Ginger raises specific questions about Laura, Laura's and my relationship, and my way of working. Her other questions lead to the heart of puzzles about the eating disorders. First, let me answer those that are specific to Laura.
Laura both refuses to eat and purges when she does eat. She has in the past been seriously anorexic and suicidal. These were the reasons for her hospitalizations. She gained greatly from her treatment at those times and subsequently, bringing her (in my belief) to the point where she could control the sexual behavior of her then boyfriend. There is in store some material to substantiate that she felt like a little girl with that man, and yet able to control him. Laura was able to realize spontaneously when she recounted it to me how it was a successful replay of her childhood situation--this time, with mastery on her part. I am not sure whether the BOL plan is to include this material for present purposes, but what she accomplished before she and I started together is important.
Laura's salesman father is probably a successful alcoholic in that he has been able to maintain himself in the community. Her mother shows signs of depression now, but it is hard for me to know whether these are connected with her diagnosis of cancer and/or her feelings of failure in regard to Laura. She also was successful in business as a key office manager for a large company and gave that up only after her cancer was deemed unstoppable. She is actually in remission now physically, but she spends her days mostly in an inert state in front of the television, as Laura describes it.
I do not believe Laura has a biological predisposition to her eating disorder. The science underlying such an hypothesis seems weak to me. In any case, there is nothing which I know of to suggest it in Laura's case.
The societal preoccupation with thinness likewise does not stand up to scrutiny as a cause. The cultural inundation of our young teenagers with sexual images, as the cause of the preoccupation with thinness, is another matter. My first anorexic patient, a college freshman, worried constantly about her perhaps having "power thighs." Anorexic girls readily admit not just to concern about fat, but to a horror of any roundness in their anatomy.
Laura's physical health at this point does not seem to suffer from her demonstrations of eating disorder. I do not know how far down her weight went before she was hospitalized, but that was when she was in her late teens and early twenties, long before I met her. When she and I began together, her bulimia was the reason she wanted treatment. She in the meantime acquired an advanced degree in a profession allied to ours. She felt she was helpful to other people, wondering why she could not be more comfortable herself.
The sexual abuse, to my understanding, was a crucial aspect of her developing an eating disorder. Such a history is not essential to the etiology of eating disorders, but I think it is logical as a strong contributor to such a development. Clinically, it seems to me I have seen the figure that eating disorders appear subsequently in over 60% of cases of known sexual abuse. This association makes sense in terms of a developmental view of the etiology of eating disorders.
As to my relationships with patients, including Laura, I see myself in partnership with people who are striving to achieve inner cohesion as a basis for a satisfying life. Inevitably, they react to me according to their previous experiences with others. I am not different from all of those others necessarily because of a superior capacity for loving nor any ability to understand them at times. I am different necessarily from all of those others in having a contract with patients to focus on their concerns as exclusively as humanly possible ("humanly" entailing imperfection). Patients can feel their control of the contract through paying a fee.
I do try to "be there" for them. Why would anyone engage in such a deeply personal enterprise unless the therapist proved to be sincerely involved, too? To be a maximally effective partner in such an enterprise for them, however, if I try to keep professional boundaries. I am committed to protecting them from feeling swooped up into my orbit, as their previous experiences with significant others may have left them feeling. At the same time, my willingness (and hopefully, ability) to withstand their ambivalences without flinching from concern for them is part of our contract.
The idea of a therapist as one who supplies from the outside what the patient still lacks is a way of seeing people from the standpoint of a deficit model. I prefer to question why the person is not free to use the potential for self-desired constructive behavior that each of us actually possesses. I have never met a person who does not demonstrate the full range of human possibilities at various times. That is why in trying to appreciate the metaphors expressed by symptoms, I ask why a particular behavior fits in at just a particular time. I find it equally intriguing to discover the contexts in which someone can be symptom-free.
As to a multiplicity of factors producing eating disorders, I think it clarifies matter to begin with the fact that there is a universal syndrome displayed by these patients, for which "eating disorder" is merely the currently favored label. (If anyone is interested in the first, classic description of the syndrome, the person who first recognized it was John Sours. The reference is his 1974 paper, "The Anorexia Nervosa Syndrome" published by the International Journal of Psycho-Analysis, 35 (4): 567-576.) The syndrome includes equally with the patient's behavior in regard to food: hyperactivity, anal preoccupation, elaborate use of denial as an adaptive mechanism, distortions about time, rigid good/bad dichotomies, severe asceticism and asexuality, extremely felt loyalty conflicts, etc. These universals are worth noting, even though each human being is unique.
Clearly, no person enacts an eating disorder syndrome with conscious determination. The whole thing is much too unpleasant. For intelligent people to carry out such a program, they must be directed by overwhelming forces that they are unable to deal with directly. Therefore, one must seek explanation in the unconscious
I think of the unconscious as a dynamic depository of life experience, from where even very early formulations of how to manage oneself can influence reactions to the new. It does not seem much of a stretch to try to relate the twin concerns of adolescence--autronomy and sexuality--to the eating disorder syndrome. When these concerns are troubling enough, the natural thing is to tap into mechanisms that got one through in dealing with the same concerns, in a sense, when one first needed to do so.
To the best of my understanding, the whole syndrome that characterizes eating disorders is recognizable universally only as a reflection of the sort of mentation that a child typically displays during the toddler years. That also happens to be when a children first conceptualize being a self, dramatizing issues of autonomy and dependence. Simultaneously, they connect gender and their extraordinary genital sensations. They use whatever cortico-neurological capacities they have already to manage their feelings. .Of course, the human capacity for compartmentalization enables an adult to utilize such primitive mechanisms later on in relation to certain matters, while in other matters responding in age-appropriate ways. In fact, sometimes a person "bargains" within the ego to utilize such primitive mechanisms, in order to be able to use adult powers at all.
I am reminded of Clinton employing part-object sexuality and childish food choice while engaging in the gravest of adult responsibilities (Presidentially discussing a prospective war with a Congressman). One might hypothesize that he could endure the inner danger of being so adult only by reinforcing himself with a replay of early-based mechanisms.
Back to eating disorders and a bit less guesswork: Sexual interest and a sense of autonomy together underwrite maturation at adolescence. This combination strongly reactivates the central conflict that children experience when they first become aware of themselves as individuals. Therefore, the critical achievements through therapy would be to help people to feel that they can be both sexual and good, autonomous and safe.
Don's idea of tuning in to the level at which a person operates symptomatically makes sense to me. As you can see, Ginger, I do not think in terms of change so much as development. The semantic difference between change and development to me is this: I am less focused on evaluating behaviors than I am on seeking how a person's primordial anxieties can be put into a context of that person's present powers (as opposed to the actual limitations the person had in an earlier period of life). I guess I am talking about outgrowing a felt need for mechanisms that have outlived their time.