From Knowing to Discovering: Some Suggestions for Work with Anorexic Patients

ABSTRACT

In this article I offer some technical suggestions for psychoanalytic work with anorexic patients. Although focused on an outpatient setting, certain parts of the article will also have utility for inpatient work. As an outpatient therapist working with an anorexic patient, especially in the acute stages of the illness, there are case management demands that need immediate attention. The setting up the particular frame is required to augment the therapeutic work. The most urgent pressure felt by the clinician is the precariousness of the patient’s physical health. This can be experienced as if there is a gun to the head of the therapist. This deathly force must be carefully and constantly grappled with, and particularly so in the most symptomatic stages of the illness. The clinician must work with a patient who might die at any time, yet an anorexic patient cannot be managed the way a suicidal patient would be. The question of technique in this situation is a complex one. Above all, the patient must be met where s/he is. Notwithstanding the uniqueness of each patient there are some specific themes that often arise in the acute stage of the illness. Certain technical suggestions are offered.     

Achievement motivation theory and occupational choice

Two studies are reported which aimed to answer several questions relating to Atkinson's model of achievement motivation. Firstly, how successfully the theory can predict the occupational choices of two different populations and what changes, if any, need to be made to the model to make it more suited to such predictions. Several conceptual errors were found in the theory which make it unsuitable in its present form for predicting occupational choices and suggestions are made as to the possible correction of these. Secondly, a comparison is made between Atkinson's model and the expectancy-valence models currently utilized to describe and predict occupational decision-making. In particular Atkinson's incentive component is contrasted with the valence measure described by expectancy-valence models, and the possible influences of the motive factors (motive to succeed and motive to avoid failure) are considered since these are typically omitted by other models of career choice. Finally, the existence of sex differences in career choice, as well as in the various components of the model are studied and discussed. The changing conceptualization of ‘fear of success’ is also included in this consideration.     

Résumé Preparation Workshop for University Students

A workshop to help university students prepare résumés is described and evaluated. Part of the workshop discusses the purpose of a résumé and describes its “advertisement” aspect. Another portion encourages participants to inventory their assets and experiences, and to gather information about their chosen occupational areas. The third segment of the workshop explains traditional formats, and the final segment offers suggestions for attractive layout and reproduction. Preliminary evaluations of workshop participants' and nonparticipants' résumés resulted in ratings that were higher for the workshop group. In general, it was found that persons who talk with counselors or friends about résumés produce more effective résumés than those who get their information only through reading materials. A pilot evaluation instrument is included. Implications of this study for counselors are discussed and suggestions for developing similar workshops are made.     

Body Poly-texts: Discourses of the Anorexic Body

It is now increasingly acknowledged that anorexia nervosa is a ‘culture-bound syndrome’ which must be understood within the context of an increasing idealization of female thinness and a high prevalence of dieting and body dissatisfaction, particularly amongst women and girls. Whilst this socioculturally-oriented perspective is important, it is also simplistic to conceptualize anorexia simply as a ‘slimmer's disease’. The ways in which contemporary Western culture is imbricated in anorexia are both complex and multiple. This paper uses a discourse-analytic approach, informed by feminist Foucauldian theory, to examine some of the multiple and often conflicting meanings and discursive constructions of the (female) anorexic body. The paper is based on a series of interviews conducted with 23 women (21 diagnosed as anorexic and 2 self-diagnosed). The analysis focuses on the explication of two discourses: a romantic discourse and a discourse of Cartesian dualism evidenced in the interviews. By contrasting the very different ways in which these two discourses constitute the anorexic body, this paper aims to provide thereby a socioculturally contextualized and gender-oriented account of the multiple discursive constructions of ‘anorexia nervosa’ and ‘anorexic’ bodies. Implications for psychotherapeutic interventions are discussed.     

TARGET ARTICLE: Limitations to Free Association and Interpretation

A core challenge that emerged from the historically based critique of Freud's work that constitutes Freud Evaluated: The Completed Arc (Macmillan, 1991, 1997) was to Freud's claim that the basic rule of psychoanalysis for inquiring into the causes of symptoms was unaffected by his "suggestions." That is, in demanding that the patient tell the analyst whatever came to mind with complete candor, the patient would not be led astray by the analyst's ideas about the possible causes of the symptoms. In this article, the assumptions underlying Freud's belief in the validity of the method of free association are made explicit and criticized. The basic indetermination inherent in interpreting material apparently recovered by the method is also made explicit. Some of the consequences of the method for psychoanalytic developmental theories and for deciding between the variant schools of psychoanalysis are set out.     

Personality Correlates of Anorexic Symptomatology in Female Undergraduates

In this study, the authors examined personality correlates (obsessiveness, dependency, self-directed hostility, and assertiveness) of anorexic symptomatology in female undergraduates. Regression analyses demonstrated that only obsessiveness and emotional reliance on another person (a measure of dependency) were related to anorexic symptoms, accounting for 19% of the variance. These findings are discussed in relation to S. Orbach's (1985, 1986) and other researchers' concept of the anorexic personality. Implications for therapeutic interventions and directions for future research are provided.     

Anorexic and bulimic states of mind in the psycho-analytic treatment of anorexic/bulimic patients and psychotic patients

SUMMARY

This paper discusses the relationship of bulimic and anorexic states of mind, and their interchangeability as manifested in the transference. The anorexic making bulimic-like greedy demands upon his/her objects. The bulimic showing all the qualities manifestly presented by the anorexic, an appetiteless approach to possibilities and peculiar searches in a non-specific fashion for satisfaction. Clinical material for discussion is presented from the analysis of three patients — one of whom was psychotic.

The paper attempts to show how in the transference in the true anorexic and bulimic, attacks are directed towards the awareness of the meaningful and intended specificity and function of all objects, so that any specific function can be mis-directed or nullified by the patient. The paper shows how some of these characteristics can appear as well in the treatment of borderline cases and affect the countertransference of the therapist.     

Anorexia Nervosa: The Hospital's Role in Family Treatment

When an anorexia nervosa patient requires hospitalization for her ¹ 1 We will use the pronoun “her” to refer to anorexic patients since the overwhelming majority are female. Our discussion will focus mainly on younger adolescent girls who are still living with their families.
medical condition, the treatment team faces the problem of integrating the individual focus of inpatient care with the systems focus of family therapy. In this paper we propose a family-systems model of hospitalization, the aim of which is to facilitate such integration. The model draws on current theories of anorexia nervosa, as well as general concepts from psychodynamic, developmental, and family systems theories. The major hypothesis of the model is that all members of the anorexic family are developmentally arrested in the area of separation-individuation. On this assumption, we propose that the entire treatment team (including medical professionals and therapists) needs to function as “parents” to the anorexic family in much the same way that two cotherapists become parental figures in family therapy. Specifically, the team needs to provide those parenting responses that facilitate the family's individuation process.     

The elephant tied up with string: a clinical case study showing the importance of NHS provision of intensive,time-limited psychoanalytic psychotherapy treatments

Prof. Richard Layard's influential advocacy for greater provision of ‘evidence-based’ psychological therapies, based in part on an economic rationale, has lead to greatly increased provision of cognitive behavioural therapy (CBT) and short-term therapies for depression, through the Increasing Access to Psychological Therapies (IAPT) initiative, whilst longer-term psychodynamic treatments are under threat, criticised as lacking an evidence base. This paper argues for the continuing provision of intensive thrice-weekly psychoanalytic psychotherapy treatments, time-limited to two years. It does so by describing such a treatment within an NHS psychotherapy department with a patient with a long history of severe personality pathology, including significant levels of perversity. The paper describes the patient's difficulties and his movement through the treatment, focussing on his difficulties making genuine emotional contact, his destructiveness of such contact, his acting out in the treatment, his perversity and the vital working through of the ending. The shifts the patient made are described, and follow-up information on the patient is given. The paper discusses the unique benefits of time-limited treatment and intensive psychoanalytic treatments for this ‘hard-to-help’ group of patients, and the economic rationale that can be made for such treatments.     

Motivations for Reading Beauty and Fashion Magazines and Anorexic Risk in College-Age Women

A growing body of research has linked the reading of women's beauty and fashion magazines with the presence of eating-disordered thinking. Most of this research has focused on the relationship between the frequency with which women read and their potential anorexic risk. In the present study, the authors explore the connection between the motivations for reading and the presence of anorexic cognitions. Specifically, this study of 536 college-age women sought to determine which reading motivations might be the most p redictive of anorexic risk and whether those motivations would be differentially related to reading frequency and to scores on the Mizes Anorectic Cognitions Scale (MACS). To test the simultaneous contribution of the possible reading motivations on the two outcomes of interest, a structural equation model using AMOS 4.0 was generated. The findings from the model indicate that reading frequency and anorexic risk are largely predicted by divergent motivational factors. The reading frequency of beauty and fashion magazines was most strongly predicted by a woman's desire for selfimprovement. Anorexic risk, as measured by MACS scores, was best predicted     

On the analysand's need to know the real person of the analyst

But the conscious achievement of inner unity clings to human relationships as to an indispensable condition. C.G.Jung (1946, p.233) Based on personal experience the main part of this paper explores the theme of the analysand's need to know the real person of the analyst and the importance, on occasion, of the analyst's disclosure of subjectivity. The concluding part offers suggestions about working with analysands where there is early emotional damage and deficits in relationship.     

Antecedents of Children's Performance on Class Inclusion Tasks: Some Zimbabwean Evidence

An analysis of covariance hierarchical regression procedure was used to examine children's performance on verbally presented classification tasks in relation to the children's socio-cultural background, age, level of schooling, and sex. Task perception and motivation were entered as covariates. A total of 296 black and white Zimbabwean children took part in the study. Social class membership, age, level of schooling, and sex explained a significant proportion of the variance in performance on the classification tasks, whereas cultural group membership did not. Implications for multicultural perspectives on children's cognitive development are discussed and suggestions made for further research.     

Individual differences in young children's suggestibility: Relations to event memory,language abilities,working memory,and executive functioning

In this paper, two empirical studies are presented in which an attempt was made to explain individual differences in two different aspects of 4-year-olds’ suggestibility, that is, their ability to resist false suggestions and memory impairments due to prior misinformation. As sources of individual differences cognitive skills along the information processing pathways were chosen: executive functioning (Study 1) and working memory (Study 2). Additionally, memory for the observed event and language proficiency were included in the studies. The results revealed that overall individual differences in language skills made a significant and consistent contribution to individual differences in the included measures of children's susceptibility to suggestions. Executive function and working memory skills were not directly related to children's tendency to yield false suggestions and their memory impairments in a recognition test after being misled. However, both executive function and working memory were related to children's language proficiency pointing to a possible indirect effect and underlining the importance of language competencies in early childhood.     

A Review of: “Groups: Applying the Functional Group Model,edited by Sharan L. Schwartzberg,Margot C. Howe, & Mary Alicia Barnes, 2008”

This paper describes the process of developing and implementing a new information system, POTENT, as part of a quality assurance exercise to improve occupational therapy documentation in the hospital record. Results of a Retrospective criteria audit are presented and are supportive of a more rigorous examination of POTENT's impact on documentation practices.     

The Superiorities of Form M of the Strong Vocational Interest Blank

Form M of the Strong Vocational Interest Blank was suppressed. For it was substituted the Strong-Campbell, which retained only the item format and one part of the logic of the original. Whereas Strong structured his test around 11 job families emerging from Thurstone's factor analysis, the Strong-Campbell uses concepts derived from Holland's armchair view. Some occupational scales have been lost and some added. Consistently with sexual politics, each scale is now scored twice. Old goring services' franchises have been ended, new ones let, the most consequential move being the cancelling of the only service that gave same-day scoring. The dropping of scales for executive jobs has severely lowered the occupational level at which counselors can work. The loss of the job families has reduced predictive range. Feedback sessions are less fertile, perhaps because they take place fortnight after the test. Separate studies showed that Form M predicted well for 14 and 40 years into the future. The power of its substitute remains to be seen.     

Residues in the analyst of the patient's symbiotic connection at a somatic level: unrepresented states in the patient and analyst

This paper discusses the residues of a somatic countertransference that revealed its meaning several years after apparently successful analytic work had ended. Psychoanalytic and Jungian analytic ideas on primitive communication, dissociation and enactment are explored in the working through of a shared respiratory symptom between patient and analyst. Growth in the analyst was necessary so that the patient's communication at a somatic level could be understood. Bleger's concept that both the patient's and analyst's body are part of the setting was central in the working through.     

THE ROLE OF THEORY

In his psychosocial theory of development, Erik Erikson poses a viable framework from within which occupational therapists may evaluate and assess adjustment to dysfunction. Occupational therapist are familiar with the application of Erikson's eight stages to developmental problems. The authors present suggestions for the application of this theory to a variety of psychosocial and physical dysfunctions affecting mental health. These problems may result in the need to resolve Eriksonian crises at later points rather than regarding each crisis from a purely age-oriented developmental view. Awareness of the role of theory in the clinical application of occupational therapy skills may suggest new approaches for the therapist.     

Is JOOP of only academic interest?

Garry Gelade's paper offers some helpful suggestions and insights regarding how JOOP and other academic journals might strengthen their appeal to practitioners. His comments fall into two areas: (i) research agenda, and (ii) communication of research. I agree that most of his recommendations could lead to valuable improvements, and note that some of them are being tried elsewhere. However, I disagree with Gelade regarding his call for less emphasis on research method. The call for occupational psychologists to make their work more accessible to practitioners can be sensibly extended to making it relevant to policy.