‘It is a joy to be alone but disaster not to be found.’ Donald Winnicott1

Within this article, I want to address the questions: Who am I with or without my eating disorder? What or who is ‘me’ or ‘not-me’?’ In order to explore this, I aim to deconstruct the ‘I’ as a single, ongoing, consistent, conscious self, and explore the concepts of ‘me’ and ‘not-me’ self-states, which arise to protect the client’s personal spirit at the expense of the body.1

If an eating disorder is a solution to a problem, which may actually kill the ‘host’, then we need to pay serious attention to the problem. We need to fully understand the decision to deprive the body of a fundamental human need for food, and understand its daemonic resistance to recovery.

Food is symbolic of our primary experience of nurturance and survival and is taken into, and processed by, the body. Our bodies are the container of all aspects of our experience of being held and contained and compared with others in terms of ‘me’ and my needs. The body is also the first indicator of emotional distress or excitement, and an eating disorder can be a form of this expression. ‘I am too full up’, ‘I am empty’ or ‘I am sick of this’ may be expressed through the concretisation of taking in, refusing, eliminating and purging. It can also be an expression of emotions, which a client may feel, but have no language to identify what they are. The eating disorder can also serve as a way of anaesthetising feeling, in the way that drugs or alcohol can.

Threats and defences to the self

Bessel van der Kolk argues that ‘the body keeps the score’.2 It is our body and limbic aspect of the brain that first alert us to threat and to react accordingly. Attachment behaviours are then evoked in order to remain safe and draw others to notice us and respond to our distress. In early childhood development, it is sensation in the body (hunger, fear), which alert us to our need. Symbols (eg the breast) respond and identify what that need is, and eventually internalised images become established as we begin to link sensation to what our needs are, which we can identify and hold in our own mind (eg the parent’s face and touch). Finally, we name our need through language and a narrative that can help us to process whatever the perceived threat to self is. If this process is successful, through our early development, then we internalise the experiences of having a secure base through ‘good enough’ parenting, which leads to trusting that we have the resilience and resources internally and externally to keep us safe.3

Kalsched, a Jungian analyst, explores what happens within the psyche when this process gets interrupted: ‘What happens in the inner world when the outer world becomes unbearable?’1 He argues that when a child experiences unbearable psychic pain or trauma, in early development, then a self-care system is established which protects the personal spirit, even at the expense of the body: ‘The violation of this inner core of the personality is unthinkable. When other defences fail, archetypal defences will go to any length to protect the self – even to the point of killing the host personality in which this personal spirit is housed (suicide).’1

However, this defence system is duplex in character, and a trickster, who protects the self and persecutes it at the same time: ‘And just as an immune system can be tricked into attacking the very life it is trying to protect (auto immune disease), so the self-care system can turn into a “self-destruct” system which turns the inner world into a nightmare of persecution and self-attack.’1

Bromberg offers another description of unprocessed affect that threatens to overwhelm the client once again: ‘Something inside them tells them that non-being is a real threat, that a powerful and terrible tsunami of chaotic and disintegrating affect lurks within.’4 If we hold this image in mind, it is not surprising that such a fear of psychic annihilation would be met by what Kalsched calls an ‘inner defence league’: ‘“Never again,” says our tyrannical caretaker, will the traumatised personal spirit of this child suffer this badly!’1

Self-care system

A client wakes up with butterflies in her stomach after recognising that she faces another day battling her eating disorder. If she does not eat, her inner persecutor becomes quieter, but she will not recover. If she eats, she moves towards recovery and pleases her ego-self, and her family, friends and professionals. However, her eating disorder aspect of self becomes archetypal and berates her for being so ‘weak, greedy, indulgent, disgusting etc’. It also tells her that if she gets well, her body will no longer show the distress currently demonstrated through an emaciated body. It then adds that family and friends will move away and think all is well in her inner world, and her distress will not be seen. It warns her that giving up her eating disorder will leave her without defences to protect her from any external and internal threats of overwhelming affect, the ‘threat of the tsunami’.3 She has no place to go.

When a client comes into our therapy room with an eating disorder, they genuinely want to get well. This is the adult ego part of the client, who presents for therapy, and wants to recover and heal. However, I believe that within the room with you is potentially another aspect of self who holds another position. This is the self-care system Kalsched speaks of. This aspect of self exists as a defence which believes the eating disorder protects the client from something else, which feels more terrifying than the impact of the eating disorder on its body. As therapists, we need to pay attention to both the ego and the unconscious self who act in this way to preserve the ‘personal spirit’, even at the expense of the body. If we enter the battle unprepared for its strength, then we can be invited to enact and re-enact archetypal battles to find the innocent personal spirit, or ‘true self’4 that has gone into hiding.

Certainly, an emaciated body or extreme purging through vomiting or laxatives can make us put on our superwoman/ man underpants and go into battle with the eating disorder. In reality, this means increasing our sense of control by becoming prescriptive or anxious, or feeling that we are not good enough, or blaming the client for not being motivated enough. I have learnt all these lessons to my cost and to the cost of the client who comes to me for help. My own experience of this process has led me to take a reflective stance with my clients, while naming all that I see happening within the room. I need to address all aspects of self who are present, including my own authentic experience of what is happening in the here and now between us.

The spaces between

Bromberg argues that the goal of therapy is to gradually help the client ‘stand in the spaces’ between ‘self-states’, where ‘safe but not too safe’, ‘edgy’ moments and enactments within the relationship can be processed in the light of a caring but reflective other, in order to increase affect tolerance and develop healthier neural pathways within the brain: ‘The patient’s fear of dysregulation, as it is relived in the enacted present, becomes increasingly containable as a cognitive event, thus enabling the mind/brain to diminish its automatic reliance on dissociation as an affective smoke detector.’3

Such a process needs courage, in both the therapist and the client, and a strong, trustworthy therapeutic relationship. The golden rope of theory and supervision have helped to ground me and pull me, and my client, back to earth after this process of going down into Hades with the client, to find the personal spirit/’true self’ who has been abducted and held captive there. It is a goal within the therapy to support the true self, synonymous with the personal spirit, in daring to believe that it may be safe to emerge. We must, however, pay due honour to the defences for their role in preserving the personal spirit, when desperate times led to desperate measures, in the job they have done for the survival of this self.

Case study

A client told me that she was doing everything she could to regain weight yet, despite this, she was losing weight each week. She was an intelligent woman who was keen to return to university in a couple of months’ time. I dared to ask her if she was excessively exercising and therefore burning off the calories. Immediately, I felt an anxious fear in my stomach and saw a flash of momentary anger in her face. Her protector was in the room and evoked because I was threatening her defence.

I named what I saw and felt. We were then able to understand the conflict between two aspects of her self. One part of her felt she did not deserve to recover until she lost more weight and became the ‘best anorexic’, which would mean hospitalisation. The other part of her genuinely wanted to be free of anorexia and return to university and her life. This exploration led to us discovering a less evident, bullied, innocent self that was either an ‘A* student’ or ‘A* anorexic’, or something far less acceptable to her inner and outer world. When these clients are ‘A*’ in their outer world, this can preserve the fragile self-esteem, but at a huge cost of constant striving to remain in this place of perfection.

However, this can never be achieved because they cannot rest in a place of being OK through anticipation of any threat that this may change. The limbic system has taken over the building. The fear or the experience of falling below this perfection becomes something else that is unbearable. In their minds, they are no longer ‘good enough’ and become a ‘failure’. Then the eating disorder’s voice becomes a seducer to their fears. It reminds them that they can remain in a place of safety, away from the demands of the world and adulthood, and have control over something that they can govern and mark as theirs: ‘The best anorexic.’

For my client, this was so. If she fell below this perfection to a ‘B’ in anorexia or her studies, she became a ‘failure, weak, not good enough, disgusting, ugly, fat’. Her inner defence league warned her to not give up her eating disorder and expose herself to any hint of failure, inside or outside her world. However, if she then put on weight, or ate something, without asking her inner gatekeeper, she was reprimanded and flooded with self-deprecating thoughts and criticism. It then attacked her for not being ‘ill enough’ and so she remained in a kind of Hades of attack and counter-attack. I needed to catch that in my countertransference. ‘Once the trauma defence is established, it screens relations with the outside world for any threat to further trauma but at the expense of any spontaneous expression in the world. The person survives but cannot live creatively.’1

As therapists, we can then experience a parallel process within our countertransference of feeling that we are the ‘A* magician’, ‘good fairy’, ‘hero/heroine’ in one moment, to an ‘F-grade’ therapist, who is a fool, witch, or devil in the next moment. Our job is not to identify with either position but to recognise the archetypal battle that lies within our client’s inner world. It is as if the relationship, in that moment, ceases with me, and instead turns to an internal ‘other’ with whom they are enmeshed and attached to. For better or for worse, in sickness and in health, until death do they integrate.

The role of the arts and the body

Communication with all these aspects can be explored more readily through the use of the arts. These can provide a container for all that is happening within the client’s inner world, and their relationship to you, or others within their lives, including the eating disorder: ‘All forms of the so-called “creative-arts” psychotherapies are extremely helpful towards this end and often these will open up traumatic affect much faster than purely verbal exploration.’1

Myth, narrative, images and symbols can help a client to begin to articulate internal and external experience, which they may previously have had no words for. The arts can give voice to all aspects of self, including the inner protector/persecutor who has attempted to take care of the beleaguered ego at any hint of threat from the tsunami of unprocessed and overwhelming affect, which threatens to emerge, at any given point.

As therapists, we also need to pay attention to shifts in self-states, which may only be noticed in our own bodies, or subtle changes within the client. The ‘child in the system is usually a personification of affect in the body… Such a body sensitive approach proceeds from the understanding that past trauma and its defences will be encoded in present physiological states, such as breath, gestures, muscular tension, averted gaze, etc and not in higher cortical regions where they could be recovered as explicit memories.’1

We can begin to listen to the sensations and attune to their communication without foreclosing or moving away. In so doing, the therapist is developmentally supporting the interrupted developmental process where sensation in the body is given a symbol/image, words name the emotion, and narrative links the right and left brain towards healing and integration. ‘Strong currents of affect reaching the psyche from the outside world or from the body must be metabolized by symbolic processes, rendered into language, and integrated into the narrative “identity” of the developing child.’3 Then this narrative can emerge in the presence of another, and be met and given cognition to his/her experience. Integration can emerge between left and right brain, body, soul, mind and emotions.

© 2017 Lesley Finney

Lesley Finney is a UKCP and MBACP registered senior psychotherapist within an NHS eating disorders service in Kent. She has over 35 years’ experience working within the helping professions and has trained as an integrative arts psychotherapist and social worker. She also has her own private practice.

References

1. Winnicott DW. The maturational processes and the facilitating environment: studies in the theory of emotional development. The International Psycho-Analytical Library 1964: 1–276.
2. Kalsched D. The inner world of trauma: archetypal defenses of the personal spirit. New York: Routledge; 1996.
3. Van der Kolk B. The body keeps the score: brain, mind, and body in the healing of trauma. New York: Viking; 2014.
4. Bromberg PM. The shadow of the tsunami and the growth of the relational mind. New York: Routledge; 2011.