Hungers and Compulsions: The Psychodynamic Treatment of Eating Disorders and Compulsions (Book Review)

Author:  Petrocelli, Jean and Stuart, Catherine
Publisher: Jason Aronson, 2001
Reviewed By: Carol Saturansky, Summer 2003, pp. 55-56

The title of this book is a little misleading. Compulsions, such as in obsessive-compulsive behavior, are not addressed here. The fact is, the title grabs the reader’s interest because the word hunger immediately evokes physical and emotional resonance. A state of hunger usually requires (or compels) an action: eating. The cover of this book piques our interest because all human beings, analysts included, have known hunger. In this volume the editors have tried to tie together numerous authors’ thinking about what is really a continuum of experience, from hunger to desire to passion to addiction; from nourishment behavior to pathological symptom.

Addictions and eating disorders are similar in that they involve ingesting (or refusing to ingest, and thereby causing the same effect) substances that alter the brain and body chemistry and result in intrapsychic, physiological and social consequences. These symptoms are highly dramatic and provocative. One cannot easily ignore, miss or minimize these behaviors. (There’s no floating around in the diagnostic murk here.) This is behavior that involves engulfing a part of the outside world: food, chemical, or human object. Eating disorders and addictions embody high drama because these symptoms are about actions that people take that affect them as well as others. But for the psychoanalytic therapist, the symptom is just one aspect of a person, and the contributors to this book all attempt to understand the symptom as part of the greater whole of that person. Still, the symptom is dramatic, discrete and more immediately distressing than say, a chronic depression. And, as we learn from the various writers, the treatment of an eating disorder or addiction regularly goes beyond understanding and usually involves more than the usual level of active participation from the therapist.

The Introduction tells us that the book grew out of a conference given by the William Alanson White Institute. There is indeed a conference feel in many of the chapters, where it seems as though the author is speaking, not writing, and the reader is part of an actively listening audience. This format is fascinating as the authors write about the subject of addiction in personal, specific and concrete ways. In terms of theory and practice, we get a chance to look at how similar material is handled by clinicians of different theoretical persuasions. Yet, the sense is that this collection of essays is a collage of ideas, not always coherently related to one another. If you read the papers in the order presented, you initially find yourself reading almost exclusively about eating disorders. After more than half the pages are read, the material shifts, and the balance of the book contains sections devoted to other varieties of addictions.

The breadth of topics presented here is impressive. There are theroretical, clinical and personal perspectives; literary, philosophical and historical references; case presentations, analyses of enactments and countertransferences, and transformative dramatic episodes for both patients and therapists. Thus, the anthology is really a sampler of ideas. The 26 chapters are divided into seven sections. The first section, entitled “Addictive Economies,” is the briefest, composed of only two chapters: one by Joyce McDougall, followed by a discussion of McDougall’s paper by Catherine Stuart. These two papers suggest two seemingly opposing ways of conceptualizing the remaining material: with either an intrapsychic emphasis, or an intersubjective and interpersonal emphasis.

The second section is called “Expanding the Analytic Space: Dissociation and the Eating-Disordered Patient.” These essays go way beyond the stated section heading, and explore the dissociation of the therapist. The writers here emphasize the need for the therapist to be more active, more real, and more reactive. Dramatic clinical examples are offered. For instance, Judith Brisman, in her paper entitled “The Instigation of Dare: Broadening Therapeutic Horizons,” describes a session in which she was finally made aware that her patient had been, for weeks, “silently screaming at me to look” at her: the woman had flossed her teeth with a strand of hair she had been playing with, and “a spitty bit of food came flying across the room nearly hitting my leg! There was a moment untouched in the room of stunned disbelief. And then I blurted ‘That’s disgusting!’ except I didn’t say it. I closer to yelled it.” It wasn’t until Brisman yelled at the patient that she realized the hair/flossing had happened several times before. The patient’s reaction to being yelled at: she “squealed with delight” (p. 59.)

Phillip M. Bromberg further illuminates the process of dissociation, but in his chapter, “Out of Body, Out of Mind, Out of Danger: Some Reflections on Shame, Dissociation, and Eating Disorders,” he articulates the positive, adaptive regulatory function of the symptom. Bromberg further elaborates how the therapist’s dissociative process can halt therapeutic progress: “It becomes very easy to grow to hate the patient’s eating disorder, and then without recognizing it, to hate that part of yourself that is trying but failing to cure it. The therapist begins to feel victimized by his own desire, and then feels the patient’s pathology as an adversary…A transitional reality has to be contructed in which trust in human relatedness begins to become possible, and this can happen only through the therapist’s surrender to his own dissociated self-experience.” Such a surrender, Bromberg thankfully adds, is “Not so simple!” (p. 77.)

Section Three is entitled “On Being Stuck: Enactments, Mutuality and Self-Regulation with Eating-Disordered Patients,” but I found very little to discriminate in content between the writings of this section and that of the previous one. Here, in a chapter entitled “The Destabilizing Dyad: Psychoanalytic Affective Engagement and Growth,” Emily Kuriloff makes the point that “Analysts are not trained to engage their bodies.” Rather, we’re trained to talk and symbolize, and words become vehicles for detachment. She describes how her patient got worse as analysis progressed (confirming Bromberg’s point in the previous section). Poetically, she writes, “Conceivably our formulations, like dried up, dead leaves fallen from supple trees, were merely repetitions of their deadened, isolated affects” (p. 128). In her clinical example it was not until she, the analyst, disclosed the fact that she had broken a tooth in the middle of the previous session that the work with one very difficult patient began to progress. She was able to identify with the patient’s rage, recognize her own frustration with the patient, and also connect with the patient’s mother, “the heretofore villain in the story.” Kurlikoff concludes, “Finally, when I became the angry, controlling mother, the one who wished to ‘kill’ her daughter, I see myself not just in but also through Penny’s eyes (Goldman, 1999). I understand her transference to me.” (p. 133.) This is also a perfect example of “active into passive,” which Weiss and Sampson describe so well (Weiss & Sampson, 1986).

Section IV is called “To Eat or Not to Eat: The Psychic Meanings of the Decision,” and the papers in this section expand upon areas touched on by earlier papers. I found Stephanie Solow Glennon’s paper “The Armored Self: The Symbolic Significance of Obesity” to be particularly clear and insightful. Here she notes the necessity of distinguishing between two separate eating disorders: the need to be fat (or not thin) versus the need to eat (without necessarily the need to be fat). As for all symptoms looked at psychoanalytically, it is important to understand the specific meaning of the fatness.

The next two sections are “Creativity and Addiction” and “Desires and Addictions.” No longer confined to eating disorders, the material sweeps into brief explorations of addiction as a defense against depression, addiction as a means of dealing with the anxiety generated by creative activity, and alcoholism as related to writers in particular (the latter essay entitled “The Muse in the Bottle” by Albert Rothenberg unfortunately succumbs to gross generalizations based on John Cheever’s life). Edgar A. Levenson contributes a stimulating piece, which explores the notion of “risk-taking” as part of the addict’s repertoire, and he notes that creativity and drug taking have “living on the edge” in common. Interestingly, he defines compulsion as behavior meant to avoid danger, and drug taking as behavior meant to court danger.

I found Darlene Bregman Ehrenberg’s paper “In the Grip of Passion: Love or Addiction? On a Specific Kind of Masochistic Enthrallment,” to be most useful and well thought out. In clear language and with the use of clinical material, Ehrenberg describes how for a patient, what may seem like a masochistic kind of addiction to a very poor object choice is really a lifeline, to be understood as such and as a vehicle to escape from a much greater inner pain: that of feeling as though she (the patient) did not exist. Ehrenberg goes on to point out that the therapist can also become a substitute addictive object, rather than a working collaborator. The subtleties of these insights make for extremely valuable reading.

The final section of the book, “Winnicott and Masud Khan: A Study of Addiction and Self-Destruction,” relates less directly to the previous work. Somehow this material, while fascinating as a sort of exposé, did not seem to stick to the topic and served as a round of arguments about what Winnicott did or did not do for his patient, the brilliant but psychologically and physically ill Masud. Historically important as Masud’s case might be, this lengthy discussion was less illuminating of the issues than the previous chapters seemed to be.

Aren’t eating disorders different from other kinds of addictions? The differences are not clearly addressed here. Is not nicotine addiction different from heroine? What about the sociological factors involved in both alcohol and drug addiction? Aren’t there sociological mechanisms involved in eating disorders as well? These topics are not included in this volume, but they are questions that cannot be completely ignored, even when attempting a psychoanalytic understanding of a symptom.

Probably every therapist who has practiced for any length of time has had the opportunity to work with a patient with an eating disorder, whether or not they knew about the problem when they began work. The experience is such that once you have worked with one of these folks, you almost feel you’ve been admitted to a kind of club—that of the clinicians who have been there and done that, and probably don’t want to go there again. The work involves a special challenge; the individuals with these symptoms can be incredibly difficult to help, and may even require a team-approach.

In this book, we find comfort in the shared clinical vignettes and we learn from the therapeutic illuminations. These are the patients who seem to drive us the most crazy,—the eating-disordered, drug-addicted, alcoholic, passionately locked-in souls. These are people who live highly dramatic lives, and it is the nature of good drama to pull the audience in, to make you pay attention. This collection of essays emphasizes the liveliness of our work because of the active and dramatic nature of these symptoms, the strong pull for the clinician, and the final recognition that the tools best used for this work are the very same ones employed for all of our psychotherapeutic work—only more so.

Weiss, J. and Sampson, H., & the Mount Zion Psychotherapy Research Group. (1986), The Psychoanalytic process: Theory, clinical observation and empirical research. New York: Guilford Press.

Correspondence may be sent to Carol Saturansky, PhD, 2225 Union Street, San Francisco, CA 94123. Telephone: (415) 441-5485. Fax: (415) 831-0324.

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