Episode 219: Eating Disorders with Tom Wooldridge, PsyD (Blog B)

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Article Authors: Tom Wooldridge, PsyD, ABPP, FIPA, CEDS-S

Part B

This article is Part B of the episode with Tom Wooldridge, PsyD. Find Part A here.

Tom Wooldridge, PsyD, ABPP, FIPA, CEDS-S, is chair of the psychology department at Golden Gate University, a licensed psychologist, and a psychoanalyst. He authored Understanding Anorexia Nervosa in Males (2016), Psychoanalytic Treatment of Eating Disorders (2018), Eating Disorders (2022), and co-edited Advancing Psychotherapy for the Next Generation. His work has been featured in Newsweek, Slate, and WebMD. Dr. Wooldridge is also a Personal and Supervising Analyst at the Psychoanalytic Institute of Northern California and a Training Analyst at the San Francisco Center for Psychoanalysis, with a private practice in Berkeley, CA.

Tom Wooldridge and David Puder have no conflicts of interest to report.

Introduction

While psychoanalysis has a long history of engaging with eating disorders, the contemporary field of eating disorders treatment and research has lost sight of its contributions. As I have written elsewhere, I am repeatedly struck by how little the psychoanalytic sensibility infuses eating disorders advocacy, treatment, and research. There are good reasons for this, including the overly reductive claims that psychoanalysts have made about the etiology of eating disorders, the neglect of the importance of family involvement for children and adolescent patients, the need for a larger, multidisciplinary treatment team, and the urgency of weight restoration, when possible, for malnourished patients. In an effort to correct for these failings, however, field may have gone too far, at times focusing solely on symptoms and, thereby, neglecting the complex emotional life of the patient and how the patient’s psychology shapes his or her symptomatic expression.

Therapists who work with eating disorders often hear stories about the crushing impact of multigenerational criticism about weight, body type, and appearance. Our patients speak to us about the multiple meanings of food, weight, and body shape and about how these meanings are embedded in complex familial and cultural systems. As we listen, we try to understand and emotionally resonate with the deep anguish our patients convey. Perhaps, I have often thought, our field’s emphasis on rapid symptom reduction signifies not only our intent to help as quickly as possible, but also our need to evade confrontation with profound emotional pain. This, of course, may foreclose a fuller empathic immersion in our patients’ lives and our understanding of each patient as a multidimensional person, which, in my view, is central to effective psychotherapy.

Psychoanalytic Concepts Helpful For The Treatment Of Eating Disorders

In this brief article, I suggest a few ways in which a psychoanalytic understanding may enrich our efforts to understand and address these complex clinical conditions. At the onset, it must be acknowledged that the term eating disorders refers to a set of descriptive diagnoses — anorexia nervosa, bulimia nervosa, binge-eating disorder, muscle dysmorphia, orthorexia, to name those most recognized — that describe sets of observable symptoms and behavioral phenomena. This differs from how psychoanalysts would understand these disorders. In contrast to a descriptive diagnosis, a psychodynamic or structural diagnosis emphasizes the patient’s personality structure, including its underlying psychodynamic mechanisms, to understand the patient as a whole person. Because eating disorders are descriptive diagnoses, they do not point to homogenous groups of people but, instead, group together people who have similar observable symptoms and behaviors.

To illustrate this point, consider an empirical study that used the Shedler-Westen Assessment Protocol (SWAP-200) to assess the personality structure of patients with anorexia nervosa and bulimia nervosa. Three categories of patients emerged: a high-functioning/perfectionistic group, a constricted/overcontrolled group, and an emotionally dysregulated/undercontrolled group. As this study suggests, reliance on descriptive diagnosis groups together anorexic patients who are high-functioning and self-critical with those who are highly disturbed, constricted, and avoidant, while also grouping together bulimic patients who are high functioning and self-critical with those who are highly disturbed, impulsive, and emotionally dysregulated (Westen & Hamden-Fischer, 2001). Distinctions such as these are profoundly important to psychotherapists who are attempting to develop a complex and specific case formulation of each patient. Such distinctions are largely neglected in empirical research that focuses on descriptive diagnosis, yet are deeply important for practicing clinicians.

With this idea as our foundation, I will suggest a few central ideas drawn from psychoanalytic theory that can enrich and deepen our understanding of patients with eating disorders. The first is alexithymia or deficits in symbolic functioning: many patients with eating disorders have trouble putting feelings into words. The empirical literature suggests that patients with eating disorders may use maladaptive eating behaviors (e.g., bingeing, purging, restricting) to regulate their emotions (Cooper, 2005). Whereas some studies report no significant differences in alexithymia across eating disorder diagnoses, others suggest individuals with anorexia nervosa experience higher levels (Nowakowski, McFarlane, & Cassin, 2013). Alexithymia appears to decrease significantly post-treatment with all eating disorders (ibid).

Historically, it was taken for granted that all psychic life was representational, either in words or imagery. Now there is now a vast literature on unrepresented states of mind: mental contents not stored in representational form as symbols and images but that nonetheless shape our experience and behavior. The concept of alexithymia emerged as psychoanalysis was beginning to turn its attention toward unrepresented states and group together patients for whom the capacity to symbolize and represent affect is markedly impaired. Psychoanalysts have sophisticated ways of thinking about alexithymia, including the idea of mentalization, a way of thinking about different “registers” of emotional expression, as well as the concept of reverie, which speaks to the intersubjective process that occurs between parent and child as well as between clinician and patient and that is central to facilitating the capacity to identify and elaborate emotional experience. These ideas can help clinicians to facilitate their patient’s ability to speak freely in treatment.

The second important idea I will describe here is abjection. Patients with eating disorders commonly describe the loathing that they experience towards their bodies. They refer to their bodies, or parts of their bodies, as disgusting, ugly, gross, and “fat.” Julia Kristeva’s (1982) notion of abjection offers a way to understand this experience more fully. For Kristeva, the abject consists of that which is taboo: horrific, monstrous elements that were once categorized as part of oneself but have now been rejected. Vomit, perhaps, is an apt example, for it was once inside of us and now, existing outside, is experienced as repellent. Writing of her struggle with anorexia in adolescence, Probyn (2004) eloquently describes this experience.

“Like many, I spent much of my childhood feeling disgusting. However, any evidence of that time is scant. Of the series of photographs that document my childhood, there is an absence that occurs about the time that I was severely anorexic. The reason for the lack of previous documentation is simple: why or how could such a sight be documented? Even now my eyes turn in aversion from memories tinged with a mixture of shame, disgust, and guilt. At the same time, I do remember the splinters of pride that accompanied the disgust: pride at the beautifully prominent set of ribs, the pelvic bones that stood in stark relief, causing shadows to fall on a perfectly concave stomach. Looking back at my experience, I wonder at the forces of pride and shame doing battle in a body that knows itself to be disgusting” (p. 127).

With Probyn’s (2004) description as an example, many patients with eating disorders locate the abject, accompanied by the affect of disgust, in their own bodies or in the bodies of others. This oscillation, between the feeling that one’s body is abject and the feeling that one has rendered their body “clean” through self-starvation and cast out infection, locating it in the other, characterizes their struggle. In my own writing, I have articulated two traumatic themes that contribute to the experience of abjection in patients with eating disorders, though there are likely others as well. Most importantly, these ideas facilitate our ability to empathically grasp the profound extent of the self-loathing and bodily disgust with which these patients struggle.

The final important idea is the object hunger. One of the most common themes observed in patients with eating disorders centers on early traumatic disappointment in the child’s attachment figures (“objects”) that derails the development of an internalized representation of those objects — a key component of healthy psychological structure. In other words, because the child experience’s recurrent, disappointed need for connection with an important other, he is unable to internalize that other and, over time, to provide, at least to some degree, for himself what that other might have originally provided for him. This fuels intense object hunger which, absent intervention, persists throughout further development. The term object hunger refers to is a desperately felt need for contact with another person who can serve as a substitute for missing segments of one’s own psychic structure. This other is loved not as a separate, whole person but, rather, is fervently needed to make up for what is missing internally. This yearning often has a desperate quality that may be conscious or, in contrast, vehemently defended against.

It has often been observed that eating disorders most commonly, though not solely, manifest in adolescence. Notably, adolescence is a period in which object hunger is exacerbated. Blos (1967) conceives of adolescence as a second individuation process: a phase in which the processes of the separation-individuation crisis (Mahler, 1963) are re-worked and expanded upon. Whereas toddlers in separation-individuation gain emotional supplies from reunion with mother, adolescents are more likely to seek supplies from peers, including through the expression of their emerging sexuality in those relationships. Adolescents are notable for seeking out experiences of heightened affect, whether of excitement and elation or pain and anguish. These are manifestations of object hunger, intensified in adolescence because of the concurrent lessening of parental ties as adolescents establish a greater sense of autonomy and personal identity.

Conclusion

To briefly recap, I began this article with an articulation of how psychoanalysis understands eating disorders, emphasizing its focus on the particularity of each patient and the clinician’s efforts to craft a case formulation that emphasizes the specificity of each patient’s personality structure and how that structure is intertwined with his or her symptoms. This emphasis is intended to complement a larger, biopsychosocial understanding of these complex disorders and is only one aspect of a comprehensive treatment team approach. With this understanding in place, I have briefly described three key psychoanalytic ideas that may be useful to clinicians working with this patient population, opening up new avenues for empathic immersion and clinical intervention. 

References: 

Blos, P. (1967). The Second Individuation Process of Adolescence. Psychoanal. Study Child, 22:162-186. DOI: 10.1080/00797308.1967.11822595

Kristeva, J. (1982), Approaching Abjection, Powers of Horror. Columbia University Press, NY, pp: 1 – 31.

Mahler, M. S. 1963 Thoughts about Development and Individuation Psychoanal. Study Child 8:307-324.

Probyn, E. (2004) Carnal Appetites: Food Sex Identities. London: Routledge.

Szmukler, G. I., Dare, C., & Treasure, J. (Eds.). (1995). Handbook of eating disorders: Theory, treatment and research. John Wiley & Sons. https://psycnet.apa.org/record/1995-98437-000

Westen, D., & Harnden-Fischer, J. (2001). Personality profiles in eating disorders: rethinking the distinction between axis I and axis II. American Journal of Psychiatry, 158(4), 547-562.