ON ANORECTIC
TRANSFERENCE
Second
international conference on eating disorders, New-York, April
1988.
According to modern opinion, anorectic
patients
should not be prescribed a classical psychoanalytic cure:
psychoanalysis in a strict sense, is said, by most specialists, to be
ill-adapted for this kind of difficult patients. Rewiewing the freudian
writings, we may find some notations on Anorexia Nervosa, mainly
described as an hysterical affection, but nowhere there is to be found
any report about the cure of such patients.
Since the now-classical description of GULL and LASSEGUES is absent
from the experience transmitted by FREUD, we must rely on his
successors or on our own therapeutic experience.
First, according to most practionners, any long-term psychotherapy
meets with difficulties. We'll try to have a look on minimum conditions
to begin and maintain a real therapy. Most of our experiences with
anorectics show a high rate of drop-outs in quite a short time. Some of
these patients come with an apparently authentical desire for therapy,
follow a few sessions and disappear at short or without notice. They
can either give up hope for any therapeutical solution or resume the
therapy with another therapist, as if the person of the therapist were
indifferent. This allows the anorectic to avoid any affective
involvment with her therapist, by focusing on a disembodied, and so
ineffective, medical help. The "as if" therapy acquires a meaning and
an importance in itself, losing touch with external reality and maybe
more dangerously with psychic reality, namely the Unconscious. The Ego
leads the way in a humdrum which may persist for years or stop on the
first occasion (illness, holidays, or any event interrupting the course
of the therapy).
The main feature of these therapies is the resistance
to change; the patient may conscienciously tell of all her life or
remain silent, nothing moves. The cure may turn short as it is
satisfying neirther to the therapist, neither to the patient. The
symptoms persist or even get worse. Maintaining such a therapy makes
the therapist uneasy: either he can tell the patient of all his
feelings about the uselessness of the whole cure, forfeit any hope and
risk a mistake by an over-pessimistic view, thus compromising all past
and future work, either he can maintain a meaningless cure for years,
hoping for something to happen, unjamming the psychic apparatus, and
permittinga release of the unconscious. This may never happen, in this
therapy, because of the death-dealing interaction of the transference
and counter-transference. Or, finally, the therapist may be tempted to
act on a more active, in fact reactive way, and to jostle the defenses
of the anorectic, waiting for a positive change. All these solutions
are to be considered as the equivalent of an acting-out from or for the
patient.
Another type of failure exists for a beginning therapy, that of extreme
transference, in fact falling in love with the therapist, whatever his
gender. Interpreting the massive transference, in usual way, at the
outset of the therapy goes against all the patient's feelings as she
isn't prepared in any way to the dynamics of the cure. Most of those
patients can't bear the neutrality of the therapist, even less his
rebuffal, and stop the cure with ressentment. The ultimatum can be
heard as "Either you stay away and there's no point in engaging a
therapy or you share my feelings and we can pursue my healing". Any of
those solutions immediatly forfeit any hope of pusuing the cure.
From the intra-psychic point of view, the anorectic way of life
represents a pathologic equilibrium, pathologic in a sense that most of
the unconscious is kept at large, thus shrinking the whole life of the
patient; and pathologic in a sense that life is threatened in his
continuity, death being the ever-present way-out. The death and life
instincts act on separate way where life instinct preserves the subject
in his life but prevents any evolution and death instinct constantly
threatens his survival but goes on the way of change. This equilibrium
is maintained with an important energy output, so any therapeutics will
go against massive defenses. To counter the therapeutic threat, the
transference relationship is perverted in an archaic way. Instead of
beginning a love or hate relationship with the therapist, this one is
used on the oral mode: swallowing or spitting him.
Massive transference at the outset of the therapy must not be
understood as a classical transference: a love/hate realtionship; in
fact this reaction bears the mark of the oral stage and the
object-relationship involved in the term transference may be
unappropriate. Incorporation and identification are nearer from our
clinical experience. Let us remind that, according to FREUD, the
primary identification represents "the most original form of an
affective bind to the object" earlier than love. This immediate
relationship, deeply related to the image, may be understood as a
print, a "Prägung" in the sense of Konrad LORENZ. This kind of
extremely archaic mecanism may explain the massive appearance of this
pseud-transference. Some very un-typical features are to be noticed:
despite the extremely affective relationship, nothing moves as the
transference is difficultly interpreted an more, nothing can be
elaborated on it. Symbols and specially talk, can't act on this
transference, the talking-cure is impotent in resolving the
transferencial problem.
In a more pragmatic way, the therapy of the anorectic is to be focused
on maintaining the cure itself as the peculiar anorectic transference
can be considered as extremely hostile, aiming for protecting the
statu-quo. Whatever the way used, manifest hostility or apparent
positive transference, both look for nullification of our work. Both
block any evolution in the therapy as they put the therapist in an
impossible position: acting and threatening the cure or do nothing and
risk physical or psychic death of the patient.
A lightly seductive
attitude, howewer staying at the edge of neutrality, from the therapist
can catch the anorectic in her own game, making a later analytic work
possible. A more seductive or friendly attitude can both avoid
rejecting the patient with massive transference, pursue the cure, or
create a bind with an hostile patient. This seductive attitude can be
considered as necessary, howewer sterile for itself, as it opens the
way for a more constructive approach. For this, psychoanalysis first
can't be used, as breaking the classical neutrality would forfeit his
essence, but an analytic-inspired therapy can be considered, in those
difficult cases, as the pre-psychoanalysis, necessary to begin the
analytical process.