On Three Cases of Anorexia Nervosa: With an Intervention by J. Lacan (1939)
Given that several psychoanalysts have expressed regret at the scarcity of published clinical cases, I thought it would be of interest to choose and group together three cases of anorexia nervosa having the same origin: strong and unsatisfied attachment to the mother. Although I do not wish to present this point of origin as a constant, it facilitates comparison of the three cases. I shall present them in as brief a form as possible. I consider the comparison interesting from two points of view:
- The cases concern three girls, ages 3 and a half, 9 and a half and 15 and a half, and illustrate clearly the growing complexity as the child advances in age.
- The cases clearly show the primordial role of parental attitudes in the genesis and treatment of such conditions.
Psychoanalysts are familiar with this condition and I do not claim to present anything new, but I will be happy if my cases can illustrate what we already know.
Greater complexity with age:
When I speak of complexity, I am not referring to the difficulties involved in conducting analysis with a child. I find, on the contrary, the greatest difficulty is with very young children: the young child never feels psychically disturbed; he has organised the symptoms which disturb his family in a way that gives him satisfaction, and doesn’t need anything from you.
He only submits to your investigations if he feels respect, love, admiration, interest, etc. for you. In other words, with young children inanalysis, only positive transference is useful; without this, the child will ignore you and instead of cooperation, all you will get from him is silence or shouting.
What I intend to talk about is not this initiation of an analysis, but rather its increasing complexity, year-by-year, through additional shocks, their interdependence, their more or less successful repression – masking the picture and creating the adult neurotics with whom, inanalysis, it is so hard to identify critical factors without searching carefully in the most opposite directions.
With a young child, things are very different. Once you have been adopted and he starts to chat, play, draw, invent stories or comment in his own words the stories his culture has handed down to him, his worries, his enthusiasms, his fears and his resentments come to light with surprising ease.
The same is true of dreams, whose symbolic ingenuity is well-known, so that some of them don’t even need interpretation. I will give as an example the dream 5-year-old girl disciplined rather harshly by a stern teacher. In the dream, the child saw herself in the classroom; but she had grown so tall that she shot through the ceiling and the roof of the school. As a result, she was the one teaching in the classroom. She was teaching the students three new words, which she confessed to me greatly embarrassed, because they were “bad words”. She revealed them in ascending order a forbidden naughtiness. She knew that the first one referred to excrement. She explained about the second, shorter word, that it was a terrible insult. As for the third word, which was “cow”, it was even worse, because the little girl came from a working-class in which “cow” was the insult reserved for the all-powerful, that is, the policeman,
I would tend to compare this great simplicity which most often characterises young children’s affective disorders with what happens on a river when a small obstruction such as a branch is carried downstream. If it encounters no obstacle, it causes no disturbance. But if it hits something, it creates a light stir, a runoff which attracts attention. It is easy to intervene and pull the branch out of the water so it won’t interfere with the flow. But if no one pays attention, the slight obstacle gradually blocks the passage of everything that flows downstream; other branches will become entangled with it, as well as leaves, straw and all the trash men dump into the river. A veritable and very complex barrage will be created, disturbing the flow, which is unable to throw it off. A long investigation will be needed, to look into dark corners in order to extricate these elements one by one, until the central core, sometimes so difficult to reach, is finally exposed.
Forgive the use of parable, not disdained by certain famous predecessors; Freud himself had recourse to it to illustrate his thought.
The simple structure of childhood conflicts can be attributed to two factors:
First, an affectivity I might call as yet free of scars, almost totally unencumbered by intellectual elements, in which emotions stand out strongly and clearly, like footprints on fresh snow.
Second, the restricted milieu in which the child lives, often consisting of the immediate family, easy to explore, a milieu from which the outside world is almost totally excluded for the child. This also explains the great influence of the members of this milieu.
The importance of parental attitudes during the treatment. Before discussing the second point that my observations will illustrate, I must highlight the enormous difference, in this respect, between the psychoanalysis of adults and that of children.
Of course, the analysis of an adult can be facilitated or hindered by the family, but for a child the parents are everything, not only concretely and before the law, but also in the eyes of the child. This is why the positive transference that you obtain, sometimes with difficulty, can only be maintained if the child feels not only the involvement, but the approval of his parents. At the least disagreement between you and them, the child closes off his communication with you and throws himself passionately under their influence. They can erase all your work with a single word, as you shall see in one of my examples.
On the other hand, we are forced to turn to the parents, not only for the child’s history, but also, to some extent, to verify events taking place at present in the child’s life. In the psychoanalysis of adults, the rule is to deal only with material revealed by the patient. The adult is able to tell his own story, while the child lives in a perpetual present. He has innocently forgotten many things about the past years, even if, and perhaps especially if, these things were crucial from an affective standpoint.
When I say that the child lives in the present, I do not mean the objective present.
Indeed, we cannot apply to the child the rule of absolute sincerity demanded of the adult. First, because some children are liars. But aboveall because with children there is something that cannot be called a lie, but is rather a half belief in purely imaginary stories which the child sincerely believes as much as he believes what is real.
Finally, there are so-called affective truths: I will cite as an example the recent confession of a four-year-old seen in Dr. Pichon’s consultancy. I had advised the godmother who was raising her to show some firmness; the child had behaved badly and was deprived of dessert. As it happened, this desert was her favourite: ice-cream! Feeling powerless, the little girl was so enraged that she bit her own arm, wounding herself. The godmother did not give in. When she saw me the next day she told me what happened. And this is the child’s version of the story: “you know, since I saw you last time, I have been very good. – Ah? – I was very good all the time, everyday; I was so good that godmother told me: ‘my little Léone, because you are so good, I will buy you ice cream for dessert; an everyday, every meal, you will have ice cream and you will always be very good.”
Thus, if we were to do without the testimony of the parents, we could easily be drawn into unreality. But if only affective reality counts, you might say, then this does not matter. But being drawn into the unreal unknowingly prevents us from learning in what way and to what extent the child felt the need to modify what was contrary to his inclination. In the previous example, knowing that the godmother promised the well-behaved child ice cream would not have contributed anything to our understanding. But knowing that the little girl had completely reversed the scene allowed us to believe that she consented to behave well in order to obtain the desired reward. We therefore advised the godmother to avoid haggling over ice-cream; not doing this would contribute to bringing the outside world in line with the child’s emotional world.
This illustrates the kind of help we can sometimes request from parents, which is particularly clear in this first case I am presenting.
It is a practice not recommended in the analysis of adults, for good reason. The origins of an adult neurosis can always be said to go back to a remote period: the past situation we glimpse is gone, inaccessible.
In the case of a child, however, this traumatising environment is there, within reach; if we are dealing with intelligent parents, we can change it, sometimes gaining considerable time in treating the symptom. The child’s concrete situation serves as a testing ground to solidify our opinion about his difficulties.
In 1928, Charles Odier, Pichon and Parcheminey published such cases in “On Brief Freudian Psychotherapeutic Treatments of Children”. In these cases, without in-depth investigation, the analysts were able to eliminate the troublesome symptom (morbid curiosity, refusal to go to school, obsessive hand-washing). Often, in childhood, an isolated symptom acts as a warning sign, and eliminating it can prevent the formation of a future neurosis.
This is the kind of intervention I present in my first discussion; the particularity of the case was that the very young child was so extraordinarily attached to her mother that I was completely unable to make contact with her, which very rarely happens. As a result, I was forced not only, as Loewenstein so cleverly puts it, “to make my therapy regress to the stage of psychotherapy”, but also, because recourse to elaborate speech was not possible, to have the mother initiate the therapy. In a manner of speaking, the mother alone was in charge of the therapy.
This is what happened:
Suzanne, a little girl who was three and a half, was sent to me because for the past two months she refused to eat, for no reason.
Before this, she ate by herself, very properly, and then suddenly she said she didn’t know how. Her mother laughed and helped her, thinking it was a game. But it wasn’t: Suzanne refused to eat by herself, cried and went without food.
If her mother fed her with a spoon, she agreed to eat, but only creamy food without lumps. Still, the process was accompanied by much grimacing and sulking. At the end of the two months, instead of gaining some weight, she had lost almost two pounds.
Suzanne had a brother, two years older than her, and got along with him well. The mother says: “he does whatever she wants, she spins him around her little finger.”Indeed, the boy is a fat and placid child who seems full of admiration and concern for his little sister.
She had never known her father, since he left the family and divorced before Suzanne was born.
Suzanne was breastfed until she was one, and the weaning, when she was spoon-fed, was poorly tolerated, so that her weight remained almost unchanged for three months. Once she accepted giving up the breast, everything went well, but the child remained abnormally attached to her mother, letting no one else give her the care needed by a child her age.
With her mother and her brother, she is gay, intelligent, chatty and cunning in getting what she wants. But with strangers she falls silent and becomes distant.
She has always lived this way, alone with her mother and brother, with no other family or friends, until her mother’s sister arrived from the country, after her husband left her, with a 14-month-old child.The two sisters had moved in together to raise the three children, over two months earlier.
I was struck by the timing, since Suzanne’s problems had started two months ago. The mother confirmed that at first Susan seemed very interested by the care with which the baby was spoon-fed by her aunt. About a week later, she started to pretend that she could not eat by herself.
When I first saw her, Suzanne was a thin child, alert, with an expressive face and sharp gaze, very busy observing me secretly. She refused to let go of her mother’s hand, hid behind her skirts and hollered if someone tried to separate them.
Not only could I not see her alone, but I couldn’t even get her attention. The next day, a second attempt remained fruitless. Neither sweets nor caresses could turn her attention away from her mother. Seeing that I couldn’t make contact with her, we decided that the mother would have to take charge.
The mother readily understood our explanation: that seeing her little cousin being fed like a baby caused Suzanne to regress to the happy period when she enjoyed the same kind of attention, and that Suzanne’s aim was 1) to make sure of having her mother to herself despite the arrival of a third person, and 2) to get as much of her mother’s attention as possible, so as to reign supreme.
Since this behavior pattern was recent – two months – we suggested that the mother avoid giving the child the help she demanded during meals by using an excuse (such as taking care of an urgent task), that she remove her plate the at the same time as everyone else’s without comment, as if she didn’t notice that the food was left uneaten, and that food not be discussed in her presence.
At the same time, the mother was advised to be very affectionate with her in other situations, to make her feel as loved as she always was. And to come back in three days.
The mother returned eight days later. She was alone. This is how she described what happened: At the first meal, Suzanne did not touch her food, and kept watching her mother with a worried look, while she chatted lightheartedly. The plates were cleared away and the little girl, astonished, refused to leave the table. So she was left there, and remained motionless for almost an hour, without playing. In the afternoon, her mother sat her on her lap and told her her favourite stories. Suzanne was laughing, and seemed to have forgotten what happened earlier. But before the evening meal, while the mother was setting the table, the child jumped on her and bit her very hard on the knee. Saddened, the mother didn’t punish her. Everyone sat down to eat. Suzanne waited… In vain. But toward the end of the meal, seeing that no one would help her, she started to eat, crying. The next day she ate alone, but still silent and sad.
In the meantime, her mother went out of her way to make her happy in every way she could. And the third day she was eating normally.
A few days later, Suzanne, who had been dressing alone most of the time, said she didn’t know how to do it anymore. For the next two days someone had to dress her; but her mother understood the symptom substitution, refused to comply and things soon went back to normal.
It must be mentioned, however, that when her mother was about to see me for the second time, Suzanne, who is told about the planned visit, had a fit of anger and crying, shouting that I was “too nasty”, so that her mother decided to come alone. The child had no trouble attributing her misfortunes to me; I even think that doing this helped her to bear them more easily than if she would have had to blame her mother for them.
Now that the alarming symptom was eliminated, I again explained to the mother all the problems a child can develop if attachment to the mother is too great. I advised her, on the one hand, to show her daughter affection in the usual ways, and on the other hand, to provide Suzanne with things that would help the child focus her attention elsewhere: friends, amusements, etc.
These events took place in January 1932. I saw Suzanne again in December 1935. Her mother had suggested: “You know what? Let’s go say hello to Mme Codet”. And to her surprise, my name no longer reminded the child of anything. She came along with no objection, and looked at me without remembering my face or my interaction with her. The little girl led a normal life, was happy to go to school, had some favourite friends, and did some chores at home. It seems that things will probably continue like this, and that the brutal treatment I was forced to use had been well tolerated. The advice to the mother to be especially affectionate at the same time certainly made the trauma more bearable; and the strong negative transference onto me accomplished the rest.
Such is the simple, even simplistic, character of this first case involving a very young child. Our second case is more complex: the child is nine-and-a-half. The school and the father play a role, as well as a certain rivalry with the opposite sex.
Lisette was brought to Professor Lereboullet’s medical ward to be treated for spina bifida, difficult eruption of teeth, anemia and eating disorders labelled “dysphagia without esophageal lesions.” Lisette is quite tall for her age, thin, with dry skin, dehydrated. Her mother dresses her with refinement, and her hair is artificially curled. She prances, proud of herself, looking with disdain at the other children in the ward who seem less privileged than she is.
The mother is a silly woman, always complaining and sighing, one of those people whose laments end up attracting all the sadistic forces of the universe. She keeps caressing the child while shedding tears, which make no impression on Lisette, who seems to find all this normal.
The drama of anorexia began very early, when the child was only two or three weeks old, and its onset was sudden, occurring after a specific trauma: Lisette was nursing peacefully in the kitchen, when her grandmother let all the pots and pans stored on a board fall on the floor beside her. The noise was deafening. The child screamed with fright, throwing herself back, away from the breast.
She refused to nurse for two days, screaming loudly whenever her mother tried to give her the breast. Finally, becoming hungry enough or perhaps appeased by the passing of time, she accepted to nurse again.
But the mother had abundant milk, and during the two days when the baby didn’t suckle, her breasts became swollen from the pressure, and the milk rushed into the baby’s mouth, filling the laryngeal cavity and the nose, suffocating her. This time the baby completely stopped nursing. She refused not only the breast, but also the bottle. With great patience, the child was trained to accept spoon feeding, when she was only a few weeks old, and this is how she was nourished, with much effort, sighs and entreaties.
Apparently, these maternal expressions of emotion, pleading and tears were repeated at every meal for the nine years of Lisette’s life, serving not only to persuade her to consume a minimum of food, but also to fill the mother’s passionate need for self-sacrifice.
She told us about her husband, a former policeman, describing him as a hard and brutal man, spending his time at the bar, ignoring her and the child, except to force them to do what he wanted. Often, these excessively emotional mothers are women disappointed in love. In this case, in our opinion, this passive woman chose the tyranny of the child over that of the husband, because, although it was just as absolute, the child’s tyranny allowed an effusive expression of love.
This is what a typical meal is like: the mother picks up the child at school and carries her backpack, which she fears is too heavy for the child. She tries to stimulate her appetite by describing what she will eat. When they get home, at 11:35, they all sit down at the table and the supplications begin. Lisette says she is not hungry. The mother begs her to eat, one mouthful at a time. The father gets angry. Lisette has her mouth full, but refuses to swallow and tries to make herself regurgitate to prove she can’t eat; she succeeds, spitting up some food from time to time, while the mother swears to God that the father’s brutality will end up killing the child.
In short, this scenario where pathetic pleas alternate with violence, last each day from eleven-thirty to two o-clock. Permission was obtained for the child to return to school around two-thirty. The teacher consented grudgingly, and lost interest in this pupil who can’t keep up with the others. She was a little harsh with Lisette, who was used to her mother’s praise and came to hate her teacher. As a result, her symptoms got worse after each vacation period, when she had to go back to school.
We start the treatment, after making some suggestions the mother has trouble accepting: sitting Lisette down at table at the same hour as her parents; never speaking to her about food; never making entreaties or threats, eating calmly, without paying attention to what she does. Clearing the table before the normal hour of returning to school, so that she can be back in class at the same time as the other children.
Having made some changes to the milieu encouraging the neurosis, we started the therapy, which was greatly facilitated by positive transference established quickly. I saw the child for three months and a half, twice a week. These are the noteworthy facts to report:
Lisette was talkative and, sitting about in the room, she started to explain her right to be sick, based on the example of two cousins, two boys her age who had always lived near her own home. One has a congenital brain defect and multiple paralyses and, consequently, trouble swallowing. The other, younger and perhaps emotionally influenced by his brother’s example, seems to be a typical anorexic.
Lisette speaks a lot about these two cousins, both violent boys. She demands to have the same rights they do, in her home. What she says about the younger boy is: “He doesn’t eat and is not even sick; I at least am sick, I have spina bifida, I have a right not to eat.”
She extends this competitive antipathy to all the boys she knows, who, according to her, are all idiots and savages. Then she speaks of her father and openly declares not liking him very much because of his brutality: “The only time we have peace is when he is not there.” “He bothers us all the time.” This “we” is constantly repeated in her speech and refers to the mother-child couple, from which the father is excluded.
Because he is hated, the others deny him the right to be the only one who can eat what he likes to eat; he has complicated tastes, shouts and throws a fit when he doesn’t like a certain dish or finds it poorly cooked, leaves the room in a rage, or throws the food out in the garden. Seeing this, Lisette forbids him to give her two slices of bread or a rice dish.
This imitation of the father could suggest identification with the paternal image, given that both of them take advantage of the mother’s gentle passivity. But a more careful analysis clearly shows, when we consider how harshly and disdainfully Lisette speaks of her father, that for her he is simply a rival to combat, if need be on his own territory. He must be stopped, whatever violent means or tricks are needed, from keeping her mother in servitude.
This attachment to the enslaved mother, the desire to possess her in a sadistic, infantile manner, as well as the fight against the father, are encapsulated in the following dream, whose elements are not even disguised.
“I dreamed that mama was lying in bed with a man, and I was lying on the carpet next to the bed. Mama leaned down towards me and showed me that in the pattern of the carpet there were pine cones; she wanted me to eat them. I didn’t want to, and climbed up on the bed. There, I saw that breasts were also pine cones, and I ate them. I found them very good. But the man wanted to stop me, got very angry and shouted loudly, so that I got scared and woke up.” She added that her father never wanted her to go into her mother’s bed, but that she does when he goes to the bar in the evening.
The strange thing about this dream is that this anorexic child who refuses to eat dreams of a food-mother, literally, since she eats her breasts, these breasts that were only hers for two or three weeks, until the troublesome incident of the pots and pans suddenly deprived her of them. It appears that subsequently she replaced this oral kinaesthetic pleasure — her mother readily consenting —, with the triumphant love ritual her meals had become. What Lisette now wants to obtain (to milk) from her mother are the thousands of tender entreaties that have become a sublimation of love-food, forbidden oral pleasure.
When the mother took our advice and stopped commenting on what the child ate or didn’t eat, the little girl was very disappointed and complained to me about it. She knew I was responsible for this new state of affairs. However, thanks to her affection for me, she gradually accepted my explanations. She accepted the idea that she had been acting like a baby who is still afraid that the feeding will cause a great, noisy upheaval (falling pots and pans or her raging father). She understood that this little baby needed her mother all the time, which was humiliating. I added that I couldn’t believe that an intelligent girl like her, who would soon be a young lady, would not quickly learn to do things on her own. She should be able to do as well as the other girls, and maybe better.
In short, after a month, thanks to her tremendous vanity, Lisette ate her meals normally, not eating more than before, but without a fuss and at the same time as her parents.
She had trouble giving up the privilege of returning to school later than the others. But the teacher, whom we had informed of the situation, began to show interest in her. Her next report card showed great improvement and, very commendably, she kept up her performance.
Now, all would have been well if the mother, who found letting go of the existing situation even more difficult than the child, had not discovered that Lisette was a little constipated… I recommended paraffin oil, but…the mother was off and running: she had found a substitute; if she no longer had to worry about the child’s meals, she would worry about her bowel habits. And so her moaning started again, this time focused on this new “food”, so to speak. “Yesterday she went to the bathroom twice! Oh, I’m desperate!” Or: “She keeps pushing, my little Lisette, but nothing comes: my life is hell.” In two weeks, Lisette had organised the entire special ritual: she held back her stool, deliberately emptied her bowels a little at a time, and remained sitting on the toilet for two hours with no result, listening to her mother’s laments — a veritable hymn of love!
I had to have two long sessions with the mother to explain the similarity of the two symptoms, and her share of responsibility in the child’s stagnation at the oral-sadistic and the anal-sadistic phase.
After that, everything went well. Two months and a half later the start of treatment the child had gained considerable weight, was eating sufficiently, was doing well in school, had normal bowel habits and helped her mother around the house. By happy chance, the mother became pregnant and focused her worries on the baby she was expecting. I took this opportunity to explain to Lisette procreation, pregnancy, the birth of the child — explanations which she accepted. I also pointed out that the “terrible” opposite sex, towards which she had had only hostile feelings, could also have valuable qualities such as providing protection, even gentleness, physical pleasure and love.
I saw the child once in a while for two years, and she continued to do well. But I must add that eight months after the birth of her second daughter, the mother came back in tears, to say that the baby refuses both the breast and the bottle.
We did not see her again because the family moved to the country.
In the wonderful paper entitled “Contributions to the Study of the feminine super-ego”, Odette Codet presents two cases of strong attachment to the mother. But these two mothers are both authoritarian women, not under any male domination, who demanded and obtained from their daughters, through a sort of completeness of the mother-child couple, a passive attitude, at least towards them.
On the contrary, through a similar mechanism, in Lisette’s case the persistence of a highly sadistic attitude at a somewhat belated age seems to have been caused to a great extent by the mother’s excessive masochism, so that there was a contributing neurosis. There is no doubt that a child’s illness is, for many mothers, an opportunity for effusive displays of affection, which they need more than the child. We must take this into account in the treatment.
Our third case involves an adolescent girl. The analysis cannot be said to be exemplary: the physician who referred the patient to me, and whom I kept informed, made some heedless remarks to the patient’s parents, bringing the analysis to an end.
Fanny is fifteen and a half. For the past two and a half years she has been treated for continuous weight loss and loss of appetite, which were attributed by turns to glandular problems, gastro-intestinal disorders, tuberculosis, diabetes, etc. She has been seen by many physicians, and most recently by a neurologist who diagnosed anorexia nervosa. During the visit, the doctor pointed out to the parents that Fanny seems to harbour great resentment against her two brothers, and that she should be separated from them during her treatment. The parents are furious at the suggestion that their daughter doesn’t love her brothers. They reprimand her; she, of course, denies the accusation, and the whole family has harsh words for the doctor.
The child is placed in a clinic, under the care of a psychiatrist. But she is able to obtain and to take some toxic substances; twice, she has severe poisoning, with vomiting, profuse diarrhea, high fever. After this the clinic declines further responsibility.
The girl is sent to live in the country with her grandmother, and there, the old physician, assisted by a nurse who is with her full time, succeed in making her gain ten kilograms in six months.
She is then allowed to go home, because she asks for her mother constantly, crying and screaming. At home, she loses the ten kilograms she gained, and is taken to see another doctor. The latter places her in a clinic where she is confined to bed and forbidden to leave the room. In any case, her state of health demands it: she is just skin and bones. But in the next three weeks she gains no weight; closer surveillance reveals that she has a supply of purgatives in her closet and, in addition, her parents were thoughtless enough to bring her a few packages of Taxol, a laxative she asked for. It is also discovered that she hides the food she is given in the chamber pot of her close stool, and then covers it with stool; that milk and soup are poured in the sink or in the hot water bottle; and that she exercises during the night. Several times, she was caught falsifying weight measurements by placing heavy objects in the pocket of the robe she was allowed to wear out of modesty.
It is interesting to note that these objects were several pocket knives belonging to her older brother, which she always kept near her.
Now, parental visits are forbidden. A nurse is present at every meal. Finally, on Dr. Pichon’s advice, the doctor starts to consider the emotional aspect of the condition, and the young girl is sent to me.
The parents explain that Fanny has a brother three years older than her, and another, six years younger. She has never been sick, started menstruating at thirteen, but only for three or four months.
Through persistent questioning I learned that anorexia – the most alarming symptom, because the girl, 1.60 metres tall, only weighed 33 kilograms – was not the only symptom, nor perhaps the most important: when she first had her period, Fanny hid this from everyone. She used cotton wads to wipe herself constantly, and these wads, as well as her stained clothes filled her with such horror and shame that she simply threw them out the window.
When the concierge found them in the courtyard of the building, she complained vehemently to her parents, who threw her out indignantly, until they recognised a piece of clothing belonging to Fanny, and had to accept the facts. The mother then tried to explain to the girl what menstruation was, but as soon as she heard the first words the child was enraged, flung herself on her mother and beat her.
Several renewed attempts to explain produced the same results. Finally, one day, when the young girl was menstruating, she went to catch crayfish by hand in a small frozen torrent, where she stayed all day waist-deep in the ice-cold water. Her menstrual flow stopped and never returned.
The onset of anorexia occurred two or three months later.
The parents also informed me that Fanny was in the habit of taking laxatives, going to the bathroom ten or twelve times a day and, all day long, introducing a finger in her anus to take something out. She always had a supply of tissue paper, and as soon as she was alone she wrapped some around her finger, to introduce it in her anus. But at the least risk of intrusion, she assumed a decent attitude, stuffing the embarrassing paper anywhere: under a cushion, in the padding of an armchair, etc. The next day, the maid reaped an abundant harvest.
This is how things stood when we began analysis, meeting four or five times a week.
At first, she made worldly conversation, speaking so volubly that she gave the impression of trying to “muddy the waters”.
She disavowed any wrongdoing, and we understood at once what determined the choice of the symptom: her darling mother, anxious to stay thing, ate very little and took sodium sulphate every day as a laxative. Fanny says that she knows she is not pretty like her mother: she is ugly with her skinniness, boniness, her dry, rough skin, brittle hair… But she doesn’t care, because she will never get married, she will always stay near her mother. And anyway, she has always been surrounded by brothers, cousins… She is fed up with boys, she hates them, she hates men.
All these boys remind her of vacations in the country, and her intense fear of snakes, which she emphasizes. She even remembers that, just before she fell ill, she used to have terrible nightmares full of snakes: they filled up her room, she couldn’t stretch out her hand without touching one, or open her eyes without seeing them. They crawled towards her, she felt that they would go into her mouth, into her eyes.
Then we talked about her rivalry with her older brother: “We always fought. We had a two-seater toy car, and I still see myself with a fistful of his hair in each hand, that I had just pulled out.” Now they get along, or rather they ignore each other and never speak. He has his own friends and pretends to be a grown-up. But when she was little, she was very jealous of him.
Then she explains, visibly hurt, that her mother adored this older brother, often sick, and never paid attention to her, because she was well and strong. Her mother always told everyone that she only liked boys.
This is why, when her mother became pregnant again, Fanny was deathly afraid that she would have another boy. Her older brother wanted a brother, but she (six-years-old at the time) prayed every night that it would be a girl.
Alas, the baby was a boy.
Fanny remembers in detail this period that was so painful for her. She remembers everything except the central figure in the picture: her mother. She is completely unable to remember anything about this adored and unappreciative mother. But she can see the room clearly, she remembers what the sick woman was given to eat. Then the horrible news of the birth of a boy came, and she remembers the emotion that made her run into her father’s arms – because he looked so sad. But alas! Her father was sad for another reason: her mother was dying. In the end she was saved, but spent months fighting acute puerperal fever. She had even been given last rites. Fanny remembers herself on her knees, crying, in front of the priest who was crossing the room.
For years she asked herself if God had wanted to punish her mother for having another boy, or if all births were so dramatic.
She says that it was only two years later that she learned that babies were carried in the bellies of their mothers. Her older brother told her this when she was eight, and she could only accept this fact by making fun of it. For several months, she and her brother “played at having a big belly” amid great bursts of laughter.
And suddenly she talks about how unpleasant it must be to have a big belly. For an entire session, she describes her anxiety as soon as she eats her fill: “I feel fat, swollen, I am afraid I’ll burst.” And she adds: “I can’t help it: I have to make sure my stomach is empty and I am afraid that if I eat it will grow huge.” Isn’t a baby formed by filling the belly this way? She asks me. Her mother told her that the baby is formed from the blood of periods, but she can’t believe “such a disgusting thing.” But she knows that when a baby is growing in the belly, there are no more periods…
She has also read that “babies are sent by God’s providence”. But her father said one day at the table that Mr. and Mrs. So-and-So didn’t want to have children. Did this mean that your will had something to do with it? And why did there have to be two people? What does the father do? She thinks that the mother must concentrate all her will on her desire to have a child, and at the same time stare at the father for a long time. Was that it?
I informed Fanny about how these things really happen, and I can still hear her exclaim: “What! It doesn’t come through the anus?” She did not know about the existence of the vagina (which is not unusual). Several sessions were devoted to discussing only sexual matters. In the meantime, she was asking the nurses about everything that happened in the maternity ward. However, although I had taken great care to present things to her in a simple and natural light, she was still filled with disgust and I had to emphasize over and over the beauty of love making and of giving birth joyfully.
Her new knowledge finally helped her to blossom, she asked me to tell her parents that she now knew all these things, and asked me to sum up my opinion of her situation. I explained that it was as if when her periods stopped she had unconsciously feared that her belly would swell as a result, like that of a pregnant woman, and that she had wanted to empty it by fasting, by purging and by digital extraction. As if, in short, Providence could have played a bad trick on her by sending her a child. Her witnessing of the dramatic circumstances in which her mother had given birth was unconsciously driving her to provoke a miscarriage through the anus.
She agreed with me and added something I hadn’t known: that she bound her chest tightly for fear of seeing her breasts swell.
But although we understood the anorexia and the emptying of the digestive tract, we still had not shed light on Fanny’s refusal to accept her menstrual periods.
Things quickly became clearer when she expressed surprise that I could feel affection for her, even though she was a girl!
According to her mother, as well as all the other sources who informed us, Fanny’s mother only felt affection for boys. Fanny explained that only boys have rights, both social and emotional. They like each other and are loved by everyone else, while women have to accept drudgery, as well as lack of love.
As far back as she could remember, she had always wanted to be a boy. She liked sports and she was stronger and more intelligent than her brothers. But her mother too is strong and intelligent, and that doesn’t prevent her from having to take care of the house all day and then spend the evening mending the children’s clothes, or from being forced to sleep with a man who snores and stops her from sleeping, and who does nothing with his days except go to his club, etc., etc.… Of course, Fanny was only repeating what she had always heard her mother and her aunts say.
Under this influence, which reinforced her desire to be a boy, that is, to be loved, she rejected with all her might the idea of being a woman. And the onset of her menstrual cycle was for her horrible and unbearable proof of something she had so vigorously rejected. I explained this to her.
Her response was the following dream of flirtation: “We are in the country, in the large corridor on the second floor, onto which open all the attic rooms; we are playing hide-and-seek “first one found”. All my boy and girl cousins are there, and some of my brothers’ friends. We go to bed. No! (she laughs), we hide in groups of two: a boy, a girl. It’s a lot of fun, we flirt, it’s very pleasant. We can do whatever we want, except play with lighters, because of the danger of causing a fire.”
While making other associations, she says about lighters: “It’s something all men have in their pockets. Papa has one and my brother too. But it’s dangerous, of course!”
In the meantime, two and a half months went by and because Fanny no longer cheated, although at first she was watched closely, she gained about one kilogram every week. For the past three weeks she had been eating alone, unsupervised, and she continued to gain weight at the same rate. Everyone was delighted. She herself had reservations and was worried about leaving the clinic: what will she do with herself? Over the past two and half years she had lost the habit of working at anything; how can she go back to school when she has fallen so far behind? And she has become accustomed to all the attention she is getting, to all the little things the nurses do for her. Would she be treated “like anyone else” if she loses her specialness? (All this is conscious and expressed; we are seeing secondary gains from the illness).
I saw no reason not to share my opinion about the case with the doctor who sent Fanny to me. He asked to see the parents to recommend a clinic that could serve as a transition before sending Fanny back to the traumatising milieu of her family, and where she could continue to see me.
Unfortunately, in order to show the parents their mistake, he said something like this: “It was your lack of interest in her which caused the illness. Even though she is a girl, you must give her all the attention she deserves in your home, etc., etc.” and the mother, hearing this not undeserved blame, turned angrily to her daughter, accusing her of bringing discredit to the family. There was a violent scene, with Fanny in tears pleading with her mother, swearing that she wanted nothing more than to be with her again.
The next day, when she saw me alone, she blamed me for betraying her, for trying to make her lose the little love her mother still had for her. Finally, her mother asked me to stop the treatment, saying she was sure that a mother’s love – even a disparaged mother – could do more good than all the psychiatry in the world.
We could only hope that this violent crisis which had flung them into each other’s arms would have the best effects – something that was possible now that the most difficult work had been done. Later, we had news about Fanny indirectly: for two months after returning home, Fanny continued to gain weight steadily, without any treatment, which was unprecedented since the onset of the illness. But gradually the anorexia – alone – reappeared, and after a year she had to be hospitalised again. We learned nothing further.
This case study resembles that of the treatment of an adult. Yet the parental omnipotence manifests itself just as strongly as in the previous cases.
We therefore wonder, as Sophie Morgenstern pointed out, whether the psychoanalysis of the parents would not be the true answer. Certainly, despite the difficulties this solution might raise, in some cases it could be considered, at least for one of the parents, if the child’s analysis shows that parent’s neurosis to be particularly harmful.
An intervention by J. Lacan
Dr. Lacan asks to what limits a child analysis should be taken. A dead branch floating down the stream cannot be considered altogether dead. It has boughs to which other material becomes attached, so that at a certain point a barrage is formed. Couldn’t a symptom isolated by a brief therapy do the same thing? He wishes to highlight two points. First, the fact that anorexics always have phallic phantasies. He cites dreams in support of this observation. And second, in his recollections of working in polyclinics, there are about thirty cases of anorexia nervosa; all of them involved Jewish boys.
1939. Revue française de psychoanalyse 11 (2), 252-272.
Translated from the French by Agnès Jacob