answer. She begins to lose weight. She feels good. Energetic. Has a sense of achievement. And the reinforcement from her mother and her friends gives her a sense of power. So does the ordered control of her food intake, the counting of calories, the subtracting of those used up in vigorous exercise, the saying no to herself and no again and again, the near-obsessional ordering of the day and what comes into her body. Meanwhile, she works even harder. The near-fast produces a high. The thinness now attracts the fuel of attention: though this may be of a morbid kind, it doesn’t matter. The body that she has created is after all not really hers.

  Once a certain point in the weight loss is reached, the family usually wakes to the dissonance of compulsion and wilful fasting. The mother begins to try and persuade the girl to eat. This has its own rewards–the rewards of attention and wilful refusal. The helplessness of the parent met by the child’s hostility and rejection is painful for the first, but may well produce a sense of triumph in the girl, who is daring at last to overstep the boundaries of what contemporary families accept as tolerable rebellion. The girl’s symptoms, after all, are her solution to her problem. She hasn’t so much lost her appetite as overcome it. She is in fact hungry all the time. But the greater the anorectic’s control, the more she may also feel out of control. The inner battle is reflected in her relations with any authority figure who attempts to make her eat.

  If the girl comes from a more traditional or an ethnic background, where food and familial meals carry more joint importance, such as in France, the point at which parents notice thinness and what from the family’s point of view is a terrible problem may come earlier. If it comes too late, the struggle with the eating problem may well take on the proportions of a war.

  Therapists, today, often implicate in the anorectic process the girl’s need to separate herself out from a powerful mother who may behave like a friend and has put few generational boundaries in place. Alternatively, the mother may be strict, herself self-restraining, or experienced by the child as devouring. She may in some way need the child to make up for what she herself lacks, say a fulfilling marriage or a career, perhaps entangling the child in what has gone wrong with her life. Like a double bind, this maternal lack can induce guilt either if the girl constrains herself to the mutually despised maternal image, or if she rejects it.

  Separating from mother is a conscious process, but it brings unconscious matter in its train. The girl may need to be alone to distinguish which bits are her, and simultaneously fear the fragility and guilt that brings. Her expressions of hostility to mother and family may indicate both the strength of her attachment and her terror at its presence and at letting go. The inner confusion, the war of conflicting desires and demands, can find its ordering anchor in the double rejection of food and of the menstruation which would thrust her down there amongst the women where her mother is. Her cruelty to others is bound up with her cruelty to herself, which she asks others painfully to witness.

  The anorectic is a liar and also deludes herself. Once the starvation pattern is in place, she finds secret, deceiving ways of not eating the food she may have agreed to eat; or of storing laxatives and purgatives in secret places. This is the case even when it is the therapist, the parental standin, who has prepared the eating pact in collaboration with her. She may both need, and need to reject, any care the mother (belatedly) offers. In any event, it always feels belated to her. Internally, the girl still sees herself as fat and needs to defend her weight loss. The mirror, in which she examines every inch of herself for hours, reflects the bulges and blemishes no one else sees. Not even her boyfriend or any of the men she may sleep with–perhaps surprisingly in a Freudian register, but less so at a time when sex can seem as unimportant as a supermarket commodity–for these days, the anorectic is often enough sexually active. She will cannily hide herself and her thinness from others with loose clothes; and deny it to herself. By now, all her thoughts are of food and, like an addict obsessed with her habit and the need, in this case, not to feed it, she can do nothing else. Friends and work fall away. She can no longer concentrate. She is utterly alone with her obsession–suffering from weakness, muscle fatigue and cold. She must wrap herself up all the more, lie in bed under blankets, depressed enough to die.

  Medically, the anorectic now shows all the signs of malnutrition. Her potassium and chloride levels will be down and her cardiovascular system affected. Her heartbeat may be irregular. She sometimes passes out. Her life is in danger, unless her system can be renourished. Later in life, if she survives, the effects of this early starvation will play themselves out in loss of bone density and early osteoporosis.

  In gruelling detail Marya Hornbacher describes a process in which the common and recognizable adolescent excess of emotion and confusion catapults into craziness, as compulsive self-starv
ation takes its toll. The round of hospitalizations doesn’t breach it: the anorectic, she notes, likes hospitalization, the constant attention, the returning to an infancy in which all needs are taken care of. Once out and fed just enough to walk and pretend, the girl will starve herself once more, playing with death, fearing to sleep in case she won’t wake up, yet unable to eat unless it’s to make herself puke again or exercise through the night. Even though she loves her ‘stoned boy’, that doesn’t stop her from leaving him to wander through the city streets all night, shivering, always cold, ‘murmuring to no one, nothing, tumbling through the strange unreal dimensions in the head’. Her hands are birdlike, papery blue and numb, and don’t grip so well any more. They just about manage the cigarettes she steals, the crusts of eaten sandwiches she doesn’t know why she picks up from dirty streets and stuffs in her pockets. She’s afraid to sleep.

  Back in hospital once more, the psychiatric notes read: anorexia nervosa, malnutrition secondary to severe starvation, ‘bulimia nervosa, major depression, recurrent’. The attendant medical notes add: bradycardia, hypotension, orthostasis (taken together, this simply means that the heart isn’t up to allowing the person to stand up without rushes of dizziness or fainting), cyanosis (skin discoloration due to impoverished blood supply), heart murmur, severe digestive ulceration. The diet that will make the young woman beautiful grips the mind and kills the body.

  Psychotherapist Susie Orbach’s Hunger Strike, based on her experience of women with eating disorders who have come to her in private care or to the London and New York Women’s Therapy Centres she co-founded, gives a feminist inflection to anorexia and its treatment. She interprets the disorder as the woman’s battle against her own emotional needs, her attempt to control them in a world which, with its contradictory demands of women, refuses her the possibility of satisfaction. Anorexia is indeed a hunger strike, a protest against times which hold out the promise of independence and a life lived beyond the home while simultaneously demanding that women, as lovers, wives, mothers or carers, service the needs of others. Within the individual woman, anorexia plays itself out as a metaphor of what society wants of her: that she not take up too much space, that she be vigilant about her own needs and restrain them. The transition between the psychic and the social is hardly, however, a straightforward mirroring.

  Writing about the mother–daughter relationship, Orbach notes the way in which women are taught by maternal actions not to be emotionally dependent, but rather to be midwives to the aspirations of others. ‘Girls…suppress many needs and initiatives that arise internally. The result is that they grow up with a sense of never having received quite enough, and often feel insatiable and unfulfilled. As an attempted solution to this psychic state of affairs, they seek connection with others and learn that this connection, especially with men, depends on the acceptability of their bodies.’

  The echo of Freud in this positing of the girl’s insatiability, the more emphatic recourse to object-relations theories, take on in Orbach and in many of the feminist psychotherapists a positive hope. If the world could be changed and the relations between the sexes altered, then the psyche would attain an equilibrium and women would attain satisfaction. This underlying hope of individual happiness is one that Freud never held out for civilization, which doomed the individual to discontent–even if he criticized the double standards of his time and wanted change.

  Orbach draws attention to the fact that the times condemn the mother to giving her infant daughter an unsatisfactory sense of her own body, restraining and containing it, so that it becomes appropriately gendered female. Restraining and curtailing her daughter’s needs, she creates a girl who feels ashamed that she has any, who defends herself against them, fails to recognize and express them and won’t let anything–not love or food–in. This would make her needs public, even to herself.

  Extending Winnicott’s idea of the false self, Orbach argues that when the infant has not had a chance to experience its physicality as ‘good, wholesome and essentially all right, it has little chance to live in an authentically experienced body’. The result can be a ‘false body’ which conceals the insecurity of the undeveloped inner body. Girls who develop an eating disorder are trying to shape their false body along acceptable lines. This plastic body, which can represent the negative, hated aspect of the unfulfilling mother, the bad object, can be shrunk into nonexistence. But at the same time, it is her body and it is all that she has: her real self is just a tiny, confused infant. Giving up on the hunger strike, says one patient after two years of therapy, is like giving up on one’s ‘whole identity’. It may not be the loss of anything good, ‘like a bad mother you don’t need anymore’, but it’s still a difficult loss. Anorexia is often intractable to treatment.

  Theories about its causal base and development abound. Some analysts interpret the food the young woman rejects as the mother she is distancing herself from. Seeing mother as food, rather than care, is a failure in symbolization, another lack linked to the infant’s early relations with the mother. Biological psychiatrists talk of anorexia being linked to depression. Parental depression may indeed have played a part in shaping the girl’s illness if a carer suffered from it during the girl’s early infancy and failed to give her an appropriate sense of her bodily reality. But the sense here is a questionable one: the girl is said to suffer from depression because she responds to antidepressants, a line of reasoning that drug-based therapies too readily employ, offering a diagnosis tailored to a response to a drug. Still other therapists see starving, with its loss of feminine shape and menstruation, as an attempt to replace the female body with a masculine one. In the 1990s, with the rise of interest in obsessive-compulsive disorder and its rituals, equations were made between OCD and anorexia, which certainly in its minute structuring of eating activity has a deeply compulsive side. It remains unclear, however, whether obsessionality can indicate a predisposition to the eating disorder and whether the serotonergic medications such as Prozac have any impact at all on patients at the lowest points of starvation.

  Anorexia is not only a middle-class disease. Today the eating disorders are seen in women from all social groups. As forensic clinicians Estela Welldon and Anna Motz have both noted, based on their experience of working with psychiatric patients in prisons, eating disorders are often coupled with self-harm and what psychiatrists designate as borderline personality disorders, which in turn regularly enough bear a history of early abuse. For these women, refusing food is often linked to an unconscious wish to stop their periods and in this way violently to reject their sexuality and the hated, sometimes complicit, mother they have incorporated. When they cut themselves, these women are not only trying to stop the pain or to come out of a state of numbness, but to cut a neglecting or abusive mother out of themselves and, with her, cut out their abused sexuality.

  Whatever theorization of anorexia clinicians prefer, one note persists in all accounts. The anorectic’s fear and rejection of food are also a rejection of any form of intrusion–which is precisely what therapy is. This makes any treatment difficult. Anorectics perennially sabotage therapy. They are as aggressive to those who attempt to help them as they are cruel to themselves. Doctors and therapists often find themselves enmeshed in a power struggle: the fading girl insists that she is just fine and must be left to her own devices. Persuasive attempts at feeding can easily grow coercive. Doctors attempt to follow procedures that the Hippocratic oath and duty tie them to. The patient’s victory over forced feeding is too often also her death.

  Marilyn Lawrence describes a patient who looks like a ‘dying child’, insisting everything is under control and she is just fine. The patient’s intransigent insistence that there is no ‘need’ at all in her, coupled with the presence of the dying body, is characteristic of the illness. Help is food in the anorectic’s lexicon. This translates into therapists’ and parents’ frustration and often enough the violence of force-feeding. Since, as Orbach notes, force-feeding reinforce
s gender stereotypes of the powerful male doctor applying invasive tubes to the female body, the procedure threatens the anorectic, whose refusal to eat is about control and overcoming appetite. Although hospitalization may be necessary and re-feeding may initially save the girl, without more comprehensive psychological treatment there will inevitably be a new cycle of illness. Few anorectics will continue the hospital diet without other kinds of help. Group work inside the hospital or on an outpatient basis can be useful. It can overcome the patient’s loneliness. She may also be better able to see the illness outside than inside herself. As for individual treatment, Orbach recommends structuring a therapeutic alliance in which eating is left in the patient’s control until she herself asks for help with it.

  There is a great need for genuine sympathy from the therapist–especially since the anorectic may have been to many professionals in the past. On the open terrain the therapy can provide, the girl-woman’s feelings of disgust and despair, her inner maps, her body image, can gradually be placed alongside the rejected food which has given them symbolic life. Eventually the geography of a new self can be charted.

  Hilda Bruch noted the usefulness of family therapy with anorectics. Many have followed her lead. The anorectic can be the bearer of psychological problems between parents, or enacting a struggle with her mother, all of which makes itself evident when the family is together. Mara Selvini Palazzoli (1916–99), the Italian therapist who understood the family as a transactional system which attempts to perpetuate itself, pointed out that anorectics’ families often cover over deep resentments with a show of excessive solicitousness towards their children, inappropriate by the time they reach adolescence. She pioneered the ‘prescription’ of rituals and shock injunctions or paradoxical interventions, much imitated and redeployed by family therapists in Britain and the USA. Palazzoli’s rituals provide precise counter-games which can budge the family out of its habitual patterns. The paradoxical intervention has the same purpose, though it functions through a few deft sentences which illuminate the family drama and redirect it. A starving girl, for example, might be told not to gain weight, since if she puts on curves her father will feel estranged in a family which is uniformly made up of women. Running counter to the expectations of the patient, such prescriptions lay bare the family power system and rupture the deadlock which has kept it in place.