Anorexia and Bulimia

the "mental field" in the small analytic group
as a tool to reach (and answer to)
the desperate request hidden behind the symptoms

by Marco Longo

(paper presented to the 1st International Congress of
the Group Branch of the EFPP, Amsterdam 28 Nov 1997)

In a therapeutic group, as in every kind of human group joining around a shared purpose, it's easy to find since the beginning phase the presence "between" the members of a strong emotional activation, mostly an unconscious one, with an illusory rather than realistic quality. This phenomenon does not only concern individual members' insides, but encloses in a sort of "shared emotion" the whole group field. It's an emotional atmosphere, all the members contribute to activate it, but it doesn't depend upon the mere sum of individual "in-tensions". It's something more than the contributions coming from single "I(s)", it's the first outline of a "We", of an "esprit de corps" (Bion).

Such a shared emotion is perceptible especially in groups with analytic function, like several IIPG group psychoanalysts conduct in the ABA (a large italian Anorexia Bulimia Association, with fourteen centres in the most important towns), in which the participants join in a setting devoted to work on themselves as patients, aware that they're in a self-chosen situation, on the basis of the common need for taking cure of some aspects of the Self (even if the most of them seem to be hardly pushed and anchored in the body). Within this setting they shall probably meet, periodically, in the same space-and-time dimension, for a long time, trying to give shape (in italian we say "to give body") to the possibility of encountering and knowing each other, of sharing, besides space and time, their thoughts (feelings, memories, fantasies, and so on).

This emotion can be mostly (and easily) noticed during ABA groups sessions, when the group is actually working, in that space and moment where a shared sense of "We" is more present . Yet it's perceptible in its dawning form also before sessions, in the waiting room, where patients comment their experiences about life or about the group they're partecipating. It's in some way a "crescendo in meeting again" or a "pre-group warming up". Similarly this emotion is present after a session, when patients linger together for a short time before breaking up and coming back to their daily lives, as if they were trying to accompany and relieve "tensions about separation" occurring at the cold, icy moment of parting.

Over the years I became more and more convinced about this working hypothesis: that, in order to understand and use for analytic and therapeutic purposes in the ABA groups such an emotional activation, it's necessary to bear in mind three particular components:

a) first, patients tendency - especially at the beginning of the group treatment - to idealise, consciously or not, their participation in an analytic group, their taking part in a "group work", a kind of mental work coped by the strength of a group. The group as a whole is in fact regarded with a common bias, that's to say considered, wrongly or rightly, as more capable than individuals alone to succeed in every effort, particularly in searching and conquering a goal so much desired, but alas! so much illusory, the "miraculous recovery";

b) second, the revival of such an enthusiasm due to the reassuring sense of being contained, supported, accompanied and protected in an "area of belonging" (in italian "area di appartenenza", C. Neri) and mutual listening. This enthusiasm probably represents an overt expression of a particular "request", largely latent and unconscious, coming from patients themselves: a request, I hope it's clear, not only for a prompt recovery from symptoms, but also for a psychotherapeutic help in a broader sense;

c) third, the fact that in the ABA group, as in every therapeutic group, all the patients feel each other - alternatively (at first) or contemporaneously (later) - so much similar and so much different; realizing that they all are suffering from something really similar and, at the same time, so differently showed in any of them, that allows to find again the hope for a prompt recognition, a recognition as separate and autonomous individuals.

Usually, there's a problem for every one of our anorexic-bulimic patients, partly related to their understandable need for emancipation from body and behaviour symptoms (even if we naturally prefere speak of personality disorder and not about symptoms, trather alking of an "anorexic-bulimic position" of these patients), there's a problem, I was saying, concerning the management of a overbearing personal need for individuation and autonomy together with a parallel need of learning again how to relate to others. That's to say how to live relationships feeling and returning deep affects without flying away or being caught in symbiotic or adhesive situations, where relationship declines to a manipulatory level.

The more these patients are oppressed by their compulsive thought and symptoms, the more they express the need to find within the ABA group an emotionally warm situation, where they can interact and communicate each other ideal expectations and the difficulties they actually meet, their hopes and anxieties. Driven by such a need, patients often appear as wanting to realise, within the space for meeting and confrontation offered by the analytic group, both their wish for a curative and maturative experience, and a chance of "embodying" the fantasy (mostly unconscious) to re-build - within the shared mental field - a "group of affective belonging"; a kind of group really capable to provide its members with loving support, to contain and accompany them in living together the difficult experience of a therapeutic path and process.

But very soon all our patients realise that there are two parallel aspects in a group:

a) a pleasant and reassuring similarity in the contents of the individual representations and communications of anxieties and conflicts; even if each member's linguistic and idiomatic means seems so different, coming from different social and cultural contexts, these representations and communications are comforting and encouraging because they are provided with a common denominator.

b) some oscillating movements between new trust, hope and confidence and at the same time the renewal of distrust in group and in other people become more and more perceptible; and that betrays a resistencial attachment, nostalgic and perverse in nature, to one's defensive and symptomatic attitudes.

Thus, we notice that two things happen simultaneously:

a) in the ABA group, slowly but clerly, emerge again more and more free the thought, and this revival of the symbolizing mental function, for such a long time blocked and now coming out from the depth of members, produce various symbolic representations that can meet and join in the group mental field. All that fosters an integration process and an ongoing development in the group of a pleasant sense of belonging (being together with) and of existence (being Self);

b) but at the same time we can feel as much clearly a continuous attack to the thought that spreads and snakes in the whole group, we can feel the dizziness of distrust and the resonance of mournful emotions; all that produce the coming up of the usual narcissistic and isolationistic drifts, which can increase the fear of a new fragmentation and dis-integration of group and self.

Analysing in the group all these dynamic elements, with the conductor as a leader of the analytic function of the group, by the course of our ABA group work, patients succeed in feeling more distinctly the co-presence, within themselves and the group, of contrasting tendencies to integration and disintegration. They become able to feel, living all this together in the group and incorporating this positive group experience, the tumultuous oscillation between the seductive charm of a "fusion with the others" and the terrible catastrophic anxiety of a languages "con-fusion", a babel-like explosion of the group, a new psychosomatic disintegration:

a) as time goes on, it becomes evident how the desired sense of cohesion could be linked to and influenced by the need to find, in other members and in the group as a whole, achievement and fulfilment of primary affective needs, as well as protection against loneliness and exclusion; especially for those who, as so often the anorexic-bulimic patients are pushed to do, self-escludes themselves, frightened from he fear of incomprehension and judgement of the others for such a symptom, feeling ashamed for a behaviour so secretly and intimately pleasant-unpleasant;

b) at the same time nostalgia for symptom and mournful emotions seem connected to the perception of impossibility to fulfil these affective needs in group, thus the impossibility to really embody that fusional illusion.

Passing through and working out - with deeper and deeper awareness - the emotional storm originated by this situation of continuous oscillation, ABA group gradually achieve such a level of functioning to allow its members to stand better and better these critical situations arising, walking together along the way to integration, which always involves an increased capacity for bearing frustration.

In all this material, there's a cue for my remark. It seems to me that, with specific reference to analytic group conduction, this marked situation of strong emotional activation we are enquiring on , requests anyway the necessity to foster an analytic work capable to lead the group to work out both a great illusory component, mostly due to the powerful expectation or to primary needs, and a delusional one of the same power, largely connected to the ri-emerging of denied difficulties, to the suffering always coming with the attempts to catch and communicate to others the meaning of what the patients feel arising within themselves and in the group.

But this delusion is also connected in the ABA group to the clearer and clearer perception of human limits themselves, representing a hard stroke to the ideal of perfection so strong in our patients. And more the delusional feeling is connected (also in the analyst) to the perception of the limits of the group treatment: as we know, a lot of limits are present in this kind of setting (like in all other kind of setting), in particular for the spatial-temporal limits affecting the degree to which an analytic work can be made in group.

But psychoanalysis is also an "experience of limits", in all kind of setting, in the public or private, and mostly in groups activated inside an institution or an association, as ABA is.

In effects patients in our groups realise soon that their desire for joining in group is a different thing from carrying on together with the analyst a group work. Furthermore, that the need for belonging to a group, or for combining in one mass with others, is not the same as fostering and using together all members' creativity, through the activation of an open spirit of co-operation, giving everybody a free hand to put at others' disposal his most original and personal contribution. This is one aspect of therapeutic opportunity offered by analytic groups, or - in Bion's words - the opportunity of "learning from experience".