Silence and the Voice in Anorexia Nervosa

Silence and speech in anorexia

No one who works with anorexia in the clinical sphere and who has been trained in the practice of listening instituted by Freud, that is, psychoanalysis, could fail to be struck by a singular trait that is most often encountered, from the initial consultations, in subjects suffering from anorexia.  This trait appertains to the dialectic of speech, insofar as it acts as its structural background, enabling it to reveal itself: silence.  It has often been asserted that the clinical treatment of anorexia nervosa most often takes the form of a treatment lacking in metaphors, in which the word fails in its unconscious role as message, highlighting a radical impasse in the subject’s relationship with the sphere of language.  Credit is due to psychoanalysts, particularly those trained in the teachings of Lacan, for according central attention, within the anorexia debate, not merely to the descriptive weight-body-food circuit at the heart of descriptive approaches inspired, nosographically, by the DSM-IV and, therapeutically, by cognitive-behavioural treatments, or to the narcissistic focus on the fundamental fragility of the Ego at the heart of post-Freudian dynamic and analytical stances on anorexia.  The Lacanian approach to anorexia is in fact centred on the anorexic subject’s relationship with the sphere of language and the dimension of enjoyment intrinsic to the anorexic solution.

Over the past twenty years, this has led to a focus on the anti-metaphoric facility intrinsic to anorexia nervosa, proving that, in this state, with the exception of its hysterical and neurotic forms, the body does not produce metaphors, nor is it structured on the basis of a phallicisation that locates it within the dialectic of desire.  From this perspective, any attempt to connect the genesis of the diffusion of this condition among girls to the social imperative of female thinness imposed by fashion proves misleading.  On the contrary, in fact, real anorexia constitutes a chess piece in the process of phallicisation of the girl’s body, and as a failure of its capacity to move within the dialectic of appearance typical of the female masquerade (Soria, 2000, p. 52).

In this light, in anorexia nervosa, the state of emaciation that results from a refusal to eat does not, in the majority of cases, hold the value of a message or request, nor does it function as a call to the Other, as an act intended to deprive the latter of a sign of love.  On the contrary, the refusal to eat is, first and foremost, an incarnation of a refusal of the Other (objective genitive), a way of defending oneself against a threatening, invasive, if not outright persecutory Other, by cutting all bridges with it.  At the same time, and fundamentally, in anorexia this refusal comes to constitute a form of enjoyment (Cosenza, 2008, pp. 140-158), a libidinal circuit not at a loss, and hence outside of discourse, which absorbs the subject entirely, and which presents numerous affinities with the enjoyment associated with drug addiction.

It is within this framework that we have sought to reread the anorexic subject’s clinical relationship with speech and language, if anything more from the logic of holophrasis than that of metaphor, drawing a connection between the territory of anorexia nervosa and the structural triad psychosis-psychosomatic phenomenon-mental weakness described by Lacan in Seminar XI (1973, pp. 264-265).  This is clearly an approximation rather than an out-and-out inclusion, but it is enough to render us somewhat prudent and to prevent us from giving into the temptation of associating the anorexic patients we encounter with the clinical framework of hysteric anorexia.

Bringing the logic of holophrasis into the clinical treatment of anorexia implies seeking a structural pivot for certain recurrent clinical phenomena in the anorexic subject.  In particular, one significant trait that emerges in this light relates to the anorexic patient’s de-subjectivised relationship with speech.  For a large part of the treatment, this relationship is characterised by a marked discursive stereotypy, by a tendency to restrict the level of enunciation to the evidence of the utterance, and by a disconnect with the unconscious that prevents the subject from assigning an enigmatic value to their oneiric productions, to the lapses, and the formations of the unconscious in general.  This phenomenology of the anorexic subject’s relationship with language rests on the structural fragility of such subjects themselves, which prevents them from functioning on the basis of the logic of discourse.  The latter functions, as formalised by Lacan, through a divided subject () a lost object (a) that generates the desire of the subject, and an articulated signifying chain (S1 – S2) within which the subject is constituted and represented by a signifier standing for another signifier.  Anorexic subjects, on the other hand, present themselves, if not structurally outside discourse as is the case in psychosis, “outside discourse de facto”, as underlined by Dewambrechies La Sagna (2006, pp. 57-70).  The fixing of signifiers that is presented when the anorexic subject speaks testifies to a crucial problem relating to the interval between signifiers, the empty space between one signifier (S1) and another (S2).  This is a space that the subject tends to close and cancel out inasmuch as it is precisely in the interval between signifiers that the space of the subject is opened up.

We often encounter this same phenomenon in analytic work with anorexic and bulimic patients.  This can be seen in the interval between one session and the next, an interval that the patient cancels out as a time of apres-coup and settling: the following session thus appears to be characterised by a sort of ‘evaporation’ of that which emerged in the preceding session.

The structural closure of this interval between S1 and S2 characterises holophrasis in the triad psychosis-psychosomatic phenomenon-mental weakness.  However, some authors have spoken of a positional, rather than structural, holophrasis, in relation to those forms of anorexia that are neither clearly attributable to a psychotic structure nor intrinsic to the neurotic-hysteric framework.

A Silence that Does not Resonate

I would now like to turn my attention to this freeze in the symbolic value of the word characteristic of anorexia nervosa, starting with its reversal, that is, in light of the silence that serves as a structural background to speech.  While attention has already been accorded within our field (as well as that of psychosomatics, in relation to the issue of alexithymia) to the critical function played by speech in anorexia, a consideration of the issue of silence in this context is considerably less common.  The following considerations therefore constitute an attempt to provide an analytical framework for the role of silence in anorexia.

We know, from analytic experience, that there are various gradations of silence, and that during the course of an analysis the analysand experiences their own silence and their relationship with the analyst’s silence in different ways.  It is not my intention here to delve into the complex phenomenology of silence during an analysis.  I am merely interested in identifying certain coordinates that might enable us to better understand the specificities of the anorexic subject’s encounter with silence.  I would therefore draw a distinction, simply, between the silence at the beginning of the analysis and that at the end, in an effort to illustrate the different tonalities presented by these two silences.  In a neurotic individual, the silence at the beginning of the analysis is one that divides, a silence that first and foremost disturbs the subject that bears it.  This is a dialectic silence, which stifles speech, conveying a request to the analyst that cannot be formulated by the analysand.  It is a silence that bears the structure of a silence-message.  It is also, at times, a provocation, a challenge directed at the analyst: a silence that incites the Other to speech, a speech-causing-silence.  “Why don’t you speak?”: this is the question cast over the analyst’s silence by that of the neurotic subject, when silence assumes the character of a request for speech directed at the Other.

The silence at the end of the analysis has a very different tonality: this is a silence that is no longer requesting anything.  It is more a silence-response than a silence-request.  Its experience is rooted more in the real of the subject; it represents a mode of existence and reception of the real that relates to it, which is itself without meaning.  It is not a silence of closure directed at the Other, without the Other, but rather a silence that delivers itself beyond the Other, that assumes the Other in its structural point of inexistence and non-guarantee.  It is not a silence that wants to be fully recognised.  It is a limited silence, in which the subject can pause without experiencing a deficit of speech.

Whether we are speaking of the silence at the outset, and over a long time, or the silence at the end of the analysis, the neurotic individual’s experience of silence is characterised by the fact that this is still a silence that resonates, in varying ways.  In the silence-request, it is the dialectic resonance of the silence that assumes control, reproducing, in the analysis, the dynamic of the relationship with the other typical of the fundamental phantom of the subject.  In the silence at the end of the analysis, the resonance can no longer be fully attributed to the phantasmal dialectic and its symbolisation.  Rather, it relates to the subject’s relationship with their most intimate reality, with the object that causes it, and is therefore associated more with speech, with the voice that the word contains, obscuring it.

It is worth reflecting here upon the issue of silence in the treatment of anorexia nervosa, in its relationship with speech and the object voice, and attempt to establish whether or not it is possible to isolate the recurring elements that structure its field of experience.  It will be helpful for us to refer to certain clinical situations.

The first hypothesis we wish to put forward is that, in the treatment of non-neurotic forms of anorexia, silence does not assume the form, at least for most of the treatment, of a silence that resonates.  It is no coincidence that the phenomenology of its forms of expression tends to be structured around two polarities: speech that closes off the space of the silence, and silence that sinks without limit.  The first case, that of speech that closes off the space of the silence, is frequent, especially during the early stages of the treatment.  It is an attempt to cover up every space of subjective enunciation in the discourse through an empty, stereotypical speech.  In a number of cases, this occurs through a frenzied rumination, expressed through an entirely stereotypical discourse centred on the topic of food, weight, and calories.  Amanda, a restrictor anorexic patient treated in a therapeutic community, once deployed an effective formula to express this: she described experiencing the pressing sensation of “having food in her brain”, of “[her] head being filled with food”, and said she could think of nothing else.  This rumination continues on the subject of food, characteristic of the behaviour of such patients, closing up the space of the subject and the interval between signifiers required for subjective division, and leading us to reflect upon its specific, paradoxical function, inasmuch as it constitutes a continuous, frantic deliberation on the object, food, of which they are depriving themselves.

In an extraordinary intuition, Lacan offers a reading of this clinical problem in a lesson from Seminar XXI, “Les non-dupes errent”.  Here, he reflects upon precisely this obsession with the discourse of food on the part of the anorexic female subject, endeavouring to draw the reason out of them.  Here, Lacan asserts that the purpose of this stereotypical, continuous speech about food is to defend the anorexic subject from something that horrifies her: an encounter with the gap in knowledge, with the inexistence of the Other.  We could thus posit that the anorexic patient is defending herself against the emergence of the unconscious in its real, unguaranteed state, in its function as a drive.  The holophrasis intrinsic to anorexia nervosa freezes and cuts off the subject’s relationship with her own unconscious.  For this reason, during treatments of anorexic patients, one constantly encounters cases in which, when the discursive stereotypy breaks down, the subject’s discourse reveals a peculiar anguish which they describe as relating to the encounter with an experience of the void.  The stereotypy protects the anorexic subject from an experience of the void, which opens up, structurally, whenever she encounters something that represents for her this gap in knowledge.  For example, when undergoing treatment in a residential institution, many such subjects cannot bear for there to be any unstructured time which is not completely filled up with activities, and when they are left to their own decisions.

One can also witness a typical principle that determines how the anorexic subject functions, namely, the rigid “all or nothing” polarisation, at work in the relationship between speech and silence.  On the one hand, as we have seen, one typical aspect concerns stereotypical speech, which cancels out the space of silence and its function as a time of interval between signifiers.  Here, empty speech closes off the silence, seeking to annihilate it.  On the opposing side, there have been certain rarer cases in which anorexia takes the form, at the level of language, of a silence that kills off the space of speech.  A silence without words.  In such cases, we are confronted with forms of anorexia in which such the subject appears mute. Silence appears obscene here, disengaged from the dialectic of speech, outside the laws of discourse, in a limit position.  In such cases, which we could term “verbal anorexia”, the threshold between anorexia and autism is often subtle, and the involvement of speech assumes a value of unbearable alienation for the subject.  Lacan comes to our aid here, too, when in Seminar X, “Angst”, he reminds us that the condition that allows speech to resonate in human experience derives from the fact that the voice, as a drive object, could have been lost by the subject, thereby becoming something separate from them, and hence extraneous even if intimate.  The fact that the voice has been lost enables the subject to incorporate it (Lacan, 2004, pp. 317-321).  This allows the voice to resonate in the void of the Other, at its point of non-guarantee.  This ‘extimacy’ of the vocal object structures the position of the neurotic subject in his/her singular relationship with speech and the sphere of language within the context of the dialectic of alienation and separation.  However, it also characterises their relationship with knowledge as a sphere structured around a lack, tantamount to the loss of the object that causes their desire.

In psychosis, the subject does not experience the loss of the voice object, which, not by chance, returns fromthe real via auditory hallucination.  The subject is hounded and invaded here by the voice, which is not separate from them.  Only if the voice is separate, if it has been lost, can it resonate for the subject, taking form in their experience of silence and of speech.  Otherwise, it assumes the form more of a voice that commands, that punishes and condemns without remedy.  Only rarely, in the treatment of anorexia nervosa, do the basic phenomena of auditory hallucination prevail.  This occurs in cases of frank psychosis, and often the voice orders the subject to refuse food on the basis that it is poisoned or contaminated, or, in cases of bulimia, to devour it without limit.  For the most part, however, what happens is that the superego command dictates the subject ruthlessly, but without the voice assuming the form of a concrete other (the mother, father…) that orders the subject to eat or refuse food.  We are thus not faced, in anorexia nervosa, with an out-and-out structure of auditory hallucination.  Rather, in the majority of cases, we encounter the eruption of a superego injunction, which makes it impossible for the subject to experience the effect of resonance intrinsic to the dialectic of speech and the function of silence as a backdrop to speech.

The Case of Alessia, or the Non-metaphorical Operation of Speech and Language in Anorexia

The case of Alessia, a patient I treated in a monosymptomatic analytically-oriented group, clearly displays the feature of anti-metaphoric melancholy which traverses and structures the relationship with speech and language in her anorexia.

This patient had remained transfixed by a traumatic scene from her early life, which she worked on in the advanced stage of her treatment: in the rear-view mirror of the car she saw her father, desperate and weeping, telling her, “Now it’s up to you to take your mother’s place!”.  Alessia’s mother had died of cancer when she was eight years old, and her brother was three.  From that point onwards, Alessia, a rather plump little girl, began to lose weight slowly at first, and then in a more pronounced way in pre-adolescence.  Her response to her father’s desperate call to take the place of her dead mother fixed her to a deadly identification to which her anorexia would become the answer.  She joined the group when she was eighteen in full restricting anorexia, claiming that she was only doing so at the request of her maternal grandfather and her boyfriend; she had no intention herself of being cured.  Alessia attended all the meetings.  She was mostly silent, but always present, because she said she could not break her word to anyone.

After a couple of years she missed an appointment with the group, at a critical juncture that clarified the subject’s structure.  That afternoon, some boys had stopped to look at her when she was kneeling down to arrange some clothes, in the window of a clothing store where she worked.  Alessia was certain that they were looking at her behind.  That same afternoon she drew my attention to a message, in which she explained that she could not come because of the eyes.  In the message she had drawn several menacing eyes watching.  The return to the real of the object “look” as a non-symbolisable object had had the effect of cracking the compensatory hold of her anorexia.

For about a month, she could not go out of the house because she could not bear to be looked at.  I made daily conference calls with her, which she always answered, until she was able to return to the group and draw her work to a close.  The persecutory effect of the object “look” diminished and disappeared within a month.  A student of law, she graduated with a study on children’s law with the goal of working as a lawyer for abandoned children.  Her mother’s death was, she explained, an unbearable abandonment for her,  which had been inescapably forced upon her, with no way out.  In the group, this led her to talk about her infinite rage toward her dead mother, who had abandoned her to her fate.

Alessia’s case clearly shows the anti-metaphorical function of anorexia as a subjective position that is not structured in such a way as to bring about a separation from the lost object.  Rather, it becomes a way of keeping and eternalising it in the body, working in the opposite direction to the process of mourning.

The early death of her mother and her father’s desperate plea for her to take her place had affected the subject as non-symbolisable events.  The subject’s response is to structure anorexia as a return to the real of a loss that she cannot symbolise, similar to nostalgic melancholy for the Thing which is realised through the rejection of symbolic castration.

Narcissistic identification with the lost object, in the case of Alessia, also found an imaginary emphasis in her striking physical resemblance to her mother, as we were able to see one day when she brought photos of her mother in to the group.

Alessia was able to overcome her anorexia only after a slow process that involved differentiating her position from that of her dead mother.  Substitution (in the meaning of ‘suppléance’ in Lacanian language) played an important role in this process, bringing out in her the plan to go on to become a lawyer of abandoned children.  Through this operation, she had found a solution beyond anorexia, allowing her to distance herself from the object “mother”, and to find, in law, an anchor that could play, in her imagination, the inoperative role of the father.
In Alessia’s life, the function of the word and the field of language assume a form that tends toward the literal and non-metaphoric.  What appears, at key moments of her life, is an encounter with sentences that are imposed as absolute commands outside the dialectic, pure imperatives deprived of a phantasmal framework.  Her use of speech in the group did not take the form of an appeal, and it was only during the later stage of the treatment that it achieved greater specificity, reaching a more subjective dimension.

For example, in her account of the onset of her female sexuality, what is striking is her claim to have experienced only annoyance, and not even any attraction for the boy with whom she had her first experience; one finds merely the belief that it was her duty to do so, because that is what girls of her age do.

 So, in response to the first advances she received in her life, she agreed to have her first sexual relationship.  No construction, no expectation or curiosity, no exploratory need, no particular satisfaction surround the event of her first intercourse: only the certainty of a duty to be performed inasmuch as she was a girl like all others.

 In place of the veil of castration, we find the deployment of a superego command that must be obeyed in order to be a young woman.  As we have already seen in this case, the onset of Alessia’s anorexia coincided with the response to her father’s call for her to take the place of her mother, who had died suddenly.

Original Italian text:  https://www.journal-psychoanalysis.eu/il-silenzio-e-la-voce-nellanoressia-mentale/