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Lost for Words:
The Psychoanalysis of Anorexia and Bulimia
by
| Contents | Preface | Acknowledgements | Chapter: | 1 | 2 | 3 | 4 | Conclusion | References |
CHAPTER THREE
THE BODY AND BODY PRODUCTS AS TRANSITIONAL OBJECTS AND PHENOMENA
Introduction
Eating disorders have never been simple. Symptoms are multidetermined and have multiple
meanings. This has become increasingly clear over the last ten years. The earlier the
difficulties start, the harder it is to find simple answers and solutions to any of the
questions that may be asked. What can be said is that the complexity of eating disorders
is ever more apparent, as is the pre-Oedipal nature of the disturbance. Anorexia and
bulimia are no longer automatically seen as involving unresolved Oedipal issues. Problems
can come from any stage of development (Schwartz, 1988
). As the layers are peeled back so
we delve deeper into primitive processes and the early mother-child relationship.
The ultimate roots of bulimic behaviour reach into the earliest stages of life when
the mental and the physiological aspects of experience are virtually inseparable
(Reiser, 1990
, p. 246). I think it is of use to take things one step further back. It may
seem hard to go back any further, but I think we need to return to the mothers body,
the child in her womb and the conscious fantasies and unconscious phantasies she has had
about her baby, both before and after she was born. This may provide additional ways of
understanding the death wishes of these patients, their pathological narcissism and their
failure to integrate body and mind.
One way to do this is to use Winnicotts (1953)
concept of the transitional object
to explain what the mother may be attempting to do for herself. It will then be possible
to explore what this might mean for her child. I shall describe Winnicotts ideas of
transitional objects in general terms before looking at more recent ideas on intermediate
objects which will provide a means of exploring mothers pathology in a particular
way. I shall then look at the historical appreciation of the mothers presence in
these disorders and how this can be understood. The effect that the mothers own
frame of mind has on her baby, before, during and after his/her birth. The devastating
impact on the child that may occur perhaps gives us a clue to understanding the difference
between bulimics and anorexics and anorexic bulimics. A baby may be thought of as being a
poor attempt by mother to create/use some kind of a transitional object. If this is the
case then the effect on the baby of being used in this way needs to be explored. The
components of the bulimic ritual can then be thought through and explored using this
paradigm.
Winnicotts Transitional Objects
Winnicotts conceptualisation of the area of transitional space and transitional
objects creates that much needed concept, one which can link and be a bridge between the
inner and outer worlds, a place where the two interact uninterrupted with the help of the
first 'not-me' possession, as perceived by the infant, the third area of experience. The
area described by Winnicott as being between the thumb and the teddy bear, between
oral erotism and true object relationship' (Winnicott, 1953
, p. 89). Winnicott describes
the special qualities with which the child embues its relationship with a transitional
object:
(1) The infant assumes rights over the object, and we agree to this assumption.
Nevertheless, some abrogation of omnipotence is a feature from the start.
(2) The object is affectionately cuddled as well as excitedly loved and mutilated.
(3) It must never change, unless changed by the infant.
(4) It must survive instinctual loving, and also hating, and, if it be a feature, pure
aggression.
(5) Yet it must seem to the infant to give warmth, or to move, or to have texture, or
to do something that seems to show it has vitality or reality of its own.
(6) It comes from without from our point of view, but not so from the point of view of
the baby, neither does it come from within; it is not an hallucination.
(7) Its fate is to be gradually allowed to be decathected, so that in the course of
years it becomes not so much forgotten as relegated to limbo. By this I mean that in
health the transitional object does not go inside nor does the feeling about
it necessarily undergo repression. It is not forgotten and it is not mourned. It loses
meaning, and this is because the transitional phenomena have become diffused, have become
spread out over the whole intermediate territory between inner psychic reality
and the external world as perceived by two persons in common, that is to say,
over the whole cultural field (1953, p. 91).
Part of what I want to discover is if it is possible to understand the earliest
mother-baby dyad in terms of a narcissistic mothers use of her baby to attempt to
heal and find her own way to a third area of experiencing. This is an unusual approach to
transitional objects. I am assuming that the mothers development has gone awry and
that she herself has not progressed beyond the stage of confusion between inner and outer.
She is, in effect, attempting to use her childs body improperly, as a transitional
object for herself, not as a transitional object proper, but as an intermediate object as
defined by Kestenberg (1970
) and Kestenberg and Weinstein (1988)
.
They describe body products and food as being intermediate objects. They are
three-dimensional, able to change shape and fuse with the individuals body and
separate from it. They are attached and linked to the baby's body in a way that
transitional objects are not. From an observers point of view intermediate objects are not
those given to others by the child, but rather originate within the body itself. They are
linked to particular organs, such as vomit being linked to the mouth and faeces to the
anus and are essential bridges in the development of a secure body image. They are objects
that are in themselves transitional to transitional objects. They are not fully
transitional because of both their source and their function. For they are usually
a bridge to mother herself. They change and decay and are destructible unlike true
transitional objects. Intermediate objects may be thought of as being a special
type of precursor to true transitional objects. They add an extra stage in the move from
the body itself to the use of a piece blanket or teddy bear, a stage where, as yet, there
is neither a secure internal mother, nor a secure internal body image. They change and
decay quickly, unlike true transitional objects. They are usually a bridge to
mother herself
The use of the childs body by the mother is what is at issue, and I shall start
by looking at the perceived role of the mother in the literature on eating disorders.
Mothers Feelings about her Child
From the time of Gull (1873
) onwards the problem of the eating disordered individual
was seen, in part, as a problem of separation from mother. In one reported case Charcot
disclaimed all responsibility for an anorexic's life when he discovered that his
intstructions to separate her from her mother had not been followed. His initial advice
was then taken, and the mother left the daughter in the hospital where she did eventually
recover (Charcot, 1889
, pp. 210-211). The reasons why it was necessary to separate mother
and daughter were not thought through, but the trend continued. Lorand tells of a patient
who remembers her mother repeating to her many times Mothers should never be born
because they suffer so much (Lorand, 1943
, p. 302) and forty-one years later Lerner
says of a patient She related thinking about the many times her mother would tell
her that she wishes she had not been born or that she was dead (Lerner, 1983
, p.
52).
As Schwartz says, It is this focus on the pathogenic role of the mothers
unconscious psychic life that uniquely characterizes the psychoanalytic literature on the
eating disorders (Schwartz, 1988
, p. 33). It is what the early historical cases
imply: despite the parents conscious eagerness to help, there was something in the
mothers relationship with her child which could threaten her life. It is not always
unconscious, as Lerners example shows. The father has not been forgotten, but his
rare appearances in the material from now on mirror a trend amongst eating disorder
families where the father is often a shadowy and absent figure (Neubauer, 1960
; Yarrow,
1964
). In practice this often means that the baby has to bear extra emotional burdens of
which she is quite unaware.
Otto Sperling (1943-1945
) suggests a mother perceives her child, to be, in a very
concrete sense, an extension of herself. This idea is well illustrated by David Krueger
who quotes a mother saying to a therapist, in a family therapy session "When she left
home it was like losing a part of me - like my arm or part of my body" (Krueger, 1990
,
p. 262). Bird (1957)
describes the failure of differentiation between the ego of mother
and child and suggests that the childs ego responds directly to the id of the
mother, with her ego reacting in turn to the id of the child (Schwartz
, 1988, p.
35). This thought can perhaps be understood as an extrapolation of Melitta Sperling's
(1949)
idea that the baby is unconsciously viewed by the mother as representing a hated
sibling or parent or a hated or a wished-for part of the self (particularly a phantasised
penis).
Moreover, for the first time she could remember what she had really been acutely aware
of throughout early childhood, namely, that both her mother and father had been greatly
disappointed that the patient, their last child, had not been born a boy (Masserman, 1941
,
p. 334).
A mothers relationship to her child maybe determined well before his/her birth.
In working through the termination phase of her analysis she recognised that her
pregnancies had not been in order to bear a live child, but in order concretely to assert
her bodily separateness from her mother; the foetus inside her was concretely the hated
mother controlling the body, who she expelled in phantasy through the abortions (Pines,
1993
, p. 132).
This woman's babies may be thought of as being an intermediate object, connected to the
body zone of the vagina where the aim was to create a bridge to mother to attack her, but
also to confirm her sense of separateness from her, to confirm her own body boundaries and
body image. This theoretical area is fraught with difficulties and there is much to be
thought about. McDougall suggests that if a baby is a mothers sole source of
libidinal and narcissistic satisfaction it will predispose the adult-to-be to the
creation of what I have termed pathological transitional objects or transitory
objects (McDougall 1989
, p. 82). It is feasible that the baby might be seen as
a fetish object and indeed
and Weinstein
say of intermediate objects 'They are frequent
forerunners of fetishes, whereby the object that stands for the maternal phallus has
developed in analogy to the shape of the fecal column' (1988, p. 91) A baby cannot be
thought to be an intermediate or transitional object in that it is has its own life and
neither does it change in the way either intermediate or transitional objects do. I would
suggest that for some mothers, those whose own internal body image is insecure, their baby
is used by them as thought it were an intermediate, or a transitional object. They do not
know the difference.
Dinora Pines' example, quoted above, of a mother repeatedly having abortions, echoes a
bulimic episode where the knowledge of the other is destroyed. Contrary to the Kleinian
approach to the requirements for developing a secure inner world, there is no
psychological intercourse, no internal creative couple who have given birth to the child.
In phantasy, she is the sole provider of her own life and life with the object. She is
also its destroyer. This phantasy is often present during the bulimic ritual,
There will be time to murder and create,
And time for all the works and days of hands
That lift and drop a question on you plate (Eliot, 1917
, p. 14).
Mother can be eaten up, destroyed and be created in phantasy during the bulimic ritual.
It is a phantasy of self-creation, where no intercourse, no conception and no gestation is
required.
The vomiting symbol is a calling back by someone who is not able to tolerate separation
and loss, which are experienced concretely, as though the act of swallowing the food
disappears the mother (Shulman, 1991
, p. 340).
By inference the vomiting brings her back. The lines between murder and creation are
blurred, the lines between mother and child even more so.
The foetus inside her own body now represents good and bad aspects of the self and of
the object, and the mother may not give it a licence to live if she herself feels that she
has never been granted one by her own mother. The pregnant mothers ambivalence
towards her unborn child may reflect earlier intense ambivalent feelings towards her own
mother, resulting in a difficulty in self-object differentiation and further difficulty in
separation-individuation... Separation is unconsciously equated with death of the self or
the object. Difficulties in accepting the mother as a good mother may lead to a
womans difficulties in accepting the creative and life-giving aspects of herself
(Pines, 1993
, p. 115).
The implication seems to be that the pathology of the mother may mean that she creates
a world where her child has to remain attached to her, or in phantasy her very life is
threatened.
The effect of a pregnancy in such cases may depend on whether the fetus is experienced
as a hostile, ego-alien invader (perhaps more often in restrictor cases), or as a
comfortingly ever-present being more integral to the self and thus worthy of nurturance
(perhaps more likely among bulimic patients) (Rizzuto, 1988
, p. 59).
The distinctions between the groups are not simple or clear cut, which is part of why
work with these patients is so hard.
We are very far removed from a childs unconscious envy (above, pp. 32-35) and are
closer to a state of mutual and perhaps terrifying confusion and entanglement of bodies
and mind. How is the child likely to understand, take in and try to work with these
experiences? All of these formulations support the idea of eating disorders being
narcissistic in nature, but they go further in suggesting not only that the problem is one
of separation of child from mother, but that it is the mother's pathology that is the
issue. She is the heavyweight. The baby is but an extra in her mother's film.
These patients have been attached to a domineering and controlling mother who attempts
to attain passive submission and perfection for the child as her own fulfilment. Power and
control exerted by the omnipotent mother is overwhelming, remarkable interfering with
separation and individuation in all phases of the childs development (Sours, 1974,
p. 571).
Its possibly malevolent power is suggested by Rizzuto:
The mother may impose from her own reality something unrelated to the child,
something that is not there. She may attribute evil intent to the childs
gestures or words or perceive them as excessive demands that must not be responded to
(Rizzuto, 1988
, p. 374).
The state of the mothers inner world and her use of her baby may go some way to
understanding why one individual develops bulimia, another both anorexia and bulimia and
another bulimia by itself. It will only be a tentative thesis as the baby, its
constitution and its experiences both with and without mother, together form the matrix of
development. The pathology of a mother of an eating disordered individual can on occasion
be strikingly similar to that of her child (Williams, 1994
). It is implicit in the above
example that the babys function is to provide something for the mother, either as an
object to attack, or use. How the baby is unconsciously perceived by the mother, whether
she is allowed to exist in the mothers mind, and what kind of an existence she is
allowed to have may influence the nature of the eating disorder the child develops.
Anorexia and anorexic bulimia are both life threatening. Normal weight bulimia can be, but
usually this is as a result of conscious suicidal impulses rather than the illness itself.
Anorexics mothers are often described as being overcontrolling and intrusive
(Sperling, 1949
; Bruch, 1973
; Palazzoli, 1978
, Wilson, Hogan and Mintz 1992
); no
separation by the baby is allowed. Many anorexics carry this feeling with them throughout
their lives. They meet what they perceive to be their mother's needs and ambitions -
usually intellectually and emotionally - and use their body as their own and their only
arena of control and selfhood, which they can unconsciously and consciously use to attack
and attempt to separate from mother. Normal weight bulimics have suffered intentional or
unintentional neglect by their maternal caregiver, who is often a mixture of over
controlling and abandoning (Johnson and Conners, 1987
; Johnson, 1991
). Their mothers are
not, for whatever reasons, able to be constant in the care of their child. Anorexic
bulimics mothers have not been thought about in such general terms, but perhaps they
manage to combine positions, showing extreme and violent ambivalence towards their
children, being at one point over-controlling and overwhelming and at another abandoning
and neglectful.
Baby as an Intermediate/Transitional Object
Rizzuto
wrote Food, feces, menstrual blood, the penis, and finally the fetus can
all be experienced as the other within (1988, p. 59). I want to explore
the idea of the mother trying to use her baby, both as an intermediate and transitional
object. She wishes to use her baby, both to confirm her own physical boundaries and
as a bridge towards whole object relations. The use of the transitional object
occurs in the area between the external and internal worlds. Winnicott
makes it clear that
the use of the object is what matters. It must be allowed to be loved, hated and attacked
and it must also seem to have some vitality of its own, whether in texture, smell or
movement. It is a stepping stone towards whole object relations and reality testing and
its importance as a developmental move must be appreciated for its role to be understood.
All of this is meant to apply to babies and their bodies, not to adults - not to
mothers and babies. Adults are meant to have progressed to art, literature and culture as
their transitional phenomena (Winnicott, 1953
). But a woman may have a baby in order to
attempt to restore, create or get in touch with a good internal object, and to restore a
missing element in her body image. This is when the trouble begins. Transitional objects
can only be used effectively as tools towards whole object relationships if there is a
good internalised mother to begin with. Winnicott puts it so: The transitional
object may therefore stand for the external breast, but indirectly, through
standing for an internal breast (Winnicott, 1953
, p. 94). Intermediate
objects fill an in-between space before a stable internalised object and a stabilised
internal body image is formed, and it is in this area that mothers can be thought of as
trying to renegotiate with the help of their child.
The Child as an Essential Intermediate Object for Mother
A mothers peculiar relationship to the actual body of her baby is the focus of
much psychoanalytic literature on eating disorders. That the mother is failing in a basic
parenting task is very clear. Krueger
explains this in terms of pathological narcissism:.
The preverbal experiences in the first year of life have failed to acknowledge and
confirm a body self separate from the mother (Krueger and Schofield, 1987
). It is as if
the mother is incapable of accurate, consistent mirroring; of reflecting the childs
aliveness, special distinctness, and body and psychic boundaries. In such cases the mother
is unable to allow the child the opportunity for an autonomous, internally directed origin
of experience and action (1988, p. 58).
Cross
makes the use of the body of the baby by the mother even more apparent:
Among other factors, a parents fetishistic focus on the infants bodily
functions and physical appearance - with little interest in the infants emotional
states - or a parents massively unempathic responses to the infants bodily
needs and somatic signals can foster the kind of early psyche/soma split that results in
an eating disorder or delicate self-mutilation (Bruch, 1973
; Doctors, 1979
; Geist, 1985
)
(1993, p. 56).
Marie Maguire
, in an article on bulimia and perversion, tells of a patient who perhaps
was also used in an eroticised way by her mother.
There is a sense in which Mrs K sees her body as a pornographic object which she tries
to control. From infancy, Mrs K seems to have experienced herself as a pretty, passive
doll, to be displayed enticingly and played with by others. It has, she says, taken her a
long time to realize that she can actively engage in, and feel herself a part of, her own
sexual life. This sense of objectification is reflected in her concern with the physical
functions of her body and its fluctuations of weight (1989, p. 120).
A patient of mine, a Ms P, suffered severely from bulimic anorexia. She was black, in
her early twenties, and came to me after seeing many other professionals. She had
attempted to take her own life on a number of occasions. She tried to destroy her body on
a daily basis. She would drink a litre of wine per day, take sixty or so laxatives, eat
little, or what she eat she would then vomit. She would walk into the room on legs which
seemed to belong to a puppet. She looked and walked like Loopy Loo, a wooden
puppet worked by strings. Her body came in, and she sometimes did. It was purely an
appendage, a doll, in which she did not seem to have a presence. She had no use for it.
She believed her body was indestructible, that death meant peace and contentment and still
being alive. Her body could die. She would not. This psychotic belief rested on her
knowledge that she was a thing. She would often refer to her mother as having
treated her like a doll or a toy. One day she brought in a photograph album for me to look
at. In the pictures of her as a child, she was beautifully dressed and looked as though
she had been placed, like a china ornament, on chairs, sofas, or floors - to be taken out
and dusted when the occasion merited it.
In our work together it became apparent that the only way she could behave towards
herself was aggressively; this behaviour was both exciting and addictive. She was certain
that she didnt want to change it. Over time, it became clear that she was
unconsciously attacking an internal representation of her mother viciously and
persistently, without ever being able to be aware of it. She wanted simultaneously to
separate from her mother by murdering her own body. She had the delusion that she would
then exist in her own right. At the same time her unconscious belief was that by killing
herself she would also destroy her mother. This need to dispense with the self, and to use
herself as she had experienced herself being used within her relationship with her mother,
suggests how and why object relationships amongst these patients may appear warped and
impervious to change. She behaved as though she were still her mothers intermediate
object, if not her fetish, and by hurting herself she was thus hurting her mother and her
mothers precious possession, herself. It was herself who was so inaccessible, as
though she never had room to grow, except in response to mothers demands, demands
that she internalised as her own.
The nature of the psychodynamics of the individual with bulimic or/and anorexic
symptoms always necessitates a specific understanding, but this does not invalidate a
general understanding of a symptom also being suggested. Not all anorexic bulimics
perceive themselves as Ms P did, but I do think that the breadth of pathology needs to
thought about in terms of the mothers unconscious and conscious use of her child,
both physically and emotionally. I think what does distinguish these disorders from others
is their narcissistic base, not only in the patient, but in the mother as well. Then
detailed individual work needs to be done on the nature of her phantasies in relation to
her damaged and narcissistic objects.
Effect on the Child
What is taken in by the child is the mothers own pathology. She is used by mother
as an object, as a container (Lerner, 1983
). But unlike a mother, a baby cannot process
mothers feelings, whether good or bad, and unlike a transitional object cannot but
be affected by them. The symptom of not eating, not digesting, can be seen as a clear
message to mother that her child has either felt starved or that she needs to starve
herself in order to free herself from mother. Mothers failure to contain and process her
babys emotion and her attempt to use her baby as a container for her own feelings
means that the babys emotions and experiences are not felt to have been recognised.
This point is well described by David Krueger
:
These individuals nuclear sense of self has not been cohesively formed, and
remains disorganised and primitive. They have never integrated mind and body and are,
therefore, unable to deny or defensively split them. The resulting maladaptive behaviors
represent deficits rather than conflicts. The individual may not simply be denying a
painful affect, she may have not developed an ability to recognise or distinguish
different affects and bodily sensations. The narcissistic individual may not have a
consolidated body image to either deny or achieve (1988, p. 60).
This is not a good beginning.
Of the transitional object it can be said that it is a matter of agreement between
us and the baby that we will never ask the question Did you conceive of this or was
it presented to you from without? The important point is that no decision on this
point is expected. The question is not to be formulated (Winnicott, 1953
, p. 95).
I think that many anorexics and bulimics are not asking this question from the inside
out. The question is more fundamental for intermediate objects, because they come from
inside rather than outside and their physical separateness from the body is therefore less
in evidence. Anorexics are not able to question their belief that they are an object, and
an essential one, for their mother. For to ask might threaten their mothers
existence and their own. They do not know it can be asked, answered and survived. A
patient of Charcot
s was reported to have said I prefer dying of hunger to
becoming big as mamma (Janet, 1929
, p. 157). Mary, a clinical example in Sugarman
and Kurash
s article, The Body as a Transitional Object in Bulimia, says:
I would rather kill myself than be like her, and thats when I throw up,
when I become my mother (Sugarman & Kurash, 1982,
p. 65). An anorexic or bulimic
anorexic is unlikely to be able to make use of transitional objects, as a stable
internalised representation of mother is so obviously absent.
An individual with an eating disorder cannot know how to move from intermediate to
transitional objects - partly because she has been misused in a confused way, as both an
intermediate and transitional object herself. She attempts to achieve an internal
experience of mother by using herself as she felt used. It is in these terms that Sugarman
and Kurash place their understanding of the use of a patients body as a transitional
object. However, the individual does not have a good internal representation of mother
which would allow her to use transitional objects effectively. She only has the experience
of being used as an intermediate object, and like her mother is busy trying to negotiate
this earlier stage of development.
If the nursing experience has not allowed a good internal breast to be created, then a
child will not be able to begin to make use of a transitional object, but is still able to
make use of intermediate objects, which are used in a more direct form as a communication
to others. The prototype for both of these comes from the nursing situation in the
experience of the baby being held and playing. As Kestenberg and Weinstein
have written,
Both, playing and holding, are the basic methods of building and maintaining the
body-image (1988, p. 82). They added:
Secure holding provides the milieu for undisturbed drive satisfaction and the freedom
to play. The feeling of mutual support facilitates the childs formation of a stable
body-image, both of himself and of his nursing mother. This fosters the feeling of owning,
of possessing both his own body and that of his mother (ibid., pp. 86-87).
The play originates with the infants own body with his toes and fingers, and the
role of the transitional object is to be played with and held to recreate the illusion of
being held safely by mother and able to play. The role of the intermediate object is to
confirm the internal body image of the area connected to the product, (faeces and anus for
example) and bridge the gap from self to other by presenting the product to mother. Few
eating disordered patients make it as far as using transitional objects. They remain fixed
in the position of an intermediate object where the illusion of being safely held is
exactly what is lacking and where a secure body-image has not yet been achieved.
The absence of play is often very noticeable amongst this group of patients and the
rigid structure of family life has often been observed, particularly amongst anorexic
families. These patterns were noticed by Hilde Bruch in her pioneering work with anorexics
and expanded upon by Philip Wilson in Psycho-Dynamic Technique in the Treatment of The
Eating Disorders (1992
). If the mothers of these patients had successfully
negotiated the use of intermediate and transitional objects they would not have had to use
their children in this way. In other words, I wish to suggest an area where intermediate
objects were used by mother, as though they were transitional but were not
used effectively as stepping stones to whole object relations, because of the absence of a
secure internal mother. This means that the patient has been played with by her mother, as
though she were a transitional object, and she had to mould herself to her mothers
wishes and expectations - in effect - to be without thought or the ability for
self-directed action.
The Binge
This view of the absence, evacuation of thought, amongst some bulimics, is a point made
by Diana Shulman
in her article A Multitiered View of Bulimia, where she says:
There is a sense of the bulimic ridding herself of her mind. She attempts to escape her
capacity to think as thinking leads to painful thoughts about loneliness, loss, and
abandonment; she instead spends all her time evacuating her mind. The crowning achievement
is a patient such as Ms Ames sitting in front of a blank television screen, which
symbolises her mindlessness, or a patient, such as Ms Baker, who makes light of her
weekend gorging and presents the details of her exploits almost as though they are
concrete things subject to expulsion (Shulman, 1991
, p. 341).
What she does not address is how these psychotic islands, or perhaps autistic cysts (S.
Klein, 1980
) may be enabling. Shulman has suggested: Although the bulimic is able to
return to the real world, she, too, is relying upon psychotic mechanisms during the
periods of time when she is actively engaged in the binge-purge cycle (1991, p.
342).
In my clinical experience her view is valid for some bulimics, some of the time, but a
binge is not always a retreat into an autistic state, even for those for whom it may be at
times. A binge is multidetermined and may represent internal object relationships from any
stage of development, and perhaps represents more than one at a time.
An adult with bulimic symptoms can be thought to be reenacting her earliest and
repeated experiences with mother during a binge (Krueger, 1988
). A potentially and often
momentarily nourishing experience becomes an unpleasant and destructive one. Mother is
overwhelming and unsatisfactory and then has to be got rid of by vomiting. In the whole
episode what is reenacted is the experience of mother forcing herself and her wishes upon
them, which are not nourishing and cannot be dealt with, except by vomiting them out, or
not allowing them in at all, as is the case with anorexics. A fleeting experience of
mother is found, but not consciously. The physical behaviour itself reeanacts being fed by
mother. I now want to side-step the black hole of the bulimic episode itself, and look at
its adjuncts: the vomit, the environment and the cleaning-up process.
Vomit as a Transitional Object
What are some of the possible meanings that food has once it has entered the mouth,
food which is mixed with saliva and partially digested, whether in the form of vomit, in
the mouth or outside the body and in the form of the presence of large amounts of
semi-digested food in the body itself? It is not the same as the food going in before it
has been chewed, but the ingredients are usually recognisable. I shall also look at the
presence of faeces, in and outside the body, and the nature of the procedures surrounding
the ritualised ending of a binge. To elucidate the possible meanings I shall describe four
clinical vignettes, focusing only on the progress of a binge and vomiting ritual. For
Winnicott
an essential feature of transitional phenomena and objects is a quality in
our attitude when we observe them (1971, p. 113). This is worth bearing in mind when
reading about the patients cited below. David Krueger
has written in this regard that:
These individuals, because of their concrete, non-symbolic mode of operation, are not
able to move to an external non-bodily transitional object. They seem instead to struggle
to create a transitional object which is external, concrete and specific.
The effectiveness of the object is fleeting, however, and can remain no more fixed in
emotional consciousness than the defective internal images of body, self or other (1988,
pp. 61-62).
David Krueger is using transitional where I would use the word
intermediate due to its transitory nature, its creation within the body and
its role in helping to define and restore a more complete internal body-image.
Patient F
Patient F was a normal weight bulimic who binged and vomited many times a day. She did
not feel able to work. After bingeing she would make herself sick. Sometimes the action
would be very violent and the vomit would splatter back into her face, around the loo and
onto her clothes and shoes. She would then spend time carefully cleaning up herself and
the bathroom. She took numerous laxatives on a daily basis, and after the bowel movement
or movements, she would change her clothes if necessary, and wash her body with care.
Patient E
E worked in an office and did not enjoy her job or her surroundings. She was extremely
creative and used her skills to earn extra pocket money away from the office. Whilst at
work she would sit at her desk and whenever she could, she would eat a procession of
biscuits, sandwiches and chocolate bars. She made them last all day long. She would eat
something, and for an hour or two hours afterwards she would ruminate, bringing the food
back up into her mouth where it would be chewed and swallowed again. This happened without
her conscious awareness, although she could prevent it happening when she wanted or needed
to.
Patient C
C was a very fit, normal weight bulimic. She lived at home with her mother and sisters.
Her mother locked up the food at certain times during the day to try and stop her from
bingeing. This failed, and C would binge secretly in her room. She kept the packaging and
wrappers of the food she ate. When she had finished bingeing she would not go to the
bathroom to be sick, as she was too frightened of being caught. She would vomit into
plastic bags in her bedroom, which she then placed either in her wardrobe, her chest of
drawers or under her bed. She did dispose of the vomit filled bags, but not at the first
opportunity, which meant there was always more than one bag of vomit in her room.
Patient M
M was a normal weight bulimic who ate compulsively on a fairly regular basis. She
worked in a hotel and did shift work. Sometimes she would binge and vomit, normally in the
evening, before going to bed. After bingeing and vomiting she would then eat again, until
she felt full, at which point she would lie down and go to sleep. She would be aware of
the food inside her and her body shape on the bed as she was going to sleep. She would
often report dream-like images before slipping into sleep.
Patients E, C and M use vomit in a rare and particular way. A normal weight or anorexic
bulimic may have many different phantasies about her vomit, at different stages in her
illness and on different days. For the nature of the vomiting and the vomit depends on
what is eaten, what is drunk, how long it is allowed to stay in the stomach, and whether
it is brought up by a clenching of the stomach muscles, or by using the hand or another
object to tickle the back of the throat. Vomit, can be thought about generally as being an
intermediate object, as with Patient F. What is rare is its attempted use as a
transitional object. For these patients have failed, as their mothers before them to
differentiate between intermediate and transitional objects. I think they turn to their
body products, their intermediate objects, and try and to turn them into transitional
objects proper, in an attempt to integrate their body image and connect up with some
experience of a good - rather than a controlling and abandoning - internal object.
I believe the above vignettes give credence to this idea. For patient E, the experience
of partially digested food, which was chewed and swallowed, and chewed and swallowed
again, worked as a method of assuaging her anxiety. The vomit was available, she played
with it in her mouth, and this provided a third area of experiencing which removed her
from an awareness of the barrenness of her inner and outer worlds. She could stay at work
as a result. It proved itself to be enabling. It was for her a transitional object.
For patient C both her vomit and the remnants of food in the form its wrappings and
packaging were there for her to use as transitional objects, but for a limited time only.
They were moved around the room, felt, played with, thrown away. In a bag, vomit has all
the sensory requirements of a transitional object, a smell, a texture, a mobility and a
life of its own. However, it is not a transitional object as it came from within her body
and decayed quickly. It had to be thrown away after a certain time, as it became mouldy.
For a baby going to sleep with a blanket in one hand is not unusual. So, too, for
patient M, who could sleep once her transitional object of food was inside her. This is
different from the sleepiness of the compulsive eater, for it was related to the vomit
that had already been expelled, and in fantasy, hunger and destruction had been dealt
with. The good mother had been experienced and the bad mother had gone. Then came for time
for something to play with, to feel in a safe place with, which enabled her to sleep.
For patient F the clearing up process itself was soothing and provided an important
in-between stage which enabled her to return to reality. The vomit may have helped to
define and clarify her body boundaries, which in turn enabled her to take care of herself,
however briefly. This use of the post-vomit time as a transitional arena is a common,
though rarely talked about part of the bulimic ritual, for many normal weight and anorexic
bulimics. Marilyn Lawrence
does refer to it, although she underdstands it a different way.
She says: 'Some women spend hours cleaning up after themselves so that others will not
discover the secret, messy part of them' (Lawrence, 1987
, p. 199).
One of Winnicott
s defining characteristics of the use of transitional objects is
that there is no climax during play:
It is to be noted that the phenomena that I am describing have no climax. This
distinguishes them from phenomena that have instinctual backing, where the orgiastic
element plays an essential part, and where satisfactions are closely linked with climax
(1971, p. 115).
I think this supports the thought of vomit being used as an intermediate object for
bulimics, but not the act of vomiting itself. For there is a climax when at some stage the
point is reached where the food has to be expelled. I do not think it always orgiastic,
although many would disagree, seeing the action of self-induced vomiting as being a
symbolic representation of coitus, in one form or another (see Chapter Two). However, the
very early nature of the disturbance suggests the act of expulsion of the food is a much
earlier representation of a dynamic which occurred with mother and whose proto-type may
have been found in the feeding dyad.
Role of Stereotyped Rituals
Winnicott
suggested that an addiction in adult life is an attempt to return to a time
when the existence of transitional objects was not questioned. Yet he describes the third
area as
an area which is not challenged, because no claim is made on its behalf except that it
shall exist as a resting place for the individual engaged in the perpetual human task of
keeping inner and outer reality separate yet inter-related (Winnicott, 1953
, p. 90).
It is a place of illusion. It is this quality, more than any other that I think
prevents the body from being understood as a transitional object during bingeing. For the
whole point of the bulimic ritual is to work out what is me from what is
not me, by the act of vomiting. This is the very opposite of the third area of
experiencing where the question is never to be asked.
I do not, however, think there is ever only one way of understanding an
individuals bingeing behaviour. What bingeing means is always dependent on the
underlying phantasies. Diana Shulman (1991)
argues that a binge recreates the experience
of mother without having to think about her. It deletes reality, and the thinking process
is forfeited for a period of time. If this is accepted for even a few patients, it
represents a concrete attempt to have a good mother inside. I think this can then help to
explain the behaviour which takes place after the food has been brought up. It is here
that the vomit in a small number of cases is used as though it were a transitional, rather
than an intermediate object. In a greater number of cases the vomit is used as an
intermediate object to clarify body-boundaries, and the cleaning-up ritual is used as
though it were a transitional object. It is used to return to a world of whole object
relating and perhaps provides the one area where a semblance of Winnicott
s third
area of experiencing is appreciated, however painfully. It becomes a bridge back to
reality. In work with patients, bingeing and vomiting are often used to enable them to
undertaken a task which they felt they could not do. For patient M bingeing and vomiting
and then eating again allowed her to go to sleep; for patient E ruminating enabled her to
stay, and perform at work.
What I hope has become clear is the very varied and complicated nature of the internal
worlds of these patients. This is demonstrated by their reliance on the bulimic ritual
itself. A ritual that cannot be thought of as normal, or healthy, but is secretive and
destructive. It must not be forgotten that viewing the bulimic ritual as being a way to
create and use transitional objects is only one way of understanding it. A way which adds
a more benign understanding to a ritual usually thought of as only being destructive. It
seems likely that the less well the individual the more likely she is to try and use vomit
as a transitional object. I would suggest that the same may apply to individuals who abuse
laxatives excessively and in phantasy thus speed up and increase the production of faeces,
with which they become overly preoccupied. In some cases becoming attached to the often
painful and time-consuming process of evacuation and clearing-up. Layers of meaning, from
sexual phantasies to primitive destructive phantasies in relation to mother's and father's
bodies are always present and need to be explored. The one generalisation that seems to be
possible is the narcissistic nature of these disorders, both in the patient and in her
mother. Once that is said the range and nature of the disturbance needs to be looked at
individual by individual.
The narcissistic quality suggests that many eating disorder patients early
experiences with their mother have prepared them for unreliable and misunderstanding
relationships, where they survive by picking up on the expectations and wishes of the
other and by responding to them, as far as they are able. They keep themselves in hiding.
They are terrified of being known or seen and some indeed hardly know they have a self and
believe knowing it, threatens their very existence (Rizzuto, 1988
). For their mother may
have used them as an intermediate object; which suggests that life apart from her would
lead to decay and death.
This has important implications for the therapeutic relationship. The therapist, for
instance, is likely to be experienced as mother, with her own hefty agenda. She is often
thought of as being there for herself, the patient being there to help her, rather than
vice-versa. There is rarely an awareness of a good object, but a definite awareness of a
persecuting, controlling, envious bad one. Negative feelings tend to prevail, particular
with the more self-destructive patients, and the thought of a safe space will be alien.
The make-up and intensity of these feelings will obviously be very different from
individual to individual, but I think the idea of being aware of the importance of these
patients vicious perceptions of their internal relationship with their mother, and
the expectations they bring to therapy, provides an essential space for the therapist. A
space which is essential so that the therapist can think and show concern, and succeed in
avoiding the powerful pull in the countertransference towards frustration, control and
sadism in either tone of voice or content of interpretations.
By focusing on the mothers conscious or unconscious use of her baby as an
intermediate object, I have tried to draw us up to the edges of Winnicotts third
area of experiencing. I use up to with care, as intermediate objects always
remain precursors to transitional ones. Vomit, faeces and babies are all intermediate
objects as they come from within, and cannot remain in an unchanged state. They either
change or decay. Some bulimics and anorexic bulimics use vomit in such a way as to
convince themselves that it possesses the characteristics of a transitional object proper,
that it can be used as they like, for as long they like. It is this line of enquiry that I
will pursue in connection to technique and the experience in both the transference and
countertransference.
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