Presentation, Group with anorexic patients: therapeutic factors

Anorexia can be described in different ways, depending on what model we employ to do this. Firstly, Freud saw it as an outcome of hysteria (1895), and Abraham as an instinctual state (or instinctual failure) of the oral stage (even up to the present day, his splendid writings on the character and stages of instinctual development, continue to help us understand the anchoring to the oral stage and the transformations of sublimation). Successively, Kleinian object psychoanalysis considered it a severe deficit in the PS_D position, whilst in the reorganization brought about by Bion’s theories, anorexic somatization is described as the realization of  an inverted container-contained function (Bruni, 2002). The point of view of the failing development of the separation-individuation process (Mahler, 1975), the symbolization (Segal 1957), and Winnicott’s idea of the transitional object, all contributed to bring the theme back onto the lines of valorising its origins in terms of relation and primary “environment” rather than considering the topographical, spatial and processual models. Some signifying models from the field of French psychoanalysis propose specific ideas in regards to the anorexic condition. Negative identity for example and its connection with the “dead mother complex” (Green 1966-85); the culture of absence and the failed experience of the mirror phase, described by Lacan (1974) and later taken up by Recalcati (1997) as a typical specific feature in anorexic situation. More recently, studies on the family led to see anorexia in the light of an illness within a family group, and transgenerational group,  linking it up to the internal object in the parental couple and its deep relation with the third object (an object on which flows the combined characteristics of the object of that very couple and the underlying system of the family group) (Nicolò, Ricciotti 1999; Zavattini, Lupinacci 2002). Also Stern’s studies (1985) on the original dyad mother-baby and those on attachment (see Candelori, Fassone, Mancone,1999)and the experience of an uncertain attachment in anorexic patients contributed to configure a new picture: We no longer see hunger, greed and possession – or its negation. The exploration of these conditions concerns elements that are linked with more general systems, examined to have a new point of view that contains the individual with his primary relationship. Recent attachment studies (Candelori, Fassone, Mancone, 1999) propose that anorexic patients had an uncertain attachment experience. Thus, we have no longer to  deal directly with hunger, and greedy feelings both of possession and its negation. But the analysis of this situation includes at present some aspects connected to more general systems, explored in order to create new perspectives and containers , though in the context of different theories and models. I think it would be different if the analyst did not speak about greed, it is as if he completely changed his perspective. The analysand is being listened to by an analyst who has another scenario in mind, that is without the conception of being emptied, the corporeal re-appropriation, and of the phantasies connected to this. It will not be important for the analyst to interpret the  defence mechanisms like the appeal to splitting or denial,  and  the culture of deprivation in order to replace the experience of need and dependence.  The conception of an exchange of person (between subject and object),  in order to transfer intolerable feelings through an emptying excess of projective identification; or the idea of the loss of the self that (or vice-versa) where borders and differences are abolished , can find now a different place. The analytic group, as a possibility of conceiving a field of undifferentiated social elements(Bion, 1961), seems to be fit for valorising and widening the aspects we have already spoken of and their acceptance. In the group the experience of hunger and the terror of being devoured and dismembered , the threatening of not existing  are not limited to their private, psychological or moral dimension (as a correspondence of  compulsive life.) On the contrary, such terrors are amplified into a collective , mytological (Corrao, 1998) and theatrical (Chianese, 1997) experience, thus it stops being monstrous (or sacred) and becomes comprehensible, in the context of the narration (Corrao, 1979; 1987; 1991; Ferro, 2004) , where they find the possibility of unfolding. The narration lives not in the vacuum of isolation ( the confrontation can often be experienced as a stimulus to anorexia and claustrophobia by the more fragile side of an anorexic personality), but rather in relational and social shared dimensions. These relations will be less directly connected to guilt, and instead situated in a net of meanings and transformations that the procedures and rituals created by the group will try to recreate in the course of time (Marinelli, 2000). The analytic group as a social structure, it succeeds in containing and representing the primitive and indistinct elements of mind (Bion, 1961), and it can give the most suitable perspective on  the appearance and elaboration of archaic workings, because their point of view  is widened to achieve the vision of a social system.  The experience of hunger , and the phantasies connected to it, may appear in its dramatic and primitive power, because it may appear in a group as enclosed in a world giving it order ,limit, a sense, a concatenation , a meaning not connected to a moral order , and so to guilt, isolation, and the burden of subjective responsibility. On the contrary such experiences will rather connect to the creative, cohesive, vital universe of exclusive and original belonging and basic globalization , the regenerating  dream (Marinelli, 2004) The extraordinary faculty, typical of the group ,to process its elements not in a personal way (first of all in the initial basic stages) make them belong to a common mind which is over-determined , able to contain and represent in an oleographic way those contents which would be too unbearable for the individual to stand. The anorexic mind whose functions and contents are predominantly archaic tends to keep alive traces of magic, religious and sacred elements. The group, through its work, brings out these aspects from time to time and keeps them in its unique memory (Correale, 1991; Corrao, 1992) where they are available to be elaborated on different planes in time (Marinelli, 2000b). It is as though the group, (and not only thanks to the analyst’s work) already creates on its own that sense of oneiric attentiveness that belongs to the myth and the dream. If there is good collective functioning, it is possible to transform the lacking or fearful elements belonging to the individual. When guilt is predominant and withdrawal and silence are very strong, the right moments to share or participate have to be created in order to continue transformation. The group provides a space to those elements that were never able to take place, expand, or to fully announce themselves. This attenuates their particularly harmful characteristics and makes them more human with the possibility of being used in a productive and legitimate way. Pent up fears increase when they are negated and segregated, whereas if they are brought out in the group they are amplified (Corrao, 1979,1987,1991; Correale, 2001) and simplified, becoming more realistic and acceptable and their origin can be re-presented in a comprehensible way. Similarly, as far as future prospects are concerned, elements that were suspended in time because of negation will become new elements that the group has in common. In his writings Bion (1970; 1974) spoke of a model of listening, on the analyst’s side, during the session where memory and desire are abolished from his/her mind. He spoke of the analyst who does not want to concern  himself/herself with healing, he/she does not want to use  memories that help understand and heal the patient. Rather, he spoke of an analyst who was to set his/her mind on the listening of the contents that are visible and the contents that have not emerged yet, and to try and “be” those contents, to be “O”, the ultimate truth of knowledge and to transform the pain through mentalization and collectiveness. But in regards to anorexia, there exists a paradox in the fact that the analyst’s expectation (without desire and memory), could be regarded as  immobility to coincide with it. The “dreamlike listening” would become a hypnotic fascination: while the immobilizing anxiety would continue to be produced in the mind of the patient, without any guide and awareness eliminating the possibility of recognizing himself. Therefore, we are not sustaining the importance of the‘word’ or expectation, here we are dealing with keeping alive (Winnicott), without ‘offending’ our patient who isn’t capable of accomplishing this; we must have respect for our patient, leaving our pride, desire and requests out. Consequently, it is unthinkable to work with a patient who expresses a sense of emptiness and annulment, if we don’t possess a complex thought about this devastating  vacuum. To maintain contact with emptiness without wanting to fill it, doesn’t mean that a part of our mind hasn’t a cognition or a memory of the traumas and the processes that constructed that vacuum. We haven’t ourselves a memory but we know that the patient has experienced a catastrophe. We shouldn’t desire the catastrophe to change nor do we want to undergo its forcefulness, but we are capable of seeing that life can keep on going. This paradox necessitates an ideational, complex and emotive effort we must make on our own; it also requires deep and acute discernment. The evocative issue  we present here is centred mostly on these themes, illustrates in different ways a type of creativity stemming from clinical and theoretical work that is particularly sensitive towards this specific sort of listening and the ability of acceptance that the analyst puts into practice in groups with anorexic patients. An introduction written by Francesca Vasta and Ottavia Caputo directs the reader towards the comprehension of the theoretic models which have more contributed up to now to found the field of listening of the anorexic condition in the group.
It is interesting the historical research in the area of the meaning of homogeneity in the group ,and the idea is analysed more widely in Francesco Comelli’s contribution, about homogeneity (in relation to proto mental elements) of Bionian basic assumptions.
In his describing moving clinical cases,  Ronny Jaffè talks about how the analyst needs to re-model Bion’s model in his/her mind, because Jaffè sees it as being too creative and important ( becoming almost a fetish), the purpose being to point up the immobility and the adversion to change that the mono-symptomatic group invariably expresses. The main element of his reflection concerns the need to transform  the  compulsion to repeat, and the contagious, reflective, repetitive similarity (in the homogeneous group), and transform the “pre-text” of the group into a new “text” (narration). Of particular interest is the connection between the idea of the repetition compulsion, the concept of infinite time that the anorexic ritual imposes on the group with the entrance of new members who reproduce recurrently the initial theme that preceded the transformations (of the group and the adolescent stage on the whole).
Comelli explores the homogeneity of the group with anorexic patients, relating it to Bion’s basic assumptions that contain an unconscious, protomental and somatic homogeneity. According to the author, the very formation of a homogeneous group has nothing to do with the identification and the reflection of the collective field, but rather, “this uniformity corresponds both to their reflection and a natural gathering of people which are already unconsciously identified on the basis of a collective emotion of opposition to a group”[2]. Anorexic patients start waging war against the transgenerational family group when they get ill, in order to differentiate themselves. Comelli also asks whether the homogeneity on which the group is formed is felt the same way by its analyst: “ What is the difference between working with psychotic or anorexic patients?”  and “Does an analyst of a homogeneous group have to sustain inwardly some of the  processes that are expressed solely by that symtomatology? If so, why?” The answer is found in his description of a “somatic, unconscious” quality that links the analyst to the group, right from the beginning of its “pre-conception”.
Lilia Baglioni’s pertinent article treats suggestive examples of homogeneous groups with anorexic and bulimic patients, advancing the idea of joining up Bionian basic assumptions with the work of the gamma function (Corrao) and syncretic sociality (Bleger), valorising above all the function the dream  which has in the group, and the emotional and affective modulation, seen as a sort of germinal membrane to heal the wounded identity. Laura  Selavaggi takes into consideration the conflicts in the context of the dependence and perturbation in the relation between the individual and his/her group of primary belonging. She suggests to connect the Bionian concepts about the relation individual- group with the specific manifestations of eating disorders recording the groupal elements within the dynamics of the individual. “Though the most direct implications seem be addressed to group therapy, the stimulation is rather referred to a quality of analytic listening, in other words to a mental setting that is able to catch group implications as a basic characteristic of mental functioning”.
A proposal to use in the group inter-personal experience is present in Nicoletta Calenzo and Luciano Gheri’s work, centred on the study of the link between interpersonal relation and groupal container. The theme is presented in the specific context of the group through the use of a mediating object, Photolanguage, regarded as a possibility of stimulating and elaborating  primary feelings arising from the here and now during the session in  contact with  images.
Luigi Onnis refers to a systematic oriented thinking, he  proposes a conception of mental anorexia as a complex syndrome in which socio-cultural,family and individual components are interconnected. Particularly, following the preliminary data of a research in progress, he examines family groups at  an interactional level as well as at a mythical one. Finally he underlines  the complementarity between these family aspects and the psychological dynamics of the individual patient.
Marisa Dillon Weston draws attention to the fundamental anorexic experience of emptiness and indicates through clear clinical examples, in which way this emptiness revokes and paralyses the matrix of the group and the analytic couple’s bond. She demonstrates, using different points of view that the anorexic emptiness has developed from a defensive experience from the “dragon-mother”. The mother who devours the psychic contents of the daughter in order to give to herself also the energy and development that she has missed and that she needs for her psychic survival.
The article of Barbara Pearlman considers a concrete work group on food re-education which is the appropriate place for decodifying concrete language. The activity of comprehension and giving meaning, ‘nourishes’ the new symbolic thought that is in the concrete expression of anxiety, and can amplify the inward, emotive potentialities of language. The author affirms that this approach reproduces the initial mother-daughter interactions where a deficit was present, caused by difficulties within the mother’s mind.  An interesting aspect put forward by the author, is the possibility of presenting concrete and primitive language to the borderline character of the anorexic patient in the group as an oneiric element, thus contributing to the communication in the group and amplifying it. The typical communications trough this group of patients are concrete but their own nature but they are valid communications, because they are expressed in the hope that “another” can understand them. But it happens only that they are expressed in a language made up of concrete objects, where we may just find a fragment of meaning and it represents only an aspect of the message. These communications can be understood better if we consider them similar to dreaming matter. The dreaming matter takes place when conscious functions are inhibited and when reality does not interact (Solms, 1999). Classically, the matter concerning dreams is interpreted within  the context of the analytic session. It is suggested here that concrete expression used on the side of anorexic patients can be understood within the therapeutic situation if the concrete object extends trough the language in symbolic form, referring to the context.
This issue also presents  a very articulate research on the development of infantile anorexia conducted by Massimo Ammaniti, Silvia Cimino, Loredana Lucarelli and  Laura Vismara. This research considers historical psychoanalytic models, but primarily focuses on the attachment model. The survey produces data and comparative evaluation and diverse clinical cases in order to demonstrate that  child anorexia is basically a product of insecure attachment. Different types of mother-child dyads are considered, reciprocal adaptation  and correspondence in the couple are associated to the relational make-up of the mother who, in turn, has her own unresolved needs. Perhaps, (I ask myself whether) a  further development of research in this field could lead in the future to a model of functioning in the group, given the “social” quality the authors attribute to the object of their study.
As we can see this issue  is rich in contributions and models and aims nearly at corresponding to the “monopolar” style (Marinelli, 2004). It is entrenched in the anorexic position which looks for the mind and dream of both the analyst and the group, so that identity can take shape and be realised trough a flow of defined thoughts.


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[1] Translator’s note: The paragraphs in italics are translated by the authors in question

[2] Translator’s note: The paragraphs in italics are translated by the authors in question