Home Mental Health & Well-Being ‘Nahrungseinfuhr’ of an Anorexic Teenager

‘Nahrungseinfuhr’ of an Anorexic Teenager

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Below is a clinical report of a psychoanalytic treatment. The title quotes a famous slip of Sigmund Freud in a letter to his friend Wilhelm Fliess about the feeding of the child. Freud wrote, ‘nahrungseinfuhr’ instead of ‘nahrungzufuhr’ which implies the idea of an ‘intromission’ of the food into the child’s mouth. This approach recalls the theory of the ‘primary seduction’ as developed by Pr Jean Laplanche. The French version of this article has been published in Psychiatrie Française, the journal of the French Psychiatrists Association. You can read the second part here. 

When she enters the waiting room with her parents, this fifteen-year-old girl – we will call her Isabelle – offers a striking contrast: on the one hand, a frail body, a pale skin despite colours brought by the summer sun. On the other hand, the intensity, if not to say the harshness of the glance. Under the vigilant attention of the girl, her mother explains: ‘This is at the request of her daughter that the appointment has been made after the latter recognised that “all her problems got out of her control”.’ The mother clarifies: Isabelle has already ‘followed several therapies with psychologists and with a child psychiatrist,’ but she promptly discontinued these therapies because she ‘did not notice any improvement of her state.’ Isabelle looked at the analyst defiantly. Although she ‘tries to eat fruits, she has no longer takes lunch,’ according to the mother. Divorced for many years, the parents accompany Isabelle to this consultation during which the mother monopolises a word, whose father, that we feel sceptical about the therapeutic approach – something he confirmed later on – remains strangely aloof.

I invite Isabelle to follow me in the office. A brilliant student in the scientific course, the teenager exposes her story with the concision of the language and a consistency of the syntax to the charms of which the analyst – a Sorbonne University graduate who loves Les Belles Lettres – could easily succumb. The symptom is firmly lashed to the absorption of food. Her ‘problem’ is not new: several years ago, Isabelle flirted with dietary restrictions, but in the recent weeks, she feels that ‘the phenomenon is no longer under her control’ and that ‘the slope becomes dangerous’. She skips lunch, avoids systematically meals with friends in order not to explain her ‘difference’, that of, as she tells to the analyst, not to order anything at the restaurant. During this first exchange, she explains that she spends her life with raising incessant questions about a scenario that repeats itself endlessly and that makes her feel guilty: she begins a relationship with a boyfriend she likes but, as it goes well, she promptly decides to orient this relation towards friendship, taking on ‘despite herself’ the role of confidante for a partner who, besides his incomprehension, conceives a sharp pain about this situation. As for Isabelle, she feels ‘very guilty’. This compulsive pattern becomes the governing principle of the future sessions during which, at first, the analyst does not fail to notice her impossibility to name everything related to the emotions and to the sexuality: this last word is even carefully hidden, either by some endless convolutions or by some embarrassed approximations that contrast with the speech capabilities of the young patient. This initial face-to-face proves the analytic rule: everything is said but appears in a palimpsest.

The session ends up with the evocation of a recurring dream: the patient is ‘sitting in the back seat of her parents’ car. Suddenly, her mother is ‘violently thrown out of the vehicle’, ‘She escapes herself from the car,’ then, ‘She is lost at the foot of a snow-covered hill trail that leads to a chalet and where she hopes to find her again.’ Back to the living room, I have to deal with the interrogation of the mother. I answer that it is up to Isabelle and to her alone, to decide whether or not, she wants to continue the work. An appointment is requested by the latter for the following week.

We will now discuss how we conducted this analysis, quite typical in fact of an anorexia nervosa among teenage girls where it predominates an incestuous problematic coupled with a questioning related to the sexual identity. First sessions show, as we mentioned in the introduction, some anguish of the genital and of the pubertal sexuality: Isabelle changes a budding romance into an accomplice friendship in order to neutralise the possibility of a physical relationship. Does this anguish recall those of the virgins and that of their ‘full horror of feeling’ vis-à-vis the sexuality? In the early stages of the treatment, the patient is surprised to dream ‘sexually from one of her university professors with whom she lives in pairs’: the transference seems to work. This perspective mentioned painfully in her free associations is barred with a sanction which plays the role of a psychic dyke: ‘That’s impossible.’

As a priori argument, her early age is gradually set aside by the patient, which permits to widen this notion of that impossibility to other registers. One of the dreams brings up a valuable aid: ‘She is on a beach for a party with a group of friends of her generation and there is an appetising buffet. With her boyfriend, the patient approaches in order to serve herself – the hunger torments her – when a series of unpredictable events (eruption of persons that the patient claims not to recognise, lively scuffle with others) happen and, abruptly, take her away from the big table.’

Reinforced by the interpretation, the patient understands that the implementation of the diet seeks to reduce and to contain the instinctual claims of her body by weakening it and by self-inflicting painful restrictions: these are all paradigmatic manifestations of the pubertal crisis. The abundant victuals on the table are easily assimilated by her to sexual pleasure. She manages gradually to distinguish fears of weight gain by eating from those due to the deformation of the body caused by pregnancy. These are displacements in the representations and in the affects. Strangely, we never talked again about food for months. This issue also gives way to questioning about her sexual identity, and, in doing so, through an obsessive thought: since her childhood, Isabelle questions herself compulsively and on an anxious mode, about her possible sexual preference for girls. She remembers, in particular, a movie which featured a female couple and, immediately after, a discussion with her mother about it. This obsession has never abandoned her even though she firmly claims feeling a desire for young men.

At this stage, two technical points can be addressed. The analyst detects a strong resistance from Isabelle on her ‘sexual choice of object’ whose determination and that of the subsequent positioning, frontally challenge her ‘vital’ need to control her psychic drive. Clearly, she refuses to choose. The difficulty, of course, does not focus on choosing between two sexual orientations. The analyst decides to move forward without trying to obtain, through interpretation, the lifting of the resistance and this, by displaying the greatest indifference to the issue of the sexual orientation.

In the session, Isabelle may continue to exercise her redeeming arbitrariness and, then, control the choice of object and that of her sexual orientation. But she is, therefore, obliged to make progress on her adult and genital sexuality. Another clinical point deserves a mention. The keen intelligence of the patient counteracts the therapeutic advances despite the strength of the transference. The analyst takes advantage of a little trick, certainly likely to be debated in practice: two or three times, the intellectual acuity of the patient is explicitly caught off guard by an interpretation that punctuates either a fading of her free associations or stagnation of her progress. I could say for instance: ‘I got accustomed to a better cleverness of yours,’ or ‘I am surprised that you have not got it yet.’ Guaranteed effects at the next meeting where, cut to the quick, Isabelle works twice as hard in her cure.

The cure progresses rapidly, including the disclosure of the incestuous nature of the relationship to her father: he has always refused his fatherhood by moving it to the field of brotherhood. More than once remembers Isabelle, her father claimed to play with her ‘as would his little brother do’. The father was under the exclusive empire of his own mother with whom the girl is obviously in open conflict. Isabelle also admits that her father is opposed to analytical processing. The father turns the words into acts as he regularly threatens to stop paying the sessions or not to carry his daughter ‘by car’. Nevertheless, some improvements are also accompanied by a clothing transformation of the patient and an impressive nail manicure, nail previously bitten and now covered with a varnish of a coarse colour: the patient assimilates this device to a ‘hatching and to an integration of her femininity’.

A broadly commented metamorphosis, she says, by her friendly environment as well as by her family and which signs, essential in the anorexia, recovery and a re-balance between the body and the psyche, between the bodily ego and the ‘ego as the projection of a surface’. A sudden interruption of 15 days, due to a fatherly ‘car breakdown’, was followed by a gloomy session during which the patient relives all the characteristics of a psychic and overflowing internal attack: a guilty speech with the returning to the ideational obsessions and the criticisms about the not progression of the cure despite the fact that she admitted the validity of it since several sessions. A couple of weeks before, she had even informed the analyst of a gradual recovery of her lunch meal.

The following week, the young girl amused herself with this brief relapse like a forgotten pleasure; ‘It has been a long time.’ A state that had become, she says, the exception. Commenting on her ‘wellness‘, she points out that this is ‘the opposite of what she has been feeling during the first session’.

The sexual precocity reveals, so to speak, the failures in the squares and in the identifications with the parents. During the divorce, Isabelle defends her mother against the violence of her father with a whole Oedipal ambiguity: while intervening in this way, she also experiences the pleasure of abducting the place of the mother as a sole interlocutor of the father. A strategy with many disastrous consequences due to the ‘enigmatic messages impregnated with unconscious sexual meaning’ of the father vis-à-vis her: this locks up Isabelle’s love on an exclusive and highly incestuous tonality, paralysing her own psychosexual development.

The mother is at the same time acts as protection and a rival, as well as the father, personifies simultaneously a love and a threat: more than once, the patient talks about this ‘impossible’ love while remembering to have felt the ‘non-natural’ dimension and the ‘unhealthy’ side of her father’s affects. To such an extent that she mentions that, while a child, she was always avoiding his ‘tenderness impulses’. Two screen-memories, presented by the young patient as both ‘insignificant’ and ‘the most unpleasant she had ever had to deal with’, must still be overcome to address the infantile sexuality. These recollections are punctuated by a dream clearly featuring her ‘amorous hesitation’ between a father figure and that of her ‘first boyfriend’.

She suddenly remembers a story, often told by her parents when, little girl, she was bathing. She was highly distressed and the only way that her ‘father found to instantly calm her in the water was to put his thumb into her mouth’. This ‘experience of satisfaction’ was doubled up with a ‘seductive experience’ because it lodges originally something sexual within it. It is difficult not to closely relate this event to the Freudian slip in a letter to Fliess about the ‘intromission’ of the presence of the other and that extends in the search for a perceptual identity, linking the satisfactory discharge of the psychic drive to a ‘representation of an elective object’. The patient demonstrates her false ingenuousness: ‘I never thought that such a simple gesture could have as many consequences’ while questioning herself about the fact that she ‘had carefully preserved this anecdote’, among the others, all forgotten, in her memory. Every gesture, every facial expression takes a signifying function, especially in this ‘oral area’, which is like an ‘appealing point and that of attaching to an heterogeneity’. Two dreams and acting out occur. First, a replica of the dream of the early stage of the treatment whose final scenario changes: the patient meets up with her parents again in the chalet. But ‘something has changed’, she said, ‘despite the reunion’.

In the second dream, she has to meet with her father by crossing a ravine through a balance beam. But in the midst of this passage, the patient falls into the void and ends up in the arms of a boy that she knows. She is surprised, in this part of the dream, ‘not to shout or not to experience any anxiety while landing in the arms of the young man.’ In the reality, the patient ‘has just fallen in love’ with a boy of her age. She is astonished by her ‘to let go’ attitude about her sexual desire as well as she surprises herself to get hungry while she is back home for lunch. One day, on the couch, she seriously questions herself on a lunch with her friend which is planned for the next day: ‘What am I going to wear?’ Acting out happens when she comes in a session with a ‘short’ haircut. Her father ‘loved so much her long hair that she never wanted to shorten them since her birth’.

The question of the maternal attachment remains unelaborated but, finally, is raised during a momentary interruption of the treatment, officially for financial reasons and for a clear ‘steady improvement’: could the mother not or did she not want to pay the sessions that she assumed to be owed by the other parent? Was it a kind of ‘settling of scores’ between divorced adults through an intermediary financial transaction? Could the acceptance of the loss of the father by Isabelle also satisfy the subsequent jealousy of the mother? The patient makes a dream: ‘she told her mother that the walls of the house are dirty and covered with mushrooms, but her mother does not want to see it.’

The dream goes on: ‘It takes two days and two nights so that together they start to clean it up.’ The associations of the patient are dazzling: ‘My mother always denied it but I always felt that she strongly wanted a boy. Moreover, the clothes she bought for me have always included a masculine touch. ‘From my seat, I look at the shoes worn by my patient, usually dressed with lots of care: in fact, she wears military boots! I interpret: yes, you are right, like these delicate opera shoes you wear.’ She gets up, looks at her shoes and bursts out laughing.

Jean-Luc Vannier is a French psychoanalyst based in Nice (French Riviera). Jean-Luc is an editorial board member of the Psychreg Journal of Psychology


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