Elizabeth Cowie Catalogue of british film institute productions 1977–1978

Abstract

All one can do is to accompany the patient on her journey into the past and support her in the present, in the hope she may learn to exist again.DINORA PINESA Woman's Unconscious Use of Her BodyIn the past 25 years, the disparate disciplines of psychoanalysis and feminism have come of age. Like two distinctly multitalented but rivalrous sisters, they are finding in their maturity much to embrace and assimilate from each other's idiosyncratic view of the world and the human condition.20, 22, 23, 24Although their disputatious adolescence is far from forgotten, manifesting itself in ongoing debates regarding theoretical bedrock issues, treatment practices, and the prescient merit of each others' appreciation of the plight of women, their reprieve is facilitating a lively amalgam of thought. This new freedom to synthesize is impacting the practice of psychoanalysis and psychiatry at large, but nowhere is the importance of the interdigitation between feminism and psychoanalysis more apparent or important than in the subspecialty of eating disorders.74, 75, 78, 81, 83Simultaneous with the emergence of a host of books and papers heralding a new integration between feminist and psychoanalytic ideas, the psychiatric literature has been peppered with a series of long-term outcome studies on the treatment of patients with an eating disorder.3, 8, 9, 11, 68 Findings in these studies are sobering to clinicians of all disciplines who immerse themselves daily in the plethora of medical and psychological issues that beset anorexic and bulimic patients.72, 73, 76 We recall the halcyon days of the 1980s when a host of behaviorally based treatment programs sprang up, the possibility of curative psychopharmacologic medications appeared on the horizon, and cognitive-behavioral techniques promised rapid, if not long-term, symptomatic control. In essence, treaters had every reason to believe that even the most severe eating problems would soon be licked, relegated to footnote status in psychiatric history.This sanguine perspective skirted many critical concerns, including an appreciation for the continuum of weight preoccupation problems among the majority of adolescent and adult females,59, 72, 75 the degree to which comorbidity frequently accompanied a bonafide eating disorder,73, 75 and the published testimonials of patients attesting to the multifaceted, recalcitrant nature of their eating problems, despite various clinical interventions.21, 32 In effect, we clinicians had scotomized a wealth of information that would have painted a more realistic, albeit serious, portrait of long-term follow-up of eating-disorder patients.Just as psychoanalysis itself had been oversold in the 1950s, so these new quasiscientific, cost-effective methods of treatment now appear to have promised more than they were able to deliver in the 1990s. Despite the near manic embrace of “scientific validating studies” heralding the usefulness of fluoxetine, cognitive behavioral psychotherapy, early family intervention, and rapid symptom control in the hospital with posthospitalization follow-up,3, 26, 39, 59 a significant number of patients remain ill after these interventions are used. Sometimes, the manifest symptomatology of the eating disorder abates with treatment, only to leave the patient desperately unhappy or feeling unfulfilled in many other life domains. It is this calamity that a synthesis between feminism and psychoanalysis seeks to rectify, addressing itself to the deeper need of the individual to develop personal and interpersonal fulfillment across the entire cycle of life.In the sense that Dinora Pines conveys in the introductory quote, eating-disordered patients do not seem to exist—or fully live—in a psychological, existential, or spiritual sense. They experience their life not as a journey but as a drudgery, denuded of interest, investment, interpersonal anchoring, and love and affection. Their capacity to bear the blows and exigencies of life that affect each of us at one time or another is limited by the significance they place in maintaining their eating disorder. Because the emphasis on shape and weight overrides the clamor to appreciate one's feelings or investment in the world, woman's autonomous, sensual, political, real self cannot be heard.27, 67, 70, 75, 76 Treatment derived from feminist psychodynamic theory strives to cultivate this voice by delving beneath the manifest symptom alone. Inherent is the notion that, although this expression may commence as a mere whisper or inarticulate utterance, sonorous carillons are possible when one probes “the underbelly of life.”51Axiomatic is the belief that a fuller expression of life's possibilities for women ultimately, beneficently imparts new political freedoms and psychological potentialities for men as well.41 At times, however, it has seemed that an unconscious, although precariously maintained, masculine prerogative has been a dread of women's development of self and voice. Women have concomitantly feared and avoided cultivating their own power,10, 14 and the conflictual currents about the nature of personal choices may manifest themselves or be imbedded in their eating disorder. Indeed, only recently have women's contributions begun to be taken seriously in academic or business life, and often these contributions are minimized. Such blights on the real achievement of women have enraged feminists and led to a notable backlash of progress for women in some circles.With respect to the field of eating disorders, it may be prudent to wonder if the driving force behind the obsessive need for symptom control in the shortest amount of time, at the lowest possible cost, is partially driven by a fear of the development of a woman's sense of self should she address and work through the deeper basis of her eating disorder. Professional interest in symptomatic remediation of an eating disorder results in the narcissistically gratifying accolades of appearances at conferences, the publication of successful manuscripts and books, and the career enhancement of investigators. Development of personal self is a slower more costly process of time and money that rarely makes headlines.More concretely, statistical surveys of treated patients with anorexia nervosa and bulimia nervosa conservatively estimate that between 25% to 40% of patients remain ill or afflicted with pervasive concerns about their bodies after treatment.3, 8, 9, 11, 68 As a profession, we must squarely acknowledge that we are not really doing as well as we would like. Those of us who work daily with these patients find these statistics bewildering and confusing but confirmatory of our own clinical experience. Sometimes, intractable eating symptomatology may remit only to leave the patient with notable impairments in work, social, and emotional life. Why is it, we ask, that at a time when our subspecialty has more to offer patients than ever before, do such a substantial number of patients remain ill? Despite our medically sophisticated and broad-based efforts to counteract starvation and metabolic deficiencies, adjust neurobiologic mechanisms with psychotropic medication, and countervail antiquated thinking patterns about body image and appearance with directive therapies and psychoeducation,3, 26 many women continue to linger with the belief that their body alone is the final arbiter of their self-esteem.This critique is not meant to disavow the significant achievements in understanding and treating eating disorders in the past 15 years. Indeed, this particular issue is a testament to the growth in the subspecialty field since the last overview statement was published in the Psychiatric Clinics in North America in 1984.40 Nor do I wish to suggest that the rapproachment between feminism and psychoanalysis will be the conclusive and essential statement on the treatment of all eating-disorder patients. Still, a fuller appreciation of what these once competing theories now offer to patients by their creative synthesis (which is, in fact, a work in evolution) may prove to be an encouraging, if not lifesaving, éntre into the lives of some, if not most, patients.I now address some of the major areas of thinking in feminism and psychoanalysis and apply them to the treatment of eating-disorder patients. Space does not permit an all-encompassing view. The task is to present some of the major islands of theoretical exploration and growth and bridge them to the larger mainland of clinical intervention. In the process, I hope to demonstrate how helping the patient explore her life experiences within a cultural context and with a deepening appreciation for her own individual psychology helps her to overcome unbearable inner pain.The eating disorder then comes to be understood as the most overt, global, symptomatic expression of the woman's inability to right her life and to offset its traumatic course.15, 16, 34, 37 It signals to the observer the inner anguish and unbearable affect the patient sought to rid herself of by a tenacious sadomasochistic relationship she has had with her own body58, 83; the cultural overvaluation of the body (and eating) becomes the quintessential conduit for expression of aggression, sexuality, and desire.60, 62, 74 Seeing herself to be ineffectual in worldly pursuits, the woman is denuded of a real control of self by her performance as a hunger artist through which she achieves power and self-soothing.By helping the patient come to reckon with the depth of her being, the truths of her past, and the efforts to extinguish her despair by turning to her eating disorder, the therapist, working within a feminist psychodynamic framework, entreats the patient to embark on a journey where her singular personhood is paramount. In the process, the patient learns to exist again— sometimes to know herself for the first time. For the therapist, the task is infinitely rewarding, gleaning new appreciation for the human courage in overcoming despair by self-exploration. Treaters must also find ways to nourish themselves because such treatments are often quite demanding of time and attention.78 We are frequently sustained by new learning and exploration of theory; we are also apt to learn as much from the patient who courageously shares the hard-won lessons of her life. In this way, too, contemporary psychoanalytic theory urges us to make use of countertransference feelings as the patient struggles with universal situations that may parallel our own; feminist theory simultaneously encourages us to eschew an intellectual, often fictitious distance from the patient in order to be more “experience near” and positive, appreciative of our human connectedness and shared cultural foundation.40, 71, 78