Tavistock and Portman E-PRINTS Online (PDF)

Tavistock and Portman E-PRINTS Online BOOK CHAPTER Original citation: Introduction in: Lawrence, Marilyn (2008) The anorexic mind. Tavistock Clinic Series . Karnac Books, London. ISBN 1855753839, 9781855753839 © 2008 Marilyn Lawrence This version available at: http://taviporttest.da.ulcc.ac.uk/ Available in Tavistock and Portman E-Prints Online: Oct 2009 The Trust has developed the Repository so that users may access the clinical, academic and research work of the Trust. Copyright © and Moral Rights for the papers on this site are retained by the individual authors and/or other copyright owners. Users may download and/or print one copy of any article(s) in Tavistock and Portman E-Prints Online to facilitate their private study or for non-commercial research. You may not engage in further distribution of the material or use it for any profit-making activities or any commercial gain. You may freely distribute the URL (http://taviporttest.da.ulcc.ac.uk/) of Tavistock and Portman E-Prints Online. This document is the published version of the introduction to The anorexic mind’. . It is reproduced here with the kind permission of Karnac Books. You are encouraged to consult the remainder of this publication if you wish to cite from it.  CHAPTER ONE Introduction T his 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 are- as 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 un- derstand 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 1  2 THE ANOREXIC MIND range of different backgrounds. Following many years of work- ing 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 think- ing about their patients. This is a group of patients with many features in common, but perhaps chief among these is a real dif- ficulty 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 react- ing to. Faced with the constant pressure and challenge from the patients to give up thinking, it should not surprise us that some- times 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. I also want to promote psychoanalysis and psychoanalytic psy- chotherapy as effective treatments for patients with eating disor- ders, though I fully acknowledge that this also has its difficulties. The psychoanalytic literature on eating disorders is developing well, and in spite of a current preoccupation with short, focused treatments, we have every reason to be optimistic that psychoanal- ysis is providing a model for treatment as well as a framework for understanding. The difficulties as well as the advantages of treating patients with a psychoanalytically based form of psycho- therapy are fully discussed in chapter 3. The fact that the book has this dual focus—psychoanalysis on the one hand, and work in inpatient settings on the other—gives it, I suspect, an uneven quality. I am aware that I move from one treatment setting to another and that very different kinds of work are being described. However, I believe and hope that this dual fo- cus will be a strength of my approach. The unconscious processes that we can identify in the consulting room can and need to be recognized and addressed within the very ill patients in hospital. Eating disorders became much more common in the second half of the twentieth century and continue to be prevalent, es- pecially among young women. This has led some researchers,  3 INTRODUCTION including myself, to speculate about the social origins of these conditions. While such speculation is interesting and it is poten- tially important to make links between psychiatry, psychoanal- ysis, and other branches of the human sciences, the stance taken here is that eating disorders are manifestations of mental illness. This statement, of course, begs the question of what is meant by “mental illness” and to what extent mental illness really parallels physical illness. These are questions I cannot answer, but however one understands it, I do regard young people who develop an eat- ing disorder as being in serious trouble and needing help. Often the patients do not recognize themselves as ill. They sometimes claim to be making “lifestyle choices”, and this kind of claim is supported by the proliferation of the so-called “pro-ana”—mean- ing pro-anorexia—websites, offering support and encouragement for the lifestyle choice of starvation. Worryingly, one sometimes reads articles by intelligent journalists who regard anorexics as in some way icons of our age. It is also noteworthy that the re- cent guidelines from the National Institute for Clinical Excellence (NICE) on the treatment of eating disorders do not mention that these are mental illnesses. I think this does imply a degree of col- lusion with the denial of the patients that they are in need of help. It is also particularly unhelpful and confusing for their parents, who can often react much more helpfully when they realize that their children have serious emotional difficulties underlying their behaviour. It seems to me essential that we keep the suffering of the anorexic and bulimic patients at the forefront of our thinking. I shall therefore examine the links and similarities between eating disorders and other forms of mental illness. Chapter 2 looks at the way eating disorders have manifested themselves and been understood historically, with special reference to psychiatric and psychoanalytic accounts. The most common age of onset of eating disorders is adoles- cence, somewhere between 12 and 20. However, there are many reports in the literature of children as young as 8 years becoming anorexic. It is also possible for people to develop an eating dis- order at any time later in life. Early in my career, I met a woman suffering from what seemed to be typical anorexia nervosa at age 70. The onset of the illness seemed to have been linked to the re- tirement of her husband and the huge change in lifestyle that this  4 THE ANOREXIC MIND brought about. Sometimes illnesses that appear to be late-onset eating disorders are, in fact, second or subsequent episodes of ill- nesses that began much earlier in life. It is sometimes impossible to be certain, but I strongly suspect that the vast majority of eating disorders begin in adolescence, or earlier, and probably have their antecedents in infancy. It is perhaps not surprising that the eating disorder may recur as a seeming “solution” to developmental dif- ficulties that occur later in life. I therefore spend quite a lot of time in this book thinking about development, from infancy through childhood and adolescence, trying to capture and recreate a sense of what mental life might have been like, in the years before they became ill, for those in- dividuals who end up as adult patients (chapters 3–6). This em- phasis on development is not based on a quest for the causes of eating disorders. We do not know the causes of many illnesses, in particular mental illnesses, and I feel under no obligation to offer a theory about what causes eating disorders. I think the search for causes, which has tended to bedevil work in this area, has occurred partly because eating disorders appear to strike out of the blue. We are often told that some of these at least are the most promising young women of their generation, who “suddenly” develop serious mental illness. My interest in the infancy, child- hood, and adolescence of the patients is rooted in my belief in the continuity of life and development in human individuals. Storms only appear to come “out of the blue” because when we look back, we don’t know what to look for. We were looking for huge grey clouds when we should have been noting changes in humidity. We look for a hurricane when really it is the very stillness of the air which should have alerted us. This emphasis on continuity should not be taken to mean that I do not believe in change. This whole book—but especially chapters 3, 7, and 8—is about how people can change in some very profound and fundamental ways. I am not referring here to changes in behaviour, but to changes that can take place in the minds of individuals, altering and enriching our sense of who we are and how we can feel related to other people. I have tried to convey the balance that I feel between ac- knowledging the terrible seriousness of the underlying illness in some cases of eating disorders as against the hope of recovery. I  5 INTRODUCTION particularly address this in chapter 6, where I try to understand more about the life-and-death struggle that I believe is taking place within the patients. I shall be suggesting that eating disorders, like other forms of illness, vary in severity and also in the emotional availability of the patients for treatment. It is very important, before deciding on the best course of action, to make a careful assessment of each patient and to try to gauge the quality and depth of the problem. The majority of the cases require a degree of teamwork, involving psychotherapists working alongside GPs and local community teams—something to which many psychotherapists are unaccus- tomed. This is fully elaborated in chapter 7. These patients, and the way they show us their difficulties, represent a huge challenge to us as mental health professionals, but also as human beings. There certainly are no simple answers, and perhaps in some cases there are no answers. The exploration of these difficulties takes us, I think, to the very heart of the human condition: our vulnerability and our need to depend on others: our parents firstly, and then the relationships that we are subsequently able to make.